• Archives of Plastic Surgery
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• v.37 no.6
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• pp.769-774
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• 2010

Purpose: As the soft tissue defect around the knee is difficult to reconstruct, local flap or free flap is used. Distally based anterolateral thigh pedicled flap introduced by Zhang uses sufficient reverse flow supplied from the vascular network around the knee. We report successful reconstruction of defect around knee by this method. Methods: Four patients with skin & soft tissue defect around knee have been treated for reconstruction using the distally based anterolateral thigh pedicled flap. First, the doppler was used to check the perforator flap of the descending branch of the lateral circumflex femoral artery and to draw and dissect the perforator flap as much as needed. After the dissection, the proximal of the descending branch was clamped and checked for sufficient supply of blood flow from the reverse flow and then ligated. It was dissected along the descending branch and in order to prevent damage to the joined parts of the descending branch and the lateral superior geniculate artery, a more careful ligation was done starting from 10 cm superior to the knee. The defect was reconstructed after securing enough vascular pedicle to cover all the damaged parts. Results: Not all patients suffered from flap necrosis. In case of the patient with chronic osteomyelitis, slight venous congestion was observed right after the surgery but it disappeared the following day. All three patients had no occurences of additional complications. Conclusion: Distally based anterolateral thigh pedicled flap was enough to provide large flap for knee reconstruction. It had sufficient blood flow and vascular pedicle. It also had taken short operation time compared to the free flap operation. The distally based anterolateral thigh pedicled flap used by the authors is a very useful way of reconstructing the area around knee.

• Archives of Reconstructive Microsurgery
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• v.16 no.1
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• pp.14-22
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• 2007

Perforator free flap (PFF) is currently a major reconstructive option for soft tissue reconstruction in adults. Although PFFs have been used commonly, most reconstructive surgeons still hesitate to perform PFFs in children. The main cause of concern is the perceived high failure rate related to the small diameter of children's perforator vessels. We present 8 consecutive cases of successful transfer of thoracodorsal artery (TDA) & anterolateral thigh (ALT) perforator flap in children. Between 2003 and 2005, 8 children(4 to 13 years old) with soft tissue defects of the extremities were reconstructed with TDA & ALT PFFs. All flaps completely survived. There were no problems relating to vascular spasm or occlusion. Range of motion of reconstructed extremities were fully recovered. Among 8 patients, only 1 patient was performed an additional flap thinning procedure. 8 cases of TDA & ALT perforator flaps were successfully transferred in children. PFF is an excellent option in reconstruction of children as well as in adults because of its thinness, long pedicle length, least donor site morbidity and acceptable donor site scar.

• Archives of Reconstructive Microsurgery
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• v.6 no.1
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• pp.103-110
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• 1997

Since R.Y. Song(1982) has reported anatomic studies about septocutaneous perforator flap, various experiences especially on thigh flaps pedicled on septocutaneous artery were reported. Baek(1983) reported an anatomic study through the cadavers dissections on medial, lateral thigh area and provided the first new cutaneous free flap of thigh for clinical use. Song, et a1.(1984) reported anterolateral thigh free flap, Koshima, et al.(1989) reported pedicle variations and its versatile clinical usages. According to their reports, accessory branches of lateral femoral circumflex artery are placed in comparatively constant location and proved to be the effective pedicle of this flap. The advantages of anterolateral thigh free flap are 1) comparatively thin 2) can obtain sufficiently large flap 3) can contain cutaneous nerve 4) can be easy to approach anatomically because pedicle is located in comparatively constant position 5) minimal donor site morbidity. We report the experience of 10 cases of anterolateral thigh free flap coverage for soft tissue defects: 4 cases of soft tissue defects on foot area, 2 cases of soft tissue defects on hand, 3 cases of partial tongue defects owing to tongue cancer ablation, and 1 case of soft tissue defect on nasal alar.

• Archives of Reconstructive Microsurgery
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• v.22 no.1
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• pp.13-17
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• 2013

Purpose: Although a fasciocutaneous perforator artery as a vascular pedicle has previously been shown to be predominant in the anterolateral thigh (ALT) flap, recent studies have shown that a myocutaneous perforator artery is predominant. We have attempted to attain a clinical understanding of the vascular variations in the ALT flap. Materials and Methods: We confirmed the origin of a perforator artery in 11 cases of ALT flap. We then reviewed the variations of the descending branch of the lateral femoral circumflex artery, known as the major origin of the flap, and the overall variations associated with an ALT flap. Results: In a total of 11 cases, there were 18 perforator arteries of the ALT flaps. In addition, there were 9 fasciocutaneous perforator arteries and another 9 myocutaneous ones. However, depending on the origin, there was great variability in the perforator artery. That is, there were unique variants in the descending branches of the lateral femoral circumflex artery, the major origin of the perforator artery, in 3 of the total 11 cases. Conclusion: Our results showed that (1) a perforator artery accounts for the high proportion of fasciocutaneous ones, (2) a perforator artery might not originate from the descending branch of the lateral femoral circumflex artery and (3) there might be unique variants in the descending branch. If considering this, surgeons would successfully elevate an ALT flap.

• Archives of Reconstructive Microsurgery
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• v.19 no.2
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• pp.112-119
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• 2010

The anterolateral thigh flap is a reliable and versatile flap. It has been extensively used for soft tissue reconstruction because minimal donor site morbidity is attractive feature of this flap. It can be harvested as a cutaneous, fasciocutaneous, muscluocutaneous flap. We can be used to form as desired shape and thickness. But variation of vascular anatomy make difficult for many surgeons. We review of vascular anatomy of the anterolateral thigh to be easier access to surgery. With understanding anatomic variation, it allows you to take advantage of this surgery using little more variable form.

• Archives of Plastic Surgery
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• v.38 no.1
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• pp.27-34
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• 2011

Purpose: Anterolateral thigh (ALT) perforator free flap is commonly used because of its various benefits. The author reports important factors of preoperative and perioperative ALT perforator free flap and causes of failure. Methods: 84 patients who were treated with ALT perforator free flap from December 2004 to 2008, and February 2010 to April 2010 were studied. 61 patients were male and 23 were female. The mean age of patients was 51.1. The main cause was neoplasm and the main reconstructive areas were head and neck area. The size of flap was various from $3{\times}4$ to $12{\times}18$ cm. 6 patients received split thickness skin graft at donor site. Preoperative angiography was checked to all patients. Results: Among the 84 patients, partial necrosis of flaps occurred in 4 patients because of atherosclerosis, varicose vein, or inattention of patient, etc. And total flap necrosis in 5 patients because of abnormal vessels of recipient area or delay of operation, etc. One case of serous cyst was found as the complication of donor area. Two cases of skin graft on donor site were done because of suspected muscle compartment syndrome, 4 cases of that because of large flap. Septocutaneous perforators were found in 7 cases. The author couldn't find reliable perforator in 3 cases, ipsilateral anteromedial thigh perforator and contralateral ALT perforator and latissimus dorsi musculocutaneous free flap were done instead of ALT. There was no case which needed reoperation because of the impairment of blood supply, and 3 cases were revised by leech because of the burn injury by a lamp or venous congestion. Conclusion: Although ALT perforator free flap is widely used with its various merits, many factors such as preoperative condition of donor or recipient area, morphology of defect and operating time need to consider to prevent flap necrosis. And operators should need careful technique because septocutaneous perforator is uncommon, and musculocutaneous perforator is common but difficult to dissect.

• Archives of Reconstructive Microsurgery
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• v.14 no.2
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• pp.117-124
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• 2005

Purpose: To present our experience and design modification of an anterolateral thigh flap in soft tissue reconstruction. Materials and Methods: Between April of 2004 and May of 2005, 26 anterolateral thigh flaps were used in 26 patients. There were 22 males and 4 females between 23 and 60 years (mean, 40years). The mean follow-up period was 11($4{\sim}18$) months. All cases were a cutaneous flap. Twenty-two were musculocutaneous perforator flaps(85%) and 4 were septocutaneous perforator flaps(15%). Four flaps were used as a sensate flap. While the donor sites were closed directly in 14 cases(54%), 12 cases(46%) underwent skin grafting of the donor site. During the flap design, a triangular skin design was added to a vascular anastomosis site in 14(54%) patients and used as a roof of the tunnel. The healing period of the skin graft between those performed above the fascia and above the muscle were compared. Results: The average size of the flaps was $16{\times}9(11-20{\times}7-12)\;cm$. The overall flap success rate was 96%. Complications encountered were infection in 4 cases, and marginal skin necrosis in 1 case. The healing period was delayed with the infection in 3 of the 6 cases involving a skin graft over the fascia. All 14 cases with the triangular skin design survived, but there was 1 flap failure and 1 marginal necrosis in 12 cases without a triangular skin design. Conclusions: It may be better to undergo a skin graft above the muscle than above the fascia in covering a donor site defect, and to use a triangular skin design in order to prevent vascular insufficiency. An anterolateral thigh flap is a versatile flap for a soft tissue reconstruction because its thickness and volume can be adjusted to the extent of the defect with minimal donor site morbidity.

• Maxillofacial Plastic and Reconstructive Surgery
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• v.35 no.3
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• pp.200-209
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• 2013

Over the past few years, a large number of perforator flaps have been revised by several microsurgeons in the USA, France, Canada and Japan. A perforator flap is a flap of skin or subcutaneous tissue that is based on the dissection of a perforating vessel, which is a perforator. In short, a perforator is a vessel that has its origin in one of the axial vessels of the human body. By reducing any muscle harvesting and trauma to a minimum, perforator flaps aim to minimize donor site morbidity, and by avoiding the transfer of dennervated muscle, the long-term bulk of the free tissue transfer becomes more predictable. There are a finite number of potential perforator flaps in the body, which are based on the named source arteries. The most commonly used perforator flaps are deep inferior epigastric perforator, superior gluteal artery perforator, thoraco dorsal artery perforator, medial sural artery perforator, and anterolateral thigh perforator flap. For a better understanding of perforators as a routine reconstructive procedure in oral and maxillofacial surgery, the definition with nomenclature, classifications with special characteristics, and review points for their individual applications must be learned and memorized by the young doctors in the course regarding the special curriculum periods for the Korean national board of oral and maxillofacial surgery. Perforator flaps have been known to have many advantages, so this review article summarized their applications to the maxillofacial reconstruction in the Korean language.

• Archives of Plastic Surgery
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• v.48 no.1
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• pp.121-126
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• 2021

Background Despite the wide demand for thin flaps for various types of extremity reconstruction, the thin elevation technique for anterolateral thigh (ALT) flaps is not very popular because of its technical difficulty and safety concerns. This study proposes a novel perforator-centralizing technique for super-thin ALT flaps and analyzes its effects in comparison with a skewed-perforator group. Methods From June 2018 to January 2020, 41 patients who required coverage of various types of defects with a single perforator-based super-thin ALT free flap were enrolled. The incidence of partial necrosis and proportion of the necrotic area were analyzed on postoperative day 20 according to the location of superficial penetrating perforators along the flap. The centralized-perforator group was defined as having a perforator anchored to the middle third of the x- and y-axes of the flap, while the skewed-perforator group was defined as having a perforator anchored outside of the middle third of the x- and y-axes of the flap. Results No statistically significant difference in flap thickness and dimension was found between the two groups. The arterial and venous anastomosis patterns of patients in both groups were not significantly different. Only the mean partial necrotic area showed a statistically significant difference between the two groups (centralized-perforator group, 3.4%±2.2%; skewed-perforator group, 15.8%±8.6%; P=0.022). Conclusions The present study demonstrated that super-thin ALT perforator flaps can be elevated safely, with minimal partial necrosis, using the perforator-centralizing technique.

• Archives of Reconstructive Microsurgery
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• v.18 no.1
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• pp.1-8
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• 2009

Purpose: The perforator flaps have established their role in the reconstruction of various soft tissue defects. For the last five years, we have extensively used anterolateral thigh (ALT) flap for the reconstruction of the complex tissue defects of the hand and upper extremity and report the clinical results and our experiences with the versatile applications of this flap. Materials and Methods: From March 2003 through May 2008, 119 free ALT perforator flaps were transferred for reconstruction of the complex tissue defects of the elbow, forearm, wrist and hand after crushing or degloving injuries as well as severe scar contractures. There were 95 females and 24 males. The mean age of the patients was 37 years and mean size of the flap was 170 $cm^2$. In 20 cases, the flap was vascularized by septocutaneous and in 99 cases by musculocutaneous perforators. Intra-muscular dissection length averaged 3.4 cm. The total length of pedicle averaged 8.4 cm and the average arterial diameter was 0.84 mm. End-to-end arterial anastomosis was performed in 103 cases and end-to-side in 16 cases. Results: Flap survival rate was 98.3%(117/119) and there were 6 cases of partial necrosis. Donor site was closed primarily in 41 cases and skin grafts were applied in 78 cases. Conclusion: The reliability and versatility of ALT flap makes it one of the foremost choices for the reconstruction of complex tissue defects of the upper extremity.