Staged Wound Closure of the Anterolateral Thigh Flap Donor Site by Combination of Shoelace Approximation and Negative Pressure Wound Therapy
Article information
Abstract
The anterolateral thigh (ALT) flap serves as a workhorse flap for reconstruction of large extremity defects. However, primary closure of the donor site is often not possible when the flap width exceeds 8–9 cm, and skin grafting is commonly required, resulting in unfavorable scarring and discomfort. Three patients received skin cancer or sarcoma resection surgery which required subsequent resurfacing with an ALT free flap. Instead of directly closing the donor sites, elastic sutures were employed in a zigzag shoelace configuration for gradual approximation of the wound edges. Subsequently, negative pressure wound therapy (NPWT) was applied to manage postoperative edema and stabilize the wounds. Complete donor wound closure was achieved between postoperative days 4 and 10. NPWT was continued in the form of incisional NPWT after definitive closure to stabilize the wound site, reduce edema, and facilitate recovery of skin pliability. Tension-releasing taping was also used together with the wound closure. No complications such as skin edge necrosis were observed. The scars were satisfactory with minimal discomfort. This staged combination of shoelace approximation and NPWT represents a simple, safe, and effective alternative to skin grafting for ALT donor sites that cannot be closed primarily, minimizing morbidity while providing aesthetically favorable outcomes.
Introduction
Since its first description by Song et al. in 1984 [1], the anterolateral thigh (ALT) free flap has become one of the most widely used options for reconstruction of various soft tissue defects. However, when large flaps are harvested, direct closure of the donor site is often not feasible and additional skin grafting is required. This may lead to unfavorable cosmetic outcomes, sensory deficits, and donor site complications. In general, primary closure of the ALT donor site is considered difficult when the flap width exceeds 8–9 cm; however, this threshold may vary depending on individual anatomical factors such as thigh circumference, skin thickness, and tissue elasticity. In addition, previous studies have suggested that direct closure is unlikely when the flap width–to–thigh circumference ratio exceeds 16% [2,3].
To address this issue, several surgical strategies have been proposed. Staged closure using a continuous external tissue expander (CETE) and V-Y advancement techniques have been described to facilitate primary closure [4,5]. Moreover, negative pressure wound therapy (NPWT) has been introduced to reduce edema and exudate at the donor site and to improve scar quality [6]. In addition, the shoelace vessel loop technique, initially developed for fasciotomy wound closure, has since been applied to various conditions, enabling delayed primary closure in selected cases [7-9].
Nevertheless, achieving stable, complication-free, and cosmetically acceptable donor site closure without the use of skin grafts remains a significant challenge for reconstructive surgeons. In this study, we report three cases of staged ALT donor site closure using shoelace elastic sutures combined with NPWT, to highlight the potential clinical value of this combined approach. Written informed consent was obtained from all patients for publication of their clinical information and accompanying images.
Idea
This report included three patients treated at a single institution between 2024 and 2025. All patients underwent ALT free flap reconstruction following resection of skin cancer or soft tissue sarcomas. In every case, the raised flap’s width exceeded 9 cm, and primary closure was deemed infeasible based on excessive wound edge tension and insufficient skin elasticity after maximal manual approximation, requiring skin grafting to cover the donor area.
The ALT flap was raised with caution and completely freed from the surrounding soft tissues (Fig. 1). After partial approximation of the donor site using conventional sutures, elastic vessel loops were applied in a zigzag shoelace configuration across the remaining open wound, allowing gradual tightening with evenly distributed tension. The elastic sutures were anchored to the dermal edges using skin staples placed at approximately 2 cm intervals along both wound margins, ensuring symmetric distribution of tension and avoidance of focal ischemia (Figs. 2, 3A and B). The raw wound surface was covered with a silicone mesh sheet over which a urethane NPWT foam was placed (Fig. 3C and D). An airtight seal was achieved using an adhesive drape dressing in combination with a hydrocolloid dressing (DuoDERM, ConvaTec) over the NPWT foam, and 125 mmHg negative pressure was applied. The NPWT dressings, applied to reduce postoperative edema and stabilize the remaining wound, were changed every 3–4 days under sterile conditions. During each dressing change, the wound was inspected for skin perfusion, edema, and patient discomfort. If adequate tissue compliance was confirmed, the shoelace sutures were incrementally tightened by approximately 1.5–2.0 cm per session to further reduce the wound width [10]. This staged approximation was continued until tension-free approximation of the wound edges became achievable. Definitive direct closure was then performed by removing the elastic sutures and replacing them with permanent sutures. Following definitive closure, reinforced skin tapes were applied to support the wound margins and reduce the risk of wound dehiscence (Steri-Strip, 3M Health Care). NPWT was subsequently maintained in the form of incisional NPWT to stabilize the repair site, reduce edema, and facilitate recovery of skin pliability.
Flap design and elevation in Patient 2. (A) Anterolateral thigh flap design. Note the flap dimension of 10×19 cm. (B) The elevated and isolated flap before pedicle division.
Partial wound closure and vessel loop application in Patient 2. (A) The remaining donor site wound after partial approximation with corner sutures. (B) Shoelace technique application for gradual approximation of the residual wound.
Staged closure technique application in Patient 3. (A) Corner sutures applied. (B) Shoelace configuration application of elastic vessel loops. (C) Protection for the exposed muscle with a silicone mesh sheet. (D) Completion of negative pressure wound therapy application.
All three cases achieved direct closure of the ALT donor site without the need for skin grafting (Figs. 4, 5). Definitive closure was achieved on postoperative days 4, 7, and 10 in Patients 1–3, respectively (Figs. 4, 5), with the earliest closure on day 4. Patient 3 required two separate sessions of gradual wound tightening, allowing complete wound closure on day 10 (Fig. 3). The mean follow-up duration was 12 months (range, 6–18 months). No complications such as skin edge necrosis, tightening pain, or wound dehiscence were observed. Tissue compliance progressively improved during staged tightening and was maintained during post-closure follow-up, with minimal patient-reported discomfort. The resulting linear scars were also favorable when compared to skin graft scars.
Definitive closure results in Patient 2. (A) Wound closure was achieved on postoperative day 7. (B) Stable healed wound after suture removal.
Clinical course of Patient 1. (A) Initiation of shoelace tightening procedure. (B) Completion of wound closure with minimal tension on postoperative day 4.
Discussion
When large ALT flaps are harvested, skin grafting is frequently required for donor site coverage, which can cause functional and cosmetic morbidity. The combined use of shoelace sutures and NPWT, as presented in this report, offers an alternative strategy to avoid skin grafts.
The shoelace technique has been traditionally used to gradually approximate wound edges, thus enabling closure without skin grafting. However, its shortcomings include prolonged treatment duration, increased wound tension due to edema, and patient discomfort from repeated tightening sessions. Modified approaches such as CETE or paper-clip adaptations have been described to address some of these limitations, but they still share certain disadvantages [4,11].
NPWT has been shown to reduce edema, improve tissue perfusion, and maintain a clean and stable wound environment. When applied concurrently with the shoelace technique before definitive closure, NPWT appears to mitigate edema-related tension and facilitate earlier safe closure. Compared with previous studies in which the shoelace technique alone required an average hospital stay of 10 days and definitive closure could be achieved about 9 days postoperatively, our series achieved delayed primary closure within 4–10 days, representing earlier closure than most previously reported shoelace-only protocols [7,10].
Most published studies on NPWT application to ALT donor sites have evaluated closed-incisional NPWT applied after definitive closure, demonstrating reductions in dehiscence and reoperation rates and improved scarring [12-14]. Similarly, in our study, NPWT was applied over the closed incision even after final closure, based on the concept of incisional wound stabilization [2,14]. The current literature on staged shoelace tightening in combination with NPWT for definitive closure remains limited. Although Kim et al. [14] reported a similar combination of NPWT and the shoelace technique for managing various soft tissue defects, their study focused on wound control in heterogeneous and often contaminated wounds. In contrast, our study applies this combined approach to the specific context of ALT free flap donor sites, with the primary aim of achieving planned, skin graft-free primary closure. This strategy enabled delayed primary closure within 4–10 postoperative days, suggesting that pre-closure NPWT may facilitate earlier and more stable skin graft-free closure of the ALT donor site and enhance wound-healing stability at an earlier stage than the conventional closed incisional NPWT-only approach [2].
The small number of cases in this report is an inherent limitation, and further investigations with larger patient cohorts will be necessary to firmly establish the efficacy of this method. In addition, we anticipate that the combined use of the shoelace technique and NPWT could be applied to not only ALT but also various other large free flap donor sites [15].
In conclusion, staged closure of the ALT donor site using shoelace elastic vessel loops combined with NPWT may represent a safe and effective method to achieve direct wound closure without skin grafting. It provides faster wound healing and satisfactory aesthetic outcomes. However, excessive tension may interfere with perfusion and lead to margin necrosis; therefore, careful intraoperative and postoperative monitoring is essential. Furthermore, as patients may experience discomfort during staged tightening, preoperative counseling and informed consent are mandatory.
Notes
No potential conflict of interest relevant to this article was reported.