Anatomy of vastus lateralis muscle flap

A vastus lateralis muscle flap is used as a pedicled and free flap. In this study, the vastus lateralis muscles of 15 adult formalin-fixed cadavers (30 cases) were dissected. The dominant pedicle was found to be descending branch of the lateral circumflex femoral artery. The mean diameter of the artery was found to be 2.1 mm. This pedicle was located 119.4 mm distal to the pubic symphysis. The mean length of the major pedicle was found to be 56.8 mm when the dominant pedicle was chosen to nourish the flap. The dominant pedicle entered the muscle 155.8 and 213.7 mm from the greater trochanter and the anterior superior iliac spine, respectively. The muscle had proximal minor pedicles from the ascending and transverse branches of lateral circumflex femoral artery. These arteries had mean diameters of 1.8 and 2.0 mm, respectively. The distal minor branches were present in all of the dissections. The distal branch had a mean diameter of 1.8 mm. The origin of this distal branch was located 83.7 mm proximal to the intercondylar line. The motor nerve of the vastus lateralis was found to be originating from femoral nerve. The nerve entered the muscle 194.6 mm from the anterior superior iliac spine.     

吻合旋股外侧血管髂骨移植在颌面部的应用

吻合血管髂骨移植是修复颌骨缺损的常用手术。作者应用吻合旋股外侧血管升支髂骨瓣移植修复颌面部骨缺损４例，证实以该血管为蒂的髂骨瓣的临床可行性。旋股外侧血管升支位置恒定、血管口径较粗，所形成的血管蒂较长，操作安全、方便。作者认为以该血管为蒂的髂骨移植是颌骨缺损修复的可供选择术式之一。本文对该髂骨瓣的血供、手术注意点等进行了讨论。     

An anatomic assessment on perforators of the lateral circumflex femoral artery for anterolateral thigh flap

The anterolateral thigh flap was originally described in 1984 as a septocutaneous flap based on the descending branch of the lateral femoral circumflex artery (LCFA). This flap has many advantages for head and neck reconstruction. However, it is not widely used as a result of the broad range of anatomic variation of the cutaneous perforators and because dissection of these perforators is tedious when they are small. The purposes of this study are to classify the vascular anatomy of the LCFA and to assess the suitability of the anterolateral thigh flap for head and neck reconstruction in Koreans. From 38 thigh dissections of Korean cadavers, the LCFA commonly arose from the deep femoral artery and divided into ascending, transverse, and descending branches. In five cases, the LCFA arose directly from the femoral artery. The cutaneous perforators were present in 37 cases except one and the septocutaneous perforators were found in 17 of the 38 cases. Of the 160 perforators, 28 (17.5%) were the septocutaneous perforators and 132 (82.5%) were the musculocutaneous perforators. The average number of cutaneous perforators for the anterolateral thigh flap was 4.2 (range, 0-8), and these perforators were concentrated in the middle third of the anterolateral thigh. The septocutaneous perforators were located more proximally than the musculocutaneous perforators. The average length of the vascular pedicle derived from the descending branch or the transverse branch was 83.3 mm (range, 53.4-124.3 mm). The results of this study suggest that the vascular anatomy of the anterolateral thigh flap was reliable and well suited for head and neck reconstruction in Koreans.     

An unusual anatomical variant of the vascular anatomy in the anterolateral thigh free flap

The anterolateral thigh flap is a fasciocutaneous flap based on the descending branch of the lateral circumflex femoral artery. The vascular pedicle and its perforators have a varied anatomical course that has led to difficulties in flap harvest. Many papers have described the anatomical variation in the origin and path of this vessel, but they all show one artery and two accompanying venae commitantes. The authors report the first case of duplication of the descending branch of the lateral circumflex femoral artery. They discuss whether this variation requires two arterial anastomoses.     

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??The lateral femoral circumflex artery system perforator flaps include anterolateral thigh perforator flap supplied by the lateral descending branch and oblique branch of lateral femoral circumflex artery??anteromedial thigh perforator flap supplied by the medial descending branch of lateral femoral circumflex artery??and tensor fascia lata perforator flap by the ascending branch of lateral femoral circumflex artery. The advantages of these flaps include the low donor site morbidity?? the convenient donor site??the good vascular quality??the large soft tissue volume??the ability to be harvested as a chimeric flap with multiple various tissue components??and being far from the head and neck region which is fit for two-team approach. The lateral femoral circumflex artery system perforator flaps can be flexibly chosen according to the different defects??so as to obtain the best effect in oral and maxillofacial reconstruction.     

腓肠内侧动脉穿支皮瓣的应用解剖及临床研究

目的: 通过对腓肠内侧动脉穿支皮瓣的解剖学研究,探讨制备腓肠内侧动脉穿支皮瓣的合理性及稳定性;并对临床上应用腓肠内侧动脉穿支皮瓣修复的患者的供区及受区术后恢复情况等进行随访,评价其在口腔颌面部缺损修复重建中的应用价值。方法: 选取 6 例中国成人下肢标本,解剖并记录腓肠内侧动脉穿支的数目、分布、部分层面血管外径及各段血管长度;同时对16 例口腔鳞癌术后缺损患者采用腓肠内侧动脉穿支皮瓣进行修复重建,皮瓣面积 3 cm×4 cm~6 cm×8 cm。术后随访12 个月,观察皮瓣存活情况,受区臃肿度,供区功能恢复,术后吞咽及语言功能情况。结果: 6 例下肢标本共测量记录到腓肠内侧动脉穿支14 条,平均 2.3 条。小腿腓肠内侧动脉穿支平均距腘皱褶下缘（9.15±4.05）cm, 距后正中线（2.82±0.91）cm,源动脉起始处外径平均为（2.11±0.17）mm。血管蒂总长度平均为（12.61±3.15）cm;16 例腓肠内侧动脉穿支皮瓣,2 例发生血管危象并部分坏死,2 例失访（术后随访 10~47 个月,平均 24 个月）。2例皮瓣移植发生血管危象伴部分坏死病例未纳入随访。腓肠内侧动脉穿支皮瓣存活率较高,供区影响小,组织量适中,受区外形不臃肿,质地、弹性良好,吞咽、语言功能均无明显影响。结论: 腓肠内侧动脉穿支皮瓣穿支数目及分布稳定,血管蒂长度及管径完全满足游离皮瓣移植要求,供区影响小,组织量适中,皮瓣受区不臃肿。结合其解剖稳定性,是口腔颌面部软组织中小型缺损修复重建的理想选择。     

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??Objective    To study the anatomic features of medial sural artery perforator flap and provide anatomic evidence for its clinical application. Methods    Totally 10 lower limbs preserved in formaldehyde from cadavers of adults were used to observe the anatomy of medial and lateral sural artery. Between April of 2010 and April of 2011?? 14 clinical cases were reconstructed by using medial sural artery perforator flap??perforator data were collected. Results    In all 10 specimens the mean number??median  of total perforators was 2.5??ranging 1 to 6??. All perforators were in an area between 5.0 cm and 19.0 cm from the popliteal crease and between 1.0 cm and 6.0 cm from the midline of the gastrocnemius muscles. In clinical study?? the mean number??median of total perforators was 2.0??ranging 0 to 4??. All perforators were in an area between 5.0 cm and 19.0 cm from the popliteal crease and between 0 cm and 5.8 cm from the midline of the gastrocnemius muscles. Most perforators entered the medial gastrocnemius muscle at a relative distance of one-fifth to one-third of the lower leg length measured from the popliteal crease. Conclusion    The medial sural artery perforator flap provides a constant anatomy with a long pedicle. It is a good alternative for oral and maxillofacial reconstruction of defects.     

An anatomical study of vascularized iliac bone grafts for dental implantation.

PURPOSE: The purpose of this study was to clarify the anatomical features of vascularized iliac bone grafts used for mandibular reconstruction and dental implantation. MATERIAL AND METHOD: Twenty-six cadavers were dissected to examine vessels and areas of iliac bone that could be used as pedicles and grafts. The length and diameter of vessels of the vascular pedicle were determined, and the length and depths of the iliac bone were measured with respect to points determined by the relative dimensions of the bone. RESULTS: The deep circumflex iliac arteries were classified as double nutrient type (75%), iliac-crest type (19%), or iliacus-muscle type (6%). The mean arterial length was 64+/-15 mm in the double nutrient type. The mean internal diameters at the origin of the deep circumflex iliac artery and vein that could be used for anastomosis were 1.7+/-0.4 mm and 2.1+/-0.7 mm respectively. The greatest mean cross-sectional width and height were 18+/-3 and 42+/-5 mm respectively. The greatest mean cross-sectional cortical thickness at the intermediate line of the iliac crest was 3.4+/-0.8 mm. CONCLUSION: These results should be useful in designing bone grafts for mandibular reconstruction followed by dental implantation.     

延长颏下动脉穿支皮瓣血管蒂修复口腔颌面部缺损的临床应用

目的:本研究通过延长颏下动脉穿支皮瓣(submental artery perforator flap,SMAPF)血管蒂的3种方法修复口腔颌面部距供区较远的缺损,并对其可行性及临床效果评价.方法:选取自2019年1月—2021年2月于中国医科大学附属口腔医院颌面头颈肿瘤外科就诊并收治,行同侧颏下动脉穿支皮瓣手术修复口...     

CT血管造影在腓肠内侧动脉穿支皮瓣血管定位中的应用

目的 探讨运用CT血管造影（CTA）技术定位腓肠内侧动脉穿支的精确性,基于CTA定位下了解腓肠内侧动脉穿支皮瓣的解剖学特征。方法 选取9例舌癌患者,术前利用CTA技术对腓肠内侧动脉穿支进行定位,术中测量腓肠内侧动脉穿支皮瓣的相关解剖数据,测量穿支数量、皮肤穿出点位置、血管蒂长度及皮瓣厚度,运用SPSS 20.0软件包进行配对t检验,与术前CTA测量结果进行比较。结果 腓肠内侧动脉穿支皮瓣血管蒂长,管径与颈部血管匹配,对供区损伤小,CTA定位的血管蒂长度、皮瓣厚度以及血管穿支到坐标原点的距离与术中测量数据进行对比,均无显著差异;术前CTA定位测量准确。结论 术前运用CTA可精确定位穿支位置,利于皮瓣制备,减少手术风险和并发症。     

Primary thinning of the myocutaneous vastus lateralis flap

To expand the indicational spectrum of the myocutaneous vastus lateralis flap, which is often too voluminous for intraoral application, primary thinning of the fat and muscle component of this microsurgical transplant was performed in 14 patients. The surgical technique includes subfascial localization of at least one myocutaneous perforating vessel of the lateral circumflex femoral artery and its dissection through the fascia, muscles and fatty tissue up to the skin. The epifascial fatty tissue is completely removed except for a 1-2 cm wide cuff around the perforating vessel. The thinning technique was used for covering 10 intraoral and 4 extraoral defects and enabled the raising of skin flaps with a thickness of 4 mm even in obese patients. The vessel pedicle length of the thinned flaps was between 12 and 16 cm; flap size varied between 4x5 and 9x15 cm and the donor sites were directly closed. In one case, there was a partial necrosis (20%), but the other flaps healed without complications. The described method allows the raising of thick myocutaneous as well as thin skin flaps from the same donor region.     

锁骨上动脉岛状瓣的应用解剖

目的:为临床应用锁骨上动脉岛状瓣提供解剖学依据。方法:在10例20侧经锁骨下动脉灌注氧化铅-明胶溶液的成人尸体标本上,对颈横动脉和锁骨上动脉的分支情况、起始位置、行程、长度和管径进行观测,观察其回流静脉情况,并在尸体标本上模拟皮瓣制备。结果:颈横动脉由甲状颈干或锁骨下动脉分支而来,在锁骨中1/3上方分为深支和浅支。锁骨上动脉由颈横动脉浅支发出后行向后外,越过斜方肌浅面和锁骨的肩峰端,走行于三角肌筋膜的浅面,并逐渐发出细小分支穿过深筋膜,进入锁骨上和肩部的皮肤和皮下组织。颈横动脉起点至锁骨上动脉起点距离平均为(4.31±0.64)cm,锁骨上动脉起点至其发出分支穿深筋膜点的距离平均为(3.62±0.42)cm。颈横动脉起点处外径平均为(2.71±0.33)mm,锁骨上动脉起点处外径平均为(1.10±0.17)mm。2条锁骨上动脉伴行静脉分别回流入颈横静脉和颈外静脉。结论:以锁骨上动脉为营养血管的锁骨上动脉岛状瓣,适于转移修复口腔颌面颈部组织缺损,也可以颈横动脉为吻合血管,制作游离皮瓣。     

腓肠内侧动脉穿支皮瓣修复舌缺损的疗效评价

目的: 研究运用游离腓肠内侧动脉穿支皮瓣修复半舌缺损的可行性与临床效果,为腓肠内侧动脉穿支皮瓣用于舌部缺损修复提供依据。方法: 选取9例舌癌患者,术前利用CT血管造影（CTA）技术对腓肠内侧动脉穿支进行定位,术中运用腓肠内侧动脉穿支皮瓣行半舌缺损修复。对成功应用该皮瓣进行舌重建的8例患者,术后1个月以及3个月进行随访,评价舌部功能及供区状况。结果: 腓肠内侧动脉穿支皮瓣血管蒂长,管径与颈部血管匹配,对供区损伤小,腓肠内侧动脉穿支皮瓣重建舌丰满,术后语音及咀嚼功能良好,舌部感觉功能欠佳。供区功能良好,仅留存线性瘢痕,供区未见明显并发症。结论: 游离腓肠内侧动脉穿支皮瓣可成为舌缺损修复重建的另一种选择,其供区隐蔽,损伤小,皮瓣厚度适合舌部缺损修复,术后患者语音及咀嚼功能恢复良好。     

Use of free flaps with supermicrosurgery for oncological reconstruction of the maxillofacial region

Supermicrosurgery involves the dissection and anastomosis of vessels<0.8 mm in diameter with minimal donor site morbidity. This study evaluated the feasibility and outcomes of free flaps using supermicrosurgery to repair oncological defects in the maxillofacial region. Forty-two patients were treated with supermicrosurgery to repair oncological defects in the maxillofacial region between December 2015 and February 2021. The supermicrosurgery technique was used for different types of free flap, including 24 superficial circumflex iliac artery perforator flaps, seven anterolateral thigh flaps, three peroneal artery perforator flaps, five medial femoral condyle osteo-adipofascial flaps, and three profunda artery perforator flaps. An artery-to-artery approach was used in 38 patients; venous grafts for anastomosis were used in four patients to resolve an arterial discrepancy. Forty-one flaps (97.6%) survived. Thirty-six patients (85.7%) healed without any complications; three flaps required revision surgery including one lost, one demonstrated wound dehiscence, and two demonstrated wound infection. Supermicrosurgery is a useful complement to conventional microsurgery in head and neck reconstruction.     

肩胛骨瓣修复下颌骨缺损

作者选用旋肩胛血管为蒂的肩胛骨瓣修复部分下颌骨缺损8例,术后骨瓣全部成活。本文对肩胛骨瓣的设计、血管蒂的解剖、切取骨瓣及其移植方法作了介绍。应用肩胛骨瓣修复下颌骨缺损,可视受区需要设计为单纯骨瓣或骨肌皮瓣,骨瓣的长、宽、厚与下颌骨相似,外形恢复良好。骨瓣供区血管位置恒定,易于寻找,血管口径与受区血管接近,吻合后通畅率高,易成活。     

Use of lateral circumflex femoral artery system free flaps in skull base reconstruction

We present a 10-year retrospective study at a tertiary center designed to evaluate the advantages, complications, and comparative results using lateral circumflex femoral artery (LCFA) system free flaps for cranial base reconstruction. In this study, a cranial base defect refers to exposed intracranial contents to the skin, paranasal sinuses, nasopharynx, oropharynx, or oral cavity. These defects resulted from resections of primary or recurrent neoplasms or from secondary problems after cranial base surgery. We performed 20 flaps in 20 patients. The selection of flap was as follows: 8 combinations of anterolateral/anteromedial thigh flaps with vastus lateralis muscle or tensor fascia lata flaps, 6 ALT fasciocutaneous flaps, and 6 muscle/myocutaneous flaps. The flap's success rate was 95% (19/20). Early major complications included 1 perioperative death, and there was 1 myocardial infarction. Minor complications included 1 partial (12%) flap loss, 2 temporal cerebrospinal fluid leak, 2 donor-site hematoma, 2 minor wound breakdown, 3 facial nerve weakness, and 4 donor-site numbness. Among 20 patients undergoing LCFA system flap reconstruction, 12 are alive and disease free. Local recurrence occurred in 1 patient. She underwent ablative surgery and a new successful free flap (forearm flap); after 2 years, the patient is disease free. The LCFA system flaps in skull base reconstruction provide versatility in flap design and availability of adequate tissues to fill dead space, and it offers vascularized fascia to augment dural repairs. It also provides a very long pedicle and allows simultaneous flap harvest with low donor-site morbidity.     

A combined superficial inferior epigastric artery flap and vascularized iliac crest flap in the reconstruction of extended composite defects of the posterior mandible and adjacent soft tissue: first clinical results

The technique of posterior facial reconstruction using a combination of a superficial inferior epigastric artery (SIEA) flap and a microvascular iliac crest flap (deep circumflex iliac artery (DCIA) flap) is described. 12 cases are reported. The patients had unilateral squamous cell carcinoma of the posterior mandible affecting parts of the soft palate and tonsil region or the posterior cheek. In all patients unilateral neck dissection, resection of the posterior and lateral mandible, was performed. Reconstruction was carried out during primary surgical therapy, followed by postoperative radiotherapy. A flap combination of a SIEA and a DCIA flap was used. There were no problems with pedicle length or anastomoses. There was no flap loss or severe postoperative complications. All patients had good aesthetic and functional results. One patient had distant metastases 2 years postoperatively. All other patients were free of tumour relapse or metastases within 12-58 months of follow up. The SIEA flap and vascularized iliac bone flap combination is useful in reconstructing the posterior face. The iliac bone flap is well suited for posterior mandible reconstruction and the SIEA flap for reconstruction of the soft palate, lateral pharyngeal wall and cheek. Both flaps are harvested from the same donor site.     

The vascular anatomy of the digastric muscle

There are plenty of flaps for the reconstruction of defects of the head and neck region. In the literature, local muscle and myocutaneous flaps such as sternocleidomastoid, pectoral, and deltopectoral flaps are proposed for obliteration of pharyngocutaneous fistulas. Restoration of facial nerve palsies in which nerve repair and nerve grafting are not feasible is accomplished by means of regional muscle transpositions. The vascular anatomy of the digastric muscle to be used in such instances is investigated after latex application to 18 neck regions of nine cadavers. The dissection continued anteriorly from the origin of the facial artery to the end of the submental artery, preserving all the branches piercing and nourishing the muscle. The submental artery courses over the posterior surface of the anterior belly of the digastric muscle, giving off the major pedicle of the muscle 1 cm after exiting behind the submandibular gland. The submental artery gives off another branch, the first minor pedicle of the muscle distal to the major pedicle at a distance of two thirds of the muscle length in a standard fashion in all the cadavers. The artery ends in the distal portion of the muscle, the second minor pedicle of the muscle. The artery gives off periosteal branches to the mandible after coursing through the insertion muscle. The anterior belly of the digastric muscle could be classified as a type II muscle, with a major pedicle and two minor pedicles, according to the system of Mathes and Nahai. The anterior digastric muscle can be a good alternative in obliteration of pharyngocutaneous fistulas, and defects of the mandible, including the body and angle of the mandible, can be amended with the split mandibular myo-osseous digastric flap.     

Application of a new classification of chimeric anterolateral thigh free flaps

BackgroundThe anterolateral thigh free flap is one of the most commonly used flaps in reconstructive procedures. The purpose of this study was to assess this new classification of chimeric anterolateral thigh free flaps.MethodsSixty-five patients underwent free anterolateral thigh chimeric free flap reconstruction of defects in the head and neck region. We summarized the anatomic features of perforators, including the number and origin of the perforators.ResultsSixty-five cases of femoral anterolateral double island flaps were divided into 3 types: trunk type (type I), 11 cases (16.9%), in which the perforators of two flaps originated in the descending branch and the transverse branch of the lateral femoral circumflex artery; branch type (type II), 45 cases (69.3%), in which both the perforators originated in the descending branch or the transverse branch of the lateral femoral circumflex artery; and bifurcation type (type III), 9 cases (13.8%), in which two perforators originated in the bifurcation of one perforator that originated in the descending branch or the transverse branch of the lateral femoral circumflex artery. All 65 flaps survived and none showed partial necrosis.ConclusionsThe anterolateral thigh chimeric flap can be divided into 3 types: trunk type (I type), branch type (II type) and bifurcation type (III type).     

The deep circumflex iliac artery perforator flap (DCIAP)—A reconstructive option for the large composite oro-mandibular cutaneous defect

The deep circumflex iliac artery (DCIA) flap is often used for mandibular reconstruction but it is bulky and causes additional donor-site morbidity because of the inclusion of an “obligatory internal oblique muscle”. Large composite segmental mandibular resections that consist of floor of mouth, subtotal tongue, and adjacent facial skin are a challenge in terms of reconstruction. They often require 2 free flaps or a free scapular flap and both have disadvantages. The deep circumflex iliac artery perforator (DCIAP) flap with a cutaneous component overcomes the disadvantages. We describe reconstructions with DCIAP flaps in 3 patients with large mandibular composite segmental defects. We report our experience of the flap and discuss some of the difficulties we encountered and the points we learned perioperatively.