Compartment syndrome as a donor-site complication of anterolateral thigh free flap: a case report

Compartment syndrome (CS), a complication at the donor site of anterolateral thigh free flap (ALT-FF), has a low incidence. Our patient was a 26-year-old male, a professional soldier with large thigh muscles. His defect on the right ankle was reconstructed with a 30×10 cm2-sized ALT-FF. By the pinch test, the flap width was designed to be sufficient for primary closure of the donor. However, on the postoperative day 8, severe pain, tense and purulent discharge were found at the donor site. We diagnosed CS clinically, and immediately performed incision and drainage. There are various extrinsic or intrinsic factors that can influence the development of CS. Therefore, in patients with these contributing factors, such as a young man with high muscle mass, a higher level of suspicion for CS is needed. Moreover, it would be safer to design the flap width smaller than the pinch test or to cover the donor site with a skin graft.

Color Doppler Ultrasound versus Computed Tomography Angiography for Preoperative Anterolateral Thigh Flap Perforator Imaging: A Systematic Review and Meta-Analysis

Background The anterolateral thigh (ALT) perforator flap is a commonly used flap with a predictable, though often variable, perforator anatomy. Preoperative imaging with color Doppler ultrasound (CDU) and computed tomography angiography (CTA) of ALT flap perforators can be a useful tool for flap planning. This study provides a complete review and analysis of the relevant preoperative ALT imaging literature. Methods Studies related to preoperative CDU and CTA imaging were reviewed, and information related to imaging method, sensitivity, false-positive rates, and perforator course identification (musculocutaneous vs. septocutaneous) were analyzed. Results A total of 23 studies related to preoperative ALT flap CDU and CTA imaging were included for review and analysis. Intraoperative perforator identification was compared with those found preoperatively using CDU (n = 672) and CTA (n = 531). Perforator identification sensitivity for CDU was 95.3% (95% CI: 90.9–97.6%) compared with the CTA sensitivity of 90.4% (95% confidence interval [CI]: 74.4–96.9%). The false-positive rate for CDU was 2.8% (95% CI: 1.1–4.5%) compared with 2.4% (95% CI: 0.7–4.1%) for CTA. Accuracy of perforator course identification was 95.5% (95% CI: 93.6–99.2%) for CDU and 96.9% (95% CI: 92.7–100.1%) for CTA. Conclusion CDU provides the reconstructive surgeon with greater preoperative perforator imaging sensitivity compared with CTA; however, false-positive rates are marginally higher with preoperative CDU. Preoperative imaging for ALT flap design is an effective tool, and the reconstructive surgeon should consider the data presented here when selecting a flap imaging modality.

Preoperative Computed Tomography Angiography for ALT Flaps Optimizes Design and Reduces Operative Time

Background Computed tomography angiography (CTA) has been widely used for perforator mapping in abdominal-based reconstruction, but it is less widespread in the anterolateral thigh (ALT) flap. However, CTA may be quite useful for ALT planning, as this flap has demonstrated substantial variability in intrapatient bilateral vascular anatomy. This study investigated whether standard use of preoperative CTA resulted in selection of the donor extremity with preferential perforator anatomy, and whether this affected operative time and postoperative outcomes. Methods A retrospective review of 105 patients who underwent proposed ALT flap reconstruction was performed. Seventy-nine patients received bilateral lower extremity CTAs, which were evaluated for dominant perforator anatomy (septocutaneous, musculoseptocutaneous, or musculocutaneous). Donor extremity selection was noted, and predicted perforator anatomy was compared with that encountered intraoperatively. Results Among the 73 patients who received bilateral imaging and ultimately received an ALT, congruent findings between imaging and surgical exploration were observed in 51 (69.8%) patients. Thirty (37.9%) patients had asymmetric perforator anatomy between their bilateral extremities on imaging. Among these, the leg with optimal perforator anatomy was selected in 70% of cases. There were no significant reductions among postoperative complication rates, but selection of the donor site with preferential anatomy was associated with a decrease in operative time (p = 0.049) among patients undergoing extremity reconstruction. Conclusion CTA is a useful tool for optimizing donor site selection for ALT flaps and reducing operative time. We believe that standard use of preoperative CTA in ALTs warrants further consideration.

Designing Anterolateral Thigh Flap Using Ultrasound

Background Preoperative knowledge of themicrovascular anatomy of a patientmay improve safetyand efficacy and reduce morbidity. Today, with the advancement in technology, ultrasound can provide minute details of the structures within the body, which makes this technology very helpful in preoperative evaluation of the traditional perforator flaps as well as thin, superthin, and pure skin perforator flaps. Methods In this article, we will describe the design of one of the most popular perforator flaps, the anterolateral thigh (ALT) flap, using high-frequency and ultrahigh-frequency ultrasound technology. Results Ultrasound technology allows to study preoperatively the ALT donor-site and its microvascular anatomy by using different US modalities in order to provide a virtual surgical plan to the operating surgeon. Conclusion Ultrasound technology allow to expand preoperative knowledge of flap microvascular anatomy and its course within the subcutaneous tissue up to and within the dermis, allowing to select the best perforator for the given reconstruction and the plane of elevation for thin, superthin and pure skin perforator flap.