Received: 27 April 2016 | Revised: 27 October 2016 | Accepted: 2 December 2016

DOI 10.1002/micr.30141

CLINICAL ARTICLE

Application of extended bi-pedicle anterolateral thigh free flaps

for reconstruction of large defects: A case series

Michele Maruccia, MD1,2,3 | Georgios Orfaniotis, FRCS(plast)1 |

Pedro Ciudad, MD, PhD1 | Fabio Nicoli, MD1 | Emanuele Cigna, MD, PhD, FRM2 |
Giuseppe Giudice, MD, PhD3 | Kidakorn Kiranantawat, MD, FRCST1 |
Diego Ribuffo, MD2 | Hung-Chi Chen, MD, PhD, FACS1

1
Department of Plastic Surgery, China
Medical University Hospital, Taichung
40447, Taiwan
2
Department of Plastic and Reconstructive
Surgery, “Sapienza” University, Rome 00161,
Italy
3
Department of Emergency and Organ
Transplantation, University of Bari “Aldo
Moro,” Plastic and Reconstructive Surgery
and Burns Unit, Bari, Italy
Correspondence
Michele Maruccia, MD, PhD, Department
of Plastic Surgery, China Medical University
Hospital, 2 Yuh-Der Road, Taichung 40447,
Taiwan.
Email: marucciam@gmail.com
Funding information
National Institutes of Health (NIH);
Wellcome Trust; Howard Hughes Medical
Institute (HHMI)
Background: The anterolateral thigh flap is a workforce flap in reconstructive surgery, however,
variations in it is vascular anatomy are not uncommon. These variations may affect flap design and
survival, especially when large flaps are required. In some anatomical variants the anterolateral
thigh flap is supplied by two separate dominant pedicles, and in these cases a bi-pedicle modifica-
tion may be necessary to ensure complete flap viability. The aim of this report is to evaluate the
outcomes, and present our approach in using bi-pedicle anterolateral thigh flaps as a method to
reduce the risk of partial flap necrosis when reconstructing sizeable soft tissue defects.
Patients and Methods: From October of 2013 to November of 2015, seventeen patients were
treated with extended bi-pedicled ALT flaps for reconstruction of large defects (16 to 25 3 8 to
13 cm). Following doppler mapping of the lateral thigh perforators, an anterior incision was made.
When a distinct oblique branch (OB) was present and the perforators of the descending branch
of the lateral circumflex femoral artery (d-LCFA) were small, the large bi-pedicle ALT flaps were
harvested based on both the oblique branch and the d-LCFA pedicle. We evaluated the perfusion
of the flap using only one pedicle by clamping alternately the OB and the d-LCFA. After flap har-
vest, we performed two end-to-end venous anastomosis between the lateral circumflex femoral
vein and a recipient vein, and the oblique branch vein with a second recipient vein. End to end
arterial anastomosis were performed between the two pedicles and two recipient arteries. Y-
shaped interposition vein graft (YVG) was applied when single recipient artery was available for
revascularization. The flaps were used for scar contracture, chest wall, lower and upper extremity
soft tissue defects, breast, scalp, oral cancer, and esophageal reconstruction.

Results: The flaps size were 18 to 26 3 10 to 14 cm. For all seventeen patients the reconstructive
goals were achieved with complete survival of the large ALT flaps with no events of partial necro-
sis or failure. We reported one case of re-exploration of a congested flap due to venous
thrombosis, which was successfully salvaged.

Conclusion: Bi-pedicled ALT flaps could be a considered as a valuable option when a second pedi-
cle is encountered and large flaps are required.

1 | INTRODUCTION
The anterolateral thigh (ALT) flap was first described by Song et al. in
1984 (Song, Chen, & Song, 1984) and it has recently gained enormous
popularity in soft-tissue reconstruction (Demirkan, Chen, Wei, Chen,
Jung, Hau, & Liao, 2000; Demirkan, Wei, Chen, Chen, Hau, & Liau,
1999; Koshima, 2000; Koshima, Hosoda, Inagawa, Urushibara, &
Moriguchi, 1998; Shieh, Chiu, Yu, Pan, Tsai, & Shen, 2000). It’s use has
multiple advantages including a long pedicle with a suitable vessel
diameter, availability of different tissue components with a large skin

26 | V
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MARUCCIA ET AL.
paddle; adaptability as a sensate or flow-through flap and low donor
site morbidity (Kimata, Uchiyama, Ebihara, Kishimoto, Asai, Saikawa,
Ohyama, Haneda, Hayashi, Onitsuka, Nakatsuka, & Harii, 1999; Kimata,
Uchiyama, Ebihara, Yoshizumi, Asai, Saikawa, Hayashi, Jitsuiki, Majima,
Ohyama, Haneda, Nakatsuka, & Harii, 1997; Koshima, Fukuda, &
Soeda, 1989; Koshima, Fukuda, Yamamoto, Moriguchi, Soeda, & Ohta,
1993). However, despite these advantages, the anterolateral thigh flap
is not considered entirely reliable, mainly due to a number of variations
on its vascular anatomy and its rather unpredictable distribution of per-
forator vessels to the skin (Kimata, Uchiyama, Ebihara, Nakatsuk, &
Harii, 1998; Shieh et al., 2000; Zhou, Qiao, Chen, Ling, & Swift, 1991).
The vascular pedicle of ALT flap consists of the descending branch
of the lateral circumflex femoral artery (d-LCFA), which originates from
the profunda femoral artery. This pedicle runs through the septum
between the rectus femoris and the vastus lateralis muscles and
emerges in the middle of the upper third of the thigh. However the d-
LCFA runs inside the vastus lateralis muscle distally in some cases. A
perforator based ALT flap consists of branches that, either traverse the
muscle (musculocutaneous), or the septum between the muscles (sep-
tocutaneous) to perfuse the skin (Chen, Lin, Chou, Chang, Chen, Xu, &
Wu, 2009).
There have been many studies that highlighted a number of varia-
tions of the descending branch of lateral circumflex femoral pedicle
and its relationships with the perforators (Kimata et al., 1998; Koshima,
Fukuda, Utunomiya, & Soeda, 1989; Valdatta, Tuinder, Buoro, Thione,
Faga, & Putz, 2002; Wei, Jain, Celik, Chen, Chuang, & Lin, 2002). “Ana-
tomical confusion” was increased when Wong et al.17 described the
oblique branch (OB) of the LCFA as possible alternative vascular pedi-
cle of the anterolateral thigh flap. Authors have also discussed the
choice of pedicle when both vessels are present (d-LCFA and ob-LCFA)
(Wong, Wei, Fu, Chen, & Lin, 2009).
The use of bi-pedicle flaps is a well-known technique in breast
reconstruction with Deep inferior epigastric perforator (DIEP) (Xu,
Dong, & Wang, 2009) flaps or combined transverse upper gracilis and
profunda artery perforator flap(TUGPAP) (Ciudad, Maruccia, Orfaniotis,
Weng, Constantinescu, Nicoli, Cigna, Socas, Sirimahachaiyakul, Sap-
ountzis, Kiranantawat, Lin, Wang, & Chen, 2015). Incorporation of a
second pedicle allows larger flaps to be harvested safely, with low risk
of partial flap loss and fat necrosis (Ciudad et al., 2015; Xu et al. 2009).
However to date, the use of two separate pedicles in a single ALT flap,
has not been reported.
In this case series we present our experience and evaluate our
results in reconstruction of sizeable defects with the use of extended
bi-pedicle ALT flaps, as a method to increase blood inflow and reduce
the risk of partial flap necrosis.
2 | PATIENTS AND METHODS
From October of 2013 to November of 2015, 167 consecutive ALT
flaps were performed in our unit. Seventeen patients were treated
with extended bi-pedicled ALT flaps for reconstruction of large defects.
Patient’s age at the time of surgery ranged from 48 to 75 years. Four
| 27
extended bi-pedicled ALT flaps were used for extremity trauma, four
for scar contracture release, two for oral cancer, two for breast recon-
struction, one for esophageal reconstruction, one for chest wall, and
one for scalp. The size of the defects were 16 to 25 3 8 to 13 cm
(Table 1).
2.1 | Surgical technique
Preoperatively, handheld Doppler mapping of the perforators was car-
ried out. In each case, we observed one audible and pulsatile Doppler
signal proximally and another one or two medially or distally along the
line drawn between the anterior superior iliac spine and the lateral bor-
der of the patella (Figure 1).
The flaps were raised with the standard technique as previously
described (Ali, Bluebond-Langner, Rodriguez, & Cheng, 2009; Demirkan
et al., 1999, 2000; Koshima, 2000; Koshima et al., 1998; Lin, Wei, Lin,
Yeh, Rodriguez Ede, & Chen, 2006; Lutz & Wei, 2005; Saint-Cyr ,
Schaveroien, Wong, et al., 2009; Serafin, Sabatier, Morris, & Georgiade,
1980; Shieh et al., 2000; Song et al., 1984). Following the initial ante-
rior incision, we carefully identified the number, location, and quality of
the skin perforators present. When a large flap was needed and a dis-
tinct OB pedicle was present ALT flaps were harvested with both pedi-
cles and their skin perforators. In the absence of the OB, the flap was
elevated on the d-LCFA including as many perforators as possible, and
the flap was designed according to the defect characteristics. In the
event of small size perforators of the d-LCFA, a cuff of muscle was
included to avoid injury.
To evaluate the perfusion of the flap using only one pedicle, we
used a microvascular hemo-clamp to obstruct initially blood flow
through the OB, and evaluated the perfusion of the flap distally and
proximally. This evaluation was carried out by clinical observation of
the colour and also by checking the bleeding from the flap edges. Sub-
sequently the clamp from the OB was released and the d-LCFA was
clamped making the same evaluation. Based on the findings of this clin-
ical observation a decision was made as to whether a second pedicle
was necessary.
Venous anastomosis was performed prior to the arterial anastomo-
sis. In all the cases we performed two end-to-end venous anastomosis
between the lateral circumflex femoral vein and a recipient vein, and
the oblique branch vein with a second recipient vein (Figure 2A,B;
Table 1).
End to end arterial anastomosis were performed between the two
pedicles and two recipient arteries in 11 cases. In seven cases, only a
single recipient artery was available for revascularization. In four of
these cases there was no second artery, whereas in the remaining
three, although an additional recipient artery was present, it appeared
sclerotic with poor flow and hence was not used. To overcome this
limitation a Y-shaped interposition vein graft (YVG) was applied. This
provided an additional arterial source so both flap pedicles could be
connected to the same recipient vessel. YVGs were harvested from the
dorsum of either the foot or hand, after identifying the flow direction.
When an YVG was used, three arterial anastomosis were carried out.
The first was performed between the recipient artery and the main
T AB LE 1 Extended bi-pedicle ALT: Patients, pedicles, donor and recipient vessels characteristics
28
|

Defect
size ALT size Pedicle length Vessel caliber
(cm) (cm) (cm) (mm) Flap
length 3 (length 3 OB Recipient Y-shaped survival
Patients Cause of defect width) width) d-LCFA OB d-LCFA OB type artery Recipient veins vein graft (%) Complications

1 Neck contracture 24 3 11 25 3 12 17.6 8.9 2.5 2 4 Right transverse Right external jugular Dorsum of the foot 100 None
following burn injury cervical artery vein, right transverse
treated with split cervical vein
thickness skin graft

2 Recurrence breast 18 3 13 21 3 14 12.5 8.4 1.9 1.3 4 Right Internal Right internal thoracic Dorsum of the hand 100 None
cancer involving thoracic artery vein, superficial vein
chest wall

3 Left Breast cancer in 21 3 11 22 3 13 14.5 7.5 2.3 1.7 3 Left Internal Left internal thoracic Dorsum of the foot 100 None
patient with previous thoracic artery vein, superficial vein
abdominal surgery

4 Right lower limb 18 3 10 20 3 11 10.8 7.6 1.7 1.5 3 Right Posterior tibial Right posterior tibial vein, Dorsum of the hand 100 None
trauma artery lesser saphenous vein

5 Right axillary 21 3 12 22 3 14 11.7 8.6 1.9 1.4 5 Right transverse Right external jugular Dorsum of the foot 100 None
contracture after cervical artery vein, cephalic vein
radiotherapy

6 Neck scar contracture 25 3 9 26 3 11 12.6 8.8 2.1 1.6 3 Right transverse Right external jugular Dorsum of the foot 100 None
following mandibular cervical artery vein, cephalic vein
reconstruction with
free fibula flap and
radiotherapy

7 Esophageal cancer 16 3 8 18 3 10 16.2 11.7 2.2 1.9 5 Left superior Left external jugular vein Dorsum of the foot 100 None
thyroid artery and left superior thyroid
vein

8 Left upper limb 18 3 9 18 3 10 12.5 7.2 1.7 2 3 Ulnar artery d-LCFA Cephalic vein, radial vein None 100 Venous
trauma end to side) radial thrombosis
artery end to side
(OB)

9 Left upper limb 21 3 10 22 3 11 11.0 7.5 1.9 1.5 3 Ulnar artery (d-LCFA Radial vein, cephalic vein None 100 None
trauma end to side) radial
artery end to side OB)

10 Oral cancer 16 3 11 18 3 12 11.5 8.3 2.1 1.5 4 Right superior thyroid External jugular vein, left None 100 None
artery (d-LCFA) Left superior thyroid vein
superior thyroid
artery (OB)

11 Right lower 24 3 13 25 3 14 14.7 9.1 1.7 1.4 3 Posterior tibial artery Posterior tibial vein, None 100 None
limb trauma (end to side with d- lesser saphenous vein
LCFA), pedis artery
(end-to end with OB)
MARUCCIA

(continued)
ET AL.
 MARUCCIA
ET AL.

T AB LE 1 (continued)

Defect
size ALT size Pedicle length Vessel caliber
(cm) (cm) (cm) (mm) Flap
length 3 (length 3 OB Recipient Y-shaped survival
Patients Cause of defect width) width) d-LCFA OB d-LCFA OB type artery Recipient veins vein graft (%) Complications

12 Oral cancer 25 3 10 26 3 11 16.2 9.0 2.1 1.5 3 Left transverse Right external jugular None 100 None
cervical artery vein and right superior
(d-LCFA) and Left thyroid vein
superior thyroid

13 Right breast 18 3 12 19 3 13 14.9 8.6 1.7 1.5 3 Right Thoracodorsal Thoracodorsal veins None 100 None
reconstruction in artery (d-LCFA), Right
patient with previous Thoracoacromial
abdominal surgery Artery(OB)

14 Right hand and upper 22 3 8 23 3 10 12.6 11.9 2.0 2.0 5 Ulnar artery (d-LCFA Cephalic vein and None 100 None
limb scar contracture end to side) radial zradial vein
after burn injury artery end to side
(OB)

15 Left lower limb 20 3 10 21 3 11 16.4 8.9 2.2 1.8 3 Posterior tibial artery Right posterior tibial vein, None 100 None
trauma (end to side with d- lesser saphenous vein
LCFA), pedis artery
(end-to end with OB)

16 Scalp reconstruction 18 3 9 20 3 11 13.5 8.5 1.8 1.4 5 Right facial artery Right external jugular None 100 None
following (OB), right superior vein and right superior
spinocellular cancer thyroid artery thyroid vein
excision (d-LCFA)

17 Left lower limb 22 3 11 23 3 13 13.9 8.7 2.2 1.6 3 Posterior Tibial Right posterior tibial vein, None 100 None
trauma Artery (end to side lesser saphenous vein
with d-LCFA),
Peroneal artery
branch (end to end
with OB)

d-LCFA: descending branch of the lateral circumflex femoral artery; OB: Oblique branch.
|
29
30 | MARUCCIA ET AL.

3 | RESULTS

In total, seventeen extended free ALT flaps were utilized, with an addi-
tional OB pedicle. The oblique branch originated from the transverse
branch (10 cases), from the profunda femoris (4 cases), and directly
from the femoral artery (3 cases). In all the cases presented, we noticed
that a good size perforator originated from the OB proximally, while 1
or 2 smaller perforators arose from the d-LCFA, at the level of middle
and distal part of the flap.
In seven cases the perfusion of the extended ALT flap was rees-
tablished using YVG to connect the OB and the d-LCFA to the recipi-
ent artery. The YVG donor wound were closed primarily and healing
occurred without complications. In all the cases the donor site of the
ALT healed eventually with only some delayed skin graft healing in
four cases.
The size of the flaps were 18 to 26 3 10 to 14 cm. The length
was respectively from 10.8 to 17.6 cm and from 7.2 to 11.7 cm for the
d-LCFA and OB. The diameter of d-LCFA was 2.5 to 1.7 mm. The
diameter of the OB was 1.4 to 2 mm. They were accompanied by
paired venae comitantes of comparable size.
The d-LCFA perforators were muscolocutaneous in 13 cases
FIGURE 1 Marking for extended bi-pedicle ALT. (OB type 3)
and septocutaneous in 4 cases, while the perforators of the OB
were in 8 cases muscolocutaneous and in 9 cases septocutaneous
trunk of the YVG. The second was carried out between one branch of
(Table 1).
the vein graft and the d-LCFA. At that stage, we released the artery
One flap was re-explored due to venous thrombosis, and suc-
and vein to revascularize the flap reducing ischemia time. Finally the
cessfully salvaged few hours after the original surgery. All 17 free
anastomosis between the second branch of the YVG and the OB was
transferred flaps survived, with no partial necrosis or other
performed (Figure 2A,B).
complications.
In all the cases the ALT donor site was closed with a split-
The representative cases are shown in Figures 3A–C, 4A,B.
thickness skin graft harvested from the ipsilateral thigh.

F I G U R E 2 (A) Y-shaped vein graft anastomosis. The first anastomosis was performed between the left transverse cervical artery (TCA) and
the main trunk of the vein (yellow vessel loop), the second between one branch of the vein graft (left blue vessel loop) and the descending
branch of the lateral circumflex femoral artery (d-LCFA). The third anastomosis was performed between the other branch of the YVG (right
blue vessel loop) and the oblique branch (OB). (B) Schematic representation of the anastomosis. (TCA: transverse cervical artery; TCV: trans-
verse cervical vein; d-LCFA: descending branch of the lateral circumflex femoral artery, OB: oblique branch, VC: comitantes veins, EJV:
external jugular vein, YVG: Y-shaped vein graft, red arrow: artery flow; blue arrow: vein flow)
MARUCCIA ET AL. | 31

FIGURE 3 (A) Patient 2 (female, 62 years old) with breast cancer recurrence involving the chest wall up to deep fascia. She had history of
breast cancer treated 2 years ago with radical mastectomy with axillar lymphadenectomy and reconstruction with free DIEP flap. (B)
Intraoperative view with extended bi-pedicle ALT dissection (d-LCFA on the left side and OB on the right side) (C) Postoperative view (6-
months follow-up)¸ early postoperative radiotherapy was possible due to complete flap healing

4 | DISCUSSION
The anterolateral thigh flap is a highly versatile flap and has now
become a prevailing choice in reconstruction of many different ana-
tomical areas, ranging from upper and lower extremity trauma (Lin
et al., 2006; Serafin et al., 1980), to head and neck (Lutz & Wei, 2005;
Shieh, Chiu, Yu, Pan, Tsai, & Shen, 2000), as well as breast reconstruc-
tion (Wei, Suominen, Cheng, Celik, & Lai, 2002), when lower abdominal
wall tissue is not available.
The ALT flap is usually supplied by the descending branch of the
lateral circumflex femoral artery (Demirkan et al., 1999, 2000; Koshima,
2000; Koshima et al., 1998; Shieh et al., 2000; Song et al., 1984). The
oblique branch was firstly described in 2009 by Wong et al. (2009) and
can be present in up to 34% of cases. It was a previously unnamed
branch, which when present, is found between the descending and
transverse branches of the lateral circumflex femoral artery. This pedi-
cle is usually visible lateral to the descending branch in the upper part
of the thigh, once the intermuscular septum is dissected. Wong et al.
described five types of the OB based on its origin (Wong et al., 2009).
In our report we found 10 cases to be type 3 (OB originated from the
transverse branch), 3 cases type 4 (OB originated from the profunda
femoris) and 4 cases type 5 (OB branch originated from the femoral
artery). In all these cases the OB and d-LCFA were two separate pedi-
cles. There are occasions where the two pedicles can join to each
other, and thus originating as a common trunk. In this event we recom-
mend dissection of the two vessels proximally to their junction. This
would alleviate the need to use a Y vein graft.
When the OB is present it may represent the dominant bloody sup-
ply to the skin of the ALT flap, taking over from the descending branch
of the LCFA. In cases of large ALT flaps and in the presence of both the
OB and d-LCFA, both providing perforators to the skin, we believe that
the addition of a second pedicle could improve the vascularization of the
flap. Hence the idea of using both these pedicles, which we believe
reduces the risk of partial necrosis in large ALT flaps, and prevents its
devastating consequences. Furthermore, in our experience we observed
that when the OB is present, the main perforators are distal to the mid-
point between the anterior superior iliac spine and the upper outer cor-
ner of the patella as previously described (Wei et al., 2002).
According to current literature, the debate is still open regarding
which pedicle is the ideal (Chen et al., 2009; Kimata et al., 1998; Kosh-
ima et al., 1989; Valdatta et al., 2002; Wei et al., 2002; Wong, 2012;
Wong et al., 2009). The descending branch is the preferred pedicle
when a choice is available, as it is usually larger and longer than the OB
(Wong et al., 2009). This difference in length and diameter between d-
LCFA and OB in also evident in our series. In some situations where a
part of the skin is supplied exclusively by the OB, this pedicle will need

FIGURE 4 (A) Patient 6 (male, 54 years old) with neck scar contracture following mandibular reconstruction with free fibula flap and
radiotherapy for oral squamous cell carcinoma. The patient presented pathological scar with restricted neck extension and rotation (B)
Frontal postoperative view after scar excision and reconstruction with extended bi-pedicle ALT flap and one debulking procedure of the
flap and multiple Z-plasty (2-years follow-up)
32 | MARUCCIA
to be included to ensure skin island survival. The OB has been shown to
be equally reliable to the d-LCFA pedicle. However, the vessel caliber is
smaller (approximately 1 mm), making the anastomosis more challenging
(Tsao, Chen, Chen, & Coskunfirat, 2003). Previous authors (Kimata
et al., 1997; Wong et al., 2009) have elected to call the oblique branch
as a “perforator” that arose directly from a source other than the
descending branch. In agreement with Wong et al., (2009), we consider
this vessel, when present, to be a proper flap vascular pedicle. This con-
sideration is based on its vascular, anatomy and its size, which does not
require any supramicrosurgery skills for successful anastomosis.
Hallock GG (Hallock, 2014) reported that according to their experi-
ence all perforator free flaps that had some form of partial failure were
ALT free flaps. Initially this was clinically unrecognizable, but ultimately
distal flap ischemia was attributed to poor flap design. Proper flap
design requires an awareness of the correct topographic axis and an
understanding of the perforasome concept to better ensure adequate
flap perfusion. In our experience with large ALT flaps, in case both the
OB and d-LCFA are present, we noticed that when the OB was
clamped, the flow in the proximal part of the flap was reduced. Respec-
tively, obstruction of the d-LCFA resulted in reduced blood flow of the
distal part of the flap. Based on this clinical observation we decided to
use both the pedicles to reduce the risk of partial flap necrosis.
Although this is not a large series, there were no partial or total flap
necrosis reported in seventeen extended ALT flaps.
In all the cases, we have tried to prepare two recipient arteries for
the anastomosis of the two pedicles. To overcome the problem of recipi-
ent vessel depletion we used in seven cases a Y-shaped vein graft to
allow anastomosis of both pedicles to a single recipient artery (Orfaniotis,
Maruccia, Sacak, Ciudad, Lima, & Chen, 2014). YVGs have been previ-
ously used to bridge arterial defects in cases of multiple digit replanta-
tions and in free flap reconstruction in injured lower extremities in
mono-vessel patients (Jones & Jupiter, 1985; Stevanovic, Vucetic, Bum-
basievic, & Vuckovic, 1991). In these circumstances the use of an YVG
provided an additional recipient artery for free flap revascularization,
whilst maintaining adequate blood supply to the distal part of the limb.
The clinical implication of the presence of an OB in the harvest of
anterolateral myocutaneous flap is also significant. Although the vastus
lateralis muscle is almost always vascularized by d-LCFA, the OB pedi-
cle may represent the principle vascular source for the skin component.
In this anomalous situation, if a large segment of muscle is needed,
both the pedicles may need to be included within the flap.
When OB is type 1 or 2, the pedicle will eventually join with either
the d-LCFA or the transverse branch. In this case, further dissection of
the two pedicles should be performed proximally, up to junction to the
common trunk, which can be then used as a single pedicle.
In our series we used a hand held Doppler to pre-operatively
assess the presence of a proximal OB pedicle. Preoperative mapping of
the ALT flap perforators with Computed Tomography Angiography
(CTA) could however have allowed a more accurate and safer planning
of an extended flap.
Although the application of this technique can be narrow, we
believe that the same principle can be applied for large chimeric flaps,
ET AL.
when reconstructing large and complex defects. Chimeric ALT flaps
provide a versatile choice for reconstruction of three-dimensional
defects, as two or more separate tissue components can be harvested
based on a single pedicle, facilitating flap inset (Huang, Chen, Jain,
et al., 2002; Jones & Jupiter, 1985; Peng, Chen, Han, Xiao, Bao, &
Wang, 2013; Jiang, Guo, Li, Huang, Jian & Munnee, 2013). But when
the two pedicles are not confluent (as in our series), we believe that
the use of a bi-pedicled ALT flap may be a valuable solution specifically
for reconstruction of complex, three-dimensional defects.
Partial necrosis is a recognized flap complication, which can often
lead to devastating results for patient and surgeon. Management of
partial flap necrosis can vary from simple dressings to the need for a
second flap (Hallock, 2014). Specifically in head and neck reconstruc-
tion (pharynx and esophagus), partial necrosis can be potentially fatal
for the patient. Equally, robust flap supply to ensure primary healing is
essential when covering metal work in extremities, or when post-
operative radio/chemotherapy is necessary
In summary, in this series we present our approach and outcomes
with the extended bi-pedicle ALT free flap. We believe that this tech-
nique could be a reliable option when reconstructing large defects.
Inclusion of the additional OB pedicle, when present, could increase
flap survival and minimize complications from partial flap necrosis.
ACK NOWLE DGME NT S
All authors hereby declare not to have any potential conflict of
interests and not to have received funding for this work from any of
the following organizations: National Institutes of Health (NIH);
Wellcome Trust; Howard Hughes Medical Institute (HHMI); and
other(s). Each author participated sufficiently in the work to take
public responsibility for the content.
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How to cite this article: Maruccia M, Orfaniotis G, Ciudad P,
Nicoli F, Cigna E, Giudice G, Kiranantawat K, Ribuffo D, and
Chen HC. Application of extended bi-pedicle anterolateral thigh
free flaps for reconstruction of large defects: A case series.
Microsurgery. 2018;38:26–33. doi:10.1002/micr.30141