Research Article
Pedicled Anterolateral Thigh Flaps for Salvage Reconstruction of Complex Abdominal Wall Defects
Gurjot S. Walia, BS, Justin M. Broyles, Joani M. Christensen, Andrea Y. Lo, Danielle H. Rochlin, Francis F. Daily, Sachin M. Shridharani and Justin M. Sacks*
Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, USA
*Corresponding author: Justin M. Sacks, Department of Plastic Surgery, The Johns Hopkins Hospital Outpatient Center, 601 N Caroline St., Suite 8161, Baltimore, MD 21287, USA
Published: 10 Feb, 2017
Cite this article as: Walia GS, BS, Broyles JM, Christensen
JM, Lo AY, Rochlin DH, et al. Pedicled
Anterolateral Thigh Flaps for Salvage
Reconstruction of Complex Abdominal
Wall Defects. Clin Surg. 2017; 2: 1298.
Abstract
Background: Extensive abdominal wall defects can arise following injury or tumor resection. Reconstruction of these full-thickness defects can be augmented with pedicle flaps, providing
necessary soft-tissue when local options are inadequate. Though the pedicled anterolateral thigh
(ALT) flap has been used to cover a wide range of defects, its utility in abdominal wall reconstruction
has not been well described. Further, many surgeons conventionally adhere to the use of a free flap
for upper abdominal defects and a pedicle flap for lower abdominal defects, yet it is our experience
that a pedicled ALT flap can be used to salvage patients and reconstruct defects anywhere in the
anterior abdomen up to the xyphoid process.
Methods: We conducted a retrospective study to assess and discuss our single institution experience
with the use of pedicled ALT flaps for salvage abdominal wall reconstruction. Inclusion criteria
were all patients of the senior author who underwent reconstruction of full-thickness composite
abdominal wall defects with a pedicled anterolateral thigh flap from 2011-2015. Charts were
reviewed for demographic data as well as outcomes measures, including fascial defect size, skin inset
paddle size, acellular dermal matrices (ADM) used, underlying etiologies, and major and minor
complications.
Results: A total of seven patients, ages 28 to 74 years, were included in this case series. All patients
had recurrent hernias, infection, sarcomas and/or enterocutaneous fistulae with multiple prior
abdominal operations. Mean inset skin paddle was 189 cm2 and mean fascial defect size was 233
cm2. Pedicled ALT flaps were inset via a subcutaneous tunnel through the groin. There were
no intraoperative complications, flap failures, or hernia recurrences. Two patients (28%) had
postoperative complications of infection, with 1 reoperation within 30 days of surgery.
Conclusion: The pedicled ALT flap is a favorable option that should be routinely considered for
reconstruction of composite full-thickness abdominal wall defects given its durable blood supply
and ability to cover large cutaneous defects with minimal donor site morbidity.
Introduction
Full-thickness composite abdominal wall defects are a common surgical problem often
warranting complex reconstruction with autologous tissue, synthetic mesh and/or biological
tissue matrix materials. A preferred reconstruction option involves using native components of
the abdominal wall, frequently with component separation or tissue expansion [1]. However, local
tissue is often insufficient in the setting of composite defects that are full-thickness with exposure
of bowel or that involve attenuated musculofascial tissues. When faced with complex defects of
the abdominal wall involving composite structures, it is critical to approach these defects in a
multidisciplinary fashion involving both general and plastic reconstructive surgical principles.
Reconstructions of extensive abdominal wall defects can be augmented with autologous tissue
in the form of a pedicle or free soft-tissue flap in a single-stage operation. While free tissue transfer
can be utilized to reconstruct defects of virtually any anatomic region of the body, it is associated
with increased operative time [2] and a higher risk of total flap necrosis as compared to pedicle flaps
[3]. It requires microvascular expertise which is not always available and thus precludes its wide
spread application. A pedicled flap allows the reconstructive surgeon to perform abdominal wall
reconstruction in an efficient and expedient fashion without the need for advanced microsurgical
skills.
Pedicled fasciocutaneous and myocutaneous flaps can provide
necessary soft-tissue for reconstruction when local options are
inadequate, yet there are limited donor sites for reconstructing large
abdominal wall defects. The pedicled anterolateral thigh flap, which
has been employed to cover defects as cephalad as the epigastrium,
is a reliable option for abdominal wall reconstruction [4-8]. The
flap provides a number of advantages over other regional flaps. For
example, the tensor fascia lata flap is primarily comprised of fascia;
therefore, this flap has limited bulk and is not capable of filling large
defects. The rectus femoris flap, which can reach the costal margin
or xiphoid, lacks a skin paddle, and, consequently, large cutaneous
defects cannot be filled [9]. The anterolateral thigh flap, however, can
be designed to contain large amounts of skin, adipose tissue, muscle
and fascia. A combination of all of the tissue elements available in the
flap can be used to reconstruct full-thickness defects of the abdominal
wall. This closure is attainable by incorporating tensor fascia lata and
nearly the entire anterolateral thigh [10]. The flap’s vascular supply is
provided by septocutaneous or musculocutaneous perforators from
the descending branch of the lateral circumflex femoral artery. There
are a number of venous drainage outlets for the anterolateral thigh
flap, including the lateral circumflex femoral vein [11]. Harvest of
the anterolateral thigh flap results in a minimal loss of postoperative
functional strength [12] and is generally considered to have low donor
site morbidity [3,4]. If the donor site cannot be closed primarily, a
split-thickness skin graft is typically placed over exposed fascia and
muscle.
Despite the advantages of using a pedicled anterolateral thigh
flap for abdominal wall reconstruction, there is currently a paucity
of literature devoted to exploring this topic [2,4,7,13-17]. Utilizing
the anterolateral thigh flap as a free tissue transfer for abdominal wall
reconstruction is well described [2,10,18-21]. Over the past several
years, we have seen that employing the anterolateral thigh in the
form of a pedicled flap allows for ease of harvest, rotation, and inset
into an abdominal wall defect. Our objective is to describe our single
institution experience for the use of a pedicled anterolateral thigh flap
when reconstructing abdominal wall defects in salvage cases.
Figure 1
Figure 1
Abdominal fascial defects and reconstruction.
(A) Fascial defect closed primarily at the superior aspect with ADM inlay to bridge the remaining defect.
(B) A 600 cm2 ADM underlay and vacuum assisted closure dressing were placed during the laparotomy 10 days prior to definitive abdominal wall reconstruction.
Figure 2
Figure 2
Template and ALT flap harvest.
(A). The flap was templated over the right thigh, with a skin paddle sufficient to cover an 180cm2 skin defect and two vascular perforators
(B) A myocutaneous ALT flap was raised including two musculocutaneous perforators.
Figure 3
Figure 3
ALT flaps inset into the abdominal wall.
(A) The flap was passed through a subcutaneous tunnel, a large portion of the skin paddle deepithelialized and buried, and the flap inset.
(B) The ALT flap was rotated and passed through a subcutaneous tunnel to the defect site, and then the tunnel opened to prevent flap and pedicle compression.
Methods
A comprehensive retrospective chart review was conducted on
patients undergoing a pedicled anterolateral thigh flap for salvage
reconstruction of abdominal wall defects between January 2011 and
December 2015 by a single surgeon at the Johns Hopkins Hospital.
The study was approved by the Johns Hopkins Institutional Review
Board. The patients were referred to the senior author (JMS) for
abdominal wall reconstruction secondary to full-thickness composite
defects. Charts were reviewed for demographic data as well as
outcomes measures, including fascial defect size, skin inset paddle
size, acellular dermal matrices (ADM) used, underlying etiologies,
and major and minor complications.
Results
Chart review revealed seven patients who underwent salvage
abdominal wall reconstruction using a pedicled anterolateral thigh
flap. All patients had loss of abdominal wall domain due to recurrent
hernias with infected mesh and/or enterocutaneous fistulae.
Underlying etiologies included Crohn’s disease, gastroschisis,
colorectal cancer, sarcomas, and ulcerative colitis. All of the patients
had undergone multiple abdominal operations in prior years, and
underwent laparotomies by a general surgery service the day of,
three days before, or ten days before definitive abdominal wall
reconstruction. Four patients were female, with a mean age of 52
years, and three patients were male, with a mean age of 54 years.
Mean length of stay was 29 days.
At the time of reconstruction, synthetic or biologic mesh,
previously placed over the fascial defect, was removed except in two
cases where an acellular dermal matrix underlay placed during the
immediately preceding laparotomy was left in place. The average
fascial defect was 233 cm2 (range 150 – 450 cm2) and porcine or
human acellular dermal matrix was inserted as an underlay for three
patients (Figure 1).
A template of the anterolateral thigh flap was then drawn onto the
right thigh according to the size of the abdominal wall skin defect and
centered over the perforator zone (Figure 2A) [22]. Skin and fascial
incisions were made, and the vascular pedicle was traced between the
vastus lateralis and the rectus femoris muscles. Two septocutaneous
perforators extending into the skin paddle were included in all seven
flaps. The raised flaps consisted of skin, adipose tissue, fascia, and a
minimal segment or cuff of vastus lateralis muscle (Figure 2B). All
flaps were tunneled under the proximal portion of the rectus femoris
muscle in order to increase the arc of rotation.
Subcutaneous tunnels, several fingerbreadths wide, were created
between the donor site and the abdominal wall. In one patient,
extensive scarring from previous operations prevented sufficient
enlargement of the soft-tissue tunnel to allow safe passage of the flap
without undue flap compression. As a result, the tunnel was converted
to two skin flaps, which were then closed over the pedicle (Figure 3B).
The vastus lateralis was sutured to the underlying fascia or acellular
dermal matrix. Large close-suction drains were placed in donor and
recipient sites prior to closure. Skin paddles were then secured to the
edges of the defect using absorbable sutures or skin staples (Figure
3). The average skin paddle size was 189 cm2 (range 150-300 cm2). In
one case, a significant portion of the skin paddle was de-epithelialized
and buried under native abdominal wall tissue (Figure 3A). Another
patient required an additional 35 cm2 full-thickness skin graft, which
was harvested from the anterolateral thigh flap, to place over exposed
adipose tissue on the abdominal wall (Figure 3B).
Regarding the anterolateral thigh donor site closure, one case
allowed for primary closure (Figure 3A), while the other six required
closure with split-thickness skin grafts, ranging from 150 cm2 to
350 cm2. All skin grafts were harvested from the medial thigh or
contralateral thigh (Figure 3B). Subsequently, the skin grafts were
covered with vacuum-assisted closure devices. In one case, a vacuumassisted
closure device was also placed on the abdominal wall along
the incision lines to help reduce edema and manage fluid egress.
There were no intraoperative complications, flap failures, or hernia
recurrences. Two patients (28%) had postoperative complications of
infection and/or abscess, with one reoperation (14%) within 30 days
of surgery. One patient experienced an abdominal wall abscess, for
which the patient received broad spectrum antibiotics and underwent
drain placement by interventional radiology. Another patient
developed a flap abscess and was taken back to the operating room on
postoperative day 6 for drainage.
Figure 4
Figure 4
Complete progress of case (intra-operative and post-operative photographs).
(A) The tumor can be seen bulging from the patient’s right lower abdomen.
(B) Due to the severity of the tumor, much of the abdominal wall is removed.
(C) After placing biologics (ADM), the pedicled ALT flap is harvested.
(D) The soft tissue is inset into the defect and a drain is placed on the donor site.
(E) Post-operative 4 month follow-up photograph displays progress.
(F) Post-operative 1 year follow-up photograph displays completely healed wounds.
Discussion
Though use of the anterolateral thigh free flap has been welldescribed,
abdominal wall reconstruction with the pedicled
anterolateral thigh flap is infrequently reported in the literature
[6]. The seven cases in this report highlight the operative flexibility
provided by the pedicled anterolateral thigh flap. In these cases, a
pedicled anterolateral thigh flap was rotated, tunneled deep to the
rectus femoris muscle proximally [20], and inset into the respective
abdominal wall defect. In one instance, scarring from previous
operations did not allow passage of the flap through the tunnel. Flap
and pedicle compression often leads to venous congestion; therefore,
skin flaps on the lower abdomen were raised, opening the tunnel and
preventing compression. Though tunneling under the rectus femoris
allows for increased flap excursion, subcutaneous tunneling may be
clinically advantageous by avoiding pedicle compression by the rectus
femoris. If pedicle length restricts the ability for the flap to reach all
aspects of the defect, the flap can be readily converted into a free flap
[2]. However, in this situation, recipient vessels need to be explored.
Options in this situation can include the ipisilateral or contralateral
deep inferior epigastric vessels. Vein grafts can be used to help create
pedicle length for free-tissue transfer. An arterio-venous loop, using
a saphenous or cephalic vein graft, can be anastomosed to the deep
inferior epigrastric vessels in an immediate or delayed setting to help
prepare for eventual free-tissue transfer of the ALT flap. The superior
epigastric vessels a continuation of the internal mammary vessels can
be used as recipient vessels, although the caliber of these vessels can
be diminutive and they are found in an intramuscular course in the
rectus muscle. Vein grafting to the internal mammary vessels can be
considered although this typically requires removal of a chondral
segment of a rib in order to gain access at vessels. Description of freetissue
transfer is evidence enough to consider a pedicled flap as a first
option for large soft-tissue reconstruction of the abdominal wall.
While there can be inconsistencies in perforator anatomy
and some difficulty in perforator dissection [23], the major factor
limiting the use of the pedicled anterolateral thigh flap for abdominal
reconstruction is the location of the defect. Some authors have
described the strict use of a free flap for upper abdominal defects
and a pedicled flap for lower abdominal defects[2]. Sacks et al. [6]
however, described the ability to use the pedicled flap for a defect
almost anywhere in the anterior abdomen [6], and Ting et al. [4]
reported using a pedicled anterolateral thigh flap to reconstruct
an epigastric defect. Certain limitations in pedicle length can be
overcome by submuscular tunneling; however, perforator selection
is also an important factor. Maxhimer et al. [3] reported increasing
excursion of the flap to the abdomen by designing a distal skin island
and a higher point of rotation [3]. In addition, restricting hip joint
range of motion in the perioperative period and slowly introducing
hip extension allows for increased cranial placement of the flap [4]. By
the orienting the skin paddle of the ALT flap on distal perforators of
the descending lateral circumflex perforator system one can optimize
the length of the pedicle flap to use. When the skin paddle placement
is performed appropriately the ALT flap can be used to cover defects
of the abdominal wall as high as the xyphoid.
There is recent evidence that the pedicled anterolateral thigh flap
is as reliable for complex abdominal wall reconstruction. Kayano
et al. [2] showed that the only significant difference between use
of a free and pedicled anterolateral thigh flap for abdominal wall
reconstruction was a longer mean operative time for the free flap
surgeries [2]. With the ability to maximize flap excursion and the
numerous advantages of reconstructing with vascularized pedicled
autologous tissue, the pedicled anterolateral thigh flap is a viable
reconstructive option for a wide range of anterior abdominal wall
tissue defects.
The pedicled ALT flap is a reliable and robust flap from the
adjacent thigh that allows full-thickness abdominal wall defects
to be reconstructed in an immediate fashion. Variable amounts of
skin, adipose tissue, fascia and vastus lateralis muscle can be used to
reinforce composite defects of the abdominal wall that would not be
able to be reconstructed without free-tissue transfer. This flap allows
both the general and plastic surgeon to collaborate and reconstruct
the most complex abdominal wall defects. Using this collaborative
approach, patients with loss of domain, fistulae and/or both can
be approached in a straightforward manner. A staged approach is
favored for patients with fistula with bowel resection followed by
primary fascial closure with or without a biological matrix underlay.
If primary fascial closure is not obtained, then a biological matrix or
synthetic mesh underlay can be used to partition the enteral contents
from the wound. Wound contamination and surgeon preference will
determine the use synthetic and/or biological matrix placement. Once
wound contamination is controlled, full-thickness abdominal wall
defects can subsequently be reconstructed using well-vascularized
tissue from the thigh in a pedicled fashion. This technique allows even
the most complex of abdominal wall defects to be reconstructed in a
straightforward, systematic and safe fashion.
Table 1
Conclusion
With our single-institution experience, the pedicled ALT flap is a favorable option that should be routinely considered for salvage reconstruction of composite full-thickness abdominal wall defects, given its durable blood supply and ability to cover large cutaneous defects with minimal donor site morbidity. Utilizing a wellorganized, multidisciplinary approach, large composite defects of the abdominal wall that involve muscle, fascia, adipose tissue and skin can be reconstructed in a systematic and safe way.
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