Lower limb necrosis after use of the anterolateral thigh free flap: is preoperative angiography indicated?

The large and potentially sensate skin territory, the reliability, and the versatility of the anterolateral thigh flap have led to its use for the reconstruction of soft-tissue defects of the head and neck region, extremities, and trunk. Most authors describe the functional disturbances in the donor site as minimal and, to date, no cases of circulatory disturbance of the lower limb as a result of anterolateral thigh flap transplantation have been described. The authors report a patient with partial necrosis of the foot and calf caused by the interruption of the descending branch of the lateral circumflex femoral artery, which acted as a critical collateral for the obstructed superficial femoral artery. Based on their observations of this patient, the authors recommend preoperative angiography of the donor leg in patients in whom palpable popliteal pulsations are lacking. Intraoperatively, the chances of postoperative circulatory disturbance of the lower leg can be decreased by observation of the lower leg circulation after clamping of the flap's pedicle. Immediate arterial reconstruction using a venous graft is to be considered in cases in which the adequacy of circulation is debatable.