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A new phalloplasty technique: the free anterolateral thigh flap phalloplasty
Journal of Plastic, Reconstructive & Aesthetic Surgery (2006) 59, 153–157
A new phalloplasty technique: the free anterolateral thigh flap phalloplasty N. Felici*, A. Felici Department of Plastic and Reconstructive Surgery, Azienda Ospedaliera ‘S. Camillo-Forlanini’, Via Portuense, 332-00149 Rome, Italy Received 3 June 2004; accepted 17 May 2005
KEYWORDS Phalloplasty; Free flap; Anterolateral thigh flap
Summary After a 10-year experience with phalloplasty in female to male gender reassignment surgery and with more than one hundred cases treated, we have introduced a new technique for creation of the neo-phallus. Between 1993 and 2002, phalloplasties were performed in our department using the free radial forearm flap or the pre-expanded suprapubic flap (modified Pryor technique). The study of long-term results and complications of these cases, as well as patient requests for a new donor site, induced us to look for an alternative flap for phalloplasty. The versatility and the low donor site morbidity of anterolateral thigh flap persuaded us to use it for phalloplasty. Since March 2003, six phalloplasties with free anterolateral thigh (ALT) flap have been performed. The results have been encouraging. The shape and the consistency of the neo-phallus are suitable, the flap can be sensate and an erectile prosthesis can easily be implanted. Penile urethral reconstruction is possible in the same operative stage. Patient satisfaction is high. The anatomy and harvesting techniques of ALT flap have already been exhaustively described by several authors and only the operative technique of phalloplasty with free ALT flap, donor site management, preliminary results and complications are reported in this paper. q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved.
A variety of flaps are available for gender reassignment surgery in female to male gender dysphoria patients. The first choice in most centres is the free
* Corresponding author. Address: Via D. Cerquetti, 34-00152 Roma, Italy. Tel.: C39 335 8428539; fax: C39 6 58704387. E-mail addresses: [email protected] (N. Felici), [email protected] (N. Felici).
radial forearm flap1–3 and also in our department it was used until 1998 (in 32 cases). Surgeons who perform phalloplasty in transsexuals must always keep in mind the particular psychological implications and patient demands when making the flap choice. Most of our female to male patients showed a very low acceptance of the forearm donor site scar because they consider it a ‘brand’ of being transsexual and they cannot hide
S0007-1226/$ - see front matter q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2005.05.016
154
N. Felici, A. Felici a flap with the following qualities: safe, sensate, hairless, with a long pedicle and large amount of soft tissues, which can be harvested in a single procedure and with a low donor site morbidity. The ALT flap has almost all these advantages.5–10 Further indications for using this flap for phalloplasty are the presence of suprapubic scars for previous pubic surgery and positive Allen test on forearm that are absolute contra-indications, respectively, for suprapubic and radial forearm flap phalloplasty. Since March 2003, we started using ALT flap for phalloplasty in selected cases.
Figure 1
Pre-operative marks.
it when wearing clothes typical of spring and summer. For this reason, in 1998 we began using the pre-expanded suprapubic flap for phalloplasties as first-choice flap (modified Pryor technique)4: a two-stage procedure. In the first intervention, two abdominal skin expanders are inserted and after 3 months phalloplasty is performed in a second intervention. The pre-expansion allows direct closure of the donor site. The continuous search for the ideal phalloplasty flap induced us to look for
Materials and methods Seven patients (six free ALT flaps) have been included in this study. Follow up ranges from 2 to 14 months (mean: 5 months). All patients were female to male transsexuals and their age at time of surgery ranged from 27 to 33. Five of them were heavy smokers (more than 20 cigarettes/day). Three of them presented a Pfannestiel suprapubic scar due to previous caesarean delivery (one case) and for previous hystero-oophorecomy (two cases). In one case the flap was not elevated because perforator vessels were not suitable. Only two patients requested urethroplasty.
Phalloplasty planning
Figure 2 (A) Flap is harvested with perforator pedicle in eccentric position. (B) Tubulisation of ALT flap.
Before surgery, perforators are located with an 8 MHz Doppler probe and marked on the skin. A line corresponding to the intermuscular septum between rectus femoris and vastus lateralis muscles is marked. Incision line is marked 3 cm anteriorly to the septum (Fig. 1). A triangular skin flap with a distal 3 cm base is marked on the pubic area with its vertex 4 cm proximally at the midline (Fig. 1). The use of this flap has two aims: the creation of the pubic site for the neo-phallus implant and the possibility of enlarging the proximal third of the neo-phallus, maintaining a good amount of soft tissue. This trick is very helpful in patients with a well-represented thigh subcutaneous fat for whom it is necessary to thin the ALT flap to tube it without creating too much compression on the pedicle. The pubic triangular flap decompresses the neo-phallus base, eliminating the need for flap defatting. The ALT flap has a rectangular shape ranging from 10!12 to 11!14 cm2, but only the medial border is marked before starting dissection and confirming the location of major perforator vessels.
A new phalloplasty technique: the free anterolateral thigh flap phalloplasty
Figure 3 (A) Periclitorideal flap mark. (B) Penile urethral flap elevated. (C) Tubulisation around catheter.
In this way, it is possible to place the skin island as distally as possible to obtain a longer pedicle.
155
divided. Proceeding from the anterior to the lateral side of the thigh, septal or muscular perforators can be seen. The lateral limit of subfascial exploration is the posterior edge of the vastus lateralis muscle. After identifying the major perforator vessel, pedicle dissection starts through the muscle (or septum in the septocutaneous type) to the descending branch of the lateral circumflex femoral artery; other branches to the muscle are ligated and divided. Motor branches of the femoral nerve running parallel or across the vascular pedicle must be carefully separated. At the end of the pedicle dissection, the marking of the skin is completed placing the skin paddle eccentrically with the skin mark of perforator pedicle located on the antero-proximal angle of the flap (Fig. 2(A)) to obtain pedicle maximum length. Skin is incised and flap harvesting is continued suprafascially from lateral to anterior flap edge leaving a small amount of fascia around the perforator pedicle; the lateral cutaneous nerve of the thigh must be included in the flap elevation and dissected and cut about 5 cm proximally to the superior edge of the flap to preserve an adequate length for neurorraphy. The flap can be thinned if the thickness of subdermal fat does not permit a safe tubulisation: compression of the pedicle must be avoided when lateral and anterior edges of the flap are sutured. If urethral reconstruction is not required by the patient, the flap is rolled on itself, sutured and tubulised before removing it from the thigh (Fig. 2(B)). The first choice recipient vessels are the femoral artery (termino-lateral microanastomosis) and the branches of the long saphenous vein at the femoral triangle on the donor site controlateral limb. If a suprapubic scar is present (from previous surgery or concomitant hystero-oophorectomy), deep inferior epigastric vessels are used. Flap reinnervation is performed to the ileo-pubic nerve. Elevation of the triangular pubic skin flap and recipient nerve and vessels dissection can be performed simultaneously by a second team. Donor site is covered with a skin graft. Glans-plasty is performed 2 months after first intervention.
Flap elevation Urethroplasty The flap is raised with the patient in standard supine position. Usually the choice of the donor limb is made according to the patient’s preference. If he has no preference, the nondominant limb is used. Flap dissection is started subfascially for easier and safer identification of the perforator vessels. Usually the first perforator encountered comes from the rectus femoris and it is ligated and
Urethroplasty is performed using a long periclitorideal hairless cutaneous flap. The base of the flap is located immediately above the clitoris and a very long and very thin flap (2!14 cm2) is dissected in the space between the clitoris and labia minora. It is rolled around a 18 Ch catheter and transposed upward to be included within the ALT flap
156
N. Felici, A. Felici implantation of the erectile prothesis, when the neo-phallus and neo-urethra stability is defined and the flap shows a suitable sensitive reinnervation.
Results In our series all the flaps (six cases) were harvested with a single perforator pedicle; in one case septocutaneous pedicle was found. The flap dimensions in different patients ranged from 10!12 to 11!14 cm2. In all six cases, the flap was raised without fascia. Only in two cases a partial defatting of the flap was performed. In one case the thigh lateral cutaneous nerve was not found. In the seventh patient, the flap was not elevated because perforator vessels were not suitable; in this case, the only suitable perforator vessel was found coming from the rectus femoris, and only two inadequate perforators from vastus lateralis—which were considered too small to support a 10!12 cm2 flap—were found. In this case, phalloplasty was performed using suprapubic flap. None of the patients had intra-operative complications. No flap losses and no partial necrosis occurred. No donor site complications occurred. No neo-urethral complications occurred during the first 6 months after surgery in the two patients who requested urethroplasty.
Discussion
Figure 4 (A) 13!11 cm2 flap. (B)–(D) Simulation on same patient of a radial forearm flap with identical dimensions: almost the entire forearm surface would have been required.
tubulisation (Fig. 3). The donor site is closed with a direct suture. Dimensions of this flap greatly exceeds the 3:1 length to breadth ratio; however, it is vascularised in the proximal third directly from flap base, while the distal two thirds of neo-urethra are vascularised in the same way as a skin graft from subcutaneous tissue of ALT flap. The female urethra (pars fixa) is anastomosed with the neo-urethra (pars mobile) 6 months to 1 year after surgery, simultaneously with the
In the last 10 years, the ALT flap has become one of the most chosen options for soft tissue reconstruction because of its versatility, its adaptability to many different losses of substance in different regions and for the very low donor site morbidity. The free ALT flap can be used as an alternative to the free radial forearm flap in almost all clinical situations requiring soft tissue reconstruction. It is provided with a suitable vascular pedicle, it is sensate and can be elevated without the sacrifice of a major vascular pedicle. Several flaps have been described for phalloplasty, but free radial forearm flap and suprapubic flap are more frequently used. Low acceptance by patients of a radial forearm donor site scar and presence of suprapubic scars are indications for phalloplasty with free ALT flap. In transsexual female to male patients, the ALT flap is particularly indicated because very often these patients are not very tall and flap sizes obtained with ALT flap can be larger than those obtained with radial forearm flap (Fig. 4).
A new phalloplasty technique: the free anterolateral thigh flap phalloplasty
Figure 5
157
(A) and (B) Thirteen months post-operative control after glans-plasty. (C) Donor site scar.
Many authors argue that the main disadvantage of the ALT flap is the anatomic variability of perforator vessels, but Wei5 demonstrated that this anatomy is relatively consistent: in his very large series (672 cases) the absence of suitable perforator vessels occurred in less than 1% of cases. In conclusion, very low donor site morbidity of the ALT flap (Fig. 5) and the possibility of easily hiding the scar when wearing summer clothes makes this flap a very suitable alternative to the radial forearm flap for phalloplasty in female to male transsexuals.
References 1. Rohrmann D, Jakse G. Urethroplasty in female-to-male transsexuals. Eur Urol 2003;44:611–4. 2. Fang RH, Kao YS, Ma S, Lin JT. Phalloplasty in female-tomale transsexuals using free radial osteocutaneous flap: a series of 22 cases. Br J Plast Surg 1999;52:217–22.
3. Monstrey S, Hoebeke P, Dhont M, De Cuypere G, Rubens R, Moerman M, et al. Surgical therapy in transsexual patients: a multi-disciplinary approach. Acta Chir Belg 2001;101:200–9. 4. Felici A. Tecniche di riassegnazione chirurgica del sesso. Trattato di tecnica chirurgica. vol. XVII/4. Padova: Piccin; 2003. p. 1713–68. 5. Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin CH. Have we found an ideal soft tissue flap? An experience with 672 anterolateral thigh flaps Plast Reconstr Surg 2002;109: 2219–26. 6. Kimura N, Satoh K, Hasumi T, Ostuka T. Clinical application of the free thin anterolateral thigh flap in 31 consecutive cases. Plast Reconstr Surg 2001;108:1198–208. 7. Kimata Y, Uchiyama K, Ebihara S, Sakuraba M, Iida H, Nakatsuka T, et al. Anterolateral thigh flap donor-site complications and morbidity. Plast Reconstr Surg 2000; 106:584–9. 8. Demirkan F, Chen HC, Wei FC, et al. The versatile anterolateral thigh flap: a musculocutaneous flap in disguise in head and neck reconstruction. Br J Plast Surg 2000;53:30–6. 9. Javaid M, Cormack GC. Anterolateral thigh free flap for complex soft tissue hand reconstructions. J Hand Surg [Br] 2003;28B:21–7. 10. Koshima I, Fukuda H, Yamamoto H, Moriguchi T, Soeda S, Ohta S. Free anterolateral thigh flaps for reconstruction of head and neck defects. Plast Reconstr Surg 1993;92:421–8.
A new phalloplasty technique: the free anterolateral thigh flap phalloplasty N. Felici*, A. Felici Department of Plastic and Reconstructive Surgery, Azienda Ospedaliera ‘S. Camillo-Forlanini’, Via Portuense, 332-00149 Rome, Italy Received 3 June 2004; accepted 17 May 2005
KEYWORDS Phalloplasty; Free flap; Anterolateral thigh flap
Summary After a 10-year experience with phalloplasty in female to male gender reassignment surgery and with more than one hundred cases treated, we have introduced a new technique for creation of the neo-phallus. Between 1993 and 2002, phalloplasties were performed in our department using the free radial forearm flap or the pre-expanded suprapubic flap (modified Pryor technique). The study of long-term results and complications of these cases, as well as patient requests for a new donor site, induced us to look for an alternative flap for phalloplasty. The versatility and the low donor site morbidity of anterolateral thigh flap persuaded us to use it for phalloplasty. Since March 2003, six phalloplasties with free anterolateral thigh (ALT) flap have been performed. The results have been encouraging. The shape and the consistency of the neo-phallus are suitable, the flap can be sensate and an erectile prosthesis can easily be implanted. Penile urethral reconstruction is possible in the same operative stage. Patient satisfaction is high. The anatomy and harvesting techniques of ALT flap have already been exhaustively described by several authors and only the operative technique of phalloplasty with free ALT flap, donor site management, preliminary results and complications are reported in this paper. q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved.
A variety of flaps are available for gender reassignment surgery in female to male gender dysphoria patients. The first choice in most centres is the free
* Corresponding author. Address: Via D. Cerquetti, 34-00152 Roma, Italy. Tel.: C39 335 8428539; fax: C39 6 58704387. E-mail addresses: [email protected] (N. Felici), [email protected] (N. Felici).
radial forearm flap1–3 and also in our department it was used until 1998 (in 32 cases). Surgeons who perform phalloplasty in transsexuals must always keep in mind the particular psychological implications and patient demands when making the flap choice. Most of our female to male patients showed a very low acceptance of the forearm donor site scar because they consider it a ‘brand’ of being transsexual and they cannot hide
S0007-1226/$ - see front matter q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2005.05.016
154
N. Felici, A. Felici a flap with the following qualities: safe, sensate, hairless, with a long pedicle and large amount of soft tissues, which can be harvested in a single procedure and with a low donor site morbidity. The ALT flap has almost all these advantages.5–10 Further indications for using this flap for phalloplasty are the presence of suprapubic scars for previous pubic surgery and positive Allen test on forearm that are absolute contra-indications, respectively, for suprapubic and radial forearm flap phalloplasty. Since March 2003, we started using ALT flap for phalloplasty in selected cases.
Figure 1
Pre-operative marks.
it when wearing clothes typical of spring and summer. For this reason, in 1998 we began using the pre-expanded suprapubic flap for phalloplasties as first-choice flap (modified Pryor technique)4: a two-stage procedure. In the first intervention, two abdominal skin expanders are inserted and after 3 months phalloplasty is performed in a second intervention. The pre-expansion allows direct closure of the donor site. The continuous search for the ideal phalloplasty flap induced us to look for
Materials and methods Seven patients (six free ALT flaps) have been included in this study. Follow up ranges from 2 to 14 months (mean: 5 months). All patients were female to male transsexuals and their age at time of surgery ranged from 27 to 33. Five of them were heavy smokers (more than 20 cigarettes/day). Three of them presented a Pfannestiel suprapubic scar due to previous caesarean delivery (one case) and for previous hystero-oophorecomy (two cases). In one case the flap was not elevated because perforator vessels were not suitable. Only two patients requested urethroplasty.
Phalloplasty planning
Figure 2 (A) Flap is harvested with perforator pedicle in eccentric position. (B) Tubulisation of ALT flap.
Before surgery, perforators are located with an 8 MHz Doppler probe and marked on the skin. A line corresponding to the intermuscular septum between rectus femoris and vastus lateralis muscles is marked. Incision line is marked 3 cm anteriorly to the septum (Fig. 1). A triangular skin flap with a distal 3 cm base is marked on the pubic area with its vertex 4 cm proximally at the midline (Fig. 1). The use of this flap has two aims: the creation of the pubic site for the neo-phallus implant and the possibility of enlarging the proximal third of the neo-phallus, maintaining a good amount of soft tissue. This trick is very helpful in patients with a well-represented thigh subcutaneous fat for whom it is necessary to thin the ALT flap to tube it without creating too much compression on the pedicle. The pubic triangular flap decompresses the neo-phallus base, eliminating the need for flap defatting. The ALT flap has a rectangular shape ranging from 10!12 to 11!14 cm2, but only the medial border is marked before starting dissection and confirming the location of major perforator vessels.
A new phalloplasty technique: the free anterolateral thigh flap phalloplasty
Figure 3 (A) Periclitorideal flap mark. (B) Penile urethral flap elevated. (C) Tubulisation around catheter.
In this way, it is possible to place the skin island as distally as possible to obtain a longer pedicle.
155
divided. Proceeding from the anterior to the lateral side of the thigh, septal or muscular perforators can be seen. The lateral limit of subfascial exploration is the posterior edge of the vastus lateralis muscle. After identifying the major perforator vessel, pedicle dissection starts through the muscle (or septum in the septocutaneous type) to the descending branch of the lateral circumflex femoral artery; other branches to the muscle are ligated and divided. Motor branches of the femoral nerve running parallel or across the vascular pedicle must be carefully separated. At the end of the pedicle dissection, the marking of the skin is completed placing the skin paddle eccentrically with the skin mark of perforator pedicle located on the antero-proximal angle of the flap (Fig. 2(A)) to obtain pedicle maximum length. Skin is incised and flap harvesting is continued suprafascially from lateral to anterior flap edge leaving a small amount of fascia around the perforator pedicle; the lateral cutaneous nerve of the thigh must be included in the flap elevation and dissected and cut about 5 cm proximally to the superior edge of the flap to preserve an adequate length for neurorraphy. The flap can be thinned if the thickness of subdermal fat does not permit a safe tubulisation: compression of the pedicle must be avoided when lateral and anterior edges of the flap are sutured. If urethral reconstruction is not required by the patient, the flap is rolled on itself, sutured and tubulised before removing it from the thigh (Fig. 2(B)). The first choice recipient vessels are the femoral artery (termino-lateral microanastomosis) and the branches of the long saphenous vein at the femoral triangle on the donor site controlateral limb. If a suprapubic scar is present (from previous surgery or concomitant hystero-oophorectomy), deep inferior epigastric vessels are used. Flap reinnervation is performed to the ileo-pubic nerve. Elevation of the triangular pubic skin flap and recipient nerve and vessels dissection can be performed simultaneously by a second team. Donor site is covered with a skin graft. Glans-plasty is performed 2 months after first intervention.
Flap elevation Urethroplasty The flap is raised with the patient in standard supine position. Usually the choice of the donor limb is made according to the patient’s preference. If he has no preference, the nondominant limb is used. Flap dissection is started subfascially for easier and safer identification of the perforator vessels. Usually the first perforator encountered comes from the rectus femoris and it is ligated and
Urethroplasty is performed using a long periclitorideal hairless cutaneous flap. The base of the flap is located immediately above the clitoris and a very long and very thin flap (2!14 cm2) is dissected in the space between the clitoris and labia minora. It is rolled around a 18 Ch catheter and transposed upward to be included within the ALT flap
156
N. Felici, A. Felici implantation of the erectile prothesis, when the neo-phallus and neo-urethra stability is defined and the flap shows a suitable sensitive reinnervation.
Results In our series all the flaps (six cases) were harvested with a single perforator pedicle; in one case septocutaneous pedicle was found. The flap dimensions in different patients ranged from 10!12 to 11!14 cm2. In all six cases, the flap was raised without fascia. Only in two cases a partial defatting of the flap was performed. In one case the thigh lateral cutaneous nerve was not found. In the seventh patient, the flap was not elevated because perforator vessels were not suitable; in this case, the only suitable perforator vessel was found coming from the rectus femoris, and only two inadequate perforators from vastus lateralis—which were considered too small to support a 10!12 cm2 flap—were found. In this case, phalloplasty was performed using suprapubic flap. None of the patients had intra-operative complications. No flap losses and no partial necrosis occurred. No donor site complications occurred. No neo-urethral complications occurred during the first 6 months after surgery in the two patients who requested urethroplasty.
Discussion
Figure 4 (A) 13!11 cm2 flap. (B)–(D) Simulation on same patient of a radial forearm flap with identical dimensions: almost the entire forearm surface would have been required.
tubulisation (Fig. 3). The donor site is closed with a direct suture. Dimensions of this flap greatly exceeds the 3:1 length to breadth ratio; however, it is vascularised in the proximal third directly from flap base, while the distal two thirds of neo-urethra are vascularised in the same way as a skin graft from subcutaneous tissue of ALT flap. The female urethra (pars fixa) is anastomosed with the neo-urethra (pars mobile) 6 months to 1 year after surgery, simultaneously with the
In the last 10 years, the ALT flap has become one of the most chosen options for soft tissue reconstruction because of its versatility, its adaptability to many different losses of substance in different regions and for the very low donor site morbidity. The free ALT flap can be used as an alternative to the free radial forearm flap in almost all clinical situations requiring soft tissue reconstruction. It is provided with a suitable vascular pedicle, it is sensate and can be elevated without the sacrifice of a major vascular pedicle. Several flaps have been described for phalloplasty, but free radial forearm flap and suprapubic flap are more frequently used. Low acceptance by patients of a radial forearm donor site scar and presence of suprapubic scars are indications for phalloplasty with free ALT flap. In transsexual female to male patients, the ALT flap is particularly indicated because very often these patients are not very tall and flap sizes obtained with ALT flap can be larger than those obtained with radial forearm flap (Fig. 4).
A new phalloplasty technique: the free anterolateral thigh flap phalloplasty
Figure 5
157
(A) and (B) Thirteen months post-operative control after glans-plasty. (C) Donor site scar.
Many authors argue that the main disadvantage of the ALT flap is the anatomic variability of perforator vessels, but Wei5 demonstrated that this anatomy is relatively consistent: in his very large series (672 cases) the absence of suitable perforator vessels occurred in less than 1% of cases. In conclusion, very low donor site morbidity of the ALT flap (Fig. 5) and the possibility of easily hiding the scar when wearing summer clothes makes this flap a very suitable alternative to the radial forearm flap for phalloplasty in female to male transsexuals.
References 1. Rohrmann D, Jakse G. Urethroplasty in female-to-male transsexuals. Eur Urol 2003;44:611–4. 2. Fang RH, Kao YS, Ma S, Lin JT. Phalloplasty in female-tomale transsexuals using free radial osteocutaneous flap: a series of 22 cases. Br J Plast Surg 1999;52:217–22.
3. Monstrey S, Hoebeke P, Dhont M, De Cuypere G, Rubens R, Moerman M, et al. Surgical therapy in transsexual patients: a multi-disciplinary approach. Acta Chir Belg 2001;101:200–9. 4. Felici A. Tecniche di riassegnazione chirurgica del sesso. Trattato di tecnica chirurgica. vol. XVII/4. Padova: Piccin; 2003. p. 1713–68. 5. Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin CH. Have we found an ideal soft tissue flap? An experience with 672 anterolateral thigh flaps Plast Reconstr Surg 2002;109: 2219–26. 6. Kimura N, Satoh K, Hasumi T, Ostuka T. Clinical application of the free thin anterolateral thigh flap in 31 consecutive cases. Plast Reconstr Surg 2001;108:1198–208. 7. Kimata Y, Uchiyama K, Ebihara S, Sakuraba M, Iida H, Nakatsuka T, et al. Anterolateral thigh flap donor-site complications and morbidity. Plast Reconstr Surg 2000; 106:584–9. 8. Demirkan F, Chen HC, Wei FC, et al. The versatile anterolateral thigh flap: a musculocutaneous flap in disguise in head and neck reconstruction. Br J Plast Surg 2000;53:30–6. 9. Javaid M, Cormack GC. Anterolateral thigh free flap for complex soft tissue hand reconstructions. J Hand Surg [Br] 2003;28B:21–7. 10. Koshima I, Fukuda H, Yamamoto H, Moriguchi T, Soeda S, Ohta S. Free anterolateral thigh flaps for reconstruction of head and neck defects. Plast Reconstr Surg 1993;92:421–8.