The use of anterolateral thigh (ALT) free flap for dorsal foot resurfacing in pediatric patients

Background: Since the first days of microsurgery, there has been reluctance in the predominant use of free tissue transfer in younger age groups, with the initial attention on the technically challenging micro-anastomosis in children. High frequency of specific accidental foot injuries in pediatrics has received some awareness in the international literature. The muscle flaps were initially the choice for the coverage of distal lower limb deficits; however, the donor site morbidity and the bulky appearance attracted attention to more delicate flaps, with the fasciocutaneous anterolateral thigh (ALT) flap becoming a basic reconstructive option. Methods: Reconstruction with a free anterolateral thigh (ALT) flap was performed in 24 pediatric patients (mean age, 9.9 ± 3.6 years; range, 4.5 - 16 years) between October 2022 and September 2024. All patients presented with post-traumatic dorsal foot and ankle defects. A hand-held Doppler (8 MHz) probe was used to detect the cutaneous perforators supplying the flap, and to evaluate patency of the recipient vessels (anterior and posterior tibial arteries). Flap dissection and vessels’ anastomoses were performed using 5x magnifying loupes. All the patients were subjected to reconstruction after 72 hours from trauma. Results: In this study, most of the children were males (75%), the mean size of the skin flap was 8.62 ± 1.61 cm in width, and 15 ± 3 cm in length. A total of 75 % of the perforators were musculocutaneous, and 25 % were septocutaneous perforators. The anterior tibial vessels were commonly used as recipient in 22 (91.66 %) cases. The overall flap survival rate was 91.66 %, two cases with total flap loss were encountered. Donor site primary closure was performed in nineteen (79.16 %) cases. Regarding flap bulkiness, fifteen (68.18 % of successful flaps) children were able to wear shoes even before flap debulking, while seven (31.81 %) patients found difficulty in wearing. All children walked and climbed stairs; however, minor gait abnormalities were observed in 6 (25 %) children Conclusion: The free ALT flap could be a safe, reliable, and aesthetically appealing option for foot/ankle resurfacing in children after traumatic soft tissue loss.