The earlier clinic experience of the reverse-flow anterolateral thigh island flap

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1 British Journal of Plastic Surgery (2005) 58, The earlier clinic experience of the reverse-flow anterolateral thigh island flap Gang Zhou, Qi-Xu Zhang*, Guang-Yu Chen Scar Multiple Treatment Centre, Peking Union Medical College, Plastic Surgery Hospital, Beijing, China Received 29 July 2004; accepted 15 October 2004 KEYWORDS Anterolateral thigh flap; Reverse-flow anterolateral thigh island flap Summary Since Song first reported the anterolateral thigh flap in 1984, this flap has been applied widely in clinical practice. In 1997, we found that the proximal end of the vascular pedicle of the anterolateral thigh flap showed active bleeding. We therefore believed that this flap could form the reverse-flow flap, which can be used clinically. From 1997 to 2002, two patients who suffered from soft tissue defects in their lower extremities have been repaired successfully with the reversed flow anterolateral thigh island flaps. The reverse-flow anterolateral thigh island flap with reliable blood supply and long vascular pedicle can be designed to repair soft tissue defects around ipsilateral knee joint or contralateral distal rejoins of the leg, especially in the difficulty cases. Q 2004 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. The anterolateral thigh flap was first reported by Song et al. 1 in 1984 and then by Luo et al. 2 Recently, the flap has been widely used in plastic surgery. 3 6 Since 1997, there have been two cases of pedicled reverse-flow anterolateral thigh island flaps successfully transferred to reconstruct soft-tissue defects of the extremities. This article presents that clinical experience. * Corresponding author. Address: Division of the Plastic Surgery, Texas University Medical Branch, Galveston, TX, USA. Tel.: (01) ; fax: (01) address: lukeqixu@hotmail.com (Q.-X. Zhang). Methods Design of the flap First, draw a line on the donor thigh between the anterior superior iliac spine and the lateral border of the patella. Then, find the exit point of the cutaneous perforator with a Doppler flowmetre near the mid point of this line. Finally, mark the skin on the surface of the donor thigh with a previously prepared pattern of the recipient defect. Formation of the flap After the thigh flap is elevated, the intermuscular septum between the rectus femoris and the vastus S /$ - see front matter Q 2004 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi: /j.bjps

2 The earlier clinic experience of the reverse-flow anterolateral thigh island flap 161 Figure 1 Design of the reverse flow anterolateral thigh island flap. LCFA, lateral circumflex femoral artery; DFA, deep femoral artery; FA, femoral artery; DB, descending branch; CP, cutaneous perforator; VK, vascular network of the knee joint. lateralis muscle is opened. The descending branch of the LCFA is identified in this intermuscular space. After identifying the direct cutaneous branch in the intermuscular septum or the myocutaneous perforator of the descending branch of the LCFA on the surface of the vastus lateralis muscle, the vascular pedicle of the thigh flap is dissected in this space along the perforator raised from the descending branch of LCFA. 4,7 When a sufficient length of the vascular pedicle of the thigh flap is free, the rotation point of the vascular pedicle is at about 5 cm above the patella. When the upper end of the vascular pedicle (the crossing point of the descending branch and the transverse branch of the LCFA) was divided, active bleeding can be seen in the end of the pedicle and the blood supply of the thigh flap was good. The motor nerve to the muscle accompanying with the descending branch of the LCFA should be preserved in the surgical procedure (Fig. 1). Transfer of the reverse-flow flap A cross-leg flap pattern can be used for treatment of the defects of contralateral distal region of the leg. Stable splint is also needed to protect vascular pedicle from tension or avulsion. Case reports Case 1 A 30-year-old female suffered from scar ulcer in the right plantar region caused following a traffic accident 7 months before. She underwent skin grafting in other hospital, but the surgery failed. The calcaneum bone and the fifth metatarsal bone were exposed. In 1997, the patient accepted further treatment in our department. The plantar scar was removed and the soft tissue defect on the right plantar was repaired with left reverse-flow anterolateral thigh island flap through the cross-leg flap pattern. In surgery, we found the posterior tibia artery and the accompanying veins were not flowing at 5 cm above the inside ankle, although the examination of the Doppler blood flow metre was normal before the surgery. We checked the vessel proximally and found the vascular wall abnormal. So we determined to use the pedicled reverse-flow anterolateral thigh island flap instead of a free flap. The greater accompanying vein of the pedicle was anatomised with the great saphenous vein. The pedicle rotation point was at 5 cm above the patella. The size of this flap was 20!12 cm 2 with an 11 cm vascular pedicle. The donor site was repaired by split skin grafts. After the surgery, the blood supply of this pedicled flap was excellent. The pedicle was cut 16 days later and the flap survived completely (Fig. 2). Five years after surgery, the function of the right foot was satisfactory, there were no functional limitation of the donor leg and the donor scar is acceptable. Case 2 A 37-year-old female suffered from left tibia comminuted fracture with anterior tibia skin avulsion by a traffic accident 5 years previously. The patient had previously been reconstructed with iliac bone grafting following contralateral gastrocnemius musculocutaneous flap transplantation. The reconstruction failed because of chronic osteomyelitis. A large scar remained in the left lower leg and the tibia bone was not healed. In October 2001, the patient accepted the repair surgery in our department. In surgery, the anterior tibia scar was excised, the inflammation tissue and the dead bone fractions were removed completely. We checked the anterior tibia artery from the defect site to proximal end, the vascular wall became thicker and the artery was stenosed by chronic inflammation. So we selected the cross-leg flap pattern to transfer the reverse-flow anterolateral thigh island instead of free flap through vascular anastomosis. The rotation point of the pedicle was at 5 cm above the patella. The size of the flap was 22!12 cm 2 with a 12 cm vascular pedicle. The donor site was repaired with split skin

3 162 G. Zhou et al. Figure 2 The treatment of the plantar soft tissue defects with the reverse anterolateral thigh island flap. A, preoperation; B, elevation the flap (arrow, vascular pedicle); C, transfer of the flap through cross-leg pattern and close the donor site with a split skin graft; D, postoperation. graft. Venous congestion of the flap occurred postoperatively at 1 day. Following bloodletting from the flap margin, the blood circulation of the flap quickly improved. Necrosis developed in a small area of the distal region of the flap but healed spontaneously. The pedicle was divided 4 weeks later. The surgical result was satisfactory (Fig. 3). Six months after the surgery, the patient accepted iliac bone grafting again, the postoperative course was smooth. There was neither flap necrosis, local infection, nor bone grafting failure. Now, three years after the surgery, she has no recurrence of the osteomyelitis, no hindrance to walking with the left leg, and no functional limitation of the donor leg. Discussion Numerous flaps have been introduced for

4 The earlier clinic experience of the reverse-flow anterolateral thigh island flap 163 Figure 3 The treatment of the distal leg soft tissue defects with the reverse anterolateral thigh island flap through cross-leg pattern. A, preoperation; B, elevation of the flap (arrow, vascular pedicle); C, before pedicle cut; D, after pedicle cut; E, postoperation.

5 164 reconstruction of soft-tissue defects of the distal region of leg In case 1, the weight-bearing plantar surface is a challenging area in which to achieve stable soft-tissue coverage. Because the area of defect is large, the local flaps, such as sural neurocutaneous flap, 11,12 is not enough to repair it. It is also difficult to use a free flap because of the posterior tibial artery and accompanying vein were damaged. Similarly, in case 2, the blood vessels were destroyed by the acute injury and chronic inflammation. Therefore, free skin flap transplantation always takes great risk. The patient had previously been reconstructed with contralateral gastrocnemius musculocutaneous flap transfer so the cross leg transposition of the reverse sural artery flap was not suitable. In this situation, the reverse flow anterolateral thigh island flap is an easier and reliable method for repairing the defects of the difficulty cases. There are many advantages with reverse-flow anterolateral thigh island flap: 1. The terminal of descending branch the LCFA ultimately anastomoses with the vascular network of the knee joint at a point of 2.5 cm above the patella. 13 So the reverse blood flow coming from the vessel of the knee joint can perfuse the flap through the connection when the trunk of descending branch was ligated proximally. The flap has a relatively constant vascular pedicle. The pedicle is long and has large caliber vessel. The blood supply of the reverse flap is sufficient. 2. The skin territory of the flap is very large and the arc rotation is flexible. The paddle of the skin flap is thinner than the musculocutaneous flap. 3. Moreover, the flap can be made as an innervated flap if the anterolateral cutaneous nerve is anastomosed with a sensory nerve in the recipient site through end-to-end or end-to-side pattern. 4. The reverse-flow anterolateral thigh island flap can be designed to repair soft tissue defects around ispilateral knee joint or contralateral distal rejoins of the leg, especially in the difficulty cases. However, there are also some disadvantages. A split skin graft is needed to close the donor site and the splint fixation brings pain and inconvenience to patients. References G. Zhou et al. 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: Luo LS, Gao JH, Chen LF. A new free skin flap anterolateral femoral flap: it s anatomy and clinical application. Chin J Plast Surg Burns 1985;1: Zhou G, Qiao Q, Chen GY, Ling YC, Swift R. Clinical experience and surgical anatomy of 32 free an terolateral thigh flap transplantations. Br J Plast Surg 1991;44: Koshima I, Fukuda H, Yamamoto H, Moriguchi T, Soeda S, Ohta S. Free anterolateral thigh flaps for reconstruction of head and neck defects. Plast Reconstr Surg 1993;92: Koshima I, Hosoda M, Moriguchi T, Kawada S. New multilobe accordion flaps for three-dimensional reconstruction of wide, full-thickness defects in the oral floor. Ann Plast Surg 2000;45: Wei FC, Celik N, Chen HC, Cheng MH, Huang WC. Combined anterolateral thigh flap and vascularized fibula osteoseptocutaneous flap in reconstruction of extensive composite mandibular defects. Plast Reconstr Surg 2002;109: Koshima I, Yamamoto H, Moriguchi T, Orita Y. Extended anterior thigh flaps for repair of massive cervical defects involving pharyngoesophagus and skin: an introduction to the mosaic flap principle. Ann Plast Surg 1994;32: Torii S, Namiki Y, Mori R. Reverse-flow island flap: clinical report and venous drainage. Plast Reconstr Surg 1987;79: Imanishi N, Nakajima H, Fukuzumi S, Aiso S. Venous drainage of the distally based lesser saphenous-sural veno-neuroadipofascial pedicled fasciocutaneous flap: a radiographic perfusion study. Plast Reconstr Surg 1999;103: Hidalgo DA, Shaw WW. Reconstruction of foot injuries. Clin Plast Surg 1986; Oberlin C, Azoulay B, et al. The posterdateral malleolar flap of the ankle: a distally based sural neurocutaneous flap report of 14 cases. Plast Reconstr Surg 1995;96: Hasegawa M, et al. The distally based superficial sural artery flap. Plast Reconstr Surg 1994;93: Tang ML. Anatomic basis of reversed anterolateral femoral island flap. Chin J Microsurg 1992;15:93.