Maximizing the Utility of the Pedicled Anterolateral Thigh Flap for Locoregional Reconstruction

The pedicled anterolateral thigh (PALT) flap is an underutilized flap for locoregional reconstruction largely because methods to maximize its reach are neither universally implemented nor fully understood. In addition, most of the available literature has focused on the utility of the free anterolateral thigh flap with less emphasis on the PALT flap. Moreover, flap design concepts to maximize its utility and reach and optimize outcomes have not been comprehensively described. In an effort to address this knowledge gap, the authors sought to review their institution’s experience with the PALT flap for locoregional reconstruction.

Key points

  • The pedicled anterolateral thigh flap (PALT) is reliable, has a good arc of rotation, and can be harvested as a fasciocutaneous flap with or without muscle depending on local anatomy and reconstructive needs. All these features make the flap a versatile option for locoregional reconstruction.

  • Understanding the anterolateral thigh (ALT) flap vascular anatomy and its variations helps in flap design and reach.

  • When ligating the arterial branch to the rectus femoris muscle, the secondary blood supply to the muscle must be assessed before ligation to avoid muscle necrosis. Also, during ALT flap harvest, care should be taken to preserve the minor pedicles to the rectus femoris muscle and ensure muscle viability.

  • Tunneling the flap deep to the rectus femoris and sartorius muscles, ligating the arterial branch to the rectus femoris when deemed necessary and safe, and including the largest distal skin paddle perforator are all key factors in maximizing the reach of the PALT flap for locoregional reconstruction.

Introduction

The anterolateral thigh (ALT) flap was initially described as a free flap by Song and colleagues in 1984. It gained popularity after Wei and colleagues published their experience using 672 free ALT flaps over a 14-year period. Since then, the clinical applications of the ALT flap have dramatically increased. The ALT flap was initially heavily used in head and neck reconstruction, and its use has extended to extremity and trunk reconstruction as well. Although primarily described as a free flap, the use of the ALT as a pedicled flap has gained more popularity recently. The pedicled anterolateral thigh flap (PALT) has been described for reconstruction of groin and abdominal wounds, perineal, penoscrotal, vaginal, vulvar, trochanteric, ischial, and posterior thigh defects. The PALT reach to reconstruct epigastric and supraumbilical defects has been reported to be reliable in about one-third of the patients. It has also been described as a functional flap for lower abdominal wall reconstruction ( Fig. 1 ).

Fig. 1
( A and B ) The PALT flap can be used to resurface the lower abdomen, epigastrium, perineum, ipsilateral groin, contralateral groin, trochanter, ischial, posterior thigh, and lower thigh defects. ( A ) Anteriorly, the PALT flap can be extended to reach the ipsilateral groin, suprapubic region/lower abdomen, contralateral groin, and periumbilical region. Laterally, the PALT flap can be extended to reach the lower flank region. ( B ) The PALT flap can reach the posterior thigh via intermuscular tunneling as well the ischial region. The PALT can also be used to resurface the trochanteric region.
(Copyright © Mayo Foundation for Medical Education and Research. All rights reserved.)

The PALT flap is a versatile flap due to its reliable vascular anatomy, relatively long pedicle, versatile skin paddle, and the feasibility of flap harvest as a chimeric flap based on the profunda artery vascular system. The PALT flap can be harvested as a fasciocutaneous, myocutaneous, or adipofascial flap. In addition, the PALT can be harvested with the rectus femoris (RF), vastus lateralis, or the tensor fascia lata (TFL), depending on the local anatomy and the reconstructive needs. Flap reach can be extended by including a distal perforator when appropriate. Suprafascial harvest has also been described to provide pliable tissue coverage when less flap bulk is needed. Few case series reported the use of PALT flap for locoregional reconstruction, but there is a paucity of technical details pertaining to extending the flap’s reach for different anatomic locations. Here the authors review their institutional experience and outcomes using the PALT flap for locoregional reconstruction with an emphasis on technical details pertaining to flap design, elevation, and extending reach.

Introduction

The anterolateral thigh (ALT) flap was initially described as a free flap by Song and colleagues in 1984. It gained popularity after Wei and colleagues published their experience using 672 free ALT flaps over a 14-year period. Since then, the clinical applications of the ALT flap have dramatically increased. The ALT flap was initially heavily used in head and neck reconstruction, and its use has extended to extremity and trunk reconstruction as well. Although primarily described as a free flap, the use of the ALT as a pedicled flap has gained more popularity recently. The pedicled anterolateral thigh flap (PALT) has been described for reconstruction of groin and abdominal wounds, perineal, penoscrotal, vaginal, vulvar, trochanteric, ischial, and posterior thigh defects. The PALT reach to reconstruct epigastric and supraumbilical defects has been reported to be reliable in about one-third of the patients. It has also been described as a functional flap for lower abdominal wall reconstruction ( Fig. 1 ).

Fig. 1
( A and B ) The PALT flap can be used to resurface the lower abdomen, epigastrium, perineum, ipsilateral groin, contralateral groin, trochanter, ischial, posterior thigh, and lower thigh defects. ( A ) Anteriorly, the PALT flap can be extended to reach the ipsilateral groin, suprapubic region/lower abdomen, contralateral groin, and periumbilical region. Laterally, the PALT flap can be extended to reach the lower flank region. ( B ) The PALT flap can reach the posterior thigh via intermuscular tunneling as well the ischial region. The PALT can also be used to resurface the trochanteric region.
(Copyright © Mayo Foundation for Medical Education and Research. All rights reserved.)

The PALT flap is a versatile flap due to its reliable vascular anatomy, relatively long pedicle, versatile skin paddle, and the feasibility of flap harvest as a chimeric flap based on the profunda artery vascular system. The PALT flap can be harvested as a fasciocutaneous, myocutaneous, or adipofascial flap. In addition, the PALT can be harvested with the rectus femoris (RF), vastus lateralis, or the tensor fascia lata (TFL), depending on the local anatomy and the reconstructive needs. Flap reach can be extended by including a distal perforator when appropriate. Suprafascial harvest has also been described to provide pliable tissue coverage when less flap bulk is needed. Few case series reported the use of PALT flap for locoregional reconstruction, but there is a paucity of technical details pertaining to extending the flap’s reach for different anatomic locations. Here the authors review their institutional experience and outcomes using the PALT flap for locoregional reconstruction with an emphasis on technical details pertaining to flap design, elevation, and extending reach.

Patients and surgical methods

Patients

Twenty-one consecutive patients underwent PALT for locoregional reconstruction at the Mayo Clinic, Rochester, Minnesota from November 2005 to April 2015. Operative details were analyzed including type and number of perforators, flap composition (fasciocutaneous or myofasciocutaneous), flap tunneling methods, intraoperative complications, postoperative complications, and methods of donor site closure. Postoperative complications were divided into early (within 30 days of the operation) and late (after 30 days).

Data Collection

There were 16 men and 5 women, who underwent PALT flap for locoregional reconstruction at a median age of 41 years. Mean follow-up was 20 months (range 0.4–64). Medical comorbidities were present in 8 (33%) of the patients, with hypertension being the most common medical comorbidity (n = 5), followed by diabetes mellitus (n = 4), hyperlipidemia (n = 4), coronary artery disease (n = 1), and chronic lung disease (n = 1). Only one patient was an active smoker at the time of the operation. Mean body mass index was 26 (range 15–40). In 6 (28%) of the patients, the recipient site received preoperative radiotherapy.

Indications and Site of the Defect that Needed Coverage

Reconstruction after oncologic resection was the most common indication of PALT flap usage (n = 13), followed by coverage of infected joints/prosthesis (n = 8), and pressure ulcers (n = 3). PALT was used for hip (n = 5), groin (n = 4), proximal thigh (n = 3), trochanteric (n = 3), lower abdomen (n = 2), posterior thigh (n = 2), ischial (n = 1), and vaginal (n = 1) reconstructions.

Perforator Patterns and Flap Composition

A pattern of septocutaneous and musculocutaneous perforators in the same patient was observed in only 3 patients, and the remaining 18 patients had either septocutaneous (9 patients) or musculocutaneous (9 patients) perforators. Myofasciocutaneous flaps were designed in 16 patients (4 of these were chimeric flaps), fasciocutaneous flaps in 4 patients, and a cutaneous flap in one patient.

Tunneling Methods

Various tunneling methods were entertained in the authors’ series to maximize the effective vascular pedicle length and minimize tension on the pedicle. Passing the flap under the RF muscle was necessary in 5 patients to avoid vascular pedicle compression and maximize length. Division of the sartorius muscle was required in 2 patients for the same reasons. Tunneling the flap subcutaneously to reach the recipient site was successfully performed in 17 patients. After completion of the subcutaneous tunneling, division of the skin bridge between the donor and recipient sites was performed in 10 of the 17 patients to avoid excessive compression on the PALT vascular pedicle by the skin bridge. This step was not necessary in the remaining 7 patients. In one patient, the flap was passed between the femur and the vastus intermedius muscle to cover a posterior thigh defect. The RF branch of the descending branch of the lateral circumflex femoral artery (LCFA) was divided in 7 patients after confirming rectus muscle viability through secondary perforators after clamping the vessel for 20 minutes. In these cases, the PALT pivot point was proximal to the RF perforator. The remaining patients had the PALT flap pivot point distal to the RF perforator (in these patients, the artery to the RF was preserved). Drain placement at the donor and recipient sites was routine.

Donor Site Management

The PALT donor site was closed primarily in 11 (52%) patients. Split-thickness skin graft (STSG) was necessary for donor site coverage in the remaining 10 (48%) patients.

Surgical Outcomes

There were no intraoperative complications. Early postoperative donor site complications occurred in 2 patients (inadequate STSG healing and infected donor site seroma). There were no late (more than 30 days) donor site complications. Two postoperative recipient site complications (one early and one late) occurred during the follow-up period. Both complications were related to recipient site infection of an underlying hip joint. Both complications required reoperation, PALT flap re-elevation, and further bone debridement. During the follow-up duration, no cases of partial or total flap loss were encountered.

Surgical pearls and pitfalls

The PALT flap is gaining popularity. It is reliable, has a good arc of rotation, has relatively consistent vascular pedicle, and can be elevated as a skin-only flap (suprafascial dissection), fasciocutaneous, or myofasciocutaneous flap. These features make the PALT flap a valuable option for locoregional reconstruction. Various tunneling options to various defect locations and technical pearls to extend flap reach were summarized based on literatures ( Table 1 ).

Table 1
Tunneling options for pedicled anterolateral thigh flap to extend its reach to various sites
Recipient Site Options for Tunneling Technical Pearls and Pitfalls
Lower abdomen
  • 1.

    Divide the skin bridge for inset

  • 2.

    Subcutaneous tunnel over the rectus mainly for lower abdominal defect

  • 3.

    Tunnel under the RF proximal to the rectus branch to increase the medial and superior extent of flap reach

  • 4.

    Alternatively, partially divide the RF laterally to increase reach

  • Tunnel proximal to the rectus branch

Epigastrium
  • 1.

    Tunnel under the RF and sartorius and then change tunneling plane to the suprafascial level to reach the epigastrium

  • Usually have to take the rectus branch to reach the epigastrium and lower costal regions

Ipsilateral groin
  • 1.

    Divide the skin bridge and inset

  • 2.

    Subcutaneous tunnel

  • 3.

    Tunnel under the RF proximal to the rectus arterial branch to increase the medial arc of rotation

Contralateral groin
  • 1.

    Medial subcutaneous tunnel extending through the pubic region to the contralateral groin

  • Be aware and careful of the medial saphenous vein when tunneling

Complex perineal and vaginal reconstruction
  • 1.

    Tunnel under the RF and in the medial subcutaneous plane (perineal route)

  • 2.

    Tunnel the flap subcutaneously in the groin and over the inguinal ligament (ligament can be divided lateral to the vessels if needed) to deliver into the pelvis (inguinal route)

  • If a large skin paddle is required, the perineal route is preferred for tunneling, although the reach is greater via inguinal region

  • Inguinal tunneling is usually preferred for an isolated vastus lateralis rather than an ALT

Greater trochanteric defects
  • 1.

    Lateral subcutaneous tunnel

  • 2.

    Lateral tunnel below the TFL

  • Design the flap based on distal perforators to maximize the superior extent of reach of the ALT flap

  • If a larger skin paddle is needed, divide the skin bridge to help enable inset

Ischial defects
  • 1.

    Lateral subcutaneous tunnel

  • 2.

    Medial subcutaneous tunnel

  • 3.

    Medial intermuscular pathway

  • 4.

    Directly via the intermuscular septum

  • Watch for the saphenous vein when tunneling medially

  • Consider tunneling via the medial intermuscular pathway when the pedicle length is short

Posterior thigh defects
  • 1.

    Lateral subcutaneous tunnel

  • 2.

    Medial subcutaneous tunnel

  • 3.

    Intermuscular tunnel via the vastus intermedius muscle

  • Decide on tunnel based on where exactly the defect is located in the posterior thigh (posterolateral vs posteromedial). The intermuscular tunnel can be a useful option when the pedicle length is small and a greater reach is needed, especially in an obese patient

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Nov 21, 2017 | Posted by in Dental Materials | Comments Off on Maximizing the Utility of the Pedicled Anterolateral Thigh Flap for Locoregional Reconstruction
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