Reconstruction of two separate defects in the upper extremity using anterolateral thigh chimeric flap

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 10 Unsatisfied Yes satisfied

Yes No 8 Unsatisfied Yes 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


wileyonlinelibrary.com

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.



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.]




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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9. Ensat F, Babl M, Conz C, Rueth MJ, Greindl M, Fichtl B, HerzogG, Ussmueller J, Spies M. The efficacy of color duplex sonographyin preoperative assessment of anterolateral thigh flap. Microsurgery2012;32:605–610.

10. Chou EK, Ulusal B, Ulusal A, Wei FC, Lin CH, Tsao CK. Using thedescending branch of the lateral femoral circumflex vessel as a sourceof two independent flaps. Plast Reconstr Surg 2006;117:2059–2063.

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.



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Reconstruction of two separate defects in the upper extremity using anterolateral thigh chimeric flap