Reverse-flow anterolateral thigh flap without antegrade venous reconstruction for knee soft-tissue reconstruction

For soft-tissue defects around the knee area, the pedicled gastrocnemius flap is classically the first choice for reconstruction. However, the gastrocnemius flap is not always sufficient, and it carries certain donor site morbidity. When local lower limb flaps are insufficient or unavailable, free-tissue transfer is considered. Because few recipient vessels are located around the knee, free-tissue reconstruction remains challenging. In addition, the optimal donor site for large soft-tissue defects has not been clearly established. The anterolateral thigh (ALT) flap is easily accessible and has minor donor site morbidity. We evaluated the reverse-flow ALT pedicled flap as a candidate for the reconstruction of large soft-tissue defects around the knee. We performed a retrospective review of charts between 2005 and 2008. A total of four patients underwent reverse-flow ALT flap for reconstructing large soft-tissue defects around the knee. None of the flaps were augmented in venous drainage with a venous supercharge. We reviewed the defect characteristics, flap size, patient factors, and reconstructive outcomes. The soft-tissue defects were successfully reconstructed for all patients intraoperatively. However, venous congestion of varying degrees developed postoperatively in all patients. Two of the patients had partial flap necrosis but were successfully treated with debridement and skin grafting or local flap repair. The reverse-flow ALT flap can be used to reconstruct large soft-tissue defects around the knee successfully. However, venous congestion remains the main cause of flap complication. In such clinical scenarios, we suggest either using a smaller flap or performing venous supercharge to enhance venous return and improve the survival ratio of the flap.