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Extremity reconstruction with super-thin and suprafascial anterolateral thigh perforator flaps
Akhil K. Seth, MD, Bernard T. Lee, MD, MBA, MPH, Matthew L. Iorio, MD.
Beth Israel Deaconess Medical Center, Boston, MA, USA.

BACKGROUND: The anterolateral (ALT) thigh flap remains a workhorse flap for the reconstruction of soft tissue defects throughout the body. However, the traditional ALT flap can often be too bulky for the resurfacing of small, shallow defects in the distal extremity, requiring additional procedures to achieve the desired contour. This study evaluates outcomes following the use of ALT flaps elevated in the suprafascial and super-thin plane during reconstruction of upper and lower extremity defects.
METHODS: Restrospective review of patients that underwent ALT free flap reconstruction from 10/2014-3/2016 at the Beth Israel Deaconess Medical Center was performed. Suprafascial and super-thin flaps were defined as flaps elevated just above the muscular fascia and within the superficial scarpal plane, respectively. Flaps elevated in the sub-muscular fascial plane were excluded. Clinical and operative factors, and complication rates were recorded, with an average 7.5 months of follow-up.
RESULTS: Data analysis revealed 20 patients that underwent suprafascial (n=12) or super-thin (n=8) ALT free flap reconstruction, with an average age and BMI of 54.2 years and 27.2, respectively. Clinical history of smoking (n=5), diabetes (n=6), peripheral vascular disease (n=4), or hypertension (n=6) were documented preoperatively. The most common sources of wounds were malignancy (n=7), trauma (n=6), and chronic infection (n=6), with the majority in the lower extremity (n=15). Average flap size was 7.9 x 20.4 cm, with the 60% (n=12) of flaps taken on one perforator. Fifty percent of anastomoses were done end-to-side with an average operative time of 435 minutes. Mean hospital stay was 7.3 days with a 20% (n=5) rate of total complications. There were no partial or complete flap losses.
CONCLUSIONS: The ALT flap, elevated in a suprafascial or super-thin plane, is a safe and effective free flap option for reconstruction of extremity soft tissue defects due to a variety of pathologies. The decreased volume and bulk of these flaps relative to the traditional ALT allows for the improved contour and pliability necessary for appropriate function in the distal extremity. The potential versatility of super-thin flaps reinforces the importance of continued innovation and application of new techniques by reconstructive microsurgeons.

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