RELIABLE OPTION FOR RECONSTRUCTION OF AMPUTATIONSTUMPS: THE FREE ANTEROLATERAL THIGH FLAP

SERKAN YILDIRIM, M.D.,* GAYE TAYLAN CALIKAPAN, M.D., and TAYFUN AKOZ, M.D.

The increased use of microsurgery has enabled reconstructive surgeons to deal with tissue defects of various sizes and compositions.The limited amount of qualified tissue for covering is the primary problem in stump reconstruction. Free flaps offer the ideal solution by pro-viding the optimal cover, and by preserving the length of the amputation site. Anterolateral thigh flaps were preferred for reconstruction oflower extremity amputation sites of nine patients admitted both in the subacute and chronic periods. All underwent previous stump recon-struction with local flaps in other clinics. Anterolateral thigh flaps avoided further shortening of the extremities, and provided stable tissuefor prosthesis use. The flap offers reliable soft-tissue reconstruction of amputation stumps. VVC 2006 Wiley-Liss, Inc. Microsurgery 26:386–390, 2006.

Though replantation of the proximal amputate is the first

plan in an emergency setting, preserving an adequate

length of the stump and a good functional recovery

should also be kept in mind when there is no chance for

extremity salvage.1 Durable and reliable amputation

stump coverage is required in order to increase the qual-

ity of life of a patient already debilitated due to a major

trauma. The options for soft-tissue reconstruction of an

amputation stump include using a flap from the ampu-

tated distal part, a local flap, or a free flap.1 Free flaps

are usually the primary choice in secondary procedures

when local tissues fail to provide adequate coverage. The

aims of amputation are preserving maximal length, and

provision of a sensate, durable, and cylindrical stump

which is pain-free.2 The anterolateral thigh flap was the

choice of flap in our limited series of stump reconstruc-

tions. This flap can be customized to individual needs in

terms of sensation, composition, and function.3 Both ten-

sor fascia lata and sensory nerves can be harvested at the

same donor site.4 We did not observe any complications

regarding flap viability or wound healing. All patients are

comforted with a reliable stump, which provided them a

qualified daily living with their prosthesis.

PATIENTS AND METHODS

Between 2002–2005, nine patients with lower extremity

amputations were operated upon for local infection and

unstable wound coverage. The mean age of patients was

33.3 (range, 17–48) years, and the female/male ratio was

2/7. The levels of amputations were the forefoot (2), below

the knee (4), and the distal tibia (3). All patients had

undergone surgery in other clinics on an emergency basis,

and local flaps were the choice for reconstruction. Two

patients with foot-level amputation had additional osteomy-

elitis, confirmed both radiologically and clinically. None of

the patients were comfortable with their prostheses, and

they complained about frequent wound occurrence requir-

ing dressing changes, which negatively affected their social

life. All patients insisted on length preservation, and free

flap transfers were planned. Anterolateral thigh flaps from

the same or the contralateral leg (6/3) were harvested. Flap

dimensions ranged between 7 3 10 and 11 3 15 cm. The

lateral femoral cutaneous nerves were included in the flaps.

Donor sites were primarily closed in three patients, and

skin-grafted in the rest. The mean hospitalization time was

15.6 (range, 11–17) days.

CASE REPORTS

Case 1

A 38-year-old man involved in a car accident under-

went amputation of his right foot from the distal tibia

level. Due to inevitability of the amputated parts to pro-

vide composite tissue, no salvage flaps were available,

and the amputation stump was reconstructed with local

flaps and primary suturation in another clinic. Four weeks

after the initial injury, he was admitted to our clinic with

a tissue defect in his amputation stump, with a progres-

sive increase in dimensions since then. He was unable to

use a prosthesis; nor he could go back to his daily activ-

ities. Radiological and clinical examinations revealed no

sign of osteomyelitis, and there was no exposed bone tis-

sue. A free tissue transfer was planned. An anterolateral

thigh flap from the contralateral thigh was harvested, pre-

serving the lateral femoral cutaneous nerve. The flap

dimensions were 8 3 15 cm. The donor site was skin-

grafted. The tibialis anterior and two concomitant veins

were used for anastomoses. The lateral femoral cutaneous

nerve was coapted to the peroneal nerve. Three months

after surgery, he was able to fit his prosthesis. He gained

Plastic, Reconstructive, and Aesthetic Surgery Clinic, Dr. Lutfi Kirdar KartalEducation and Research Hospital, Istanbul, Turkey

*Correspondence to: Serkan Yıldırım, Kozyatagı Mah., Sakacı Sok., Altıngeyi-kler Apt. 52/23, 34742 Kadıkoy, Istanbul, Turkey.E-mail: serk99@hotmail.com

Received 26 December 2005; Accepted 31 January 2006

Published online 16 June 2006 in Wiley InterScience (www.interscience.wiley.com). DOI 10.1002/micr.20256

VVC 2006 Wiley-Liss, Inc.

deep sensibility of the flap. A follow-up period of 3 years

called for no revisional surgery of the flap (Figs. 1, 2).

Case 2

A 48-year-old man sustained a left forefoot amputa-

tion due to a train injury. Coverage of the stump with

local injured tissue had resulted in a tissue defect, neces-

sitating reconstruction with good-quality tissue. He was

referred to our clinic in his third week of injury. The

stump was full of granulation tissue. An anterolateral

thigh flap from the contralateral thigh was planned for

transfer. A flap 10 3 15 cm was harvested, including the

lateral femoral cutaneous nerve. The anterior tibial artery

and concomitant vein were the recipient vessels. The do-

nor site was skin-grafted. Deep pressure and pain were

observed at the center of the flap. He felt fine touches at

the periphery of the flap. He was able to fit his prosthesis

4 months after surgery. A follow-up period of 3 years re-

vealed a healthy stump with no ulceration (Figs. 3, 4).

Case 3

A 17-year-old girl sustaining a right forefoot amputation

due to a train injury 2 years earlier was admitted to our clinic

for a nonhealing ulcer at the amputaton stump. Local tissue

had been used on an emergency basis for stump reconstruc-

tion. Radiological and clinical examination revealed osteomy-

elitis of the remanining tarsal bones. An anterolateral thigh

flap transfer and excision of the tarsal bones were planned.

Intraoperative debridement of the infected bony and soft tis-

sue, and placement of antibiotic regimens and soft-tissue re-

construction with an anterolateral thigh flap, were performed.

A flap 7 3 12 cm was harvested from the same extremity.

The donor site was skin-grafted. No sign of osteomyelitis was

observed clinically or radologically for 2 postoperative years.

Figure 1. Preoperative views of stump. [Color figure can be

viewed in online issue, which is available at www.interscience.wiley.

com.]

Figure 2. Early/late postoperative views. [Color figure can be

viewed in online issue, which is available at www.interscience.

wiley.com.]

Figure 3. Preoperative views of defect and perioperative anterolat-

eral thigh flap. [Color figure can be viewed in online issue, which is

available at www.interscience.wiley.com.]

Figure 4. Late postoperative views. [Color figure can be viewed

in online issue, which is available at www.interscience.wiley.

com.]

Amputations and Free Anterolateral Thigh Flaps 387

Microsurgery DOI 10.1002/micr

She feels light touches and pain in the flap-normal skin neigh-

borhood (Figs. 5, 6).

RESULTS

Local infection resolved in the two patients involved,

and no wound dehiscence occurred. All flaps survived.

The mean follow-up period was 2.4 years (range, 1–3 years).

Flap sensibility was assessed with two-point discrimination

and the Semmes-Weinstein monofilament system. All patients

recovered deep pressure, and only two felt light touches

and pain at the periphery of the flap. The patients are

comfortable with their prostheses, and none have required

reoperation so far (Table 1).

DISCUSSION

Amputation of a major limb is one of the most debili-

tating traumas. It is usually not very easy for patients to

deal with problems in their new life with a prosthesis. A

nonhealing wound creates further discomfort in the social

life to which they are adapting. The surgeon must offer

the best solution, with minimal morbidity.

Although secondary revisions of amputation stumps by

bone-shortening can be performed with unstable stump-heal-

ing, it should be kept in mind that the length of the extremity

matters in terms of prosthesis fitting and the psychological

health of the patient.5 Isik et al. reconstructed troublesome

amputation stumps in 4 patients with neurosensorial free

medial plantar flaps from unaffected feet without shortening.5

Gallico et al.6 used a variety of flaps for reconstruction

of below-knee amputation stumps to preserve a functional

prosthetic level, including latissimus dorsi myocutaneous

flaps, groin flaps, foot-fillet flaps, and latissimus dorsi mus-

cle flaps with skin grafts. They mentioned the importance

of a stable and functional knee joint after lower leg trauma

for the rehabilitation of the patient.6 The major problem

their patients developed in long-term follow-up was ulcera-

tion on or adjacent to flaps. We did not observe any ulcers,

though continuing follow-up may show these as well.

The ‘‘free fillet flap’’ is an established strategy that

allows the creation of flaps without additional donor-site

morbidity.7–10 However, the patient must be admitted in

the acute period, both for revascularization-replantation and

for spare-part transfer choices. All our patients were already

operated upon primarily by other clinics, and were in the sub-

acute or chronic period.

Erdmann et al. mentioned their preference for free flaps in

elective reconstructions of amputation stumps.7 Among the

flaps that have been transferred are scapular flaps, fillet flaps

from the amputated extremity, anterolateral thigh flaps, and

lateral arm flaps.7 They summarized the indications for micro-

surgical free flap transfers to amputation sites as follows:

� Microsurgical free flap transfer in emergency settings;

� Unstable tissue and/or localized soft-tissue infection; and

� Reconstrction after extensive tumor resection.7

Figure 5. Preoperative view of defect and elevated flap. [Color figure

can be viewed in online issue, which is available at www.interscience.

wiley.com.]

Figure 6. Early/late postoperative views. [Color figure can be viewed

in online issue, which is available at www.interscience.wiley.com.]

388 Yıldırım et al.

Microsurgery DOI 10.1002/micr

Kasabian et al. preferred the foot as first choice if

available. Otherwise, the parascapular free flap was their

donor site of choice.10

Tukiainen et al. used latissimus dorsi free flaps for

the reconstruction of amputation stumps to avoid further

amputation. The reconstructions were done in the acute

period, posttraumatic phase, and chronic period.1

Both latissimus dorsi and parascapular flaps necessi-

tate positional changes during flap harvest, which in turn

avoids simultaneous two-team work. Furthermore, flap thin-

ning is not an option for these flaps. While sensory branches

are divided during flap elevation, a sensory flap is not feasi-

ble for both flaps.

Ghali et al. preserved leg length with pedicled fillets

of foot flaps after traumatic amputations. When planned well,

the procedure avoids donor-site morbidity and microsurgery

as well.2

The anterolateral thigh flap can be used for reconstruction

of various defects. Among its advantages are; long and large-

caliber vascular pedicle, wide, reliable skin pedicle, elevation

as a sensory flap, different types of tissue composition (mus-

culocutaneous or fasciacutaneous), available for thinning

procedure, and permission for a two team work.11 Yıldırım

et al. demonstrated excellent functional and cosmetic results

with anterolateral thigh flaps used for soft-tissue reconstruc-

tion of various regions of the body.12 The anterolateral thigh

flap was postulated by Ozkan et al. as an ideal and versatile

flap for lower extremity reconstruction.13 Yıldırım et al.

mentioned the various advantages of the anterolateral thigh

flap for lower extremity reconstruction in its maximal recon-

structive capacity.14

The superior results of neural continuity as mentioned by

Arnez et al. encourage the use of sensorial flap transfers.15

The lateral femoral cutaneous nerves were included in the

flaps. All patients had deep-pressure sensibility, and two had

a moderate amount of protective sensation. No ulcers oc-

curred in a maximal follow-up period of 5 years.

The fascia component of the flap serves different re-

constructive purposes, as studied by Yıldırım et al.16 Sekido

et al. studied anterolateral thigh flaps for reconstruction

of large-sized defects at the weight-bearing plantar re-

gion. They demonstrated that the anterolateral thigh flap,

while providing adequate bulk and contour of the foot,

also withstands weight pressure and shearing force. It has

the ability to provide recovery of sensation.17 Though both

thighs were used as donor sites, our primary choice was the

same thigh, in order to protect the unviolated healthy thigh.

However, when this was not possible, we used the contralat-

eral thigh as the donor site.

The variations in the vascular anatomy of the flap is

compensated with the surgeon’s experience as this flap is

routinely used by our clinic.

Reconstructive requirements for amputation stumps are

variable, for that reason every stump reconstruction must be

handled individually by means of flap characteristics. While

forefoot amputations necessitate very thin flaps, below-knee

sites, dead spaces, or the existence of an infection may re-

quire bulky flaps with a muscle component. Anterolateral

thigh flaps enable both thin and thick flaps, with fascia and

muscle components added or excluded as required.

As a promising multipurpose flap, the anterolateral

thigh flap provides a durable and reliable cover for ampu-

tation stumps. It offers both soft tisssue and some amount

of sensation required for stump reconstruction. The ease

of dissection when it is frequently performed diminishes

the operative time and failure rate. Among various alter-

natives, we prefer the anterolateral thigh flap for elective

reconstruction of amputation stumps.

REFERENCES

1. Tukiainen EJ, Saray A, Kuokkanen HO, Asko-Seljavaara SL. Sal-vage of major amputation stumps of the lower extremity with latissi-mus dorsi free flaps. Scand J Plast Reconstr Surg Hand Surg 2002;36:85–90.

2. Ghali S, Haris PA, Khan U, Pearse M, Nanchahal J. Leg length pres-ervation with pedicled fillet of foot flaps after traumatic amputations.Plast Reconstr Surg 2005;115:498–505.

3. Lutz BS. Aesthetic and functional advantages of the anterolateralthigh flap in reconstruction of tumor-related scalp defects. Microsur-gery 2002;22:258–264.

4. Pribaz JJ, Orgill DP, Epstein MD, Sampson CE, Hergrueter CA.Anterolateral thigh flap. Ann Plast Surg 1995;34:585–592.

Table 1. Patients’ Characteristics

Patient

(years)

age/sex

Amputation

level

Follow-up

(years)

Hospitalzation

time (days)

Presence of

osteomyelitis Sensibility

Flap

dimensions

(cm)

38/M Distal tibia 3 12 No Deep pressure 8 3 15

48/M Forefoot 3 15 No Deep pressure 10 3 15

17/F Forefoot 2 21 Yes Light touch, pain 7 3 12

26/F Below knee 2 11 No Deep pressure 9 3 12

39/M Below knee 3 13 No Deep pressure 9 3 15

47/M Distal tibia 1 17 Yes Light touch, pain 7 3 11

31/M Below knee 3 15 No Deep pressure 8 3 13

33/M Below knee 3 14 No Deep pressure 7 3 13

21/M Distal tibia 2 13 No Deep pressure 10 3 14

Amputations and Free Anterolateral Thigh Flaps 389

Microsurgery DOI 10.1002/micr

5. Isik S, Guler MM, Selmanpakoglu N. Salvage of foot amputationstumps of chopart level by free medial plantar flap. Plast ReconstrSurg 1998;101:745–750.

6. Gallico GG III, Ehrlichman RJ, Jupiter J, May JW Jr. Free flaps topreserve below-knee amputation stumps: long-term evaluation. PlastReconstr Surg 1987;79:871–877.

7. Erdmann D, Sundin BM, Yasui K, Wong MS, Levin LS. Microsurgi-cal free flap transfer to amputation sites: indications and results. AnnPlast Surg 2002;48:167–172.

8. Chiang YC, Wei FC, Wang JW, Chen WS. Reconstruction ofbelow-knee stump using the salvaged foot fillet flap. Plast ReconstrSurg 1995;96:731–738.

9. Hammond DC, Matloub HS, Kadaz BB, Yousif NJ, Sanger JR, Lar-son DL. The free fillet flap for reconstruction of the upper extremity.Plast Reconstr Surg 1994;94:507–512.

10. Kasabian AK, Glat PM, Eidelman Y, Colen S, Longaker MT,Attinger C, Shaw W. Salvage of traumatic below-knee amputationstumps utilizing the fillet of foot free flap: critical evaluation of sixcases. Plast Reconstr Surg 1995;96:1145–1153.

11. Ozkan O, Coskunfirat OK, Ozgentas HE. An ideal and versatile ma-terial for spft-tissue coverage: experiences with most modifications

of the anterolateral thigh flap. J Reconstr Microsurg 2004;20:377–383.

12. Yıldırım S, Avci G, Akoz T. Soft-tissue reconstruction using a freeanterolateral thigh flap: experience with 28 patients. Ann Plast Surg2003;51:37–44.

13. Ozkan O, Coskunfirat OK, Ozgentas HE. The use of free anterolat-eral thigh flap for reconstructing soft tissue defects of the lowerextremities. Ann Plast Surg 2004;53:455–461.

14. Yıldırım S, Gideroglu K, Akoz T. Anterolateral thigh flap: ideal freeflap choice for lower extremity soft-tissue reconstruction. J ReconstrMicrosurg 2003;19:225–233.

15. Arnez ZM, Valdatta L, Sassoon E, Planinsek F, Ahcan U. Salvageof a below knee amputation stump with a free sensate total sole flappreserving continuity of the posterior tibial nerve. Br J Plast Surg1998;51:470–472.

16. Yıldırım S, Taylan G, Akoz T. Use of fascia component of the an-terolateral thigh flap for different reconstructive purposes. Ann PlastSurg 2005;55:479–484.

17. Sekido M, Yamamoto Y, Furukawa H, Sugihara T. Change ofweight-bearing pattern before and after plantar reconstruction withfree anterolateral thigh flap. Microsurgery 2004;24:289–292.

390 Yıldırım et al.

Microsurgery DOI 10.1002/micr