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DORSAL FOOT RESURFACING USING FREE ANTEROLATERALTHIGH (ALT) FLAP IN CHILDREN

TAREK A. EL-GAMMAL, M.D.,1* AMR EL-SAYED, M.D.,1 MOHAMED M. KOTB, M.D.,1 WALEED RIAD SALEH, M.D.,1

YASSER FAROUK RAGHEB, M.D.,1 OMAR EL-REFAI, M.D.,1 and MOHAMMED HASSAN ALI EL FAHAR, M.D.2

Very limited literature described the use of the free anterolateral thigh (ALT) among other flaps for pediatric lower limb reconstruction. Theaim of this study is to present our experience using the free ALT flap for reconstruction of soft tissue defects over the dorsum of the footand ankle in children. The study included 42 children aged 2.5–13 years with a mean of 6.18 years. Three children had crush injuries whilethe rest were victims of run over car accidents. All of the flaps were vascularized by at least two perforators; 88.23% were musculocutane-ous and 11.77 were septocutaneous perforators. All flaps were raised in a subfascial plane. Initial thinning was performed in five flaps and35% required subsequent debulking. Mean Flap surface area was 117.11 cm2. The recipient arteries were the anterior tibial artery in 38cases and posterior tibial artery in four cases. Venous anastomosis was performed to one vena commitant and in nine cases the longsaphenous vein was additionally used. Mean ischemia time of the flap was 2 hours while total operative time averaged 6.3 hours. About41% of donor sites were closed primarily while 59% required skin grafting. Primary flap survival rate was 92.8% (39/42 cases). Three flapsshowed venous congestion. After venous reanastomosis, two flaps showed partial loss and one flap was lost completely. Post-operativehospital stay averaged 7.5 days. The free ALT flap could be as safe, reliable, and aesthetically appealing option for foot/ankle resurfacingin children after traumatic soft tissue loss. VVC 2012 Wiley Periodicals, Inc. Microsurgery 33:259–264, 2013.

The anterolateral thigh (ALT) flap was first described by

Song et al.1 In the last three decades, the ALT flap has

gained popularity as a versatile and reliable option for

soft tissue reconstruction. The possibilities of transferring

large skin paddles and different tissue types on a large

and long pedicle, potential for thinning, reinnervation,

flow through revascularization and coverage of the

extremities, with minimal donor-site morbidity are some

of the reasons which have led to the success of this flap.2

Microvascular free tissue transfer has been shown to

be safe and reliable in adults and in children with success

rates >90%.3 Free-flap reconstruction of post-traumatic

tissue defects in children need to be planned carefully

with regards to the specific pediatric anatomy. Also, the

evolution of children’s tissue and skeletal structures need

to be taken into account. Apart from surgical considera-

tions, psychosocial ramifications, and discomfort of pro-

longed disability at a young age have to be kept in

mind.4

This article presents our clinical experience using the

free ALT flap for reconstruction of soft tissue defects

over the foot and around the ankle in children.

PATIENTS AND METHODS

From January 2005 to December 2010, 42 children

received free ALT flap for coverage of large and exten-

sive soft tissue defects over the dorsum of the foot and

ankle exposing the extensor tendons and/or metatarsals

with or without associated fractures of the metatarsals or

ankle or open joints. Small defects eligible for local or

pedicle skin flaps and defects associated with plantar loss

or bone loss requiring bone grafts were excluded.

Hospital records were reviewed and data were col-

lected regarding patients’ demographics, type of trauma,

timing of microsurgical reconstruction, flap dimensions,

operative time, number, and type of perforators, donor-

site closure, postoperative course and complications. The

age of the children ranged between 2.5 and 13 years

(mean age, 6.18 6 2.54 years). There were 10 females

and 32 males. All children had post-traumatic skin and

soft tissue loss over foot and around the ankle (Table 1).

Three children had crush injuries while the rest were

victims of run over car accidents. The left foot was

involved in 55.9% of the cases and the right in 44.1%.

All patients underwent reconstruction >72 hours after

trauma within a mean of 15.8 6 2.54 days.

Initial Management

All wounds were debrided thoroughly. Bone fixation

was done at the time of initial debridement. Additional

reconstructive procedures were done at the time of ALT

flap transfer. Bone fixation was done using k-wires and

foot was supported in a posterior slab. Daily closed

wound dressing was done using conventional paraffin

gauze and antibiotic ointment. No vacuum assisted

closure VAC was used. All wounds were followed up by

1Reconstructive Microsurgery Unit, Assiut University Hospitals and School ofMedicine, Assiut, Egypt2Plastic & Reconstructive Surgery, Mansoura University School of Medicine,Mansoura, Egypt

*Correspondence to: Tarek Abdalla El-ammal, M.D.; ReconstructiveMicrosurgery Unit, Assiut University Hospitals and School of Medicine,Assiut 71526, Egypt . E-mail: [email protected]

Received 24 June 2012; Revision accepted 3 November 2012; Accepted 5November 2012

Published online 26 December 2012 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/micr.22074

VVC 2012 Wiley Periodicals, Inc.

serial wound culture. Patency of the anterior and poste-

rior tibial vessels was evaluated using a hand held Dopp-

ler and no angiographic studies as CTA or MRA were

performed preoperatively.

Surgical Technique

A Two team approach was adopted, one for explora-

tion/dissection of the recipient vessels and the other for

harvesting the flap from the contralateral donor thigh.

Normal skin edges were reached by excision of any

tissues of doubtful viability to re-evaluate of the defect

prior to determining final flap dimensions.

Vessels exploration was done under tourniquet with-

out exsanguination. The anterior tibial vessels outside the

zone of injury were evaluated. If the flow was inadequate

or there were signs of intimal injury on microscopic

examination, the posterior tibial vessels were used for

end to side anastomosis.

A line was drawn between the anterior superior iliac

spine and the midpoint of the lateral border on the patella

on the donor thigh, with the child in the supine position.

The location of the main perforators was detected with

Doppler ultrasound and was centered primarily at the

midpoint of the line. Additional perforators were located

5–10 cm proximal and distal to the midpoint perforator.

Perforators at these locations were designated from

proximal to distal as vessels A, B, and C, respectively

(Fig. 1). The design of the skin paddle was centered over

two perforators using a patron tailored from the defect

that included both of them. A pinch test was used to

establish the amount of the skin that could be harvested

allowing primary closure of the donor site if possible.

The incision of the skin was started from the medial

border at subfascial plane till the rectus femoris muscle

was visualized and retracted exposing the intermuscular

septum between it and the vastus latralis. Dissection of

the perforators was carried out with the use of surgical

loupes (3.5x or 4.5x). If a visible and pulsatile septocuta-

neous perforator arising from the descending branch or

originating directly from the LCFA was present, then the

flap could be harvested as a septocutaneous flap. If not,

the flap could be elevated as a musculocutaneous flap by

including 2 cm cuff of vastus lateralis muscle.

Venous anastomosis was done first followed by the

arterial anastomosis using 10/0 interrupted monofilament

nylon sutures. Heparinized saline (100 U/mL) was used

as a local irrigant and intravenous bolus of 50–100 U/kg

was administrated just before releasing the clamps.

The donor site was closed primarily after undermining

if the defect was less than 10 cm wide, otherwise, a split

thickness skin graft was used. Light dressing and non-

adherent gauze impregnated with paraffin was used as a

closed dressing for the grafted donor.

Dextran 40 was usually run at 8–10 milliliters/kg/24

hours approximately 5 days post-operatively. All children

received post-operative sedation. Careful monitoring of

the general condition of the patient and vital signs was

done for the first 24 hours. All flaps were monitored ev-

ery 1 hour for the first 24 hours then every 2 hours for 5

days as regards color, temperature, and capillary refill to

ensure patent microvascular anastomosis. Passive exer-

cises were initiated 2 weeks postoperatively for 2 weeks

then followed by active exercises for another 3 months.

When required, flap debulking was done 6 months af-

ter the initial surgery. The outline of the flap was marked

and the proximal edge of the flap was incised along the

scar for up to 50% of the flap circumference, the subcuta-

neous fat was removed and the flap was advanced proxi-

mally in order to reduce any redundant skin.

Statistics were performed with IBM1 SPSS1 Statis-

tics Version 19. Values are given as mean 6 standard

deviation.

RESULTS

All of the flaps were vascularized by at least 2 perfo-

rators. A total of 88.23% of the perforators were muscu-

locutaneous and 11.77% were septocutaneous perforators.

All flaps were raised in a subfascial plane. Initial thinning

was performed in five flaps and 35.7% required subse-

quent debulking. Mean Flap dimensions were 15.5 6

2.72 cm 3 7.44 6 1.28 cm with a mean surface area of

117.11 6 37.91 cm2. The recipient artery was the

anterior tibial artery in 38 cases, and the posterior tibial

Table 1. Associated Injuries of the Foot and Ankle

Indication of coverage Number

Exposed metatarsals and extensor tendons 18

Exposed medial or lateral malleolus 4

Open fracture one or more metatarsals 7

Open fracture dislocation of the ankle joint 13

Total 42

Figure 1. Marking of the donor site : (A) proximal perforator, (B)

main perforator, (C) distal perforator anterior superior iliac spine

(ASIS). [Color figure can be viewed in the online issue, which is

available at wileyonlinelibrary.com.]

260 El-Gammal et al.

Microsurgery DOI 10.1002/micr

artery in four cases. Venous anastomosis was performed

to one vena commitant and in nine cases the long saphe-

nous vein was additionally used. Mean ischemia time of

the flap was 2.07 6 0.51 hours while the total operative

time was 6.33 6 1.05 hours. The average blood loss was

453.29 6 104.11 cc. 41.18% of donor sites were closed

primarily while 59.52% needed skin grafting (Table 2).

Post-operative hospital stay averaged 7.5 6 1.16

days. Follow up averaged 42 months. All limbs survived.

Primary flap survival rate was 92.86% (39/42 cases).

Three flaps showed venous congestion. After venous

reanastomosis, two flaps showed partial loss and one flap

was lost completely. More than 70% of the cases were

able to wear shoes even before debulking. Fifteen chil-

dren complained that it was difficult to put on shoes

because of the bulky flap and that the flap contour was

not aesthetically pleasing. After the debulking satisfactory

results were achieved in terms of contour and functional

outcome (Table 3). Two representative cases are shown

in Figures 2–3.

DISCUSSION

The unique architecture of the soft tissue of dorsum

of the foot consists of a thin pliable surface that allows

for significant excursion and tendon gliding. Reconstruc-

tive options must preserve these important functions and

allow for reasonable contour so the patient may wear a

shoe postoperatively. There is often a paucity of local

flap options in the setting of trauma, and free flap recon-

struction is frequently indicated. The need for durable

coverage of contaminated wounds or exposed joints, frac-

tures, or hardware makes the free flap particularly well

suited to trauma reconstruction.5

In the last three decades, the advent and refinement

of microsurgical techniques have brought about a revolu-

tion in the treatment of distal lower extremity trauma. In

the adult population, the principles of successful treat-

ment of high-energy injuries of the ankle and foot are

well defined.6 The use of free tissue transfer in children

has demonstrated that it can be performed with accepta-

ble morbidity.7,8 Although children’s anatomy may pres-

ent unique technical challenges, the absence of diabetes,

hypertension, atherosclerosis, and venous stasis in chil-

dren makes free tissue transfer a particularly attractive

option for complex reconstruction.5

Namdar et al. reviewed several studies reporting the

success of free latissimus dorsi muscle transfer in chil-

dren for lower extremity reconstruction; he also reported

that the hospital stay ranged from days to months due to

seroma formation and conclude that because of the large

volume and size of the transferred latissimus dorsi mus-

cle, there was a common need for surgical revisions even

if there are no clinical signs of malperfusion.4 In larger

studies (5–12 children) a free latissimus dorsi muscle flap

survival rate of 67–80% has been reported.9–11 Haasbeek

and collaeages described free gracilis muscle transfer for

coverage after release of severe clubfoot deformity in

children older than 4 years of age. The small vessel di-

ameter often found in children younger than 4 years of

age is not suitable for anastomosis.12 Recently, Tan et al.

used nerve sparing latissimus dorsi flap to cover soft tis-

sue defect with limited donor site morbidity.13 This study

included one child with crush injury to the leg.

Very limited literature described the use of the free

ALT among other flaps for pediatric lower limb recon-

struction. These previous studies did not address the

peculiarities of the ALT flap in the pediatric population

and held true the considerations based on experiences in

an adult population.14–18 The indication for use of ALT

flap in our series was coverage of large and extensive

soft tissue defects over the dorsum of the foot and ankle

exposing the extensor tendons and/or metatarsals with or

without associated fractures of the metatarsals or ankle or

open joints. Small defects eligible for local or pedicle

skin flaps were excluded. Defects associated with plantar

loss or bone loss requiring bone grafts were treated with

free muscle or osteocutaneous flap respectively. Our

study is the largest in number regarding dorsal foot and

ankle resurfacing using the free ALT for post traumatic

soft tissue loss in children (Table 4).

Road traffic accidents and crush injuries are the most

frequently reported causes of extensive foot trauma in

children, which require free-flap transfer for foot sal-

vage.9,11,19 In the current study, 94.11% were victims of

road traffic accidents and three cases suffered from crush

injuries caused by heavy objects.

All children underwent delayed reconstruction more

than 3 days after trauma. This indicates that post-traumatic

Table 2. Aesthetic Outcome

Aesthetic outcome

Donor site

Primary closure 59.52%

Skin graft 40.47%

Hypertrophic scar 4.76%

Keloid 7.14%

Recipient site

Flap Bulkiness 35.71%

Table 3. Functional Scoring

Functional scoring

Walk normally for 10 m back and forth 3 times 90.47%

Climb 10 stairs up 88.09%

Wear normal shoes before debulking 71.42%

Wear normal shoes after debulking 95.23%

Dorsal Foot Resurfacing using Free ALT 261


lower extremity reconstruction may be safely and reliably

performed when the wound is adequately debrided and

when other injuries have been stabilized. Karanas et al.

adopted similar strategy in a series of 14 patients who

underwent delayed microvascular reconstruction to lower

limb injures.20 Recently, Arslan et al., have shown that the

final results obtained after delayed definitive soft tissue

reconstruction compared favorably with the results of early

closure within 7 days of trauma.21

Yildirim et al. suggested that there are several steps

that should be followed when pediatric microsurgery is

performed.16 Though lesser magnification is adequate

for adults with reasonable vessel size, children usually

require higher magnification (16x or 20x), and a better

light source. Dissection should be performed with mi-

croscopic magnification as well. Suture sizes of 11/0

with 50 l needle are preferred for pediatric microsur-

gery. In the presented cases we have used loop magnifi-

cation (3.5x or 4.5x), as we have not performed

intramuscular dissection to save time. Anastomosis was

performed using 10/0 with 50 l needle. Vessel dissec-

tion should be kept as minimal as possible to minimize

vasospasm. It is reasonable to use a local vasodilator

(papaverin, 2% lidocain).

Figure 2. (A) A 5 year-old male child with extensive soft tissue loss over the dorsum of the foot with exposed metatarsals. (B) Immediately

after free ALT transfer. (C) One year follow up. (D) donor site appearance following primary closure. [Color figure can be viewed in the

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



Chen et. al., in their report on 126 cases with lower

extremity injuries, who had free tissue transfer have

noticed that the anterior tibial artery had a much higher

incidence of injury with more extensive damage than the

posterior tibial artery.22 In our series, we have found that

anastomosis to anterior tibial vessels was very safe

in children so long trauma was confined to the foot. In

addition, harvesting a long pedicle allowed doing the

anastomosis outside the injury zone. We recommend

adding one saphenous vein to help drainage of the flap.

Post-operative analgesia is recommended to avoid postop-

erative anxiety and vasospasm. Low molecular-weight

dextran should be stopped at the 5th postoperative day to

avoid bleeding complications.

Five flaps were thinned at the time of inset in rela-

tively obese children. It is safe doing limited primary

thinning, as the subcutaneous fat in children is relatively

higher than in adults. This has been confirmed by Demi-

rtas et al. who successfully carried out primary thinning

of the flaps and considered it an option especially for

smaller flaps.17 Nearly one third of the successful flaps

required debulking, which lead to improvement in con-

tour with improving ability to wear normal shoes from

71.42% to 95.23% without complications. Askouni et al.

reported that delayed flap thinning using liposuction can

lead to significant improvements in cosmetic outcomes in

adult patient.23 Long follow up is recommended for those

children’s donor site to evaluate any morphological

growth changes.

Garb et al., in their report on 20 children who under-

went free ALT reconstruction, noticed that donor-site clo-

sure required split-thickness skin grafts in six cases (30%).

In the present study, with the larger mean surface area of

the flap, 117.11 cm compared to that of 91.75 cm in Garb

et al. series,18 nearly less than half (41.18%) of donor sites

were closed primarily. This is related to elasticity of pedi-

atric skin and aggressive undermining of skin edges with

two-layer closure and fascia approximation. Donor-site

grafting in children produces ugly scars and are at higher

risk for hypertrophic scars, therefore it should be avoided

if possible.24 Garb et al. recommended silicon sheeting

and scar management.18 Gupota and Sharma recommended

corticosteroid augmented by pressure garment and silicon

sheeting to manage hypertrophic scars that might develop

in children.25 We recommend the same protocol to prevent

post-operative wound complications.

Our vascular re-exploration rate was 7.2% (3 of 42

cases), in the lower range of the 4–29% re-exploration

rates reported in the literature for lower extremity free

flaps in the pediatric population.3,7,26 Zhang et al.

Figure 3. (A) A 5 year-old male child with extensive soft tissue loss

over the right medial malleolus (B) Immediately after free ALT

transfer. (C) One year follow up after flap debulking. [Color figure

can be viewed in the online issue, which is available at wileyonline-

library.com.]

Table 4. Free ALT Flap for Pediatric Lower Limb Reconstruction-previous Reports

Year Authors No Mean Age Defects Etiology Survival

2007 Segev et al.14 2 10 LL Trauma, burn

contracture

100%

2008 Upton and Guo15 4 – UL/LL – –

2008 Yildirim et al.16 2 9.5 UL/LL – 100%

2010 Demirtas et al.17 5 4.8 Foot Trauma 100%

2011 Gharb et al.18 8 10.5 LL Trauma, burn,

osteomyelitis

2 partial flap

necrosis

2012 Current study 42 6.18 Dorsum of the

foot and ankle

Trauma 91.17%

UL, Upper limb; LL, Lower limb.

Dorsal Foot Resurfacing using Free ALT 263


reported an average operative time of 7 hours with a

range of 5–10 hours in adult.27 Our operative time was

<7 hours in children due to avoidance of intramascular

dissection of the flap and the adaptation of two team

approach. The relatively short hospital stay free ALT flap

transfer to the foot (7.5 6 1.16 days) indicates that this

transfer is a safe option in children.

CONCLUSION

The present study is the largest in number regarding

dorsal foot and ankle resurfacing using the free ALT for

post traumatic soft tissue loss in children. Alongside fa-

miliarity of the vascular anatomy of ALT flap, long, and

sizable vascular pedicle that allows anastomosis outside

the trauma zone. We think that the free ALT flap could

be as safe, reliable, and aesthetically appealing option for

foot/ankle resurfacing in children especially after trau-

matic soft tissue loss.

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