Chimeric anterolateral thigh-vastus lateralis free flap with propeller skin island for functional quadriceps reconstruction

Introduction: Soft-tissue sarcomas arising in the thigh may require total or subtotal compartmentectomy, with subsequent need for functional reconstruction with free functional muscle transfer (FFMT). We present our series, describing a new approach with chimeric propeller antero-lateral thigh-vastus lateralis (ALT-VL) free flap, which allows for independent muscle inset and soft tissue defect resurfacing. Patient and methods: A retrospective review of a prospectively maintained database was performed, analyzing all patients referred to Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy, between 2018 and 2023 for soft-tissue sarcomas of the thigh requiring wide excision and reconstruction with functional ALT-VL. Cases involving a functional chimeric ALT-VL flap with propeller skin island were reported. Results: Eight patients underwent quadriceps reconstruction with functional ALT-VL. All of them underwent neoadjuvant radiation therapy. Patients’ age ranged from 59 to 82 years old (mean 68 years old). Skin defect size ranged from 54.95 cm2 to 324.99 cm2 (mean 204.26 cm2). The mean operation time was 611.5 min. Two of these patients required the chimeric flap harvesting with independent propeller mobilization of the skin island. The recipient vessels used were the descending branch of lateral circumflex femoral artery and venae comitantes. The recipient nerve was the motor branch to vastus lateralis. Minor complications occurred in three patients (one seroma and two cases of marginal skin necrosis with delayed wound healing), with no requirement for additional surgery. One patient developed an infected seroma with wound breakdown, necessitating hospital readmission and revision surgery. One patient experienced local relapse one year after surgery. Conclusion: The free functional chimeric ALT-VL flap with propeller skin island is a valid reconstructive option for complex defects of the anterior compartment of the thigh, especially indicated when functional impairment is associated with wide or transversely-oriented skin defects.