Restoration of Flap Sensation Using Neurotized Anterolateral Thigh Flaps for Lower Extremity Reconstruction
Stephen L. Viviano, MD, Farrah C. Liu, BS, Zachary S. Gala, BME, Nicholas C. Oleck, BA, Paul J. Therattil, MD, Edward S. Lee, MD, Jonathan D. Keith, MD.
Rutgers - New Jersey Medical School, Newark, NJ, USA.
In recent years, the anterolateral thigh (ALT) flap has become a workhorse flap with widespread indications. Lower extremity salvage rates have dramatically increased as a result. However, use of the ALT as a neurotized or re-innervated flap capable of restoring sensation in lower extremity reconstruction has been widely underreported in the literature.
We performed a retrospective review of all lower extremity (LE) reconstructions between 2013 and 2015 performed by the senior author. Anterolateral thigh flap reconstructions that employed neurorrhaphy of the lateral femoral cutaneous nerve (LFCN) to a recipient site peripheral nerve were identified and selected for inclusion. Sensory testing was performed on the flaps at follow up visits.
A total of 15 lower extremity free ALT flaps were identified, 10 of which were neurotized free ALT flaps and eligible for inclusion. The mean age at time of reconstruction was 41.6 (range 7.1 - 56.7) years, with a male predominance of 80%. The mean operative time was 740 (range 113 - 1110) minutes, and mean length of hospital stay was 14.3 (range 7 - 31) days. Of the 10 procedures, the mean flap size was 186.6 (range 23 - 324) cm2. Trauma (n=6), infection (n=3) and tumor extirpation (n=1) were the most common indications for salvage. Average follow-up was 174.25 days (range 72-555 days). There was a 100% limb salvage rate, and there were no cases of total or partial flap loss. There was one (n=1) tumor recurrence at a site distant from the primary resection. Return of protective sensation was evaluated via Semmes-Weinstein Monofilament, two-point discrimination, and light touch testing. Protective sensation (two point discrimination < 15 mm) was regained in 3 of 7 patients (43%). Light touch returned partially or fully in 6 of 7 patients (86%). Those with segmental or no return of sensation were of shorter duration of follow-up.
Neurotization of the ALT flap with the LFCN can restore protective sensation in complex lower extremity reconstructions, which will potentially reduce the complications related to insensate flaps in the foot and leg. Minimal donor site morbidity, a long vascular pedicle, the option to include muscle or fascia, and the ability to provide sensory re-innervation to the lower extremity make the neurotized ALT free tissue transfer an ideal flap for use in lower extremity reconstruction.
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