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Handchir Mikrochir Plast Chir 2009; 41(4): 193-202
DOI: 10.1055/s-0029-1220916
Übersichtsarbeit

© Georg Thieme Verlag KG Stuttgart · New York

The Versatility of the Anterolateral Thigh Flap in Lower Extremity Reconstruction

Die Vielseitigkeit der anterolateralen Oberschenkel-Lappenplastik in der Rekonstruktion der unteren ExtremitätJ. H. Dayan 1 , C. -H. Lin 1 , F. C. Wei 1
  • 1Department of Plastic Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
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Publikationsverlauf

eingereicht 26.3.2009

akzeptiert 16.4.2009

Publikationsdatum:
21. Juli 2009 (online)

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Abstract

The anterolateral thigh flap (ALT) has emerged as one of the major workhorses in lower extremity reconstruction. As knowledge of the local anatomy and familiarity with intramuscular dissection has grown, so has the multitude of applications of the ALT flap. Its abundance of tissue, long and large caliber pedicle, minimal donor site morbidity, and the ability to use a two-team approach affords the surgeon with a reliable reconstructive option. The variety of tissues that may be harvested from the lateral circumflex femoral axis can provide like-with-like tissue replacement for most components in the lower extremity. Some of the creative applications successfully reported include flow-through flap for revascularization, vascularized fascia lata for single-stage tendon reconstruction, functional muscle transfer, sensate flaps, and chimeric flaps for extensive composite defects. The following article summarizes our technique for reliable flap harvest, a thorough review of both the benefits and limitations of the anterolateral thigh flap, and a review of its many applications reported in the international community.

Zusammenfassung

Die anterolaterale Oberschenkel-Lappenplastik („ALT Flap”) hat sich in den letzten Jahren zu einem Arbeitspferd in der Unterschenkelrekonstruktion entwickelt. Mit den Erfahrungen im Umgang mit der Anatomie bei der Hebung und intramuskulären Präparation der Perforans-Gefäße wurde auch eine Vielzahl von verschiedenen Anwendungen der Lappenplastik entwickelt. Die Menge an Gewebe, der lange Gefäßstiel mit großem Kaliber, der geringe Hebedefekt und die Möglichkeit in zwei Teams zu arbeiten, machen die Lappenplastik für den rekonstruktiven Chirurgen zu einer attraktiven und zuverlässigen Option. Die Vielzahl der Gewebetypen, die von der A. circumflexa femoris lateralis versorgt werden, erlaubt eine Rekonstruktion der unteren Extremität dem Grundsatz des „Ähnliches mit Ähnlichem”-Ersatzes folgend für die meisten Gewebekomponenten. Zu diesen kreativen Anwendungen zählt die Durchfluss-Lappenplastik zur Revaskularisation des Unterschenkels, vaskularisierte Fascia lata für eine einzeitige Sehnenrekonstruktion, der funktionelle Muskeltransfer, sensible Lappenplastiken und chimäre Lappenplastiken bei ausgedehnten Defekten. Die vorliegende Arbeit stellt unsere Operationstechnik zur zuverlässigen Hebung der Lappenplastik dar und gibt eine Übersicht der Möglichkeiten und Grenzen der anterolateralen Oberschenkel-Lappenplastik sowie eine Literaturübersicht zur Vielzahl der Anwendungen.

Key words

microsurgery - fascia flap - skin flap - muscle flap - lower limb reconstruction - flow-through flap

Schlüsselwörter

Mikrochirurgie - Faszienlappenplastik - Hautlappenplastik - Muskellappenplastik - untere Extremität - Perforans-Lappenplastiken

References

  • 1 Song YG, Chen GZ, Song YL. The free thigh flap: a new free flap concept based on the septocutaneous artery.  Br J Plast Surg. 1984;  37 149-159
    Google Scholar
  • 2 Hallock GG. Lower extremity muscle perforator flaps for lower extremity reconstruction.  Plast Reconstr Surg. 2004;  114 1123-1130
    Google Scholar
  • 3 Chana JS, Wei FC. A review of the advantages of the anterolateral thigh flap in head and neck reconstruction.  Br J Plast Surg. 2004;  57 603-609
    Google Scholar
  • 4 Gedebou TM, Wei FC, Lin CH. Clinical experience of 1284 free anterolateral thigh flaps.  Handchir Mikrochir Plast Chir. 2002;  34 239-244
    Google Scholar
  • 5 Ozkan O, Coskunfirat OK, Ozgentas HE. The use of free anterolateral thigh flap for reconstructing soft tissue defects of the lower extremities.  Ann Plast Surg. 2004;  53 455-461
    Google Scholar
  • 6 Pribaz JJ, Orgill DP, Epstein MD. et al . Anterolateral thigh free flap.  Ann Plast Surg. 1995;  34 585-592
    Google Scholar
  • 7 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 2219-2226 , ; discussion 2227–2230
    Google Scholar
  • 8 Yazar S, Lin CH, Lin YT. et al . Outcome comparison between free muscle and free fasciocutaneous flaps for reconstruction of distal third and ankle traumatic open tibial fractures.  Plast Reconstr Surg. 2006;  117 2468-2475 , ; discussion 2476–2467
    Google Scholar
  • 9 Gravvanis A, Tsoutsos D, Karakitsos D. et al . Blood perfusion of the free anterolateral thigh perforator flap: its beneficial effect in the reconstruction of infected wounds in the lower extremity.  World J Surg. 2007;  31 11-18
    Google Scholar
  • 10 Park JE, Rodriguez ED, Bluebond-Langer R. et al . The anterolateral thigh flap is highly effective for reconstruction of complex lower extremity trauma.  J Trauma. 2007;  62 162-165
    Google Scholar
  • 11 Salgado CJ, Mardini S, Jamali AA. et al . Muscle versus nonmuscle flaps in the reconstruction of chronic osteomyelitis defects.  Plast Reconstr Surg. 2006;  118 1401-1411
    Google Scholar
  • 12 Blondeel PN, Van Landuyt KH, Monstrey SJ. et al . The “Gent” consensus on perforator flap terminology: preliminary definitions.  Plast Reconstr Surg. 2003;  112 1378-1383 , ; quiz 1383, 1516; discussion 1384–1377
    Google Scholar
  • 13 Geddes CR, Morris SF, Neligan PC. Perforator flaps: evolution, classification, and applications.  Ann Plast Surg. 2003;  50 90-99
    Google Scholar
  • 14 Hallock GG. The complete classification of flaps.  Microsurgery. 2004;  24 157-161
    Google Scholar
  • 15 Wei FC, Celik N, Jeng SF. Application of “simplified nomenclature for compound flaps” to the anterolateral thigh flap.  Plast Reconstr Surg. 2005;  115 1051-1055 , ; discussion 1056–1057
    Google Scholar
  • 16 Begue T, Masquelet AC, Nordin JY. Anatomical basis of the anterolateral thigh flap.  Surg Radiol Anat. 1990;  12 311-313
    Google Scholar
  • 17 Fathi M, Reza Fathi H, Hatamipour E. et al . Anatomical study of lateral circumflex femoral arterial system for the anterolateral thigh flap.  Minerva Chir. 2008;  63 283-288
    Google Scholar
  • 18 Kawai K, Imanishi N, Nakajima H. et al . Vascular anatomy of the anterolateral thigh flap.  Plast Reconstr Surg. 2004;  114 1108-1117
    Google Scholar
  • 19 Ouezzani S, Gangloff D, Garrido I. et al . Anterolateral thigh flap: from anatomic study to surgical technique].  Ann Chir Plast Esthet. 2008;  53 232-238
    Google Scholar
  • 20 Wong CH, Wei FC, Fu B. et al . Alternative vascular pedicle of the anterolateral thigh flap: the oblique branch of the lateral circumflex femoral artery.  Plast Reconstr Surg. 2008;  in press
    Google Scholar
  • 21 Alkureishi LW, Ross GL. Unusual branching of the lateral circumflex femoral arterial system for anterolateral thigh flaps.  Plast Reconstr Surg. 2003;  111 2481
    Google Scholar
  • 22 Kimata Y, Uchiyama K, Ebihara S. et al . Anatomic variations and technical problems of the anterolateral thigh flap: a report of 74 cases.  Plast Reconstr Surg. 1998;  102 1517-1523
    Google Scholar
  • 23 Koshima I, Fukuda H, Utunomiya R. et al . The anterolateral thigh flap; variations in its vascular pedicle.  Br J Plast Surg. 1989;  42 260-262
    Google Scholar
  • 24 Schaverien M, Saint-Cyr M, Arbique G. et al . Three- and four-dimensional computed tomographic angiography and venography of the anterolateral thigh perforator flap.  Plast Reconstr Surg. 2008;  121 1685-1696
    Google Scholar
  • 25 Rozen WM, Ashton MW, Pan WR. et al . Anatomical variations in the harvest of anterolateral thigh flap perforators: A cadaveric and clinical study.  Microsurgery. 2009;  29(1) 16–23
    Google Scholar
  • 26 Kuo YR, Jeng SF, Kuo MH. et al . Free anterolateral thigh flap for extremity reconstruction: clinical experience and functional assessment of donor site.  Plast Reconstr Surg. 2001;  107 1766-1771
    Google Scholar
  • 27 Tsuji N, Suga H, Uda K. et al . Functional evaluation of anterolateral thigh flap donor sites: isokinetic torque comparisons for knee function.  Microsurgery. 2008;  28 233-237
    Google Scholar
  • 28 Hage JJ, Woerdeman LA. Lower limb necrosis after use of the anterolateral thigh free flap: is preoperative angiography indicated?.  Ann Plast Surg. 2004;  52 315-318
    Google Scholar
  • 29 Xu DC, Zhong SZ, Kong JM. et al . Applied anatomy of the anterolateral femoral flap.  Plast Reconstr Surg. 1988;  82 305-310
    Google Scholar
  • 30 Yu P, Youssef A. Efficacy of the handheld Doppler in preoperative identification of the cutaneous perforators in the anterolateral thigh flap.  Plast Reconstr Surg. 2006;  118 928-933 , ; discussion 934–925
    Google Scholar
  • 31 Rodriguez ED, Bluebond-Langner R, Park J. et al . Does fascia lata repair facilitate closure and does it affect compartment pressures of the anterolateral thigh flap donor site?.  Plast Reconstr Surg. 2007;  120 1300-1304
    Google Scholar
  • 32 Hallock GG. Doppler sonography and color duplex imaging for planning a perforator flap.  Clin Plast Surg. 2003;  30 347-357 , , v–vi
    Google Scholar
  • 33 Iida H, Ohashi I, Kishimoto S. et al . Preoperative assessment of anterolateral thigh flap cutaneous perforators by colour Doppler flowmetry.  Br J Plast Surg. 2003;  56 21-25
    Google Scholar
  • 34 Celik N, Wei FC, Lin CH. et al . Technique and strategy in anterolateral thigh perforator flap surgery, based on an analysis of 15 complete and partial failures in 439 cases.  Plast Reconstr Surg. 2002;  109 2211-2216 , ; discussion 2217–2218
    Google Scholar
  • 35 Wei FC, Mardini S. Free-style free flaps.  Plast Reconstr Surg. 2004;  114 910-916
    Google Scholar
  • 36 Kimata Y, Uchiyama K, Ebihara S. et al . Versatility of the free anterolateral thigh flap for reconstruction of head and neck defects.  Arch Otolaryngol Head Neck Surg. 1997;  123 1325-1331
    Google Scholar
  • 37 Koshima I, Hosoda M, Moriguchi T. et al . A combined anterolateral thigh flap, anteromedial thigh flap, and vascularized iliac bone graft for a full-thickness defect of the mental region.  Ann Plast Surg. 1993;  31 175-180
    Google Scholar
  • 38 Kuo YR, Seng-Feng J, Kuo FM. et al . Versatility of the free anterolateral thigh flap for reconstruction of soft-tissue defects: review of 140 cases.  Ann Plast Surg. 2002;  48 161-166
    Google Scholar
  • 39 Shieh SJ, Chiu HY, Yu JC. et al . Free anterolateral thigh flap for reconstruction of head and neck defects following cancer ablation.  Plast Reconstr Surg. 2000;  105 2349-2357 , ; discussion 2358–2360
    Google Scholar
  • 40 Cavadas PC, Sanz-Jimenez-Rico JR. Use of the extended-pedicle vastus lateralis free flap for lower extremity reconstruction.  Plast Reconstr Surg. 2005;  115 1070-1076
    Google Scholar
  • 41 Koshima I. Free anterolateral thigh flap for reconstruction of head and neck defects following cancer ablation.  Plast Reconstr Surg. 2000;  105 2358-2360
    Google Scholar
  • 42 Kimata Y, Uchiyama K, Ebihara S. et al . Anterolateral thigh flap donor-site complications and morbidity.  Plast Reconstr Surg. 2000;  106 584-589
    Google Scholar
  • 43 Addison PD, Lannon D, Neligan PC. Compartment syndrome after closure of the anterolateral thigh flap donor site: a report of two cases.  Ann Plast Surg. 2008;  60 635-638
    Google Scholar
  • 44 Hong JP, Kim EK. Sole reconstruction using anterolateral thigh perforator free flaps.  Plast Reconstr Surg. 2007;  119 186-193
    Google Scholar
  • 45 Koshima I, Nanba Y, Tsutsui T. et al . Perforator flaps in lower extremity reconstruction.  Handchir Mikrochir Plast Chir. 2002;  34 251-256
    Google Scholar
  • 46 Lin CH, Mardini S, Wei FC. et al . Free flap reconstruction of foot and ankle defects in pediatric patients: long-term outcome in 91 cases.  Plast Reconstr Surg. 2006;  117 2478-2487
    Google Scholar
  • 47 Rodriguez ED, Rosson GD, Bluebond-Langner R. et al . The utility of the anterolateral thigh donor site in reconstructing the United States trauma patient.  J Trauma. 2007;  62 892-897
    Google Scholar
  • 48 Yildirim S, Gideroglu K, Akoz T. Anterolateral thigh flap: ideal free flap choice for lower extremity soft-tissue reconstruction.  J Reconstr Microsurg. 2003;  19 225-233
    Google Scholar
  • 49 Kuo YR, An PC, Kuo MH. et al . Reconstruction of knee joint soft tissue and patellar tendon defects using a composite anterolateral thigh flap with vascularized fascia lata.  J Plast Reconstr Aesthet Surg. 2008;  61 195-199
    Google Scholar
  • 50 Kuo YR, Kuo MH, Chou WC. et al . One-stage reconstruction of soft tissue and Achilles tendon defects using a composite free anterolateral thigh flap with vascularized fascia lata: clinical experience and functional assessment.  Ann Plast Surg. 2003;  50 149-155
    Google Scholar
  • 51 Lin CH, Wei FC, Lin YT. et al . Lateral circumflex femoral artery system: warehouse for functional composite free-tissue reconstruction of the lower leg.  J Trauma. 2006;  60 1032-1036
    Google Scholar
  • 52 Yildirim S, Taylan G, Akoz T. Use of fascia component of the anterolateral thigh flap for different reconstructive purposes.  Ann Plast Surg. 2005;  55 479-484
    Google Scholar
  • 53 Pan SC, Yu JC, Shieh SJ. et al . Distally based anterolateral thigh flap: an anatomic and clinical study.  Plast Reconstr Surg. 2004;  114 1768-1775
    Google Scholar
  • 54 Ao M, Nagase Y, Mae O. et al . Reconstruction of posttraumatic defects of the foot by flow-through anterolateral or anteromedial thigh flaps with preservation of posterior tibial vessels.  Ann Plast Surg. 1997;  38 598-603
    Google Scholar
  • 55 Hsu CC, Lin YT, Lin CH. et al . Immediate emergent free anterolateral thigh flap transfer for the mutilated upper extremity.  Plast Reconstr Surg. , (in press)
    Google Scholar
  • 56 Ceulemans P, Hofer SO. Flow-through anterolateral thigh flap for a free osteocutaneous fibula flap in secondary composite mandible reconstruction.  Br J Plast Surg. 2004;  57 358-361
    Google Scholar
  • 57 Koshima I, Fujitsu M, Ushio S. et al . Flow-through anterior thigh flaps with a short pedicle for reconstruction of lower leg and foot defects.  Plast Reconstr Surg. 2005;  115 155-162
    Google Scholar
  • 58 Sananpanich K, Tu YK, Kraisarin J. et al . Flow-through anterolateral thigh flap for simultaneous soft tissue and long vascular gap reconstruction in extremity injuries: anatomical study and case report.  Injury. 2008;  39 ((Suppl 4)) 47-54
    Google Scholar
  • 59 Koshima I, Yamamoto H, Hosoda M. et al . Free combined composite flaps using the lateral circumflex femoral system for repair of massive defects of the head and neck regions: an introduction to the chimeric flap principle.  Plast Reconstr Surg. 1993;  92 411-420
    Google Scholar
  • 60 Lin YT, Lin CH, Wei FC. More degrees of freedom by using chimeric concept in the applications of anterolateral thigh flap.  J Plast Reconstr Aesthet Surg. 2006;  59 622-627
    Google Scholar
  • 61 Kimura N, Saito M, Itoh Y. et al . Giant combined microdissected thin thigh perforator flap.  J Plast Reconstr Aesthet Surg. 2006;  59 1325-1329
    Google Scholar
  • 62 Lin CH, Lin YT, Yeh JT. et al . Free functioning muscle transfer for lower extremity posttraumatic composite structure and functional defect.  Plast Reconstr Surg. 2007;  119 2118-2126
    Google Scholar
  • 63 Posch NA, Mureau MA, Flood SJ. et al . The combined free partial vastus lateralis with anterolateral thigh perforator flap reconstruction of extensive composite defects.  Br J Plast Surg. 2005;  58 1095-1103
    Google Scholar
  • 64 Zhang G. Reversed anterolateral thigh island flap and myocutaneous flap transplantation.  Zhonghua Yi Xue Za Zhi. 1990;  70 676-678 , , 646
    Google Scholar
  • 65 Chang SH. Anterolateral thigh island pedicled flap in trochanteric pressure sore reconstruction.  J Plast Reconstr Aesthet Surg. 2007;  60 1074-1075
    Google Scholar
  • 66 Chen CY, Hsieh CH, Kuo YR. et al . An anterolateral thigh perforator flap from the ipsilateral thigh for soft-tissue reconstruction around the knee.  Plast Reconstr Surg. 2007;  120 470-473
    Google Scholar
  • 67 Gravvanis AI, Iconomou TG, Panayotou PN. et al . Medial gastrocnemius muscle flap versus distally based anterolateral thigh flap: conservative or modern approach to the exposed knee joint?.  Plast Reconstr Surg. 2005;  116 932-934
    Google Scholar
  • 68 Hallock GG. The proximal pedicled anterolateral thigh flap for lower limb coverage.  Ann Plast Surg. 2005;  55 466-469
    Google Scholar
  • 69 Luo S, Raffoul W, Piaget F. et al . Anterolateral thigh fasciocutaneous flap in the difficult perineogenital reconstruction.  Plast Reconstr Surg. 2000;  105 171-173
    Google Scholar
  • 70 Uygur F, Duman H, Ulkur E. et al . Are reverse flow fasciocutaneous flaps an appropriate option for the reconstruction of severe postburn lower extremity contractures?.  Ann Plast Surg. 2008;  61 319-324
    Google Scholar
  • 71 Yildirim S, Avci G, Akan M. et al . Anterolateral thigh flap in the treatment of postburn flexion contractures of the knee.  Plast Reconstr Surg. 2003;  111 1630-1637
    Google Scholar
  • 72 Zhou G, Zhang QX, Chen GY. The earlier clinic experience of the reverse-flow anterolateral thigh island flap.  Br J Plast Surg. 2005;  58 160-164
    Google Scholar
  • 73 Lin RY, Chien WH. Experiences in harvesting type II distally based anterolateral thigh flaps.  Plast Reconstr Surg. 2006;  118 282-284 , ; author reply 284–286
    Google Scholar
  • 74 Wang C, Kang Q, Song W. Vascular pedicle elongation technique in anterolateral thigh island flap transplantation].  Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2007;  21 1284-1286
    Google Scholar
  • 75 Yu P. Reinnervated anterolateral thigh flap for tongue reconstruction.  Head Neck. 2004;  26 1038-1044
    Google Scholar
  • 76 Hong JP, Shin HW, Kim JJ. et al . The use of anterolateral thigh perforator flaps in chronic osteomyelitis of the lower extremity.  Plast Reconstr Surg. 2005;  115 142-147
    Google Scholar
  • 77 Ribuffo D, Cigna E, Gargano F. et al . The innervated anterolateral thigh flap: anatomical study and clinical implications.  Plast Reconstr Surg. 2005;  115 464-470
    Google Scholar
  • 78 Agostini V, Dini M, Mori A. et al . Adipofascial anterolateral thigh free flap for tongue repair.  Br J Plast Surg. 2003;  56 614-618
    Google Scholar
  • 79 Davies H, Ross G, Juma A. A potential complication of the anterolateral thigh adipofascial perforator flap.  Plast Reconstr Surg. 2004;  114 280-281
    Google Scholar
  • 80 Hsieh CH, Yang CC, Kuo YR. et al . Free anterolateral thigh adipofascial perforator flap.  Plast Reconstr Surg. 2003;  112 976-982
    Google Scholar
  • 81 Huang CH, Chen HC, Huang YL. et al . Comparison of the radial forearm flap and the thinned anterolateral thigh cutaneous flap for reconstruction of tongue defects: an evaluation of donor-site morbidity.  Plast Reconstr Surg. 2004;  114 1704-1710
    Google Scholar
  • 82 Kimura N, Saito M, Sumiya Y. et al . Reconstruction of hand skin defects by microdissected mini anterolataral thigh perforator flaps.  J Plast Reconstr Aesthet Surg. 2008;  61 1073-1077
    Google Scholar
  • 83 Kimura N, Satoh K, Hasumi T. et al . Clinical application of the free thin anterolateral thigh flap in 31 consecutive patients.  Plast Reconstr Surg. 2001;  108 1197-1208 , ; discussion 1209–1110
    Google Scholar
  • 84 Uysal AC, Lu F, Mizuno H. et al . Defining vascular supply and territory of thinned perforator flaps: part I.  Anterolateral thigh perforator flap. Plast Reconstr Surg. 2006;  118 288-289
    Google Scholar
  • 85 Yang WG, Chiang YC, Wei FC. et al . Thin anterolateral thigh perforator flap using a modified perforator microdissection technique and its clinical application for foot resurfacing.  Plast Reconstr Surg. 2006;  117 1004-1008
    Google Scholar
  • 86 Tsai FC, Yang JY, Mardini S. et al . Free split-cutaneous perforator flaps procured using a three-dimensional harvest technique for the reconstruction of postburn contracture defects.  Plast Reconstr Surg. 2004;  113 185-193 , ; discussion 194–18
    Google Scholar
  • 87 Chou EK, Ulusal B, Ulusal A. et al . Using the descending branch of the lateral femoral circumflex vessel as a source of two independent flaps.  Plast Reconstr Surg. 2006;  117 2059-2063
    Google Scholar

Korrespondenzadresse

F. C. WeiMD, F. A. C. S 

Department of Plastic Surgery

Chang Gung Memorial Hospital

College of Medicine

Chang Gung University

5 Fu-Shing Street

Taoyuan

Taiwan

R.O.C.

Telefon: +886/3/328 12 00 ext. 3660

Fax: +886/3/328 72 60

eMail: fcw2007@cgmh.org.tw

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