In nature and especially within the specialty of plastic surgery, symmetry is king. Indeed, symmetry is what we strive for in many of our reconstructive pursuits. Not surprisingly, the majority of flaps we harvest also have symmetrical skin paddle designs. This might seem strange, however, given that most defects we are called upon to reconstruct are far from symmetrical. The anterolateral thigh (ALT) flap, arguably one of the most versatile and commonly used flaps worldwide,1 is designed with elliptical skin paddles despite the fact that the defects they are used to reconstruct are rarely elliptical in shape. Indeed, with this approach, the widest part of the flap is normally placed around the midpoint of the thigh, and this often leads to the need for a skin graft at this location.
In a previous study performed at our institution, we demonstrated that it was possible to directly close ALT donor-site defects that were less than 16% of the thigh circumference.2 This figure was based upon measurements taken at the midpoint of the thigh. Indeed, with most elliptical ALT designs, this will normally equate to the widest part of the donor site. If up to 16% of the thigh circumference can be directly closed at the midpoint of the thigh, it is logical that up to 16% can also be directly closed above and below this midpoint.
By taking the midpoint of the thigh as being located halfway between the anterosuperior iliac spine and the superolateral patella border, we can mark point “A” as lying midway between this point and the anterosuperior iliac spine, point “B” is the midpoint, and point “C” is located halfway between the midpoint and the superolateral patella (Fig. 1). If we now measure the thigh circumference at these points in a healthy middle-aged man (the figures used in this illustration were those of the corresponding author, S.F.J.), we get figures of 61 cm, 53 cm, and 47 cm, respectively. By plotting 16% of these thigh circumferences onto the ALT (Fig. 1), we are effectively marking out the maximal dimensions of the skin flap that will allow for direct primary closure of the donor site. We can see that a teardrop shape is made (a': 9.8 cm, b': 8.5 cm, c': 7.5 cm). We feel that using this “teardrop”-shaped design may allow for the direct primary closure of the ALT donor site in situations where the conventional elliptical design would otherwise lead to skin grafting.
The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors.
1. Wei FC, Jain V, Celik N, et al. Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps. Plast Reconstr Surg. 2002;109:2219–2226
2. Boca R, Kuo YR, Hsieh CH, et al. A reliable parameter for primary closure of the free anterolateral thigh flap donor site. Plast Reconstr Surg. 2010;126:1558–1562