Journal of Plastic, Reconstructive & Aesthetic Surgery (2012) 65, 525e526

CASE REPORT

Split anterolateral thigh (ALT) free flap for vulvareconstruction: A case report

G. Filobbos*, T. Chapman, U. Khan

Department of Plastic Surgery, North Bristol NHS Trust, Frenchay Hospital, Bristol, United Kingdom

Received 5 August 2011; accepted 7 August 2011

KEYWORDSAnterolateral thigh flap;ALT flap;Vulva reconstruction;Split ALT flap

* Corresponding author. Tel.: þ44 75E-mail address: gfilobbos@yahoo.c

1748-6815/$-seefrontmatterª2011Bridoi:10.1016/j.bjps.2011.08.019

Summary The anterolateral thigh (ALT) flap is a popular reconstructive choice due to itsversatility and minimal donor site morbidity. It has been used in the reconstruction of perinealand vulval defects as a pedicled or free flap. We describe, for the first time, use of a split ALTflap to reconstruct a vulval defect following excision for recurrent tumour. Splitting the ALTincreases the versatility yet further without compromising flap vascularity.ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published byElsevier Ltd. All rights reserved.

Introduction

The anterolateral thigh (ALT) flap is a popular reconstruc-tive choice due to its versatility and minimal donor sitemorbidity.1 It has been used in the reconstruction of peri-neal and vulval defects as a pedicled2 or free flap.3 Wedescribe, for the first time, use of a split ALT flap toreconstruct a vulval defect following excision for recurrenttumour. Splitting the ALT increases the versatility yetfurther without compromising flap vascularity.

Case report

An 87-year-old lady developed local recurrence of a vulvalsquamous cell carcinoma managed by further excision and

45784921.om (G. Filobbos).

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radiotherapy, one year after her initial presentation andsurgery. Complete excision of the aggressive recurrencenecessitated total vulvectomy and pelvic exenteration. Theresultant defect was reconstructed with a free ALT flapanastomosed to the superficial femoral artery and saphe-nous vein. The ALT flap was designed as an eccentric ellipsearound the perforator and it was split longitudinally fora third of its length on the side furthest from the perforatorentry (Figure 1). The patient had an uneventful recoverywith a satisfactory cosmetic and functional outcome(Figure 2).

Discussion

Vulval defects have been traditionally reconstructed withlocal or regional flaps4 but these flaps stand a higher inci-dence of delayed wound healing especially in patients whoreceived radiotherapy.4 Use of pedicled flaps based on thedeep inferior epigastric artery may be limited by bulk due

tiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.

Figure 1 Diagram showing the split ALT flap.

Figure 2 Post operative view.

526 G. Filobbos et al.

to the thickness of subcutaneous fat, and a tendency toundergo fat necrosis.5 Therefore the free ALT flap repre-sents a good alternative for well vascularised flap recon-struction of these defects with matching contour.

Reconstruction of large, bilateral vulvar defects witha single flap can be challenging. Therefore Zeng et al.(2011) describe the techniques of either fenestrating theALT flap or splitting it based on separate perforators.3 Inthat report, the fenestrated ALT flap was based on oneperforator and was less reliable than a split ALT flap based

on 2 (or more) perforators. The limitation to this techniqueis that it requires the presence and dissection of at least 2perforators which is not always feasible.

The technique of splitting the ALT flap we present,onthe other hand, can be safely done based on one perforatorby applying the perforasome theory of the ALT flap whichdemonstrated,using computerised tomographic angiog-raphy, that the ALT flap is safely and adequately suppliedby one perforator.6 To the best of our knowledge thistechnique has not been described before in perinealreconstruction. Splitting an ALT based on one perforatorhas been safely described, but only in total upper and lowereyelid reconstruction.7

In 2010 Zhang et al.1 studied the anatomy of ALT flaps inten cadavers and reported that the three-dimensionalvascular structure of the ALT flap resembles a tree, inthat the nutrient vessels arborise in each layer. Thebranching vessels connect with each other across thesuprafascial and subdermal plexus. Therefore, based ontheir study, we believe that this technique of splitting theALT flap is anatomically safe.

Conclusion

The described technique in this case report of splitting theALT flap for vulval reconstruction is safe, and is yet anotherway to increase the versatility of the ALT flap. As well as inperineal reconstruction, this technique may be useful in thereconstruction of other defects.

Conflict of interest/funding

None.

References

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3. Zeng A, Qiao Q, Zhao R, Song K, Long X. Anterolateral thigh flap-based reconstruction for oncologic vulvar defects. PlastReconstr Surg United States; 2011:1939e45.

4. Weikel W, Schmidt M, Steiner E, Knapstein P-G, Koelbl H.Reconstructive plastic surgery in the treatment of vulvarcarcinomas. Eur J Obstetrics, Gynecol Reprod Biol 2008;136(1):102e9.

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