Case Series of Anterolateral Thigh Free Flap Reconstruction in Rwanda

Abstract

Background:

The anterolateral thigh free flap is a versatile reconstructive option for lower limb and head and neck defects. It provides a large skin paddle with a reliable vascular pedicle—the descending branch of the lateral circumflex femoral artery—and is ideal for covering complex soft tissue defects. Its minimal donor site morbidity, along with the option to include muscle or fascia, makes it a versatile choice for reconstruction of various anatomical sites.

Methods:

All 3 patients included in this case series were selected after assessing that their defects could not be covered with local flaps. A detailed history was obtained for each patient, including smoking status, diabetes, and other vascular diseases, along with any prior radiotherapy. Computed tomography angiography was performed for every patient to confirm that the recipient vessels are patent, along with the standard preoperative workup.

Results:

The 3 patients who presented, 1 for a scalp basal cell carcinoma defect postexcision and 2 with left leg defect for coverage of exposed and fractured left tibia following trauma, demonstrated good clinical outcomes. None of the patients required a return to the operating room for microvascular compromise, and there were no instances of flap necrosis, or congestion. However, all patients reported postoperative flap fullness, which may necessitate flap debulking in the future.

Conclusions:

This case series is not intended to draw definitive conclusions regarding the use of the free anterolateral thigh flap, but rather, the cases are presented to illustrate local microsurgical capacity made possible through international collaboration.

Takeaways

Question: Is it possible to develop a sustainable microsurgical capacity in a resource-limited setting?

Findings: We conducted a case series of 3 patients. Two of them had exposed tibia bones following road traffic accidents, and 1 had a scalp defect after wide excision of a basal cell carcinoma, which we reconstructed with free anterolateral thigh flaps. All patients reported good outcomes with no vascular compromise.

Meaning: This case series demonstrated the feasibility and success of establishing a microsurgery program in a resource-limited setting such as Rwanda.

INTRODUCTION

The anterolateral thigh (ALT) free flap is a useful flap for lower limbs and head and neck reconstruction. Cannady et al described this flap as having a pliable and tolerable donor site morbidity.¹ The benefits of this flap include its reliable vascular anatomy, long pedicle, and minimal donor site morbidity. Additionally, 2 teams can work simultaneously without the need to reposition the patient.²

The ALT free flap can be raised to cover defects up to 15 × 40 cm and be shaped based on reconstruction needs.² Hoshal et al described that the ALT has favorable anatomy in approximately 95% of the population when compared to the anteromedial thigh flap for reconstructing head and neck defects. Since their initial report, others have shared their experiences, emphasizing the ALT flap as a primary workhorse flap for head and neck reconstruction.³

In Rwanda, a collaborative effort involving visiting professors from the American College of Surgeons and the Surgeons in Humanitarian Alliance for Reconstruction Research and Education provided Rwandan plastic and reconstructive surgeons and residents with hands-on microsurgery training. Using surgical loupes, consultant plastic surgeons and residents performed arterial and venous anastomoses on chicken thigh models. This was the beginning that allowed us to perform the cases described in the following section.

SURGICAL TECHNIQUES USED FOR ALT FLAP HARVESTING AND ANASTOMOSIS

In all 3 cases, we performed the following surgical techniques for the flap harvesting. All patients were placed in the supine position under general anesthesia. We marked the flap starting at the midpoint between the superior arc of the patella and the anterior supine iliac spine. The perforators were identified and mapped preoperatively using a handheld pencil Doppler. The flap was designed with its long axis aligned parallel to the thigh and centered over the dominant perforators.

The flap elevation approach began on the medial side of the thigh, with an incision carried down to the fascia in a bloodless field. The perforator to the skin was clearly visualized within the intermuscular septum between the biceps femoris and vastus lateralis muscles, arising from the descending branch of the lateral circumflex femoral artery.

We carefully dissected until an adequate pedicle length of approximately 10–13 cm was obtained. Following visualization of the perforator, the recipient vessels were dissected and skeletonized. After the flap perforator was divided, heparinized saline of 5000 IU mixed with 50 mL of 0.9% normal saline was used to flush the vessels to prevent thrombosis formation, and end-to-end anastomosis was performed. In all 3 cases, the ischemia time ranged from 2 to 2.5 hours. A 2-team approach was used, with the patient maintained in the supine position throughout, which facilitated flap harvest and inset without changing the patient’s positioning.

TRAINING, COMPETENCE, AND ROAD MAP TO SUSTAINABILITY OF THE PROGRAM

Plastic and reconstructive surgery residents were actively engaged in microsurgical training before the clinical application. This training included practice on chicken thigh models, and residents performed end-to-end anastomoses under supervision. These sessions provided a safe environment to refine microsurgical dexterity, suturing techniques, and familiarity with instruments. During surgery, residents participated in flap harvest and performed end-to-end anastomoses under direct supervision with notable confidence while carrying out these intraoperative tasks, reflecting the effectiveness of the training before surgery. We anticipated establishing a self-sustaining microsurgical training program, with residents who demonstrated the capacity to contribute to vascular anastomoses, and this outlined a road map to the sustainability of the program.

Case 1

A 33-year-old woman presented to Kigali University Teaching Hospital, 3 weeks after a road accident in which she sustained an open fracture of the left tibia or fibula with exposed tibia bone and soft tissue defect. She had undergone multiple debridements to provide a clean wound. The soft tissue defect was 20 × 15 cm and was covered with a free ALT flap, harvested from the contralateral thigh. The donor site was closed with a skin graft. The free ALT flap was anastomosed to the posterior tibial vessels on the left leg. This was an end-to-end anastomosis. The tibia fracture was fixated with an external fixator. This patient’s hospital stay was 25 days, and the procedure was performed in 2023 (Fig. 1).

Fig. 1.

This patient presented with an exposed and fractured tibia bone, which was reconstructed with a free ALT flap after serial debridements. A, Day 2 post-ALT free flap for left leg defect reconstruction posttrauma, showing a small area of flap bruising that resolved without reexploration. B, Result after 2 years.

Case 2

A 55-year-old albino woman presented to Kigali University Teaching Hospital (CHUK) with a 3-year history of a right-sided frontoparietal scalp lesion. A biopsy revealed basal cell carcinoma. She underwent a wide local excision with a 2-cm margin as well as bilateral neck dissections. The resulting scalp defect was 15 × 15 cm and was covered with an ALT free flap after the margins were confirmed negative. The recipient vessels used were the ipsilateral facial artery and vein, with an end-to-end anastomosis. The flap was supercharged with a second venous anastomosis using the external jugular vein. A portion of the flap skin paddle was inset in the preauricular area to prevent compression of the flap pedicle. This patient’s hospital stay was 23 days, and the procedure was performed in 2023 (Figs. 2 and 3).

Fig. 2.

Preoperative patient with forehead/scalp basal cell carcinoma.

Fig. 3.

This patient, who has albinism, presented with a scalp lesion whose biopsy showed basal cell carcinoma, which was excised and reconstructed with a free ALT flap. A, Day 5 postoperative result post-ALT free flap reconstruction. B, Two-year follow-up results.

Case 3

A 28-year-old man presented with a 1-day history of an open fracture of the left tibia and fibula after a landslide. He underwent debridement with a soft tissue defect of 8 × 5 cm. The defect was covered with a free ALT flap, with an end-to-end anastomosis to the posterior tibial artery and vein. He developed flap tip necrosis, which was managed with a simple wound dressing change. His hospital stay was 41 days, and this free flap procedure was performed in 2024.

POSTOPERATIVE MANAGEMENT

All patients received an immediate postoperative dose of 40 units of intravenous heparin. Additionally, the 2 patients with lower limb defects received prophylactic anticoagulant doses of heparin of 40 IU subcutaneously and 100 mg of oral aspirin once daily, which was continued up to day 5 as they were bedridden. The patient with a post–basal cell carcinoma wide local excision scalp defect was prescribed 100 mg of aspirin once daily for 5 days without heparin. Postoperative flap monitoring was performed hourly on the first day and every 2 hours from day 2 to day 3 (Fig. 4).

Fig. 4.

This patient was involved in a road traffic accident and sustained open fractures of the tibia and fibula, which were reconstructed with a free ALT flap. A, Preoperative left leg defect with open tibia/fibula fracture. B, Day 36 post-ALT free flap reconstruction.

DISCUSSION

The anterolateral thigh flap, regarded as a workhorse flap, possesses several properties that make it an ideal choice for head and neck reconstruction.^1,2 These include a long pedicle, good color match with the recipient site, reduced donor site morbidity, and suitability for a 2-team approach.^3,4 Lamaris et al found the ALT free flap to be the flap of choice for scalp reconstruction with a good cosmetic appearance and durable scalp coverage.^5,9

Even though distal lower extremity reconstruction is challenging, patients who underwent reconstruction with the ALT free flap demonstrated high satisfaction.⁶ Van Landuyt emphasized that the ALT flap replaced the radial forearm flap as being the workhorse in head and neck surgery.^7,8 Donor site morbidity is minimal compared with many other free flaps, as the flap does not involve removal of the muscle, and primary closure of the donor site is possible.⁹ Its long pedicle has made the ALT free flap the best option for complex defects of the extremities.¹⁰

Some risk factors for the ALT free flap have been reported in other studies such as venous congestion, arterial and venous thrombosis, and tissue edema, which are the risks for flap failure.¹¹ In Africa, building microsurgery capacity is still a challenge due to a shortage of trained staff (91%), a shortage of surgical expertise (84%), a lack of operating equipment/instruments (81%), limited operating theater time (78%), and inadequate postoperative patient monitoring (84%).¹² Although we did not encounter any major complications in our study, potential complications will be carefully considered in future cases. One patient reported flap tip necrosis, which was managed with simple dressing changes.

CONCLUSIONS

Our experience demonstrates that it is possible and impactful to build a microsurgery program in a resource-limited setting. With committed local plastic and reconstructive surgeons and support from experienced international partners, remarkable progress can be achieved even with limited resources. Slow is fast, and this means that sustainable change takes time, but with collaboration and dedication, an independent microsurgical team can be developed. Our journey in Rwanda serves as an example of what can be achieved.

DISCLOSURES

The authors have no financial interest to declare in relation to the content of this article. The authors declare that Operation Smile had no role in the development of this study.

PATIENT CONSENT

All patients voluntarily provided consent for the use of their photographs in publication.

ACKNOWLEDGMENTS

The authors acknowledge the support from the hospital administration for providing an environment for working and conducting the procedures. They recognized and acknowledged support from the American Society of Plastic Surgeons Visiting Professors, Operation Smile, SHARE Community, and the Rwanda plastic surgery team for their continued education and mentorship. All 3 procedures were funded by Operation Smile, with an estimated cost of USD 8000 per case.

ETHICAL APPROVAL

This study was approved by the Kigali University Teaching Hospital institutional review board, with reference number: EC/CHUK/CR/003/2025.