title: Application of extended bi-pedicle anterolateral thigh free flaps for reconstruction of large defects: A case series.
abstract: BACKGROUND
  The anterolateral thigh flap is a workforce flap in reconstructive surgery, however, variations in it is vascular anatomy are not uncommon. These variations may affect flap design and survival, especially when large flaps are required. In some anatomical variants the anterolateral thigh flap is supplied by two separate dominant pedicles, and in these cases a bi-pedicle modification may be necessary to ensure complete flap viability. The aim of this report is to evaluate the outcomes, and present our approach in using bi-pedicle anterolateral thigh flaps as a method to reduce the risk of partial flap necrosis when reconstructing sizeable soft tissue defects.
  
  
  METHODS
  From October of 2013 to November of 2015, seventeen patients were treated with extended bi-pedicled ALT flaps for reconstruction of large defects (16 to 25 × 8 to 13 cm). Following doppler mapping of the lateral thigh perforators, an anterior incision was made. When a distinct oblique branch (OB) was present and the perforators of the descending branch of the lateral circumflex femoral artery (d-LCFA) were small, the large bi-pedicle ALT flaps were harvested based on both the oblique branch and the d-LCFA pedicle. We evaluated the perfusion of the flap using only one pedicle by clamping alternately the OB and the d-LCFA. After flap harvest, we performed two end-to-end venous anastomosis between the lateral circumflex femoral vein and a recipient vein, and the oblique branch vein with a second recipient vein. End to end arterial anastomosis were performed between the two pedicles and two recipient arteries. Y-shaped interposition vein graft (YVG) was applied when single recipient artery was available for revascularization. The flaps were used for scar contracture, chest wall, lower and upper extremity soft tissue defects, breast, scalp, oral cancer, and esophageal reconstruction.
  
  
  RESULTS
  The flaps size were 18 to 26 × 10 to 14 cm. For all seventeen patients the reconstructive goals were achieved with complete survival of the large ALT flaps with no events of partial necrosis or failure. We reported one case of re-exploration of a congested flap due to venous thrombosis, which was successfully salvaged.
  
  
  CONCLUSIONS
  Bi-pedicled ALT flaps could be a considered as a valuable option when a second pedicle is encountered and large flaps are required.
authors.affiliation: Department of Plastic Surgery, China Medical University Hospital, Taichung, 40447, Taiwan.|Department of Plastic and Reconstructive Surgery, "Sapienza" University, Rome, 00161, Italy.|Department of Emergency and Organ Transplantation, University of Bari "Aldo Moro," Plastic and Reconstructive Surgery and Burns Unit, Bari, Italy.
authors.forename: Michele
authors.initials: M
authors.lastname: Maruccia
authors.affiliation: Department of Plastic Surgery, China Medical University Hospital, Taichung, 40447, Taiwan.
authors.forename: Georgios
authors.initials: G
authors.lastname: Orfaniotis
authors.affiliation: Department of Plastic Surgery, China Medical University Hospital, Taichung, 40447, Taiwan.
authors.forename: Pedro
authors.initials: P
authors.lastname: Ciudad
authors.affiliation: Department of Plastic Surgery, China Medical University Hospital, Taichung, 40447, Taiwan.
authors.forename: Fabio
authors.initials: F
authors.lastname: Nicoli
authors.affiliation: Department of Plastic and Reconstructive Surgery, "Sapienza" University, Rome, 00161, Italy.
authors.forename: Emanuele
authors.initials: E
authors.lastname: Cigna
authors.affiliation: Department of Emergency and Organ Transplantation, University of Bari "Aldo Moro," Plastic and Reconstructive Surgery and Burns Unit, Bari, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Giudice
authors.affiliation: Department of Plastic Surgery, China Medical University Hospital, Taichung, 40447, Taiwan.
authors.forename: Kidakorn
authors.initials: K
authors.lastname: Kiranantawat
authors.affiliation: Department of Plastic and Reconstructive Surgery, "Sapienza" University, Rome, 00161, Italy.
authors.forename: Diego
authors.initials: D
authors.lastname: Ribuffo
authors.affiliation: Department of Plastic Surgery, China Medical University Hospital, Taichung, 40447, Taiwan.
authors.forename: Hung-Chi
authors.initials: HC
authors.lastname: Chen
mesh_terms: D000368:Aged; D005260:Female; D005500:Follow-Up Studies; D058752:Free Tissue Flaps / Q000098:blood supply / Q000637:transplantation*; D006801:Humans; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D019651:Plastic Surgery Procedures / Q000379:methods*; D013848:Thigh / Q000098:blood supply* / Q000601:surgery