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Distally-based Anterolateral Thigh Flap for Knee Coverage

March 01, 2017

Contributors: Bert Vanmierlo; Francis Bonte, MD; Jean F Goubau, MD, PhD; Koen Mermuys, MD; Pieter Pierreux Jr, MD; Petrus Van Hoonacker, MD; Laurent B Willemot, MD

Knee soft-tissue coverage is challenging. The pedicled gastrocnemius flap is classically the first choice for reconstruction. This flap is not always sufficient and carries substantial donor site morbidity. Anatomically consistent perforators are scarce in the area around the knee and reliable recipient vessels for free flap reconstruction are few. The distally based anterolateral thigh flap (dbALT) is a reliable solution for challenging reconstructive problems. This flap, first described by Zhang in 1990 and optimized by Wei in 2015, is characterized by a consistent anatomy, a wide arc of motion, limited donor-site morbidity, and a straight-forward dissection. The most frequently encountered complication is venous congestion. Several authors contribute this problem to the slow venous flow after reversing the flow in the pedicle. In my perspective, this problem is caused by the presence of valves in the deep veins, draining the flap. When reversing the blood flow, competent valves cause venous congestion and thrombosis. It can easily be solved by adding venous supercharge to the flap. In this video we present a distally based ALT flap for knee coverage. We clearly demonstrate several technical points in the performance of this flap reconstruction. The first pearl to a successful flap is to identify the dominant perforator and the pivot point of the flap by preoperative ultrasound. In the operating theater we demonstrate how to raise this flap, how to perform the set-in at the knee, and how to seal the knee articulation with vascularized fascia lata. Then we illustrate how venous congestion occurs at the level of the deep veins. This is easily managed by adding venous supercharge to the flap. In our patient, one of the comitant veins of the pedicle is bypassed with a contralateral saphenous vein graft.

Results for "Knee"

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