Optimizing limb salvage in critical mangled extremities: one-step acute repair with bilateral anterolateral thigh perforator flaps

Background/Objectives: Complex distal extremity trauma often involves both extensive soft tissue loss and vascular injury. While the anterolateral thigh (ALT) free flap is a mainstay for limb salvage, large defects may exceed the capacity of a single flap and are associated with higher complication rates. We report a one-stage bilateral ALT free-flap reconstruction strategy designed to provide stable wound coverage and improve functional outcomes. Methods: In six patients with severe distal extremity trauma (affecting upper or lower limbs) treated from 2018 to 2020, one-stage reconstruction was performed using bilateral ALT free flaps. Flaps were inset via tandem or parallel vascular configurations based on recipient vessel status. Functional outcomes were assessed by DASH scores (upper limbs) or LEFS (lower limbs) with 5 years of follow-up. Four patients had postoperative photon-counting CT (PCCT) angiography to assess anastomotic patency. Results: All flaps survived without major complications. By final follow-up, all patients had achieved stable soft-tissue coverage and satisfactory functional recovery. Functional outcome scores improved in every case, and notably the pediatric patient attained normal gait and limb development after reconstruction. The four patients underwent PCCT angiography were confirmed patent anastomoses and robust perfusion. Conclusions: One-stage bilateral ALT free-flap reconstruction is a safe and feasible approach for complex distal extremity trauma. It provides reliable wound coverage and facilitates timely functional recovery while avoiding the morbidity of staged procedures. Long-term outcomes demonstrate sustained flap viability and functional gains, supporting this approach to avoid staged procedures and improve limb salvage.