RECONSTRUCTIVE SURGERY AND BURNS

Reconstruction of the Skin Defect of the Knee Using a Reverse

Anterolateral Thigh Island Flap
Cases Report
Tsung-Yu Liu, MD, Seng-Feng Jeng, MD, Johnson Chia-Shen Yang, MD, Hsiang-Shun Shih, MD,
Chien-Chung Chen, MD, and Ching-Hua Hsieh, MD, PhD

the distal stump of severed arteries was adequate enough to establish a

Abstract: A reverse anterolateral thigh island flap with the dimensions of 6
successful free flap reconstruction.8 Furthermore, similar successful
3, 15 6, and 26 8 cm, respectively, was elevated in 3 patients to repair the
flap reconstructions based on the reverse flow, such as the distal sural
skin defects in the knee resulting from crush injuries. The pedicle of the flap was
flap9 and the flap based on distal anterior tibial vessels,10 have been well
isolated in a retrograde fashion along the descending branch of the lateral
validated. The application of pedicled ALT flaps to skin defects of the
circumflex femoral artery to obtain sufficient length until the pivot point was
knee region has been reported in the literature,1,5,10,11 here we present
reached. The distal point of the defect to which the flap could reach for the
our experience in performing reconstruction of the skin defect in the
reconstruction was 12 cm below the knee. All flaps survived, but skin necrosis
knee region using a reverse ALT island flap.
occurred in the margins of those 2 large flaps. With a wide arc of rotation and
sufficient skin paddle, the reverse anterolateral thigh island flap based on reverse
flow is a good option for repairing skin defect around the knee; however, a MATERIALS AND METHODS
staged or delayed operation might be considered in elevating a large flap. From July 2005 to January 2008, a total of 3 male patients
underwent reverse ALT island flap elevation in our hospital to repair
Key Words: knee reconstruction, reverse anterolateral thigh island flap,
distally based anterolateral thigh flap, pedicled island flap the knee defects resulting from crush injuries. Before flap elevation,
Doppler mapping of the perforator(s) was performed. The method
(Ann Plast Surg 2010;64: 198 201) was similar to the conventional method to harvest an ALT flap; with
the identified perforator(s) in the center, the flap size was outlined
according to the size of the skin defect. A search for cutaneous
perforators was performed either in the suprafascial or subfascial plane
T reatment of skin and soft-tissue defects around the knee joint is
often challenging for reconstructive surgeons. Only a few reli-
able local flaps or recipient vessels for free flap are available in the
lateral to the incision. All sizable perforators to the ALT were identified
and the ideal perforator(s) in the descending branch of the lateral
treatment of soft-tissue defects.1 The anterolateral thigh (ALT) flap, circumflex femoral vessels was dissected in a retrograde fashion. The
which has been used widely in reconstruction surgery, is advanta- pedicle of the flap was isolated distally along the descending branch
geous, because it provides a large area of skin coverage, a long to obtain sufficient length until the designated pivot point was
vascular pedicle, and a combination of sensory nerves and fascia, reached. Intramuscular dissection of the perforator with skeletoniza-
thus resulting in minimal donor scar.2 Perfusion of the ALT flap was tion of the descending branch helped increase the degree of the flap
based on the musculocutaneous or septocutaneous perforators of the advancement. The pivot point was determined at 6 to 7 cm above the
descending branch of the lateral circumflex femoral artery (LCFA).3 knee joint and located proximal to the division of the descending
This descending branch was anastomosed to the lateral superior branch. Before the proximal end of the descending branch of the
genicular artery or profunda femoral artery, or both; forming a LCFA was divided, we clamped the proximal pedicle by using a
vascular network in the knee joint, approximately 2.5 to 6 cm above vascular clamp and checked for dermal bleeding of the flap to test
the patella.1,35 The reverse ALT island flap was designed and first whether the blood supply from the reverse flow was adequate for the
introduced in 1990 to prevent active bleeding from the distal end of flap. After the flap perfusion was examined, the reverse ALT island
the descending branch of the LCFA.6 The concept of using free flaps flap was elevated and transposed to repair the skin defect around the
based on reverse arterial flow perfusion in the legs was demonstrated knee.
by Haddad et al in 1995.7 According to the measurements by Pan et
al,1 the mean proximal antegrade and retrograde blood pressure of RESULTS
the descending branch was 78.6 13.0 mm Hg and 45.8 11.6 mm The reverse ALT island flaps survived in all 3 cases. The
Hg, respectively, whereas the distal antegrade and retrograde blood dimensions of the flaps ranged from 6 3 to 26 8 cm. The most
pressure was 65.8 11.6 mm Hg and 61.1 17.1 mm Hg, distal point of the defect region to which these flaps could be extended
respectively. It was reported that the perfusion from the reverse flow in for reconstruction was 12 cm below the knee joint. There were 2
patients had complications after the operation. One patient (case 1)
Received September 23, 2008, and accepted for publication, after revision, showed necrosis in a small area of the distal and proximal medial
January 9, 2009. margins of the flaps, which healed secondarily 1 month later. The
From the Department of Plastic and Reconstructive Surgery, Chang Gung Me- second patient (case 2) had necrosis in the distal margin and required a
morial Hospital-Kaohsiung Medical Center, Chang Gung University College second operation for debridement of the proximal tip of the flap.
of Medicine, Kaohsiung Hsien, Taiwan.
Reprints: Ching-Hua Hsieh, MD, PhD, Department of Plastic and Reconstructive
Surgery, Chang Gung Memorial Hospital- Kaohsiung Medical Center, Chang CASE REPORTS
Gung University College of Medicine, 123, Ta-Pei Road, Niao-Sung Hsiang,
Kaohsiung Hsien, Taiwan. E-mail: [email protected]. Case 1
Copyright 2010 by Lippincott Williams & Wilkins
ISSN: 0148-7043/10/6402-0198 On July 20, 2005, a 28-year-old man suffered a contusion
DOI: 10.1097/SAP.0b013e31819bd6f7 above his right knee following a car accident. Severe swelling and

198 | www.annalsplasticsurgery.com Annals of Plastic Surgery Volume 64, Number 2, February 2010
Annals of Plastic Surgery Volume 64, Number 2, February 2010 Reverse Anterolateral Thigh Island Flap

FIGURE 1. (Case 1) A, A 23 6
cm skin defect above the lateral
side of the right knee following
debridement; B, Descending
branch of the LCFA (right loops)
and the perforator to the flap was
dissected intramuscularly; the left
and middle loops indicated the
motor nerve to the vastus lateralis;
C, A 26 8 cm reverse ALT island
flap was harvested after dividing
the proximal descending branch
and preserving the motor nerve; D,
Photograph of the flap at 4
months of follow-up.

local heat developed 2 days later. He visited a local clinic where he On July 19, 2006, the patient underwent debridement in the proxi-
was diagnosed with cellulitis and prescribed oral antibiotics; how- mal tip of the flap and closure of the wound. Finally, 2 months later,
ever, the swelling of right knee progressed and skin necrosis devel- an acceptable esthetical contour was achieved (Fig. 2D).
oped 10 days later. He was referred to a local hospital where
debridement and fasciotomy were performed on August 1, 2005. Case 3
Because there was progressive necrosis in the soft tissues with poor On September 20, 2006, a 24-year-old man sustained a right
wound healing, he was transferred to our hospital on August 5, 2005, femoral type II supracondylar open fracture following a traffic
and he presented with a 23 6 cm skin defect above the lateral side accident. He underwent open reduction with internal fixation and a
of the right knee and right thigh (Fig. 1A). The skin defect distally series of debridements. Poor healing of the left knee wound was
extended 12-cm below the knee, and the underlying ligaments were noted 6 months postoperatively. We noted a 2 3 cm skin defect in
exposed. A 26 8 cm reverse ALT island flap was harvested from the anterior aspect of the proximal knee, knee stiffness and severe
the same thigh to repair the defect. The musculocutaneous perforator scarring of the surrounding tissues, and exposure of the underlying
was identified and skeletonized by performing an intramuscular tibia bone and fixation plate (Fig. 3A). Due to severe soft-tissue
dissection of the descending branch of the LCFA (Fig. 1B). The scarring and numerous incision scars around the knee, primary
pivot point was at 7-cm above the knee where, after transposition of closure of the wound and rotation or advancement of the local flap
the flap, a sufficient length of the pedicle without tension could be was difficult to perform. On October 3, 2007, a reverse ALT island
acquired. Finally, a reverse ALT island flap was harvested from the flap with a dimension 6 3 cm having a 7 cm reverse vascular
same thigh (Fig. 1C) and extended to cover the lateral knee and leg pedicle was harvested to repair the defect (Fig. 3B). The postoper-
skin defects. The wound was closed primarily and the lower leg was ative course was uneventful, with no wound infection or necrosis in
immobilized using a long limb splint. Gangrenous changes in the the margins (Fig. 3C, D). No wound infection was noted during the
skin over the distal tip and proximal medial margin of the flaps were 6-month follow-up.
noted postoperatively. The wound healed gradually in the following
month, and there was no remarkable limitation of the range of
movement at 4 months of follow-up (Fig. 1D). DISCUSSION
Several local muscular flaps, including those from gastrocne-
Case 2 mius,1214 sartorius,15 vastus medialis,16 and distally based vastus
A 45-year-old male patient had a traffic accident on June 25, lateralis,17 have been used to repair soft-tissue defects around the
2006. On July 10, 2006, after debridement, he had skin defects with knee. However, these muscle flaps are too bulky to cover skin
a dimension of 15 6 cm in the right knee, which was associated defects around the knee region, and impairment of the muscle
with exposure of the patella tendon and necrosis (Fig. 2A). The function in the donor thigh was a matter of concern.17 Local
composite defect was reconstructed using a 15 6 cm reverse ALT cutaneous flaps, such as the lateral genicular artery island flap and
island flap with its pedicle passing through the subcutaneous tunnel lateral sural cutaneous artery island flap, are difficult to harvest, and
(Fig. 2B). After the entire wound was closed, we covered the donor obtaining these flaps would involve sacrificing the perforators of the
site with a Biobrane sheet to prevent tension on the pedicle because superior lateral genicular artery and the sural nerve, respectively.
direct closure seemed to reduce the flap viability (Fig. 2C). Flap The saphenous flap, which is a good option for knee reconstruction,
viability was good after the operation; however, small areas of carries a considerable risk of sensory disturbance in the leg.4
necrosis in the proximal and distal margins of the flap were noted. Moreover, this flap was unable to cover skin defects in the lateral

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Liu et al Annals of Plastic Surgery Volume 64, Number 2, February 2010

FIGURE 2. (Case 2) A, A right knee

skin defect with a dimension of
15 6 cm with exposure of the
patella tendon and necrosis; B, A
15 6 cm reverse ALT island flap
was elevated to repair the defect
with its pedicle passing through
the subcutaneous tunnel; C, A Bio-
brane sheet was used to cover the
donor site to prevent tension on
the subcutaneous pedicle; D, An
acceptable esthetical contour was
acquired at 2 months of follow-up.

FIGURE 3. (Case 3) A, A 2 3 cm
skin defect in the anterior aspect of
the proximal knee with exposure of
bone and severe scarring of the
surrounding tissues; B, A 6 3 cm
reverse ALT island flap was elevat-
ed; C, Postoperative flap viability
was good, without occurrence of
wound infection in the anterior
view; D, Postoperative flap viability
was good, without occurrence of
wound infection in the lateral view.

side of the limbs, as observed in case 1, and this flap would require defects by using skin flaps from surrounding regions seems to be an
to be elevated if incision scarring in the medial side of the knee was attractive option for reconstruction.
noted, as observed in case 3. In some situations, physicians may use In this article, we described the use of a reverse ALT island
split-thickness skin grafting to repair wounds after the growth of flap to repair skin defects in the knee region in 3 cases; the flap was
granulation tissues by using various types of dressing or a vacuum- placed on the lateral side of the knee in 1 patient and in the anterior
assisted closure system; however, this technique could lead to a loss aspect of the knee in 2 patients. The dimension of the largest free
of the graft and impede knee movement. Therefore, repair of skin ALT flap having a single pedicle that has been reported thus far was

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Annals of Plastic Surgery Volume 64, Number 2, February 2010 Reverse Anterolateral Thigh Island Flap

25 35 cm. In our patients, ALT flaps as large as 26 8 cm, which 2. Koshima I, Fukuda H, Utunomiya R, et al. The anterolateral thigh flap;
was reported as the largest reverse ALT flap, could be supplied by variations in its vascular pedicle. Br J Plast Surg. 1989;42:260 262.
reverse blood flow and be used to cover skin defects that are 12 cm 3. Zhou G, Zhang QX, Chen GY. The earlier clinic experience of the reverse-
below the knee. If required, the fascia lata of the ALT flap could be flow anterolateral thigh island flap. Br J Plast Surg. 2005;58:160 164.
rolled and used for the reconstruction of the patellar tendon.1 4. Acland RD, Schusterman M, Godina M, et al. The saphenous neurovascular
However, because there was skin necrosis in the margins of the flap, free flap. Plast Reconstr Surg. 1981;67:763774.
time-consuming procedures such as clamping of the proximal de- 5. Gravvanis AI, Tsoutsos DA, Karakitsos D, et al. Application of the pedicled
anterolateral thigh flap to defects from the pelvis to the knee. J Reconstr
scending branch may cause complications if a large reverse ALT Microsurg. 2006;26:432 438.
flap requires to be elevated. Simultaneous transfer of a reverse ALT
6. Zhang G. Reversed anterolateral thigh island flap and myocutaneous flap
island flap and fascia for the reconstruction of the patella tendon transposition. Zhonghua Yi Xue Za Zhi. 1990;70:676 678.
may be beneficial in the clinical setting. Further investigation is
7. Haddad JL, Gomez Otero A, Lopez H, et al. Free flap with reversed arterial
required to examine whether this flap could be harvested as a flow in the leg: Case report. J Reconstr Microsurg. 1995;11:351354.
chimeric flap with adjacent muscular and bony components as the 8. Neligan PC, She-Yue H, Gullane PJ. Reverse flow as an option in microvas-
conventional ALT flap, and whether it can be perfused by reverse cular recipient anastomoses. Plast Reconstr Surg. 1997;100:1780 1785.
blood flow. 9. Jeng SF, Hsieh CH, Kuo YR, et al. Distally based sural island flap. Plast
An important step while elevating this flap involves determi- Reconstr Surg. 2003;111:840 841.
nation of the pivot point. The pivot point of the reverse ALT island 10. Gravvanis AI, Iconomou TG, Panayotou PN, et al. Medial gastrocnemius
flap can be located 2.5 to 10 cm proximal to the lateral superior muscle flap versus distally based anterolateral thigh flap: conservative or
angle of the patella by cadaveric dissection.1,3,5 Dissection of the modern approach to the exposed knee joint? Plast Reconstr Surg. 2005;116:
terminal portion of the descending branch was recommended within 932934.
a distance of 10 cm above the knee.1 The reverse ALT island flap 11. Yildirim S, Avci G, Akan M, et al. Anterolateral thigh flap in the treatment
can rotate medially, laterally, and at 180 degrees.5 The radius of the of postburn flexion contractures of the knee. Plast Reconstr Surg. 2003;111:
arc of rotation of the flap is equivalent to the length of the vascular 1630 1637.
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taneous flap. Plast Reconstr Surg. 1978;62:1523.
penetrates the skin paddle. The pivot point was located 6 to 7 cm
above the knee joint and is proximal to the branching of the 13. Moscona AR, Keret D, Reis ND. The gastrocnemius muscle flap in the
correction of severe flexion contracture of the knee. Arch Orthop Trauma
descending branch. Dissection distal to the branching of the de- Surg. 1982;100:139 142.
scending branch might carry a risk of compromising flap perfusion.
14. Chowdri NA, Darzi MA. Z-lengthening and gastrocnemius muscle flap in the
In addition, we tested the dermal bleeding of the flap before dividing management of severe postburn flexion contractures of the knee. J Trauma.
the proximal descending branch to validate whether the perfusion of 1998;45:127132.
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a staged operation or procedure change to free flap reconstruction muscle flap: case report. Plast Reconstr Surg. 1978;62:458 461.
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closure of the exposed knee joint. Plast Reconstr Surg. 1981;68:69 72.
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