“Extended” Anterolateral Thigh Free Flap For Reconstruction Of Large Soft Tissue Defects

Background Large defects of the integument pose a challenge because even with free flap coverage a sufficiently large fasciocutaneous paddle is often unavailable. A workhorse resort in these cases is the anterolateral thigh (ALT) flap, which allows harvest up to 35 cm, in most series. However, the proximal end is prone to necrosis after traditional ALT harvest. We describe a technique to overcome this: turbocharging the standard ALT– in effect recruiting adjacent angiosomes – thus increasing the area that can be reliably harvested. We report 16 patients where the extended free ALT was indicated at our center. Patient demographic and operative details (flap dimensions, the area successfully harvested, the number of perforators recruited) and outcomes were collated. Mean follow up was 6 months. Technique involves dissecting and dividing the transverse branch of the LCFA during harvest and in-vivo end-to-end anastomosis of this branch to the rectus femoris branch of the pedicle (descending branch of the LCFA). Results 50% of patients had traumatic wounds and the other 50% had post tumor ablation defects. 12 were extremity wounds and 4 were head and neck defects. Mean flap dimensions were 33.3 x 13 ± 4 cm; mean gain in the area by extending the ALT flap was 36 cm2. All flaps survived in full at 6 months follow up. Conclusion Extending the standard ALT-free flap by turbocharging prevents peripheral necrosis and allows harvest of much larger skin paddles, as needed.