Contralateral Pedicled Anterolateral Thigh Flap (ATL) for Upper Thigh Defect in the Era of Free ATL?

DEAR EDITOR The radical surgery for fungating inguinal lymph nodes is commonly done in patients with penile and vulvar cancers, creating complex groin defects. These defects are managed most commonly with either pedicled ipsilateral anterolateral thigh (ATL) flap or tensor fascia lata (TFL) flap. The reconstruction with complex flaps provide durable coverage and prevent scar contractures, which tend to form in the flexural regions such as the groin. The pedicled ATL flap is one of the most commonly used flaps for ipsilateral groin defects. Its blood supply depends on intact femoral vessels. In a scenario where femoral vessels are resected and reconstructed with synthetic graft as part of radical surgery for cancer, either a free or ipsilateral pedicled anterolateral thigh flap is not an option.1,2 We report a case of recurrent synovial sarcoma of thigh with skin and femoral vessel infiltration following prior wide excision and external beam radiotherapy, for which wide excision and femoral vascular reconstruction was done creating a large skin and soft tissue defect in upper thigh and groin area. As options of both ipsilateral pedicled ATL or free ATL could not be exercised, we planned and covered the defect with pedicled anterolateral thigh flap from the opposite thigh. We are reporting this case as the literature describing the use of contralateral pedicled ATL is sparse. A 34-year-old lady who was treated earlier for soft tissue sarcoma of the right upper thigh area with surgery, radiotherapy and chemotherapy presented 2 years later with local recurrence. On local examination, there was a 7x6 cm hard mass present over the medial aspect of the right upper thigh with fixity to the overlying skin. The femoral artery pulsation could not be felt in the area of the mass. There was no clinically significant inguinal lymphadenopathy. The Preoperative MRI revealed vascular involvement. As the patient desired limb preservation a multidisciplinary discussion was held a decision was made to re resect the tumor with femoral vascular reconstruction. Hence a radical excision of the tumor, wide area of involved skin along with the involved segment (15 cm) of femoral artery and vein was done, leaving a large defect (15x10 cm). The vascular reconstruction was done by the vascular surgeon with the PTFE graft (17 cm). The large skin defect needed a flap to cover the vascular graft area. Since no microvascular reconstruction was possible due to lack of vessels for anastomosis in the thigh, a pedicled contralateral ATL was planned (Figure 1). Letter to Editor