Hand Reconstruction Using Anterolateral Thigh Free Flap by Terminal Perforator-to-Digital Artery Anastomosis: Retrospective Analysis

Abstract

This study aimed to analyze cases of anterolateral thigh (ALT) free flap used for hand reconstruction with terminal perforator-to-digital artery anastomosis. Patients who underwent ALT free flap placement with terminal perforator-to-digital artery anastomosis for hand reconstruction between January 2011 and August 2021 were included. The number, length, and diameter of the perforators and veins, flap size, and operative time were investigated through a retrospective review of charts and photographs. The occurrences of arterial thrombosis, venous thrombosis, arterial spasm, and flap necrosis were analyzed. In total, 50 patients were included in this study. The mean diameter and length of the perforators were 0.68 mm and 3.25 cm, respectively, and the mean number of veins anastomosed was 1.88, with a mean diameter of 0.54 mm. Complications included four cases of arterial thrombosis, one case of venous thrombosis, seven cases of partial necrosis, and one case of total flap failure. Regression analysis showed that a longer perforator was associated with arterial thrombosis whereas larger flap size and number of anastomosed veins were associated with partial necrosis ( p < 0.05). The terminal perforator-to-digital artery anastomosis offers advantages in using compact free flaps with short pedicle lengths to cover small hand defects.

Keywords: hand injuries; microsurgical free flap; perforator flaps; reconstructive surgical procedures.

Fig. 1

Schematic diagram of anastomosis. ( A ) Long perforator dissection up to the source vessel and recipient suitable artery. ( B ) Terminal perforator-to-digital artery anastomosis.

Fig. 2

Using deep fascia as the criterion, we differentiated proximal and terminal perforators. This study included anterolateral thigh free flaps with terminal perforators harvested at the superficial level of the deep fascia.

Fig. 3

( A , B ) Patient with soft tissue defect of middle phalanx from the dorsal side to the voloradial side, which required a pliable flap coverage with versatility. ( C ) The anterolateral thigh free flap was harvested with the terminal perforator secured at the superficial fascial plane. ( D ) The perforator was anastomosed to the radial digital artery located at the proximal phalanx. ( E , F ) Follow-up photographs taken 3 months later.

Fig. 4

( A , B ) A volar side soft tissue defect occurred on the entirety of the right middle finger, requiring soft tissue coverage from the proximal phalanx to the fingertip. ( C , D ) An anterolateral thigh free flap was harvested to match the size of the defect and a terminal perforator was secured for anastomosis to the radial digital artery of the middle finger. ( E ) The following day, congestion occurred with venous thrombosis, which was resolved using venorrhaphy during a revisional surgery. ( F ) Follow-up photographs taken 1 year later.

Fig. 5

( A – D ) Two subtotal defects occurred in the index and middle fingers after carcinoma resection. ( E , F ) Two free flaps based on the terminal perforator were harvested from the anterolateral thigh to cover each defect. ( G , H ) Both flaps were applied to each finger, and the perforator was anastomosed to the digital artery (yellow arrow). ( I ) The flaps were successfully inset onto each finger. ( J ) Follow-up photographs taken 1 year later.