DORSAL FOOT RESURFACING USING FREE ANTEROLATERALTHIGH (ALT) FLAP IN CHILDREN
TAREK A. EL-GAMMAL, M.D.,1* AMR EL-SAYED, M.D.,1 MOHAMED M. KOTB, M.D.,1 WALEED RIAD SALEH, M.D.,1
YASSER FAROUK RAGHEB, M.D.,1 OMAR EL-REFAI, M.D.,1 and MOHAMMED HASSAN ALI EL FAHAR, M.D.2
Very limited literature described the use of the free anterolateral thigh (ALT) among other flaps for pediatric lower limb reconstruction. Theaim of this study is to present our experience using the free ALT flap for reconstruction of soft tissue defects over the dorsum of the footand ankle in children. The study included 42 children aged 2.513 years with a mean of 6.18 years. Three children had crush injuries whilethe rest were victims of run over car accidents. All of the flaps were vascularized by at least two perforators; 88.23% were musculocutane-ous and 11.77 were septocutaneous perforators. All flaps were raised in a subfascial plane. Initial thinning was performed in five flaps and35% required subsequent debulking. Mean Flap surface area was 117.11 cm2. The recipient arteries were the anterior tibial artery in 38cases and posterior tibial artery in four cases. Venous anastomosis was performed to one vena commitant and in nine cases the longsaphenous vein was additionally used. Mean ischemia time of the flap was 2 hours while total operative time averaged 6.3 hours. About41% of donor sites were closed primarily while 59% required skin grafting. Primary flap survival rate was 92.8% (39/42 cases). Three flapsshowed venous congestion. After venous reanastomosis, two flaps showed partial loss and one flap was lost completely. Post-operativehospital stay averaged 7.5 days. The free ALT flap could be as safe, reliable, and aesthetically appealing option for foot/ankle resurfacingin children after traumatic soft tissue loss. VVC 2012 Wiley Periodicals, Inc. Microsurgery 33:259264, 2013.
The anterolateral thigh (ALT) flap was first described bySong et al.1 In the last three decades, the ALT flap has
gained popularity as a versatile and reliable option for
soft tissue reconstruction. The possibilities of transferring
large skin paddles and different tissue types on a large
and long pedicle, potential for thinning, reinnervation,
flow through revascularization and coverage of the
extremities, with minimal donor-site morbidity are some
of the reasons which have led to the success of this flap.2
Microvascular free tissue transfer has been shown to
be safe and reliable in adults and in children with success
rates >90%.3 Free-flap reconstruction of post-traumatictissue defects in children need to be planned carefully
with regards to the specific pediatric anatomy. Also, the
evolution of childrens tissue and skeletal structures need
to be taken into account. Apart from surgical considera-
tions, psychosocial ramifications, and discomfort of pro-
longed disability at a young age have to be kept in
This article presents our clinical experience using the
free ALT flap for reconstruction of soft tissue defects
over the foot and around the ankle in children.
PATIENTS AND METHODS
From January 2005 to December 2010, 42 children
received free ALT flap for coverage of large and exten-
sive soft tissue defects over the dorsum of the foot and
ankle exposing the extensor tendons and/or metatarsals
with or without associated fractures of the metatarsals or
ankle or open joints. Small defects eligible for local or
pedicle skin flaps and defects associated with plantar loss
or bone loss requiring bone grafts were excluded.
Hospital records were reviewed and data were col-
lected regarding patients demographics, type of trauma,
timing of microsurgical reconstruction, flap dimensions,
operative time, number, and type of perforators, donor-
site closure, postoperative course and complications. The
age of the children ranged between 2.5 and 13 years
(mean age, 6.18 6 2.54 years). There were 10 femalesand 32 males. All children had post-traumatic skin and
soft tissue loss over foot and around the ankle (Table 1).
Three children had crush injuries while the rest were
victims of run over car accidents. The left foot was
involved in 55.9% of the cases and the right in 44.1%.
All patients underwent reconstruction >72 hours aftertrauma within a mean of 15.8 6 2.54 days.
All wounds were debrided thoroughly. Bone fixation
was done at the time of initial debridement. Additional
reconstructive procedures were done at the time of ALT
flap transfer. Bone fixation was done using k-wires andfoot was supported in a posterior slab. Daily closed
wound dressing was done using conventional paraffin
gauze and antibiotic ointment. No vacuum assisted
closure VAC was used. All wounds were followed up by
1Reconstructive Microsurgery Unit, Assiut University Hospitals and School ofMedicine, Assiut, Egypt2Plastic & Reconstructive Surgery, Mansoura University School of Medicine,Mansoura, Egypt
*Correspondence to: Tarek Abdalla El-ammal, M.D.; ReconstructiveMicrosurgery Unit, Assiut University Hospitals and School of Medicine,Assiut 71526, Egypt . E-mail: firstname.lastname@example.org
Received 24 June 2012; Revision accepted 3 November 2012; Accepted 5November 2012
Published online 26 December 2012 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/micr.22074
VVC 2012 Wiley Periodicals, Inc.
serial wound culture. Patency of the anterior and poste-
rior tibial vessels was evaluated using a hand held Dopp-
ler and no angiographic studies as CTA or MRA were
A Two team approach was adopted, one for explora-
tion/dissection of the recipient vessels and the other for
harvesting the flap from the contralateral donor thigh.
Normal skin edges were reached by excision of any
tissues of doubtful viability to re-evaluate of the defect
prior to determining final flap dimensions.
Vessels exploration was done under tourniquet with-
out exsanguination. The anterior tibial vessels outside the
zone of injury were evaluated. If the flow was inadequate
or there were signs of intimal injury on microscopic
examination, the posterior tibial vessels were used for
end to side anastomosis.
A line was drawn between the anterior superior iliac
spine and the midpoint of the lateral border on the patella
on the donor thigh, with the child in the supine position.
The location of the main perforators was detected with
Doppler ultrasound and was centered primarily at the
midpoint of the line. Additional perforators were located
510 cm proximal and distal to the midpoint perforator.
Perforators at these locations were designated from
proximal to distal as vessels A, B, and C, respectively
(Fig. 1). The design of the skin paddle was centered over
two perforators using a patron tailored from the defect
that included both of them. A pinch test was used to
establish the amount of the skin that could be harvested
allowing primary closure of the donor site if possible.
The incision of the skin was started from the medial
border at subfascial plane till the rectus femoris muscle
was visualized and retracted exposing the intermuscular
septum between it and the vastus latralis. Dissection of
the perforators was carried out with the use of surgical
loupes (3.5x or 4.5x). If a visible and pulsatile septocuta-
neous perforator arising from the descending branch or
originating directly from the LCFA was present, then the
flap could be harvested as a septocutaneous flap. If not,
the flap could be elevated as a musculocutaneous flap by
including 2 cm cuff of vastus lateralis muscle.
Venous anastomosis was done first followed by the
arterial anastomosis using 10/0 interrupted monofilament
nylon sutures. Heparinized saline (100 U/mL) was used
as a local irrigant and intravenous bolus of 50100 U/kg
was administrated just before releasing the clamps.
The donor site was closed primarily after undermining
if the defect was less than 10 cm wide, otherwise, a split
thickness skin graft was used. Light dressing and non-
adherent gauze impregnated with paraffin was used as a
closed dressing for the grafted donor.
Dextran 40 was usually run at 810 milliliters/kg/24
hours approximately 5 days post-operatively. All children
received post-operative sedation. Careful monitoring of
the general condition of the patient and vital signs was
done for the first 24 hours. All flaps were monitored ev-
ery 1 hour for the first 24 hours then every 2 hours for 5
days as regards color, temperature, and capillary refill to
ensure patent microvascular anastomosis. Passive exer-
cises were initiated 2 weeks postoperatively for 2 weeks
then followed by active exercises for another 3 months.
When required, flap debulking was done 6 months af-
ter the initial surgery. The outline of the flap was marked
and the proximal edge of the flap was incised along the
scar for up to 50% of the flap circumference, the subcuta-
neous fat was removed and the flap was advanced proxi-
mally in order to reduce any redundant skin.
Statistics were performed with IBM1 SPSS1 Statis-
tics Version 19. Values are given as mean 6 standarddeviation.
All of the flaps were vascularized by at least 2 perfo-
rators. A total of 88.23% of the perforators were muscu-
locutaneous and 11.77% were septocutaneous perforators.
All flaps were raised in a subfascial plane. Initial thinning
was performed in five flaps and 35.7% required subse-
quent debulking. Mean Flap dimensions were 15.5 62.72 cm 3 7.44 6 1.28 cm with a mean surface area of117.11 6 37.91 cm2. The recipient artery was theanterior tibial artery in 38 cases, and the posterior tibial
Table 1. Associated Injuries of the Foot and Ankle
Indication of coverage Number
Exposed metatarsals and extensor tendons 18
Exposed medial or lateral malleolus 4
Open fracture one or more metatarsals 7
Open fracture dislocation of the ankle joint 13
Figure 1. Marking of the donor site : (A) proximal perforator, (B)
main perforator, (C) distal perforator anterior superior iliac spine
(ASIS). [Color figure can be viewed in the online issue, which is
available at wileyonlinelibrary.com.]
260 El-Gammal et al.
Microsurgery DOI 10.1002/micr
artery in four cases. Venous anastomosis was performed
to one vena commitant and in nine cases the long saphe-
nous vein was additionally used. Mean ischemia time of
the flap was 2.07 6 0.51 hours while the total operativetime was 6.33 6 1.05 hours. The average blood loss was453.29 6 104.11 cc. 41.18% of donor sites were closedprimarily while 59.52% needed skin grafting (Table 2).
Post-operative hospital stay averaged 7.5 6 1.16days. Follow up averaged 42 months. All limbs survived.
Primary flap survival rate was 92.86% (39/42 cases).
Three flaps showed venous congestion. After venous
reanastomosis, two flaps showed partial loss and one flap
was lost completely. More than 70% of the cases were
able to wear shoes even before debulking. Fifteen chil-
dren complained that it was difficult to put on shoes
because of the bulky flap and that the flap contour was
not aesthetically pleasing. After the debulking satisfactory
results were achieved in terms of contour and functional
outcome (Table 3). Two representative cases are shown
in Figures 23.
The unique architecture of the soft tissue of dorsum
of the foot consists of a thin pliable surface that allows
for significant excursion and tendon gliding. Reconstruc-
tive options must preserve these important functions and
allow for reasonable contour so the patient may wear a
shoe postoperatively. There is often a paucity of local
flap options in the setting of trauma, and free flap recon-
struction is frequently indicated. The need for durable
coverage of contaminated wounds or exposed joints, frac-
tures, or hardware makes the free flap particularly well
suited to trauma reconstruction.5
In the last three decades, the advent and refinement
of microsurgical techniques have brought about a revolu-
tion in the treatment of distal lower extremity trauma. In
the adult population, the principles of successful treat-
ment of high-energy injuries of the ankle and foot are
well defined.6 The use of free tissue transfer in children
has demonstrated that it can be performed with accepta-
ble morbidity.7,8 Although childrens anatomy may pres-
ent unique technical challenges, the absence of diabetes,
hypertension, atherosclerosis, and venous stasis in chil-
dren makes free tissue transfer a particularly attractive
option for complex reconstruction.5
Namdar et al. reviewed several studies reporting the
success of free latissimus dorsi muscle transfer in chil-
dren for lower extremity reconstruction; he also reported
that the hospital stay ranged from days to months due to
seroma formation and conclude that because of the large
volume and size of the transferred latissimus dorsi mus-
cle, there was a common need for surgical revisions even
if there are no clinical signs of malperfusion.4 In larger
studies (512 children) a free latissimus dorsi muscle flap
survival rate of 6780% has been reported.911 Haasbeek
and collaeages described free gracilis muscle transfer for
coverage after release of severe clubfoot deformity in
children older than 4 years of age. The small vessel di-
ameter often found in children younger than 4 years of
age is not suitable for anastomosis.12 Recently, Tan et al.
used nerve sparing latissimus dorsi flap to cover soft tis-
sue defect with limited donor site morbidity.13 This study
included one child with crush injury to the leg.
Very limited literature described the use of the free
ALT among other flaps for pediatric lower limb recon-
struction. These previous studies did not address the
peculiarities of the ALT flap in the pediatric population
and held true the considerations based on experiences in
an adult population.1418 The indication for use of ALT
flap in our series was coverage of large and extensive
soft tissue defects over the dorsum of the foot and ankle
exposing the extensor tendons and/or metatarsals with or
without associated fractures of the metatarsals or ankle or
open joints. Small defects eligible for local or pedicle
skin flaps were excluded. Defects associated with plantar
loss or bone loss requiring bone grafts were treated with
free muscle or osteocutaneous flap respectively. Our
study is the largest in number regarding dorsal foot and
ankle resurfacing using the free ALT for post traumatic
soft tissue loss in children (Table 4).
Road traffic accidents and crush injuries are the most
frequently reported causes of extensive foot trauma in
children, which require free-flap transfer for foot sal-
vage.9,11,19 In the current study, 94.11% were victims of
road traffic accidents and three cases suffered from crush
injuries caused by heavy objects.
All children underwent delayed reconstruction more
than 3 days after trauma. This indicates that post-traumatic
Table 2. Aesthetic Outcome
Primary closure 59.52%
Skin graft 40.47%
Hypertrophic scar 4.76%