Hand Reconstruction Using the ThinAnterolateral Thigh FlapRoberto Adani, M.D., Luigi Tarallo, M.D., Ignazio Marcoccio, M.D., Riccardo Cipriani, M.D.,Chiara Gelati, M.D., and Marco Innocenti, M.D.Modena, Bologna, and Firenze, Italy

Background: Perforator flaps have beenintroduced for various kinds of reconstruc-tion and resurfacing; in particular, the freethin anterolateral thigh flap is becomingone of the most preferred options for re-construction of soft-tissue defects.Methods: Between 1999 and 2002, the au-thors used this flap as a free flap for nine casesfor covering hand defects after burn, crushinginjuries, or severe scar contracture release.There were eight men and one woman, themean age of the patients was 31 years, and thesize of the flaps ranged from 7 � 3.5 cm to 15� 9 cm; thinning was performed in all flaps.Results: All flaps survived completely, and thedonor site was closed directly in seven cases; intwo cases, the exposed muscle was covered withsplit-thickness skin graft.Conclusions: The anterolateral thigh flap wasthin enough for defects on the dorsum and/or palm of the hand and for first web recon-struction after scar contracture release. It hasmany advantages in free flap surgery includ-ing a long pedicle with a suitable vessel diam-eter, andthedonor-sitemorbidity is acceptable.The thin anterolateral thigh flap is a versa-tile soft-tissue flap that achieves good handcontour with low donor-site morbidity. (Plast.Reconstr. Surg. 116: 467, 2005.)

The anterolateral thigh flap is a fasciocuta-neous flap based on septocutaneous or muscu-locutaneous perforators supplied by the lateral

femoral circumflex system; it was first intro-duced by Song et al.1 and was developed forwidespread clinical application by Koshima etal.2–4 and Kimata et al.5,6 The anterolateralthigh flap has become the standard flap forsoft-tissue reconstruction of the upper andlower extremities and the trunk.7–11 It has manyadvantages in free flap surgery, including along pedicle with a suitable vessel diameter,the availability of different tissue with a largeamount of skin, and acceptable donor-site mor-bidity.

Different methods of reconstruction areavailable for the treatment of hand defects: alocoregional flap such as the distal pedicle ra-dial forearm fasciocutaneous flap with its mod-ification12–14 or the posterior interosseous flapshould be used when the defect is closed di-rectly.15,16 Free flaps have advantages in termsof providing tissue with similar color and tex-ture that gives good hand contour with mini-mal donor-site morbidity.17 In this article, wepresent the application of the anterolateralthigh flap in hand reconstruction.

PATIENTS AND METHODS

Between 1999 and 2002, we used the antero-lateral thigh flap in nine cases for coveringhand defects after burn, friction injury, crush-ing injury, and severe scar contracture release(Table I).

There were eight men and one woman, witha mean age of 31.5 years (range, 8 to 53 years).Anterolateral thigh flap size ranged from 7 to15 cm in length and 3.5 to 9 cm in width.

From the Department of Orthopedic Surgery, University of Modena and Reggio Emilia; the Plastic Surgery Unit, Policlinico S. Orsola-Malpighi;and the Hand and Microsurgery Unit, Orthopaedic Traumatological Center. Received for publication April 20, 2004; revised August 9, 2004.

Presented in part at the Second Congress of the World Society for Reconstructive Microsurgery, in Heidelberg, Germany, June 11 to 14, 2003.

DOI: 10.1097/01.prs.0000173059.73982.50

467

According to the recent terminology on perfo-rator flaps,18–20 in six cases, the flap was vascu-larized by septal perforator (septal perforatorflap) and in three by a muscle perforator (mus-cle perforator flap). Donor sites were closeddirectly in seven cases, and in two cases theexposed muscle was covered with split-thick-ness skin graft. All flaps were dissected withloupe magnification, and vessel anastomoseswere performed with an operating microscope.In five cases, anastomoses were performed end-to-end at the snuff-box with the dorsal branchof the radial artery, in three cases end-to-sidewith the radial artery, and in one case end-to-end to the radial artery. All patient were oper-ated on by means of the operative techniquedescribed in a previous article.3,6,21–25 Thinninghas been performed in all the flaps beforedividing the pedicle (Fig. 1). Thinning is per-formed over the entire flap except for 2 to 3cm around the entry of the main perforator tothe flap11 and is achieved by removing the ad-ipose tissue, which is composed of large fatlobules and lies deeply to the superficial fas-cia.26 During this procedure, it is necessary topreserve the veins that run in the layer of smallfat lobules superficial to the fascia. To identify

these small veins, blood flow should be pre-served in the flap during the thinning proce-dure and should be performed with the aid ofmagnifying loupes. The thickness of the flap isapproximately 3 to 4 mm after thinning.26

None of the patients had any intraoperativeand/or postoperative complications.

CASE REPORTS

Case 3A 53-year-old man suffered a crush injury with complete

necrosis of the right thumb and index finger ray (Fig. 2). Afterradical debridement, an anterolateral muscle perforator flapmeasuring 14 � 8 cm was elevated from the contralateralthigh. The lateral femoral circumflex artery was sutured end-to-end to the dorsal branch of the radial artery and one venaecomitans to the cephalic vein. The donor flap area was closedprimarily and postoperative recovery was uneventful and theflap survived completely. A satisfactory result was obtained at1-year follow-up, and now the patient is scheduled for thumbreconstruction.

Case 5A 25-year-old man presented severe scar contracture at the

first web space of the right hand after having suffered ageneral burn treated elsewhere 18 years before using a ran-

TABLE IPatient Details

PatientAge(yr) Sex Cause Defect

Flap Size(cm)

Typeof Flap

DonorFlap Area

1 35 M Burn injury Right first web space release 10 � 7 SPF D2 8 F Electrical burn Right hypothenar and wrist 7 � 3.5 SPF D3 53 M Crush injury Right radial hand 14 � 8 MPF D4 36 M Crush injury Right palmar hand 15 � 9 SPF SG5 25 M Burn injury Right first web space release 13 � 7 SPF D6 23 M Friction injury Left dorsal hand 8 � 6 MPF D7 22 M Hot press injury Right dorsal hand 9 � 9 SPF SG8 34 M Home-made explosives Right first web space release 12 � 7 MPF D9 48 M Electrical burn Right volar wrist 7 � 6 SPF D

D, direct closure; SG, skin graft; SPF, septal perforator flap; MPF, muscle perforator flap.

FIG. 1. With presentation of the subdermal plexus, a thin flap can be obtained with removalof a considerable amount of fatty tissue. Blood flow should be maintained in the flap during thisprocedure, and therefore the flap should not be made completely free until the thinning iscompleted.

468 PLASTIC AND RECONSTRUCTIVE SURGERY, August 2005

dom abdominal flap with separate septa for each of the fin-gers (Fig. 3). After extensive release of the first web space, athin anterolateral thigh septal perforator flap measuring 13� 7 cm and approximately 3 to 4 mm thick except in thevascular perforator area was transferred from the left thigh tothe defect. The pedicle was anastomosed end-to-end to theradial artery and the cutaneous vein at the anatomic snuffbox.The flap survived completely and the contracture improvedenough to enable the patient to open the first web spacecompletely (Fig. 4).

Case 7

A 22-year-old man sustained a severe hot press injury onthe dorsum of the right hand. The patient was treated 20 daysafter the initial trauma (Fig. 5). After debridement of thenecrosed tissue preserving the extensor tendons, an antero-lateral septal perforator thigh flap measuring 9 � 9 cm wasraised from the left thigh. A considerable amount of fattytissue was removed. The proximal end of the lateral circum-flex femoral artery and one comitant vein were anastomosed

FIG. 2. The patient in case 3. (Above, left) Crush injury with necrosis of the thumb and indexfinger. (Above, right) Intraoperative view: elevated anterolateral muscle perforator flap. (Below,left) Appearance 1 year after surgery. (Below, right) Donor-site result.

FIG. 3. The patient in case 5. (Left) Severe scar contracture at the first web space. (Center) Intraoperative view: elevatedanterolateral septal perforator flap. (Right) Result at the end of operation.

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to the radial artery end-to-side and to the cephalic vein end-to-end. The donor defect was covered with split-thickness skingraft harvested from the thigh. The postoperative course waswithout problems and the flap survived completely (Fig. 6).

DISCUSSION

The principle of the anterolateral thigh flapis to make a skin flap very thin by performingsurgical procedures on the flap before its trans-fer.3,11,24,26 The flap can be thinned to a thick-ness of approximately 3 to 4 mm with removalof a considerable amount of fatty tissue; how-ever, partial flap necrosis may be caused by anexcessive defatting procedure.5,24,27,28 This maybe avoided by leaving enough fatty tissuearound the perforators to ensure good vascu-larity into the thin flap.26

For reconstruction of the hand, the idealflap should have the following features: liketissue for replacing like area, thin and pliableflap for molding the hand contour, minimaldonor-site morbidity, and sizable pedicle formicrosurgical anastomosis; also, change ofposition intraoperatively should not be nec-essary.7,29,30 We believe that the anterolateralthigh flap, especially after thinning proce-dures, has all these features. Until now, theanterolateral thigh flap has received littleattention from hand surgeons,31 and only afew reports have focused on this reconstruc-tive procedure in hand reconstruction.31–34

This flap represents a good alternative toother fasciocutaneous flaps. The lateral armflap is limited by its short pedicle; the scap-

FIG. 4. Final result in the patient in case 5.

FIG. 5. The patient in case 7. (Left) Hot press injury on the dorsum of the hand. (Center) After debridement, a skin defectwith exposure of the extensor tendons is seen. (Right) Elevation of the anterolateral thigh flap.

470 PLASTIC AND RECONSTRUCTIVE SURGERY, August 2005

ular flap requires a change of position dur-ing the operation, hindering a two-team ap-proach; and the radial or ulnar flap has beencriticized because of the sacrifice of a majorartery to the hand and the poor donor-siteresult.35,36 These problems can be partiallysolved by the retrograde radial fascia-fat fore-arm flap, which removes only the fascia andfat layers of the forearm tissue and leaves theradial artery and the forearm skin intact.37

There are some disadvantages of this flap:the adipofascial pedicle is relatively bulkyafter rotation, which makes direct closuredangerous to the pedicle, and it is difficult toextend to the distal hand.14

The posterior interosseous flap with reverseflow offers good cosmetic results, but an arteryis killed (posterior interosseous artery) that isof secondary importance for vascularization ofthe hand. The greatest disadvantage resides inthe limited sizes available for the flap: closureof the donor site can be achieved if it is lessthan 3 to 4 cm wide, giving minimal donor-sitemorbidity,15,16 and poor aesthetic results areobserved when the donor area is skin grafted.38

For this reason, it is not frequently indicated inthe treatment of extensive loss of substance.31

Compared with these flaps, the anterolateralthigh flap has numerous advantages: simulta-neous flap elevation and preparation are pos-sible and total operative time is shortened, re-positioning the patient is unnecessary forharvesting the flap, a vascular pedicle approx-imately 10 cm long can be obtained, and thevascular pedicle is approximately 2 mm and alarge skin paddle can be obtained even whenonly a single cutaneous perforator is avail-able.5,10,21

Defects of the donor site smaller than 8 cmin width can be closed primarily without a skingraft,5,9,25 and its scar is less noticeable thanthat of other flaps, especially those obtainedfrom the arm and forearm. In our series ofclinical cases, a split-thickness skin graft wasnecessary in two patients (patients 4 and 7).The donor-site scars associated with use of skingrafts in large defects may preclude their use,particularly in female patients.10,29 For this rea-son, we consider that it will be necessary forwomen to use a tissue expander to improve thedonor-site appearance.26 Moreover, there is ahigh incidence of hairy skin in this area inmen.9 If needed, laser can be used successfullyto remove these hairs9; however, none of ourmale patients has complained about the hairyappearance of a flap. The flap is generally thinand suitable for hand reconstruction; never-theless, in the Western world, the flap is not sothin and the flap must be thinned. This couldmean that a major degree of fat dissection isrequired to achieve the desired thickness inFar East patients with the risk of some vasculardamage to the vessels that run obliquelythrough the fat to supply the skin,27 explainingthe patterns of skin necrosis recently report-ed.28

Preoperative Doppler examination is usefulto confirm localization of the perforators ofthe anterolateral thigh flap.3,4,8,9 Evaluation issafe because there are several perforators de-riving from the lateral circumflex femoral ves-sels entering the flap. If a visible septocutane-ous vessel is found in the intermuscular septumbetween the vastus lateralis and the rectus fem-oris muscle, the flap can be harvested as aseptal perforator flap (six cases). If the skin

FIG. 6. The patient in case 7. (Left) Final result. Right Appearance of the donor site resurfaced witha skin graft.

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vessel is a musculocutaneous perforator, theprocedure is more difficult9,10 because it re-quires dissection of the perforator vessels inthe vastus lateralis muscle (muscle perforatorflap: three cases). A sensory flap using the lat-eral femoral cutaneous nerve can also be ob-tained6,10; however, no attempt was made inour cases to suture the nerve of the flap to anerve in the recipient hand.

The anterolateral thigh flap is adaptable tomany clinical situations and can substitute formost of the commonly used soft-tissue flaps.Some of our hand defects could have beenmanaged by regional island flaps,12,15 but (ex-cept in case 2) the resultant defects were of asize where the final cosmetic results at the do-nor site were unacceptable. In these circum-stances, the thin anterolateral thigh flap canreplace the radial and/or the posterior in-terosseous flap.

In case of severe adduction of the thumb, itis necessary to perform a wide release of allcontracted deep first web structures, and thisstep creates a defect so wide and deep that it isnot possible to cover it with the more usuallocal flaps. In our series, we used the antero-lateral thigh flap in three cases characterizedby full adduction of the thumb and severeretraction of the first web space. This flap per-mits reconstruction of a normal web that isanatomically correct in width and depth; inparticular, the anterolateral thigh flap matchesthe skin of the dorsum of the hand in textureand thickness and represents a good alterna-tive choice to the lateral arm flap.39 Finally, weused the anterolateral thigh flap to cover de-fects located on the dorsal (Fig. 6) and thevolar aspects of the hand. The choice of usingthe anterolateral thigh flap instead of the eas-ier distally based radial forearm fascial flap14,37

was forced by the wide defect, where an islandflap would not have sufficed. The acceptableresults obtained suggest that this flap is alsosuitable for soft-tissue reconstruction of thepalm and the dorsum of the hand.

CONCLUSIONS

We believe that the thin anterolateral thighflap represents an excellent option for cover-ing various defects in the hand and wrist. Theflap provides a thin, pliable, vascularized tissuefor covering the exposed tendons or bone andfor replacing the skin in particular areas, suchas the first web space.

Roberto Adani, M.D.Clinica Ortopedica e TraumatologicaPoliclinicoLargo del Pozzo 7141100 Modena, Italyadani.roberto@unimo.it

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38. Angrigiani, C., Grilli, D., Dominikow, D., and Zancolli,E. A. Posterior interosseous reverse forearm flap:Experience with 80 consecutive cases. Plast. Reconstr.Surg. 92: 285, 1993.

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