Anterolateral Thigh Flap: Anatomical Study of the ...



Title: Anterolateral Thigh Flap: Anatomical Study of the Brazilian Population and Clinical Application

Authors: Luis H. Ishida, MD; Luis C. Ishida, MD; Hugo A. Nakamoto, MD; Fábio L. Saito, MD; Gustavo P. Sturtz, MD; Leandro Rodrigues, MD; Júlio M. Besteiro, PhD; Marcus C. Ferreira, PhD

Introduction

Anatomic studies of cutaneous vascularization were first performed by Manchot and Spalteholz, in XIX century. More recently, the angiossome concept described by Taylor encouraged plastic surgeons to return to the dissection room. New flap types and classifications were developed.

The anterolateral thigh flap was first described by Song, in 1984, as a fasciocutaneous flap. Since the development of the perforator flaps by Kroll in 1988 and Koshima in 1989, many studies have been made, concluding that the majority of the anterolateral flaps did not have a septocutaneous pedicle. These flaps were nourished by muscle perforating vessels from lateral circumflex artery descent branch.

The antero-lateral thigh flap represents a good option in reconstructive surgery. Particularly in head and neck reconstruction, it offers a reliable covering, thin enough for good contour, malleable to fulfill tridimensional defects, with minimal donor-site morbidity, feasible and reproductible.

The aim of this paper is to study Brazilian population anatomy of anterolateral tight flaps and to report our experience in clinical practice.

Method

Anatomical Study

Fifty-eight antero-lateral tight flaps were dissected in 29 fresh cadavers.

Flaps were demarked in a 25 cm area centered in the middle point between superior anterior iliac spine and lateral face of patela (figure x).

The lengh and external diameter of the pedicle vessels, thickness of the flap (dermis and subcutaneous tissue) and intamuscular path lengh (if present) were assessed and measured with an electronic pachometer.

Clinical Series

From December 2000 to January 2002, 29 flaps were used in the clinical series for head and neck reconstructive surgery (70% for cutaneous and 30% for aesophagus reconstruction) in the Hospital das Clínicas da Faculdade de Medicina da USP.

Figure 1- Flap localization

Results

The majority of vessels were distributed around the middle point between the superior iliac spine and the patella’s lateral edge (graphic 2). Pedicles presented good length in all dissections with a mean size of 13,48 cm and an average intramuscular path of 4,46 cm (graphic 3). The majority of the perforators came from the vastus lateralis muscle (72%), while only 16% of the perforators had a septal course (graphic 4). The mean artery diameter was 2,55 mm and mean vein diameter was 3,47 mm.

In the clinical series the same parameters of the anatomic study were observed. There was 1 (one) complete failure (3 %) due to kinking of the pedicle and no partial loss was observed. The largest flap’s dimension was 40 x15 cm and was based in 2 perforators. Faps as wide as 10 cm could be used with primary closure of the donor area.

|  |Age |BMI (kg/m2) |  |Sex |Race |

|Mean |64,17647 |20,9405 |  |Male 60% |Black 44% |

|SD |15,35138 |3,672608 |  |Female 40% |Caucasian 56% |

Table 1- Data from dissected cadavers.

[pic] [pic]

Graphic 1- Number of perforators found per flap. Graphic 2- Distribution of the perforator vessels around the middle point between the superior iliac spine and the patella's lateral edge.

[pic] Graphic 3- Total and intramuscular length of the pedicles in centimeters.

[pic]

Graphic 4- Origin of the perforators.

Conclusion

Our anatomical study showed a similar anatomy of the brazilian population when compared with the asian population described in previous studies.

Although there is a quite variable distribution of the perforators, we believe that the anterolateral thigh flap is reliable and has minor donor area deficit.

Despite perforator vessels were founded in all dissected cases, it is recomended the use of Doppler in preoperatory programation due to the absence of perforator pedicles in 4% of the cases as reported previously.

References

1. Koshima I, Hosoda M, Moriguchi T , et al. New multilobe "accordion" flaps for three-dimensional reconstruction of wide, full-thickness defects in the oral floor. Ann Plast Surg;45:187-921;2000.

2. Shieh SJ, Chiu HY, Yu JC , et al. Free anterolateral thigh flap for reconstruction of head and neck defects following cancer ablation. Plast Reconstr Surg;105:2349;2000.

3. Zhou G, Qiao Q, Chen GY , et al. Clinical experience and surgical anatomy of 32 free anterolateral thigh flap transplantations. Br J Plast Surg;44:91;1991.

4. Koshima I, Yamamoto H, Hosoda M , et al. Free combined composite flaps using the lateral circumflex femoral system for repair of massive defects of the head and neck regions: an introduction to the chimeric flap principle. Plast Reconstr Surg;92:411;1993.

5. Kimura N, Satoh K. Consideration of a thin flap as an entity and clinical applications of the thin anterolateral thigh flap. Plast Reconstr Surg;97:985;1996.

6. Demirkan F, Chen HC, Wei FC , et al. The versatile anterolateral thigh flap: a musculocutaneous flap in disguise in head and neck reconstruction. Br J Plast Surg;53:30;2000.

7. Koshima I, Moriguchi T, Fukuda H , et al. Free, thinned, paraumbilical perforator-based flaps. J Reconstr Microsurg;7:313;1991.

8. Kroll SS, Rosenfield L. Perforator-based flaps for low posterior midline defects. Plast Reconstr Surg;81:561;1988.

9. Koshima I, Fukuda H, Utomomya R, Soeda S. The anterolateral thigh flap: Variations in its vascular pedicle. Br J Plast Surg; 42:260;1989.

10. Pa-Chuen X, Shi-Zhen Z, Ji-Ming K, Guo-Ying W, Muzhi L, Li-Sheng, Jian-Hua G. Applied anatomy of the anterior lateral femoral flap. Plast Reconstr Surg;82:305;1988.

11. Kuo YR, Jeng SF, Kuo MH, HuangMN,Liu YT, ChiangYC, Yeh MC, Wei FC. Free anterolateral thigh flap for extremity reconstruction: clinical experience and functional assessment of donor site.

Plast Reconstr Surg.;107(7):1766-71;2001.

12. Kimata Y, Uchiyama K, Ebihara S, Sakuraba M, Iida H, Nakatsuka T, Harii K. Anterolateral thigh flap donor-site complications and morbidity. Plast Reconstr Surg.;106(3):584-9;2000.

13. Pribaz JJ, Orgill DP, Epstein MD, Sampson CE, HergrueterCA. Anterolateral thigh free flap. Ann Plast Surg.;34(6):585-92;1995.

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