Designing the Anterolateral Thigh Flap without Preoperative Doppler or Imaging

ABSTRACT

The anterolateral thigh (ALT) flap is now considered a workhorse for head and neck reconstruction in many centers. However, designing and raising the ALT flap has been traditionally recognized as being difficult, tedious, and technically demanding due to its variation in perforator anatomy. Designing the ALT flap on data gained solely using the handheld Doppler can be misleading, as its specificity and sensitivity varies greatly depending on amount of subcutaneous fat and the Doppler itself. Authors have investigated multiple imaging modalities in the search of the best way to predict and map the site and size of perforators before dissecting a flap. In this article, we describe a simplified technique for the ALT flap design and dissection without the use of preoperative imaging or vascular studies. Utilizing anatomic landmarks, the location of the three perforators (A, B, and C) can be anticipated and safely dissected. We conclude that accurate use of the ABC system is one approach in consistently dissecting the ALT flap.

Anterolateral thigh flap - Doppler - head and neck - thigh-based reconstruction - ALT flap

REFERENCES

• 1 Blondeel P N, Beyens G, Verhaeghe R et al.. Doppler flowmetry in the planning of perforator flaps.  Br J Plast Surg. 1998;  51 202-209
• 2 Wei F C, Celik N, Chen H C, Cheng M H, Huang W C. Combined anterolateral thigh flap and vascularized fibula osteoseptocutaneous flap in reconstruction of extensive composite mandibular defects.  Plast Reconstr Surg. 2002;  109 45-52
• 3 Yu P. Reinnervated anterolateral thigh flap for tongue reconstruction.  Head Neck. 2004;  26 1038-1044
• 4 Yu P, Robb G L. Pharyngoesophageal reconstruction with the anterolateral thigh flap: a clinical and functional outcomes study.  Plast Reconstr Surg. 2005;  116 1845-1855
• 5 Yu P, Sanger J R, Matloub H S, Gosain A, Larson D. Anterolateral thigh fasciocutaneous island flaps in perineoscrotal reconstruction.  Plast Reconstr Surg. 2002;  109 610-616 discussion 617-618
• 6 Wei F C, Suominen S, Cheng M H, Celik N, Lai Y L. Anterolateral thigh flap for postmastectomy breast reconstruction.  Plast Reconstr Surg. 2002;  110 82-88
• 7 Wei F C, Jain V, Celik N, Chen H C, Chuang D C, Lin C H. 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
• 8 Kimata Y, Uchiyama K, Ebihara S, Nakatsuka T, Harii K. Anatomic variations and technical problems of the anterolateral thigh flap: a report of 74 cases.  Plast Reconstr Surg. 1998;  102 1517-1523
• 9 Koshima I, Fukuda H, Utunomiya R, Soeda S. The anterolateral thigh flap; variations in its vascular pedicle.  Br J Plast Surg. 1989;  42 260-262
• 10 Song Y G, Chen G Z, Song Y L. The free thigh flap: a new free flap concept based on the septocutaneous artery.  Br J Plast Surg. 1984;  37 149-159
• 11 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 934-935
• 12 Xu D C, Zhong S Z, Kong J M et al.. Applied anatomy of the anterolateral femoral flap.  Plast Reconstr Surg. 1988;  82 305-310
• 13 Yu P. Characteristics of the anterolateral thigh flap in a Western population and its application in head and neck reconstruction.  Head Neck. 2004;  26 759-769
• 14 Giunta R E, Geisweid A, Feller A M. The value of preoperative Doppler sonography for planning free perforator flaps.  Plast Reconstr Surg. 2000;  105 2381-2386
• 15 Smit J M, Dimopoulou A, Liss A G et al.. Preoperative CT angiography reduces surgery time in perforator flap reconstruction.  J Plast Reconstr Aesthet Surg. 2008;  , July 31 (Epub ahead of print)
• 16 Rozen W M, Phillips T J, Ashton M W, Stella D L, Gibson R N, Taylor G I. Preoperative imaging for DIEA perforator flaps: a comparative study of computed tomographic angiography and Doppler ultrasound.  Plast Reconstr Surg. 2008;  121(1 suppl) 1-8
• 17 Rozen W M, Ashton M W, Stella D L et al.. Developments in perforator imaging for the anterolateral thigh flap: CT angiography and CT-guided stereotaxy.  Microsurgery. 2008;  28 227-232
• 18 Tsukino A, Kurachi K, Inamiya T, Tanigaki T. Preoperative color Doppler assessment in planning of anterolateral thigh flaps.  Plast Reconstr Surg. 2004;  113 241-246
• 19 Hallock G G. Doppler sonography and color duplex imaging for planning a perforator flap.  Clin Plast Surg. 2003;  30 347-357, v–vi