Utilization of a Continuous External Tissue Expansion System to Assist in Primary Closure of a Large Anterolateral Thigh Donor Site Defect

Primary closure of a large anterolateral thigh (ALT) flap donor site defect with the assistance of an external tissue expansion system is presented. The dimensions of this donor site (12？cm × 40？cm) and its percentage of leg circumference (34%) would make this site likely to require skin grafting or further flap coverage based on the results of previously published literature. 1. Introduction The anterolateral thigh (ALT) flap has become a popular choice of reconstructive surgeons when soft tissues are required for a given defect. Although the donor site morbidity is generally thought to be minimal, a significant cosmetic deformity can result, especially when a skin graft is required for closure of larger donor sites [1–3]. Additional reported complications of the utilization of skin grafts at ALT donor sites include the following: lack of durability, pain, contour deformity, and limited maneuverability from adhesions to underlying musculature [1–6]. Although these complications can essentially be negated through primary closure of the donor site, compartment syndrome has been reported as a complication of overly aggressive closure [6]. With regard to potential primary closure of the ALT donor site, several studies have been published to elucidate which defects are likely to necessitate a skin graft for closure. In their experience with 672 ALT flaps, Wei et al. stated that 40% of their donor sites, often those with width greater than 6 to 9？cm, would require a skin graft [7]. Perhaps Boca et al., who found that a flap width greater than 16% of the midthigh circumference was likely to require a skin graft, have determined a superior preoperative indicator [8]. In order to facilitate the closure of the donor site without the need for a skin graft, several techniques have been described. These techniques include additional flaps and internal tissue expansion, the placement of which has been described before, during, and after the time of flap harvest [9, 10]. To the authors knowledge, there have not been any published reports of the utilization of an external tissue expander in the closure of these donor sites. 2. Case Report The patient was a 55-year-old diabetic male who developed necrotizing fasciitis of the left foot and leg. After the infection was eradicated, a large soft tissue deficit was present. This deficit was reconstructed with an ALT flap (design in Figure 1) with a length of 40？cm and a width of 12？cm. The circumference of the thigh at the midpoint of the flap was 35？cm. Figure 1: ALT flap design. Dimensions 12？cm × 40？cm. The tissue