Anterolateral thigh flap
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plastic & reconstructive surgery
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Anterolateral thigh flap
- 2. History by Song et al ο 1984 - 1st introduced ο 1986 - for head & neck reconstruction 1st described by ο ο ο ο ο Koshima et al 1992 β 1st microvascular transfer of VL muscle flap β Wolff 1995 β for lower extremity defect 1996 β ultrathin flap (3-4 mm) preserving subdermal plexus β Kimura et al Very popular reconstructive flap in Asia 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
- 4. Contraindications ο Previous surgeries ο Injury to upper thigh ο Morbid obesity β too thick flap β Difficult intramuscular dissection ο Severe peripheral disease
- 5. Types ο Free flap ο Pedicled flap ο Distally based (on distal minor pedicle) β for knee defect ο Proximally based β ο ο ο ο Trochanteric bed sore Lower abdominal defects Perineal reconstruction Gluteal defect
- 6. Types ο Type B/C Fasciocutaneous flap (type B - septocutaneous ο ο ο ο ο ο ο ο ο perforator) or ( type C - musculocutaneous perforator ) Musculocutaneous flap Fascial flap Adipo fascial flap β 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)
- 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.
- 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
- 12. Muscles of antero lateral thigh
- 13. Vascular system of Anterolateral thigh & standard skin paddle
- 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
- 17. Flap harvesting ο Skin incision completed after perforator identification ο Retrograde dissection of pedicle to descending ο ο ο ο 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 β no intramuscular dissection pedicle twisting will be less Lateral femoral cutaneous nerve β sensate flap Thinning performed in deep fat layer to avoid pedicle injury.
- 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.
- 27. Medial flap incision & septum identification
- 29. Septum dissection distal to proximal
- 30. Medial retraction of RF & Identification of pedicle
- 31. Dissection of perforator & preservation of motor branches of femoral nerve
- 32. Final skin paddle & Readjustment
- 33. Medial retraction of RF & Identification of DLCFA
- 34. Skin incision
- 36. Exposure of vascular pedicle
- 39. Identification of perforator & distal ligation of pedicle
- 40. Circumcision of skin paddle
- 41. Fixation of skin paddle to muscle
- 42. Dissection of vascular pedicle
- 43. Cross section anatomy of flap
- 44. Flap ready for microvascular transfer
- 45. Myo-cutaneous flap containing 2 perforator
- 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.
- 47. Disadvantages ο Bulky flap ο Hair bearing flap in male ο Primary closure of donor site is not possible in most cases.
- 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 ο ο ο STSG loss Wound infection Dog ears Pain & weakness in thighinjury 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)
- 55. Follow up recipient areaβ¦. Functional ο Speech problems ο Oral incompetence ο Eating problems ο Facial pain ο Nasal obstruction
- 56. Follow up β Donor area Aesthetic ο Hypertrophic scar ο Hypo/hyper pigmentation ο Keloid ο Contour defect
- 57. Follow up donor siteβ¦. Functional ο Slightly limping gait ο Sensory disturbances ο Cold intolerance
- 58. Controversies ο Anatomy β unpredictable ο Dissection β difficult ο Doppler identification of perforator is difficult.
- 59. Future ο Emerged as new workhouse flap for soft tissue head & neck reconstruction.