Free Anterolateral Thigh Flap Reconstruction After Excision of Extensive Vascular Malformations in Toddlers: Report of Two Cases

Sep 30, 2026

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Vascular malformations often manifest during childhood and may require multidisciplinary management, yet reports describing pediatric resection followed by free flap reconstruction are uncommon. This open-access case report presents two toddler cases reconstructed using free anterolateral thigh (ALT) flaps. Case 1 involved a submandibular venous malformation with consumptive coagulopathy treated by ALT transfer with multiple anastomoses, achieving complete flap survival and normalized coagulation. Case 2 addressed a painful forearm ulcer from a capillary-lymphatic venous malformation reconstructed with ALT, where partial necrosis required secondary closure but ulcer symptoms resolved without donor-site complications. The authors conclude that meticulous microvascular techniques and multiple anastomoses can reduce microvascular complications in young patients.

LanguageEnglish

CategoryHealthcare

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Introduction

Case Reports

Case 1

Case 2

Microsurgery CASE REPORT OPEN ACCESS Free Anterolateral Thigh Flap Reconstruction After Excision of Extensive Vascular Malformations in Toddlers: Report of Two Cases Kou Fujisawa | Shimpei Miyamoto | Mutsumi Okazaki Department of Plastic and Reconstructive Surgery, The University of Tokyo, Tokyo, Japan Correspondence: Kou Fujisawa ([kofujisawa@gmail.com](kofujisawa@gmail.com)) Received: 14 September 2025 | Revised: 7 November 2025 | Accepted: 2 January 2026 Keywords: anterolateral thigh flap | multiple anastomosis | pediatrics | vascular malformation ABSTRACT Vascular malformations often become symptomatic during childhood and require multidisciplinary intervention. However, reports of resection followed by free flap reconstruction in pediatric patients remain rare. We report two toddler cases of vascular malformations reconstructed with free anterolateral thigh (ALT) flaps. Case 1 was a 2-year-old boy with a submandibular venous malformation complicated by coagulopathy. After lesion resection with overlying skin (5 × 10cm), an ALT flap (5.5 × 12cm) was transferred. The flap artery was interposed with the transected facial artery, and the veins were anastomosed end-to-side to the internal and external jugular veins. The flap survived completely, and coagulation parameters normalized. Case 2 was a 3-year-old boy with a painful forearm ulcer caused by a capillary lymphatic venous malformation. After ulcer debridement (5.5 × 13cm), the defect was reconstructed with an ALT flap (6 × 14cm). The flap vessels were anastomosed to the radial artery and its concomitant veins in a flow-through manner. Partial flap necrosis required secondary wound closure, but the ulcer did not recur, and the pain resolved completely. No anastomotic failure or donor-site complications occurred in either case. Extensive resection followed by ALT flap reconstruction is a reliable option for pediatric vascular malformations. Meticulous microvascular techniques and multiple anastomoses may reduce microvascular complications in young patients. 1 | Introduction Vascular malformations are congenital anomalies of vascular and/or lymphatic structures that arise during embryonic angiogenesis (Cooke-Barber et al. 2020; Gibson and Barnacle 2020; Zhuo et al. 2017) . Although present at birth, the clinical onset varies. These lesions can occur anywhere in the body and may present as cosmetic deformity, pain, bleeding, or functional impairment, leading to significant reductions in quality of life. Treatment options include compression garments, sclerotherapy, and targeted systemic therapies (Lokhorst et al. 2021) . Nevertheless, surgical resection remains an effective treatment for achieving definitive results. Extensive resections, however, often produce large soft tissue defects that require reconstruction. Although free flap transfer provides a versatile method for reconstruction, reports of free flap reconstruction after vascular malformation excision in pediatric patients remain scarce (Upton and Guo 2008; Gharb et al. 2011) . Compared with other free flaps—including the groin, radial forearm, and scapular flaps—the anterolateral thigh (ALT) flap provides a larger skin paddle, results in lower donor-site morbidity, and allows harvest without patient repositioning. These advantages are especially beneficial in small children (Srikanth 2019) . This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. © 2026 The Author(s). Microsurgery published by Wiley Periodicals LLC. Microsurgery, 2026; 46:e70173 1 of 5 [https://doi.org/10.1002/micr.70173](https://doi.org/10.1002/micr.70173) We report two toddler cases with extensive vascular malformations successfully reconstructed using free ALT flaps, highlighting t

FAQs

Why are vascular malformations often challenging during childhood?

They frequently become symptomatic after birth and can cause pain, bleeding, cosmetic deformity, or functional impairment, typically requiring multidisciplinary care.

What reconstructive strategy was used in the two reported toddler cases?

Both defects were reconstructed using free anterolateral thigh (ALT) flaps with microvascular anastomoses, including multiple vessel connections to recipient sites.

What were the key clinical outcomes after ALT flap reconstruction?

Case 1 achieved complete flap survival and remission of coagulopathy, while Case 2 had partial flap necrosis requiring secondary closure but the ulcer did not recur and pain resolved.

Sep 30, 2026

Uploaded by Mimi