It was with great pleasure and interest that we read “The Versatility of the Anterolateral Thigh Flap” by Ali et al. published in the December Supplement “Advances in Reconstructive Microsurgery” of the Journal.
I have been charmed by the anterolateral thigh flap since my residency in plastic and reconstructive surgery, and for this reason I wrote and discussed my degree thesis of specialization on this topic, entitled “On the Utility of the Anterolateral Thigh Flap in Head and Neck Reconstructions.” I read and reviewed more than 110 articles, many of which were published in Plastic and Reconstructive Surgery by our Asiatic colleagues as results from the references cited by the authors. I realized that the widespread use of this flap in Asia is justified by the different constitution of Asians; indeed, the high incidence of obesity limits the diffusion in our countries and, as a consequence, extensive thinning is necessary to obtain the desired thickness.1 This is especially true regarding head, neck, and limb reconstructions because of anatomical reasons that lead physicians to turn over other, thinner flaps.
I think that it was a lot of work for Ali et al. to review all the applications of this flap all over the human body, including the head and neck, thorax, limbs, extremities, and perineum. It would be more appropriate to entitle the article “The Versatility of the Fasciocutaneous Anterolateral Thigh Flap” because the authors wonderfully elucidate to the readers the versatility of the fasciocutaneous configuration of the flap all over the body, equipped by well-managed difficult cases.
The adipofascial anterolateral thigh flap has several advantages compared with the fasciocutaneous anterolateral thigh flap, the main one of which is that it relies on a safer vascularization because the fascial plexus in kept intact during the thinning procedure, thus reducing partial or marginal necrosis. It is of particular importance when this flap is used to reconstruct oral cavity or limb defects because of the reduced thickness necessary.1
The three main indications of the adipofascial anterolateral thigh flap are as follows: oral cavity defects, lower/upper limbs reconstruction, and contour restoration in facial atrophy. The versatility of the adipofascial anterolateral thigh flap in oral cavity reconstruction and hemifacial atrophy has been elucidated in several publications supported by the common experience of other colleagues as well.2 The first article, published in 2003, describes in detail a successful reconstruction of the right mobile tongue after squamous cell carcinoma resection3; the adipofascial anterolateral thigh flap was used successively to reconstruct the retromolar trigone, floor of the mouth, cheek, and the entire mobile tongue, with a superior outcome as compared with radial forearm and fasciocutaneous anterolateral thigh flaps.4 Recently, a case of hemifacial atrophy correction with a buried adipofascial anterolateral thigh flap with a stable outcome 7 years after surgery has been reported, proving that liposuction is a safe procedure for reshaping.5
Moreover, on account of the described properties of the deep fascia, the possibility emerges of avoiding a double-paddle flap to cover internal and external surfaces and through-and-through defects deriving from the resection of advanced tumors of the cheek and the floor of the mouth.4
The defatting procedure of the anterolateral thigh flap is a slow, meticulous procedure that must preserve all the vascular branches to the skin; it has the main advantages of leaving in place the deep fascia, reducing the risk for muscle herniation (the suprafascial anterolateral thigh flap). Such “ultrathin” flaps would be best applied for the reconstruction of a postburn anterior cervical contracture, where the inextensible fascia lata is not indicated, or for the dorsum of feet and hands as described in the authors' algorithm.
The increased number of publications on the anterolateral thigh flap proves the versatility of this flap in the different configurations proposed, both as a free flap and as a pedicled flap: suprafascial, fasciocutaneous, adipofascial, and musculocutaneous anterolateral thigh flaps. Each variant is equipped with well-defined indications according to the recipient site.
I would emphasize how the adipofascial anterolateral thigh flap provides for the limits of the fasciocutaneous anterolateral thigh, rendering the flap enforceable all over the body and as the primary preference in several institutions.
The authors have no commercial associations that might pose or create a conflict of interest with information presented in this communication.
Tommaso Agostini, M.D.
Vittorugo Agostini, M.D.
Department of Plastic and Reconstructive Surgery
University of Florence
Davide Lazzeri, M.D.
Department of Plastic and Reconstructive Surgery
Hospital of Pisa
1.Agostini T, Agostini V. Adipofascial versus fasciocutaneous anterolateral thigh flap in oral cavity reconstruction: Focus on the vascular supply. J Plast Reconstr Aesthet Surg
2.Teng L, Jin X, Wu G, et al. Correction of hemifacial atrophy using free anterolateral thigh adipofascial flap. J Plast Reconstr Aesthet Surg.
3.Agostini V, Dini M, Mori A, Franchi A, Agostini T. Adipofascial anterolateral thigh free flap for tongue repair. Br J Plast Surg
4.Agostini T, Agostini V. Further experience with adipofascial ALT flap for oral cavity reconstruction. J Plast Reconstr Aesthet Surg
5.Agostini T, Agostini V. Adipofascial anterolateral thigh free flap in hemifacial atrophy. Acta Otorhinolaryngol Ital
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