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Burns 30 (2004) 729–738

Double free flaps harvested from one or two donor sites for one or
two-staged burn reconstruction: models of sequential-link and
independent-link microanastomoses
Samir Mardini, Feng-Chou Tsai

, Jui-yung Yang
Division of Plastic Surgery, Department of Surgery, Taipei Medical University Hospital, Taipei Medical University,
252 Wu Hsing Street, Taipei 110, Taiwan
Accepted 3 March 2004
Abstract
Extensive burn injuries and subsequent scarring result in functional and aesthetic impairments. The use of free flaps in burn reconstruc-
tions provides superior outcomes especially when other, more conservative reconstructive methods fail and curtail efforts of relentless
rehabilitation. Multiple chronic scar-associated problems and extensive acute burn defects are conventionally resolved by multiple proce-
dures. Thus, two or extensive scar regions are typically reconstructed using two free flaps (double free flaps) in two separate, procedures
utilizing two independent donor sites. This leads to a protracted course of repetitive operations, hospitalizations, and rehabilitation, causing
a prolonged period of discomfort and disability. The definition of double free flaps is two independent free flaps with two sets of microanas-
tomoses. This paper illustrates, via a case-series, that double free flaps could be performed in one procedure, with both flaps harvested
from either one or two donor sites. Two flaps are then utilized to resolve one large or two problem areas at the same time. Revascularization
of the flaps is achieved via either a sequential-link or independent-link microanastomoses. The advantages of harvesting double free flaps
from one region and using them in one stage to reconstruct one or two defect area include: (1) providing a large area of soft, pliable skin
from one region for re-surfacing burn injuries or resolving scar associated problems, (2) decreasing the treatment course and potential
disability, (3) decreasing donor site morbidities, (4) increasing maneuverability and conformability of the flap, and (5) affording a better
functional and aesthetic outcome.
© 2004 Elsevier Ltd and ISBI. All rights reserved.
Keywords: Free flaps; Burns; Microsurgery
1. Introduction
The primary advantage of using free flaps as tissue re-
placement for burn reconstruction is the low recontracture
rate. Conventional reconstructive methods such as split and
full thickness skin grafting often produce a recontracture
that requires other procedures to correct the primary defor-
mity [1–7]. Donor sites for free tissue transfer are limited
and may pose a problem when deciding on potential donor
sites. Ironically, these patients with limited donor sites often
require more tissue as they have more than one contracture
site. The traditional principle of free tissue transfer, which re-
solves one problem region at a time such as multiple-staged
reconstruction, prolongs patient hospitalization, procedural
time, rehabilitation and period of disability. The surgeon is

Corresponding author. Tel.: +886-2-27372181x1336.
E-mail address: plastytsai@hotmail.com (F.-C. Tsai).
also often faced with the dilemma of prioritizing sites of
contracture release and donor sites of free flaps.
Double free flaps performed in one setting have the advan-
tage of limiting the number of procedures. In addition, when
two flaps are harvested from the same donor region, the pa-
tient becomes less debilitated and overall recovery time may
be improved. Previous reports of double free flaps have fo-
cused on their use in reconstructing composite defects pro-
duced by trauma or head and neck cancer ablation [8–11].
Long operative times and the potential for great donor site
morbidity have precluded surgeons from performing these
extensive procedures. The purpose of this case-series is to
classify and evaluate the different types of double free flaps
used in post-burn contracture release according to the num-
ber of stages involved, number of donor sites required and
number of contracture regions reconstructed. This paper will
also endeavor to demonstrate the optimal reconstructive way
0305-4179/$30.00 © 2004 Elsevier Ltd and ISBI. All rights reserved.
doi:10.1016/j.burns.2004.03.009
730 S. Mardini et al. / Burns 30 (2004) 729–738
to utilize double free flaps harvested from one donor site as
a one-stage procedure.
2. Patients and methods
Between March 2000 and January 2003, 11 patients were
treated with double free flaps. There were 8 males and 3 fe-
males with a mean age of 39.6 years (range: 28–60). The
etiology of burn injuries included flame burns (7 patients),
electrical burns (3 patients), and chemical burns (1 patient).
Indications for free flaps in burn reconstruction were: (1)
exposure of vital structures, (2) significant limitations in ac-
tive or passive range of motion (ROM), and (3) the pres-
ence of discomfort and disability. Double free flaps were
used in four patients for the reconstruction of acute burn
defects and in seven patients to cover the defects created
following the release of chronic burn contractures. Double
free flaps were classified into three different types according
to the operative times, duration of hospitalization, treatment
period, number of donor sites, number of reconstructive re-
gions, associated morbidities and reconstructive outcome
(Tables 1–3).
Table 1
Two-staged reconstruction with double free flaps harvested from two different regions for the reconstruction of two separate defects
Case Etiology Defect Flap and anastomosis type
(S or I)
Size
(cm × cm)
Operation
time (h)
Total hospital stay (days) Complication
Acute burn
1 Electric Foot MP (I) 9 × 5.5 4 29 Nil
Hand ALT (I) 19 × 11 4.5 Nil
2 Electric Left wrist LD (I) 18 × 5 4 100 Nil
Right wrist G (I) 25 × 4.5 4.3 Nil
3 Flame Foot MP (I) 10 × 5 4 46 Nil
Hand ALT (I) 14 × 7.5 4.5 Nil
Chronic burn
4 Flame Neck Left LD (I) 21 × 7 3.4 7 Nil
Hand Right pre-expanded LD (I) 28 × 15 3.5 8 (interval: 2.8 months) Nil
5 Flame Left axilla Left TFL (I) 20 × 6 3.2 19 Marginal necrosis
Right axilla Right pre-expanded TFL (I) 28 × 9.5 3.9 7 (interval: 3.6 months) Nil
6 Flame Neck Right ALT (I) 25 × 5 4.5 14 Nil
Left hand Left ALT (I) 20 × 5 4.8 7 (interval: 3.4 months) Nil
ALT: anterolateral thigh; LD: latissimus; G: gracilis; TFL: tensor fascia lata; MP: medialis pedis; S: sequential-link; I: independent-independent
microanastomosis.
Table 2
One-staged reconstruction using double free flaps harvested from two different regions for the reconstruction of two separate defects
Case Etiology Defect Flap and
anastomosis
type (S or I)
Size (cm × cm) Operation time (h) Total hospital stay (days) Complication
7 Chemical Axilla Right ALT (I) 28 × 7 5.5 7 Nil
Neck Left MT (I) 24 × 7
8 Flame Axilla (right) Right ALT (I) 29 × 7.5 7.5 7 Nil
Axilla (left) Left ALT (I) 28 × 7.5
3. Case report
3.1. Two-staged reconstruction with double free flaps
harvested from two different regions for the reconstruction
of two separate defects
3.1.1. Case 1: acute burn
A 54-year-old male suffered from 40% total body surface
area (TBSA) electrical burn involving the four limbs, depth
varying from second to third degrees. The right index and
middle fingers, the big and second toes were amputated due
to severe tissue damage. The right foot defect measured 9 cm
× 5.5 cm with exposed bone and the right hand defect mea-
sured 19 cm × 11 cm (Figs. 1A, B and 2A). Nine days later,
in a 7 h operation, the foot defect was debrided and covered
with a free medialis pedis flap (Fig. 1C–E). Eight days after
the initial operation, in a 7.5 h operation, the hand defect was
reconstructed with a free anterolateral thigh (ALT) perfora-
tor flap (Fig. 2B–D) Both flaps survived and the donor sites
were closed with skin grafts. The patient was discharged 29
days following the initial presentation. A thinning procedure
of the ALT flap was performed after 4 months. At 3 years
follow-up, the patient was doing well (Figs. 1F and 2E, F).
S. Mardini et al. / Burns 30 (2004) 729–738 731
Table 3
One-staged reconstruction using double free flaps harvested from the same donor region for the reconstruction of one defect
Case Etiology Defect Flap and
anastomosis
type (S or I)
Size (cm × cm) Operation time (h) Total hospital stay (days) Complication
Acute burn
9 Electric Scalp Right ALT (S) 18 × 8 6.2 28 Nil
Right TFL (S) 18 × 6
Chronic burn
10 Flame Hand Right ALT (S) 18 × 7 5.7 15 Marginal necrosis (ALT flap)
Right MT (S) 15 × 5
11 Flame Neck Left ALT (I) 14 × 7 6.2 21 Marginal necrosis (ALT flap)
Left TFL (I) 14 × 7
MT: medial thigh.
3.1.2. Case 5: chronic bilateral axillary contractures
A 37-year-old male worker suffered from bilateral ax-
illary contractures as a result of a previous flame burn
injury. Split thickness skin grafting followed by 1 year
course of aggressive postoperative physical rehabilitation
were performed with minimal improvement. The left ax-
illary contracture was excised and released. A free ten-
sor fascia lata (TFL) cutaneous perforator flap measuring
20 cm × 6 cm was harvested from the left thigh to cover
the defect; its vessels were anastomosed to the left tho-
racodorsal artery and a concomitant vein (Fig. 3A). Two
rectangular-shaped tissue expanders (500 and 350 cc) were
inserted into the right thigh, around the perforator vessels
Fig. 1. (A and B) Deep burn injuries over the right big toe and second toe with bone exposure. (C–F) A free medialis pedis flap from the left foot was
used to cover the exposure defect.
of the right TFL perforator flap at the same time. Total
operative time was 3.2 h, and the patient was discharged
after on postoperative day 19. The donor site was closed
with a skin graft due to wound dehiscence. After serial
saline injections over 3.6 months, the pre-expanded free
TFL perforator flap (measuring 28 cm × 9.5 cm) was used
to cover the defect after right axillary contracture release
and the donor site was closed primarily. Operative time
was 3.9 h and total hospital stay was 7 days. Both flaps
healed without complications. A de-fatting procedure of the
right axilla flap was performed at 2 months postoperatively.
At 6 months follow-up, excellent functional results were
seen.
732 S. Mardini et al. / Burns 30 (2004) 729–738
Fig. 2. (A) The exposed second to fourth metacarpophalangeal joint with dorsal skin defect after debridement. (B–F) The defect was resurfaced with a
free anterolateral thigh perforator flap.
3.2. One-staged reconstruction using double free flaps
harvested from two different regions for the reconstruction
of two separate defects
3.2.1. Case 7: chronic left neck and axillary contractures
A 30-year-old male worker presented with cervical and
axillary contractures following a chemical burn injury. De-
spite a 6 months course of aggressive rehabilitation, mini-
mal improvement was noted. A one-staged double free flap
procedure was performed. The contracture over the left neck
was excised and covered with a free medial thigh (MT) per-
forator flap from the left thigh (24 cm × 7 cm); its vessels
were anastomosed to the left superior thyroid artery and a
branch of internal jugular vein. A free ALT perforator flap
(28 cm × 7 cm) from the right thigh was used to reconstruct
the defect in the right axilla created following the contracture
release. Both donor sites were closed primarily. The total
operative time was 5.5 h, and total hospital stay was 7 days.
There were no complications. No aggressive rehabilitation,
splinting, or revision procedure was performed postopera-
tively. At 7 months follow-up, good functional and aesthetic
results were seen (Fig. 4).
3.3. One-staged reconstruction using double free
flaps harvested from the same donor region for the
reconstruction of one defect
3.3.1. Case 9: chronic dorsal hand contracture
A 40-year-old male suffered from a flame burn injury
which resulted in a contracture of the dorsal aspect of
the right hand. Despite 6 months of rehabilitation, no im-
provement was noted in the range of motion (Fig. 5A).
Contracture release followed by double free flap coverage
was performed. A special lazy-S design was made over
the left thigh and two flaps were harvested: medial and
ALT flaps (Fig. 5B). The MT perforator flap (15 cm ×
5 cm) (Fig. 5C) and ALT perforator flap (18 cm × 7 cm)
were inset into the defect and the flap vessels were se-
quentially linked and anastomosed to the superficial radial
artery and cephalic vein over the snuff box (Fig. 5D). The
donor site was closed primarily, and the total operative
time was 5.7 h. Despite some marginal necrosis of the ALT
flap, which was debrided, both flaps healed without further
incidents. At 11 months follow-up, the patient was satis-
fied with the aesthetic and functional outcome (Fig. 5E
and F).
4. Results
All perforator flaps survived without re-exploration. Three
flaps had a small area of marginal necrosis that healed fol-
lowing bedside debridement and a short course of dress-
ing changes. Hospital stay, treatment and operative times
are shown in Table 4. No significant donor site morbid-
ity was present. All patients got the maximal functional
improvement within average 2 weeks of home rehabilita-
tion. An improved passive and active range of motion was
achieved in all cases at an average follow-up time of 7
months.
S. Mardini et al. / Burns 30 (2004) 729–738 733
Fig. 3. (a) Left axilla: (above) preoperative limited range of motion; (below) postoperative photographs after reconstruction with a TFL perforator flap. (b)
Right axilla: (A and B) contracture area; (C) tissue expander was inserted over the right thigh; (D) flap harvest with a tissue expander (TE); (E and F)
postoperative photographs after 6 months follow-up.
734 S. Mardini et al. / Burns 30 (2004) 729–738
Fig. 4. Preoperative and postoperative photographs: (above) lateral cervical contracture; (below) axillary contracture. MT: medial thigh perforator flap. ALT:
anterolateral thigh perforator flap.
Fig. 5. (A) Dorsal contracture of the right hand; (B) double free flaps (MT and ALT perforator flaps) were harvested via a midline incision over the left
thigh; (C) the MT perforator flap; (D) both flaps were positioned together to cover the contracture defect via a sequential-link microanastomosis; (E and
F) postoperative photographs after 11 months follow-up.
S. Mardini et al. / Burns 30 (2004) 729–738 735
Table 4
Comparison between different methods
Two-staged, two donor site, two-regions One-staged, two
donor site,
two-regions
One-staged, one donor site, one-region
Total treatment course
(plus interval)
Acute: 58.3 days; chronic: 110
days (interval: 3.1 months)
7 days Acute: 28 days; chronic: 18 days
Hospital stay Acute: 58.3 days; chronic: 20 days 7 days Acute: 28 days; chronic: 18 days
Operation time Acute: 4.2 h; chronic: 3.88 h 6.5 h Acute: 6.2 h; chronic: 5.95 h
5. Discussion
Although skin grafting is the most popular procedure used
around the world for burn injuries due to its re-usability,
stability and simplicity, its drawbacks, however, include the
tendency to re-contract and discolor, not to mention donor
site scarring as an associated morbidity [12–14]. Free flaps
offer an option of reconstruction with good quality tissues for
replacement or coverage in burn injuries and associated scar
contractures. Local and pedicled flaps have limited value
due to the lack of good quality tissue available in the same
region of the defect and due to their inherent poor blood
supply at the most critical part (the distal part of the flap).
There appears to be an increasing inclination towards the
usage of free flaps in reconstructive surgery as it provides a
better functional and cosmetic outcome concurrently. Micro-
surgery is currently performed mainly in specialized centers
of teaching institutions and tertiary referral establishments
due to the need for a specialized surgical team and postop-
erative care. However, any surgeon who wants to provide
a quality reconstructive service should feel an obligation to
broaden their reconstruction options and techniques, in an
attempt to overcome surgical limitations and offer their pa-
tients the better treatment option [15].
Thin free perforator flaps provide good quality tissue that
is particularly suitable for burn reconstruction as the main
component required in a burn defect is skin [16–18]. Tsai
and coworkers advocated the use of free ALT perforator flaps
Fig. 6. Comparison of donor sites from two different flap harvests for the same size defect: (left) one large free flap with skin graft coverage at the
donor site; (right) double free flaps with primary closure of the donor site.
for the reconstruction of anterior cervical contractures after
failure of other reconstructive methods; excellent neck mo-
bility and aesthetic results were achieved [6]. Other choices
of free flaps have been proposed for re-surfacing contrac-
tures, however, certain disadvantages have limited their use.
For example, when free musculocutaneous flaps are used, a
more significant donor site morbidity is noted and the flap
is usually too bulky [1,2,7].
One single free flap resolves one specific problem region,
thus theoretically, more free flaps can re-surface more prob-
lemareas. Due to the limited donor sites available in burn pa-
tients, the surgeon is often faced with the predicament of pri-
oritizing the reconstructive efforts. When the most severely
affected region is reconstructed first, often the other regions
are neglected or they may undergo worsening of the contrac-
ture due to a shift in focus of the rehabilitation treatment.
Even if treated within the same operation, the less severe
region may be treated with less optimal methods. Multiple
reconstructive procedures can also result in a prolongation
of the total recovery time and rehabilitation period. This can
bear heavily on the patient dealing with undergoing such an
extensive treatment protocol. In addition, the scarring asso-
ciated with skin grafting may discourage patients who are
already dealing with large areas of scars in other regions.
The definition of double free flaps is two independent
free flaps with two sets of microanastomoses. Double free
flaps have been used for reconstructing extensive composite
defects of the head and neck region [8–11]. Whereas ablative
736 S. Mardini et al. / Burns 30 (2004) 729–738
Table 5
Comparison of different kinds of staged procedures
Two-staged, two donor site, two-regions One-staged, two donor site, two-regions One-staged, one donor site, one-region
Total treatment course Long Short Short
Hospital stay Long Short Short
Operation time Short Long Moderate
Donor site morbidities ++ ++ +
Fig. 7. (a) Sequential-link and independent-link microanastomoses. (b) The layout of the sequential-link microanastomosis, note the ALT ‘connector
pedicle’ and its two ends. PC: the proximal connecting microanastomosis with recipient vessels; DC: the distal connecting microanastomosis with medial
thigh pedicle.
S. Mardini et al. / Burns 30 (2004) 729–738 737
surgery results in defects requiring thick, composite tissue,
burn reconstruction requires thin, pliable skin only. Although
double free flaps are more technique dependent and demand
longer operative times, burn scar reconstruction should focus
on decreasing the number of stages, donor site morbidities
and rehabilitation needs. More areas can be treated while
achieving excellent functional and aesthetic results in all
regions (Table 5). That is, to perform a one-stage procedure,
utilizing two free flaps, from one donor site to reconstruct a
bigger or greater number of problem regions, also allowing
for primary closure of the donor site (Fig. 6). This provides
a more efficient result with less overall morbidities.
Microanastomoses for double free flaps are classified
into two types: sequential-link and independent-link [16]
(Fig. 7a). The sequential-link microanastomoses, so-called
“flow-through” microanastomoses is analogous to that of a
three-way intravenous connector, which diverts the blood
supply evenly into two separate destinations. The pedicle
of the first flap has two microanastomoses, the proximal
connection, which is linked to the recipient vessels, and
the distal connection, which is linked to the pedicle of
the second flap (Fig. 7b). In all sequential-link anasto-
moses, the first flap must have a ‘connector pedicle’, that
is, a pedicle with a perforator which is perpendicular to
the main supply vessel (T-shaped), thus enabling adequate
blood flow to either continue into or drain from the second
anastomosis; the ALT flap, and forearm flap pedicles are
examples of a ‘connector pedicle’. This type of anastomo-
sis is especially valuable in areas with limited numbers of
suitable recipient vessels, such as the dorsum of the hand
or the scalp. The independent-link microanastomosis con-
sists of two pedicles anastomosed separately to two sets
of independent recipient vessels. The fear of flap failure
associated with sequential-link microanastomoses is a rea-
sonable concern, however, excellent patency rates achieved
with free tissue transfer allow this method to be performed.
Both sequential link and independent link models require
the same number of anastomoses to be performed with
less time spend on searching for a second set of recipient
vessels.
Cutaneous perforator flaps from the thigh offer a consis-
tent anatomy and an availability of multiple flaps that can
be harvested independently or in combination [19–29]. The
thigh is an ideal model for multiple flaps, as it provides,
through one midline incision, ALT flaps, TFL flaps, MT
flaps and posterior thigh (PT) flaps. Thus, the advantages of
thigh flaps in burn reconstruction include: (1) excellent flap
consistency to match the defect (thinness and pliability), (2)
availability of multiple flaps that can be harvested together
or separately, (3) easy concealment of the donor site scar
with clothing, and (4) minimal donor site morbidity. Double
free flaps can be harvested from one thigh if the distance be-
tween the two perforators of the flaps is optimal. MT, ALT
and TFL perforator flaps are particularly suitable in this in-
stance because they have independent cutaneous perforators
adequately apart.
One-stage reconstruction with double free flaps elim-
inates the intervening recovery and rehabilitation period
found when two stage operations are performed. In our se-
ries, the average period between the first and second stage
was 3.1 months in chronic contracture cases and 8 days for
acute reconstructions. Although double free flaps require
long operative times, with proper planning and a two team
approach, this period is minimized. Patient recovery is more
optimal and less overall energy is expended by the patient
on rehabilitation and recovery.
In summary, the use of one-staged double free perforator
flaps for burn reconstruction harvested from one donor site
has many advantages: (1) provision of a larger area with soft
pliable skin for re-surfacing burn injuries; (2) decreasing
the duration of total treatment course and period of disabil-
ity, recovery, pain, and rehabilitation; (3) decreasing donor
site morbidities, especially in allowing for primary closure
of these sites; (4) increasing maneuverability of the flap to
conform to the defects and (5) providing a superior func-
tional and aesthetic outcome than other methods of burn re-
construction. The disadvantages are few, consisting of the
need for a longer operative time and the demand for better
microsurgical techniques.
Double free perforator flaps performed in one opera-
tive procedure is a viable alternative for reconstruction of
acute burn defects and for defects created after chronic
contracture release. In one setting, from one donor site,
large or two defects can be reconstructed with supple pli-
able skin with minimal morbidity inflicted on the donor
site.
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