Anterolateral Thigh Flap For Reconstruction Research Articles

Surgical Algorithmic Approach to Facilitate Primary Closure of the Anterolateral Thigh Flap Donor Site in Head and Neck Reconstruction.

Use of the anterolateral thigh (ALT) flap has gained popularity in head and neck reconstruction. However, donor sites that cannot achieve primary closure are reported to have poorer functional and aesthetic outcomes. Therefore, we propose an algorithm to facilitate primary closure of the donor site. Since May 2013, when an attempt at donor site direct closure failed, we have used a VY advancement flap or a propeller flap for primary closure of the donor site, using the remnant lateral thigh perforator or nearby medial thigh perforator. Otherwise, a skin graft was used. A total of 91 patients were enrolled in this algorithmic approach. We retrospectively reviewed patients with head and neck cancer who underwent cancer ablation and immediate ALT flap reconstruction since August 2010. The patients were then categorized into a "before" group and an "after" group according to the application time of the algorithm. Their demographics, intraoperative findings, and postoperative outcomes were analyzed. A total of 321 patients (309 men, 12 women) were enrolled, with 230 patients in the before group and 91 patients in the after group, with a mean age of 52.9 years. The mean size of the flap was 130 cm, with a mean width of 8.1 cm. No statistical difference existed between the groups. The donor site was directly closed in 82 patients (35.7%) in the before group. Using the perforator-based flap in 21 patients (23.1%), the donor site was closed primarily in 72 patients (79.1%) in the after group, contributing to a significantly higher donor site closure rate (P < 0.001). The average operative time was 348.7 minutes. The overall flap survival rate was 97.2%, donor-site complication rate was 6.9%, and hospitalization length was 23.5 days. None showed statistical differences between the groups. The proposed algorithm may considerably increase the primary closure rate of the ALT flap donor site.

Modified thin anterolateral thigh flaps for reconstruction of hand and foot defects

Objective To evaluate the clinical efficacy of modified thin anterolateral thigh flaps for reconstruction of hand and foot defects. Methods Between March, 2016 and September, 2017, 17 patients were reconstructed with modified thin anterolateral thigh flap. There were 6 cases for reconstruction of hand, and 3 of them were located in the back dorsal of hand defects. There were 11 cases for reconstruction of ankle and foot, and 5 of them were located in the dorsal of foot. The size of the flap was 5 cm×3 cm-33 cm×10 cm. The traditional perforator flap was elevated just above the deep fascial plane. The debulking procedures could follow before the pedicle was cut off. The modified method was that the flap was elevated from the superficial fascia and the plane between deep and superficial fat without intraoperative debulking procedures. Results Three flaps were eventually survived after secondary exploratory operation caused by the hematoma. Two flaps had partial loss, 1 of which needed secondary skin grafting, and the other flap healed with additional intention. Followed-up period was 3-18(average, 7) months . All flaps showed relatively good contour and the patients were satisfied with clinical outcomes. Conclusion It is a safe and reliable way that perforator flap can be elevated from the superficial fascia and the plane between deep and superficial fat. It can obtain a thin flap immediately and reduce donor-site morbidity without additional defatting and time-consuming. The flap is soft with good contour. This technique is an ideal option for covering defects composed of dorsal of the hand or foot and the head and neck regions. Key words: Anterolateral thigh flap; Perforator flap; Modified method of thin type flap; Microsurgical operation

Free radial forearm flap and anterolateral thigh flap for reconstruction of hemiglossectomy defects: A comparison of quality of life

ObjectivesThe purpose of the retrospective study was to compare the differences of quality of life (QOL) outcomes 2 or more years postoperatively between the free radial forearm flap (FRFF) and anterolateral thigh flap (ALTF) in reconstruction of defects of a hemiglossectomy. MethodsNinety patients who had a lapse ≥2 years since the reconstructive flap surgery were evaluated by the University of Washington quality of life scale (UW-QOL), and Performance Status Scale for Head and Neck (PSS-HN). ResultsPatients in the FRFF group reported statistically and clinically significantly better scores in the recreation, swallowing, chewing and speech domains of the UW-QOL compared with those in the ALTF group (P < .05). Similarly, FRFF provided better results in the understandability of speech and normalcy of diet of the PSS-HN, than the ALTF (P < .05). ConclusionsFRFF had the advantage of oral functions, such as chewing, speech and swallowing, over the ALTF for reconstruction of defect of half of the tongue. These results may provide useful information for surgeons to select a suitable free flap for tongue reconstruction.

Late-onset Anterolateral Thigh Free Flap Failure in Buccal Carcinoma Reconstruction

Objective: To report a case of late-onset anterolateral thigh free flap failure in reconstruction of a defect from excision of buccal carcinoma.&#x0D; Methods:&#x0D; Design: Case Report&#x0D; Setting: Tertiary Government Hospital&#x0D; Participant: One&#x0D; Results: Complete flap failure of the anterolateral thigh free flap used for reconstructing the defect from a buccal cancer excision was documented on the 29th post-operative day.&#x0D; Conclusion: Late-onset flap failure is mainly non-vascular in etiology. However, flap failure is more likely multifactorial. Frequent follow-up after hospital discharge is recommended to monitor flap viability.&#x0D; Keywords: free flap, anterolateral thigh flap, flap failure, microvascular surgery, head and neck reconstruction

The Use of a Honeycomb Technique Combined with Ultrasonic Aspirators and Indocyanine Green Fluorescence Angiography for a Superthin Anterolateral Thigh Flap: A Pilot Study.

Harvesting an optimally thinned anterolateral thigh flaps is a challenge in overweight individuals and in the Western population. The authors describe a novel honeycomb technique to achieve a superthin anterolateral thigh flap in overweight patients. Forty patients with a body mass index greater than 25 kg/m(2) who required a thinned anterolateral thigh flap for reconstruction were assigned randomly to a honeycomb technique group or a microdissection technique group. The honeycomb technique group underwent flap thinning with the Cavitron Ultrasonic Surgical Aspirator, and flap thinning was performed with a conventional microdissection technique in the microdissection technique group. Perfusion of all flaps was measured by indocyanine green fluorescence angiography before and after thinning. Hypoperfusion was defined as 30 percent. The mean body mass index was 28.6 ± 2.0 kg/m(2) and 27.3 ± 1.9 kg/m(2) in the honeycomb group and the microdissection group, respectively. Flap size, perforator, type of dissection, and initial perfusion were comparable between the two groups. However, significantly more patients (nine of 21) experienced final hypoperfusion in the microdissection group than in the honeycomb group (two of 19) (p = 0.034). In addition, blood loss and final flap thickness were significantly lower in the honeycomb group (p < 0.05), and the duration of thinning was comparable between the two groups. No flap necrosis was found in either group. The honeycomb technique in combination with the Cavitron Ultrasonic Surgical Aspirator and indocyanine green angiography was able to remove adipose tissue but protect the integrity of the subcutaneous vascular plexus to reduce potential risk of jeopardizing flap perfusion while obtaining a superthin anterolateral thigh flap in an overweight population. Therapeutic, II.

Combined Use of Liposuction and Arthroscopic Shaving for Delayed Debulking of Free Flaps in Head and Neck Reconstruction.

Bulky appearance after free flap reconstruction in patients with head and neck cancer is common and requires revision to achieve improved final outcomes. Although different delayed debulking methods have been reported, the procedure can be technically difficult in patients with severe scaring after adjuvant radiotherapy. The present study proposes a combined method of liposuction and arthroscopic shaving for delayed contouring of free flaps in head and neck reconstruction. In this study, 12 patients with head and neck cancer who had bulky flaps after cancer ablation surgery and immediate free anterolateral thigh flap reconstruction were included. These patients underwent delayed debulking through the combined arthroscopic shaving and liposuction method at least 3 months after the initial reconstruction or the completion of adjuvant radiotherapy (if required). Age, sex, cancer stages, the presence or absence of adjuvant radiotherapy, the interval between the initial free flap reconstruction and the debulking procedure, complications, and subjective satisfaction ratings were recorded 1 and 6 months after the revision surgery. All patients were men, with an average age of 56.3 years (43-69 years), and 9 (75%) patients underwent adjuvant radiotherapy. Partial flap loss was not observed in the study patients, and subjective satisfaction ratings improved after the debulking procedure. The combined liposuction and arthroscopic shaving method can facilitate the debulking and contouring procedures in patients with head and neck cancer after free flap reconstruction. With appropriate timing, the combined procedure can be simple and safe, even in patients with severe scaring after adjuvant radiotherapy.

Application of digital assisted technology in double skin paddle anterolateral thigh flap reconstructing degloved injury of foot

Objective To assess preliminary clinical efficacy of digital assisted technology in double skin paddle anterolateral thigh flap reconstructing degloved injury of forefoot or midfoot. Methods From March 2013 to December 2015, eight patients with degloved injury of forefoot or midfoot were retrospectively analyzed by case series study. They were seven males and one female, with age range of 18-51 years (mean, 34.5 years). The foot skin defect area ranged from 18 cm×12 cm to 13 cm×10 cm. All patients underwent computed tomography angiography (CTA) in lower extremities preoperatively. The CTA data were entered into Mimics 15.0 software in DICOM format. Based on perforating condition of descending branch of lateral femoral circumflex artery and the size of foot defect, one thigh was chosen for three dimensional reconstruction of anterolateral thigh flap. The flap size ranged from 24 cm×9 cm to 19 cm×7 cm. All reconstructive surgeries were performed secondarily. Patients were all at II stage recovery. The survival of flaps and healing status of flap donor sites were observed in one month after surgery. The number of debulking flaps was recorded. The appearance of flaps, shoe wearing, gait and related complications were recorded. Results The follow-up was 10-21 months (mean, 15.5 months). All flaps survived uneventfully, and all donor sites were sutured directly. Three patients had twice debulking procedures, three patients had one debulking procedure, and two patients had no debulking. At the last visit in follow-up, the color and texture of flaps were good. All patients were able to wear shoes normally, two patients remained mild abnormal gait, and one patient presented superficial ulcer at the medial of the forefoot. Conclusions Double skin paddle anterolateral thigh flap for reconstruction of degloved injury of forefoot or midfoot can prompt wound healing and decrease complications. Digital assisted technology is an excellent supplementary method in double skin paddle anterolateral thigh flap for reconstruction of degloved injury of foot, which makes precise preoperative planning and intraoperative accurate cutting. Key words: Foot injuries; Soft tissue injuries; Surgical flaps; Computer-aided design

Variations in the Anterolateral Thigh Flap's Vascular Anatomy in African Americans.

Variations in anterolateral thigh (ALT) arterial anatomy are well documented. Ethnicity is a known risk factor for vascular variation in several organ systems, but its impact on ALT anatomy has not been studied. Anecdotally, we observed frequent ALT arterial variation in African American (AA) patients. We thus hypothesized that AA patients have higher rates of anomalous branching. A total of 277 computed tomography angiograms (513 lower extremities) captured between May 1, 2013 and May 31, 2015 at a tertiary academic medical center were retrospectively analyzed to determine ALT arterial branching. Patient records were examined to ascertain demographics. Data were analyzed using descriptive statistics and multinomial logistic regression. Males comprised 84.5%. Ethnic distribution was 55.2% AA and 36.5% Caucasian. The descending branch of the lateral circumflex femoral artery (dLCFA) originated from non-LCFA arteries (deep femoral, common femoral, or superficial femoral arteries) in 18.9% of Caucasian versus 9.1% of AA (odds ratio [OR]: 2.28; 95% confidence interval [CI]: 1.33-3.93, p < 0.01). An oblique branch was identified in 41.1% of Caucasian versus 51.9% of AA (OR: 1.56; 95% CI: 1.08-2.24, p = 0.02). Ethnicity was the only driving factor of dLCFA and oblique branch of the LCFA (oLCFA) anatomy (Wald chi-square: 14 and 11, p = 0.03 and 0.02, respectively). Ethnicity significantly affects ALT arterial anatomy. AA are more likely to have classical dLCFA branching with a fourth oLCFA branch. A flap with an unrecognized oLCFA-dominant supply places patients at a higher risk for flap failure and loss. We recommend preoperative imaging before undertaking an ALT flap reconstruction.

Anterolateral thigh flap for reconstruction of defects after en bloc resection of buccal cancer : a retrospective study of 23 cases

This study was aimed to observe the effects of anterolateral thigh flap for reconstruction of tissue defects after en bloc resection of buccal cancer. Twenty-three patients with soft tissue defects after en bloc resection of buccal cancer underwent simultaneous reconstruction with anterolateral thigh flap from May, 2013 to May, 2015 were observed. Anterolateral thigh flaps were designed and harvested in form of single or multiple islands to restore the defect in buccal region after surgery. The appearance and function of both the oral and maxillofacial region and the donor site were recorded and evaluated. All the 23 flaps survived. Only 3 of them experienced vascular crisis within 24 hours after surgery, and recovered gradually after salvage. The success rate was 100%. One to three years of follow-up showed satisfying morphology and function for both the receipt sites and the donor sites. Buccal abscess was observed in 1 patient and recovered after rinsing and drainage. Two patients died of recurrence. Good effects can be achieved using anterolateral thigh flap to reconstruct buccal defects after en bloc resection of cancer, which is suitable for application in clinical practice.

Super-Thin and Suprafascial Anterolateral Thigh Perforator Flaps for Extremity Reconstruction

Background The anterolateral thigh (ALT) flap remains a workhorse for soft tissue reconstruction. However, the traditional ALT flap is often too bulky for resurfacing shallow, distal extremity defects, prohibiting adequate function, or well-fitted orthotics. This study evaluates extremity reconstruction using ALT flaps elevated in the suprafascial or super-thin plane. Methods Retrospective review of ALT free flap reconstruction from October 2014 to July 2016 was performed. Suprafascial and super-thin flaps were those elevated just above the crural fascia and within the superficial scarpal plane, respectively. Adjunct operative procedures, demographics, and complications were recorded. Results A total of 25 patients underwent suprafascial (n = 14) or super-thin (n = 11) ALT flap reconstruction for primarily lower extremity wounds (n = 19), with an average age and body mass index of 53.8 years and 26.3 kg/m2, respectively. Follow-up was 6.3 months. Comorbidities included smoking (n = 7), diabetes (n = 8), peripheral vascular disease (n = 6), and hypertension (n = 8). The presence of hardware (n = 9), trauma (n = 10), and chronic infection (n = 12) were common risk factors. Average flap size was 8.2 × 21.5 cm, with 64% (n = 16) taken on one perforator. Forty-eight percent (n = 12) were end-to-side anastomoses and 62% (n = 13) utilized one venous anastomosis. Mean hospital stay was 7.8 days with a 24% (n = 6) complication rate. There were no partial or complete flap losses. Conclusion The ALT flap, elevated in a suprafascial or super-thin plane, is a safe, effective option for extremity soft tissue reconstruction. The decreased flap volume and bulk provides the improved contour and pliability necessary for appropriate distal extremity function. The potential versatility of super-thin flaps reinforces the importance of continued innovation by reconstructive microsurgeons.

Adipofascial anterolateral thigh flaps for reconstruction of maxillary defects with infratemporal fossa extension

Adipofascial anterolateral thigh flaps for reconstruction of maxillary defects with infratemporal fossa extension

Variation in the origin of lateral circumflex femoral artery

Introduction: The lateral circumflex femoral artery arises from the lateral side of the profundafemoris artery, passes horizontally between the divisions of the femoral nerve and behind the Sartorius and rectus femoris, and divides into ascending, transverse and descen variation in the origin of lateral circumflex femoral artery was observed unilaterally in an old aged female cadaver. In the present study, the lateral circumflex femora branches of lateral circumflex femoral artery are used in making anterolateral thigh flap for reconstruction of defects in face, aorto-popliteal bypass, coronary artery bypass and is frequently visualized by various radiological imaging techniques, anatomical variations of itself as well as its branches have significant clinical importance.

VIDEO: Preoperative CT Angiography for Anterolateral Thigh Flap Reconstructions.

This video article will review the relevant vascular anatomy of the anterolateral thigh flap, describe the CT angiography (CTA) image acquisition, and describe how to report the locations of the perforating arteries along with characteristics that may be important to the surgeon. Our method of performing and reporting CTA for patients scheduled to undergo anterolateral thigh flap reconstruction provides a reproducible method of identifying perforating vessels and communicating their location to surgeons.

Computed Tomography Angiography for the Chimeric Anterolateral Thigh Flap in the Reconstruction of the Upper Extremity.

Background The chimeric anterolateral thigh (ALT) flap has been an ideal option for restoring complex soft tissue defects. However, as the vascular anatomy of the ALT is variable, the positions of its perforators are uncertain, which makes the surgery more challenging. Therefore, our study utilized computed tomographic angiography (CTA) for preoperative perforator mapping. Methods From October 2013 to October 2015, 37 patients suffering upper extremity soft tissue defects underwent CTA before ALT flap reconstruction. Perforators originating from the same source vessel were mapped by CTA, and the donor thigh and preferred perforators were selected accordingly. All preoperative parameters of perforators detected by CTA were checked during operation. Results Thirty-three dual-skin paddles, three tri-skin paddles, and one quad-skin paddles flap were designed and used in this study. Eighty-seven perforators were mapped by CTA preoperatively. Seventy-nine (90.8%) were used; 97.5% of these were musculocutaneous and 2.5% septocutaneous. All perforators used intraoperatively were consistent with preoperative parameters. Post-operatively, 2 patients experienced complications but there was 100% flap survival overall. The donor sites primarily underwent primary closure, apart for 7 cases which underwent skin grafting. There was no donor site morbidity. Conclusion Preoperative mapping by CTA is a useful, fast, and noninvasive method for assessing the source vessels, and can be a significant aid in chimeric ALT flap surgery.

The anterolateral thigh flap for soft tissue reconstruction in patients with tongue squamous cell carcinoma.

BackgroundSurgery remains the first choice of treatment for tongue cancer. Immediate reconstruction should be performed after wide resection of tumour. The aim of this study was to evaluate the anterolateral thigh flap for reconstruction of lingual defects.MethodsWe report 39 consecutive oral tongue squamous cell carcinoma patients who underwent lingual reconstruction with the anterolateral thigh flap between 2009 and 2010.ResultsThe width of the skin island was 4 to 5 cm and the length of the skin island was 6 to 8 cm in 31 patients with T2 tumour, while the width of the skin island was 5.5 to 6 cm and the length of the skin island was 9 to 12 cm in 8 patients with T3/4 tumours. The all flap survival rate was 97.5 % in our series.ConclusionsWe could obtain sufficient flap volume using the anterolateral thigh flap for tongue reconstruction. The single perforator-based anterolateral thigh flap is a good option for soft tissue reconstruction in patients with oral tongue squamous cell carcinoma.

One versus Two Venous Anastomoses in Anterolateral Thigh Flap Reconstruction after Oral Cancer Ablation.

Whether one-vein or two-vein drainage yields better outcomes in anterolateral thigh flap reconstruction after oral cancer ablation is still being debated. Thus, the authors investigated this question. In this retrospective cohort study, the authors reviewed the charts of 321 patients with oral cancer who, between August of 2010 and July of 2014, had undergone ablative surgery and then immediate reconstruction with the anterolateral thigh flap. Patients who underwent simultaneous reconstruction with additional free flaps were excluded. The patients were subgrouped into newly diagnosed (n = 221) and previously treated (n = 100) groups and then subgrouped into one-vein and two-vein groups. Overall, operative time was significantly longer (366.8 ± 112.7 minutes versus 336.3 ± 99.7 minutes; p = 0.009) and hospitalization was significantly shorter (22.0 ± 13.3 days versus 24.5 ± 13.8 days; p = 0.027) in the two-vein group. In the newly diagnosed two-vein group, operative time was also significantly longer (355.5 ± 91.7 minutes versus 319.9 ± 95.9 minutes; p = 0.008), anterolateral thigh flap take-backs for vascular compromise (3.2 percent versus 10.9 percent; p = 0.041) and venous congestion (1.1 percent versus 7.8 percent; p = 0.027) were fewer, and flap survival was greater (100 percent versus 95.3 percent; p = 0.041). Differences between the one-vein and two-vein previously treated subgroups were not significant. In newly diagnosed patients undergoing anterolateral thigh flap reconstruction after oral cancer ablation, better outcomes are achieved with two venous anastomoses rather than one. Therapeutic, III.

Predictors of Failed and Delayed Decannulation after Head and Neck Surgery.

To determine the variables that are predictive of failed decannulation (FD), delayed decannulation (DD), and days to decannulation in patients who underwent head and neck cancer resection with free tissue transfer reconstruction for head and neck squamous cell carcinoma. Case series with chart review. Tertiary care otolaryngology-head and neck surgery referral center. Patients (N = 108) were included who underwent head and neck cancer resection with free tissue transfer reconstruction and tracheostomy between 2011 and June 2014. Patients with laryngectomy, previous tracheostomy, and other airway pathology necessitating tracheotomy were excluded. Preoperative patient variables and cancer site/staging variables were analyzed, as well as extent of structures resected and type of reconstruction. Univariate and multivariate binary logistic and Cox regression analyses were used to determine predictors of FD and DD. Cox regression analysis was used to determine predictors of days to decannulation. Of the 108 included patients, 16 had FD, and 26 had DD. Univariate analysis demonstrated that advanced stage (r = 0.233, P = .021), total glossectomy (r = 0.924, P < .001), anterolateral thigh flap reconstruction (r = 0.906, P < .001), smoking at time of surgery (r = 0.319, P = .002), and pack years (r = 0.322, P = .001) were associated with FD. Cox regression analysis showed that total glossectomy, exp(B) = 15.837 (95% confidence interval [95% CI]: 1.949-128.679); anterolateral thigh flap reconstruction, exp(B) = 8.439 (95% CI: 2.435-29.620); and smoking status, exp(B) = 2.970 (95% CI: 1.617-5.456) were independent predictors of days to decannulation and FD. Patients with total glossectomy defects and those who continue to smoke are at increased risk for FD and DD. Aggressive smoking cessation programs may decrease the risk of FD and DD. Patients should be counseled about their risk profiles.

Selection of ideal perforators and the use of a free-style free flap during dissection of an anterolateral thigh flap for reconstruction in the head and neck

The technique of raising an anterolateral thigh (ALT) perforator flap has been revolutionised by free-style retrograde intramuscular dissection of perforators to overcome anatomical variations, but choosing the appropriate perforator is still the key to success. We have shown this in a 41-year-old man with cancer of the buccal mucosa treated by wide excision and reconstruction with an ALT free flap that failed because of formation of microthrombi within the perforator. We identified only one tiny perforator that followed an 8cm, tortuous course within the vastus lateralis muscle. A long, narrow lumen in the perforator increases resistance proportionally to the length and four times the radius. Difficult dissection of the root makes the vessels prone to spasm. If no sizeable perforator is found, adjacent tissues on the medial or proximal thigh could be raised as alternative free-style flaps.

Use of the anterolateral thigh flap for reconstruction of the pediatric anophthalmic orbit

Children with acquired anophthalmia pose unique reconstructive challenges. With implant-based reconstruction, the current standard of care, there is a tendency toward intraorbital and adnexal tissue contraction and an increasing volume discrepancy with orbital growth, resulting in enophthalmos and eyelid retraction, and also difficulty in retaining an ocular prosthesis. We describe a novel technique for secondary reconstruction of the pediatric anophthalmic orbit using a small free anterolateral thigh (ALT) flap. The technique involves release of retracted eyelids and restoration of orbital volume with an ALT flap based on the superficial temporal vessels. The purpose of this study is to detail the results of treatment of a series of four consecutive patients with unilateral acquired anophthalmia managed with ALT flaps. Improved symmetry, successful retention of an ocular prosthesis, and patient satisfaction were achieved in all cases.

Repeated Elevation of the Anterolateral Thigh Flap for Lower Extremity Orthopedic Trauma Does Not Affect Flap Viability.

The anterolateral thigh (ALT) flap has a key role regarding limb salvage and has facilitated the preservation of function and esthetics in lower extremity reconstruction. The purpose of this study is to review the advantages of the ALT flap when used early in the reconstruction of the trauma patient; specifically, its long-term viability when ALT flap reconstruction is followed by recurrent flap elevation performed to allow a variety of sequential orthopedic operations including washout, antimicrobial disc placement, and reinstrumentation. A retrospective analysis was performed to review all ALT flaps performed by the authors from January 2009 to October 2012 at the Orlando Regional Medical Center. A total of 69 patients with an average age of 38 years were included in the study leading to a total of 69 ALT flaps indicated for traumatic orthopedic wounds. Out of these, 29 flaps were elevated at least once leading to a total of 49 flap elevations. The median number of days to flap elevation was 117 with a minimum of 1 day and a maximum of 540 days. A total of 42% flaps were elevated at least once after initial placement for reinstrumentation, washout, or antibiotic disk placement. Overall, 52% of the flaps were lifted once, 34% were lifted twice, and 14% were lifted more than thrice. There is no statistically significant difference in the complication rate between elevating the flap compared with primary ALT placement. We conclude, therefore, there is no elevated risk to long-term viability by elevating the ALT flap. This combined with the ease of elevation makes it a safe procedure to be performed as needed for access to the deep tissues.