Sunday, October 10, 2004

The use of free anterolataral thigh flap for large plantar defect reconstruction

Masaki Takeuchi, MD, Kenji Sasaki, MD, Motohiro Nozaki, MD, Ted Huang, MD, and Hiroyuki Sakurai, MD.

Objective: Although the advent of microsurgical composite tissue transfer technique has made the reconstruction of a large plantar defect more plausible, the functional and aesthetic outcomes achievable in practice are far from being ideal. The bulkiness of a composite tissue graft commonly used for reconstruction; i.e., musculocutaneous flaps or muscle flap, renders recontouring of the sole difficult and of skin sensation impossible. The subcutaneous fatty layer in the anterior and anterolateral area of the upper thigh is generally thin. A skin paddle of various sizes can be designed in the area and harvested to reconstruct a bodily defect. It has a long vascular pedicle of large caliber vessels accompanied with sensory nerves. The morbidities associated with graft harvesting are nil. The anterolateral skin flap is, therefore, an ideal grafting material to reconstruct a large soft tissue defect, such as the solar surface.

Clinical Materials: Over the past five years, we had the opportunity of using the anterolateral skin flap to reconstruct a large plantar surface defect in seven patients. A wide resection was prescribed for managing squamous cell carcinoma developed in the sole of the foot subsequent to burn injuries of the past years. The injured extremity was treated initially with skin graft. An indolent ulcer developed in recent years necessitated treatment. There were two men and one woman and were 42,42 and 68 years of age. The defects were measured to be 7.0 cm x 8.5 cm, 5.0 cm x 10.0 cm, and 6.5 cm x 13 cm respectively.

Description of the Techniques: A skin paddle with its size varied between 14 to 20 cm in length and 5 to 9 cm in width was marked over the anterolateral aspect of the upper thigh. The perforator of the descending branch of the lateral circumflex femoral vessels was isolated and fabricated as the pedicle. The lateral femoral cutaneous nerve was used for flap sensory restoration. The flap was transferred to the foot to cover the defect consequential to tumor excision. The posterior tibial vessels were used for flap revascularization and the posterior tibial nerve was used restore the sensation.

Outcome: There was no loss of flap transferred. The contour was aesthetically pleasing and most of all, the patients were able to ambulate within 55 days after surgery. Although the protective sensation was judged to be less than ideal, the tactile sensation was sufficient for walking and shoe-wearing and most importantly, there was no break down of the skin occurred in the pressure bearing areas of the sole.

Conclusion: The anterolateral thigh flap transferred via a microsurgical technique is a better flap material for restoring a plantar defect. The skin is thin and the vascular pedicle is long. Furthermore, sensation may be restored.

View Synopsis (.doc format, 370.0 kb)