The role of the anterolateral thigh flap in complex defects of the scalp and cranium

THE ROLE OF THE ANTEROLATERAL THIGH FLAP IN COMPLEXDEFECTS OF THE SCALP AND CRANIUM

PAO-YUAN LIN, M.D.,1 ROS MIGUEL, M.D.,1 KHONG-YIK CHEW, M.B.B.S., M.R.C.S.,2 YUR-REN KUO, M.D., Ph.D., F.A.C.S.,1* and

JOHNSON CHIA-SHEN YANG, M.D.1

In this study, we introduced scalp reconstruction using free anterolateral thigh (ALT) flaps and evaluated postoperative outcomes in ninepatients between March 2000 and April 2012. Five patients had problems of exposed prosthesis, three required reconstruction after resec-tion of scalp tumor and one patient presented with third degree flame burns of the scalp. All flaps survived without re-exploration, exceptthree flaps with tip necrosis requiring secondary procedures of debridement and small Z-plasty reconstructions. The superficial temporalartery and its concomitant vein were used as recipient vessels, apart from two cases where previous surgery and flame burns excludedthese choices, for which facial arteries and veins were used instead. Primary closure of the donor-site was possible in six cases; with skingrafting performed for the other three patients. All donor sites healed without complications. The ALT flap offers the advantage of customiz-able size, option of fascia lata as vascularized dural replacement, and minimal flap atrophy typical of muscle flaps. Indications include verylarge defects, defects with exposed prosthesis, or defects with bone or dural loss. Our experience lends credible support to the use of cus-tomized free ALT flaps to achieve functional and cosmetically superior result for the reconstruction of large scalp defects, especially withbone exposure. VVC 2013 Wiley Periodicals, Inc. Microsurgery 34:14–19, 2014.

Free tissue transfer is often required for large complex

defects of the scalp including those with infection, radia-

tion damage, bone loss or prosthesis exposure.1–4 Although

the latissimus dorsi (LD) muscle or musculocutaneous free

flaps are acceptable alternative,2,5–10 the main disadvantage

is of the limited skin paddle, need for skin grafts and sig-

nificant atrophy of muscle, which lead to palpable or

exposed hardware. Alternatives such as the scapular flap,

rectus abdominis flap and radial forearm flaps have been

described but is limited to smaller sized defects.11–14

Song et al.15 first described the anterolateral thigh

(ALT) flap in 1984, based on the descending or trans-

verse branch of the circumflex femoral artery. It has

become a workhorse flap in many centers because of its

reliability and versatility. Koshima et al.16 first introduced

this flap for scalp defect reconstruction in 1993, and it

has since gained popularity owing to its ease of harvest

and versatility for defects of varying sizes. The ALT flap

has an added advantage of including the fascia lata as a

robust, vascularized dural replacement; effective in pre-

venting leakage of cerebrospinal fluid.17–19

Based on a large body of experience with the ALT

flap for reconstruction in head and neck cancer and ex-

tremity trauma in Kaohsiung Chang Gung Memorial Hos-

pital,20–22 we sought to assess the role of this flap in

large defects complicated with skull defect or exposed

prosthesis. A total of nine patients were identified during

the period under review with follow-up reaching 12

years.

PATIENTS AND METHODS

Information related to the patients’ data were gathered

from the medical records. Besides age and gender, rele-

vant history gathered include mechanism of injury, size

of defect and choice of recipient vessels. Outcome pa-

rameters such as complications, survival of flap, and sec-

ondary procedures performed were detailed and analyzed.

RESULTS

This retrospective review of cases performed at Kaoh-

siung Chang Gung Memorial Hospital from March 2000

to April 2012 identified a total of nine cases of scalp

reconstruction using ALT flaps. Most cases involved

male subjects, with one exception. All patients were

between 35 and 56 years of age with an average of 43

years. Five cases involved complications of exposed pros-

thesis or hardware following local flap coverage. Three

cases involved defects resulting from tumor resection,

consisting of dermatofibrosarcoma, low-grade fibromixoid

sarcoma and angiosarcoma respectively. One case suf-

fered from third degree flame burn to the scalp. The size

of scalp defects was ranged from 7 3 7 to 40 3 15 cm2.

Eight ALT flaps were harvested from the left thigh and

one from the right. The superficial temporal artery and its

concomitant veins were used as recipient vessels, except

for two cases where the facial vessels were used instead,

due to damage to the superficial temporal vessels. Of the

Pao-Yuan Lin and Ros Miguel are contribute equally to this work.

1Department of Plastic and Reconstructive Surgery, Kaohsiung Chang GungMemorial Hospital and Chang Gung University College of Medicine, Kaoh-siung, Taiwan2Department of Plastic, Reconstructive and Aesthetic Surgery, Kandang Ker-bau Women’s and Children’s Hospital, Singapore

*Correspondence to: Yur-Ren Kuo, M.D., Department of Plastic and Recon-structive Surgery, Kaohsiung Chung Gung Memorial Hospital, 123, Ta-PeiRoad, Niao-Sung District, Kaohsiung 833, Taiwan. E-mail:[email protected]

Received 3 January 2013; Revision accepted 5 February 2013; Accepted11 February 2013

Published online 2 May 2013 in Wiley Online Library (wileyonlinelibrary.com).DOI 10.1002/micr.22103

VVC 2013 Wiley Periodicals, Inc.

two cases, one had a previous cranioplasty procedure

resulting in damage to the superficial temporal vessels,

while the other case suffered from burn injury to the tem-

poral regions. The donor-site was closed primarily in six

cases, while split-thickness skin grafting was necessary in

three patients (Patients 2, 4, and 7), and all the donor

wounds healed without any complication.

In this series, all nine flaps remained viable without

major complication such as flap loss. The minor compli-

cations involved partial necrosis of the flap tip detected

on postoperative day 7 in Patients 4, 8, and 9, where the

area of necrosis was 1 3 1.5 cm2 on average. All cases

underwent debridement followed by correction with a

small Z-plasty. One patient developed a mild local infec-

tion, which resolved with antibiotics without requiring

additional procedures (patient 4). The length of follow-up

was from 8 months to 149 months. At the end of the

study period (April 2012), all but one patient survived

and all flaps remained viable. One patient expired due to

local recurrence of angiosarcoma, 4 months after chemo-

therapy and radiotherapy. Table 1 is a summary of all

nine patients’ data.

CASE REPORTS

Case 6

In July 2008, a 40-year-old male patient with a his-

tory of epilepsy presented with rupture of an intracranial

arterio-venous malformation in the temporoparietal lobe,

for which an emergent decompression craniectomy was

performed. Four months later, the patient underwent cra-

nioplasty using prosthesis for cranial vault resurfacing

and a local advancement scalp flap for coverage. Prosthe-

sis exposure developed subsequently and this problem

persisted despite another two advancement procedures in

the following year (Fig. 1). The patient was then referred

for scalp reconstruction, for which a free ALT flap was

used for the final defect, measuring 15 3 6 cm2 (Fig. 2).

Microvascular end-to-end anastomosis was performed to

the right superficial temporal artery and vena comitants

using 9-0 nylon, while the thigh donor-site was closed

primarily. At 1-month follow-up, the flap healed unevent-

fully, and the patient was discharged without complica-

tions (Fig. 3).

Case 8

This 36-year-old male was involved in multiple trau-

mas and suffered from head injury 10 years ago, during

which he underwent craniectomy followed by cranio-

plasty using prostheses. He presented in December of

Table 1. A Summary of Patients’ Data, Etiology, Recipient Vessel, Complication, and Secondary Procedure

No. Age/sex Etiology

Defect

size (cm2)

Recipient

vessel

Donor

site repair Complication

Second

procedure

1 36/M Head injury with exposed

prosthesis

13 3 8 STA P Nil Nil

2 56/M Angiosarcoma 13 3 10 STA S Recurrence of

angiosarcoma

Nil

3 35/M Dermatofibrosarcoma 7 3 7 STA P Nil Nil

4 43/F Head injury with exposed

prosthesis

10 3 10 STA S Local infection DebridementþZ-plastyPartial necrosis of

the flap tip

5 55/M Fibromixoid sarcoma 12 3 6 STA P Nil Nil

6 40/M Ruptured AVM with exposed

prosthesis

15 3 6 STA P Nil Nil

7 47/M Flame Burn 40 3 15 FA S Nil Nil


prosthesis

30 3 7 FA P Partial necrosis

of the flap tip

DebridementþZ-plasty


prosthesis

25 3 7 STA P Partial necrosis

of the flap tip

DebridementþZ-plasty

AVM: arteriovenous malformation, STA: superficial temporal artery, FA: facial artery, P: primary closure, S: split-thickness skin grafting.

Figure 1. Preoperative marking of a free anterolateral fasciocutane-

ous flap for the reconstruction of exposed prosthesis and scalp

defect. An incision at the right superficial temporal region is made

for recipient vessel dissection. [Color figure can be viewed in the

online issue, which is available at wileyonlinelibrary.com.]

Free ALT Flap for Scalp Reconstruction 15

Microsurgery DOI 10.1002/micr

2011 with an exposed and infected prosthesis at the left

temporoparietal area. Following excisional debridement

and removal of the prosthesis, a scalp defect measuring

30 3 7 cm2 was noted (Fig. 4). A free ALT flap was

performed via end-to-end anastomosis to the left facial

artery and vein. The left thigh donor site was closed pri-

marily. At 1 week, the distal flap tip developed necrosis

and required debridement of a 2.5 cm segment, followed

by a small Z-plasty to close the defect. Subsequent heal-

ing proceeded uneventfully at 1-year follow-up (Fig. 5).

DISCUSSION

For uncomplicated small- to moderate-sized defects,

local flap coverage is the best option for reconstruction,

typically involving a single or multiple transposition pro-

cedures depending on the defect size and location.23,24

However, local and regional flaps reach their limit when

defects extend beyond 200 cm2, especially when com-

pounded by complications such as infection, radiation

therapy, multiple prior surgeries and composite tissue and

bone loss. Although tissue expansion has been proven to

be successful for resurfacing large scalp defects, its role

is limited due to the requirement of prior planning,

patient compliance, and absence of infection. In complex

cases, only well-vascularized free-tissue transfer can meet

both structural and protective requirements, albeit result-

ing in a hairless reconstruction.4,25

The advent of reconstructive microsurgery has

allowed single stage, complete scalp reconstruction using

distant tissue, and can be performed at the time of tumor

extirpation. Consequently, numerous free flaps have been

described for scalp reconstruction, including free omen-

tum flap with skin graft,26,27 groin flap,1 LD muscle or

Figure 2. Debridement of scarred and necrotic tissue prior to flap

inset. [Color figure can be viewed in the online issue, which is avail-

able at wileyonlinelibrary.com.]

Figure 3. Final result at 1-month follow-up. The wound has healed

without complication. [Color figure can be viewed in the online

issue, which is available at wileyonlinelibrary.com.]

Figure 4. A scalp defect measuring 30 3 7 cm2 after excisional de-

bridement and with prosthesis removed. [Color figure can be

viewed in the online issue, which is available at wileyonlinelibrary.-

com.]

Figure 5. The wound has healed without any major complication at

1-year follow-up. [Color figure can be viewed in the online issue,

which is available at wileyonlinelibrary.com.]

16 Lin et al.


musculocutaneous flap,7–10 radial forearm flap,28–31 rectus

abdominis flap19 and ALT flap.16–18,32 The advantages

and disadvantages of free flaps used in the coverage of

scalp defects are listed in Table 2.

LD muscle or musculocutaneous flaps are good

options for scalp reconstruction thanks to its large surface

area, long vascular pedicle, and provision of reliable,

well-vascularized tissue.39,40 In the case of concomitant

chronic infection such as osteomyelitis, LD muscle flap

provides abundant vascularity to overcome this process.12

However, in the treatment of the infected calvarial

wound, no clinical study has yet proven the superiority of

muscle flaps over cutaneous flaps.41 Furthermore, muscle

atrophy can be significant after surgery, leading to con-

tour irregularities and depression of the scalp-flap junc-

tion. More seriously, palpable or exposed skull or hard-

ware can be a problem in the long run.24 Compared to

cutaneous flaps, skin grafts on muscle flaps are much less

pliable and have less resistance against abrasions and

shearing forces. Compared to fasciocutaneous flaps, the

reported revision rates for free myocutaneous flaps are as

high as 20–33%; in addition, potential problems such as

significant postoperative swelling, difficult muscle-to-skin

inset, and difficulty in estimating flap size may present

significant technical challenges.8,12

Chicarilli et al.28 first reported the use of the radial

forearm flap on the scalp in 1986. This flap has the ideal

feature of a thin and durable skin cover, and the advan-

tages of a long pedicle with large-caliber vessels, reliable

anatomy and uncomplicated dissection. However, the

main limitations of this flap are its size and its donor site

morbidity. For defects larger than 7 cm, or in elderly

patients with significant dermal atrophy or loss of elastic-

ity, use of the radial forearm flap is not recommended.31

To address the size limitation, Kobienia et al.29 intro-

duced pre-expansion of the radial forearm flap to double

the flap size. Unfortunately, this comes at the expense of

another surgery, painful injections, and risks of implant

extrusion, and is not applicable for cases with malignant

or rapidly growing tumors, which require surgery without

delay.

The ALT flap has a number of advantages, such as a

long pedicle with a suitable diameter for anastomosis and

a large skin paddle with acceptable donor-site morbidity.

In 1993, Koshima et al.16 first described the successful

use of an ALT flap for a large scalp defect in two cases.

Since then, the ALT flap has become one of the most

commonly used flaps for the reconstruction of scalp

defects. In many ways, the ALT flap can substitute a

number of commonly used conventional soft-tissue flaps.

Its thickness can be adjusted to suit defects of different

depth; the flap can be thinned by excising the deep fascia

and subcutaneous fat, or thickened by including a cuff of

the vastus lateralis muscle.42 In other words, the ALT

flap can be harvested as thinned skin, or a fasciocutane-

ous flap, myocutaneous flap, or chimeric flap to provide

the necessary volume to restore a natural scalp contour.

In 2004, Heller et al.17 reported the use of ALT fasciocu-

taneous flaps to provide different tissue components for

the repair of dura and scalp. The well-vascularized fascia

components of ALT flaps were used to successfully to

seal dural defects and overcome refractory infection in

the area. This concept was applied successfully in three

of our cases following extirpation of tumor involving the

scalp, bone and dura. Successful dural seal provided by

the fascia component in these cases prevented cerebrospi-

nal fluid leakage.

With regards to donor-site morbidity, Boca et al.20

concluded in his study that primary closure can be

expected when the maximum width of the ALT flap was

less than 16% of the thigh circumference, beyond which

split-thickness skin grafts should be used to assist in clo-

sure. Donor site analysis showed that primary closure

was preferred over skin graft wherever possible, as the

latter would limit the range of motion at the hip and

knee joint owing to adhesions between the skin graft and

underlying muscle.43

Cranioplasty is performed for both functional and aes-

thetic restoration of the cranial vault, the former being

protection of intracranial contents and the latter for resto-

ration of the natural head contour.44 However, the deci-

sion for cranioplasty can only be made after stabilization

Table 2. Advantages and Disadvantages of Free Flaps Used in the Coverage of Scalp Defects

Flap

Size

(cm2)

Pedicle

length (cm)

Ease of

dissection

Sensate

flap

Thickness

of flap

Skin graft

needed

Donor site

morbidity

Omentum33 25 3 35 4–5 þþþ 2 þ þ þþGroin34 20 3 30 2–5 þþþ 2 þþ 2 þLatissimus dorsi muscle35 20 3 40 Up to 15 þþþþ 2 þþþa þ þþþþRadial forearm36 8 3 15 Up to 10 þþþþ 2 þ 2 þþþþRectus abdominis muscle37 12 3 27 5–7 þþþþ 2 þþþa þ þþþþALT38 Up to 8 3 25c Up to 14 þþ þþ þþþb 2 þ

Score is varied from þ (slight) to þþþþ (significant). ALT: anterolateral thigh.aMuscle atrophy is expected up to 60% of the initial volume 1 year later.bThe flap can be thinned immediately.cThe skin paddle can be as large as 8 3 25 cm2 with primary closure.



of the patient and the intracranial pathology.45 Our expe-

rience with five patients in this series demonstrates this

basic principle, where patients underwent cranioplasty for

intracranial protection and restoration of calvarial contour

after resolution of head injury. These patients underwent

local flap coverage as the first line of treatment, as this rep-

resents the best option for reconstruction of scalp defects.

The ALT flap was used only when this option failed to

achieve its goal. Our patients invariably express dissatisfac-

tion to being socially handicapped, due to the unsightly

appearances of exposed hardware or prosthesis after wound

dehiscence or breakdown of the local scalp flap. Compared

to local flaps, the free ALT flap proved competent in expe-

dient coverage of these defects, had shorter recovery time

and minimized damage to remnant scalp.

Superficial temporal vessels are most commonly used

as recipient vessels in free flap reconstruction of a scalp

defect, not only because of their superficial location, but

also its proximity to scalp defects. Scalp defects com-

monly occur in the anterior scalp, and in particular the

frontal and temporal regions.18 In our series, the superfi-

cial temporal vessels were used in seven out of nine

patients. In cases where extensive trauma or radiotherapy

has damaged the superficial temporal vessels, the alterna-

tives for recipient vessels are the facial artery and veins.

When this is encountered, interposition grafts are always

necessary for flap vascularization.

Complications of using the ALT flaps in our series

were seen in a minority of cases where partial necrosis

of the flap tip necessitated secondary procedures of de-

bridement followed by a small Z-plasty. Possible causes

include a long and narrowed flap tip or disruption to

intraflap circulation from electrocautery during dissection.

Nevertheless, overall flap success was a hundred percent,

with neither serious complications such as cerebrospinal

fluid leak nor the need for secondary procedures for

debulking or scar revision. All patients recovered well

without major complication, although one patient expired

during the study period due to recurrence of malignancy

four months following adjuvant chemo- and radiotherapy.

CONCLUSION

The use of ALT flap for scalp and skull base recon-

struction has been well documented in the literature.46,47

Our experience also has shown the free ALT flap to be

more than a viable alternative for the reconstruction of

large scalp defects. In this case series, it has proven to be

a reliable, robust and versatile flap suitable for defects of

varying sizes, depth and complexity. Its advantage over

local flaps and other free flaps stem from the availability

of a large cutaneous component, multiple tissue types and

the ability to be tailored to the individual defect, allowing

it to fulfill both functional and aesthetic deficiencies

while offering less donor-site morbidity than competing

flaps. In cases of infected or exposed bone and hardware

following unsuccessful local flaps, the ALT flap has also

been shown to be useful in managing this difficult com-

plication. A unique quality of the ALT flap is the added

availability of a fascia layer for repair of the dura, even

in the presence of recalcitrant infection. Although not

seen in our series, possible secondary procedures may be

required for aesthetic reasons, such as flap debulking or

alopecia management. However, the limitation of small

series in this report has to be noticed. More scalp recon-

structions using ALT flaps should be performed to pro-

vide more detail outcome results.

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The role of the anterolateral thigh flap in complex defects of the scalp and cranium