Plastic Surgery

A case of post traumatic defect of the entire dorsum of right foot with exposed bone, tendons who underwent a classical anterolateral thigh (ALT) free flap reconstruction. Though such defects and ALT flap cover is a common surgical procedure done, the reason for presenting this case is because of  challenge faced in microvascular perforator anatomy of ALT flap and successful transfer down by two arterial and three venous anastomosis of flap vessels.

Description: A classical ALT flap is harvested on a septo-cutaneous  or musculo-cutaneous Perforator of descending branch of lateral circumflex femoral vessel (LCFA) with its venae commitantes. In more than nearly 15% of cases, such Perforator is absent and hence either the flap harvest has to be abondoned to find another donor site or have to convert the flap to tensor fascialata flap moving the skin paddle more superolaterally based on the transverse branch of LCFA.

In present case we had a septo-cutaneous Perforator which was found very small ( around 1mm internal diameter) and hence TFL pedicle was harvested in addition as mentioned before. But intraoperatively we landed up with a situation where the flap perfusion was not adequate with the latter which prompted us to add second end-to-side arterial supercharge with the former tiny Perforator which in fact augmented the supply very well. To furnish complete venous return we had to connect three veins of both arterial territories. To make the matters difficult we had huge mis-match of the vessel wall sizes of recipient anterior tibial vessels.

When such a large area skin flap is committed and it becomes a precious flap where a failure ends up with big donor site loss and need for an alternative big flap. So accomplishment of a successful outcome of this flap is a big boost for our microsurgical work.