CUSTOMIZED RECONSTRUCTION WITH THE FREEANTEROLATERAL THIGH PERFORATOR FLAP

HOLGER ENGEL, M.D.,1* EMRE GAZYAKAN, M.D., M.Sc.,1 MING-HUEI CHENG, M.D., M.H.A.,2 DAVID PIEL, M.D. (Student),1

GUENTER GERMANN, M.D., Ph.D.,1 and GOETZ GIESSLER, M.D.1

From April of 2003 through September of 2006, 70 free anterolateral thigh (ALT) flaps were transferred for reconstructing soft-tissuedefects. The overall success rate was 96%. Among 70 free ALT flaps, 11 were elevated as cutaneous ALT septocutaneous vessel flaps.Fifty-seven were harvested as cutaneous ALT myocutaneous ‘‘true’’ perforator flaps. Two flaps were used as fasciocutaneous perforatorflaps based on independent skin vessels. Fifty-four ALT flaps were used for lower extremity reconstruction, 11 flaps were used for upperextremity reconstruction, 3 flaps were used for trunk reconstruction, and 1 flap was used for head and neck reconstruction. Total flap fail-ure occurred in 3 patients (4.28% of the flaps), and partial failure occurred in 5 patients (7.14% of the flaps). The three flaps that failedcompletely were reconstructed with a free radial forearm flap, a latissimus dorsi flap and skin grafting, respectively. Among the five flapsthat failed partially, three were reconstructed with skin grafting, one with a sural flap, and one with primary closure. The free ALT flap hasbecome the workhorse for covering defects in most clinical situations in our center. It is a reliable flap with consistent anatomy and a long,constant pedicle diameter. Its versatility, in which thickness and volume can be adjusted, leads to a perfect match for customized recon-struction of complex defects. VVC 2008 Wiley-Liss, Inc. Microsurgery 28:489–494, 2008.

Since the first successful free flap transfer in 1971,1 the

continuous development of microsurgical instruments and

technique refinements led to further rapid evolution of

flap surgery with the upcoming of the clinical use of per-

forator flaps. Because flap survival rates have risen from

79% to 96%,2 microsurgeons focus today on function and

esthetic appearance of the recipient and donor sites. To

fully meet the requirements of ‘‘up-to-date’’ flap surgery,

individual customized functional and esthetic reconstruc-

tion has to be achieved.

The anterolateral thigh (ALT) flap was first described

by Song et al.3 In the last years, free ALT flap was

established as the workhorse for soft-tissue reconstruction

in many clinical situations at most centers.4–20

Similar to the well-recognized donor site of the sub-

scapular artery system,21 the lateral circumflex femoral

artery (LCFA) system with its main transverse and

descending branches offers multiple possibilities for the

reconstruction of complex three-dimensional defects.7,22,23

Advantages of the free ALT flap, such as a long pedi-

cle, reliable anatomy,24–31 suitable vessel diameter, the

availability of different tissues with large amounts of

skin, skin-to-skin closure, its adaptability as a sensate

and/or compound (composite and combined) flap,9 adapta-

ble volume and thickness, no repositioning of the patient

during operation and simultaneously working in two teams

and good esthetic outcome, are well known4–20,32–36 and

stand against a challenging dissection of musculocutaneous

perforators with a prolonged operation time and unsatisfac-

tory esthetic outcome if the donor site has to be skin-

grafted.

This article presents our clinical experience using the

free ALT flap for reconstruction of complex defects for

upper and lower extremity, and trunk and head/neck

region.

PATIENTS AND METHODS

Seventy patients were operated between April 2003

and September 2006 (59 male, 11 female). Their age

ranged from 18 to 80 years with a mean age of 51 years.

The operations were always performed with two teams in

supine position of the patient. The operation time ranged

from 164 to 771 min (mean, 401 min.).

Fifty-four free ALT flaps were used for lower extrem-

ity reconstruction, 11 flaps for upper extremity recon-

struction, 3 flaps for trunk reconstruction, and 2 flaps for

head and neck reconstruction.

Among 70 free ALT flaps, 11 were elevated as a

cutaneous ALT flap with septocutaneous vessels, 57 as

cutaneous ALT flap with myocutaneous ‘‘true’’ perfora-

tors,9,37 and two flaps were used as ‘‘split-ALT’’

described by Chou et al.8 as fasciocutaneous perforator

flaps based on independent skin vessels.

Forty-eight flaps were transferred to reconstruct lower

extremity (10 patients with simultaneous fractures of tibia

and fibula, 14 patients with third degree open fractures of

tibia and fibula, 8 patients with open ankle fractures

1Department of Plastic and Hand Surgery, Burn Center, Trauma Center Lud-wigshafen, Plastic and Hand Surgery, The University of Heidelberg, Ludwig-shafen, Germany2Department of Plastic and Reconstructive Surgery, Chang Gung MemorialHospital, Chang Gung Medical College, Chang Gung University, Tao Yuan,Taiwan

*Correspondence to: Holger Engel, M.D., Department of Plastic and HandSurgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic and HandSurgery, The University of Heidelberg, Ludwig-Guttmann Str. 13, 67071Ludwigshafen, Germany. E-mail: holgerengel@email.de

Received 2 January 2008; Accepted 15 May 2008

Published online 6 August 2008 in Wiley InterScience (www.interscience.wiley.com). DOI 10.1002/micr.20538

VVC 2008 Wiley-Liss, Inc.

followed by osteosynthesis and wound healing problems,

6 patients with avulsion injury of the foot, 4 patients

with chronic soft tissue defect after trauma, and 1 patient

after luxation fracture of the Lisfranc joint), upper

extremity (1 patient with shotgun wound, 1 patient with

decollement of the left arm, 1 patient after amputation of

the upper arm, and 1 patient with a devastating injury of

the hand caused by a circular saw), and head/neck (skull

fracture followed by osteosynthesis and wound healing

problems) in patients with acute or subacute wounds

resulting from trauma. Three flaps were transferred to

head/neck (1 patient with third recurrence of an oropha-

ryngeal carcinoma involving the right gum of the oral

cavity), upper (Paravasat after chemotherapy) and lower

extremity (sarcoma) because of cancer. Six flaps were

transferred to upper extremity (2 patients after suicide, 2

soldiers after mine detonation), lower extremity (1 patient

after boiled water injury), and trunk (1 soldier injured

after grenade explosion) because of severely burned

patients. Six chronic ulcers at the lower extremities and

seven flaps because of other causes were transferred.

SURGICAL TECHNIQUE

A line is drawn between the anterior superior iliac

spine and the midpoint of the lateral border on the patella

on the donor thigh, with the patient in a supine posi-

tion.27,30,31,34 The location of the main perforators is

detected with Doppler ultrasound and is centered primar-

ily at the midpoint of the line. The design of the skin

paddle is based on a template tailored from the defect.

The branches of the lateral circumflex femoral vascular

bundle are identified in the intermuscular septum between

the rectus femoris and the vastus lateralis muscle. If a

visible septocutaneous perforator arising from the de-

scending branch or transverse branch of the LCFA or

originating directly from the LCFA is present, then the

flap can be harvested as a septocutaneous flap. In most

cases, the septocutaneous perforators are absent, the flap

may be elevated either as a musculocutaneous flap by

including a cuff of vastus lateralis muscle, or as a perfo-

rator flap with intramuscular dissection of the musculocu-

taneous perforator. The motor branches of the femoral

nerve should be preserved as much as possible. When the

flap is raised as a sensate flap, the incision is extended to

the lateral proximal part of the flap to include branches

of the lateral femoral cutaneous nerve. The donor site

can be closed directly, when the width of the flap is

smaller than 8 cm in obese patients or less than 10 cm

wide in elderly or thinner patients.

RESULTS

In total, 67 of 70 flaps survived providing a success

rate of 96%. Total failure occurred in three patients

(4.28% of the flaps) and partial failure occurred in five

patients (7.14% of the flaps; Table 1)

The three flaps that failed totally were reconstructed

with a free radial forearm flap, a latissimus dorsi flap,

and skin grafting, respectively. Among the five flaps that

failed partially three were reconstructed with skin graft-

ing, one with a sural flap and one with primary closure.

In this series, the donor sites could be closed primarily in

51 patients (73%), whereas 19 (27%) had to be closed by

split thickness skin graft. In terms of defect size and flap

size, no adequate data is available. Only some operational

records state a flap size equivalent to defect sizes of

8 3 10 cm up to 30 3 11 cm. This only can point out

to potential sizing of this flap.

Forty-five patients (64%) were followed up 6 and

12 months postoperative, 24 patients (35%) were lost to

Table 1. Patient Data with Summarized Information of the Customized ALT Free Flaps

Myocutaneous ALT Septocutaneous ALT Fasciocutaneous ALT

Number of flaps 57 11 2

Recipient lower extremity (n 5 54) 47 6 1

Recipient upper extremity (n 5 11) 8 3 0

Recipient trunk (n 5 3) 1 2 0

Recipient head and neck (n 5 2) 1 0 1

Hematoma 3 2 0

Re-anastomosis 3 0 0

Wound healing problem donor site 3 2 0

Wound healing problem recipient site 3 0 0

Partial flap loss 2 2 1

Total flap loss 2 1 0

Overall survival rate in % 96 91 100

1 Perforator 28 6 1

2 Perforators 26 4 1

3 Perforators 1 0 0

4 perforators 2 1 0

490 Engel et al.

Microsurgery DOI 10.1002/micr

follow-up, and 1 patient died (1%) within the follow-up

period.

In general, there was an uneventful follow-up regard-

ing the flap in terms of long-term survival after complete

mobility of the patient. In almost all cases, anesthesia of

the flap with no functional deficit resulted. Scarce infor-

mation is valid about the overall result in terms of func-

tion and overall satisfaction. Overall flap satisfaction was

85%.

Patient Reports

Patient 1. A 36-year-old male patient suffered from a

diabetic malum perforans at the right feet following

superinfection resulting in a full thickness defect. Exci-

sion of the defect had to be performed. A split-ALT, fas-

ciocutaneous perforator flap from the left thigh, was har-

vested to reconstruct the extensive defect, both on the

plantar and dorsal surface of the foot. Flap healing was

uneventful. The patient walks in his normal shoes. No

complication occurred regarding ambulation or donor site

(Figs. 1A–1E).

Patient 2. A 24-year-old female patient suffered from

severe car accident with fractures of the skull, causing

frontotemporal defect with exposed implants. A free cuta-

neous ALT myocutaneous ‘‘true’’ perforator flap from the

left thigh was harvested to reconstruct the defect. The

flap healed without complications (Figs. 2A and 2B).

Patient 3. A 64-year-old male patient suffered from

third recurrence of an oropharyngeal carcinoma involving

the right gum of the oral cavity. A wide composite exci-

sion of the tumor, marginal mandibulectomy, and a radi-

cal neck dissection of the lymph node were performed. A

free split-ALT flap from the left thigh was harvested

because of its bulk for reconstructing the extensive com-

posite defect in the oral cavity. The flap healed without

complications. The donor-site had to be skin-grafted. The

patient tolerated a soft diet. No complications occurred

concerning ambulation or the donor site (Figs. 3A–3C).

Figure 1. A: An anterolateral thigh flap was harvested and splitted in two skin paddles. B: Dorsal surface of the foot after operation.

C: Plantar surface of the foot after operation. D: Dorsal surface 6 months after operation. E: Plantar surface 6 months after operation.

Customized Reconstruction with ALT 491

Microsurgery DOI 10.1002/micr

Figure 2. A: Status postsurgical debridement of all necrotic tissue with exposed implants after frontotemporal scalp defect and skull frac-

ture. B: Defect coverage with free cutaneous ALT flap.

Figure 3. A: Third recurrence of an oropharyngeal carcinoma involving the right gum. B: Wide composite tumor excision with marginal

mandibulectomy and neck dissection. C: A split ALT flap with two skin paddles for reconstruction of inner lining and external cheek. At 6

months of follow-up, the patient may tolerate the soft diet and acceptable appearance.

492 Engel et al.

Microsurgery DOI 10.1002/micr

DISCUSSION

The ALT flap is based on septocutaneous or musculocuta-

neous perforators, or both from the LCFA.4,6–10,13–15,17,19,32–36,38

It sends perforators through the septum between the

vastus lateralis and the rectus femoris or through the

vastus lateralis muscle and supplies a large skin flap on

the anterolateral aspect of the thigh. If a visible septocu-

taneous perforator is found, the flap can be harvested as

a septocutaneous flap. However, if septocutaneous perfo-

rators are absent, the flap can then be harvested as a mus-

culocutaneous flap, with a small vastus lateralis muscle

cuff for added bulk, or as a perforator flap with intramus-

cular dissection of the musculocutaneous perfora-

tors.9,37,39 In anatomic studies, most authors found the

blood supply of the ALT flap to be musculocutaneous

perforators rather than septocutaneous perforators.24–31,40

In this current series, we found the major blood supply

of the ALT flap to be musculocutaneous perforators

(84.3%) followed by septocutaneous perforators (15.7%).

We harvested most of the flaps as a cutaneous ALT myo-

cutaneous ‘‘true’’ perforator flap (81.4%). Another 11

were elevated as cutaneous ALT septocutaneous vessel

flaps (15.7%). The remaining two flaps (2.86%) were

used as split-ALT described by Chou et al.8 as fasciocu-

taneous perforator flaps based on independent skin ves-

sels. However, in this series, septocutaneous or musculo-

cutaneous perforators were always present at the antero-

lateral aspect of the thigh and allowed this flap to be

elevated safely.

The discrepancy found in the literature in the inci-

dence of perforator absence in ALT flaps is due to confu-

sion and lack of definition of ‘‘perforator.’’24–27,31,40 In an

early study by Koshima et al.,25 no perforators were

found in 5 of 13 patients. In a more recent study, Ko-

shima et al.,25 claimed that in the beginning they used

the flaps with a septocutaneous vessel and rarely used

flaps based on the musculocutaneous perforators because

of difficult vascular dissection within the vastus lateralis.

This indicates that he referred to perforators as septocuta-

neous vessels and not the ‘‘true’’ musculocutaneous perfo-

rators, and explains the high incidence of no skin perfora-

tor in this early ALT flap experience.

The variability of perforators and the difficult dissec-

tion of the musculocutaneous perforator may be the major

challenge for a surgeon, especially at the beginning of

the learning curve, causing a prolonged operation time.

We concur with Cheng and coworkers42 that preoperative

mapping with a Doppler probe to locate the perforators is

mandatory. Meticulous dissection of the perforators under

surgical loupe, inclusion of a small fascia cuff around the

perforator, and intermittent topical use of lidocaine during

the intramuscular dissection decreases the probability of

complications significantly.

Similar to the well-established donor site of the sub-

scapular artery system,21 the LCFA system with its main

transverse and descending branches offer a comparable

variety for reconstructing complex three-dimensional

defects.7,22,23

Advantages of the free ALT flap, such as a long pedi-

cle, reliable anatomy,24–31 suitable vessel diameter, the

availability of different tissues with large amounts of

skin, skin-to-skin closure, its adaptability as a sensate

and/or compound (composite and combined) flap,9 adapt-

able volume and thickness,34 no repositioning of the

patient during operation and simultaneously working

in two teams, and good esthetic outcome, are well

known.4–20,32–36 Disadvantages such as challenging dis-

section of musculocutaneous perforators with a prolonged

operation time and unsatisfactorily esthetic outcome if

the donor site has to be skin-grafted were taken deliber-

ately into consideration.

Despite these disadvantages, the free ALT flap has

become the workhorse for covering complex defects in most

clinical situations for the lower extremity in our center.

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