A systematic review of anterolateral thigh flap donor site morbidity.

The anterolateral thigh (ALT) flap, first described as a septocutaneous perforator-based flap by Song et al (1) in 1984, has recently gained popularity (2–43) and has become an important option for reconstruction of multiple anatomical locations such as the head and neck (3–7,9,10,12–14,16,18–23,25–30,32,34,36,38,39,41–43), upper (15–19,26,32,35,37,38,42) and lower (8,16–19,22,24,26,31,32,38,42) extremities, trunk (2,14,18,22,30,32,33,38) and perineum (11,18,22). The popularity of the ‘work-horse’ ALT flap is often attributed to its multiple advantages, which can be divided into three categories: pedicle, flap design and operative technique (1,2,6,7,13,14,21,26,38,44–46). With regard to the pedicle, the ALT flap has a long pedicle with good calibre, which can be located and dissected out before committing to the final flap design. Furthermore, there is the potential for converting to another type of flap, such as a tensor fascia lata flap, with only minor changes to the skin paddle (47) if needed due to anatomical variation in the vascular pedicle. Flap design benefits include a large and pliable skin territory with the ability to design more than one skin paddle depending on the perforator anatomy; the ability to modify flap thickness by elevating a thin fasciocutaneous flap, or providing bulk by incorporating muscle (vastus lateralis), or further thinning the flap by removal of the deep fascia and subcutaneous fat tissues; versatility, because it can be customized with the addition of bone (ileum), tendon, fascia (tensor fascia lata) or nerve (lateral femoral cutaneous); and the ability to tailor the flap as a pedicle or free flap, using vessels as a single anastomosis or as flow-through. In terms of operative technique, advantages of the ALT flap include the ability of two teams to work on the donor and recipient sites at the same time because the patient can be placed in a supine position; and the feasibility of performing the procedure under epidural anaesthesia for lower extremity reconstruction in a patient unfit for a general anesthetic. One final advantage of the ALT flap is the seemingly minimal donor site morbidity, which can be as important as the result at the recipient site in terms of the outcome and the patient’s postoperative quality of life. In the multitude of studies reporting recipient site outcomes with the use of this flap, donor site complications are occasionally mentioned (2–43). However, because the sample sizes of most of these studies was relatively small, and the incidence of most of the reported complications was low, exact figures of specific complication occurrences have not been objectively documented. By collecting and analyzing reported data systematically, the sample size is increased and the true frequency of a complication can be more accurately determined (48). Factors that may influence or lead to these complications can also be more clearly delineated. As a result, improvement in techniques can be focused on specific targets, and a more factual informed consent conversation can occur with the patient regarding donor site complications. Herein, the authors summarize the types of complications and their incidence regarding the donor site of the ALT flap, with a discussion of factors that influence these complications and recommendations to avoid them.