Anterolateral Thigh Free Flap

Anterolateral Thigh

Free Flap Garrett Hauptman M.D.

Faculty Advisor: Vicente A. Resto, M.D., Ph.D.

The University of Texas Medical Branch

Department of Otolaryngology

Grand Rounds Presentation

April 2, 2008

Head & Neck Reconstruction Goals

#1 = Wound healing

#2 = Function

#3 = Cosmesis

Reconstructive Ladder

Secondary intention

Primary closure

Skin grafting

Local flaps

Distant pedicled flaps

Free tissue transfer

Overview

Anatomy

Flap Design

Literature Review

Comparisons

Complications

Applications

Anatomy of the Leg

Muscular Anatomy

Vascular Anatomy

Sensory Innervation

History and

Emergence

Nomenclature Clarification

ALT

1984 - Song

Anterolateral thigh skin

Lateral circumflex femoral → Descending branch

No repositioning

Lateral Thigh

1983 - Baek

Posterolateral thigh skin

Profunda femoris → 3rd cutaneous perforator

Repositioning or flexed internally rotated hip with flexed knee

Emergence of the ALT

Very popular reconstructive flap in Asia

Limited reports of use in Western countries,

particularly United States

Possible reasons

Vascular anatomy variations

Difficult dissection

Thick thigh fat

Creatures of Habitus

Workhorse Attributes

No repositioning

Remote from defect

Long pedicle

Flap Design

Tale of the Tape

Maximum size

From horizontal line at greater trochanter to horizontal line 3cm above patella

25cm X 40cm

Vascular pedicle

Length = 16cm

Diameter Artery = 2.1mm

Vein = 2.6mm

Donor site defect can be closed primarily if width < 8cm

Vascular Pedicle

Lateral circumflex femoral a. → Descending branch → Perforators

Descending branch Runs superior to inferior in intramuscular space between rectus femoris

and vastus lateralis

Terminates in vastus lateralis just above knee

Perforators: 2 types Septocutaneous: run between rectus femoris and vastus lateralis and

traverse the fascia lata to skin

Musculocutaneous: traverse vastus lateralis and deep fascia to skin

Details 8 – 16cm

2 venae commitantes

Landmarks

Line drawn between anterior superior

iliac spine (ASIS) and lateral border of

patella

Approximates septum between rectus

femoris and vastus lateralis

Skin perforators mapped by Doppler

Accuracy decreases as BMI increases

Yu P. Plast Reconstr Surg 2006

Perforator Mapping

Kimata Y. Plast Reconstr Surg 1998

70 pts.

Perforator Mapping

Yu P. Head Neck 2004

72 pts.

Perforator Mapping

Most consistently present perforator midway between ASIS and superolateral patella

Another perforator may be found more distally and more proximally All within 5cm apart from each other

Perforators labeled A, B, and C A = most proximal

C = most distal

Perforators range between 0 and 3 per patient with 2.04 being the mean per patient 0 = 2%

1 = 22%

2 = 54%

3 = 22%


Cutaneous Perforator Origin

3 Different Origins

Type I: descending branch of lateral circumflex femoris artery (90%)

Type II: single cutaneous perforator originates from the transverse branch of lateral circumflex femoris artery and travels longitudinally in vastus lateralis (4%)

Type III: single perforator from profundus femoris artery pierces through rectus femoris (4%)



Cutaneous Perforator Origin

Type I

Right Thigh


Type II

Left Thigh


Type III

Right Thigh


Perforator Classification

Type 1 (50%): extends

perpendicularly to subdermal

plexus

Type 2 (35%): branch in

adipose and extends to

subdermal plexus

Type 3 (15%): extend along

deep fascia and gradually into

adipose

Kimura N et al. Plast Reconstr Surg 2001

Flap Harvesting

Initial skin incision on medial flap aspect

Lateral dissection

Suprafascial technique for thin flap carried laterally

until perforators identified

Fasciocutaneous flap (subfascial) involves incision

through deep fascia with lateral dissection until

perforators identified

Flap Harvesting

Flap Harvesting

Flap Harvesting

Skin incisions completed upon perforator identification

Retrograde dissection of pedicle to descending branch

May involve dissection of vastus lateralis- cuff of muscle may

be left to protect perforating branches

Lateral femoral cutaneous nerve of thigh may be used

for sensation

Thinning performed in deep fat layer to avoid pedicle

injury

Sensory Innervation

Lateral femoral cutaneous nerve

Direct branch of lumbar plexus (L2-L3)

Enters thigh deep to lateral aspect of inguinal ligament near anterior superior iliac spine

Follows path of deep circumflex iliac artery and vein

Lies along line connecting ASIS to lateral patella

Travels in deep subcutaneous layer immediately superficial to deep fascia

Sensory Innervation


Flap Composition

Subcutaneous

Fasciocutaneous

Myocutaneous

Adipofascial

Modifications

Two Independent Flaps

Chou EK. Plast Recostr Surg 2006

Use of Tissue Expander to Allow

Primary Closure

Hallock G. Ann Plast Surg 2004

The Survey Says

RF’s “Big Brother”

34 consecutive cases

2 flaps with partial necrosis

No flap failures

No significant donor morbidity

Skin

Large – 40cm X 25cm

Moderately thick

Uniform

Sensate potential

Multipaddle skin potential

Lueg E. Arch Otolaryngol Head Neck Surg 2004

Largest Case Series

672 ALTs in 660 pts.

87% musculocutaneous perforators & 13% septocutaneous perforators

439 flaps cutaneous/fasciocutaneous based on musculocutaneous perforators

Flap failure (15) Total = 1.8%

Partial = 2.5%

Wei F. Plast Reconstr Surg 2002

Septocutaneous –vs-

Musculocutaneous Amount & Type Septocutaneous (%) Musculocutaneous (%)

Song 1984 9 flaps 100 0

Xu 1988 42 cadavers 40 60

Koshima 1989 13 flaps 61.5 38.5

Zhou 1991 32 flaps 37 63

Wolff 1992 100 cadavers 10 90

Pribaz 1995 44 flaps 36 64

Shimizu 1997 41 cadavers 49 51

Kimata 1997 38 flaps 26.3 73.7

Sheih 1998 37 flaps 16.2 83.8

Kimata 1998 70 flaps 18 82

Luo 1999 152 flaps 18 82

Demirkan 2000 59 flaps 12 88

Wei 2002 672 flaps 13 87

Makitie 2003 39 flaps 23 77

Septocutaneous –vs-

Musculocutaneous Amount & Type Septocutaneous (%) Musculocutaneous (%)

Song 1984 9 flaps 100 0

Xu 1988 42 cadavers 40 60

Koshima 1989 13 flaps 61.5 38.5

Zhou 1991 32 flaps 37 63

Wolff 1992 100 cadavers 10 90

Pribaz 1995 44 flaps 36 64

Shimizu 1997 41 cadavers 49 51

Kimata 1997 38 flaps 26.3 73.7

Sheih 1998 37 flaps 16.2 83.8

Kimata 1998 70 flaps 18 82

Luo 1999 152 flaps 18 82

Demirkan 2000 59 flaps 12 88

Wei 2002 672 flaps 13 87

Makitie 2003 39 flaps 23 77

ALT Versus

ALT –vs- RF for Intraoral Defects

ALT

Increased learning curve

Primary closure

Morbidity related to

vastus lateralis damage

Potential dysfunction

Quadriceps

Pain

Disto-lateral thigh

anesthesia/parasthesia

RF

Potential tendon exposure

Sacrifice dominant distal

forearm blood supply

Usually close with STSG

Potential dysfunction

Hand stiffness

Pain

Anesthesia/parasthesia

No functional difference with speech or swallow in

20 pts. – 10 ALT, 10 RF

Farace F. J Plast Reconstr Aesth Surg 2007

Advanced Tongue Cancer

Reconstruction: Functional Outcome

Chien C. J Cancer Surg 2006

Advanced Tongue Cancer

Reconstruction: Functional Outcome

Chien C. J Cancer Surg 2006

Reconstruction Trends:

Pharyngectomy

153 pharyngectomy pts.

85 partial

68 circumferential

Clark J. Laryngoscope 2006

Reconstruction Trends:

Pharyngectomy

Clark J. Laryngoscope 2006

Pharyngoesophageal Reconstruction:

ALT –vs- Jejunal Flaps

57 circumferential reconstructions

26 ALT & 31 FJT

Results

Better function

Quicker recovery

More cost-effective

Similar complication rates


Complications: ALT –vs- FJT


TEP Speech: ALT –vs- FJT

ALT = 89% FJT = 22%


Swallowing: ALT –vs- FJT


Hospital Course: ALT –vs- FJT


New Sensation

Implications of Sensory Innervation


Implications of Sensory Innervation

Superior sensory recovery in all testing modalities

2 point discrimination

Monofilament testing

Pain

Temperature

Improves swallow function

Improves patient satisfaction

Post-op XRT may delay sensory recovery


Complications

ALT Failure Etiology

Inadvertent perforator division at fascial plane

Inadvertent perforator injury during intramuscular dissection

Pedicle twisting during inset

Vessel size mismatch

Celik N. Plast Reconstr Surg 2002

ALT Failure Rates

Failure (%)

Sheih 2000 2.7

Demirkan 2000 3.3

Wei 2002 2.2

Makitie 2003 2.6

Donor-Site Morbidity

37 pts. with free or pedicled ALT

32 primary closure & 5 STSG closure

Results

Primary closure All normal ADLs

87.5% appearance satisfaction

1 pt. with ↓ ROM

STSG 3/5 with ↓ ROM

Less appearance satisfaction

Sensation deficit in 87.5% of entire group

Kimata Y. Plast Reconstr Surg 2000

Donor-Site Morbidity:

ALT –vs- RF

37 pts. : 18 ALT, 19 RF

Telephone questionnaire

Results

Bothered by cold

RF: 26% -vs- ALT: 0%

Shape difference bothersome

RF: 32% -vs- ALT: 11%

Novak C. Microsurgery 2007

Complications

Necrosis of lower limb- case

report

Obstructed superficial

femoral artery by

angiography

Lateral circumflex femoral

artery supplied critical

collaterals

Importance of checking

popliteal pulsations

Absence necessitates

angiography

Hage J. Ann Plast Surg 2004

Post-Operative Complications

Mureau M. Plast Reconstr Surg 2005

23 patients

Objective Functional and Aesthetic

Follow-up: Recipient Site


14 patients

Objective Functional and Aesthetic

Follow-up: Donor Site


14 patients

Post-Op Scar

Flap Smorgasbord

AVM

Pre-operative selective embolization

Resection & ALT reconstruction 6 months post-

embolization

Koshima I. Ann Plast Surg 2003

Buccal Mucosa Defects

Mouth opening and oral intake preserved

Chuang HC. Otolaryngol Head neck Surg 2007

Buccal Through-and-Through

Lower Lip

Yildirim S. Plast Reconstr Surg 2006

Pharyngoesophageal Reconstruction

Genden E. Arch Otolaryngol Head Neck Surg 2005

Lateral Skull Base Defects

Malata C. Ann Plast Surg 2006

Tongue and FOM

Agostini V. Brit J Plast Surg 2003

Anterior Skull Base

Scalp

Calikapan G. Microsurgery 2006

Scalp

Combined with Fibula Free Flap

How About Us?

“We’re Doing ’em”

Anterior Skull Base

Total Glossectomy-Total

Laryngectomy

Total Glossectomy – Total

Laryngopharyngectomy

Questions

Bibliography

Hallock GG. The preexpanded anterolateral thigh free flap. Ann Plast Surg. 2004 Aug;53(2):170-3.

Lueg EA. The anterolateral thigh flap: radial forearm's "big brother" for extensive soft tissue head and neck defects. Arch Otolaryngol Head Neck Surg. 2004 Jul;130(7):813-8.

Lin DT, Coppit GL, Burkey BB. Use of the anterolateral thigh flap for reconstruction of the head and neck. Curr Opin Otolaryngol Head Neck Surg. 2004 Aug;12(4):300-4. Review.

Rodríguez-Vegas JM, Trillo Bohajar E, Ruiz Alonso E, Casado Pérez C. Refining the anterolateral thigh free flap to prevent orocervical fistula in head and neck reconstruction. Plast Reconstr Surg. 2004 Jul;114(1):174-7. No abstract available.

Hage JJ, Woerdeman LA. Lower limb necrosis after use of the anterolateral thigh free flap: is preoperative angiography indicated? Ann Plast Surg. 2004 Mar;52(3):315-8.

Yu P. Reinnervated anterolateral thigh flap for tongue reconstruction. Head Neck. 2004 Dec;26(12):1038-44.

Yu P. Characteristics of the anterolateral thigh flap in a Western population and its application in head and neck reconstruction. Head Neck. 2004 Sep;26(9):759-69.

Mäkitie AA, Beasley NJ, Neligan PC, Lipa J, Gullane PJ, Gilbert RW. Head and neck reconstruction with anterolateral thigh flap. Otolaryngol Head Neck Surg. 2003 Nov;129(5):547-55.

Hsieh CH, Yang CC, Kuo YR, Tsai HH, Jeng SF. Free anterolateral thigh adipofascial perforator flap. Plast Reconstr Surg. 2003 Sep 15;112(4):976-82.

Agostini V, Dini M, Mori A, Franchi A, Agostini T. Adipofascial anterolateral thigh free flap for tongue repair. Br J Plast Surg. 2003 Sep;56(6):614-8.

Koshima I, Nanba Y, Tsutsui T, Takahashi Y, Watanabe A, Ishii R. Free perforator flap for the treatment of defects after resection of huge arteriovenous malformations in the head and neck regions. Ann Plast Surg. 2003 Aug;51(2):194-9.

Ross GL, Dunn R, Kirkpatrick J, Koshy CE, Alkureishi LW, Bennett N, Soutar DS, Camilleri IG. To thin or not to thin: the use of the anterolateral thigh flap in the reconstruction of intraoral defects. Br J Plast Surg. 2003 Jun;56(4):409-13.

Baek CH, Kim BS, Son YI, Ha B. Pharyngoesophageal reconstruction with lateral thigh free flap. Head Neck. 2002 Nov;24(11):975-81.

Lutz BS. Aesthetic and functional advantages of the anterolateral thigh flap in reconstruction of tumor-related scalp defects. Microsurgery. 2002;22(6):258-64.

Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin CH. Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps. Plast Reconstr Surg. 2002 Jun;109(7):2219-26; discussion 2227-30.

Celik N, Wei FC, Lin CH, Cheng MH, Chen HC, Jeng SF, Kuo YR. Technique and strategy in anterolateral thigh perforator flap surgery, based on an analysis of 15 complete and partial failures in 439 cases. Plast Reconstr Surg. 2002 Jun;109(7):2211-6; discussion 2217-8.

Rajacic N, Gang RK, Krishnan J, Lal Bang R. Thin anterolateral thigh free flap. Ann Plast Surg. 2002 Mar;48(3):252-7.

Cipriani R, Contedini F, Caliceti U, Cavina C. Three-dimensional reconstruction of the oral cavity using the free anterolateral thigh flap. Plast Reconstr Surg. 2002 Jan;109(1):53-7.

Kimura N, Satoh K, Hasumi T, Ostuka T. Clinical application of the free thin anterolateral thigh flap in 31 consecutive patients. Plast Reconstr Surg. 2001 Oct;108(5):1197-208; discussion 1209-10.

Kim HG, Ha B, Baek CH, Park YJ, Hyon WS, Kim JJ, Shin MS. The short head of the biceps femoris as a monitor for the free lateral thigh flap in pharyngoesophageal reconstruction. Br J Plast Surg. 2001 Jan;54(1):62-6.

Kimata Y, Uchiyama K, Ebihara S, Sakuraba M, Iida H, Nakatsuka T, Harii K. Anterolateral thigh flap donor-site complications and morbidity. Plast Reconstr Surg. 2000 Sep;106(3):584-9.

Shieh SJ, Chiu HY, Yu JC, Pan SC, Tsai ST, Shen CL. Free anterolateral thigh flap for reconstruction of head and neck defects following cancer ablation. Plast Reconstr Surg. 2000 Jun;105(7):2349-57; discussion 2358-60.

Demirkan F, Chen HC, Wei FC, Chen HH, Jung SG, Hau SP, Liao CT. The versatile anterolateral thigh flap: a musculocutaneous flap in disguise in head and neck reconstruction. Br J Plast Surg. 2000 Jan;53(1):30-6.

Ao M, Uno K, Maeta M, Nakagawa F, Saito R, Nagase Y. De-epithelialised anterior (anterolateral and anteromedial) thigh flaps for dead space filling and contour correction in head and neck reconstruction. Br J Plast Surg. 1999 Jun;52(4):261-7.

Hayden RE, Deschler DG. Lateral thigh free flap for head and neck reconstruction. Laryngoscope. 1999 Sep;109(9):1490-4.

Luo S, Raffoul W, Luo J, Luo L, Gao J, Chen L, Egloff DV. Anterolateral thigh flap: A review of 168 cases. Microsurgery. 1999;19(5):232-8.

Ha B, Baek CH. Head and neck reconstruction using lateral thigh free flap: flap design. Microsurgery. 1999;19(3):157-65.

Kimata Y, Uchiyama K, Ebihara S, Nakatsuka T, Harii K. Anatomic variations and technical problems of the anterolateral thigh flap: a report of 74 cases. Plast Reconstr Surg. 1998 Oct;102(5):1517-23.

Truelson JM, Leach JL. Lateral thigh flap reconstruction in the head and neck. Otolaryngol Head Neck Surg. 1998 Feb;118(2):203-10.

http://www.ncbi.nlm.nih.gov/sites/?Db=pubmed&Cmd=ShowDetailView&TermToSearch=15269589&ordinalpos=40&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum



























































Bibliography

Novak CB, Lipa JE, Noria S, Allison K, Neligan PC, Gilbert RW. Comparison of anterolateral thigh and radial forearm free flap donor site morbidity. Microsurgery. 2007;27(8):651-4.

Chuang HC, Su CY, Jeng SF, Chien CY. Anterior lateral thigh flap for buccal mucosal defect after resection of buccal cancer. Otolaryngol Head Neck Surg. 2007 Oct;137(4):632-5.

Posch NA, Mureau MA, Dumans AG, Hofer SO. Functional and aesthetic outcome and survival after double free flap reconstruction in advanced head and neck cancer patients. Plast Reconstr Surg. 2007 Jul;120(1):124-9.

Farace F, Fois VE, Manconi A, Puddu A, Stomeo F, Tullio A, Meloni F, Pisanu G, Rubino C. Free anterolateral thigh flap versus free forearm flap: Functional results in oral reconstruction. J Plast Reconstr Aesthet Surg. 2007;60(6):583-7. Epub 2007 Jan 24.

Hurvitz KA, Kobayashi M, Evans GR. Current options in head and neck reconstruction. Plast Reconstr Surg. 2006 Oct;118(5):122e-133e. Review.

Yu P, Youssef A. Efficacy of the handheld Doppler in preoperative identification of the cutaneous perforators in the anterolateral thigh flap. Plast Reconstr Surg. 2006 Sep 15;118(4):928-33; discussion 934-5.

Malata CM, Tehrani H, Kumiponjera D, Hardy DG, Moffat DA. Use of anterolateral thigh and lateral arm fasciocutaneous free flaps in lateral skull base reconstruction. Ann Plast Surg. 2006 Aug;57(2):169-75; discussion 176.

Calderón W, Borel C, Roco H, Piñeros JL, Olguin F. Primary closure of donor site in anterolateral cutaneous thigh free flap. Plast Reconstr Surg. 2006 Jun;117(7):2528-9. No abstract available.

Chou EK, Ulusal B, Ulusal A, Wei FC, Lin CH, Tsao CK. Using the descending branch of the lateral femoral circumflex vessel as a source of two independent flaps. Plast Reconstr Surg. 2006 May;117(6):2059-63.

Yildirim S, Gideroğlu K, Aydogdu E, Avci G, Akan M, Aköz T. Composite anterolateral thigh-fascia lata flap: a good alternative to radial forearm-palmaris longus flap for total lower lip reconstruction. Plast Reconstr Surg. 2006 May;117(6):2033-41.

Spyriounis PK. The extended approach to the vascular pedicle of the anterolateral thigh perforator flap: anatomical and clinical study. Plast Reconstr Surg. 2006 Mar;117(3):997-1001; discussion 1002-3.

Yu P, Lewin JS, Reece GP, Robb GL. Comparison of clinical and functional outcomes and hospital costs following pharyngoesophageal reconstruction with the anterolateral thigh free flap versus the jejunal flap. Plast Reconstr Surg. 2006 Mar;117(3):968-74.

Calikapan GT, Yildirim S, Aköz T. One-stage reconstruction of large scalp defects: anterolateral thigh flap. Microsurgery. 2006;26(3):155-9.

Ozkan O, Mardini S, Chen HC, Cigna E, Tang WR, Liu YT. Repair of buccal defects with anterolateral thigh flaps. Microsurgery. 2006;26(3):182-9.

Clark JR, Gilbert R, Irish J, Brown D, Neligan P, Gullane PJ. Morbidity after flap reconstruction of hypopharyngeal defects. Laryngoscope. 2006 Feb;116(2):173-81.

Chien CY, Su CY, Hwang CF, Chuang HC, Jeng SF, Chen YC. Ablation of advanced tongue or base of tongue cancer and reconstruction with free flap: functional outcomes. Eur J Surg Oncol. 2006 Apr;32(3):353-7. Epub 2006 Feb 7.

Lyons AJ. Perforator flaps in head and neck surgery. Int J Oral Maxillofac Surg. 2006 Mar;35(3):199-207. Epub 2005 Nov 15. Review.

Genden EM, Jacobson AS. The role of the anterolateral thigh flap for pharyngoesophageal reconstruction. Arch Otolaryngol Head Neck Surg. 2005 Sep;131(9):796-9.

Posch NA, Mureau MA, Flood SJ, Hofer SO. The combined free partial vastus lateralis with anterolateral thigh perforator flap reconstruction of extensive composite defects. Br J Plast Surg. 2005 Dec;58(8):1095-103. Epub 2005 Jul 25.

Chen CM, Chen CH, Lai CS, Lin SD, Huang IY, Shieh TY. Anterolateral thigh flaps for reconstruction of head and neck defects. J Oral Maxillofac Surg. 2005 Jul;63(7):948-52.

Sekido M, Yamamoto Y, Sugihara T. Arterial blood flow changes after free tissue transfer in head and neck reconstruction. Plast Reconstr Surg. 2005 May;115(6):1547-52.

Mureau MA, Posch NA, Meeuwis CA, Hofer SO. Anterolateral thigh flap reconstruction of large external facial skin defects: a follow-up study on functional and aesthetic recipient- and donor-site outcome. Plast Reconstr Surg. 2005 Apr;115(4):1077-86.













































Documents

Anterolateral Thigh Free Flap