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The Role of ALT Flaps in Foot Reconstruction: Assessing Functional and Aesthetic Outcomes
Alisa Timashpolsky, BA, Taher M. Gulamhusein, MD, Johnathan Shih, BS, Gabriel M. Klein, MD, Alexander B. Dagum, MD, Mark A. Gelfand, MD, Duc T. Bui, MD.
Stony Brook University Hospital, Stony Brook, NY, USA.

BACKGROUND:Foot and ankle reconstruction can be challenging and complex in a wide variety of settings, from trauma to the management of diabetic and vascular complications. The Anterolateral Thigh (ALT) flap has recently become one of the more commonly used flaps to cover large and irregularly shaped defects in the distal lower extremity due to its large tissue yield and lower donor-site morbidity. Thus far, few studies have specifically examined the functionality and aesthetic outcomes of these flaps in patients with lower extremity reconstruction. In this study we investigate aesthetic and functional outcomes and patient satisfaction in patients with ALT flap reconstruction for foot and ankle deformities.
METHODS:From 2010 to 2014, a retrospective review of patients who underwent reconstructive surgery of the foot and ankle with ALT free flaps was performed. Data regarding the etiology of injury, size of defects, and subsequent revision surgery was collected. Patients were contacted and asked about their ability to wear shoes and ambulate, foot symmetry, pain, and overall satisfaction. Additionally, the circumferences of the forefoot, midfoot, hindfoot, and ankle were measured post-operatively. These values were compared using a paired t-test to assess for any significant differences between the affected and unaffected foot.
RESULTS: A total of 14 patients were recruited for this study. Twelve patients were trauma victims, one had necrotizing fasciitis, and another presented with a non-healing ulcer. The sizes of the defects ranged from 50-350 cm^2, with an average of 129 cm^2. All but one patient received revision surgery by debulking and liposuction. The average number of revisions was 1.5; and the average length of time to revision surgery was 218 days. Of the 6 patients available for questioning, three reported no difficulty wearing shoes or ambulating, two reported some difficulty and required orthotics, and one patient who had not received surgery was not able to ambulate or wear shoes. Three patients reported good symmetry, while the others reported that the affected foot was visibly larger. No patients reported long-term postoperative pain, and all but one patient were satisfied with their outcome. Six patients returned for follow-up measurements. Of the four measured areas, only the midfoot showed significantly larger circumferences in the affected foot (p<.05).
CONCLUSIONS: In lower extremity reconstruction, the ALT flap has become a popular option due to the flap's predominant skin and fat composition. This allows for easier debulking surgeries to contour the flap and achieve good aesthetic and functional outcomes in patients. In our study population, most patients underwent revision surgery, and those who had successful debulking surgeries were satisfied and had good to excellent functional outcomes. In the future, we hope to implement the Lower Extremity Functionality Score in order to quantify the functionality of the patients who have lower extremity reconstruction with ALT flaps.

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