Combined Free Partial Vastus Lateralis with Anterolateral Thigh Perforator Flap for Reconstruction of Extensive Composite Defects

Musculocutaneous (MC) free flaps are useful for many reconstructive indications. Perforator flaps have become a standard of care. The anterolateral thigh flap (ALT) is popular. With it, varying sizes of the vastus lateralis (VL) muscle can be harvested as an MC flap. The skin islands of these flaps have a great range of freedom when dissected on their perforators. It was hypothesized that the VL-ALT perforator flap would offer adequate tissue stock combining maximal freedom in planning with minimal donor site morbidity.

From November 2001 to November 2003, a free partial VL with ALT perforator flap was used in 14 patients to reconstruct large defects. Indications for adding a muscular component were exposed bone, skull base, (artificial) dura, or osteosynthesis material, open sinuses, and lack of muscular bulk. Flaps were planned as standard ALT flaps, after which three types of dissection were performed: true MC flap; muscle flap with a skin island on one perforator, which could be rotated up to 180 degrees; chimera skin perforator flap with muscle being harvested on a separate branch from the source vessel or on a side branch of the skin perforator.

The mean skin size of the MC-ALT flaps was 131 cm². Mean muscle part size of the MC-ALT flap was 268 cm³. Muscular portions were custom designed for all defects. No total or partial flap failures were seen. Color mismatch was seen in 6 of 8 patients, when skin was used in the facial area in this all white population. Excessive flap bulk was found in 8 of 14 patients at 6 weeks; however, only in 2 of 14 patients after 6 months. Patients were (very) satisfied with the functional results (8 of 14 patients) as well as the cosmetic result of their reconstruction (7 of 14 patients). All less satisfied patients had received their flaps for external facial skin reconstruction. Donor-site morbidity was minimal.

The combined free partial VL with ALT perforator flap proved valuable as a (chimera type) MC flap, with maximal freedom of planning to meet specific reconstructive demands and minimal donor-site morbidity.