It has been two decades since the description of the anterolateral thigh (ALT) flap;
however, skepticism still prevails in certain parts of the world about the reliability
of this donor site. The aim of this presentation was to systematically evaluate the
pitfalls that a beginner could experience in flap dissection, in order to simplify
flap harvest and decrease dissection time. The experience is based on 85 flaps performed
in various reconstructive procedures in the last 5 years.
The first mistake is to consider the ALT flap as a septocutaneous flap, which is a
myocutaneous flap of the vastus lateralis muscle in 85% of the cases. Therefore, an
indication requiring a thinner flap will necessitate perforator flap dissection, which
might be difficult or unexpected for the inexperienced surgeon. The second mistake
is to rely on a hand-held Doppler in flap design, which has been shown to have only
a 40% correlation with the actual perforators. When required, a color Doppler study
should be performed instead, which is even capable of discriminating between septocutaneos
and myocutaneous perforators. The third mistake is to plan and incise the skin flap
before identifying the perforator status. In addition, incision and dissection should
begin from the medial aspect, never circumferentially.
The fourth mistake is to be lost in the anatomic variations published. These variations
are limited to 10% of cases, and those which make this donor site invalid are less
than 4%. It should also be noted that the vessel referred to as perforators in one
article may not be the same type of vessel described in the next. This is particularly
true for the earlier studies that frequently reported absence of the perforators;
they were referring to the absence of septocutaneous perforators, as the perforator
flap concept based on myocutaneous perforators was not available yet. The fifth mistake
is to start dissection of a perforator from periphery to center without identifying
the proximal main vessel. This may lead the surgeon to other pedicle dissections,
thus wasting time. The sixth mistake is to cut the motor nerve to the vastus lateralis
muscle due to its twisting around the perforators. It is possible to free the nerve
from the vascular pedicle following pedicle division in all single-perforator flaps.
By avoiding these pitfalls, the authors did not encounter any dissection-related flap
failures in their series. When the confusion in the nomenclature and knowledge about
dissection techniques of the ALT flap are clarified, this flap becomes one of the
most versatile and reliable donors.
