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The anterolateral thigh (ALT) flap is a versatile flap with broad indications, and it can cover almost any defect in the body from head to foot. It has become a workhorse flap in reconstructive plastic surgery and has a very high success rate of more than 95% when performed by an experienced team. This activity outlines the use of ALT flaps in reconstructive microsurgery and highlights the role of the interprofessional team in managing patients with difficult and chronic non-healing wounds. Objectives: Review the anatomy of the anterolateral thigh flap and outline its indications for use in reconstructive microsurgery. Describe the equipment, personnel, preparation, and technique in the harvest of the anterolateral thigh flap. Summarize the potential complications and clinical significance of the anterolateral thigh flap. Outline interprofessional team strategies for improving care coordination and communication in the management of difficult and chronic wounds, and improve patient outcomes following anterolateral thigh flap reconstructive surgery. Access free multiple choice questions on this topic.

The anterolateral thigh (ALT) flap, which was first described by Song (1984), is now well-established in reconstructive microsurgery as a workhorse flap. It is a versatile flap with many excellent attributes that include long vascular pedicle with adequate vessel diameter, ability to harvest large areas of skin without added donor site morbidity, adaptability for use as a sensate flap, use as a flow-through flap for vascular gaps in the extremities, flexibility of the flap to be folded for use as a double skin paddle, and use as a chimeric flap to reconstruct composite soft tissue defects almost anywhere in the body. A two-team approach permits simultaneous flap harvest and resection/debridement at the recipient area. The ALT flap can also be used for breast reconstruction if lower abdominal skin is unavailable due to previous scars or surgeries.[1][2] The ALT flap is relatively easy to harvest if the principles of perforator dissection are followed. The vascularity of the flap is reliable even though there is some variability in its perforator anatomy.[3][4][5]

The most dreaded complication following a free flap transfer is flap failure, hence the importance of postoperative flap monitoring. The causes of flap failure include: Venous or arterial insufficiency, more often venous (8-9:1) Thrombosis Venous congestion Twisting of the pedicle Compression of the pedicle Tension at flap edges leading to marginal flap loss Other complications include: Color mismatch between flap and recipient site Excessively bulky flaps leading to fat necrosis Hematoma Seroma Infection Delayed wound healing Wound dehiscence Hypertrophic scarring of the donor site Failure of skin graft take over the donor site and sensory loss over the donor thigh[25]

The anterolateral thigh flap has become an essential part of the plastic surgeon's armamentarium, and its widespread use involves a team approach wherein the plastic surgeon plays an important role in the management of a multispecialty problem. The ALT flap can be used to cover difficult open complex lower extremity fractures, which will involve the plastic surgeon, orthopedic surgeon, anesthetist, physical medicine specialist, and physiotherapist. This orthoplastic approach in extremity reconstruction involves the simultaneous application of the principles and practice of orthopedic and plastic surgery to enhance and optimize patient outcomes following limb reconstructive surgery. Similarly, in head and neck reconstruction where a multidisciplinary team approach is essential to prevent the locoregional and distant spread of tumors, the concept of wide local excision combined with immediate reconstruction with free flaps and adjuvant chemoradiation is gaining popularity. In these cases, the ablative and reconstructive surgeon are often one and the same, although plastic surgeons, facial plastic surgeons, and oral-maxillofacial surgeons are often called upon by the head and neck surgical oncologist or otorhinolaryngologist. [Level 3]

One of the most important factors contributing to the success of free flap surgery is timely intervention in the case of early complications, especially flap failure; to that end, recognition of complications through proper monitoring and good postoperative care is critical. The role of ward nurses and other allied staff is critical to increase the likelihood that patients who undergo ALT flap reconstructions experience good outcomes. To ensure these goals are met, there should be a good understanding and coordination among the members of the plastic and reconstructive surgery team, with each member having a clear understanding of his or her own roles, responsibilities, and limitations. Postoperative monitoring of ALT free flaps is most critical during the first 24 to 72 hours and should be performed diligently until at least the first week after surgery. Proper monitoring improves salvage rates of failing free flaps, as there is an inverse relationship between the length of time a failed flap takes to get to the operating room and its chance of survival. Hourly flap monitoring by nurses includes: color, warmth, turgor, capillary refill, handheld doppler signals from flap pedicle, signs of hematoma, bleeding, and checking for compression or pressure over the flap pedicle. During the initial 48-72 hours, hourly flap monitoring is mandatory. Once the danger period has passed, monitoring the flap every three to four hours for a few days should be sufficient.