MICROSURGERY

Fascia-Only Anterolateral Thigh Flap for Extremity Reconstruction Paige Fox, MD, PhD, Ryan Endress, MD, Subhro Sen, MD, and James Chang, MD Introduction: The ability to use the anterolateral thigh (ALT) f lap as a vascularized fascial f lap, without skin or muscle, was first documented by Koshima et al in 1989. The authors mention the possibility of using the fascia alone for dural reconstruction. Despite its description more than 20 years ago, little literature exists on the application of the ALT f lap as a vascularized fascial f lap. In our experience, the ALT f lap can be used as a fascia-only f lap for thin, pliable coverage in extremity reconstruction. Methods: After approval from the institutional review board, the medical records and photographs of patients who had undergone fascia-only ALT free f laps for extremity reconstruction were reviewed. Photographic images of patients were then matched to patients who had undergone either a muscleonly or a fasciocutaneous free f lap reconstruction of an extremity. Photographs of the final reconstruction were then given to medical and nonmedical personnel for analysis, focusing on aesthetics including color and contour. Results: Review of cases performed over a 2-year period demonstrated similar ease of harvest for fascia-only ALT flaps compared to standard fasciocutaneous ALT flaps. Fascia-only flaps were used for thin, pliable coverage in the upper and lower extremities. There was no need for secondary procedures for debulking or aesthetic flap revision. In contrast to muscle flaps, which require muscle atrophy over time to achieve their final appearance, there was a similar flap contour from approximately 1 month postoperatively throughout the duration of follow-up. When a large flap is required, the fascia-only ALT has the advantage of a singleline donor-site scar. Photograph comparison to muscle flaps with skin grafts and fasciocutaneous flaps demonstrated improved color, contour, and overall aesthetic appearance of the fascia-only ALT over muscle and fasciocutaneous flaps. Conclusions: The fascia-only ALT f lap provides reliable, thin, and pliable coverage with improved contour and color over muscle and fasciocutaneous f laps. The fascia-only ALT is another excellent option for reconstructive surgery of the extremities. Key Words: ALT, extremity reconstruction, free flap (Ann Plast Surg 2014;72: S9YS13)

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ultiple and variable uses of the anterolateral thigh (ALT) f lap have been published in the literature since its first description by Song et al in 1984.1 It is a well-documented reconstructive option for head and neck, extremity, and perineal reconstruction. The f lap can be pedicled or transferred as a free f lap depending on the defect requiring coverage. The ALT f lap has become a workhorse because of the variety of roles it can fill in reconstruction. The value of the ALT f lap comes from its long vascular pedicle, ease of dissection, and reliability.2Y4 The added benefit of the ALT f lap is the multiple ways in which it can be harvested. Variable

Received June 20, 2013, and accepted for publication, after revision, December 29, 2013. From the Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Stanford, CA. Conflicts of interest and sources of funding: none declared. Reprints: James Chang, MD, Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, 770 Welch Rd, Suite 400, Palo Alto, CA 94304. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0148-7043/14/7201-S009 DOI: 10.1097/SAP.0000000000000146

Annals of Plastic Surgery

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amounts of the vastus lateralis can be included in the f lap to provide bulk if needed. When harvested as a fasciocutaneous f lap, it can be thinned to provide the ideal thickness for the defect of interest.4,5 If multiple components are required, the rectus femoris or tensor fascia lata can be added.6 The ALT f lap has also been described as a neurotized f lap for tongue reconstruction.7 The ability to use the ALT as a vascularized fascial f lap, without skin or muscle, was first documented by Koshima et al.8 The authors recorded the use of the fascia alone in the reconstruction of an abdominal defect. In the same manuscript, the authors mention the possibility of using the fascia alone in dural reconstruction. Despite its description more than 20 years ago, little literature exists on the application of the ALT f lap as a vascularized fascial flap. Agostini et al have described their experience with the adipofascial ALT flap for oral reconstruction, whereas Parrett et al recorded its use for dorsal hand reconstruction.9Y11 Here, we document our experience using the fascia-only ALT free f lap for thin, pliable coverage in the extremities. Additionally, we surveyed a varied population consisting of surgeons and laypersons asking them to compare aesthetic outcomes after the fascia-only ALT free f lap versus traditional muscle and fasciocutaneous free f laps for extremity reconstruction.

METHODS After approval from the institutional review board, the medical records and photographs of patients who had undergone fasciaonly ALT free f laps for extremity reconstruction were reviewed. The patient’s age, medical comorbidities, surgical history, operative reports, and postoperative course were compiled. Patients with fasciaonly ALT free f laps were matched to patients who had undergone a muscle free f lap or fasciocutaneous free f lap. All fascia-only ALT f laps and muscle f laps required split-thickness skin graft (STSG) coverage. Pictures for comparison were selected from a senior microsurgeon’s collection deemed by the surgeon to be good to excellent results in patients without complications. Comparison photographs that highlighted both color and contour of the f lap were selected. A questionnaire and paired photographs of the outcome after reconstruction were given to surgeons and laypersons for analysis. The questionnaire focused on aesthetic outcome including color and contour. Respondents were asked a series of 3 questions about each photograph based on a 5-point scale (1, unacceptable; 2, poor; 3, acceptable; 4, good; and 5, excellent). Respondents were then asked to select the overall better aesthetic outcome among the pair or to rate them as equivalent. Respondents were not told the type of f lap represented in each photograph. A representative photograph pairing and standard set of questions for each set of photographs can be seen in Figure 1.

RESULTS Case Series Between October of 2010 and February of 2012, 5 patients underwent extremity reconstruction with fascia-only ALT free flaps by 1 senior surgeon. A representative flap is shown in Figure 2. Four patients required lower extremity reconstruction, whereas 1 patient required reconstruction of his thumb and first web space. Three patient www.annalsplasticsurgery.com

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FIGURE 1. Sample set of survey questions and photographs. Left, Survey questions for each of 5 sets of photograph pairs. Right, Sample set of pictures for comparison of different f laps (photographs 1A and 1B). The type of f lap being analyzed was not disclosed to the respondent.

wounds resulted from fracture fixation with hardware, whereas 2 patient wounds resulted from infections. The average patient age was 55 years at time of reconstruction. Wound sizes ranged from 1 to 56 cm2. Patients had an average length of stay of 14 days and average follow-up of 12 months. Three patients had uncomplicated recoveries. One flap developed venous congestion requiring return to the operating room. The flap was salvaged but a portion of the skin graft did not survive and the patient required repeat skin grafting. One patient was lost to follow-up. Pictures of long-term follow-up are shown in Figure 3. Data are summarized in Table 1.

selected as equivalent in 1 of 5 pairings. A summary of results appears in Figure 4.

DISCUSSION Multiple publications have described the usefulness of the ALT free f lap in reconstructive surgery.3,12,13 In this manuscript, we have reviewed our experience with the fascia-only variation of this f lap specifically for extremity reconstruction.

Photograph Comparison Survey One hundred eighty-five people responded to the photograph comparison survey. One hundred sixty-seven people completed all questions within the survey. Twenty-nine residents, 10 fully trained physicians, and 2 medical students responded, accounting for 24% of respondents. Overall, 42% of respondents were in the medical profession in some capacity (nurse, therapist, administrative, sales, etc). Almost 11% of respondents had a friend or family member whom had undergone extremity reconstruction. A summary of respondent demographics is seen in Table 2. The fascia-only ALT f laps and the fasciocutaneous f laps scored similarly in analysis of color with average scores of 3.2 and 2.9, respectively, corresponding to an ‘‘acceptable’’ rating. In contrast, the average color score for the muscle f laps was 1.7, corresponding to a ‘‘poor’’ rating. In terms of contour, the fascia-only ALT f laps scored better than other f laps with an average score of 3.2 compared to 2.4 and 2.5 for the fasciocutaneous f laps and the muscle f laps, respectively. The fascia-only ALT f laps also outscored other f laps when judged on overall appearance with an average rating of 3.1 or ‘‘acceptable.’’ In a direct head-to-head comparison, the fascia only f lap was selected over other f laps in 4 of 5 pairings. It was S10

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FIGURE 2. Fascia-only ALT f lap. Shown after completion of dissection before vessel division; demonstrating the thin, pliable nature of the f lap. * 2014 Lippincott Williams & Wilkins

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Fascia-Only ALT

FIGURE 3. Long-term results of fascia-only ALT f laps. A, SBV12 month follow-up, (B) ICV6 month follow-up, (C) BLV21 month follow-up, and (D) NRV22 month follow-up.

We noted 3 major advantages of the fascia-only variation over other muscle and fasciocutaneous flaps. First, we noted a stable and predictable appearance of the flap over time with less atrophy compared to muscle flaps. Second, in contrast to other fasciocutaneous flaps used for extremity reconstruction,14 patients did not require secondary procedures for thinning to improve flap contour. Contour prominence of a flap can affect function such as digit motion in the hand or the ability to wear shoes in the foot and ankle area. Third, donor-site incisions resulted in consistent, straight-line scars, regardless of the size of the flap. In contrast, large fasciocutaneous ALT free flaps often require STSG for donor-site closure.15 Therefore, stable, thin form and straight-line donor incision are the major advantages. One potential disadvantage of the fascia-only ALT f lap noted was unreliable skin graft take. Although 3 patients seen in long-term follow-up did not have skin graftYrelated complications, 1 patient required revision skin grafting. Since the time of this case series, we have modified our harvest technique to include careful dissection over the fascia, protection of the loose superficial areolar tissue, and avoidance of electrocautery along this plane. With refinement in technique, we have experienced an improvement in skin graft take over the fascia-only ALT f lap in short-term outcomes. The photograph comparison survey was designed to have both medical and nonmedical independent observers assess color, contour, and overall aesthetic outcomes after free flap reconstruction of the extremities. A second goal of the survey was to allow for a head-to-head

comparison of fascia-only ALT flaps with STSG to either muscle flaps with STSG or fasciocutaneous f laps. The color match of the fasciaonly ALT f lap to the surrounding normal extremity was rated as ‘‘good’’ in most of the photographs. In contrast, the color match was rated as ‘‘poor’’ for all muscle f laps. One criticism of this article is the comparison of sheet skin grafts over the fascia-only ALT f lap to meshed skin grafts over the muscle f laps. This factor might account for some of the difference in rating. We hypothesized that the fasciocutaneous f laps would have a higher color match rating than the f laps requiring skin grafting; however, this was not the case. The fasciocutaneous f laps received the highest color match rating when the f lap was harvested from the same portion of the body in which it was inset (eg, ALT to leg). The color match of fasciocutaneous f laps that were inset into distant recipient sites (eg, radial forearm f lap to leg) were rated as ‘‘poor.’’ In terms of contour match to the surrounding extremity, muscle f laps have been noted to have a favorable contour in long-term follow-up as the muscle atrophies and conform to the shape of the underlying tissue. However, the survey results from this study demonstrated that the muscle flap was rated only slightly better than the fasciocutaneous flaps and poorer than fascia-only flaps. We hypothesize that this is due to the stable and predictable contour of the fasciaonly flap in comparison to the muscle flap. The muscle flap atrophies over weeks to months and, long-term, does not appear the same as it does on the day of surgery. In contrast, the appearance of the fascia-only

TABLE 1. Summary of Case Series Patients Patient

Age, y

Sex

Wound Location

Prior Procedures

Indications

Length of Stay, d

Complications

Follow-up, mo

SB IC

60 71

F F

Tibia (distal 1/3) Tibia (middle 1/3)

Hardware exposure Bone exposure

7 11

None None

12 6.5

BL NR

72 45

F F

Ankle Tibia (distal 1/3)

ORIF Antibiotic spacer for chronic osteomyelitis Total ankle arthroplasty IM rod and ICBG

Hardware exposure Bone exposure

13 25

DV

25

M

First web space and thumb

Debridement for infection

Soft tissue reconstruction

14

None Venous congestion; partial STSG loss Lost to follow-up

21 22 0

ICBG indicates iliac crest bone graft; IM, intramedullary; ORIF, open reduction internal fixation.

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TABLE 2. Summary of Respondent Demographics Age, y G18 18Y25 26Y40 41Y60 960

Medical Profession 0 5 109 31 24

Resident Fully trained physician Nurse Administrative Therapist Sales/marketing Medical student Other

29 10 10 10 7 3 2 17

flap at the time of surgery is very similar to its appearance in the weeks, months, and years after surgery. The flap can be tailored to the wound at the time of the initial operation and thereby avoid secondary procedures. In 2010 Parrett et al11 surveyed 5 medical personnel examining the aesthetic outcomes after free f lap reconstruction of the dorsal hand. Venous f laps rated highest in overall aesthetic outcome and color in their series. Muscle and fascia f laps scored significantly higher than fasciocutaneous f laps in terms of color and overall aesthetic outcome. Muscle and fascia f laps scored equivalently in terms of contour and all both were rated above fasciocutaneous flaps. In our series, we noted a similar superior rating of fascia-only f laps in color, contour, and overall appearance. However, fasciocutaneous f laps ranked above muscle f laps in terms of color and overall appearance. We feel these differences likely stem from both the difference in the audience surveyed and the use of sheet versus meshed skin grafts, which can significantly inf luence aesthetic outcomes as noted by Parrett et al. The most surprising result of the photograph survey was the low rating all f laps received for overall aesthetic outcomes. As reconstructive plastic surgeons, we strive to restore function and form which should include aesthetic considerations. In the case of extremity reconstruction, the area of reconstruction is visible to the

FIGURE 4. Survey results. The fascia-only ALT (blue) scored higher on average than the fasciocutaneous (red) and muscle (green) f laps in color, contour, and overall aesthetic result. 1, unacceptable; 2, poor; 3, acceptable; 4, good; and 5, excellent. S12

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Family or Friend Who Has Undergone Reconstruction

Specialty Plastic surgery General surgery Orthopedic surgery Emergency medicine Critical care Sports medicine Neurosurgery Cardiac surgery Hand surgery Radiology OB-Gyn Otolaryngology

19 6 2 1 1 1 1 1 1 1 1 1

Yes No

18 151

patient, and possibly the public. Most of the 167 respondents to our survey rated the overall aesthetic appearance of 6 of 10 f laps as ‘‘poor.’’ Although advances in reconstruction have allowed us to salvage more extremities and improve f lap survival, the results of this survey indicate that both the medical and nonmedical communities believe we have room to improve the aesthetic outcome of our reconstructions. Klinkenberg et al16 surveyed patient satisfaction after free f lap reconstruction, noting that greater than 70% of patients would choose their f lap again. In the same study, average patient satisfaction ranged from good to fair/satisfactory (2.5 to 2.9 on a 6-point scale with 1 as excellent and 6 as poor/fail). Perhaps those patients rated their overall outcome higher than the respondents in our survey because after reconstruction, patients appreciate how far they have come from their original wound/injury.

CONCLUSIONS The fascia-only ALT free f lap is a good option for extremity reconstruction with favorable color and contour match to the surrounding extremity. The f lap is thin and pliable with a stable contour, limiting the need for secondary revision procedures. 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;37:149Y159. 2. 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;109:2211Y2216; discussion 2217Y2218. 3. 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: 2219Y2226; discussion 2227Y2230. 4. Koshima I, Fukuda H, Yamamoto H, et al. Free anterolateral thigh flaps for reconstruction of head and neck defects. Plast Reconstr Surg. 1993;92:421Y428; discussion 429Y430. 5. Kimura N, Satoh K. Consideration of a thin flap as an entity and clinical applications of the thin anterolateral thigh flap. Plast Reconstr Surg. 1996;97: 985Y992. 6. Sasaki K, Nozaki M, Nakazawa H, et al. Reconstruction of a large abdominal wall defect using combined free tensor fasciae latae musculocutaneous flap and anterolateral thigh flap. Plast Reconstr Surg. 1998;102:2244Y2252. 7. Kimata Y, Uchiyama K, Ebihara S, et al. Comparison of innervated and noninnervated free flaps in oral reconstruction. Plast Reconstr Surg. 1999;104: 1307Y1313. 8. Koshima I, Fukuda H, Utunomiya R, et al. The anterolateral thigh flap; variations in its vascular pedicle. Br J Plast Surg. 1989;42:260Y262. 9. Agostini V, Dini M, Mori A, et al. Adipofascial anterolateral thigh free flap for tongue repair. Br J Plast Surg. 2003;56:614Y618.

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10. Agostini T, Agostini V, Lazzeri D. Current roles of adipofascial anterolateral thigh flap in head and neck reconstructions. Head Neck. 2011;33:595Y596; author reply 596Y597. 11. Parrett BM, Bou-Merhi JS, Buntic RF, et al. Refining outcomes in dorsal hand coverage: consideration of aesthetics and donor-site morbidity. Plast Reconstr Surg. 2010;126:1630Y1638. 12. 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;48:161Y166.

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Fascia-Only ALT

13. Lin PY, Miguel R, Chew KY, et al. The role of the anterolateral thigh flap in complex defects of the scalp and cranium. Microsurgery. 2014;34:14Y19. 14. Agostini T, Lazzeri D, Spinelli G. Anterolateral thigh flap thinning: techniques and complications. Ann Plast Surg. 2014;72:246Y252. 15. Collins J, Ayeni O, Thoma A. A systematic review of anterolateral thigh flap donor site morbidity. Can J Plast Surg. 2012;20:17Y23. 16. Klinkenberg M, Fischer S, Kremer T, et al. Comparison of anterolateral thigh, lateral arm, and parascapular free flaps with regard to donor-site morbidity and aesthetic and functional outcomes. Plast Reconstr Surg. 2013;131:293Y302.

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Fascia-only anterolateral thigh flap for extremity reconstruction.

The ability to use the anterolateral thigh (ALT) flap as a vascularized fascial flap, without skin or muscle, was first documented by Koshima et al in...
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