Anatomy Overview:

• Workhorse flap in plastic surgery given that it is a highly versatile.  It can provide muscle/skin/fascia, large skin paddle, minimal donor site morbidity 
• Three major thigh compartments – the anterior, posterior, and medial or “adductor” compartment
• Anterior compartment – Sartorius, RF, VL, VI, VM
• Arterial supply is the DLCFA
• CFA branches into SFA and the PF, PF gives off MCFA and then the LCFA. 
• LCFA has 3 branches – ascending, transverse, descending branch
• DLCFA runs between the rectus femoris and vastus lateralis.
• Venous drainage are the vena comitantes that run with the pedicle
• Innervation is the lateral femoral cutaneous nerve
• Lateral superior genicular artery, which is a branch off the popliteal, if the blood supply for a reverse ALT

Topics Covered:

• What are your general thoughts on the ALT? Is this a flap you commonly use in your practice? What do you use it for? 
• What do you think are some of the advantages/disadvantages of this flap? 
• How do you like to do your markings for an ALT? As residents at Duke we know you use the ABC system. Can you walk us through that? 
• Do you use a doppler to identify perforators? Pre op CT? Other imaging?
• What are some operative pearls you can share for raising an ALT? What parts of the case do you think are trickiest and what are some tricks that you have found to make those parts of the case easier? 
• What is your goal in terms of the number of perforators supplying the flap? Will you raise a single perforator flap?
• I have read that occasionally surgeons need to convert to an AMT flap if they cannot locate lateral perforators? Have you ever encountered this? 
• Donor site closure – STSG vs. primary closure, drain/no drain?
• As we know – ALT flaps can be quite thick. How do you address flap thinning? Any primary thinning? Secondary thinning at a later date?
• Any special considerations in head/neck or lower extremity recon? For lower extremity defects, how do you decide whether to use the thigh contralateral vs. ipsilateral to the defect?
• BONUS QUESTION – what inspired you to pursue a career as a microsurgeon and what advice do you have for residents who may be considering a microsurgery fellowship? 

References:

• Flaps and Reconstructive Surgery Second Edition Wei FC, Mardini S, eds.; Elsevier, 2017
• Reconstructive Surgery: Anatomy, Technique, and Clinical Application – Michael Zenn (Author), Glyn Jones (Author)
• Microsurgeon.org