Clin Orthop Surg.  2017 Sep;9(3):348-354. 10.4055/cios.2017.9.3.348.

Differences between the Upper Extremity and the Lower Extremity in Reconstruction Using an Anterolateral Thigh Perforator Flap

• Lee SH
• Suh JT
• Ahn TY
• Hong SM
• Lee HY

• KMID: 2412272
• DOI: http://doi.org/10.4055/cios.2017.9.3.348

Abstract

BACKGROUND
While reconstruction of soft tissue defects is the common purpose, surgical reconstructions of upper extremities and lower extremities have different goals in terms of functional and aesthetic outcomes. The purpose of the current study was to compare and analyze differences between reconstructions of upper extremities and lower extremities using an anterolateral thigh (ALT) flap.
METHODS
We analyzed 74 patients who underwent reconstructions of upper extremities and lower extremities using an ALT flap from October 2006 to August 2012 (upper extremities, 45 cases; lower extremities, 29 cases). The study focused on the statistical analysis of patient satisfaction according to the donor site of the ALT flap and the timing of a debulking procedure.
RESULTS
On the choice of donor site, in the upper extremity reconstruction, flap elevation from the opposite side of the recipient limb was preferred (p = 0.019) because it causes less inconvenience while walking. In the lower extremity reconstruction, flap elevation from the same side of the recipient limb (p = 0.002) was preferred. The debulking procedure performed on the upper extremities at 4 weeks after reconstruction led to better functional results and enhanced patient satisfaction (p = 0.022). In the case of lower extremities, enhanced satisfaction was noted in patients who underwent the procedure at 6 months after reconstruction (p < 0.001).
CONCLUSIONS
Elevation of the flap in reconstruction reduced inconvenience when performed on the same side of the recipient limb for lower extremities and on the opposite side for upper extremities. In addition, debulking resulted in better satisfaction when performed 4 weeks postoperatively in the upper extremities and 6 months postoperatively in the lower extremities.

Keyword

Upper extremity and lower extremity; Debulking; Anterolateral thigh flap

MeSH Terms

Arm/*surgery
Arm Injuries/etiology/surgery
Humans
Leg/*surgery
Leg Injuries/etiology/surgery
Operative Time
Patient Satisfaction
Perforator Flap/*surgery
Reconstructive Surgical Procedures/*methods
Thigh/*surgery

Reference

1. Jacobson JH, Suarez EL. Microsurgery in anastomosis of small vessels. Surg Forum. 1960; 11:243–245.

2. Knobloch K, Herold C, Vogt PM. Free latissimus dorsi flap transfer for reconstruction of soft tissue defects of the lower extremity. Oper Orthop Traumatol. 2012; 24(2):122–130. PMID: 22446843.

3. Hasegawa H, Okazaki M, Sasaki K. Restoration of thumb abduction damaged by electrical burn using the free dorsalis pedis flap with the extensor hallucis brevis tendon. J Reconstr Microsurg. 2006; 22(1):33–36. PMID: 16425119.

4. Moukarbel RV, White JB, Fung K, Franklin JH, Yoo JH. The scapular free flap: when versatility is needed in head and neck reconstruction. J Otolaryngol Head Neck Surg. 2010; 39(5):572–578. PMID: 20828522.

5. Ulusal BG, Lin YT, Ulusal AE, Lin CH. Free lateral arm flap for 1-stage reconstruction of soft tissue and composite defects of the hand: a retrospective analysis of 118 cases. Ann Plast Surg. 2007; 58(2):173–178. PMID: 17245144.

6. Yildirim S, Calikapan GT, Akoz T. Reliable option for reconstruction of amputation stumps: the free anterolateral thigh flap. Microsurgery. 2006; 26(5):386–390. PMID: 16783808.

7. 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(2):149–159. PMID: 6713155.

8. Koshima I, Fukuda H, Yamamoto H, Moriguchi T, Soeda S, Ohta S. Free anterolateral thigh flaps for reconstruction of head and neck defects. Plast Reconstr Surg. 1993; 92(3):421–428. PMID: 8341740.

9. Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin CH. Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps. Plast Reconstr Surg. 2002; 109(7):2219–2226. PMID: 12045540.

10. Lee JH, Chung DW, Han CS. Outcomes of anterolateral thigh-free flaps and conversion from external to internal fixation with bone grafting in gustilo type IIIB open tibial fractures. Microsurgery. 2012; 32(6):431–437. PMID: 22434519.

11. 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(1):209–214. PMID: 19910852.

12. Lee JC, St-Hilaire H, Christy MR, Wise MW, Rodriguez ED. Anterolateral thigh flap for trauma reconstruction. Ann Plast Surg. 2010; 64(2):164–168. PMID: 20098100.

13. Yildirim S, Taylan G, Eker G, Akoz T. Free flap choice for soft tissue reconstruction of the severely damaged upper extremity. J Reconstr Microsurg. 2006; 22(8):599–609. PMID: 17136672.

14. Engel H, Lin CH, Wei FC. Role of microsurgery in lower extremity reconstruction. Plast Reconstr Surg. 2011; 127(Suppl 1):228S–238S. PMID: 21200295.

15. Hollenbeck ST, Woo S, Komatsu I, Erdmann D, Zenn MR, Levin LS. Longitudinal outcomes and application of the subunit principle to 165 foot and ankle free tissue transfers. Plast Reconstr Surg. 2010; 125(3):924–934. PMID: 20009789.

16. Song K, Nam S, Choi S, Kim J, Lee J, Bae Y. Objective preoperative estimation of the ability of primary closure on anterolateral thigh free flap donor site: circumference and area ratios of deep tissue to thigh. Microsurgery. 2013; 33(4):270–274. PMID: 23345120.

17. Demirtas Y, Kelahmetoglu O, Cifci M, Tayfur V, Demir A, Guneren E. Comparison of free anterolateral thigh flaps and free muscle-musculocutaneous flaps in soft tissue reconstruction of lower extremity. Microsurgery. 2010; 30(1):24–31. PMID: 19774628.

18. Chowdary RP, Murphy RX. Delayed debulking of free muscle flaps for aesthetic contouring debulking of free muscle flaps. Br J Plast Surg. 1992; 45(1):38–41. PMID: 1737206.

19. Hallock GG. Liposuction for debulking free flaps. J Reconstr Microsurg. 1986; 2(4):235–239. PMID: 3761244.

20. Lin TS, Jeng SF. Full-thickness skin graft as a one-stage debulking procedure after free flap reconstruction for the lower leg. Plast Reconstr Surg. 2006; 118(2):408–412. PMID: 16874211.

21. Gavrilenko AV, Sandrikov VA, Svirshchevskii EB, Omarzhanov OA. Surgical decision-making in management of patients with lower limb critical ischaemia using radioisotope scintigraphy. Angiol Sosud Khir. 2009; 15(3):43–48.

22. Ismailov NB, Vesnin AV. Study of the microbial spectrum of ulcerative-and-necrotic lesions in gerontological patients with lower limb chronic ischaemia. Angiol Sosud Khir. 2009; 15(2):36–40. PMID: 19806937.

23. Malakhov IuS, Aver'ianov DA, Ivanov AV. Analysis of outcomes of surgical management of patients presenting with ischemic etiology pyonecrotic lesions of lower limbs. Angiol Sosud Khir. 2009; 15(1):133–137.

24. Ozkan O, Coskunfirat OK, Ozgentas HE. The use of free anterolateral thigh flap for reconstructing soft tissue defects of the lower extremities. Ann Plast Surg. 2004; 53(5):455–461. PMID: 15502461.