Anatomical variations in the harvest of anterolateral thigh flap perforators: a cadaveric and clinical study

Background: The anterolateral thigh (ALT) flap has become increasingly popular due to its versatility and minimal donor site morbidity. Its major limitation has been uncertainty in predicting perforator anatomy, with the occasional absence of suitable perforators and high variability in their size and course. The variability of this anatomy has not been adequately explored previously. Methods: A cadaveric study was undertaken, in which 19 thighs (from 10 fresh cadavers) underwent contrast injection and angiographic imaging. Anatomical variations of the vasculature were recorded. A clinical study of 44 patients undergoing ALT flap reconstruction was also undertaken. Perforator anatomy was described in the first 32 patients, and the subsequent 12 patients underwent computed tomography angiography with a view to predicting individual anatomy and improving operative outcome. Results: Cadaver angiography was able to highlight and classify the variations in arterial anatomy, with four patterns observed and marked variability between cases. In 32 patients undergoing ALT flaps without preoperative CT angiography (CTA), five patients (16%) did not have any suitable perforators from the descending branch of the lateral circumflex femoral artery. By selecting the limb of choice with preoperative CTA, the incidence of flap unsuitability was reduced to 0%. Comparing CTA with Doppler, CTA was more accurate (sensitivity 100%) and provided more information. Conclusion: The perforators supplying the ALT flap show significant variability in location and course, with the potential for unsuitable perforators limiting flap success. Preoperative CTA can demonstrate the vascular anatomy and can aid perforator selection and operative success. © 2008 Wiley‐Liss, Inc. Microsurgery, 2009. [This is a corrected version of the abstract first published online on 22 October 2008 — the corrected version appears in print.]     

The profunda femoris artery "fourth perforator" island flap: a new perforator flap in lower-limb reconstruction

Although the lateral thigh flap has been well described as a fasciocutaneous flap based on one or more of the four perforators of the profunda femoris artery, the role for these individual perforators as perforator flaps has not been described. These profunda femoris artery perforators offer a particularly useful option in lower-limb reconstruction. In fact, a perforator flap based on the profunda femoris artery fourth perforator (PFA-P4) has not been described to our knowledge. We describe the utility of the PFA-P4 flap, offering modes of preoperative imaging and a role for its use in lower-limb reconstruction. Computed tomographic angiography (CTA) was able to identify the location and course of a PFA-P4, and Doppler ultrasound confirmed the CTA findings. A FA-P4 flap was designed and harvested, with direct closure of the donor site achieved. There were no operative complications. Perforator flaps based on the perforating branches of the profunda femoris artery have not been widely described, largely due to individual variability in perforator anatomy. With the advent of CTA for perforator mapping, the "freestyle" nature of such flaps is eliminated, and perforator flaps such as the PFA-P4 flap can be planned and harvested safely and confidently.     

Reconstruction of two separate defects in the upper extremity using anterolateral thigh chimeric flap

We presented our experience on the use of anterolateral thigh (ALT) chimeric flap to reconstruct two separate defects in upper extremity. From December 2009 to August 2012, we used this ALT chimeric flap to reconstruct two separate defects in upper extremity on five patients (mean age: 36.6 years; range: 15～47 years). The locations of defect were palm and fingers in four patients and forearm in the other patient. The sizes of defect ranged from 4.5 × 1.5 cm to 20 × 10 cm. A minimum of two separate perforator vessels in the flap were identified. The skin paddle was then split between the two perforators to shape two separate paddles with a common vascular supply. There were no cases of flap failure or re‐exploration. Four donor sites were directly closed and one was covered by a skin graft. Donor‐site morbidity was negligible. The ALT chimeric flap provides customized cover for two separate defects in upper extremity. © 2013 Wiley Periodicals, Inc. Microsurgery 33:631–637, 2013.     

Antegrade anterolateral thigh perforator flap advancement for soft‐tissue reconstruction of the knee: Case report

Reconstruction of soft‐tissue defects of the knee has always been a challenging task to the plastic surgeon. In some cases, local or regional flaps are too small or have limited arc of rotation for adequate coverage. Free flaps can be technically demanding and time consuming. We report for the first time an antegrade anterolateral thigh perforator flap advancement, used to reconstruct the knee soft tissue defect in a 54‐year‐old man. The operative procedure required skeletonizing the perforators of anterolateral thigh flap and advancing the flap in the defect. The postoperative course was uneventful with the patient returned to normal daily activity and full range of motion 3‐months postoperatively. The shorter operating time with decreased donor‐site morbidity make this flap as a valuable alternative for soft‐tissue reconstruction of the knee. © 2010 Wiley‐Liss, Inc. Microsurgery, 2010.     

Improving the utility and reliability of the deep circumflex iliac artery perforator flap: the use of preoperative planning with CT angiography

Background: The deep circumflex iliac artery (DCIA) is rarely used as a perforator flap, despite a clear clinical need for thin osteocutaneous flaps, particularly in head and neck reconstruction. The poor adoption of such a flap is largely due to a poor understanding of the perforators of the DCIA, despite recent publications demonstrating suitable vascular anatomy of the DCIA perforators, particularly evident with the use of preoperative computed tomographic angiography (CTA). We have applied this method of peroperative imaging to successfully select those patients suitable for the DCIA perforator flap and use it clinically. Methods: We present a case series of patients who underwent DCIA perforator flap reconstruction following preoperative planning with CTA. Imaging findings, clinical course, and outcomes are presented. Results: Six out of seven patients planned for DCIA perforator flap reconstruction underwent a successful DCIA perforator flap, with imaging findings confirmed at operation, and without any flap loss, hernia, or other significant flap‐related morbidities. Because of abberent anatomy and change in defect following excision of pathology, one patient was converted to a free fibular flap. Conclusion: With preoperative CTA planning, the DCIA perforator flap is a versatile and feasible flap for reconstruction of the mandible and extremities. © 2011 Wiley Periodicals, Inc. Microsurgery, 2011.     

以旋股外侧动脉降支为蒂的穿支嵌合皮瓣修复口腔颌面部缺损

目的 设计以旋股外侧动脉降支为蒂的股部皮肤穿支血管的嵌合皮瓣,为修复口腔颌面部的大面积、复杂的洞穿性缺损提供一种新的方法.方法 根据旋股外侧动脉降支的走行及分支、其在股部正面及两侧可能存在的皮肤穿支血管,设计以旋股外侧动脉降支为蒂的穿支嵌合皮瓣修复口腔颌面部软组织缺损8例.此种皮瓣可分为3种类型:股前外侧皮瓣+股前内侧皮瓣、股前外侧皮瓣+股直肌穿支皮瓣、股前外侧皮瓣+股前外侧皮瓣.结果 术后8例16块皮瓣均成活,无并发症,且供区均直接拉拢缝合,未行皮片移植.术后随访1～9个月,患者面部外形和功能均良好,供区畸形和功能障碍均不明显.结论 以旋股外侧动脉降支为血管蒂的穿支嵌合皮瓣吻合血管数量少,较切取2个皮瓣供区损伤小,组织量大,适合口腔颌面部大型复杂的组织缺损的修复.     

Tripaddled anterolateral thigh flap for simultaneous reconstruction of bilateral buccal defects after buccal cancer ablation and severe oral submucous fibrosis release: A case report

For buccal squamous cell carcinoma (SCC) patients accompanied with severe oral submucous fibrosis (OSF), it is a challenge to simultaneously reconstruct bilateral buccal defects created from cancer resection and contralateral OSF release to improve postoperative mouth opening. Herein, we present a case of reconstruction of bilateral buccal defects in a 46‐year‐old patient who had left buccal SCC accompanied with severe OSF. Extensive ablation involved the left full‐thickness cheek as well as part of mandible and a release of right OSF tissue were performed. A tripaddled anterolateral thigh (ALT) flap with three independent sets of perforators was harvested for reconstruction. The flap survived in its entirety. No donor or recipient site complication occurred. The preoperative inter‐incisor distance (IID) was 1 mm, while the postoperative IID was 23 mm. This is the first report on the use of one tripaddled ALT flap for reconstruction of bilateral buccal defects created from cancer ablation and severe contralateral OSF release. © 2013 Wiley Periodicals, Inc. Microsurgery 33:667–671, 2013.     

Intraoperative flap design using ICG monitoring of a conjoined fabricated anterolateral thigh/tensor fasciae latae perforator flap in a case of extensive soft tissue reconstruction at the lower extremity

In this report, we present a case of the use of a conjoined fabricated free anterolateral thigh (ALT)/tensor fascia latae (TFL) perforator flap for reconstruction of the lower extremity with intraoperative flap design using intraoperative indocyanine green (ICG) monitoring. The flap was used for reconstruction of a 16 cm × 28 cm sized defect of the lower leg in a 24‐year‐old man. The defect was caused by a third degree open fracture to the tibia. Upon dissection of the ALT perforators, ICG monitoring showed that both dominant ALT perforators did not yield a sufficient perforasome (～16 cm × 17 cm) for the larger flap needed. An adjacent TFL perforator also supplied a large perforasome (～15 cm × 11 cm), so a conjoined fabricated flap was harvested and transplanted to cover an extensive lower leg defect. The artery of the TFL perforator pedicle was being in‐flap anastomosed to a side branch of the ALT pedicle. Postoperative course was uneventful and there were no complications. Length of follow‐up was 6 months, aesthetic and functional outcome was good. The patient was very satisfied with the aesthetic outcome. Both legs were fully mobile after intensive physiotherapy for the reconstructed leg. The leg where the flap had been harvested showed full strength in knee joint flexion. This case could show that identification of the supplying vessels may be possible by ICG monitoring. © 2015 Wiley Periodicals, Inc. Microsurgery 36:684–688, 2016.     

Reconstruction of an upper posterior thigh extensive defect with a free split‐anterolateral thigh (s‐ALT) flap by perforator‐to‐perforator anastomosis: A case report

The anterolateral thigh (ALT) flap is one of the most commonly used flap worldwide in reconstructive surgery, as both free flap and pedicled local flap. Here, we report the use of a free split anterolateral thigh (s‐ALT) flap for reconstruction of a 14 cm × 16 cm soft tissue defect of the left upper posterior thigh region due to sarcoma resection in a patient. The ALT flap was harvested based on two musculocutaneous perforators from the right thigh and anastomosed to the contralateral descending branch of the lateral circumflex femoral artery (LCFA) in perforator‐to‐perforator manner, in order to gain more pedicle length and being able to cover the posterior thigh defect. The post‐operative course was uneventful and the patient was discharged at 1 week post‐operative. Eleven months after the operation, the aesthetic outcome was satisfactory with no functional deficit. Even though it requires technical skills and experience in perforator dissection, we believe that the s‐ALT flap anstomosed to the contralateral LCFA in perforator to perforator fashion, may be a good solution in case of such a difficultly located extensive defect of the posterior thigh.     

Does the preoperative imaging of perforators with CT angiography improve operative outcomes in breast reconstruction?

Background: Breast reconstruction is increasingly performed with the use of the abdominal wall donor site, with potential complications including donor site morbidity and impaired flap viability. As a tool for selecting the optimal perforators which will ultimately supply the flap, preoperative imaging with computed tomography angiography (CTA) has become increasingly popular. Potential benefits include reduced intramuscular dissection, with faster and safer dissection, reduced donor site morbidity and improved flap vascularity and survival. Despite the potential for improvements in operative outcome, any benefits are yet to be established. Methods: A cohort study of 104 breast reconstructions in 88 patients was conducted. All patients underwent breast reconstruction based on an abdominal wall free flap. Of these, 40 patients undergoing preoperative imaging with CTA and 48 patients not undergoing CTA were included, with all CTAs undertaken at a single institution. Length of operation, length of stay, and operative complications were assessed. An evaluation of operative stress was achieved with the use of visual analogue scales (VAS) administered to the surgeons. Results: The use of CTA was associated with decreased operating time (mean: 77 min for bilateral cases), significantly decreased complications related to flap viability (particularly partial flap loss), and a statistically significant reduction in donor site morbidity. Psychometric testing of surgeons revealed a statistically significant decrease in operative stress (41% decrease) with the use of preoperative CTA. Conclusion: The use of CTA for preoperative imaging in breast reconstruction is associated with improved operative outcomes. © 2008 Wiley‐Liss, Inc. Microsurgery, 2008.     

Pedicled chimeric sensitive fasciocutaneous anterolateral thigh (ALT) and vastus lateralis muscle (VLM) flap for groin defect reconstruction: A case report

The anterolateral thigh (ALT) flap is one of the most commonly used flap worldwide, as both free flap and pedicled local flap. Here, we report the use of a pedicled chimeric sensitive ALT and vastus lateralis muscle (VLM) flap in a patient with a 12 cm × 8 cm contaminated soft tissue defect of the right inguinal region with exposed femoral vessels. The flap was harvested based on two perforators, one musculocutaneous and one pure muscular, each nourished separately a sensitive fasciocutaneous component and a vastus lateralis muscle component, respectively. The muscle part was tailored to wrap around the exposed vascular structures, while the innervated skin and fascia component of the flap provided a tension‐free closure of the wound. The post‐operative course was uneventful and the patient was discharged at 1 week post‐operative. Even though it requires technical skills and experience in perforator dissection, we believe that the pedicled chimeric sensitive ALT and VLM flap may be one of the best solutions in case of exposed femoral vessels in contaminated wounds.     

Bilateral pedicle anterolateral thigh (ALT) flap combined with bilateral sartorius muscle flap for reconstruction of extensive perineoscrotal and medial thigh defect because of Fournier's gangrene

Fournier's gangrene is an acute and potentially lethal necrotizing fasciitis that can lead to extensive defects of the perineoscrotal area and lower abdominal wall as well. Such defect poses challenging tasks for both functional and cosmetic reconstruction. Local perforator pedicle flaps and muscle flaps can be employed and combined for such a reconstruction. In this report we present a case of reconstruction of a massive perineoscrotal and upper medial thigh defect because of Fournier's gangrene using a bilateral pedicle anterolateral thigh (ALT) flap and sartorius muscle flap. A 61 year‐old male who suffered from Fournier's gangrene resulted in a perineal, scrotal, and medial thigh defect of 27 × 30 cm² with exposure of the femoral vessels. A bilateral pedicle ALT flap measuring 30 × 9 cm² based on two perforators and a bilateral sartorius muscle flap were harvested for soft tissue defect reconstruction and inguinal vessels coverage, respectively. The flaps survived completely, with no recipient or donor site morbidity. The length of follow‐up was 6 months and was uneventful. A bilateral pedicle ALT flap combined with bilateral sartorius flap may be considered as a valid and safe option for an extensive inguinal and perineoscrotal reconstruction in selected cases. © 2016 Wiley Periodicals, Inc. Microsurgery 37:669–673, 2017.     

股前外侧组织瓣临床应用112例分析

目的 总结分析股前外侧组织瓣解剖规律及其在组织缺损修复重建中的适应证和应用价值。方法1985年3月-2004年8月，对112例股前外侧组织瓣移植进行临床总结。其中男67例，女45例。年龄5～65岁，平均38．5岁。针对受区不同情况，将股前外侧组织瓣切取分为4类：吻合血管的游离皮瓣移植78例；吻合血管的游离脂肪筋膜瓣移植22例；带蒂顺行岛状皮瓣移位5例；远端为蒂逆行岛状皮瓣移位7例。对面、颈、肢体、躯干等部位的软组织缺损所致功能障碍或外观缺陷进行修复，并对术后效果和供区恢复情况进行评价。结果营养股前外侧组织瓣的动脉皮支出现率100％，具有肌间隙皮穿支（33％）和肌皮穿支（67％）两种基本解剖类型。组织瓣源血管均为旋股外侧动脉降支或横支。皮瓣移植成活107例，成活率达95．6％。术后33例获随访6个月～11年，远期随访效果满意率91％，供区无功能受限。结论股前外侧组织瓣解剖恒定，具有多种突出优点，是修复软组织缺损的理想材料。尤其是穿支皮瓣形式，可保持受区形态，降低供区损伤，成为应用趋势。     

Reconstruction of extensive abdominal wall defect using an eccentric perforator‐based pedicled anterolateral thigh flap: A case report

Reconstruction of extensive abdominal wall defects is a challenge for reconstructive surgeons. In this report, a case of reconstruction of a large abdominal wall defect using an eccentric perforator‐based pedicled anterolateral thigh (ALT) flap is presented. A 30‐year‐old man presented with recurrent desmoid‐type fibromatosis in the abdominal wall. The recurrent tumor was radically excised, and the en bloc excision resulted in a full‐thickness, large abdominal wall defect (25 cm × 20 cm). An eccentric perforator‐based pedicled ALT flap, including wide fascial extension, was transferred to the abdominal defect; fascial portions were sutured to the remnant abdominal fascia. Plication of the fascia along the sutured portion was performed to relieve the skin tension between the flap and the marginal skin of the abdominal defect. Eight months after surgery, the reconstructed abdomen had an acceptable esthetic appearance without tumor recurrence or hernia. The use of an eccentric perforator‐based pedicled ALT flap may be an alternative method for the reconstruction of extensive abdominal wall defects. © 2013 Wiley Periodicals, Inc. Microsurgery 33:482–486, 2013.     

Chimeric flap in clinical use

With the development of modern microsurgical reconstruction, there are several alternative methods for the complicated head and neck defect or injured extremity. The double-paddled flap, double flaps, and double flap with vascular flow-through linkage are good tools for extensive wide, composite, and three-dimensional defects. When faced with a difficult reconstruction, the expense, morbidity of the donor site, and operative time must be taken into consideration. Compared with other combined composite flaps and other methods, the chimeric flap has many advantages including: easy three-dimensional insetting, acceptable aesthetic appearance, reduced donor site morbidity, design with the least effort and operation time, and one pair of recipient vessel. The disadvantages of the chimeric flaps include: the variation of perforators, the requirement of a learning curve, and, sometimes, the need for a second venous drainage or shifting to double flaps. Overall, in selected cases, the chimeric flap is a good option for the reconstruction of extensive, composite, and three-dimensional defects.     

Profunda artery perforator based V‐Y rotation advancement flap for total vulvectomy defect reconstruction—A case report and literature review

Reconstruction of total vulvectomy defect represents a challenge, and reconstructive methods include skin graft, local skin flap, musculocutanous flap, and pedicled perforator flap. We report a case of a 63‐year‐old patient affected by extramammary Paget's disease of vulva who underwent total vulvectomy receiving reconstruction with bilateral profunda artery perforator based V‐Y rotation advancement flap. The literature about vulva reconstruction was reviewed. This innovative flap design combined the classic rotation flap and V‐Y advancement flap with inclusion of the profunda artery perforators to augment the flap blood supply. Besides, the internal pudendal nerve was preserved to maintain the sensation of the neo‐uvula. The flap survived completely without major post‐operative complications with 9‐months follow‐up. Profunda artery perforator based V‐Y rotation advancement flap may represent a valuable option in total vulvectomy defect reconstruction. © 2015 Wiley Periodicals, Inc. Microsurgery 35:668–671, 2015.     

Computed tomographic angiography: assessing outcomes

Perforator flaps are preferable for breast reconstruction after mastectomy in many patients. Preoperative imaging of the perforators and source vessels is desirable to reduce surgeon stress, limit donor and recipient site complications, and minimize operative time and associated costs. Computed tomographic angiography (CTA) has been shown to provide highly accurate representations of vascular anatomy with excellent spatial resolution. A critical review of the currently available literature was performed to identify the benefits of preoperative imaging (specifically CTA) in perforator flap reconstruction.     

Using the proximal perforator‐based anterolateral thigh flap from the same donor site to salvage the reconstruction after failure of the distal perforator‐based anterolateral thigh flap

We presented a patient who experienced the anterolateral thigh (ALT) flap failure but the reconstruction was successfully salvaged by harvesting a second ALT flap from the same donor site 2 days after the first reconstruction. A 47‐year‐old man received cancer ablation for right mouth floor squamous cell carcinoma. The resultant defect was planned to be reconstructed with the ALT flap. During the flap dissection, we identified three proximal cutaneous perforators originating from the transverse branch of the lateral circumflex femoral artery (t‐LCFA) and two distal cutaneous perforators originating from the descending branch (d‐LCFA). We harvested a skin flap based on the distal two perforators and divided the d‐LCFA just distal to the bifurcation of the d‐LCFA and the t‐LCFA. Unfortunately, the ALT flap showed venous congestion on postoperative day 2 and eventually failed. We harvested a second ALT flap from the same donor site based on the previously preserved perforators. The recovery course was smooth thereafter. We believe that the harvest of a second ALT flap from the same donor site may be an option, to avoid other donor site violation, in some patients who experienced the first flap loss. © 2014 Wiley Periodicals, Inc. Microsurgery 34:409–412, 2014.     

Chimeric ALT Plus TFL Perforator Flap for Breast Reconstruction Post Radical Mastectomy with Large Skin Defect

A 17-year-old girl with large malignant phyllodes tumor of left breast underwent a radical mastectomy with large skin excision resulting in defect of 20 cm × 18 cm. Postoperative radiation therapy necessitated robust cover with flap. The challenge was compounded by her body habitus. Both abdomen and back were deficient as donor sites and a single-island anterolateral thigh (ALT) flap would need skin grafts, volume deficit withstanding. We harvested chimeric ALT plus tensor fascia lata (TFL) perforator free flap sparing all muscles and nerves. Microvascular anastomoses were done to the second internal mammary artery (IMA) perforator artery and vein. The donor site was closed primarily. The TFL flap territory recruited almost three times the volume of ALT territory and allowed us to create a matching breast mound in addition to covering the defect. She tolerated 40 Gy radiation well and doesn’t desire further augmentation. Consistency of ALT and TFL perforators makes this a replicable procedure.