Surgical Techniques to Achieve Direct Anterolateral Thigh Flap Donor-Site Closure

Sir:FigureThe anterolateral thigh flap width recommended to achieve primary donor-site closure varies from 6 to 9 cm.1,2 Over 9 cm, it is possible to close the thigh directly using several techniques listed in Table 1; three of them achieve primary closure using local fasciocutaneous flaps.3–5 Yamada et al. propose island V-Y advancement flaps, one flap distally based on the retrograde flow of the descending branch of the lateral circumflex femoral artery by means of the lateral superior genicular artery and one flap proximally based or on the anterograde flow through the descending branch of the lateral circumflex femoral artery or on the retrograde flow of the transverse branch of lateral circumflex femoral artery. They experienced eight types of flap elevation in patients with head and neck tumors, and in all cases they exposed more than three perforators. The authors advise that the validity of the retrograde flow through the transverse branch of lateral circumflex femoral artery be investigated.3 Zhao et al. use the groin flap to close the thigh following anterolateral thigh flap harvest; their method is similar in concept to a bilobed flap but with crucial differences, because it is an axial fasciocutaneous flap based on a specific vascular axis.4 Even if previously introduced by Pribaz et al. in 1999 with the concept of prefabricated flaps in head and neck reconstructions,5 Hallock suggests preexpanding the thigh skin in a suprafascial plane to obtain primary closure; because it is a two-stage procedure, he applied tissue expansion in burn patients for contracture release because the technique clearly delays tumor management.6 In 2006, Calderón et al. dissected suprafascial anterolateral thigh flaps and achieved donor-site closure through advancement of two rectangular flaps from the thigh sides.7 Recently, Marsh and Chana from the United Kingdom introduced the concept of an elliptical flap design and dissection of two distinct perforators, harvesting de facto a split-skin paddle anterolateral thigh flap; acting on the rotation arch of the perforators, they achieved not only donor-site closure but also large defect repair (up to 30 × 18 cm; i.e., 540 cm2). A distal division of the perforators represents the limit to the technique because limiting the rotation arch with consequent interference with donor-site repair which, nevertheless, can be overcome by dissecting a perforator from the transverse branch of the lateral circumflex femoral artery and performing the anastomosis to the main trunk of the lateral circumflex femoral artery.8 Nevertheless, it is possible to obtain a delayed donor-site closure with a shorter operative time but to the detriment of patient compliance (Table 2).Table 1: Surgical Techniques to Achieve Immediate Anterolateral Thigh Flap Donor-Site ClosureTable 2: Surgical Techniques to Achieve Delayed Anterolateral Thigh Flap Donor-Site ClosureFurther discussion concerns single-based patient evaluation because donor-site morbidity has less impact in head and neck oncology as compared with immediate reconstruction following injuries or delayed reconstruction following contracture scar release. Evidently, the oncologic group of patient needs to start adjuvant therapy as soon as possible, with the possibility of availing themselves of reconstructive surgery later. Successful long- and short-term recovery has been reported following direct donor-site closure with local flaps as compared with split-thickness skin grafts charged by long-term morbidity with pain, numbness, contour deformity, and unsightly scar that contribute to poor patient-reported outcome.9 However, anterolateral thigh donor-site repair is hard to solve and troublesome for massive flaps, as demonstrated by recently published series of patients that are more likely to undergo delayed reconstructive surgery.10 Tommaso Agostini, M.D. Davide Lazzeri, M.D. Burns and Plastic Surgery Unit, Cisanello, Pisa, Italy DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.