Staged Wound Closure of the Anterolateral Thigh Flap Donor Site by Combination of Shoelace Approximation and Negative Pressure Wound Therapy

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.