BACKGROUND: Traditional anterolateral thigh flaps transplantation has been widely used in clinics; however, a new generation of perforator free flap transplantation is still in an initial phase at home.OBJECTIVE: To investigate the method, effectiveness and clinical application of anterolateral thigh perforator free flaps transplantation for reconstruction of soft tissue defects of the head and extremeties after tumor resection.DESIGN: Case analysis.SETTING: First Affiliated Hospital of Nanhua University.PARTICIPANTS: A total of 16 patients needing skin flap transplantation were selected from Department of Burns and Plastic Surgery, the First Affiliated Hospital of Nanhua University and Department of Plastic Surgery, General Hospital of Toronto, Toronto University from April 2004 to April of 2006. Soft tissues of all patients could not be directly sutured so as to cause the exposure of tendon, vessel, nerve and sclerotin. There were 13 males and 3 females aged from 26 to 72 years. The anterolateral thigh perforator free flap for reconstruction of the soft tissue defects and/or bone exposure occurred on the head (nine cases, mean age of 50 years) or extremities (seven cases, mean age of 39 years) following tumor resection. All patients provided the informed consent.METHODS: After general anaesthesia with tracheal intubation, a two-team approach was used for resection of the tumor, and harvest of the free flap simultaneously or successively. The tumor was removed by head and neck surgeon or orthopedic surgery. And the plastic surgeons assumed the responsibility for reconstruction of the defects following the tumor resection. The dissection of recipient blood vessels (e.g., superior thyroid artery, facial artery, a branch of internal jugular vein, or external jugular vein, artery and vein of dorsal of foot, anterior tibial artery or vein) was performed. In addition, the ends of sural nerve at recipient sites that need be repaired with the anterolateral thigh cutaneous nerve were utilized in two cases with soft tissue defect on the lateral malleolus. The dimensions of the anterolateral thigh perforator flaps were determined on the basis of the defect size. The perforator flap design: A line was drawn between anterosuperior iliac spine and lateral-superior patella for the longitudinal axis of the flap. The required perforator was sought at the middle point of the longitudinal axis in the anterolateral thigh. In general, there would be one to two major perforating branches were confirmed with an ultrasound Doppler monitoring device in the flap. In this article, the biggest anterolateral thigh perforator flap measured 28 cm×15 cm with two major perforating branches. Incision of the skin and subcutaneous tissue was carried out along the periphery of the flap, and dividing and separating subcutaneous tissue layer from deep fascia layer was performed under surgical loupe magnification little by little carefully and slowly to ensure preserving one to two major perforating branches. Retrograde dissection of the deep fascia and/or muscles and/or intermuscular tissue tracing the major perforating branches until the pedicle blood vessels length and diameter were enough for anastomosis with the blood vessels in the recipient sites. If an innervated flap is required, the lateral cutaneous nerve of the thigh can be harvested with the flap. In this article, two cases used flap innervation. The incision could be primary sutured usually and a suction drain should be put at donor sites. The anastomosis of the blood vessels or nerves with 9-0 or 10-0 nylon sutures was performed under the microscope. Interrupted sutures of the edges between the flap and defect region were made; and a suction drain should be put under the flaps. The sutures on the head would be removed at 9-11 days (but 12-15 days, on the extremities) days after operation. The drainage tube would be pulled out generally at 3 days after operation. Recovery condition was observed after operation. Healing phase was classified into phase Ⅰ(healing on time after operation) and phase Ⅱ (non-healing on time after operation). Meanwhile, whether skin flap was necrosis and wound was broken were observed at the same time.MAIN OUTCOME MEASURES: Survival state of patients after skin flap transplantation; shape and function of donor site and recipient site of skin flap.RESULTS: All 16 patients who needed skin flap transplantation were involved in the final analysis. Of the sixteen cases in this group, fifteen perforator flaps survived completely; one flap underwent partial failure. Primary wound healing was achieved (stage I) in all the donor sites, in14 recipient sites and delayed in two (stage Ⅱ). In one case a small portion (about 2.5 cm) necrosed at the distal end of the flap. After removing the necrotic tissue, the wound healed. In another case with a 3 cm long wound dehiscence in the face, the wound healed through dressing change and resuture. After wound healing, there was no significant scaring, and no effect on the lower limb weight bearing and walking. But, there was a sensory loss on a small piece of skin below the donor site, due to destruction of the anterolateral thigh cutaneous nerve on that area.CONCLUSION: Because of less dornor site morbidity, superior result at the reconstructed sites, use of anterolateral thigh perforator flap free grafting is a very acceptable technique for reconstruction of soft tissue defects on head and extremeties after tumor resection.