"The Safety Check": A simple and reproducible intraoperative test to support surgeons in training during ALT flap harvesting.

Abstract

The anterolateral thigh (ALT) flap is widely used in reconstructive surgery due to its versatility and favorable donor site characteristics. However, its harvest remains technically challenging, primarily due to the anatomical variability of the perforators. Experienced surgeons make intraoperative decisions based on anatomical knowledge, tactile feedback, and visual cues, but these skills may be underdeveloped in surgeons in training, increasing the risk of complications. To address this issue, we present "The Safety Check," a simple and reproducible intraoperative test designed to assist trainees in decision-making during ALT flap harvest. This method is based on the visual assessment of arterial pulsatility along the course of perforators and the pedicle, formalizing a step that is often intuitive for experienced surgeons. The technique was applied in 52 cases over a 6-month period, with perforators monitored in three phases: before dissection, during dissection, and after dissection until flap elevation. Preliminary results showed that "The Safety Check" improved trainee confidence, facilitated the early identification of compromised perforators, and increased surgical efficiency without adding significant time to the procedure. Additionally, the method served as an educational tool, fostering active learning and intraoperative discussions. While no quantitative data were collected, qualitative feedback supported its value as an adjunct to training in perforator flap techniques. Key words:Perforator flap, Microsurgery training, Intraoperative technique, Flap harvesting, Surgical education.