The antero-lateral thigh (ALT) flap: a pragmaticapproach

Sir,The British Journal of Plastic Surgery has had adefining role in bringing the anterolateral thigh(ALT) flap to the plastic surgical community throughthe publication of Song et al.’s seminal paper in1984.1 Review of this paper, however, does give riseto some confusion regarding the vascular anatomyof this highly versatile flap. Song et al. describedthe cutaneous artery emerging from ‘the intermus-cular septum at a fixed point situated at thejunction of the middle and upper thirds of thethigh, where the rectus femoris muscle, vastuslateralis muscle and Fensor fasciae latae musclemeet.’

These surface markings are repeated in twopopular surgical atlases.2,3 This contrasts with theanatomical description in Cormack and Lamberty’sclassic work which places the usual position of thelargest perforator infero-lateral to the mid-point ofthe thigh.4

Iida et al.5 present a thoughtful study of the roleof the colour Doppler scanner in planning the ALTflap for head and neck reconstruction in adults.They suggest that the ALT flap is not widely usedbecause the flap elevation is often complicated andthe anatomy variable. Our approach to this flap hasbeen somewhat pragmatic.

We began by plotting perforators with the colourDoppler and with time and patience were able todetect multiple perforators (Fig. 1(A)) althoughthese did not always have a precise anatomicalcorrelation probably due to the size (,0.5 mmdiameter—Fig. 1(B)). Our standard procedure now isto use the conventional (Cormack and Lamberty)markings and with the hand held Doppler listen forperforators in the region of the intersection of thesurface markings of the intramuscular septum andthe descending branch of the lateral circumflexfemoral artery (LCFA). We do not plot all perfora-tors but aim for at least two (Fig. 2(A)). The processtakes around 5 min. If no perforator is found weexamine the contralateral thigh. Peri-operativelywe begin by making an incision on the medial aspectof the proposed flap and then extend this distallyover the line of the intramuscular septum. We thenlook for the intramuscular septum, a process aidedby observing the orientation of the muscle fibres.Having defined the septum we then explore thedepth of the septum and usually have to incise theaponeurotic condensation on the medial side overthe vastus lateralis to find the distal extent of thedescending branch of the LCFA. Finger dissection

sweeps the rectus medially and as we reach theinferior extent of the flap it is obvious, whether, wehave a septal or muscular arrangement of perfora-tors. The medial edge of the fascia, in the flap andoverlying the rectus femoris is picked up anddissected laterally. As Iida et al. describe, thisloose areolar tissue is dissected carefully as wesearch for a cutaneous perforator(s). The intramus-cular septum is then explored proximally with fingerdissection to expose the full extent of the descend-ing branch of the LCFA and the origin of perforatingvessels. We then begin to dissect out the perfora-tors either by the ‘open-cast’ technique (Fig. 2(B))or by tunnelling if the perforator is extremelylaterally positioned (Fig. 2(C)). This technique isquick and simple for the vast majority of flaps andthe question that has to be asked is whether theextensive pre-operative investigations are war-ranted on every case? We have decided it is not.

The anatomy is variable6 but we suspect that this

Fig. 1 (A) Multiple cutaneous perforators marked on theleg after an extensive investigation by the radiologistusing the Duplex scanner. (B) The type of perforatordifficult to detect. Four musculo-cutaneous vessels allwith diameter ,0.5 mm in an eight-year-old child.

Short reports and correspondence 837

does not deter surgeons from using the flap as Iidaet al. suggest. The flap was first described in theOrient and subsequently very large series have beenreported from Mainland,7 Taiwanese8 and Japa-nese6 centres. Recent small series have appearedfrom Western Centres describing breast reconstruc-tion from the USA,9 post-burn knee contracturesfrom Turkey10 and limb reconstruction fromFrance.11 Valdatta et al. have suggested thatthere may be anatomical differences to explainthe discrepancy in popularity of this flap betweenoriental and western populations.12

We suspect, however, that there are two otherfactors that have an important role in the pattern ofusage. The principle use in the Orient has been inthe field of Head and Neck reconstruction. This isbecause the characteristic Oriental donor site istypified by a paucity of subcutaneous fat and hair.The Western populations have a greater tendencytowards obesity and also hair growth (particularly inmales) on the antero-lateral thigh. It is of interestto note that whilst Professor Fu Chan Wei’s group atChung Gung now report well over a thousand ALTflaps13 just five have been used for breast recon-struction.14

In summary then, our impression is that mor-phology and hirsuitism rather than vascular anat-omy per se are responsible for the variation in use ofthe ALT flap. Our ‘pragmatic’ approach is predi-cated upon lean, hairless thighs but as thesubcutaneous fat increases so the versatility ofthe colour Doppler scan may become more relevantin pre-operative assessment.

References

1. Song YG, Chen GZ, Song YL. The free thigh flap: a new freeflap concept based on the septocutaneous artery. Br J PlastSurg 1984;37:149—59.

2. Strauch B, Yu HL, Chen ZW, Liebling R. Anterolateral thighflap. Atlas of microvascular surgery—anatomy and operativeapproaches. New York: Thieme Medical Publisher; 1993.p. 194—95.

3. Begue T, Masquelet AC. In: Strauch B, Vasconez LO, Hall-Findlay EJ, editors. Anterolateral thigh flap, 2nd ed.Grabb’s encyclopedia of flaps, vol. III. Philadelphia: Lippin-cott-Raven; 1998. p. 1872—4.

4. Lateral circumflex femoral artery—anterolateral thigh fas-ciocutaneous flap. In: Cormack GC, Lamberty BGH, editors.The arterial anatomy of skin flaps, 2nd ed. Edinburgh:Churchill Livingstone; 1994. p. 366—7.

5. Iida H, Ohashi I, Kishimoto S, et al. Preoperative assessmentof anterolateral thigh flap cutaneous perforators by colourDoppler flowmetry. Br J Plast Surg 2003;56:21—5.

6. Kimata Y, Uchiyama K, Ebihara S, et al. Anatomic variationsand technical problems of the anterolateral thigh flap: areport of 74 cases. Plast Reconstr Surg 1998;102:1517—23.

7. Luo S, Raffoul W, Luo J, Luo L, Gao J, Chen L, Egloff DV.

Fig. 2 (A) Two perforators marked in an adult after5 min with the hand held Doppler. (B) The ‘open-caste’technique with one short perforator. (C) The tunnellingtechnique. The flap is on the lower aspect of thedissection with traction being applied to the musculo-cutaneous perforator by the vascular sling. The perfora-tor is travelling diagonally into a long intra-musculartunnel and small deep muscular branches are now beingidentified and ligated.

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Anterolateral thigh flap: a review of 168 cases. Microsurgery1999;19:232—8.

8. Wei FC, Jain V, Celik N, et al. Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps.Plast Reconstr Surg 2002;109:2219—26.

9. Kaplan JL, Allen RJ, Guerra A, Sullivan SK. Anterolateralthigh flap for breast reconstruction: review of the literatureand case reports. J Reconstr Microsurg 2003;19:63—8.

10. Yildirim S, Avci G, Akan M, Misirlioglu A, Akoz T. Ante-rolateral thigh flap in the treatment of postburn flexioncontractures of the knee. Plast Reconstr Surg 2003;111:1630—7.

11. Stussi JD, Aboualtout Y, Beau P, Meley M. Anterolateral thighflap for limb reconstructive surgery: four case reports.Revue de Chirurgie Orthopedique et Reparatrice de lAppareil Moteur 2002;88:298—305.

12. Valdatta L, Tuinder S, Buoro M, Thione A, Faga A, Putz R.Lateral circumflex femoral arterial system and perforatorsof the anterolateral thigh flap: an anatomic study. Ann PlastSurg 2002;49:145—50.

13. Gedebou TM, Wei FC, Lin CH. Clinical experience of 1284free anterolateral thigh flaps. Handchirurgie, Mikrochirur-gie, Plastische Chirurgie 2002;34:239—44.

14. Wei FC, Suominen S, Cheng MH, Celik N, Lai YL. Anterolateralthigh flap for postmastectomy breast reconstruction. PlastReconstr Surg 2002;110:82—8.

Andrew Burd, Peter PangDivision of Plastic and Reconstructive Surgery,

Department of Surgery, Prince of Wales Hospital,The Chinese University of Hong Kong, Shatin,

Hong Kong, People’s Republic of China

doi:10.1016/j.bjps.2003.08.002

Is sacrifice a sacrosanct ritual?

Sir,The face can be envisioned as composed ofneighbouring geographic territories limited bynatural lines, folds, and changes in skin texture,as well as the hairline.1 Gospel dictates thatresurfacing the face should follow these facialaesthetic units. Millard emphasises the principle asfollows: ‘Do not cut a flap or graft to fit a randomdefect. Make the defect fit the natural aestheticunit and then fit the flap or graft to that unit.’2 Ihave been unswerving (unthinking) in keeping thefaith. In burn victims with involvement of one cheekand half the forehead, I have tended to flap theentire cheek unit and apply a thick skin graft to theentire forehead (Fig. 1), sacrificing the unscarredforehead at the altar of blind faith. The relativelyinferior aesthetic results of grafts compared to

flaps, in pigmented skin, has led me to question mydogmatic approach.

Recently I had occasion to wander. A 15-year-oldacid burn victim, with involvement of one half ofthe face and neck, underwent facial resurfacing.Deviating from my normal practice, I extended the

Fig. 1 Hyperpigmentaion of the skin grafted foreheadand the evident contrast between the forehead andcheek.

Fig. 2 Old acid burn injury to one half of the face andneck; appearance after multiple attempts at skin graftresurfacing.

Short reports and correspondence 839