USING THE PROXIMAL PERFORATOR-BASED ANTEROLATERALTHIGH FLAP FROM THE SAME DONOR SITE TO SALVAGE THERECONSTRUCTION AFTER FAILURE OF THE DISTALPERFORATOR-BASED ANTEROLATERAL THIGH FLAP

KUN-HAN CHEN M.D., HAW-YEN CHIU M.D., Ph.D., JING-WEI LEE M.D., SHYH-JOU SHIEH M.D., Ph.D., and

YAO-CHOU LEE M.D.*

We presented a patient who experienced the anterolateral thigh (ALT) flap failure but the reconstruction was successfully salvaged by har-vesting a second ALT flap from the same donor site 2 days after the first reconstruction. A 47-year-old man received cancer ablation forright mouth floor squamous cell carcinoma. The resultant defect was planned to be reconstructed with the ALT flap. During the flap dis-section, we identified three proximal cutaneous perforators originating from the transverse branch of the lateral circumflex femoral artery(t-LCFA) and two distal cutaneous perforators originating from the descending branch (d-LCFA). We harvested a skin flap based on thedistal two perforators and divided the d-LCFA just distal to the bifurcation of the d-LCFA and the t-LCFA. Unfortunately, the ALT flapshowed venous congestion on postoperative day 2 and eventually failed. We harvested a second ALT flap from the same donor sitebased on the previously preserved perforators. The recovery course was smooth thereafter. We believe that the harvest of a secondALT flap from the same donor site may be an option, to avoid other donor site violation, in some patients who experienced the first flaploss. VC 2014 Wiley Periodicals, Inc. Microsurgery 34:409–412, 2014.

The anterolateral thigh (ALT) flap has been renowned

for a variety of advantages such as long pedicle length,

large caliber, versatility in volume and contents, and

minimal donor site morbidity since its first introduction

by Song et al. in 1984.1 The perforators of the ALT flap

were reported from the descending branch of the lateral

circumflex femoral artery (d-LCFA) in 67.6% and from

the transverse branch (t-LCFA) in 32.4%.2 Yu further

categorized the perforators of the ALT flap into perfora-

tor “A,” perforator “B,” and perforator “C” by defining

the “B” perforators located around the midpoint between

anterior superior iliac spine and superolateral patella, “A”

perforators about 5 cm proximal to the midpoint, and

“C” perforators about 5 cm distal to the midpoint.3 Clini-

cally, we usually can identify more than one perforators

originating from the same or different source vessels and

theoretically capable to harvest an ALT flap with multi-

ple skin paddles. Reconstruction of separate defects with

two or three skin paddles from one ALT donor site has

been reported to be a useful technique.4–9 Of those cases,

multiple skin flaps from one ALT donor site were always

harvested in a simultaneous fashion.

Herein, we presented a patient who experienced the

ALT flap failure but the reconstruction was successfully

salvaged by harvesting a second ALT flap from the same

donor site 2 days after the first reconstruction.

CASE REPORT

A 47-year-old man with diagnosis of right mouth

floor squamous cell carcinoma was presented. The result-

ant intraoral defect was 14 3 6 cm2 after cancer ablative

surgery. During the left ALT flap dissection, we identi-

fied five cutaneous perforators which included two “A”

perforators, one “B” perforator, and two “C” perforators.

We performed retrograde dissection to clarify the source

vessel of each perforator and found that the “A” and “B”

perforators were originated from the t-LCFA whereas the

“C” perforators were from the d-LCFA. We designed a

fasciocutaneous flap (14 cm 3 6 cm) based on these two

“C” perforators to reconstruct the intraoral defect (Fig.

1). The flap edges showed fresh bleeding before the pedi-

cle division. We divided the pedicle vessels just distal to

the bifurcation of the d-LCFA and the t-LCFA and a 19-

cm pedicle length was obtained. The “A” and “B” perfo-

rators and the t-LCFA were well preserved. The pedicle

artery and vein were anastomosed in an end-to-end fash-

ion with right superior thyroid artery and right external

jugular vein, respectively. The donor site was closed pri-

marily. Unfortunately, the flap showed venous congestion

on postoperative day 2. In the salvage operation, the flap

still showed poor capillary refill and diminished venous

backflow after thrombectomy and flap milking. There-

fore, we decided to harvest a second ALT flap from the

same donor site by using the previously preserved “A”

Division of Plastic and Reconstructive Surgery, Department of Surgery,National Cheng Kung University Hospital, College of Medicine, NationalCheng Kung University, Tainan, Taiwan.

*Correspondence to: Yao-Chou Lee, MD, Attending Plastic Surgeon, Divisionof Plastic and Reconstructive Surgery, Department of Surgery, NationalCheng Kung University Hospital, 138 Sheng-Li Rd., Tainan 70403, Taiwan.E-mail: yclee@mail.ncku.edu.tw

Received 15 July 2013; Revision accepted 2 January 2014; Accepted 6January 2014

Published online 18 January 2014 in Wiley Online Library(wileyonlinelibrary.com). DOI: 10.1002/micr.22227

� 2014 Wiley Periodicals, Inc.

and “B” perforators which were originated from the t-

LCFA (Fig. 2). A bulky skin flap in the size of 18 cm 3

7 cm with a pedicle length of 7 cm was obtained. The

bulkiness of this proximal perforator-based ALT flap was

reduced by immediate thinning procedure. The shortage

of the pedicle length was overcome by proximal de-

epithelialization of the skin paddle. The pedicle artery

was anastomosed to right superior thyroid artery in an

end-to-end fashion and the pedicle vein was anastomosed

with right internal jugular vein in an end-to-side fashion.

The donor site was closed primarily again. The patient

was discharged uneventfully after 21 days of hospitaliza-

tion. The follow-up 3 months later showed satisfactory

results (Fig. 3).

DISCUSSION

Simultaneous reconstruction of separate defects by

using multiple skin paddles from one ALT donor site has

been proved to be a feasible and effective method. Com-

plex pharyngoesophageal defects could be reconstructed

with a single ALT flap that was divided into two skin

islands based on separate cutaneous perforators: one for

esophageal reconstruction and the other for external neck

defect or as a monitor flap.4,5 Two independent flaps

from one single ALT flap donor site were also able to be

harvested to reconstruct two separate defects either on

the lower extremity or in the oral cavity.6,7 Peng et al.

successfully applied this technique to reconstruct two

separate defects in the upper extremity at the same time.8

Tripaddled ALT flap for simultaneous reconstruction of

bilateral buccal defects after buccal cancer ablation and

severe oral submucous fibrosis release was also success-

fully performed in a patient with three widely separated

perforators on the ALT donor site.9 All the aforemen-

tioned reports described that multiple skin flaps from one

ALT donor site could be simultaneously harvested if two

or more cutaneous perforators were available. In our

report, we showed that a second ALT flap may be har-

vested from the same donor site in a delayed fashion.

In our case, the ALT flap vascular anatomy showed

the presence of two proximal “A” perforators, one mid-

dle “B” perforator, and two distal “C” perforators. The

“A” and “B” perforators were originated from the t-

LCFA and the “C” perforators were originated from the

d-LCFA. It was feasible to harvest an ALT flap based on

the “A” and “B” perforators with the t-LCFA or the “C”

perforators with the d-LCFA. We decided to design an

Figure 1. A: Intraoral defect after cancer ablation. B: Perforator pattern of the left ALT donor site. The arrows indicated two proximal “A”

perforators and one middle “B” perforator originated from the t-LCFA, and two distal “C” perforators from the d-LCFA. Pedicle would be

divided at the level just distal to the bifurcation of the d-LCFA and the t-LCFA (arrowhead). C: Flap design. D: The raised flap was well

nourished by two “C” perforators. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]

410 Chen et al.

Microsurgery DOI 10.1002/micr

ALT flap based on the distal “C” perforators at the first

reconstructive surgery because the distal ALT flap was

thin and pliable to avoid disturbing tongue mobility.

Traditionally, we divide the pedicle vessels just distal

to the branch to the rectus femoris muscle to avoid the

complication of rectus femoris muscle necrosis and to

obtain a sufficient pedicle length and caliber.10,11 How-

ever, in this case, we intentionally divided the pedicle

more distally to preserve another three perforators origi-

nating from the t-LCFA. Although additional 2–3 cm

pedicle length can be obtained if we sacrificed the “A”

and “B” perforators originating from the t-LCFA, the

selection of “C” perforators originating from the d-LCFA

already allowed us to obtain a lengthy pedicle which was

19 cm in our case. Because the pedicle reached to the

recipient vessels without difficulty, we believed that the

shorter than usual pedicle by preservation of the “A” and

“B” perforators did not responsible for the flap loss in

Figure 2. A: The flap showed venous congestion on postoperative day 2. B: Surface marking of a second ALT flap from the same donor

site. C: Perforator pattern of a second ALT flap. The arrows indicated two proximal “A” perforators and one middle “B” perforator origi-

nated from the t-LCFA. D: Proximal de-epithelialization of the skin flap (shadow area) was performed to facilitate the pedicle vessel reach-

ing the recipient vessel. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]

Figure 3. The follow-up 3 months postoperatively showed (A) good flap survive and (B) minimal donor site morbidity. [Color figure can be

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

Harvest a Second Anterolateral Thigh Flap from the Same Donor Site 411

Microsurgery DOI 10.1002/micr

our case. Surprisingly, this decision allowed us to have a

second chance to harvest another ALT flap from the

same donor site after flap failure in this patient.

However, the proximal perforator-based ALT flap had

the disadvantages of bulkiness and short pedicle length.

In order not to violate other donor site, we still decided

to harvest the second ALT flap from the same donor site.

The flap bulkiness was reduced by immediate thinning

procedures. The drawback of short pedicle length was

overcome by harvesting a longer flap with proximal de-

epithelialization of the skin paddle to facilitate the pedi-

cle vessel reaching the recipient vessel.

We believe that this is the first case showing the har-

vest of a second ALT flap from the same donor site in a

delayed fashion in the scenario of first flap failure. By

doing this, additional donor site violation could be mini-

mized. However, it seems premature to recommend this

technique after just one case. In addition, the harvest of

a second ALT flap from the same donor site has some

limitations. First, if only single perforator could be iden-

tified in the ALT donor site, harvest of a second ALT

flap would be impossible. Second, if the defects required

a large ALT flap, harvest of another large flap from the

same donor site would be infeasible. Third, harvest of a

second flap based on another set of intentionally pre-

served vascular system in a delayed fashion may be diffi-

cult due to severe scarring. The harvest of a second ALT

flap from the same donor site in a delayed fashion should

take these into considerations in the circumstance of sal-

vage of reconstruction after failure of the first ALT flap.

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