The anterolateral thigh – Vastus lateralis conjoint flap for complex defects of the lower limb

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  • The anterolateflap for comple

    Chin-Ho Wong a,*, Ye

    aDepartment of Plastic Reconstru169608, SingaporebDepartment of Plastic Surgery, CTaoyuan, Taiwan

    cepted

    Trauma;Soft tissue;

    Results: The mean size of the skin flap was 355 cm (range: 312e420 cm ) and the volume ofthe muscle flap was 210 cm3 (range: 42e360 cm3). All flaps survived completely and no infec-

    severely traumatised with significant tissue loss, the muscle component can be precisely posi-

    aler

    byElsevier Ltd. All rights reserved.

    * Corresponding author. Tel.: 65 63214686; fax: 65 62209340.E-mail address: wchinho@hotmail.com (C.-H. Wong).

    Journal of Plastic, Reconstructive & Aesthetic Surgery (2012) 65, 235e239

    1748-6815/$-seefrontmatter2011BritishAssociationofPlastic,ReconstructiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.doi:10.1016/j.bjps.2011.08.043tioned to obliterate the dead space and to optimise soft-tissue coverage of the wound.Conclusion: The anterolateral thighevastus lateralis conjoint flap is superior to conventionflaps available for coverage of extensive defects of the lower limb. It can cover far greatarea as well as providing the versatility needed to optimise soft-tissue coverage. 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Publishedtive complications were noted in our patients. The skin and muscle component were widelyseparated to expand the area of coverage. In cases where specific areas of the wound wereLeg;Lower limb

    Methods and materials: From Jan 2010 to June 2011, seven patients were reconstructed withthe anterolateral thighevastus lateralis conjoint flap. Three cases were traumatic deglovinginjury of the lower limb, three were open fractures of the tibia with extensive soft-tissue lossand one was a large soft-tissue defect as a result of necrotising fasciitis. The skin island andmuscle component were raised with independent pedicles to allow complete freedom in theinset of each flap based on a common pedicle. The descending and oblique branches of thelateral circumflex femoral artery were used as the pedicle of the conjoint flap in four andthree cases, respectively.

    2 2Received 8 August 2011; ac

    KEYWORDSChimeric;ral thigh e Vastus lateralis conjointx defects of the lower limb

    e Siang Ong a, Fu-Chan Wei b

    ctive and Aesthetic Surgery, Singapore General Hospital, Outram Road, Singapore

    hang Gung Memorial Hospital and Medical College, Chang Gung University,

    21 August 2011

    Summary Introduction: Complex and extensive lower limb defects remain difficult recon-structive problems. Conventional flaps may not be large enough or lack the versatility thatallows precise tissue positioning to optimally cover the wound. The anterolateral thighevastuslateralis conjoint flap provides a superior reconstructive solution for these difficult wounds.

  • as abscess formation and osteomyelitis.3,4

    the problem of inadequate dimension due to inherent

    236 C.-H. Wong et al.are identified and the rectus femoris is then lifted off the calcaneum as well as the distal tibia were exposedlimitation of movement and mobility between the muscleand the skin paddle.

    The design of an anterolateral thighevastus lateralisconjoint (ALT-VL(c)) flap is able to provide both skin andmuscle components independently based on differentvascular branches from the same pedicle source vessel. Ithelps increase the surface area available for coverage ofdefects of greater dimensions. The relative independenceof the skin paddle and vastus lateralis also allows moreprecise positioning of both two components to optimisetheir use for coverage defect, soft-tissue volume replace-ment as well as for dead space obliteration.9,10 This articlereports our experience with its application in reconstruc-tion of complex lower limb defects. It also highlights theclinical significance of the anatomy of the anterolateralthigh flap recently known.11

    Materials and methods

    From January 2010 to June 2011, seven patients withcomplex lower limb defects were reconstructed with theALT-VL(c) flap. Three cases were traumatic degloving injuryof the lower limb, three were open fractures of the tibiawith extensive soft-tissue loss and one was a large soft-tissue defect as a result of necrotising fasciitis.

    Surgical technique

    The anterolateral thigh flap was raised as previouslydescribed8 with modifications specific to harvesting theALT-VL(c) flap highlighted here. The dimensions of the skinisland required based on the defect size is marked centredon the skin vessel as located by the hand-held Doppler. Themedial incision is made and the skin flap elevated to theintermuscular septum between the rectus femoris and thevastus lateralis. The skin vessels that will supply the flapThe anterolateral thigh flap, with is versatility and lowdonor-site morbidity, is increasingly becoming the flap ofchoice for coverage of a variety of lower limb defects.4e7

    However, for reconstruction of defects of greater dimen-sions, anterolateral thigh skin flap may not be sufficient asthe transverse dimension that can be reliably harvested isusually

  • The anterolateral thigh 237(Figure 1-A). In view of the extensive nature of the defectwith vital structures exposed anteriorly, posteriorly as wellas inferiorly, reconstruction with a free ALT-VL(c) flap wasplanned. This was harvested based on the descendingbranch of the lateral circumflex femoral artery with a skinpaddle measuring 26 12 cm2 and a piece of the vastuslateralis measuring 12 8 2 cm3 (Figure 1-B). Micro-anastomoses were performed to the dorsalis pedis. Theskin was used to cover the posteroinferior aspect of thewound (the Achilles tendon and calcaneum) and themuscle was transposed cephalically to cover the exposedtibia. Skin grafting was performed over the muscle as wellas areas of the wound that is not covered by the flap.Healing was uneventful and he was able to return to workas a dispatch driver 3 months after his injury. Figure 1-Cshows him at 1-year follow-up.

    Figure 1 (A) A left leg and foot degloving injury. Critical structuretibia. (B) The anterolateral thighevastus lateralis conjoint flap harvup. He was able to return to work and reported no discomfort witCase 2

    A 34-year-old man presented with Gustillo type III B openfracture. In addition to the large circumferential soft-tissuedefect involving the entire leg, the tissue loss was partic-ularly severe over the distal third of the leg with significantbone loss (Figure 2-A). An ALT-VL(c) flap was harvested with28 14 cm2 skin flap and a piece of vastus lateralis musclemeasuring 4 7 1.5 cm3 was harvested based on theoblique branch of the lateral circumflex femoral artery(Figure 2-B). Microanastomoses were performed end to sideto the anterior tibial artery and end to end to the venacomtantes of the anterior tibial artery. The muscle wasinset into the distal leg bony defect to obliterate the deadspace and the entire distal leg wound covered by the skinflap. Proximally, the wound was skin grafted. The flap

    s exposed include the calcaneum, tendoarchilles and the distalested. DB; descending branch. (C) The patient at 1-year follow-h his daily activities.

  • 238 C.-H. Wong et al.survived completely and this optimised soft-tissue recon-struction allowed for a second stage bone grafting andexchange plating which was performed 3 months after theaccident. The patient was able to ambulate and return towork subsequently (Figure 2-C).

    Discussion

    In selected complex lower limb wounds, the ALT-VL(c) flapis superior to the anterolateral thigh skin flap, its

    Figure 2 (A) Gustillo III B open fracture with circumferential extesignificant bone loss and comminution of the bone. (B) Intraoperperforators, were noted to originate from the oblique branch (OBbranch leaving the descending branch (DB) in situ. (C) The anteroeralis (VL) was precisely inset over the area of bone exposure and ctissue replacement in this area of more severe trauma. The entire w(ALT). (E) Patient at 4 months post-op, before the exchange platinmyocutaneous counterpart or any available conventionalmuscle or skin flaps.10 It is particularly useful in thefollowing situations. First, in wounds that are in need ofextensive resurfacing where part of the defect can beresurfaced by the skin component and part of it by themuscle component. This in effect achieves coverage thatcan be only provided by two conventional free flaps witha single conjoint flap. In our experience, the ALT-VL(c) flapis able to cover far greater dimensions that are achievablewith the latissimus dorsi flap, considered one of the largestmuscle flaps available. More importantly, because of the

    nsive soft-tissue loss over the leg. In the distal tibia, there wasatively, the anterolateral thigh skin, supplied by the A and B). The ALT-VLc flap was thus harvested based on the Obliquelateral thighevastus lateralis conjoint flap. (D) The vastus lat-omminution, obliterating the dead space and providing for soft-ound bed was then covered over by the anterolateral thigh sking and bone grafting.

  • independent mobility of each component, these can beaccurately inset into critical areas that need to be coveredby well-vascularised tissue. This gives the conjoint flap anadded versatility if the critical areas to be covered arewidely separated within a larger wound. Second, the ALT-VL(c) flap is also versatile in complex wounds witha specific area of concern within a larger area that needs

    Ethical approval

    Not required.

    Funding

    flex femoral artery. Plast Reconstr Surg 2008 Feb;123:571e7.

    ison between free muscle and free fasciocutaneous flaps for

    The anterolateral thigh 239coverage. Providing a piece of well-vascularised muscleinto the area of severe trauma, dead space or in the areamost deficient of soft tissues will provide an optimisedreconstruction.

    We prefer to place the skin component over areas thatpotentially need to be re-elevated for secondary proce-dures, such as for later exchange plating. Furthermore, it ispreferred over areas of high stresses as skin is able towithstand the sheering forces better. Muscle is preferen-tially placed where obliteration of dead space is a majorconsideration as it conforms better than that of the skinflap into tight and narrow spaces.13

    Implications of the vascular anatomy of the antero-lateral thigh flap to the harvest of the conjoint flap, inparticular the relevance of the recently described obliquebranch of the lateral circumflex femoral artery, should bediscussed. The oblique branch is a variably present vessel inthe anterolateral thigh. It is present in about 35% ofpatients, and when present, it takes over the supply of theproximal anterolateral thigh skin.11 It also provides a largemuscle branch to the rectus femoris muscle. This isparticularly relevant in the harvest of the ALT-VL(c) flap asthe proximal skin vessels are used to supply the skincomponent while the more distal vessels need to be ligatedin order to increase the size of the muscle component thatcan be harvested. Not uncommonly, when the anterolateralthigh vascular anatomy is explored intra-operatively, theproximal skin perforators originate from the oblique branchof the lateral circumflex femoral artery. In this situation, toinclude the skin, the oblique branch would have to a usedas the pedicle of the flap. We have found that the obliquebranch can reliably supply a large piece of the vastus lat-eralis, even the entire vastus lateralis muscle. To procurea longer and larger pedicle, it can be traced proximally byligating the muscle branch to the rectus femoris. This issafe and does not compromise the blood supply to therectus femoris as the descending branch reliably suppliesa co-dominant muscle branch to the muscle. This is ourrecommended approach to harvesting the ALT-VL(c) flap inthis situation. Including the descending branch to vascu-larise the vastus lateralis while feasible will cause too muchdevascularisation of the anterolateral thigh musculature,potentially needing to ligate the two large muscle branchesto the rectus femoris (one from the descending and obliquebranches each) as well as the potentially transverse branchof the lateral circumflex femoral artery, compromising therectus femoris and the tensor fascia lata, respectively. Thisapproach is hence not advised.reconstruction of distal third and ankle traumatic open tibialfractures. Plast Reconstr Surg 2006 Jun;117(7):2468e75.12. Tan BK, Wong CH, Chew W, Hong SW. Use of the slit arterio-tomy for end-to-side arterial anastomosis in free-tissue trans-fers to the extremities. J Plast Reconstr Aesthet Surg 2009Nov;62(11):1519e23.

    13. Yazar S, Lin CH, Lin YT, Ulusal AE, Wei FC. Outcome compar-None declared.

    Conflict of interest

    None declared.

    References

    1. Lin CH, Lin YT, Yeh JT, Chen CT. Free functioning muscletransfer for lower extremity posttraumatic composite struc-ture and functional defect. Plast Reconstr Surg 2007 Jun;119(7):2118e26.

    2. Tham C, Tan BK, Hong SW, Chew WY, Low CK, Tan KC. Salvageof the massively traumatized lower extremity with sequentialfree flaps. Plast Reconstr Surg 2004 May;113(6):1746e50.

    3. Ong YS, Levin LS. Lower limb salvage in trauma. Plast ReconstrSurg 2010 Feb;125(2):582e8.

    4. Lin CH, Wei FC, Lin YT, Yeb JT, Rodreguez Ede J, Chen CT.Lateral circumflex femoral artery system: warehouse for func-tional composite free-tissue reconstruction of the lower leg. JTrauma 2006 May;60(5):1032e6.

    5. Wei FC, Jain V, celik N, et al. Have We found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps.Plast Reconstr Surg June 2002;109(7):2219e26.

    6. Wong CH, Wei FC. Microsurgical free flap in head and neckreconstruction. Head Neck 2010 Sep;32(9):1236e45.

    7. Lutz BS, Wei FC. Microsurgical workhorse flaps in head andneck reconstruction. Clin Plast Surg 2005 Jul;32(3):421e30.

    8. Wong CH, Wei FC. Anterolateral thigh flap. Head Neck 2010Apr;32(4):529e40.

    9. Posch NA, Mureau MA, Flood SJ, Hofer SO. The combined freepartial vastus lateralis with anterolateral thigh perforator flapreconstruction of extensive composite defects. Br J Plast Surg2005 Dec;58(8):1095e103.

    10. Lin YT, Lin CH, Wei FC. More degrees of freedom by usingchimeric concept in the applications of anterolateral thighflap. J Plast Reconstr Aesthet Surg 2006;59(6):622e7.

    11. Wong CH, Wei FC, Fu B, et al. Alternative vascular pedicle of theanterolateral thigh flap: the oblique branch of the lateral circum-

    The anterolateral thigh Vastus lateralis conjoint flap for complex defects of the lower limb Introduction Materials and methods Surgical technique Results Illustrative cases Case 1 Case 2

    Discussion Ethical approval Funding Conflict of interest References

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