Knee soft-tissue coverage is a challenge. Classically, a pedicled gastrocnemius flap is the first choice for reconstruction. A pedicled gastrocnemius flap is not always sufficient for reconstruction and is associated with substantial donor site morbidity. Anatomically consistent perforators are scarce in the area about the knee, and few reliable recipient vessels are available for free flap reconstruction.

A distally based anterolateral thigh flap is a reliable solution for patients in whom reconstruction is a challenge. A distally based anterolateral thigh flap, which was first described by Zhang in 1990 and optimized by Wei in 2015, is associated with consistent anatomy, a wide arc of motion, limited donor-site morbidity, and straightforward dissection. Venous congestion is the complication most frequently associated with a distally based anterolateral thigh flap. Several studies attribute this problem to slow venous flow after reversing the flow in the pedicle. In our opinion, this problem is caused by the presence of valves in the deep veins, draining the flap. When reversing the blood flow, competent valves cause venous congestion and thrombosis. This can be easily solved by adding venous supercharge to the flap.

This video discusses the use of a distally based anterolateral thigh flap for knee coverage. The video demonstrates several technical points during flap reconstruction. The first pearl for a successful distally based anterolateral thigh flap is to identify the dominant perforator and the pivot point of the flap via preoperative ultrasonography. The video demonstrates how to raise the flap, perform set-in at the knee, and seal the knee articulation with vascularized fascia lata. The video then discusses how venous congestion occurs at the level of the deep veins. This is easily managed by adding venous supercharge to the flap. In the patient shown in this video, one of the comitant veins of the pedicle is bypassed with the use of a contralateral saphenous vein graft.