ORIGINAL ARTICLE

Clinical experience using a tensor fascia lata flapin oncology patients

Akira Saito • Hidehiko Minakawa • Noriko Saito •

Kazuo Isu • Hiroaki Hiraga • Toshihisa Osanai

Received: 5 March 2012 / Accepted: 19 July 2013

� Springer Japan 2013

Abstract

Purpose The tensor fascia lata (TFL) flap is used to

reconstruct various anatomical structures in different

regions of the body. We herein describe the use of TFL

flaps for a variety of indications, and discuss the results of

such procedures with respect to postoperative complica-

tions in oncology patients.

Methods We reviewed 15 oncology patients who were

treated with TFL flaps.

Results The lesions were located in the groin in five patients,

the lower abdomen in five, and the buttocks, ischium, shoul-

der, thigh and upper abdomen in one patient each. Abdominal

wall reconstruction was performed in nine patients. Three

patients underwent resection of femoral vessels and the tumor

in the groin, followed by a vascular graft implant. In these

patients, the combined flaps were transferred to reconstruct

the defects. Nine patients developed complications. No total

flap loss occurred in any patient.

Conclusions Postoperative complications, such as necro-

sis in the distal part of the flap (33 %) and ventral hernias

(11 %) were seen, but these percentages were comparable

to those seen in previous reports. Our review shows that the

TFL flap is useful to reconstruct the defects in various

anatomical sites in oncology patients.

Keywords Tensor fascia lata flap � TFL flap �Reconstruction � Abdominal wall reconstruction �Oncologic patients

Introduction

The tensor fascia lata (TFL) flap is a versatile flap, and is used

both as a pedicled flap and as a free flap to reconstruct struc-

tures in various anatomical regions [1]. A TFL flap is the

preferred choice of pedicled flap used in the treatment of

pressure sores and inguinal and abdominal defects [2]. In

particular, the TFL flap is most commonly used for abdominal

wall reconstruction, since the flap undersurface is dense with a

strong sheet of fascia, the overlying skin is reliably supplied by

an anatomically constant vascular pedicle and it can offer

simultaneous fascia and skin replacement as a single unit [3].

This study aimed to show the use of TFL flaps for a

variety of indications and to discuss the postoperative

complications associated with these procedures in oncol-

ogy patients.

Patients

From 2001 to 2010, 15 oncology patients [seven (47 %)

males and eight (53 %) females] were treated with TFL

muscle flaps or myocutaneous flaps at the Hokkaido Cancer

Center, and these patients were included in a retrospective

chart review. Their mean age was 55.5 years (range

30–81 years). The mean follow-up time after surgery was

37 months (range 0–116 months).

A. Saito (&) � H. Minakawa

Division of Plastic and Reconstructive Surgery, Hokkaido

Cancer Center, Kikusui 4-2, Shiroishi-ku,

Sapporo 003-0804, Japan

e-mail: rogoredo84@gmail.com

N. Saito

Department of Plastic and Reconstructive Surgery, Graduate

School of Medicine, Hokkaido University, Kita 15, Nishi 7,

Kita-ku, Sapporo 060-8638, Japan

K. Isu � H. Hiraga � T. Osanai

Division of Orthopaedics, Hokkaido Cancer Center, Kikusui 4-2,

Shiroishi-ku, Sapporo 003-0804, Japan

123

Surg Today

DOI 10.1007/s00595-013-0733-z

Results

The patient data are summarized in Table 1. Defects after the

resection of soft tissue sarcomas were the most common

precondition (n = 13), followed by radiation ulcers (n = 2).

The lesions were located in the groin in five patients, the

lower abdomen in five patients, and in the buttocks, ischium,

shoulder, thigh and upper abdomen in one patient each.

Among 13 patients presenting with manifest tumor disease,

10 underwent surgery for primary disease and three for

recurrent disease. Among all 15 patients, six patients had

been administered radiation therapy (44–66 Gy) at the

recipient site prior to the current operation.

All flaps were harvested unilaterally. One flap was

transferred as a free vascularized flap and the other as a

pedicle flap. The flaps were harvested as a myocutaneous

flap in seven patients, as a muscle flap in two, as a muscle

flap combined with the vastus lateralis (VL) muscle in

three, as a myocutaneous flap combined with the VL

muscle in one, as a myocutaneous flap combined with the

rectus femoris muscle in one and as a myocutaneous flap

combined with the posterior thigh fasciocutaneous flap in

one case.

In all nine patients treated with a myocutaneous flap, the

donor site required a skin graft. There were eight full-

thickness abdominal wall defects and one partial-thickness

abdominal wall defect (defects involving only the loss of

skin and subcutaneous tissue). Abdominal wall recon-

struction was performed in these patients. Among these nine

patients, one developed a ventral hernia postoperatively.

Overall, nine patients (60 %) developed complications.

None of the patients had total flap loss. Four patients had

Table 1 Patient summary

Case Age Sex Diagnosis Previous treatment Site of the

lesion

Free or

pedicled

Type of flap Vascular

graft

Abdominal

wall

reconstruction

Complication Revision

surgeryOperation RT

1 30 M Synovial

sarcoma

(-) (-) Shoulder Free TFL mc-flap (-) (-) Wound

infection

(?)

2 43 F Chondrosarcoma (-) (-) Lower

abdomen

Pedicled TFL m-flap ? VL

m-flap

(-) (?) Partial flap

necrosis

wound

infection

(?)

3 56 F Epithelioid

sarcoma

(?) 66 Gy Ischium Pedicled TFL-mc

flap ? Posterior

thigh flap

(-) (-) Wound

infection

(-)

4 64 F MFH (-) 50 Gy Groin Pedicled TFL-m flap ? VL

m-flap

Autologous

vessel

(?) (-) N/A

5 76 F Radiation ulcers (?) 57 Gy Buttock Pedicled TFL mc-flap (-) (-) Partial flap

necrosis

wound

infection

(-)

6 81 M MFH (-) 44 Gy Groin Pedicled TFL m-flap ? VL

m-flap

Prosthesis (?) (-) N/A

7 53 M Radiation ulcers (?) 59.4 Gy Thigh Pedicled TFL mc-

flap ? VL

m-flap

(-) (-) (-) N/A

8 61 M Fibrosarcoma (?) (-) Groin Pedicled TFL mc-flap (-) (?) Partial flap

necrosis

ventral

hernia

(-)

9 45 F Synovial

sarcoma

(-) 44 Gy Lower

abdomen

Pedicled TFL m-flap ? RF

m-flap

Prosthesis (?) (-) N/A

10 62 F MFH (-) (-) Lower

abdomen

Pedicled TFL mc-flap (-) (?) Wound

infection

(-)

11 72 F MFH (-) (-) Lower

abdomen

Pedicled TFL mc-flap (-) (?) Partial flap

necrosis

(?)

12 30 M Leiomyosarcoma (?) (-) Groin Pedicled TFL m-flap (-) (-) Wound

dehiscence

(-)

13 44 F MPNST (-) (-) Lower

abdomen

Pedicled TFL mc-flap (-) (?) (-) N/A

14 42 M Clear cell

sarcoma

(-) (-) Upper

abdomen

Pedicled TFL m-flap (-) (?) (-) N/A

15 74 M Liposarcoma (-) (-) Groin Pedicled TFL mc-flap (-) (-) Partial flap

necrosis

(?)

RT radiation therapy, MFH malignant fibrous histiocytoma, MPNST malignant peripheral nerve sheath tumor, TFL mc-flap tensor fascia lata myocutaneous flap, TFL m-flap

tensor fascia lata muscle flap, VL m-flap vastus lateralis muscle flap, RF m-flap rectus femoris muscle flap

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distal necrosis of the skin paddle and one had distal

necrosis of the muscle flap. Five patients developed wound

infections, and one developed wound dehiscence. Among

the nine patients with complications, four required surgical

revisions. These procedures consisted of local wound

debridement, readvancement of the muscle flap, skin

grafting and the transfer of another flap. Delayed wound

healing occurred in five patients; however, no secondary

procedure was required in these patients.

The medical history of the 15 patients was acquired

from the patient charts. Of these patients, five died because

of their malignant disease and one had died the day after

the operation, but the cause of that one death was unknown.

Case report

Case 13

A 44-year-old female presented with a tumor in the left

groin. A needle biopsy had confirmed the diagnosis of

sarcoma at her previous hospital, and she was referred to

the division of Orthopaedics, Hokkaido Cancer Center, for

treatment. The tumor was approximately 5 9 5 cm in size

(Fig. 1). She underwent a wide local excision of the tumor,

including part of the rectus abdominis muscle and the

pubis, resulting in a huge defect (Fig. 2). The excised

region was covered with a pedicled TFL myocutaneous

flap from the left thigh (Fig. 3). The donor site required a

split skin graft. She recovered uneventfully, but developed

local recurrence 9 months later. She received neo-adjuvant

chemotherapy, followed by tumor resection, and abdomi-

nal wall reconstruction using a fascia lata graft. She has

remained healthy 9 months after the surgery, and there has

been no evidence of a ventral hernia (Fig. 4).

Discussion

The TFL flap has several advantages over other flaps. First,

it has consistent anatomical features [4]. The blood supply

is provided through the ascending branch of the lateralFig. 1 The sarcoma in the left groin (5 9 5 cm in size)

Fig. 2 The patient underwent a wide local excision of the tumor,

which resulted in a huge and full-thickness abdominal wall defect

Fig. 3 The design of the TFL myocutaneous flap on the left thigh

Fig. 4 The surgical results 18 months after the operation. There has

been no evidence of a ventral hernia

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femoral circumflex artery [5], which arises from the pro-

fundus femoris in 80 % of patients, or alternately, from the

common femoral or medial circumflex arteries [1]. Raising

the TFL flap is an uncomplicated procedure, and an ade-

quate-sized flap can be obtained [6]. Moreover, donor-site

morbidity is not critical [7, 8]. The donor sites for flaps up

to 10 or 12 cm in size can be closed directly [7].

Using a TFL flap is a reconstructive option for the

treatment of defects in various anatomical regions,

including the head, neck, trunk, upper limb and lower limb.

The flap can be used as either a pedicled flap or a free flap.

The TFL flap is most commonly used as a pedicled flap for

the treatment of pressure sores and groin and abdominal

wall defects [2]. In particular, this flap seems to be well

suited for abdominal wall reconstruction, as it structurally

resembles the strong and dense fascia and the thin skin

paddle of the abdominal wall [3, 8]. As a free flap, the TFL

is used for reconstructing large abdominal wall defects, as

well as head and neck, composite extremity and perineal

defects [9].

In this series, 14 out of 15 flaps were used as pedicled

flaps and only one flap was used for functional recon-

struction of a shoulder defect following tumor ablation; the

pedicled flap is frequently modified for reconstruction in

the groin and the lower abdomen. To reconstruct larger

defects, the TFL flap can be combined and used with other

flaps like the rectus femoris muscle flap [10], anterolateral

thigh flap [11] or VL muscle flap [12, 13]. We used

combined flaps in six patients; a muscle flap combined with

the VL muscle in three patients, a myocutaneous flap

combined with the VL muscle in one, a myocutaneous flap

combined with the rectus femoris muscle in one and a

myocutaneous flap combined with the posterior thigh fas-

ciocutaneous flap in one case.

All the flaps required a relatively large volume of tissue

for transfer because of the large defects following tumor

resection or debridement of irradiated tissue.

The groin is believed to be the most common site of

distal extremity graft infection [14]. The incidence of

prosthetic vascular graft infections is 1–6 % [14]. The use

of a muscle flap to cover exposed native vessels or to

salvage prosthetic material used in arterial reconstruction

has also been advocated [15]. A muscle provides bulk to

obliterate any dead space, thus diminishing the possibility

of recurrent infection [14]. The flap options include the

sartorius muscle, rectus femoris muscle, rectus abdominis

muscle, gracilis muscle and omental flaps [14, 16].

In oncology patients, it is necessary to not only cover the

vessels, but also reconstruct the skin and soft tissue defects.

In this series, three patients underwent the resection of

femoral vessels, together with the tumor in the groin

region, followed by vascular grafting. In all of these

patients, the combined flaps were transferred to reconstruct

the skin and soft tissue defects and to obliterate the dead

space around the grafts. One patient with an autologous

vessel graft died the day after the operation, but the cause

of death was unknown. Two patients received prosthetic

grafts. One of them had tumor recurrence that caused

occlusion of the femoral artery, and this patient died of

sepsis 20 months after the operation. In another patient, no

infection was observed at the 30-month follow-up.

Although the TFL flap is said to have consistent ana-

tomical features [4], distal necrosis of the TFL flap has

been frequently reported [13, 17–19]. Gosain et al. [20]

evaluated the perfusion of an extended TFL flap raised to

include the skin as far as the lateral aspect of the knee.

They described that the flap usually becomes unreliable

about 8–10 cm proximal to the knee joint. Muramatsu et al.

[17] have reported that one of 10 patients in their study

developed partial necrosis. Agarwal et al. [13] have

reported two cases of marginal flap necrosis among 15

cases studied. Rifaat et al. [18] have reported that distal flap

necrosis occurred in four out of 12 patients. Similarly, de

Vries Reilingh et al. [19] described that partial flap necrosis

can be expected in 10–50 % of patients. In this study, no

total flap loss occurred, but there were five cases of distal

necrosis (33 %), which was comparable to that docu-

mented in other reports.

It is usually assumed that the donor sites for flaps up to

10 or 12 cm in size can be closed directly [7]. However, the

most common problem of the TFL flap is reported to be

excessive tension and eventual suture separation at the

confluence of the donor site flaps and the TFL flap [21]. In

our series, the donor site required a skin graft in all nine

patients with a myocutaneous flap to prevent suture sepa-

ration, even though the flap was less than 10 cm in width

for some patients.

The TFL flap can be used to reconstruct the musculo-

fascial layer of the abdominal wall to prevent postoperative

hernia formation; however, a hernia can still be a possible

complication. Rifaat et al. [18] have reported that one out

of five patients developed a ventral hernia after undergoing

abdominal wall reconstruction with the TFL flap. Tukiai-

nen and Leppaniemi [9] have reported that a ventral hernia

occurred in one among 20 patients who underwent

abdominal wall reconstruction with a free TFL flap. Tang

et al. [22] have recommended enforcing repair with a

synthetic or biological mesh to minimize the incidence of

ventral hernia. In our series, one among the nine patients

developed a ventral hernia, but a synthetic or biological

mesh had not been used for repair.

Radiation therapy is a treatment modality used for the

pre- or postoperative local control of malignant disease

[23]. Radiation damage is known to delay healing and

increase the risk of wound infection [24], and it is rea-

sonable to choose muscle or myocutaneous flaps for an

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irradiated field, since they may be more resistant to bac-

terial infection or may not cause residual infection [23].

In this study, six patients had undergone preoperative

radiation therapy, and two patients developed complica-

tions (33 %). A wound infection developed in one of these

patients, and distal flap necrosis along with wound infec-

tion developed in another.

Conclusion

The TFL flap has proven to be versatile, and is associated

with several advantages, including consistent anatomical

features, an ease of elevation and simple donor-site repair.

In this study, we reviewed our clinical experiences using

TFL flaps in oncology patients. Postoperative complica-

tions such as distal necrosis of the flap developed in 33 %

of patients and a ventral hernia developed in 11 %, but

these incidences were comparable to those reported in

previous studies.

The number of patients in this series is very small, but

our review shows that the TFL flap is useful to reconstruct

the defects in various anatomical sites, because there were

no total flap loss or donor-site complications.

Conflict of interest None.

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