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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 29  |  Issue : 1  |  Page : 51-54

Pedicled anterolateral thigh flap: A reliable flap for reconstruction of difficult regional defects in pediatric patients


Department of Plastic, Reconstructive and Aesthetic Surgery, Faculty of Medicine, Menoufia University, Sheben El-Kom, Menoufia, Egypt

Date of Submission13-Feb-2020
Date of Acceptance11-Mar-2020
Date of Web Publication31-Dec-2020

Correspondence Address:
Dr. Mohamed Abdalla Elnahas
Essam Omar Street, Sheben El-Kom, Menofia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjps.tjps_10_20

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  Abstract 


Background: Once it has been first described by Song et al., in 1984, anterolateral thigh (ALT) flap gains wide popularity as a free flap with only a few reports in the literature regarding its application as a pedicled flap in regional soft-tissue reconstruction in pediatric patients. Materials and Methods: The author describes his experience about the role of pedicled ALT flap in reconstruction of different local defects in pediatric patients. Representative cases are presented for illustration. Results: Nine patients with ischial, trochanteric, and groin defects have been reconstructed by pedicled ALT flap between January 2018 and January 2019. The patients were between 7- and 15-year-old. The size of the flaps measured from 4 cm × 6 cm to 19 cm × 17 cm. The type of the flap was myocutaneous flaps in six cases and as perforator flaps in three cases. Primary closure of the donor site has been done in seven cases while split-thickness skin grafts were done in two cases. Eight flaps have been totally survived while partial necrosis has been occurred in the distal end of one case. Conclusion: Pedicled ALT flap provide a reliable and versatile option for plastic surgeons in reconstruction of difficult regional soft-tissue defects in pediatric patients especially when bulkiness and resistance of infection is indicated, with accepted functional and cosmetic results.

Keywords: Anterolateral thigh, pediatric patients, pedicled flap


How to cite this article:
Elnahas MA. Pedicled anterolateral thigh flap: A reliable flap for reconstruction of difficult regional defects in pediatric patients. Turk J Plast Surg 2021;29:51-4

How to cite this URL:
Elnahas MA. Pedicled anterolateral thigh flap: A reliable flap for reconstruction of difficult regional defects in pediatric patients. Turk J Plast Surg [serial online] 2021 [cited 2021 Mar 6];29:51-4. Available from: http://www.turkjplastsurg.org/text.asp?2021/29/1/51/305902




  Introduction Top


To reconstruct a wide, irregular chronic wound defect in the pelvic and groin area especially in pediatric patients without the complexity of microvascular procedure represents a challenge for plastic surgeons.[1] From it has been first described by Song et al.,[2] in 1984; anterolateral thigh (ALT) flap become one of the most popular workhorse free flap that is being used to reconstruct different types of defects in many sites of the body such as head, neck, upper, and lower limbs.[3] This is due to the properties of the ALT flap that make it an ideal flap for soft-tissue reconstruction like its long vascular pedicle, versatility to harvest different tissue component in the same flap and insignificant donor site morbidity.[4]

Once it has been first described as a pedicled flap by Koshima et al.,[5] for reconstruction of an extensive perineal defect; there are few reports that describe the use of ALT as a pedicled flap.[6]

The author asses the reliability of pedicled proximally based ALT flap in coverage of regional soft-tissue defects in pediatric patients.


  Materials and Methods Top


This is a study of nine cases of pedicled ALT flaps done from January 2018 to January 2019 for pediatric patients with irregular ischial, trochanteric and groin defects. There were 6 females and 3 males. Age group ranges from 7 to 15 years with mean age of 11 years. Follow-up ranges from 3 months to 1 year. The design of the flap was done to be proximally based in all the cases and it was used to cover a post trochanteric pressure sores defects in four patients, an ischial pressure sores defects in two patients and post burn groin contracture release defects in three patients. All the data about the vascular system anatomy, the length of the pedicle, donor site morbidity, and the flap outcomes regarding the functional and the aesthetic outcomes were recorded.

Surgical procedure

Under general anesthesia in all patients with supine position, intraoperative marking of the flap was done. The longitudinal axis of the flap designed along a line connecting the anterior superior iliac spine with the superior lateral edge of the patella represents the intermuscular septum between the vastus lateralis and the rectus femoris muscle. The site of the perforators was identified using intraoperative Doppler Device within a 3-cm radius circle around the midpoint of this line. The size of the flap has been measured according to the defect. Medial incision over the rectus femoris muscle done first and dissection done in subfascial plane until reaching the intermuscular septum then the perforators have been identified. In cases where the perforators were myocutaneous ones a protective cuff of vastus lateralis muscle were harvested around the perforators to avoid intramuscular dissection. Further dissection in the septum was done for identification and exposure of descending branch of the lateral circumflex femoral artery until its origin from the profunda femoris artery. Finally, posterior incision of the flap was done and the flap has been harvested to cover the defect as an island flap. Closure of the donor site was done either primary or by split-thickness skin grafts (STSG).


  Results Top


From January 2018 to January 2019, 9 pedicled ALT flaps were done for reconstruct regional defects in 9 pediatric patients. Four flaps were done for trochanteric defects, two flaps for ischial defects, and three flaps for groin defects [Table 1]. All were proximally based flaps for unilateral defects. The size of the flaps ranged from 6 cm × 4 cm to 19 cm × 17 cm. The largest one has been used to cover a big post trochanteric pressure sore defect. The level of the defect that can be closed by the flap ranged from the area around the anterior superior iliac spine, greater trochanter, and the groin crease. The type of the flap was myocutaneous flaps in six cases in which the perforators were myocutaneous and a cuff of the vastus lateralis muscle was harvested with the flap while in three cases the flap was harvested as a perforator flap with true septocutaneous perforators. The pedicle of the flap was the descending branch of the lateral circumflex femoral artery in all nine cases with lengths ranged from 7 to 15 cm. Eight flaps have been totally survived while partial necrosis has been occurred in the distal end of one case (conservative management by daily dressing was done). Primary closure of the donor site has been done in seven cases while STSG was done in two cases [Table 2].
Table 1: Defect data

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Table 2: Flaps data

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Case illustrations

Case 1

Female patient 9-year-old with post burn groin contracture [Figure 1]a, release of the contracting scar has been done resulting in an irregular shape groin defect [Figure 1]b, harvesting and in setting the island pedicled ALT in the defect has been done [Figure 1]c then closure of the defect and primary closure of the donor site [Figure 1]d.
Figure 1: (a) Preoperative photo showing post burn groin contracture. (b) The groin defect after releasing the contracting scar. (c) In setting, the pedicled anterolateral thigh flap in the defect. (d) Postoperative photo after closure of the defect and the donor site

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Case 2

A 15-year-old, female patient with a large neglected trochanteric pressure sore defect [Figure 2]a, preoperative mapping of the perforators and the flap has been performed [Figure 2]b. Harvesting and in setting the flap in the defect with primary closure of the donor site [Figure 2]c.
Figure 2: (a) Preoperative photo showing large trochanteric pressure sore defect. (b) Preoperative marking of the flap. (c) The defect and the donor site after closure

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  Discussion Top


Reconstruction of upper thigh, pelvic, groin, trochanteric, and lower abdominal defects in pediatric patients considers as a challenge for plastic surgeons whatever it is done by local or free flaps. Although there are many flaps that the surgeons can use to cover these regional defects but the ALT flap still has the advantage that makes it an ideal option to be used. Its long sizable pedicle, the ability to harvest the flap as fasciocutaneous or myocutaneous flap that allow to cover a big size defects and the minimal donor site morbidity giving the flap a superiority to other reconstructive options.[7]

In our study, the cause of the defects was mainly due to post pressure sores (four trochanteric and two ischial pressure sores) that have been reconstructed by a myocutaneous ALT flap with part of vastus lateralis muscle. In the other three cases; the cause of the defect was after release of post burn contracture in groin area and was reconstructed by a fasciocutaneous ALT flap.

According to Kuo et al.,[8] there is minimal functional impairment of the thigh even a myocutaneous ALT flap is harvested. The type of the flap in our study was myocutaneous flaps in six patients which gives us additional benefits in coverage of post pressure sore defects (the main cause of defects in our cases); the size of the flap become larger as it contains two different tissue components (part of the vastus lateralis muscle with the skin of the ALT area), fill the dead space of the defects by the muscle component that resist the common infection persists in such like defects[9] and finally saving a lot of time that are spending on dissection around the myocutaneous perforators by harvesting a protective cuff of muscle around them. All of these benefits are of great value in pediatric patients and make the pedicled ALT our first choice in such cases.

Regarding to donor site complications and according to a study made by Gravvanis et al.[3] The donor site was closed primarily in nine cases; while in the other two cases, a STSG was used to allow closure without tension;. All donor site wounds healed uneventfully within 2 weeks without any signs of infection, wound dehiscence, delayed healing, or seroma. In our study, the donor site has been closed primarily in seven cases and usage of STSG was used in two cases. The healing process was very smooth in all cases without any functional or aesthetic problems.

Collecting all these benefits of the pedicled ALT flap from its reliability, accepted functional and cosmetic results, relatively easy harvesting especially when a protective cuff of vastus lateralis muscle included around the myocutaneous perforators and finally preserving time in comparison to usage a free flap technique, this review of literature provide a good choice for plastic surgeons to utilize in pediatric patients complying from such like defects.


  Conclusion Top


Pedicled ALT flap provides a reliable and versatile option for plastic surgeons in reconstruction of difficult regional soft-tissue defects in pediatric patients especially when bulkiness and resistance of infection is indicated, with accepted functional and cosmetic results.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgments

My Colleagues in Plastic Surgery Department, Faculty of Medicine, Menoufia University.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Friji MT, Suri MP, Shankhdhar VK, Ahmad QG, Yadav PS. Pedicled anterolateral thigh flap: A versatile flap for difficult regional soft tissue reconstruction. Ann Plast Surg 2010;64:458-61.  Back to cited text no. 1
    
2.
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;37:149-59.  Back to cited text no. 2
    
3.
Gravvanis AI, Tsoutsos DA, Karakitsos D, Panayotou P, Iconomou T, Zografos G, et al. Application of the pedicled anterolateral thigh flap to defects from the pelvis to the knee. Microsurgery 2006;26:432-8.  Back to cited text no. 3
    
4.
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;109:2219-26.  Back to cited text no. 4
    
5.
Koshima I, Tai T, Yamasaki M. One-stage reconstruction of the penis using an innervated radial forearm osteocutaneous flap. J Reconstr Microsurg 1986;3:19-26.  Back to cited text no. 5
    
6.
Ng RW, Chan JY, Mok V, Li GK. Clinical use of a pedicled anterolateral thigh flap. J Plast Reconstr Aesthet Surg 2008;61:158-64.  Back to cited text no. 6
    
7.
Yildirim S, Gideroğlu K, Aköz T. Anterolateral thigh flap: Ideal free flap choice for lower extremity soft-tissue reconstruction. J Reconstr Microsurg 2003;19:225-33.  Back to cited text no. 7
    
8.
Kuo YR, Jeng SF, Kuo MH, Huang MN, Liu YT, Chiang YC, et al. Free anterolateral thigh flap for extremity reconstruction: Clinical experience and functional assessment of donor site. Plast Reconstr Surg 2001;107:1766-71.  Back to cited text no. 8
    
9.
Mathes SJ, Feng LJ, Hunt TK. Coverage of the infected wound. Ann Surg 1983;198:420-9.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2]



 

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