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Background  Distal lower extremity reconstruction can be challenging in terms of flap design. Bulky flaps result in limited mobility accompanied with the need of customized footwear. Raising the ALT-flap in a superficial fascial plane (thin ALT-flap) can be beneficial. This study evaluates thin ALT-flaps for lower distal extremity reconstruction. Methods  In a retrospective study, patients that underwent microvascular extremity reconstruction at the level of the ankle and dorsal foot at the University of Freiburg from 2008–2018 were reviewed. Results  95 patients could be included in the study (35 perforator flaps, 8 fascia flaps and 54 muscle flaps). Among the perforator flaps, 21 ALT-flaps were elevated conventionally and 14 in the superficial fascial plane (thin ALT-flap). Among the conventional ALT-flaps, there was one flap loss (5%) and one successful revision (5%). 5(24%) flaps received secondary thinning. 57%(n  = 12) were able to wear conventional footwear. There were 2(15%) successful revisions of thin ALT-flaps. 100% of thin ALT-flaps survived and 85%(n  = 11) of the patients wore ordinary footwear after defect coverage. Among fascial flaps, 50%(n  = 4) had to be revised with 2(25%) complete and 1 (13%) partial flap loss. All patients achieved mobility in ordinary shoes (n  = 8). In muscle flaps, there were 7(13%) revisions and 5(9%) flap losses. 5(9%) flaps received secondary thinning. Only 33%(n  = 18) were mobile in ordinary footwear. Conclusion  The thin ALT-flap is a save one-stage evolution for lower distal extremity reconstruction with a favorable flap survival rate. Compared with conventional ALT-flaps it might be beneficial in reducing the need for expensive custom fitted shoes and secondary thinning procedures. [ABSTRACT FROM AUTHOR]

Perforator flaps become a reliable option for coverage of various defects and the interest is change from survival of perforator flaps to make thin flaps for better aesthetic and functional outcomes. Multiple flap thinning methods have been demonstrated but it has not been widely attempted because of concerns about compromising circulation of flap thinning. This article will demonstrate the feasibility and benefits of flap thinning technique: defatting after conventional flap elevation. [ABSTRACT FROM AUTHOR]

Flap thinning is a procedure for making a thick flap thinner. This procedure does more than simply fill in the defected area, and it is better for reconstructing the area both functionally and aesthetically. However, because flap thinning is a rather blind procedure, it may have harmful effects on flap vascularity. Therefore, the vasculature of a flap must be understood before performing flap thinning. This paper analyzes the basic anatomy underlying flap thinning based on the previous anatomic study that categorized flaps into 6 types by their vascular structures. This paper also reviews specific studies of frequently practiced flap procedures (deep inferior epigastric artery perforator flap, thoracodorsal artery perforator flap, and anterolateral thigh flap) and presents important precautions for flap thinning procedures. Finally, this paper briefly examines the axiality of the subdermal plexus, which needs to be taken into account when performing flap thinning. [ABSTRACT FROM AUTHOR]

A free flap can be harvested leaving an inconspicuous donor site in the lower gluteal region. The different possibilities of free transplantation depend above all on the microvascular supply within the flap. We have prepared gluteal flaps in ten autopsies. The inferior gluteal artery was perfused with a solution of lead oxide and gelatin. After fixation in formaldehyde, the flaps were dissected in three layers and radiographs were taken. Larger branches of the inferior gluteal artery were found even in the superficial subcutaneous tissue. They give rise to smaller vessels which form a muscular, an epifascial and a subdermal subcutaneous network. The inferior gluteal flap is, thus, supplied in all three compartments by the inferior gluteal artery. The isolation of a free subcutaneous compartment as a free tissue transfer seems to be possible, and flap thinning is favored in the middle subcutaneous tissue. [ABSTRACT FROM AUTHOR]