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RECONSTRUCTION OF TWO SEPARATE DEFECTS IN THE UPPEREXTREMITY USING ANTEROLATERAL THIGH CHIMERIC FLAP
FENG PENG, M.D., Ph.D.,1,2,3 LIN CHEN, M.D.,1,2,3 DONG HAN, M.D.,1,2,3 CHENWEI XIAO, M.D.,1,2,3
QIYUAN BAO, M.D.,1,2,3 and TAO WANG, M.D.1,2,3*
We presented our experience on the use of anterolateral thigh (ALT) chimeric flap to reconstruct two separate defects in upper extremity.From December 2009 to August 2012, we used this ALT chimeric flap to reconstruct two separate defects in upper extremity on fivepatients (mean age: 36.6 years; range: 15�47 years). The locations of defect were palm and fingers in four patients and forearm in theother patient. The sizes of defect ranged from 4.5 3 1.5 cm to 20 3 10 cm. A minimum of two separate perforator vessels in the flapwere identified. The skin paddle was then split between the two perforators to shape two separate paddles with a common vascular sup-ply. There were no cases of flap failure or re-exploration. Four donor sites were directly closed and one was covered by a skin graft.Donor-site morbidity was negligible. The ALT chimeric flap provides customized cover for two separate defects in upper extremity.VC 2013 Wiley Periodicals, Inc. Microsurgery 33:631–637, 2013.
The anterolateral thigh (ALT) flap, as first described
by Song et al.,1 has emerged as one of the most pop-
ular reconstructive options for multiple body sites in
the last two decades. The use of flaps based on the
lateral circumflex femoral system to provide large
amounts of skin and varying combinations of tissue
for reconstruction of challenging defects has been well
documented.2–4
Based on a perforator flap harvest concept, the ALT
flap encompasses the advantages of versatility, pliability,
and potential for composite tissue replacement. A ALT
chimeric flap technique is to design the flap such that
each half of the skin paddle is supplied by a separate
skin perforator, both originating from the same source
vessel.3 The skin paddle can then be divided into two
between the perforators, allowing the two paddles to
reconstruct two closely aligned but separate or eccentri-
cally placed defects with only one vascular anastomosis.
Here, we describe our experience of the ALT chi-
meric flap to provide customized wound cover for two
separate defects in upper extremity.
PATIENTS AND METHODS
From December 2009 to August 2012, we have used
the ALT chimeric flap to successfully treat five patients
with two separate defects in upper extremity (Tables 1
and 2). There were four male and one female patients,
with a mean age of 36.6 years. The cause of the defects
was all trauma by machine crush. The sizes of defect
ranged from 4.5 3 1.5 cm to 20 3 10 cm. All wounds
had bone or tendon exposure.
Surgical Technique
The ALT chimeric flap was designed to have two
individual skin paddles supplied by two separate skin
perforators. Each perforator originated from the same
source vessel, most commonly being the descending
branch of the lateral circumflex femoral artery (LCFA).
When the two perforators were identified, the flap was
divided between the perforators into two skin paddles
and could be transferred to cover two defects. This
design allowed the ALT flap to be used for reconstruc-
tion of two separate defects with only one set of vascular
anastomosis.
The flap was marked with the patient supine. The
longitudinal axis of the flap based on a line joining the
anterior superior iliac spine and superolateral patella
approximates the underlying intermuscular septum
between the vastus lateralis and the rectus femoris. Color
Doppler ultrasonography was used preoperatively to
accurately identify the perforators. The area of the
defects was estimated, and a geometrical template was
made to help with the planning of the size of ALT flap
to be harvested. At least two perforators were identified
within the area of flap, which will eventually be split
into two skin paddles, with each separate paddle supplied
by a separate perforator.
To harvest the flap, the lateral border incision was
made down to or through the fascia covering the vastus
lateralis muscle, depending on the preferred plane of dis-
section. Then the flap elevated medially to the intermus-
cular septum between rectus femoris and vastus lateralis,
until at least two perforators supplying the skin paddle
were identified.
1Department of Hand Surgery, Huashan Hospital, Fudan University, Shang-hai, China2Key Laboratory of Hand Reconstruction, Ministry of Health, Shanghai,China3Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
*Correspondence to: Tao Wang, M.D. E-mail: [email protected]
Received 13 April 2013; Revision accepted 14 July 2013; Accepted 17 July2013
Published online 23 September 2013 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22170
� 2013 Wiley Periodicals, Inc.
The dissection was continued to identify perforating
branches of the descending or transverse lateral circum-
flex femoral vessels in their intramuscular or intraseptal
courses. Dissection of the selected perforators proceeds
in a retrograde fashion to connect with the source vessel
in the intermuscular septum. If the flap was raised in the
suprafascial plane, a small fascial cuff should be left
around each perforator to decrease the risk of damage to
the perforators.
Having dissected out the perforators and the common
source vessel (LCFA), the paddle was split into two
while still perfused.
The motor nerve to the quadriceps runs superolater-
ally with the main pedicle and was preserved during per-
forator dissection. If the motor nerve ran between two
perforators, the motor nerve could be preserved after the
flap was split into two.
The donor site was closed directly when the width of
the ALT flap was less than 8 cm. If the flap width was
more than 8 cm, a skin graft should be used to avoid
compartment syndrome.
RESULTS
All flaps were successfully performed and the postop-
erative course was uneventful. There were no cases of
flap failure or re-exploration. The mean length of the per-
forator was 8.55 cm (range, 6–11 cm). The mean length
of the combined pedicle was 5.5 cm (range, 2–10
cm).Four donor sites were directly closed and one was
covered by a skin graft. Donor-site morbidity was negli-
gible (Tables 1 and 2).
The follow-up time was from 6 months to 36 months
(mean 18 months). The appearance of flaps and function
of repaired finger or hand were satisfied in three patients
(Tables 1 and 2). The other two patients received sec-
ondly flap debulking.
CASE REPORTS
Case 1
A 15-year-old male was referred to our department
with two soft tissue defects over dorsum of index finger
Table 2. Patient Summaries (Extended)
Flap survival
Complications
including
donor site
Follow-up
Time (months)
Appearance of
flaps
Secondly operation
for flap debulking
Functional
recovery
Yes No 36 Satisfied No satisfied
Yes No 30 Satisfied No satisfied
Yes No 10 Unsatisfied Yes satisfied
Yes No 8 Unsatisfied Yes satisfied
Yes No 6 Satisfied No satisfied
Table 1. Patient Summaries
Patient
No.
Gender
(Age)
Mechanism
of injury
Defect
location
Defect Size
(length 3 width;
cm)
Perforator
1 length
(cm)
Perforator
2 length
(cm)
Combined
pedicle
length
(cm)
Donor site
closure
Intraoperative
flap
debulking
1 Male
(38 years)
Machine
crush
Dorsum of
middle
finger and
ring finger
4.5 3 1.5 and
6 3 2
7 9 2 Closed
directly
Yes
2 Male
(44 years)
Machine
crush
Palm of index
finger and
ulnar side of
hand palm
3 3 5 and 4 3 7 8 10.5 3 Closed
directly
Yes
3 Male
(39 years)
Machine
crush
Palm of
forearm and
ulnar side
of forearm
11 3 7 and
13 3 6
7 11 10 Closed
directly
No
4 Female
(47 years)
Machine
crush
Palm of Hand
stump
20 3 10 and
12 3 10
7 10 8 Skin graft Yes
5 Male
(15 years)
Machine
crush
Dorsum of index
finger and
middle finger
5.5 3 2.5 and
5 3 2.5
6 10 4.5 Closed
directly
Yes
Average 36.6 8.55 5.5
632 Peng et al.
Microsurgery DOI 10.1002/micr
Figure 1. Case 1. A: The perforators were identified preoperatively by color Doppler ultrasonography (Arrow: the points of perforators
identified). B: A right ALT flap was harvested with two perforators identified as arising from the descending branch of LCFA. C: The skin
paddle was split into two while still perfused. D: The arterial anastomosis was performed onto a branch of the radial artery. E: Flap inset
after anastomoses were completed. F and G: The postoperative results after 6 months. [Color figure can be viewed in the online issue,
which is available at wileyonlinelibrary.com.]
Anterolateral Thigh Chimeric Flap 633
Microsurgery DOI 10.1002/micr
and middle finger of 5.5 cm 3 2.5 cm and 5 cm 3 2.5
cm respectively 1 month after a crush injury of left hand
by machine accident. Extensor tendons were exposed in
the wounds. A right suprafascial ALT flap was harvested
with two perforators identified as arising from the
descending branch of LCFA (Figs. 1A and 1B). The skin
paddle was then divided between the two perforators
(Fig. 1C). The one skin paddle was 5.5 cm 3 3.5 cm,
and the other was 6.5 cm 3 3.5 cm. The arterial anasto-
mosis was performed end to end onto a branch of the
radial artery (Figs. 1D and 1E). The donor site was
directly closed. After 6 months’ follow-up, he was satis-
fied with the appearance of flaps and the ROM of the
two fingers was recovered to normal. The postoperative
results are shown in Figures 1F and 1G.
Case 2
A 39-year-old male worker involved in a machine
accident sustained a injury to right forearm, resulting in
an irregular wound on the palm and ulnar side of fore-
arm which could be divided into two defects (11 3 7 cm
and 13 3 6 cm) with no associated fractures. An ALT
flap was raised from the left thigh, perforators were iden-
tified and both were dissected back to the descending
branch of LCFA in a retrograde fashion. (Fig. 2A) The
perforator vessels and flap were lifted free from the
underlying fascia, and the skin paddle was divided into
two obliquely to suit the two defects (Figs. 2B and 2C).
In this case, the vascular anastomosis was performed end
to end onto a branch of humeral artery. The donor site
was closed directly. The flap survived in its entirety
without any major complications. The patient was unsa-
tisfied with the appearance of flaps and received secondly
flap debulking after 4 months. The last follow-up time
was 10 months. The functional recovery of hand was
satisfied. The postoperative result is shown in Figure 2D.
Case 3
A 38-year-old male sustained a hand crush injury of
left middle finger and ring finger while worked with
machine, and he was referred to our department with two
soft tissue defects over dorsum of left middle finger and
Figure 2. Case 2. A: The two perforators were identified and both were dissected back to the descending branch of LCFA. B: The skin
paddle was divided into two to cover different defects. C: Flap inset after anastomoses were completed. D: The postoperative result after
10 months. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
634 Peng et al.
Microsurgery DOI 10.1002/micr
ring finger of 4.5 3 1.5 cm and 6 3 2 cm, respectively
(Fig. 3A). A right suprafascial ALT flap was harvested
with two musculocutaneous perforators identified as aris-
ing from the descending branch of LCFA (Fig. 3B). The
skin paddle was then divided between the two perforators
(Fig. 3C). The arterial anastomosis was performed end to
end onto the radial digital artery of ring finger (Fig. 3D).
The donor site was directly closed. After 36 months’
follow-up, he was satisfied with the appearance of flaps.
The ROM of the left middle finger and ring finger was
recovered as same as the right side. The postoperative
result was shown in Figures 3E and 3F.
DISCUSSION
Since its first description by Song et al. in 1984,1 the
ALT flap has evolved as one of the most versatile perfo-
rator flaps. The versatility of the ALT flap hinges on the
Figure 3. Case 3. A: The defects on dorsum of middle finger and ring finger before coverage. B: The flap was harvested based on two
perforators. C: The skin paddle was divided between the two perforators. D: Flap inset after anastomoses were completed. E and F: The
postoperative results after 36 months. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
Anterolateral Thigh Chimeric Flap 635
Microsurgery DOI 10.1002/micr
ability to harvest multiple tissue components in various
combinations; the reliable size and position of the perfo-
rators supplying the large skin paddle; and the long,
wide-caliber pedicle.3 In our department, it is the work-
horse flap for reconstruction of complex defects of the
upper or lower extremity.
The recently acquired perforator flap concept will grad-
ually become the most popular method of microsurgical
reconstruction, as it minimizes donor-site morbidity and
replaces “like tissue with like tissue.”4 Based on this con-
cept, if more than one perforator is available, the skin flap
can be separated in smaller skin flaps, each one of them
based on one perforator. This ALT chimeric flap design is
a modification of the classic ALT flap which increases the
applications of the flap for use in reconstruction of two
closely aligned but separate or eccentrically placed defects
with only one set of vascular anastomosis.
Marsh et al. described their ALT chimeric flap design
technique which allows the ALT flap to be used for
reconstruction of very large defects whilst maintaining
direct closure of the donor site, providing improved aes-
thetic and functional outcomes at both the donor and
recipient sites.5 Lin et al. introduced their experience on
reconstruction of extensive head and neck defects with
ALT chimeric flap in four patients.6 Lai et al. suggested
that the chimeric ALT flap was excellent for reconstruc-
tion with two independent perforators to cover both sides
of the buccal mucosa and lips defect and reported a case
using this technique.7 Tan et al. also described their case
series with advanced hypopharyngeal cancer and anterior
neck skin invasion, which received an ALT chimeric flap
for composite inner pharyngeal and outer skin defect
reconstruction after wide composite resection.8
Our experience also proved this technique would help
reconstruct two separate defects in the upper extremity at
the same time.
Based on the observations made in our group of
patients, the mean perforator length was 8.55 cm. That
means if the distance of two separate defects was less
than 16 cm, the defects theoretically could be covered by
the ALT chimeric flap. It could meet most of the needs
for this kind of patients.
Careful preoperative planning and identification of
perforators remain the cornerstone of successful flap har-
vest. We preferred color Doppler ultrasonography is used
preoperatively to accurately identify the perforators.
Color Doppler ultrasonography is a highly reliable tool
in the preoperative assessment of ALT flaps. Localization
and course of perforators can be determined accurately
and vascular anomalies can be identified.9 Once perfora-
tors are identified, variations in skin paddle design allow
for multiple skin paddle configurations, central or eccen-
tric orientations, and custom-made flaps tailored to fit
almost any defect.10,11
A disadvantage of the ALT chimeric flap design tech-
nique is that this technique is skill demanded. The course
of perforators may be unpredictable, and the small and
long perforators may be difficult to harvest and inset. The
microsurgeon needs to have superior microsurgical skills
and be familiar with perforator flaps and intramuscular per-
forator dissection before he or she attempts this flap.
Another limitation of this technique is intraoperative
flap debulking should be more cautious compared with
that for conventional flaps.12 Primary debulking, in which
the flap is thinned before ligation of the pedicle, should
be performed under microscope guidance to decrease the
risk of pedicle injury, but the area where the pedicle
enters the flap must be safeguarded.13 Our experience is
the area (2 3 2 cm) where the pedicle enters the flap
must be protected. Despite the proven reliability of
thinned flaps, including the outcomes in our patients, the
procedure has proven controversial, with reports of par-
tial or total flap loss following primary debulking.14
We did limited primary flap debulking in four
patients, whose defects locations were palm or digits.
The appearance of flaps was satisfied in three patients
and the other one still need secondly flap debulking.
Having two skin paddles also increases the risk of
kinking or twisting the vascular pedicle; so it is advised
that maximal care is taken on the flap inset to minimize
this potential complication.5
In summary, the ALT chimeric flap design allows the
flap to be used for reconstruction of two separate defects
in the upper extremity at the same time.
REFERENCES
1. Song YG, Chen GZ, Song YL. The free thigh flap: A new free flapconcept based on the septocutaneous artery. Br J Plast Surg 1984;37:149–159.
2. Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin CH. Have wefound an ideal soft-tissue flap? An experience with 672 anterolateralthigh flaps. Plast Reconstr Surg 2002;109:2219–2226; discussion2227–2230.
3. Ali RS, Bluebond-Langner R, Rodriguez ED, Cheng MH. The versa-tility of the anterolateral thigh flap. Plast Reconstr Surg 2009;124(6 Suppl):e395–e407.
4. Spyropoulou A, Jeng SF. Microsurgical coverage reconstruction inupper and lower extremities. Semin Plast Surg 2010;24:34–42.
5. Marsh DJ, Chana JS. Reconstruction of very large defects: A novelapplication of the double skin paddle anterolateral thigh flap designprovides for primary donor-site closure. J Plast Reconstr AesthetSurg 2010;63:120–125.
6. Lin PY, Chen CC, Kuo YR, Jeng SF. Simultaneous reconstructionof head and neck defects following tumor resection and trismusrelease with a single anterolateral thigh donor site utilizing a lateralapproach to flap harvest. Microsurgery 2012;32:289–295.
7. Lai CL, Ou KW, Chiu WK, Chen SG, Chen TM, Li HP, Chang SC.Reconstruction of the complete loss of upper and lower lips with achimeric anterolateral thigh flap: A case report. Microsurgery 2012;32:60–63.
8. Tan NC, Yeh MC, Shih HS, Nebres RP, Yang JC, Kuo YR. Singlefree anterolateral thigh flap for simultaneous reconstruction of com-posite hypopharyngeal and external neck skin defect after head andneck cancer ablation. Microsurgery 2011;31:524–528.
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11. Caulfield RH, Maleki-Tabrizi A, Birch J, Ramakrishnan V. Salvageof finger length in septicemic necrosis using 3 free flaps from a sin-gle anterolateral thigh donor site. Ann Plast Surg 2008;60:623–625.
12. Chang CC, Wong CH, Wei FC. Free-style free flap.Injury 2008;39(Suppl 3):S57–S61.
13. Nojima K, Brown SA, Acikel C, Arbique G, Ozturk S, Chao J,Kurihara K, Rohrich RJ. Defining vascular supply and territoryof thinned perforator flaps: Part I. Anterolateral thigh perfora-tor flap. Plast Reconstr Surg 2005;116:182–193.
14. Ross GL, Dunn R, Kirkpatrick J, Koshy CE, Alkureishi LW,Bennett N, Soutar DS, Camilleri IG. To thin or not to thin: The useof the anterolateral thigh flap in the reconstruction of intraoraldefects. Br J Plast Surg 2003;56:409–413.
Anterolateral Thigh Chimeric Flap 637
Microsurgery DOI 10.1002/micr