Journal of Plastic, Reconstructive & Aesthetic Surgery (2012) 65, 474e481

Outcomes of anterolateral thigh free flap thinningusing liposuction following lower limb trauma

Evita Paraskevi Askouni a, Adam Topping a, Simon Ball b,Shehan Hettiaratchy a, Jagdeep Nanchahal a,c, Abhilash Jain a,c,*

aDepartment of Plastic and Reconstructive Surgery, Imperial College Healthcare NHS Trust, Charing Cross Hospital,Fulham Palace Road, W6 8RF London, United KingdombDepartment of Orthopaedic Surgery, Imperial College Healthcare NHS Trust, Charing Cross Hospital, United KingdomcKennedy Institute of Rheumatology, Imperial College London, United Kingdom

Received 12 August 2011; accepted 6 November 2011

KEYWORDSAnterolateral thighflap;ALT flap;Flap thinning;Liposuction

* Corresponding author. DepartmentFulham Palace Road, W6 8RF London,

E-mail address: ajainuk@aol.com (

1748-6815/$-seefrontmatterª2011Bridoi:10.1016/j.bjps.2011.11.007

Summary Background: Whilst soft tissue closure is the priority to prevent infection in openfractures of the lower limb, some patients find that bulky flaps interfere with function anddislike the appearance. We report the outcomes of delayed free anterolateral thigh flap thin-ning with liposuction.Material and methods: 38 patients treated between 2006 and 2009 were offered flap contour-ing. 23 chose flap thinning and 15 did not. We measured outcomes using the SF-36v2 question-naire and cosmetic outcome scores pre and postoperatively at a mean follow up of 12 weeks(range 10e16 weeks).Results: SF-36v2 physical health (PH) scores improved from a mean of 67 preoperatively to 80postoperatively (p Z 0.01) in the thinned group, while mental health (MH) scores remainedunchanged (74e72). The mean SF-36v2 scores for the non-thinned group were 77 (PH) and86 (MH). Following liposuction the median cosmetic outcome scores out of 5 improved from1 (not at all satisfied) to 4 (very satisfied) postoperatively (p Z 0.0005), which was also higherthan the non-thinned group (3) [moderately satisfied], p Z 0.004). There was no difference insex, age, BMI and region on the leg of free flap reconstruction between the non-thinned andthinned groups.Conclusions: Delayed contouring of free ALT flaps used for lower limb reconstruction results inimprovements in physical health measures and cosmetic outcomes. Patients not requestingthinning are generally satisfied with their reconstruction.ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published byElsevier Ltd. All rights reserved.

of Plastic and Reconstructive Surgery, Imperial College Healthcare NHS Trust, Charing Cross Hospital,United Kingdom. Tel.: þ44 203 311 1790.A. Jain).

tishAssociationofPlastic,ReconstructiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.

Outcomes of anterolateral thigh free flap thinning using liposuction 475

Introduction Patients and methods

Table 1 Number of free flaps performed to the variousregions of the lower limb in those undergoing flap thinningand those that did not.

Region onLower Leg

Non-thinnedgroup (n Z 15)

Thinned group(n Z 23)

Foot 2 2Malleolar 4 7Distal third tibia 4 5Middle third tibia 5 8Proximal third tibia 0 1

Open fractures of the tibia require early soft tissuecoverage. Free flaps are often necessary for distal thirdfractures, large defects and when the perforators havebeen damaged through trauma. The anterolateral thigh(ALT) flap is being increasingly used for a variety of softtissue defects1 including reconstruction of the lowerextremity.2 This flap has proven popular as it providesa long pedicle enabling anastomoses outside the zone ofinjury, large calibre donor vessels, a large fasciocutaneouspaddle and it can be raised as a composite flap incorpo-rating a segment of muscle. The latter is particularly usefulfor covering diaphyseal fractures.3,4 It also avoids theproblem with unstable skin grafts over insensate freemuscle flaps around the ankle and is easier to elevate forsecondary bone grafting of tibial shaft fractures. Even forlarge flaps, the donor site is relatively inconspicuous as it isusually covered by clothing. It can, however, be bulky incertain individuals, influencing both the final functional andcosmetic outcome. Despite this we find it extremelyversatile, and if excessive bulk is a problem, we offerpatients liposuction and revision of the flap once the frac-ture has united and the swelling settled.

ALT flap thinning has been well described in the liter-ature.5e15 Cadaveric studies looking at the effect of ALTflap thinning on skin blood supply suggested that immediatethinning may not be advisable in Western populations.5

Indeed, a recent systemic review has suggested that it isinadvisable to primarily thin ALT flaps in Western patients,especially when large flaps are required as is often the casefollowing lower limb trauma. These authors postulated thatthis difference was due to increased amounts of subcuta-neous fat in Western patients compared to those from theFar East.6

Ohjimi et al16 compared a group of non-thinned freeflaps to a group of predominantly rectus abdominis freeflaps, which were thinned at primary surgery to cover lowerextremity defects. They reported one flap failure in thenon-thinned group and two flaps with partial necrosis in thethinned group. Other techniques include full thickness skingrafting as a second stage debulking procedure after limbreconstruction.11,17 This involves the harvest of the fullthickness skin from the flap, which is then grafted backonto the in-situ thinned flap.

ALT flap thinning with the combination of liposuctionand w-plasty as a delayed single stage procedure has beendescribed after oral cancer reconstruction.8 Recently,power assisted suction lipectomy has been recommendedas a delayed one stage procedure following reconstructionwith fasciocutaneous flaps following upper limb surgery (11patients) with good results. These authors also describedgood results in four patients that had ALT flaps for lowerlimb trauma.18

We report our results in a group of 23 patients of delayedALT flap thinning using liposuction following lower limbreconstruction. We measured outcomes using the shortform-36 version 2 (SF-36v2) health survey questionnaire anda modified cosmetic outcome score19 and compared thisgroup to patients who chose not to have a flap thinningprocedure (15 patients).

Thirty eight patients underwent free ALT flap reconstruc-tion of soft tissue defects to cover lower limb fracturesbetween 2006 and 2009 (Table 1). All patients wereoffered flap thinning once the fracture had united and theswelling settled. Patients were divided into 2 groups; thosethat chose to undergo flap thinning and those that did not.The non-thinning group consisted of 15 patients (male tofemale ratio 2:1) and the thinning group consisted of 23patients (male to female ratio 2:1). The mean age ofpatients in the flap thinning group was 44 years (range22e80 years) and in the non-thinning group was 40 years(range 21e69 years).

Data were collected on patients that had flap thinningprocedures between April 2007 and May 2010. There were26 procedures performed, 20 patients had one procedureand 3 patients underwent two staged procedures. Flapthinning took place at a mean of 14.5 months (range7e29 months) after the initial microsurgical reconstruc-tion. For those patients that had two flap thinningprocedures the length of time was calculated from ALT tofirst (mean 14.5 months, range 8e21 months), and fromfirst to second procedure (mean 16 months, range 9e21months).

Our unit is a tertiary referral centre for lower limbtrauma and many of our patients were referred fromoutside our region. Despite repeated attempts to contactpatients some were lost to follow up. Other patients did notfill in all the questionnaires. This made it difficult to collectcomplete data for all outcome measures. Nevertheless, inthe liposuction group, cosmetic outcomes were collected in15 patients preoperatively and postoperatively. Cosmeticscores were collected in 8 of the non-thinned group. SF-36v2 scores were collected in 10 out of 15 non-thinned flappatients and in 12 patients preoperatively in the thinnedgroup. The number of patients who completed the SF-36v2questionnaire postoperatively in the thinned group rose to19 patients. Complete matched pre and postoperative SF-36v2 data was available for 9 patients in the thinned group,which allowed for subgroup statistical analysis. Data onbody mass index (BMI) was available for 13 patients in thethinned group and 7 patients in the non-thinned group.Data collected on the site of the soft tissue defect, volumeof liposuction fluid/fat and recorded complications (e.g.infection, haematoma and flap problems) were availablefor all patients.

476 E.P. Askouni et al.

Outcome measures

As part of the service evaluation of our orthoplastic service,data are routinely collected on outcomes following lowerlimb trauma.20 Patients were asked to complete the SF-36v2health survey questionnaire21 prospectively. The SF-36v2 hasbeenwidely used as an outcomemeasure in a wide variety ofclinical conditions, including adult lower extremity trauma.22e24 It consists of 36 questions which measures 8 variablesand includes physical and social functioning, role limitationdue to physical problems or emotional problems, mentalhealth, energy and vitality, pain and general perception ofhealth. Each question is given a score and individual patientaverages calculated based on published tables.

In 2009 the Lower Extremity Assessment Project (LEAP)study group published a cosmetic outcome score which wasdesigned to evaluate the outcomes of amputation versusreconstruction in patients with severe lower extremitytrauma.19 Cosmetic outcome scores were based on thequestion: “On a scale of 1e5, with 1 being not satisfied and5 being very satisfied, how satisfied are you with theappearance of your injured leg or artificial leg?” We modi-fied this question to take into account that none of ourpatients had amputations by removing the words “or arti-ficial leg”. We applied this retrospectively to a group of 9patients that had flap thinning before 2009 and prospec-tively to 6 patients who had thinning after publication ofthe score. Patients in the non-thinned flap group wereasked the same question on the appearance of theirreconstructed leg. Patients undergoing thinning were askedto fill in the SF-36v2 and cosmetic questionnaire at a meanfollow up of 12 weeks (range 10e16 weeks) postoperatively.Patients not undergoing thinning were assessed at a meanof 24 months (range 6e42 months).

Operative technique

All procedures were performed under general anaestheticand tourniquet control. The outline of the flap was markedand then infiltrated with a standard solution of 40 ml of0.25% bupivacaine, 1 ml of hyalase 1:1,500, and 1 ml ofadrenaline 1:1000 in 500 ml of 0.9% sodium chloridetumescent solution. The flap was debulked using powerassisted liposuction (Mentor) using a 4FG blunt tippedcannula via a two port technique. The mean amount of fluidremoved by liposuction was 203 ml (range 80e500 ml). Theproximal edge of the flap was incised for up to 50% of thelength along the scar and advanced proximally in order toreduce any redundant skin (Figure 1). This was particularlyimportant when the flap was in the distal third of the tibiaas it allowed improved contouring of the flap around theankle and foot. After advancing the flap any excess softtissue was excised and the flap inset with 3/0 Monocrylsuture (Ethicon). The flap edges were dressed with Steri-strips and gauze, wool and crepe were applied. Thepatients were kept in hospital overnight for leg elevation.The following day the outer dressings were removed,a double tubigrip dressing (Comfigrip, Synergy Health)applied and the patients were discharged home fully weightbearing. Follow up was at one, six and a mean of twelveweeks (range 10e16 weeks) postoperatively.

Statistical analysis

The mean changes in cosmetic and SF-36v2 scores in theflap thinning group at follow up, compared to preoperativevalues, were assessed using the paired Student’s t-test.Mean ages, BMI, SF-36v2 and cosmetic scores between thenon flap thinned group and the thinned flap group werecompared using the unpaired Student’s t-test for para-metric data and the Mann Whitney test for non-parametricdata (mental health score in non-thinned group). Signifi-cance was achieved if p � 0.05.

Results

Both groups had the same male to female ratio (2:1) andthe mean age of patients was not statistically different.The distribution of free flaps on the lower limb was similarin both groups (Table 1). The majority of free flaps wereperformed for distal third tibial fractures including the footand ankle (24 of 38), 13 flaps were performed for mid shaftdiaphyseal fractures (Figure 2) and one free flap performedfor a proximal third injury. There was no statistical differ-ence in the BMI between the thinned (mean 26 � 5) and thenon-thinned group (mean 26 � 5).

SF-36v2 outcomes

The mean SF-36v2 results for all patients in which data wasavailable in the three groups are summarised in Table 2.The SF-36v2 has 8 categories; however, two summarymeasures can be calculated from these scales. These arethe physical and mental health component summary scores,which allow analysis of the physical and mental healthstatus respectively. There was no statistical difference incomponent physical health scores between both thepreoperative (mean 61 � 22) and postoperative (mean83 � 17) thinned group when compared to the non-thinnedgroup (mean 77 � 22) when the groups as a whole areanalysed. However, there was a statistically significantdifference (p Z 0.03) in the mental health componentscores between the preoperative thinned group (mean64 � 26) and the non-thinned group (mean 86 � 15) sug-gesting that the non-thinned group were overall moreaccepting of their reconstruction than the preoperativethinned group. There was no statistical difference betweenthe post-thinning mental health component scores (mean76 � 19) when compared to the non-thinned group.

We collected matched pre and postoperative data ina subgroup of patients who underwent thinning and ana-lysed these matched patients using the paired Student’s t-test. The component mental health scores in these ninepatients who underwent thinning did not demonstrate anystatistically significant change in preoperative (mean74 � 21) and postoperative (mean 72 � 15) scores, sug-gesting that the surgery did not affect individual patient’sperceived acceptance of their reconstruction (Table 3).Analysis of the matched group of patients undergoingthinning (Table 3) demonstrated a statistically significantimprovement (p Z 0.01) in the physical componentsummary score from preoperatively (mean 67 � 22) topostoperatively (mean 80 � 16).

Figure 1 (Top left) ALT flap following reconstruction of an open ankle fracture in a 59 year old female patient. (Top right)Immediately after liposuction the debulked flap demonstrates significant cutaneous laxity treated by elevation of the proximal flapmargin (middle left) and excess tissue excision (middle right), before being re-inset without tension (bottom right and left). Thispatient reported a cosmetic outcome score of 1 out of 5 preoperatively which improved to 4 out of 5 following thinning.

Outcomes of anterolateral thigh free flap thinning using liposuction 477

Cosmetic outcomes

The cosmetic questionnaire was published in 200919 and wetherefore administered it retrospectively to 9 patients whohad undergone flap thinning prior to this date and prospec-tively to 6 patientswhohad surgery after this date. Themeancosmetic scores in both these groups increased from 1preoperatively to 4 postoperatively. There was no statisticaldifference in the mean cosmetic scores between those whoanswered the question retrospectively and those thatanswered the question prospectively (unpaired Student’s t-test). We therefore analysed the data in both groupstogether. Matched pre and postoperative cosmetic scores inthe 15 patients improved significantly (p Z 0.0005) fromamean of 1 out of 5 (range 1e4) preoperatively to ameanof 4out of 5 (range 3e5) postoperatively. The preoperative scorewas significantly lower (p Z 0.0038) and the postoperativescore significantly higher (p Z 0.004) in the thinned groupthan in the non-thinned group (mean 3 out of 5, range 1e4).

Complications

The only complication we had was in a 38 year old immu-nocompromised male smoker in whom we undertook flap

thinning 8 months following reconstruction (Figure 3). Hesuffered partial flap necrosis affecting approximately 5% ofthe proximal flap edge, which settled with dressings. Therewere no infections or haematomas.

Discussion

Primary ALT flap thinning has been advocated in the FarEast but is not recommended in Western populations.6

Previous studies have reported delayed ALT flap thinningfollowing lower limb reconstruction,11,18,25 but none hasquantified patient reported outcomes. Our single centrestudy has attempted to quantify patient reported outcomesusing the SF-36v2 and cosmetic outcomes questionnaire.The SF-36v2 is a well-recognised, validated measure ofhealth status that has wide use.21,26 We therefore chosethis as a measure of physical and mental health status inour patient group. We were not able to collect completeoutcomes data on every individual as some patients werelost to follow up or did not complete the questionnaires.However, we had sufficient responses to be able to statis-tically analyse from matched pre- and post-operative datain patient sub-groups and have no reason to believe theseresponses were not representative of the group as a whole.

Figure 2 ALT flap used to cover a middle third tibial fracturein a 32 year old male patient. Figures demonstrate appearancepre-thinning (top left and right) and post-thinning (bottom leftand right).

Table 3 Mean (�SD) SF-36v2 scores measured ina subgroup of nine patients both pre and postoperatively.Physical component summary score is composed of physicalfunction, role e physical, bodily pain and general healthscores. Mental health component summary score iscomposed of vitality, social function, role e emotional andmental health scores.

SF-36v2 category Pre-thinning(n Z 9)

Post-thinning(n Z 9)

Physical function 67 � 26 69 � 25Role e physical 56 � 41 77 � 21Bodily pain 75 � 20 74 � 21General health 70 � 17 100 � 0Vitality 69 � 19 67 � 18Social function 71 � 24 67 � 18Role e emotional 76 � 38 79 � 22Mental health 79 � 16 75 � 19

Physical componentsummary

67 � 22 80 � 16*

Mental health componentsummary

74 � 21 72 � 15

*p Z 0.01 when compared to pre-thinning scores.

478 E.P. Askouni et al.

Furthermore, we compared those patients who had flapthinning to a group of patients that chose not to undergothinning. Both groups were well matched with regards toage, sex, BMI and distribution of free flaps.

Table 2 Mean (�SD) SF-36v2 scores in all patients that answecomponent summary score is composed of physical function, rohealth component summary score is composed of vitality, social

SF-36v2 category Pre-thinning (n Z 12

Physical function 64 � 24Role e physical 44 � 42Bodily pain 67 � 23General health 68 � 15Vitality 63 � 21Social function 63 � 26Role e emotional 59 � 45Mental health 70 � 22

Physical component summary 61 � 22Mental health component summary 64 � 26

*p Z 0.03 when compared to pre-thinning group.

Our study shows that delayed flap thinning using lipo-suction can lead to significant improvements in cosmeticoutcomes with patients reporting as being “not satisfied”preoperatively, being “very satisfied” postoperatively(p Z 0.0005). Furthermore, there is a significant improve-ment in matched physical component summary scores asassessed using the SF-36v2 questionnaire (p Z 0.01)following thinning. Our data looking at matched pre andpostoperative mental health component scores ina subgroup of nine patients showed no difference, sug-gesting that surgery does not alter the patients’ perceptionof their reconstruction (Table 3). It was interesting that themean mental health component score for the preoperativethinned group (64 � 26) was significantly lower (p Z 0.03)than that of the non-thinned group (86 � 15). This suggeststhe psychological status of patients choosing liposuction

red the questionnaire in each of the three groups. Physicalle e physical, bodily pain and general health scores. Mentalfunction, role e emotional and mental health scores.

) Post-thinning (n Z 19) No thinning (n Z 10)

76 � 23 76 � 2876 � 28 68 � 4179 � 21 83 � 1399 � 5 80 � 1468 � 22 83 � 1174 � 26 85 � 2183 � 20 90 � 3278 � 23 86 � 8

83 � 17 77 � 2276 � 19 86 � 15*

Figure 3 A 38 year old HIV and Hepatitis B positive male smoker underwent flap thinning in the standard manner. He gavea cosmetic score of 1 out of 5 for the preoperative appearance of his ALT flap (top left and right). Immediately postoperatively theappearance of the flap had improved (middle left and right). One week postoperatively partial flap necrosis of the proximal edgewas noted (bottom centre). This improved with simple dressings. Despite this complication he was “very satisfied” with theoutcome and gave a cosmetic score of 4 out of 5 once the flap had settled.

Outcomes of anterolateral thigh free flap thinning using liposuction 479

may have been worse than that of patients who weresatisfied with their reconstruction and did not choose flapthinning. Our study was not randomised as patients madetheir own decision on whether to undergo thinning. Thepsychological status of patients may have influenced theirdecision to undergo surgery in the thinned group whereasthose with higher mental health scores were better able toadjust psychologically to their reconstruction and thereforechose not to undergo further surgery. Interestingly,patients that chose not to undergo surgery were moresatisfied with the cosmetic appearance of their limbcompared to the preoperative thinning group (p Z 0.0038).However, after surgery the thinning group scores weresignificantly higher than the non-thinning group(p Z 0.004). This suggests that flap thinning does havea beneficial role in the cosmetic outcome of lower limbreconstruction.

It could be argued that the group who chose thinning hadbulkier flaps and hence were more in need of thinningprocedures. However, while we did not measure flapvolume we did record the BMI in a subgroup of patients.There was no statistical difference in the mean BMI

between the two groups, suggesting that body habitus maynot have contributed to flap bulk. A recent study has shownthat 27% of patients required aesthetic refinement proce-dures following lower limb reconstruction, 15 of whichunderwent liposuction.25 In our study 23 of 38 patientschose flap thinning. Interestingly, there was a similar maleto female ratio in each group, suggesting that gender didnot bias the desire for refinement.

Studies using liposuction to reduce lower limb ALT flapshave reported thinning between 3 months18 and 8 months25

following microvascular reconstruction. The mean timefollowing primary reconstruction to thinning in our studywas 14.5 months (range 7e29 months). The majority of ourpatients had tibial fractures (Gustilo grade IIIB) and ourpublished mean time to union for tibial shaft fractures is6.5 months.20 Furthermore, some patients require subse-quent additional orthopaedic procedures, which requirethe flap to be elevated.25 We, therefore, usually wait atleast 12 months following primary reconstruction to allowfor the fracture to have united and any additional ortho-paedic procedures to have been completed beforeproceeding to flap thinning. We had only one complication

Figure 4 Preoperative images of a large ALT flap in a 32 yearold female used to cover a distal third tibial fracture withtissue loss around the ankle and foot (top left and right).Following thinning in one stage she had marked improvementin function and her cosmetic score improved from 1 out of 5preoperatively to 4 out of 5 postoperatively (lower left andright).

480 E.P. Askouni et al.

of partial flap loss in our thinned group. This patient’ssurgery was performed in the standard manner but it ispossible that a combination of smoking and timing ofsurgery, at 8 months following reconstruction, may havecontributed to this complication.

The majority of patients required only one procedure inorder to achieve a result that was acceptable to them.Three of our patients required a second thinning procedurebefore they were satisfied. It is often considered that theprimary goal of liposuction is to improve cosmetic outcome.However, we have demonstrated that physical health canalso be improved. This is particularly pertinent for bulkyflaps around the ankle and foot as they can influence bothchoice of foot wear and ankle movement, which in turn caninfluence function (Figure 4).

Conflict of interest

None.

Funding

We are grateful for support from the NIHR BiomedicalResearch Centre funding scheme.

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