Anterolateral thigh flap
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plastic & reconstructive surgery
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Anterolateral thigh flap
- 2. 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
- 3. 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
- 4. Contraindications Previous surgeries Injury to upper thigh Morbid obesity – too thick flap – Difficult intramuscular dissection Severe peripheral disease
- 5. 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
- 6. 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)
- 7. 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
- 8. 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.
- 10. Flap dimensions Maximum length – 30 cm Maximum width – 15 cm For direct closure – maximum width – 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 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
- 17. 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.
- 20. 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.
- 21. 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 )
- 23. 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
- 24. 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 .
- 25. 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.
- 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 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.
- 47. Disadvantages Bulky flap Hair bearing flap in male Primary closure of donor site is not possible in most cases.
- 48. Post operative care Removal of drain - output < 30 ml/day, with sero sanguinous discharge. Encourage to walk on 3rd post op day.
- 49. 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.
- 50. Outcome & prognosis Minimal long term donor site complications Allowed to walk after 3 days No significant decrease in strength or range of motion
- 51. 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
- 52. 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
- 53. ALT Failure Etiology Inadvertent perforator divison at fascial plane Inadvertent perforator injury during intramuscular dissection Pedicle twisting during inset
- 54. Follow up – recipient area Aesthetic Sagging of flap Hair growth on flap Contour defect Flap bulkiness – need of debulking ( shoe wearing)
- 55. Follow up recipient area…. Functional Speech problems Oral incompetence Eating problems Facial pain Nasal obstruction
- 56. Follow up – Donor area Aesthetic Hypertrophic scar Hypo/hyper pigmentation Keloid Contour defect
- 57. Follow up donor site…. Functional Slightly limping gait Sensory disturbances Cold intolerance
- 58. Controversies Anatomy – unpredictable Dissection – difficult Doppler identification of perforator is difficult.
- 59. Future Emerged as new workhouse flap for soft tissue head & neck reconstruction.