Anterolateral thigh flap
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Anterolateral thigh flap

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plastic & reconstructive surgery

plastic & reconstructive surgery

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Anterolateral thigh flap Anterolateral thigh flap Presentation Transcript

  • Dr Subhakanta Mohapatra IPGME&R,Kolkata.INDIA
  • History by Song et al  1984 - 1st introduced  1986 - for head & neck reconstruction 1st described by      Koshima et al 1992 – 1st microvascular transfer of VL muscle flap – Wolff 1995 – for lower extremity defect 1996 – ultrathin flap (3-4 mm) preserving subdermal plexus – Kimura et al Very popular reconstructive flap in Asia Limited use in West – vascular anatomy variations difficult dissection thick thigh fat
  • Indications Head & neck reconstructions  Buccal mucosa defect  Buccal through & through defect  Pharyngo-oesophageal reconstruction  Lower lip  Tongue  Lateral & anterior skull base  Scalp  Combined with free fibula flap Extremity reconstruction
  • Contraindications  Previous surgeries  Injury to upper thigh  Morbid obesity – too thick flap – Difficult intramuscular dissection  Severe peripheral disease
  • Types  Free flap  Pedicled flap  Distally based (on distal minor pedicle) – for knee defect  Proximally based –     Trochanteric bed sore Lower abdominal defects Perineal reconstruction Gluteal defect
  • Types  Type B/C Fasciocutaneous flap (type B - septocutaneous          perforator) or ( type C - musculocutaneous perforator ) Musculocutaneous flap Fascial flap Adipo fascial flap – for Romberg disease Sensate flap(include lateral femoral cutaneous nv.) Osteo fascio cutaneous flap Chimeric flap ( 2 or more separate defect) 2 small independent flaps Muscle only flap Flow through flap (to salvage extremity, where proximal & distal ends of pedicle anastomosed to recipient vessel)
  • Pre-Op preparation  Exclude previous trauma/surgery to thigh  Doppler study over  lateral intermuscular septum  2-3 cm lateral to lateral intermuscular septum(over medial part of VL)  Angiography - not helpful  Check for popliteal pulsation  Consent for - failure/risk/alternate (RFFF)  Donor site morbidity, knee instability / limping gait  No IV line in flap leg
  • Landmarks  Line drawn between ASIS & supero-lateral border of patella  Corresponds to the septum between RF & VL.  Skin perforators mapped by Doppler  Accuracy of Doppler decreases as BMI increases.
  • Flap dimensions  Maximum length – 30 cm  Maximum width – 15 cm  For direct closure – maximum width – 8 - 10 cm or < 16% of thigh circumference
  • Muscles of antero lateral thigh
  • Vascular system of Anterolateral thigh & standard skin paddle
  • Standard flap design
  • Flap harvesting  Initial skin incision on medial flap aspect over RF , 2-3 cm medial to lateral inter-muscular septum.  Proximal incision between TFL & RF  Sub-fascial – incision through deep fascia with lateral dissection until perforators identified  Supra-fascial - for thin flap carried laterally until perforators identified
  • Flap harvesting  Skin incision completed after perforator identification  Retrograde dissection of pedicle to descending     branch May involve dissection of VL. A cuff of muscle may be left to protect perforating branches. Advantage of taking a part of VL easy harvest – no intramuscular dissection pedicle twisting will be less Lateral femoral cutaneous nerve – sensate flap Thinning performed in deep fat layer to avoid pedicle injury.
  • Pedicle  1 Artery, 2 Venae commitantes, motor branch of femoral nerve to VL  Based on perforators from descending branch of lateral circumflex femoral artery (90%).  From transverse branch of LCFA (4%).  From profunda femoris (4%) – pierces through RF. Descending branch  Can be safely dissected proximally to its major branch to RF, which should be preserved  Runs in inter-muscular space b/w RF & VL.  Terminates by anastomosing with superior lateral genicular artery.
  • Dimensions of vascular pedicle  Average length of pedicle – 12 cm  Diameter ( DLCFA )  Artery - 1.5 – 2.5 mm ( Avg - 2.1 mm )  Veins – 1.8 – 3.3 mm ( Avg - 2.3 mm )
  • Cutaneous perforator origin
  • Perforators  Mapping – A (most proximal),B, C (most distal)  Musculocutaneous perforator (80-90%) - traverse VL (close to medial edge) & deep fascia to supply skin  Septocutaneous perforator (10-20%) –  runs in-between RF & VL  pierces the fascia lata to supply skin
  • Perforator classification  Type 1 (50 %) – Perpendicularly to subdermal plexus.  Type 2 (35%) – Branch in adipose & extends into subdermal plexus.  Type 3 (15%) – Extends along deep fascia & gradually into adipose .
  • Sensory innervations Lateral femoral cutaneous nerve(L2-L3)  Direct branch of lumbar plexus  Enters thigh deep to IL near ASIS.  Follows path of deep circumflex iliac artery & vein  Lies along line connecting ASIS to lateral patella.  Pierces fascia lata 10 cm distal to IL.  Travels in deep subcutaneous layer immediately superficial to deep fascia.
  • ALT Flap Markings
  • Medial flap incision & septum identification
  • Opening of septum
  • Septum dissection distal to proximal
  • Medial retraction of RF & Identification of pedicle
  • Dissection of perforator & preservation of motor branches of femoral nerve
  • Final skin paddle & Readjustment
  • Medial retraction of RF & Identification of DLCFA
  • Skin incision
  • Incision of fascia
  • Exposure of vascular pedicle
  • Detachment of inter-muscular septum
  • Separation of pedicle components
  • Identification of perforator & distal ligation of pedicle
  • Circumcision of skin paddle
  • Fixation of skin paddle to muscle
  • Dissection of vascular pedicle
  • Cross section anatomy of flap
  • Flap ready for microvascular transfer
  • Myo-cutaneous flap containing 2 perforator
  • Advantages  Minimal long term donor site morbidity  Long,reliable,larger pedicle  Large skin paddle  Can cover complex wound  Good pliability  No major artery is sacrificed  Ability to tailor the thickness of flap.
  • Disadvantages  Bulky flap  Hair bearing flap in male  Primary closure of donor site is not possible in most cases.
  • Post operative care  Removal of drain - output < 30 ml/day, with sero sanguinous discharge.  Encourage to walk on 3rd post op day.
  • Post op complications Recipient site  Flap necrosis  Fistula (head & neck reconstruction )  Haemorrhage  Arterial occlusion  Local abscess  Exposed bone/plate Donor site     STSG loss Wound infection Dog ears Pain & weakness in thighinjury to nerve to VL.  Seroma/haematoma  Partial necrosis of foot & calf – in a case of DLCFA act as a critical collateral for an obstructed superficial femoral artery.
  • Outcome & prognosis  Minimal long term donor site complications  Allowed to walk after 3 days  No significant decrease in strength or range of motion
  • ALT vs Radial forearm free flap ALT  Increased learning curve  Primary closure  Morbidity related to vastus lateralis damage  Potential dysfunction – Quadriceps Pain Disto-lateral thigh anaesthesia /paraesthesia Radial forearm free flap  Potential tendon exposure  Sacrifice of dominant distal blood supply  Closure with STSG  Potential dysfunctions Hand stiffness Pain Anaesthesia / paraesthesia
  • Anatomical Variations  Absence of cutaneous perforator – in 5.4 %  Absence of descending branch – in 22.6 % replaced by medial descending branch ( inominate branch )  Ascending branch can supply a perforator to upper part of ALT, which can be used when normal ALT perforators are inadequate  Other leg can be used
  • ALT Failure Etiology  Inadvertent perforator divison at fascial plane  Inadvertent perforator injury during intramuscular dissection  Pedicle twisting during inset
  • Follow up – recipient area Aesthetic  Sagging of flap  Hair growth on flap  Contour defect  Flap bulkiness – need of debulking ( shoe wearing)
  • Follow up recipient area…. Functional  Speech problems  Oral incompetence  Eating problems  Facial pain  Nasal obstruction
  • Follow up – Donor area Aesthetic  Hypertrophic scar  Hypo/hyper pigmentation  Keloid  Contour defect
  • Follow up donor site…. Functional  Slightly limping gait  Sensory disturbances  Cold intolerance
  • Controversies  Anatomy – unpredictable  Dissection – difficult  Doppler identification of perforator is difficult.
  • Future  Emerged as new workhouse flap for soft tissue head & neck reconstruction.