A novel step in the anterolateral thigh free flap harvest.

The ALT is a versatile flap in head and neck reconstruction1. Classically this flap allows for suprafascial or subfascial identification of perforators. Subsequent retrograde dissection of the perforators through the intermuscular septum or muscle identifies the pedicle (descending branch of the lateral circumflex artery). This technique can be time consuming and risks injury to the delicate perforators. • Technique used in 75 consecutive patients undergoing ALT flap. • Approximate harvest time is 1 hour. • No change in infection or hematoma at donor site has been observed. • No neurovascular injury. • Complication: false loading GIA stapler (1) which required obtaining hemostasis with bipolar cautery. The Anterolateral thigh (ALT) flap, based on branches of the circumflex femoral artery, has increasingly become a popular flap in head and neck reconstruction because of its versatility1 י2. Classically described as a perforator flap, the ALT flap can be harvested to include skin only, skin and muscle and as a chimeric flap with separately perfused skin paddles2 י3. As with all free tissue transfer procedures in the head and neck, efficiency in technique is paramount in reducing the overall surgical duration. We describe the technique of retrograde pedicle dissection and the adapted use of a GIA 80 stapler in harvesting ALT flaps. This technical modification has been implemented in 75 consecutive patients with an approximate harvest time of one hour. 1.Song YG, Chen GZ, Song YL. The free thigh flap: A new flap concept based on the septocutaneous artery. Br J Plast Surg 37:149-159, 1984. 2. Demirkan F, Chen HC, Wei FC, et al. The versatile anterolateral thigh flap: A musculocutaneous flap in disguise I head and neck reconstruction. Br J Plast Surg53:30-36, 2000 3.Xu DC, Zhong SZ, Kong JM, et al. Applied anatomy of the anterolateral femoral flap. Plast Reconstr Surg 82:305-310,1988. 4. Koshima I, yamamoto H, Hosoda M et al. Free combined composite flaps using the lateral circumflex femoral system for repair of massive defects of the head and neck regions:An introduction to the chimeric flap principle. Plast Reconstr Surg 92: 411-427, 1993. Technique Step 1: The ALT is exposed and a flap is designed based upon the perforators. Step 2: The medial edge of the flap is incised down to fascia. The septum between the rectus femoris vastus lateralis muscles is identified and separated. Step 3: The descending branch of the circumflex femoris artery is identified as it courses on or through the vastus lateralis muscle. Step 4: The perforators to the flap are then clearly identified and outlined. Step 5: The lateral margin of the skin flap is incised down to fascia. Step 6: While protecting the perforators and the main pedicle, the GIA staple is applied to divide a cuff of the vastus lateralis muscle above and below the most superior and inferior perforators. Step 7: The descending branch of the lateral circumflex femoral artery is then traced in a retrograde manner till adequate pedicle length and vessel caliber is achieved. Step 8: The flap may be thinned down, when desirable, by carefully debulking muscle and subcutaneous fat from the flap periphery. For very thin flaps, antegrade dissection of the perforators through the vastus lateralis muscle may be necessary. • Safe technical modification. • Efficiency in a time consuming procedure. • GIA stapler beneficial to the pedicle No thermal energy for hemostasis In single maneuver keeps protective cuff of muscle to protect pedicle. The flap is harvested in typical fashion with the exception of a novel technical modification . We outline the technique used at our institution for ALT flap harvest: Results