2. Historyο 1984 - 1st introduced by Song et al
ο 1986 - for head & neck reconstruction 1st described by
Koshima et al
ο 1992 β 1st microvascular transfer of VL muscle flap β
Wolff
ο 1995 β for lower extremity defect
ο 1996 β ultrathin flap (3-4 mm) preserving subdermal
plexus β Kimura et al
ο Very popular reconstructive flap in Asia
ο Limited use in West β
vascular anatomy variations
difficult dissection
thick thigh fat
3. Indications
Head & neck reconstructions
ο Buccal mucosa defect
ο Buccal through & through defect
ο Pharyngo-oesophageal reconstruction
ο Lower lip
ο Tongue
ο Lateral & anterior skull base
ο Scalp
ο Combined with free fibula flap
Extremity reconstruction
5. Types
ο Free flap
ο Pedicled flap
ο Distally based (on distal minor pedicle) β for knee defect
ο Proximally based β
ο Trochanteric bed sore
ο Lower abdominal defects
ο Perineal reconstruction
ο Gluteal defect
6. Types
ο Type B/C Fasciocutaneous flap (type B - septocutaneous
perforator) or ( type C - musculocutaneous perforator )
ο Musculocutaneous flap
ο Fascial flap
ο Adipo fascial flap β for Romberg disease
ο Sensate flap(include lateral femoral cutaneous nv.)
ο Osteo fascio cutaneous flap
ο Chimeric flap ( 2 or more separate defect)
ο 2 small independent flaps
ο Muscle only flap
ο Flow through flap (to salvage extremity, where proximal &
distal ends of pedicle anastomosed to recipient vessel)
7. Pre-Op preparation
ο Exclude previous trauma/surgery to thigh
ο Doppler study over
ο lateral intermuscular septum
ο 2-3 cm lateral to lateral intermuscular septum(over
medial part of VL)
ο Angiography - not helpful
ο Check for popliteal pulsation
ο Consent for - failure/risk/alternate (RFFF)
ο Donor site morbidity, knee instability / limping gait
ο No IV line in flap leg
8. Landmarks
ο Line drawn between ASIS & supero-lateral border of
patella
ο Corresponds to the septum between RF & VL.
ο Skin perforators mapped by Doppler
ο Accuracy of Doppler decreases as BMI increases.
9.
10. Flap dimensions
ο Maximum length β 30 cm
ο Maximum width β 15 cm
ο For direct closure β
maximum width β 8 - 10 cm or < 16% of thigh
circumference
15. Flap harvesting
ο Initial skin incision on medial flap aspect over RF , 2-3
cm medial to lateral inter-muscular septum.
ο Proximal incision between TFL & RF
ο Sub-fascial β incision through deep fascia with lateral
dissection until perforators identified
ο Supra-fascial - for thin flap carried laterally until
perforators identified
16.
17. Flap harvesting
ο Skin incision completed after perforator identification
ο Retrograde dissection of pedicle to descending
branch
ο May involve dissection of VL. A cuff of muscle may be
left to protect perforating branches.
ο Advantage of taking a part of VL
easy harvest β no intramuscular dissection
pedicle twisting will be less
ο Lateral femoral cutaneous nerve β sensate flap
ο Thinning performed in deep fat layer to avoid pedicle
injury.
18.
19.
20. Pedicle
ο 1 Artery, 2 Venae commitantes, motor branch of
femoral nerve to VL
ο Based on perforators from descending branch of
lateral circumflex femoral artery (90%).
ο From transverse branch of LCFA (4%).
ο From profunda femoris (4%) β pierces through RF.
Descending branch
ο Can be safely dissected proximally to its major
branch to RF, which should be preserved
ο Runs in inter-muscular space b/w RF & VL.
ο Terminates by anastomosing with superior lateral
genicular artery.
21. Dimensions of vascular pedicle
ο Average length of pedicle β 12 cm
ο Diameter ( DLCFA )
ο Artery - 1.5 β 2.5 mm ( Avg - 2.1 mm )
ο Veins β 1.8 β 3.3 mm ( Avg - 2.3 mm )
23. Perforators
ο Mapping β A (most proximal),B, C (most distal)
ο Musculocutaneous perforator (80-90%) - traverse
VL (close to medial edge) & deep fascia to supply skin
ο Septocutaneous perforator (10-20%) β
ο runs in-between RF & VL
ο pierces the fascia lata to supply skin
24. Perforator classification
ο Type 1 (50 %) β
Perpendicularly to subdermal
plexus.
ο Type 2 (35%) β
Branch in adipose & extends into
subdermal plexus.
ο Type 3 (15%) β
Extends along deep fascia &
gradually into adipose .
25. Sensory innervations
Lateral femoral cutaneous nerve(L2-L3)
ο Direct branch of lumbar plexus
ο Enters thigh deep to IL near ASIS.
ο Follows path of deep circumflex iliac artery & vein
ο Lies along line connecting ASIS to lateral patella.
ο Pierces fascia lata 10 cm distal to IL.
ο Travels in deep subcutaneous layer immediately
superficial to deep fascia.
46. Advantages
ο Minimal long term donor site morbidity
ο Long,reliable,larger pedicle
ο Large skin paddle
ο Can cover complex wound
ο Good pliability
ο No major artery is sacrificed
ο Ability to tailor the thickness of flap.
48. Post operative care
ο Removal of drain - output < 30 ml/day, with sero
sanguinous discharge.
ο Encourage to walk on 3rd post op day.
49. Post op complications
Recipient site
ο Flap necrosis
ο Fistula (head & neck
reconstruction )
ο Haemorrhage
ο Arterial occlusion
ο Local abscess
ο Exposed bone/plate
Donor site
ο STSG loss
ο Wound infection
ο Dog ears
ο Pain & weakness in thigh-
injury to nerve to VL.
ο Seroma/haematoma
ο Partial necrosis of foot &
calf β
in a case of DLCFA act as a
critical collateral for an
obstructed superficial
femoral artery.
50. Outcome & prognosis
ο Minimal long term donor site complications
ο Allowed to walk after 3 days
ο No significant decrease in strength or range of motion
51. ALT vs Radial forearm free flap
ALT
ο Increased learning curve
ο Primary closure
ο Morbidity related to vastus
lateralis damage
ο Potential dysfunction β
Quadriceps
Pain
Disto-lateral thigh
anaesthesia /paraesthesia
Radial forearm free
flap
ο Potential tendon exposure
ο Sacrifice of dominant
distal blood supply
ο Closure with STSG
ο Potential dysfunctions -
Hand stiffness
Pain
Anaesthesia / paraesthesia
52. Anatomical Variations
ο Absence of cutaneous perforator β in 5.4 %
ο Absence of descending branch β in 22.6 %
replaced by medial descending branch
( inominate branch )
ο Ascending branch can supply a perforator to upper
part of ALT, which can be used when normal ALT
perforators are inadequate
ο Other leg can be used
53. ALT Failure Etiology
ο Inadvertent perforator divison at fascial plane
ο Inadvertent perforator injury during intramuscular
dissection
ο Pedicle twisting during inset
54. Follow up β recipient area
Aesthetic
ο Sagging of flap
ο Hair growth on flap
ο Contour defect
ο Flap bulkiness β need of debulking ( shoe wearing)