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Free Anterolateral Thigh Versus Vastus Lateralis Muscle Flaps For Coverage Of Lower Extremity Defects In The Chronic Wound Population: Does A Discrepancy In Post-Reconstruction Ambulation Exist?
Elizabeth G. Zolper, BS1, Cara K. Black, BA1, Laurel D. Ormiston, BS2, Jonathan Schwitzer, MD1, Kyle Luvisa, MPH2, Christopher E. Attinger, MD1, Kenneth L. Fan, MD1, Karen K. Evans, MD1.
1MedStar Georgetown University Hospital, Washington, DC, USA, 2Georgetown University School of Medicine, Washington, DC, USA.

Purpose: The thigh has been called the reconstructive warehouse. The anterolateral thigh (ALT) and vastus lateralis (VL) flaps are popular options for free tissue transfer (FTT) in lower extremity (LE) reconstruction. With our experience using thigh-based flaps for LE reconstruction in the chronic wound population, we sought to compare outcomes and appraise our approach to flap selection.
Methods: We retrospectively reviewed patients in whom FTT using ALT vs. VL with skin graft
was performed by a single surgeon between 2012 and 2018. ALT perforator flaps were preferentially selected when skin resurfacing was needed, and a thin donor site was present. VL flaps were selected when elimination of dead space was critical or when significant thigh adiposity existed. No preference was given in weight bearing regions. Patients undergoing a chimeric flap of ALT combined with muscle or Achilles reconstruction were excluded. Patient demographics, complications, and outcomes were recorded and analyzed.
Results: 50 ALT and 34 VL flaps were identified. Average follow up was 1.36 and 1.19 years for the ALT vs VL groups, respectively (p>0.05). Comorbidities were similar between groups with the exception of BMI (ALT 27.575.16, VL 31.127.03; p=0.0091). Overall complication rates were not significantly different: 26.0% ALT and 38.24% VL. Rates of infectious complications, including recurrent osteomyelitis, were also similar. Recipient site skin grafts were required in 97.06% (33/34) of VL patients and only 38.0% of ALT (19/50) patients. The rate of skin graft revision was not statistically different (p=0.1887). Subsequent reoperation for tissue debulking was performed in 8.0% of ALT and 8.8% of VL recipients (p=1.0000). Flap success (ALT: 92.0%, VL 94.1%, p>0.05) and limb salvage rates (ALT: 82.0%, VL: 88.2%, p>0.05) were similar. Ambulation rate was significantly higher for the ALT cohort at 92.0% compared to 73.5% for the VL cohort (p=0.0216). When accounting for the confounder of BMI,
the odds ratio for ambulation between the two cohorts was no longer statistically significant (OR 0.301; 95% CI 0.080-1.127).
Conclusions: We present the largest comparison study of ALT and VL flaps in LE salvage. Complication rates, flap success, and limb salvage were similar between the two cohorts. Ambulation rate was also similar after controlling for BMI. An algorithm focused on donor site availability and wound requirements can lead to successful outcomes.


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