Discussion Discussion: The Anterolateral Thigh Flap for Groin and Lower Abdominal Defects: A Better Alternative to the Rectus Abdominis Flap Matthew M. Hanasono, M.D. Houston, Texas
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n the article “The Anterolateral Thigh Flap for Groin and Lower Abdominal Defects: A Better Alternative to the Rectus Abdominis Flap,” LoGiudice et al. compare their experience with the pedicled anterolateral thigh flap to the pedicled rectus abdominis myocutaneous flap for reconstruction of wounds in the region of the groin. In their series of 30 anterolateral thigh and 10 rectus abdominis flaps, they found that the early postoperative complication rate was equivalent but that the rate of delayed postoperative complications was significantly higher in the rectus abdominis group. Notably, five of 10 patients developed a hernia at the rectus abdominis donor site because of the opening left in the fascia for the deep inferior epigastric vascular pedicle to pass through. Use of the pedicled anterolateral thigh flap is not new, although LoGiudice et al. are among the first to perform a comparative study with other techniques, specifically, the rectus abdominis myocutaneous flap, which has been considered the workhorse flap for most sizable defects in the groin region. Prior publications have described use of the pedicled anterolateral thigh flap for lower extremity, vaginal, penile, perineal, and abdominal wounds.1–3 Most recently, we reported its utility in reconstructing wounds resulting from internal hemipelvectomy.4 Although internal hemipelvectomies spare the lower limb, they often result in considerable defects of the bony pelvis and overlying soft tissues, and patients may benefit not only from use of the anterolateral thigh skin paddle to achieve tension-free wound closure but also from use of the vastus lateralis muscle to fill dead space and protect the abdominal organs (Fig. 1).
From the Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center. Received for publication August 9, 2013; accepted August 13, 2013. Copyright © 2013 by the American Society of Plastic Surgeons DOI: 10.1097/01.prs.0000437227.92681.a2
As the authors mention, the pedicled anterolateral thigh flap has numerous advantages. Our group has previously shown that there is minimal morbidity following anterolateral thigh flap harvest, including good functional recovery, even when some or all of the vastus lateralis muscle is included in the flap.5 As the authors point out, unlike the rectus abdominis myocutaneous flap, a fascial opening for the pedicle that puts the patient at risk for a hernia is not needed for the anterolateral thigh to reach the groin. In addition, our experience is that the pedicle to the rectus abdominis myocutaneous flap is often divided as part of radical resection, requiring a microvascular repair that may involve vein grafting, use of the contralateral rectus abdominis myocutaneous flap (which may have less reach), or use of another reconstructive flap. Both flaps may be relatively contraindicated in obese patients, although use of the rectus abdominis or vastus lateralis muscle covered by a skin graft remains an option. The main disadvantage of the anterolateral thigh flap is its somewhat variable vascular anatomy. In approximately 6 percent of cases, the cutaneous perforator may be absent or be too small to be reliable.6 In addition, in some cases, a perforator that arises directly from the profunda femoris artery rather than the descending or transverse branch of the lateral circumflex femoral artery may result in a pedicle with more restricted reach. The authors allow their patients to sit in a chair and ambulate as tolerated on the first postoperative day. It is reassuring to know that such early mobilization, particularly sitting, which requires joint flexion in the vicinity of the pedicle of either flap, does not adversely affect blood flow to the flap. As the authors describe, we have
Disclosure: The author has no financial interest to declare in relation to the content of this Discussion or of the associated article.
www.PRSJournal.com
169
Plastic and Reconstructive Surgery • January 2014
Fig. 1. Defect resulting from a combined Enneking type II and III internal hemipelvectomy for sarcoma in a patient who underwent neoadjuvant irradiation and chemotherapy (left). The defect was reconstructed with bioprosthetic mesh and a pedicled anterolateral thigh (ALT) myocutaneous flap, which was tunneled beneath the rectus femoris muscle (center). Completed reconstruction (right).
not witnessed significant pedicle compression secondary to transposing the anterolateral thigh flap under the rectus femoris muscle, and agree that this maneuver can substantially extend the reach of the flap. We do restrict the patient’s knee movement with a knee immobilizer for 1 to 2 weeks after surgery when the anterolateral thigh donor site has been skin grafted to minimize shearing of the graft from the underlying quadriceps muscle bed. Doing so has decreased our rate of skin graft loss, which was a relatively common complication observed in the series by LoGiudice et al. The comparison between the anterolateral thigh and the rectus abdominis myocutaneous pedicled flaps is limited by small sample sizes, particularly of the rectus abdominis myocutaneous group. Nevertheless, using the anterolateral thigh flap, which lies entirely outside the abdominal cavity, can eliminate the most common and morbid delayed complication in the rectus abdominis myocutaneous group, the development of incisional hernia at the site of the pedicle opening. This and the other advantages of the anterolateral thigh flap outlined above certainly argue for strongly considering its use in cases involving reconstruction in the groin region, and we expect that an increasing number surgeons will favor its use in the coming years. However, every case must be considered individually based not only on the parameters of the wound but also on the patient’s body habitus and vascular anatomy. In some cases, the rectus
170
abdominis myocutaneous flap or other pedicled and free flap options may offer the best risk-tobenefit ratio, emphasizing that the surgeon should continue to strive to be familiar with as many methods in the reconstructive toolbox as possible. Matthew M. Hanasono, M.D. Department of Plastic Surgery The University of Texas M. D. Anderson Cancer Center 1400 Pressler, Unit 1488 Houston, Texas 77030 [email protected]
REFERENCES 1. Wong S, Garvey P, Skibber J, Yu P. Reconstruction of pelvic exenteration defects with anterolateral thigh-vastus lateralis muscle flaps. Plast Reconstr Surg. 2009;124:1177–1185. 2. Lannon DA, Ross GL, Addison PD, Novak CB, Lipa JE, Neligan PC. Versatility of the proximally pedicled anterolateral thigh flap and its use in complex abdominal and pelvic reconstruction. Plast Reconstr Surg. 2011;127:677–688. 3. Nosrati N, Chao AH, Chang DW, Yu P. Lower extremity reconstruction with the anterolateral thigh flap. J Reconstr Microsurg. 2012;28:227–234. 4. Chao AH, Neimanis SA, Chang DW, Lewis VO, Hanasono MM. Reconstruction after internal hemipelvectomy: Outcomes and reconstructive algorithm. Ann Plast Surg. (in press). 5. Hanasono MM, Skoracki RJ, Yu P. A prospective study of donor-site morbidity after anterolateral thigh fasciocutaneous and myocutaneous free flap harvest in 220 patients. Plast Reconstr Surg. 2010;125:209–214. 6. 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.
I
F1
n the article “The Anterolateral Thigh Flap for Groin and Lower Abdominal Defects: A Better Alternative to the Rectus Abdominis Flap,” LoGiudice et al. compare their experience with the pedicled anterolateral thigh flap to the pedicled rectus abdominis myocutaneous flap for reconstruction of wounds in the region of the groin. In their series of 30 anterolateral thigh and 10 rectus abdominis flaps, they found that the early postoperative complication rate was equivalent but that the rate of delayed postoperative complications was significantly higher in the rectus abdominis group. Notably, five of 10 patients developed a hernia at the rectus abdominis donor site because of the opening left in the fascia for the deep inferior epigastric vascular pedicle to pass through. Use of the pedicled anterolateral thigh flap is not new, although LoGiudice et al. are among the first to perform a comparative study with other techniques, specifically, the rectus abdominis myocutaneous flap, which has been considered the workhorse flap for most sizable defects in the groin region. Prior publications have described use of the pedicled anterolateral thigh flap for lower extremity, vaginal, penile, perineal, and abdominal wounds.1–3 Most recently, we reported its utility in reconstructing wounds resulting from internal hemipelvectomy.4 Although internal hemipelvectomies spare the lower limb, they often result in considerable defects of the bony pelvis and overlying soft tissues, and patients may benefit not only from use of the anterolateral thigh skin paddle to achieve tension-free wound closure but also from use of the vastus lateralis muscle to fill dead space and protect the abdominal organs (Fig. 1).
From the Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center. Received for publication August 9, 2013; accepted August 13, 2013. Copyright © 2013 by the American Society of Plastic Surgeons DOI: 10.1097/01.prs.0000437227.92681.a2
As the authors mention, the pedicled anterolateral thigh flap has numerous advantages. Our group has previously shown that there is minimal morbidity following anterolateral thigh flap harvest, including good functional recovery, even when some or all of the vastus lateralis muscle is included in the flap.5 As the authors point out, unlike the rectus abdominis myocutaneous flap, a fascial opening for the pedicle that puts the patient at risk for a hernia is not needed for the anterolateral thigh to reach the groin. In addition, our experience is that the pedicle to the rectus abdominis myocutaneous flap is often divided as part of radical resection, requiring a microvascular repair that may involve vein grafting, use of the contralateral rectus abdominis myocutaneous flap (which may have less reach), or use of another reconstructive flap. Both flaps may be relatively contraindicated in obese patients, although use of the rectus abdominis or vastus lateralis muscle covered by a skin graft remains an option. The main disadvantage of the anterolateral thigh flap is its somewhat variable vascular anatomy. In approximately 6 percent of cases, the cutaneous perforator may be absent or be too small to be reliable.6 In addition, in some cases, a perforator that arises directly from the profunda femoris artery rather than the descending or transverse branch of the lateral circumflex femoral artery may result in a pedicle with more restricted reach. The authors allow their patients to sit in a chair and ambulate as tolerated on the first postoperative day. It is reassuring to know that such early mobilization, particularly sitting, which requires joint flexion in the vicinity of the pedicle of either flap, does not adversely affect blood flow to the flap. As the authors describe, we have
Disclosure: The author has no financial interest to declare in relation to the content of this Discussion or of the associated article.
www.PRSJournal.com
169
Plastic and Reconstructive Surgery • January 2014
Fig. 1. Defect resulting from a combined Enneking type II and III internal hemipelvectomy for sarcoma in a patient who underwent neoadjuvant irradiation and chemotherapy (left). The defect was reconstructed with bioprosthetic mesh and a pedicled anterolateral thigh (ALT) myocutaneous flap, which was tunneled beneath the rectus femoris muscle (center). Completed reconstruction (right).
not witnessed significant pedicle compression secondary to transposing the anterolateral thigh flap under the rectus femoris muscle, and agree that this maneuver can substantially extend the reach of the flap. We do restrict the patient’s knee movement with a knee immobilizer for 1 to 2 weeks after surgery when the anterolateral thigh donor site has been skin grafted to minimize shearing of the graft from the underlying quadriceps muscle bed. Doing so has decreased our rate of skin graft loss, which was a relatively common complication observed in the series by LoGiudice et al. The comparison between the anterolateral thigh and the rectus abdominis myocutaneous pedicled flaps is limited by small sample sizes, particularly of the rectus abdominis myocutaneous group. Nevertheless, using the anterolateral thigh flap, which lies entirely outside the abdominal cavity, can eliminate the most common and morbid delayed complication in the rectus abdominis myocutaneous group, the development of incisional hernia at the site of the pedicle opening. This and the other advantages of the anterolateral thigh flap outlined above certainly argue for strongly considering its use in cases involving reconstruction in the groin region, and we expect that an increasing number surgeons will favor its use in the coming years. However, every case must be considered individually based not only on the parameters of the wound but also on the patient’s body habitus and vascular anatomy. In some cases, the rectus
170
abdominis myocutaneous flap or other pedicled and free flap options may offer the best risk-tobenefit ratio, emphasizing that the surgeon should continue to strive to be familiar with as many methods in the reconstructive toolbox as possible. Matthew M. Hanasono, M.D. Department of Plastic Surgery The University of Texas M. D. Anderson Cancer Center 1400 Pressler, Unit 1488 Houston, Texas 77030 [email protected]
REFERENCES 1. Wong S, Garvey P, Skibber J, Yu P. Reconstruction of pelvic exenteration defects with anterolateral thigh-vastus lateralis muscle flaps. Plast Reconstr Surg. 2009;124:1177–1185. 2. Lannon DA, Ross GL, Addison PD, Novak CB, Lipa JE, Neligan PC. Versatility of the proximally pedicled anterolateral thigh flap and its use in complex abdominal and pelvic reconstruction. Plast Reconstr Surg. 2011;127:677–688. 3. Nosrati N, Chao AH, Chang DW, Yu P. Lower extremity reconstruction with the anterolateral thigh flap. J Reconstr Microsurg. 2012;28:227–234. 4. Chao AH, Neimanis SA, Chang DW, Lewis VO, Hanasono MM. Reconstruction after internal hemipelvectomy: Outcomes and reconstructive algorithm. Ann Plast Surg. (in press). 5. Hanasono MM, Skoracki RJ, Yu P. A prospective study of donor-site morbidity after anterolateral thigh fasciocutaneous and myocutaneous free flap harvest in 220 patients. Plast Reconstr Surg. 2010;125:209–214. 6. 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.
