Reconstruction of Extensive Soft Tissue Defects of Lower Extremity With the Extended Anterolateral Thigh Flap

Abstract

The anterolateral thigh flap is a classic flap used for various reconstruction defects. However, the flap viability of extended large skin paddles (ie, 240 cm²) was doubted by many surgeons. This study reports successful experience of reconstructing extensive soft tissue defects of lower extremity using extended large skin paddles. Twelve consecutive patients who had undergone reconstruction of defects using an extended anterolateral thigh flap were identified. Patient characteristics (age, sex, defect location, injured structures, and type of flap) and outcome data were analyzed retrospectively. One artery and 2 accompanying veins were anastomosed to vascularize each flap. Follow-up periods ranged from 10 to 91 months postoperatively. The average size of the flaps was 268.75 cm² (range = 220-391 cm²). All flaps were perforator flaps with one perforator except that 2 perforators were used in 3 patients. Two patients suffered partial flap necrosis of the distal portion with delayed healing. In conclusion, the extended anterolateral thigh flap is a considerable option for massive defects requiring composite tissue coverage. This flap is advantageous for reconstructing various complex defects in the lower extremities, providing a pliable and vascularized tissue to cover exposed extensive defects including tendons, nerves, and bones.

Keywords

lower extremity anterolateral thigh flap extended flap

Introduction

Reconstruction of extensive defects in the lower extremity, especially those involving exposure of bone, joints, or tendons, is a major surgical challenge. There are several reconstructive options available, like skin grafts, locoregional flaps, pedicled flaps, and free flaps.¹ Local-regional flaps have limitations because of the inadequate amount of available soft tissue. The anterolateral thigh flap, as first described by Song et al, is a classic flap based on the cutaneous perforators branching from the lateral femoral circumflex artery. The anterolateral thigh flap has been a workhorse flap recently for the reconstruction of various soft tissue defects.² The anterolateral thigh flap provides thin, pliable skin paddle; large caliber of vascular pedicle; and can be utilized in various composite components like vascularized skin, fascia, and muscle chimeric flaps. The donor site can usually be closed primarily. In situations where donor site primary closure is not possible, skin grafting is relatively simple and considered yield-acceptable scars. Anterolateral thigh flaps with larger vascular territory of 240 cm² are defined to be extended in some studies.^3,4 Many studies have demonstrated their reliability based on a single perforator branching from the lateral femoral circumflex artery.⁵ The purpose of this study was to introduce a single center’s experience of extended anterolateral thigh flaps for the surgical reconstruction of massive skin and soft tissue defects.

Patients and Methods

From March 2010 to August 2016, we treated 12 patients for extensive lower extremity soft tissue defects with extended anterolateral thigh flaps with flap sized of larger than 220 cm² in the Seoul National University Bundang Hospital. Of the 12 patients, 8 were men and 4 were women, with ages ranging from 19 to 69 years (average age = 47.3 years). The defect areas were all located in the foot, ankle, and lower leg. The etiology of the defects was crush injury in 7 cases, tumor excision in 3 cases, and Marjolin ulcers from extensive burn scars in 2 cases. Patient details are shown in Table 1. Outcomes assessed included flap complications, wound complications, and functional evaluation. For the functional evaluation, all patients were given the Lower Extremity Functional Scale (LEFS) questionnaires at 1-year follow-up. The Korean translation of the LEFS⁶ served to measure donor site morbidity. The LEFS contained 20 items and each was rated on a 5-point scale, from 0 (extreme difficulty/unable to perform activity) to 4 (no difficulty). The overall score is the sum total of all the item scores and ranges from 0 to 80. If the patient was affected to the joint, active and passive range of motion were measured by using a goniometer with the patient lying in supine position at 1-year follow-up. Two-point discrimination was tested for evaluation of sensory function and it was performed on the central portion of the flap. All statistical analyses were performed with SPSS version 22.0 (SPSS Inc).

Table 1.

Patient Characteristics and Outcome Data.

Patient no.	Sex/age	Defect location	Type of flap	Injured structures	Flap dimension (cm²)	Donor site repair	No. of perforators	Donor nutrient vessel (artery and vein)	Complications	AROM/PROM of knee joint (°)	Functional results (LEFS)	Follow-up (months)
1	Female/69	Right knee—lower leg	Extended ALT MC perforator flap	Bone, joint, tendon, muscle, and skin	23 × 17	STSG	1	A: ATA V: vena comitans	None	0-130/0-140	74	82
2	Male/69	Left lower leg	Extended ALT MC perforator flap	Bone, muscle, and skin	25 × 11	STSG	1	A: ATA V: vena comitans	None	10-100/0-120	57	41
3	Female/19	Left knee—lower leg	Extended ALT MC perforator flap	Bone, joint, tendon, muscle, and skin	25 × 11	STSG	1	A: peroneal artery V: vena comitans	None	15-110/0-125	61	70
4	Female/51	Right foot	Extended ALT MC perforator flap	Bone, muscle, and skin	24 × 11	STSG	2	A: ATA V: vena comitans	None	—	71	91
5	Male/57	Left foot	Extended ALT MC perforator flap	Tendon, muscle, and skin	22 × 10	Primary closure	1	A: ATA V: vena comitans	Partial necrosis	—	74	80
6	Male/52	Right foot	Extended ALT SC perforator flap	Bone, joint, tendon, muscle, and skin	25 × 10	Primary closure	1	A: PTA V: PTV	None	—	69	86
7	Male/51	Left foot	Extended ALT MC perforator flap	Bone, joint, tendon, muscle, and skin	22 × 13	STSG	1	A: ATA V: vena comitans	None	—	66	31
8	Male/23	Left knee—lower leg	Extended ALT MC perforator flap	Bone, joint, tendon, muscle, and skin	23 × 10	STSG	2	A: ATA V: vena comitans	None	5-100/0-115	53	15
9	Male/46	Left knee—thigh	Extended ALT MC perforator flap	Bone, joint, tendon, muscle, and skin	22 × 12	STSG	1	A: branch of popliteal artery V: branch of GSV	Partial necrosis	5-95/5-110	63	16
10	Female/21	Right lower leg	Extended ALT MC perforator flap	Bone, tendon, muscle, and skin	22 × 12	STSG	1	A: peroneal artery V: vena comitans	None	—	75	15
11	Male/65	Right foot	Extended ALT MC perforator flap	Bone, joint, tendon, muscle, and skin	22 × 13	STSG	1	A: ATA V: vena comitans	None	—	69	13
12	Male/45	Left knee—lower leg	Extended ALT MC perforator flap	Bone, joint, tendon, muscle, and skin	20 × 11	STSG	2	A: ATA V: vena comitans	None	5-120/5-130	59	10

Abbreviations: ALT, anterolateral thigh; AROM, active range of motion; ATA, anterior tibial artery; GSV, great saphenous vein; LEFS, Lower Extremity Functional Scale; MC, myocutaneous; PROM, passive range of motion; PTA, posterior tibial artery; PTV, posterior tibial vein; SC, septocutaneous; STSG, split thickness skin grafts.

Surgical Techniques

In cases of crushing injuries accompanied by fractures and tumor excision involving bone or joint, the cooperation with orthopedic team was performed initially. The initial treatment of the patient consisted of the wide excision of tumor or the debridement of nonviable tissue. After these processes, bone stabilization and tendon repair were performed where necessary. For the reconstruction of defect sites, operations were performed by a 2-team approach. One harvested the flap while the other dissected the recipient area. The size of flap was determined according to the size of the defect. With the patient in a supine position, the skin paddle was marked on the anterolateral surface of the thigh along a line connecting the anterior superior iliac spine to the superolateral border of the patella.² Preoperatively, a handheld audible Doppler probe was used to locate the cutaneous perforators, which were actually around the well-established landmark, the midpoint of the line. A template designed according to the defect was placed over the mapped perforators, and the flap margins were marked. We designed the skin paddle so that the selected perforator would be in the center, to maximize perfusion. The medial border incision of the flap was placed first. Once the fascia was incised, it was dissected over the rectus femoris muscle. The dissection plane was subfascial to obtain vascularized fascial graft, but suprafascial when fascial portion was not needed for reconstruction. In this case, the subfascial dissection was started near the perforators (~3 cm away from the vessels). The dissection proceeded laterally, to identify either septocutaneous or musculocutaneous perforators branching from the descending or transverse lateral circumflex femoral vessels. The largest perforators present were identified systematically after creating and dissecting the medial incision. In most cases, the dominant perforator was dissected. Intermuscular dissection was performed for septocutaneous perforators between the rectus femoris and vastus lateralis muscles. Intramuscular dissection through the vastus lateralis muscle was performed preserving a small muscle cuff for perforator protection, for musculocutaneous perforators. After all mapped perforators were identified, their location, diameter, and reliability were evaluated. Then, 1 or 2 of them were used to feed the flap. Other perforators were sacrificed with microvascular staplers. The femoral nerve branch innervating the vastus lateralis muscle was identified and preserved. Pedicle dissection was continued until sufficient length was obtained. For a sensate flap, the lateral cutaneous nerve was preserved and included in the flap. The rest of the flap border was then incised. The pedicle was cut distal to the nutrient vessel feeding the rectus femoris muscle. When flap thinning was required, it was performed intraoperatively after pedicle dissection was completed. The thinning was achieved by excising loose areolar fat tissue deep to Scarpa’s fascia. Nevertheless, all tissue within the 3 cm radius from the perforator was preserved, to ensure flap viability. Flap viability was evaluated before the pedicle was transected. The flap viability was evaluated and inset to the defect. One artery and 2 veins were anastomosed. The donor site was covered with a split-thickness skin graft if primary closure could not be achieved. Dressing was done with care not to compress the flap, with a window to allow visual flap monitoring.

Results

Patients were followed for 10 to 91 months (mean: 45.8 ± 31.7 months). Septocutaneous perforators were found in 1 of 12 cases. Musculocutaneous perforators were found in 11 cases. The average size of the anterolateral thigh flaps was 268 cm² (95% confidence interval = 243.7-293.9). The operation time ranged from 4 to 7 hours with an average of 5 hours. All flaps survived successfully except 2 flaps that had partial necrosis distally due to excessive thinning, which healed secondarily. Donor sites were directly closed in 2 patients and those of the other patients were covered with split thickness skin grafts. No wound infection or donor site morbidity occurred. The average score of questionnaires (LEFS) was 65.9 (95% confidence interval = 61.8-70.0). In 5 patients, the lateral cutaneous nerve was preserved and anastomosed to the cutaneous sensory nerve. The mean 2-point sensory discrimination distance in the sensate flaps was 16.4 ± 7.7 mm and in the non-sensate flaps was 25.3 ± 7.1 mm. The difference between the groups was statistically significant (Mann-Whitney U test, P < .05).

Case Reports

Case 1

A 69-year-old woman who had neurofibromatosis type I presented with a large mass of the right lower leg. This was later confirmed by pathology reports to be a neurofibroma. The patient had undergone the reductive surgery of infiltrative lesion 17 years earlier in another center. The patient strongly desired and insisted on excision and immediate reconstruction owing to discomfort and pain during ambulation. Her medical history was otherwise insignificant. Examination revealed an oblique scar from the superolateral aspect of the right patella to the middle portion of the medial anterior tibial area. Magnetic resonance imaging studies revealed possible invasion to the knee joint. The orthopedic team opened the knee joint, removed the intraarticular infiltrating lesions, and excised the external lesion with an ellipsoid incision. The plastic surgery team elevated the contralateral anterolateral thigh fasciocutaneous free flap. The flap measured 23 × 17 cm, and it was impossible to close the donor sites primarily due to tension. Two split-thickness skin grafts were harvested from the right thigh and were used as mesh grafts to cover the donor site. The flap was anastomosed to the anterior tibial artery and its vena comitans, 1 artery and 2 veins, in an end-to-end manner. The debulking procedure was performed 6 years later from the initial reconstruction. At her 82-month follow-up, the patient had recovered from the surgery with the ability to resume her original work (Figure 1).

Case 2

A 69-year-old man presented with a large skin and soft tissue defect and Gustilo IIIB open tibial fracture after being in a motorcycle accident. He was previously diagnosed with unstable angina and had undergone external fixation in another hospital. His medical history was otherwise insignificant. All tissues of questionable viability were debrided. A 25 × 11 cm anterolateral thigh fasciocutaneous free flap was elevated from the contralateral side. The donor site was primarily closed. Due to open tibial fracture, anterior tibial artery distal to the fracture site was damaged. Proximal dissection was performed to find the intact portion of anterior tibial artery and the flap was anastomosed to the anterior tibial artery and its vena comitans, 1 artery and 2 veins, in an end-to-end manner. At his 41-month follow-up, the patient had recovered from the surgery with the ability to resume his original work (Figure 2).

Case 3

A 19-year-old woman presented with a large skin and soft tissue defect and a Gustilo IIIB open tibial fracture after being in a motorcycle accident. Her medical history was insignificant. After emergent external fixator application by the orthopedic team, all tissues of questionable viability were debrided. A 25 × 11 cm anterolateral thigh fasciocutaneous free flap was elevated from the contralateral side. In this case, the patients had extensive tissue defect including tibialis anterior, extensor digitorum longus, extensor halluces longus muscles, and anterior tibial artery. Suitable vessels for anastomosis were not found in proximal dissection. We confirmed the intactness of posterior tibial artery behind the tibialis posterior muscle and used one branch of the peroneal artery and its vena comitans as the recipient vessels. Owing to the nonsymmetrical, peculiar shape of the defect, AlloDerm and a split-thickness skin graft were utilized for the remaining defect. The donor site was primarily closed. Knee arthrodesis was performed later by the orthopedic team. At her 70-month follow-up, the patient was able to walk without crutches (Figure 3).

Discussion

The reconstruction of soft tissue defects of the lower extremity is complicated by accompanying injuries of structures like tendons, nerves, bones, or vessels.^7,8 In our study, the anterolateral thigh flap provided a large, thin, and pliable skin paddle to reconstruct the defects with a good functional outcome.⁹ Both the free fasciocutaneous and muscle flap are good reconstructive options for large complex defects. However, sacrifice of muscle is unavoidable during muscle flap harvest, which raises the issue of donor site morbidity. Fasciocutaneous flaps have the advantage regarding muscle sacrifice–related donor site morbidity.¹⁰ Moreover, skin-grafted muscle flaps lack sensation and are more vulnerable to trauma, especially if radiation therapy is performed. Scar contracture and fibrosis can be significant, which may be a burden for additional operations.^1,11 Various fasciocutaneous flaps have been introduced with the advantage of less functional donor site morbidity. Different types of flaps have different disadvantages to consider. The radial forearm fasciocutaneous flap is a very well-known flap, but its drawbacks are the sacrifice of major upper limb artery and conspicuous scar.¹² The scapular flap was a once popular fasciocutaneous flap in the past, has the disadvantage that 2-team approach is not possible, as flap harvest can only be done with a lateral decubitus position.¹³ The lateral arm flap is also a recommended flap for lower extremity reconstruction. Consistent anatomy, easy flap harvest, thin skin paddle, sufficient vessel caliber for vascular anastomosis, and no sacrifice of a major artery are advantages of the flap.¹⁴ Beyond this, 2 teams may work simultaneously. Compared with the anterolateral thigh flap, the smaller skin paddle, lack of usable vascularized tendon is a disadvantage. For covering extensive skin and soft tissue defects, numerous flaps with large skin paddles have been reported. The transverse rectus abdominis myocutaneous flap can provide a large flap with a primarily closed donor site. However, vascular reliability may vary according to the zone, limiting its utility. The vertical rectus flap is another option for a large skin paddle but can be bulky and be associated with donor site morbidity. The thoracodorsal artery–based flap provides a large skin paddle, but the donor site usually requires skin grafting, often resulting in suboptimal results.¹⁵ The anterolateral thigh flap is used in various reconstructive defects, due to its well-known versatility and reliability.^5,9,16-18 Our clinical experience supports this, with extremely large flaps based on 1 or 2 perforators surviving without wound-healing problems. In most of our series, a single perforator was enough to vascularize a large fasciocutaneous flap. When harvesting the extended anterolateral thigh flap, a small cuff of deep fascia and vastus lateralis muscle must be preserved not only to protect the cutaneous perforators but also the connections to the subdermal plexus, which is responsible for the blood supply of the superficial layer and skin.^17,19-22 To secure the flap viability, a larger cuff of muscle and deep fascia was preserved around the perforator, in situations where 2 distinct perforators could not be included in the flap.⁸ Following the freestyle flap concept, we harvested any cutaneous perforators by retrograde dissection.²³ The descending branch of lateral circumflex artery runs distally either through an intramuscular course of the vastus lateralis muscle or an intermuscular course between the rectus femoris and vastus lateralis muscle.^24,25 Near the knee joint, it then eventually branches 2 to 5 cutaneous perforators to the lateral aspect of the thigh, in the vastus lateralis muscle.^4,26 More distal flap dissection was required for larger flap harvest. For larger flap harvest, flap dissection involved more distal portions. Flap viability was evaluated after flap elevation. Flap dissected more distal to the classic flap anatomy was still reliable. Although not critical, including tensor fasciae latae perforators may increase proximal circulation to the skin.²⁷ Furthermore, inclusion of the tensor fasciae latae perforators can be detrimental as it is likely to decrease the functional pedicle length of the flap. Vascular anastomosis for free tissue transfer should be performed outside the zone of injury. Zone of injury can often extend over areas of obviously observable injury and should be determined carefully as inflammatory response due to trauma involves perivascular effects to blood vessels that can increase the risk of procoagulant response.^7,28 Hence, a longer vascular flap pedicle may be required, which should be considered in flap selection. The vascular pedicle of the anterolateral thigh flap is reported as 8 to 12 cm long, which is usually sufficient for anastomosis “outside the zone of injury.”²⁹ However, the long, narrow pedicle could be vulnerable to compression near recipient vessels, which are usually located proximal to the ankle. Meticulous hemostasis and functional drainage system minimizes hematoma formation. During the early postoperative period, careful flap monitoring is crucial for flap survival. Failure of recipient vessel selection outside the zone of injury can result in flap failure.²⁸ The 2 accompanying veins of the descending branch of the lateral circumflex femoral artery vary in size and blood flow. We anastomosed both veins for better flap viability. A disadvantage of the extended anterolateral thigh flap is donor site–related complications, which have an incidence ranging from 11% to 21.3%. The most frequent complications were dehiscence (3.8%), seroma (2%), and hematoma (0.9%).³⁰ Performing secure primary closure rather than skin grafting can help avoid these complications as well as achieve more acceptable scars. Primary closure is not easy after extended anterolateral thigh flap elevation because it can only be performed when the maximum width of the anterolateral thigh flap does not exceed 16% of the thigh circumference, or <8 cm, although some studies report achieving primary closure of flaps up to 15 cm wide.^3,15,31 Nevertheless, donor site complications are usually considered to be superior to other flaps owing to the minimal loss of function and the fact that the donor site scar can be covered by normal clothing.² Other possible modalities for donor site closure are skin grafts, continuous external tissue expanders, and negative pressure wound therapy.^30,32,33 Despite the positive long-term results, the limitation of this study is its small number of patients and further studies are needed to determine the utility of these extended anterolateral thigh flaps and its true long-term outcomes.

Conclusion

The extended anterolateral thigh flap is a reliable flap for extremely large lower extremity skin and soft tissue defects. Large flaps could be elevated stably within short time and survive on a single reliable perforator. The long-term functional and aesthetic results were good in our series. We believe the extended anterolateral thigh flap can be a useful option for the reconstruction of complex, large defects of the lower extremities.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Jong-Ho Kim

Seokchan Eun

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