CASE REPORT Muscle herniation: A complication at the anterolateral thigh perforator flap donor site J. Odili a,b,*, E. Wilson a, J.S. Chana a,b a Department of Plastic and Reconstructive Surgery, Mount Vernon Hospital, Northwood, Middlesex HA6 2RN, UK b Department of Plastic and Reconstructive Surgery, The Royal Free Hospital, Hampstead, London NW3 2QE, UK Received 7 June 2007 accepted 29 December 2007 KEYWORDS Anterolateral thigh perforator flap Donor site morbidity Muscle hernia Summary The anterolateral perforator flap is becoming the flap of choice for a wide variety of complex defects. It has been known to provide excellent donor site morbidity even in cases where vastus lateralis is included within the flap. We report a case of herniation of the vastus lateralis and rectus femoris muscles through the overlying fascia, following ALT perforator flap harvest. In this case muscle herniation at the donor site required surgical repair. ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. The anterolateral thigh (ALT) flap, which was originally described by Song in 1984, has rapidly become the flap of choice for a wide variety of soft tissue defects.1 A key fac- tor in the decision to use this flap is the excellent donor site. Donor site morbidity has previously been thought to be minimal even when a small amount of vastus lateralis muscle is harvested with the flap.2,3 Few other donor sites in the body offer such an ample and versatile flap for recon- struction. We report on a case of muscle herniation through the fascial defect of the donor site requiring operative repair. Case report A 32-year-old gentleman sustained a Gustillo grade IIIB open fracture to his right tibia and fibula following a road traffic accident. This was stabilised with a calcaneal pin and an external fixation device by orthopaedic surgeons. He was transferred to our unit on day two after the accident for soft tissue management of his wounds. The right leg was debrided and the resulting defect reconstructed with an ALT perforator flap from his left uninjured thigh. The method of harvesting this flap has previously been described.4 The flap was raised with a small cuff of fascia around the perforator. No muscle (vastus lateralis) was harvested with the flap. The ALT flap was anastamosed end-to-side to the posterior tibial artery and vein. The donor site was closed in layers, with 3.0 monocryl used to close the tensor fascia over the underlying vastus lateralis. The dermis was closed * Corresponding author. Address: 75 Windermere Avenue, Finch- ley, London N3 3RD, UK. Tel.: þ44 7968 582646 fax: þ44 20 83499561. E-mail address: everjoyous@aol.com (J. Odili). 1748-6815/$-seefrontmatterª2009BritishAssociationofPlastic,ReconstructiveandAestheticSurgeons.PublishedbyElsevierLtd.Allrightsreserved. doi:10.1016/j.bjps.2007.12.071 Journal of Plastic, Reconstructive & Aesthetic Surgery (2009) 62, 1530e1533

with 3.0 monocryl. The skin was closed with subcuticular 3.0 Prolene. The thigh was then wrapped in a crepe bandage for compression. The patient’s postoperative course was uneventful and the flap healed without compli- cations. The patient developed bony union of his tibia at 15 months. A year postoperatively the patient complained of a ‘bulge’ in his left thigh at the donor site. He had noticed a small bulge developing 6 months after the operation. This coincided with him resuming his exercise regime which involved walking, cycling and lunges. He had a very athletic and muscle-bound physique as a result of his rigorous exercise regime. As he increased his exercise programme the size of the thigh bulge also increased until he felt what he described as the muscle ‘pop’. On examination in the outpatients department he had an obvious muscle hernia- tion of the vastus lateralis, which became more pronounced when he tensed the muscle (Figure 1), and was even visible through his clothing. At surgical exploration an obvious herniation of vastus lateralis and rectus femoris was noted through a defect in the tensor fascia lata which measured 27 16 cm (Figure 2). The fascia itself had become attenuated and was extremely thin and friable. The edges of the fascia were elevated and an attempt was made to partially close the defect proxi- mally and distally with 2-0 PDS. Complete closure of the fascia was not possible due to the large quadriceps muscles (Figure 3). Vastus lateralis and rectus femoris were sutured to each other in a double-breasted fashion to reduce the bulge further. A polyProlene mesh was sutured to the fascia and quilted down with looped 0.0 nylon sutures to further reduce and secure the hernia completely (Figure 4). The overlying tissues were closed with 3.0 monocryl (dermis) and subcuticular 3.0 Prolene. He was kept in hospital for 2 weeks to prevent weight bearing before being allowed to mobilise. He was discharged home with a compression dressing around his thigh. He was seen at 3 months and at 6 months postoperatively without recurrence of the hernia (Figure 5). Discussion Perforator flaps represent the most recent advance in microvascular surgery. The main advantage of perforator flaps is the avoidance of muscle harvest with improved donor site morbidity. In recent years advances in perforator flap surgery have provided familiarity of the technique required for safe dissection, thereby popularising the use of this type of flap for a wide variety of indications.5e10 The ALT perforator flap has been known to provide excellent Figure 1 Preoperative view of left thigh showing bulge at ALT perforator flap donor site. Figure 2 Interoperative view of herniated vastus lateralis and rectus femoris muscles. The forceps are holding the medial edge of the attenuated tensor fascia. Figure 3 The herniated muscles have been partly reduced by partial closure of the tensor fascia. Muscle herniation 1531