Designing the Anterolateral Thigh Flap

without Preoperative Doppler or Imaging

Samuel J. Lin, M.D.,1 Amr Rabie, M.D.,1 and Peirong Yu, M.D.2

ABSTRACT

The anterolateral thigh (ALT) flap is now considered a workhorse for head and
neck reconstruction in many centers. However, designing and raising the ALT flap has
been traditionally recognized as being difficult, tedious, and technically demanding due to

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its variation in perforator anatomy. Designing the ALT flap on data gained solely using the
handheld Doppler can be misleading, as its specificity and sensitivity varies greatly
depending on amount of subcutaneous fat and the Doppler itself. Authors have inves-
tigated multiple imaging modalities in the search of the best way to predict and map the site
and size of perforators before dissecting a flap. In this article, we describe a simplified
technique for the ALT flap design and dissection without the use of preoperative imaging
or vascular studies. Utilizing anatomic landmarks, the location of the three perforators
(A, B, and C) can be anticipated and safely dissected. We conclude that accurate use of the
ABC system is one approach in consistently dissecting the ALT flap.

KEYWORDS: Anterolateral thigh flap, Doppler, head and neck, thigh-based

reconstruction, ALT flap

T he ultimate goal in reconstructive surgery is to
replace tissue with similar tissue, with minimal donor
site morbidity. Currently, it is possible to dissect a
perforator flap consisting of skin and subcutaneous fat
with its neurovascular supply through perforating vessels
and nerves while preserving underlying structures (e.g.,
muscle). Depending on the location of the donor site,
there may be anatomic variability with flap dissection.
Blondeel et al observed that there is significant variability
in the anatomy of the perforators of the deep inferior
epigastric perforator (DIEP) and the thoracodorsal ar-
tery perforator (TAP) and recommended the use of color
duplex scanning for planning the DIEP and TAP flaps.1
Although preoperative imaging may provide use-
ful information to aid flap design, it may not be feasible
in many centers and may not be necessary for all
perforator flaps. The anterolateral thigh (ALT) flap
is now considered the workhorse for head and neck
reconstruction in many centers due to its numerous
advantages.2–4 It is also a good option for pelvic, chest
wall, and extremity reconstruction.5–7 The ALT flap has
many advantages, including a reliably long and good-
caliber vascular pedicle; the possibility of combination
with cutaneous sensation; minimal donor site morbidity;
an inconspicuous donor site that can be closed primarily
in most cases; the possibility of being harvested as
fasciocutaneous or musclocutaneous flap; and, impor-
tantly, the opportunity of being harvested simultaneously
at the same time of tumor ablation. However, the ALT
flap has been traditionally criticized for its variations of
perforator anatomy, making flap dissection difficult.
Early reports with small series seem to show confusing

1
Division of Plastic Surgery, Beth Israel Deaconess Medical Center,
Harvard Medical School, Boston, Massachusetts; 2Department of
Plastic Surgery, The University of Texas M. D. Anderson Cancer
Center, Houston, Texas.
Address for correspondence and reprint requests: Peirong Yu,
M.D., Department of Plastic Surgery, The University of Texas M. D.
Anderson Cancer Center, 1515 Holcombe Blvd, #443, Houston,
TX 77030 (e-mail: peirongyu@mdanderson.org).
J Reconstr Microsurg 2010;26:67–72. Copyright # 2009 by Thieme
Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001,
USA. Tel: +1(212) 584-4662.
Received: January 27, 2009. Accepted after revision: May 26, 2009.
Published online: August 11, 2009.
DOI: http://dx.doi.org/10.1055/s-0029-1234023.
ISSN 0743-684X.
67
68 JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 26, NUMBER 1
perforator anatomy and did not provide a consistent and
easy method for flap design and dissection, thus making it
difficult for younger surgeons to follow.8–10
This article describes the senior author’s simpli-
fied technique in flap design and dissection without the
use of preoperative imaging or vascular studies.
MATERIAL AND METHODS
Between August 2001 and November 2008, the ALT
flap was attempted in 250 patients by the senior author.
There were no perforators in 12 thighs (4.8%). An
anteromedial thigh (AMT) flap was successfully raised
in the ipsilateral thigh in two patients. The contralateral
thigh was explored in the other 10 patients, and an ALT
flap was successfully raised in six patients. In the remain-
ing four patients, there were no ALT perforators on the
contralateral thigh either (1.6%), and a different flap was
chosen. Therefore, a total of 244 ALT free flaps were
raised successfully. There were 61 female and 183 male
patients. Patients’ age ranged from 7 to 91 (59
13)
years old with a body mass index (BMI) from 13.7 to
37.9 (24.7
4.5). The majority of the ALT flaps were
used for head and neck reconstruction (Table 1).
Preoperative Doppler Examination
and Intraoperative Findings
Preoperative Doppler examination was performed in
the first 120 ALT flaps as described previously.11 Two
types of Doppler devices were used. The Huntleigh
Mini Dopplex D-900 unit with an 8-MHz probe
(Huntleigh Diagnostics Ltd., Cardiff, UK) was used
in the clinic during consultation. Just before the in-
cision was made, Doppler examination was repeated in
the operating room with the use of a Koven ES-100X
MiniDoppler unit with a 10-MHz probe, which can be
sterilized (Koven Technology, Inc., St. Louis, MO).
During Doppler examination, the patient was placed in a
supine position with the leg straight in a neutral position
(without eversion). A line was drawn connecting the
Table 1 Clinical Applications of the Anterolateral Thigh
Flap
Clinical Applications Number of Flaps
Pharyngoesophageal 89
Craniofacial 54
Floor of mouth and tongue 45
Posterior mandible and oropharynx 25
Double free flap with a fibula 17
Other head neck soft tissue 5
Scalp 2
Trachea 1
Trunk and extremity 6
Total 244
2010
anterior superior iliac spine (ASIS) and the superolateral
corner of the patella (AP line). The midpoint of the AP
line was marked. Doppler examination was performed
within a 3-cm radius around the midpoint to identify
perforator B.12 Once a signal was obtained, perforators A
and C were examined in a 3-cm radius 5 cm proximal and
5 cm distal to the perforator B signal or the midpoint of
the AP line if no signals were obtainable for perforator B.
The locations of the Doppler signals with each
device for the three perforators, if present, were mapped
for each patient. The distances between the Doppler
signals and the AP line were plotted on the x-axis
(horizontal), and the distances between the Doppler
signals and the ASIS were plotted on the y-axis
(Fig. 1). The ALT flaps were designed based on the
locations of the Doppler signals. During flap elevation,
the exact locations of the cutaneous perforators entering
the fascia were marked on the skin surface and then
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plotted on the x- and y-axes as described above. The
discrepancies (distances) between the Doppler signals
and the actual perforator locations were measured. The
perforator sizes were grouped as large (greater than
1 mm), medium (0.5 to 1.0 mm), and small (less than
0.5 mm) based on the larger perforator vein.
Intraoperative mapping of the perforators as de-
scribed above revealed that the perforators followed a
consistent pattern with perforator B near the midpoint
1.4 cm lateral to the AP line, and perforators A and C
were located 5 cm proximal and distal to perforator B,
respectively (the ABC system).11,13 In the next 124 ALT
flaps, preoperative Doppler examination was not used.
Flap design was solely based on the ABC system. Intra-
operative findings of the perforators were recorded as
described above.
Surgical Technique
Following flap design, flap elevation was performed
simultaneously with tumor resection. Only the anterior
(medial) incision 15 cm long is made initially. Sub-
fascial dissection, which is preferred by the authors as the
fascia can be useful during reconstruction, proceeds
laterally until the cutaneous perforator is identified,
then the intermuscular space is entered following the
perforator to the origin of the descending branch of the
lateral circumflex femoris artery. Various amounts of
vastus lateralis muscle around the cutaneous perforators
can be harvested when muscle is needed. With both the
perforators and the pedicle in view, the perforators are
freed either through intramuscular dissection or taking a
cuff of muscle. The ALT flap should not be isolated until
dissecting out the perforators. Most of the flap dissection
can be completed through the anterior incision. The
lateral incision can be adjusted according to the actual
perforator locations and final defect size. In cases where
no suitable cutaneous perforators can be identified, the
 DESIGNING THE ALT THIGH FLAP WITHOUT PREOPERATIVE IMAGING/LIN ET AL 69

length) on perforator locations, relative distance on the

y-axis (points) was also calculated (distance from the
ASIS divided by the length of the AP line). The length
of the AP line was 46
3 cm. The number of perforators
in each flap is shown in Table 3. A branch of the motor
nerve to the vastus lateralis muscle was divided (and
repaired immediately) to free the perforators in 24% of
patients. Mean flap width was 8.5
3 cm and primary
closure of the donor site was possible in 86% of patients.
Donor site complications included 10% seroma, 3%
hematoma, and 1% dehiscence.

Doppler Findings
The Huntleigh unit was overly sensitive, giving a sensi-
tivity of 100%, a specificity of 0%, and a positive
predictive value of 89%. The Koven unit had a sensitivity
of 91% and a specificity of 55%, with a positive predictive

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value of 94% and a negative predictive value of 43%. The
location of the Doppler signal detected by the Huntleigh
device was within 1 cm of the actual cutaneous perforator
location in 43%, 74%, and 71% of the flaps for perfo-
rators A, B, and C, respectively. The Doppler signal
detected by the Koven unit was within 1 cm of the actual
cutaneous perforator location in 80%, 70%, and 87% of
the flaps for perforators A, B, and C, respectively. The
accuracy of Doppler examinations decreased with
increasing BMI.

Flap Design without Doppler Examination

Figure 1 The locations of preoperative Doppler signals and
actual perforators were plotted on the x- and y-axes.
All 124 ALT flaps designed without preoperative
Doppler examination were raised uneventfully. The
cutaneous perforators were identified in the predictable
AMT perforators are explored through the same inci- locations in all patients based on the ABC system.
sion, or the contralateral thigh is explored.

RESULTS
Intraoperative Findings
The perforator locations are summarized in Table 2 and
Fig. 2. To eliminate the effect of patient height (thigh
DISCUSSION
Most traditional flaps can be designed and raised
according to anatomic landmarks. Perforator flaps,
however, require more precise localization of the
cutaneous perforators, which is the most crucial point
in the success of perforator flap elevation. Many

Table 2 Perforator Locations and Characteristics

Perforators
A B C

Presence (%) 53 87 59
Septocutaneous (%) 46 19 12
y-axis (cm) 18.4
2.2 (point 0.4) 23.5
2.0 (point 0.5) 28.6
2.3 (point 0.6)
x-axis (cm) 1.4
0.6 1.4
0.7 1.5
0.6
Size: small (%) 18 17 72
Size: medium (%) 27 37 19
Size: large (%) 55 46 9
70 JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 26, NUMBER 1
Figure 2 Overall distribution of all cutaneous perforators from 244 anterolateral thigh flaps. The perforator locations seem to
follow a consistent pattern with perforator B near the midpoint (point 0.5) of the line connecting the anterior-superior iliac spine
and the superolateral corner of the patella (AP line), perforator A near point 0.4, and perforator C near point 0.6.
imaging modalities have been introduced. Giunta
et al studied the value of preoperative Doppler sonog-
raphy in planning perforator flaps. In their series of 32
DIEP flaps and eight superior gluteal artery perforator
flaps, a preoperatively marked vessel was used in 37 of
40 patients. In the remaining three patients, a vessel
was used that had not been preoperatively marked.
The authors concluded that preoperative Doppler
sonography is a useful tool in locating the position
of individual perforators.14 Smit et al found that
preoperative computed tomographic (CT) angiogra-
phy performed for patients having DIEP flaps aided in
visualization of perforators more accurately, helped in
reducing surgical time, and may have decreased the
number of postoperative complications.15 Rozen et al
compared preoperative CT angiography and Doppler
ultrasound in patients undergoing DIEP flap surgery
for breast reconstruction. The authors state that CT
angiography was highly specific (100%) and more
sensitive in mapping and visualizing perforators; CT
angiography was superior to Doppler ultrasound in
identifying the course, branching pattern, and perfo-
rators of deep inferior epigastric artery. In addition,
CT angiography purportedly removed the interob-
server error associated with Doppler ultrasono-
graphy.16 Rozen et al in another study demonstrated
that CT angiography and CT-guided stereotaxy were
useful adjuncts to Doppler ultrasound in detecting
Table 3 Presence of Perforators
Single: 26% Double: 49% Triple: 25%
A B C AþB BþC AþC ABC
3% 20% 3% 18% 24% 7% 25%
2010
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size, location, and course of perforators prior to ALT
flaps.17 Tsukino et al found that acoustic Doppler
examination was unreliable in identifying the perfo-
rators during planning ALT flap, whereas color
Doppler examination was significantly more accurate
and provided three-dimensional anatomic information
around the perforators that were useful in flap eleva-
tion.18 Hallock demonstrated color duplex imaging
during preoperative planning to have the capability
to localize perforators to permit the identification of
additional characteristics, including caliber, course,
and flow velocity. Nevertheless, with the current state
of technology, a simple handheld Doppler unit re-
mains a more rapid and convenient way for perforator
localization and is popular among most surgeons as the
other advanced techniques are expensive and time-
consuming and may not be readily available.19
Although handheld Doppler units can be sensi-
tive and reasonably accurate in thin patients, the
accuracy decreases with increasing BMI. We have
shown that the thickness of the ALT flap in our
patient population is twice as that reported in the
Japanese population.13 This may explain why surgeons
in Asia generally note greater accuracy of handheld
Doppler devices than their Western counterparts. The
main perforator branches out once it enters fascia and
subcutaneous tissue. These branches may take an
oblique course reaching the subdermal plexus. Because
of the flap thickness, Doppler device may not detect
the main perforator as it does in thin flaps, which may
explain the discrepancy of the locations of the Doppler
signal and actual perforators. Therefore, preoperative
handheld Doppler examination should be used
with caution in flap design in patients with a high
BMI.11
 DESIGNING THE ALT THIGH FLAP WITHOUT PREOPERATIVE IMAGING/LIN ET AL
On the other hand, the ABC system was de-
veloped based on intraoperative findings of the actual
perforators. Our experience seems to suggest that the
ABC system is reliable and can guide flap design
without the need for Doppler examination or other
imaging study. The variation of perforator location on
the y-axis is less problematic (Fig. 1) because a long
longitudinal incision will be needed regardless to
dissect out the main vascular pedicle. The variations
on the x-axis are, however, crucial as inaccurate local-
ization may put the actual perforators at the edge or
outside the flap design. Our study showed that the
perforators were located, on average, 1.4 cm lateral to
the AP line with a standard deviation of 0.7 cm.
Therefore, centering the flap width on the x-axis
1.4 cm lateral to the AP line will ensure capture of
the perforators as demonstrated in our 124 flaps with-
out Doppler examination. Because the AP line is the
key landmark, it is extremely important to draw an
accurate AP line. Perhaps the most important step is
to position the leg in a neutral position (with the
patella facing straight up) without external rotation,
which is the natural tendency when the patient is
under general anesthesia. Wrapping both feet with
towels and then clipping the towels together after
correct positioning may prevent such rotation.
Once the leg is correctly positioned and an
accurate AP line is drawn, the perforator B is marked
at the presumed location near (slightly distal to) the
midpoint of and 1.4 cm lateral to the AP line. Perfo-
rators A and C are marked 5 cm proximal and distal to
perforator B, respectively, in an average adult. Flap
design is centered on perforator B. Only the anterior
(medial) incision is made first until all perforators are
dissected out. The lateral incision may be adjusted
according to the actual perforator locations and final
defect size.
For younger surgeons, preoperative Doppler
examination may make the surgeons feel more com-
fortable, although it may give a false sense of security.
Our advice is simply to use the Doppler device with
caution and combine the Doppler examination with
the ABC system. Positive Doppler signals do not
necessarily guarantee the presence of perforators, and
likewise one should not be discouraged by the absence
of Doppler signals. Because the number of perforators
is few, the value of imaging studies in preoperatively
selecting the straightest course and largest-caliber
perforators as in DIEP flaps is low in ALT flap
harvesting.
CONCLUSIONS
Many advanced radiological devices are being inves-
tigated for their possible role in preoperative design of
the ALT flap. Despite their presumed accuracy, logistic
71
difficulties and additional costs still keep the handheld
Doppler ultrasound more commonly used in preoper-
ative flap design, despite being less accurate. Never-
theless, the ALT flap can be easily designed and
successfully raised using the ABC system without
preoperative Doppler examination. Whether using
Doppler or not, correct leg positioning and drawing
an accurate AP line are the key steps in precisely
locating the perforators.
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