HAND RECONSTRUCTION WITH MULTI- PEDICLED
ANTEROLATERAL THIGH FLAP
ABSTRACT
Keywords: Hand complex defects, ALT flap, multiperforator flap, thinned
flap, microsurgery
INTRODUCTION
The hand is a delicate anatomical structure with complex functions. Hand
injuries may be the result of various factors, including trauma, domestic accidents,
occupational incidents, burns and burnscar, and venomous snake bites. These
injuries often involve multiple anatomical components, such as skin, tendons,
bone, and blood vessels. Complex hand injuries present with varying degrees of
tissue loss, ranging from pure skin defects to multifaceted injuries involving
composite tissue damage across different anatomical units of the hand, such as the
digits, dorsum, and palm. Complex hand defects with multi-component and
various units, leads to significant challenges to for reconstructive surgery, as it it
necessitates achieving both optimal functional restoration and aesthetic outcomes.
For covering extensive soft tissue defects, conventional methods using local or
regional flaps may not be adequate due to donor site limitations, flap volume
restrictions, or concomitant trauma to donor site. In this situation, microsurgical
flaps have emerged as a gold-standard approach and typically preferred by
surgeons, as they ensure both aesthetic and functional restoration for the hand. Free
flaps provide the benefits of a larger flap volume and a stable vascular supply, and
they can be can be harvested in the form of multipedicled flaps, such as
thoracodorsal perforator flap, Drrrp deep inferior perforator flap, superior
circumflex illiac perfotator flap, and anterolateral thigh (ALT) flap, which is the
optimal option for complex defect reconstruction. Among these, the ALT flap is
among the most versatile selections in reconstructive microsurgery due to several
advantages: a long vascular pedicle, multiple perforators originating from one
pedicle, along with various components that can be used, ease of harvesting, and
minimal donor site morbidity. Thinning techniques applied to the ALT flap have
been refined to produce sufficiently thin flaps suitable for reconstructing hand
defects where maintaining contour and minimizing bulk is are critical for hand
function. Beyond hand reconstruction, the multiperforator ALT flap has
demonstrated efficacy in complex reconstructions of the head, body, and limb.
In our research involving 116 patients treated with the ALT flap for hand
lesions, we specifically focus on our experience with 20 patients who received an
ALT multipedicle flap for complex hand defects. This article presents the surgical
technique, material selection, and indications associated with this procedure.
PATIENTS AND METHOD
Between 2009 and 2024, our department conducted a retrospective case
series involving 20 consecutive patients who underwent hand reconstruction using
the free, multipedicted anterolateral thigh (ALT) flap. The patients, aged 17 to 63
years with an average age of 42.1, comprised 19 males and one female. The hand
defects resulted from a variety of injuries: 8 patients experienced crush and friction
injuries, 6 were affected by snakebites, 1 had a snakebite scar, 1 sustained an
electric burn, and 4 had burn scars. The defects were located in several areas of the
hand, specifically: Dorsum with tendon (10 cases, 50%); Dorsum with palm (2
cases, 10%); Dorsum with finger (2 cases, 10%); Dorsum with first web (2 cases,
10%); Dorsum with wrist (1 case, 5%); Palm with finger (2 cases, 10%); Finger
with first web (1 case, %).
Surgical Technique
Patients with hand injuries undergo necrotic tissue debridement upon
admission. Those who have suffered snake bites will receive negative pressure
wound therapy (NWPT) for five days before reconstructive surgery. When
identifying perforators in the anterolateral thigh area, use a handheld Doppler is
used. Prioritize thighs that contain two or more perforators for the ALT flap
harvest. The first team prepared the injured hand site by determining the wound
area, location, and affected structures, then assessed the severity of damaged
components. The recipient vessels for this procedure may include the ulnar or
radial arteries, concomitant veins, or superficial veins in the wrist area.
The second group is responsible for harvesting the ALT flap. Begin by
making a skin incision on the anterior thigh and dissecting along the subfascial
plane. Next, identify the descending branch of the lateral circumflex femoral artery
(LCFA) and dissect the retrograde perforators. Choose suitable perforators for
either the skin island or the fascial flap, prioritizing those that originate from a
common trunk as descending branches, ensuring they are spaced apart. The size of
the skin islands should correspond to the dimension of the skin defect. If the fascial
flap is intended for tendon reconstruction, determine the perforator's entry point
into the fascia and excise a fascial island size based on the number of tendons
requiring reconstruction. Carefully separate the fascia from the overlying
cutaneous layer. If thinning of the skin flap is necessary, remove the entire deep fat
layer beneath the superficial fascia, or remove fat lobules from the superficial fat
layer using a microscope. Generally, retain approximately 1-2 cm of the fascial
island surrounding the perforator's skin endpoint. Hemostasis should be performed
meticulously with bipolar cautery across the entire surface of the skin and fascia
flap. Dissect the flap vessel pedicle close to its origin, ensuring the pedicle is long
enough to reach 8-10 cm. Ligate the pedicle and transfer it to the hand area. The
donor site can be closed primarily or using a combination of partial closure, skin
grafting, or an adjacent perforator flap. Transfer the flap to the recipient site,
anastomosing the artery either end-to-end or end-to-side to the radial or ulnar
artery and the vein in an end-to-end manner to the accompanying veins. After
successful vascular anastomosis, fix the flap to the defect site. For tendon defects,
the fascial flap should be sutured to the both remaining tendon ends using 4-0
nylon sutures. In cases of extensive defects, skin flaps are utilized to cover
extensive defects in the palm, dorsum, or fingers.
Monitor the flap every 3 hours during the first two days. Remove drains on
the third day, and sutures can be taken out after two weeks. Patients are typically
discharged after approximately 10-12 days. In instances where the ALT flap covers
multiple fingers, a surgical procedure may be conducted to separate the fingers,
followed by skin grafting on the lateral aspects. If the flaps covering the dorsum of
the hand are thick and impair function, liposuction can be performed six months
after the initial surgery. Hand function and range of motion should be assessed 3-6
months post-operation.
RESULTS
Forty flaps from 20 patients included in this study were utilized to restore
hand defects. Each hand presented with two associated injuries in different units or
damaged component. damaged. In total, thirty skin flaps were used to cover skin
defects in various parts of the hand: 17 flaps were used for the dorsum (42.5%), 4
for the palm (10%), 6 for other areas (15%), 3 for the first web (7.5%), and 10 FL
flaps (25%) for restoring tendon defects. Ten adipocutaneous bi-pedicled flaps
were used to cover defects, while the remaining 10 included adipocutaneous and
FL bi-pedicled flaps for covering skin defects and reconstructing extensor tendons.
A total of 48 perforators supplied blood to the 40 flaps, averaging 4.2 ± 1.4 cm in
length (range, 2-8 cm). 40 pedicles originated from the descending branch (branch-
based type) in 16 cases (80%), while 8 pedicles originated from perforator vessels
(perforator-based type) in 4 cases (20%). The average length of the flap pedicle
was 9.1 ± 1.7 cm (range, 7-13 cm). In the branch-based type, the distance of the
two perforators from the descending branch was 5.4 ± 1.8 cm (range: 3-9 cm). The
average width of the skin paddle flap was 7.1 ± 2.4 cm (range, 3-14 cm), and the
average flap length was 11.8 ± 4.8 cm (range: 5-27 cm). The width of the FL flaps
varied from 3 to 5 cm, averaging 3.2 ± 0.6 cm, while the length ranged from 5 to
12 cm, averaging 7.7 ± 1.9 cm. The skin flaps were thinned in 25 flaps (83%). The
average thickness of the flaps before thinning was measured at 21 mm (range: 15-
25 mm) and reduced to an average of 6.5 mm (range, 3-13 mm) after thinning.
The flap pedicle was anastomosed with radial vessels in 14 cases (70%) and
with ulnar vessels in 6 cases (30%). The donor site was closed directly in 15 cases
(75%) and required a skin graft in 5 cases (25%). One flap (2.5%), measuring 3x5
cm and used to create the first web, experienced total necrosis due to damage to the
pedicle. Additionally, two flaps (5%) exhibited minor ischemia (less than 2 cm) at
the distal end, which required no intervention. The overall incidence of surviving
flaps was 97.5%. The average follow-up time was 19.3 months (range, 2-80), and
patients expressed satisfaction with the functional and aesthetic results. Two
patients required defatting after one year. The characteristics of the flaps are
presented in Table 1 and Table 2.
DISCUSSION
Since its discovery by Song, the ALT flap has come to refer specifically to
the site on the anterior lateral thigh rather than the origin of the perforators. The
perforator that supplies the skin and fascia of the flap originates from the
descending, oblique, or transverse branches of the LCFA. The presence of these
perforators varies significantly across studies, with estimates ranging from 50% to
89%. Most perforators primarily arise from the descending branch. Notably, 80%
of the cutaneous end of the perforator can be found within a 3-centimeter radius
centered on the midpoint of a straight line connecting the anterior superior iliac
spine to the lateral border of the patella. The number of perforators originating
from the descending branch typically ranges from 0 to 10 and supplies various
local components, including skin, fat, fascia, and muscle. This supply can vary
from individual to individual. It is important to note that as the number of
perforators increases, their size tends to decrease. Perforators sharing the same
origin from the descending branch are favorable sources for creating multi-pedicle
flaps. There are two types of perforators that supply blood to the skin and fascia of
the anterolateral thigh. The first type is the perforator-based type, consisting of 2-3
small perforators that share the same pedicle originating from the descending
branch. These perforators are typically small and feature a short pedicle length
ranging from 0.6 to 3 cm. One characteristic of this type is that the distance to the
cutaneous endpoint is often short, making it less favorable for creating skin islands
with independent vascular pedicles. However, this type of vessel does allow for the
creation of both a skin island and a fascia island, as these two components are
independent of each other. The second type is the branch-based perforator. In this
type, perforators separate from the descending branch and are completely
independent of each other. The distance from the origin of these perforators can
vary. This type is commonly used to create independent multi-pedicle flaps for
both cutaneous and fascial flaps. The greater the distance between these perforators
and the more perforators available, the easier it becomes to create large skin
islands and perform flap thinning, as well as create larger fascial flaps. Perforators
originating from the distal end of the descending branch can provide a long enough
pedicle to facilitate the reconstruction of distal units, such as fingers, or distant
areas like the dorsum of the hand and palm. When perforators reach the skin, they
typically pass through the fascia before entering it. The fascia is supplied through
the suprafascial, intrafascial, and subfascial systems, so the fascial flap is
considered a vascularized flap with an independent perforator pedicle. Utilizing
various components such as fat, skin, fascia, or a single fascial flap is one of the
advantages of the anterolateral thigh perforator flap.
The skin structure of the hand must remain thin to ensure optimal function of
the hand and fingers. One notable advantage of the ALT flap is its ability to be
easily thinned to a thickness of 3-6 mm, depending on the specific characteristics
of the perforator as it enters the skin. Hand lesions are typically not large, allowing
for the design of skin flaps that are also not too large. This facilitates the thinning
process and minimizes the risk of skin flap necrosis. The technique employed for
thinning the flap—whether through primary thinning or microdissection—depends
on the orientation of the perforator as it enters the skin. If the perforating vessels
are perpendicular to the skin flap, microdissection can be carried out with a 1-2 cm
fascia reversal, allowing the skin flap thickness to be reduced to 3 mm without
compromising its blood supply. In contrast, when the perforator is oriented
obliquely, primary thinning should be performed with a fascia reversal greater than
3-6 cm, and a thickness reduction of 8-12 mm is recommended. Thinning the flap
is essential for achieving favorable outcomes in both the functionality and
aesthetics of finger reconstruction.
Reconstructing soft tissue defects in the hand has three main objectives:
providing coverage, achieving three-dimensional contouring, and recreating the
injured components of the hand. Effective coverage requires using a sufficiently
thin skin flap to restore early coverage and hand function. Complex hand defects
are often found on the dorsum of the hand, as well as in areas such as the thumb,
fingers, or interdigital spaces. Soft tissue defects can occur in various units, making
it challenging to use a single large flap to cover multiple areas, even if the flap is
appropriately thinned. Multi-pedicle flaps offer a solution by allowing for the
separation and reconstruction of different units without compromising flap
continuity or necessitating additional surgeries for repair. These flaps are versatile
in their ability to be shaped to fit the specific contours of the soft tissue defect.
Independent flaps with long vascular pedicles are particularly useful for
reconstructing distant units, especially finger defects when the defect surface is on
different planes. Multi-pedicle flaps are especially effective for reconstructing the
interdigital space, as two adjacent flaps can recreate the three-dimensional
configuration of this area, increase its length, and remain unaffected by the
thickness of the flap. For simultaneous defects on both sides of the hand, such as
the dorsum and palm, using two independent flaps of a sufficiently small size
enables flexible coverage of both defects without the need for flap folding. When
covering and reconstructing components like the extensor tendon simultaneously, a
multi-pedicled flap that incorporates both skin and fascial layers is more effective
than many other reconstruction methods. The fascial layer can be utilized to
reconstruct the extensor tendon. When there are 2-4 perforators available in the
anterolateral thigh, priority should be given to 2-3 perforators for supplying the
skin island, while the remaining perforators can be used to provide blood to the
fascial island. With independent vascular pedicles, a large fascial flap can be
harvested to reconstruct 2-3 extensor tendons simultaneously. Tendon
reconstruction is further simplified when the flaps are independent, allowing for
proper placement of the tendon in the reconstruction area without influence from
the skin flap's shape. The selection of the skin flap to match the defect is highly
adaptable and is made after completing the tendon reconstruction. Since the tendon
has its own vascular supply, the healing process is expedited, allowing
rehabilitation to commence earlier.
One limitation of multi-pedicle flaps is the presence of multiple perforators
from descending brach, which enables their creation. However, when perforators
are absent or when perforators arise from oblique or transverse branches, it
complicates the choice of pedicle. Additionally, constructing a flap using a
descending perforator with an pedicle skin island on the opposite side can lead to
increased surgical time and a higher risk of complications during anastomosis. In
cases of multi-unit injuries, particularly in finger injuries affecting the dorsum or
palm, the extent of damage is often complex, resulting in impaired functional
recovery. Even when cosmetic outcomes are satisfactory for the patient, the
restoration of full finger function may remain inadequate.
CONCLUSION
Multi-pedicle flaps featuring two skin islands or a combination of skin
islands and FL flaps are ideal for complex, multi-unit hand reconstruction. The
success of this technique is influenced by several factors, including the type and
number of perforators, the composition of the flap, the method of flap thinning,
and the arrangement of the flaps tailored to each specific defect on the hand.
Table 1: patient’s and technique data
No Gender Diagnosis Injured Skin flap FL flap Perforator Pedicle Complictions Esthetic/ Follow
Age location size Size type length Functional up
(cm) (cm) (cm) results (month)
1 M/50 Trauma Palmar 8x10 BB 7 Non Joint stiffness 20
Thumb 4x5
2 M/18 Trauma Finger 11x22 BB 8 Non Joint stiffness 12
1 web 3x8
3 M/17 Trauma Dorsal 9x15 PB 11 Non Good 12
Tendon 3x7
4 M/26 Snackbite Dorsal 7x12 BB 7 Non Good 80
Scar V EDC 3x8
5 M/16 Burnscar Dorsal 8x11 BB 9 Partial Necrosis Good 6
1 web 3x4
6 M/22 Burnscar Dorsal 11x13 BB 13 Good 18
1 web 5x7 Total Necrosis
7 M/33 Trauma Dorsal 8x12 BB 11 Non Joint stiffness 9
Finger 7x9
8 M/15 Trauma Dorsal 5x9 PB 12 Non Joint stiffness 10
Finger 5x7
9 M/32 Burnscar Dorsal 6x12 PB 9 Non Good 6
Wrist 6x7
10 M/27 Burnscar Palmar 10x14 BB 7 Non Joint stiffness 7
Thumb 6x7
11 M/34 Electric Dorsal 8x12 PB 8 Non Good 40
Burn Tendon 3x8
12 F/29 Trauma Dorsal 7x14 BB 8 Non Good 58
Tendon 3x5
13 M/39 Trauma Dorsal 8x12 BB 10 Non Good 8
Palmar 14x18
14 M/23 Snakebite Dorsal 5x8 BB 10 Non Good 9
Thumb 3x8
15 M/46 Snakebite Dorsal 8x18 BB 9 Non Good 19
Tendon 3x6
16 M/31 Snakebite Dorsal 6X13 BB 12 Non Good 2
Tendon 3x6
17 M/63 Snakebite Dorsal 7X13 BB 7 Non Good 19
Tendon 3x7
18 M/48 Snakebite Dorsal 5X15 BB 8 Non Good 18
Tendon 3x10
19 M/62 Snakebite Dorsal 10X27 BB 9 Non Good 17
Tendon 5x12
20 M/35 Trauma Dorsal 8x11 BB 8 Non Good 3
Palmar 4x6
F: female; M: male;
PB:perforator-based, BB: branch-based,
Table 2: Flap characteristics.
Number perforator: 48
Branch-based type. 40
Perforator-based type. 8
Skin flap size (cm) 30/40 flaps
Width 7.1 4.7 [3-9 ]
Length 11.8. 4.8 [5-27]
FL flap size (cm) 10/40 flaps
Width 3.2 ± 0.6 [3 - 5]
Length. 7.7 ± 1.9 [5 - 12]
Skin flap thicknesse (mm)
Before thinning 21 [15-25]
After thinning. 6.5 [3-13]
Pedicle length (cm) 9.1 ± 1.7 [7-13]
