The combined free partial vastus lateralis withanterolateral thigh perforator flap reconstructionof extensive composite defects

N.A.S. Posch, M.A.M. Mureau, S.J. Flood, S.O.P. Hofer*

Department of Plastic, Reconstructive and Hand Surgery, Erasmus University Medical Center Rotterdam,P.O. Box 2040, 3000 CA Rotterdam, The Netherlands

Received 16 April 2004; accepted 22 April 2005

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KEYWORDSAnterolateral thighflap;Vastus lateralismuscle;Chimera flap;Microsurgery

007-1226/$ - see front matter q 20i:10.1016/j.bjps.2005.04.022

* Corresponding author. Tel.: C31 1E-mail address: sophofer@hotmail.

Summary Myocutaneous (MC) free flaps are useful for many reconstructiveindications. Perforator flaps have become standard of care. The anterolateral thighflap (ALT) donor site is popular. With the ALT flap varying sizes of vastus lateralis (VL)muscle can be harvested as a MC flap. The skin islands of these flaps have a great range offreedom when dissected on their perforator. It was hypothesised that the VL–ALTperforator flap would offer adequate tissue volume combining maximal freedom inplanningwithminimal donor sitemorbidity. FromNovember 2001 to February 2003 a freepartial VL with ALT perforator flap was used in 11 patients to reconstruct large defects.Indications for adding a muscular component were exposed bone, skull base, (artificial)dura, or osteosynthesis material, open sinuses, and lack of muscular bulk. Flaps wereplanned as standard ALT flaps, after which three types of dissection were performed: I.trueMCflap; II.muscleflapwitha skin islandononeperforator,whichcouldbe rotatedupto1808; III. chimera skin perforatorflapwithmuscle being harvestedona separatebranchfrom the source vessel or on a side branch of the skin perforator. Mean skin size of theMC-ALT flaps was 131 cm2. Meanmuscle part size of the MC-ALT flaps was 268 cm3. Muscularparts were custom designed for all defects. No total or partial flap failures were seen.Colourmismatchwas seen in6of8patients,whenskinwasused in the facial area in this allwhite population. Excessive flap bulk was found in 8 of 11 patients at 6 weeks, however,only in 2of 11patients after 6months. Patientswere satisfiedwith the functional result (8of 11 patients) as well as the cosmetic result of their reconstruction (7 of 11 patients). Allless satisfiedpatientshad receivedtheirflap forexternal facial skin reconstruction.Donorsitemorbiditywasminimal. The combined free partial VLwithALTperforator flapprovedvaluable as a (chimera type) MC flap with maximal freedom of planning to meet specificreconstructive demands and minimal donor site morbidity.q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rightsreserved.

British Journal of Plastic Surgery (2005) 58, 1095–1103

05 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved.

0 463 4638; fax: C31 10 463 3731.com (S.O.P. Hofer).

N.A.S. Posch et al.1096

In current practice myocutaneous free flaps arevery useful for a wide array of reconstructiveindications. The TRAM flap and latissimus dorsiflap are probably among the most commonlyused and best known larger-size myocutaneousfree flaps.1,2 These flaps are reliable and offerexcellent tissue stock. Both flaps can be har-vested with multiple skin islands. The latissimusdorsi flap can be harvested as part of a classiccombination or chimera flap based on theregional system of the subscapular vessels.3

Donor site morbidity in both flaps is mainlyattributed to muscular harvest and is lessfavourable in TRAM flaps.4,5

Over the past few years a renaissance in flapanatomy has occurred with the widespread useof perforator based flaps.6–10 These flaps haveimproved donor site morbidity by only taking thetissues which are needed, based on direct orindirect perforators, and consequently sparingunderlying muscles. Refinements in perforatorflaps, such as flap thinning, perforator uponperforator anastomosis, and adipofascial har-vest, have further explored their boundaries.11–14 In addition, the concept of chimera flaps hasbeen put into a new perspective due to theadvent of perforator flaps.7 Previously a chimeraflap consisted of the raising of standard flaps onone known source vessel system. In the perfora-tor flap age this concept can be redefined, asparts of different tissues supplied by perforatorsfrom one flap vessel can be harvested as achimera perforator flap.

Combining the need for myocutaneous tissueswith the knowledge of modern principles ofperforator and chimera flaps, the anterolateralthigh (ALT) was chosen as a donor site. Theclassic myocutaneous ALT flap has neverreached great popularity even though thedonor site morbidity after vastus lateralis (VL)harvest is only minimal.15 The ALT flap withmuscular addition has been described pre-viously with an emphasis to facilitate dissec-tion.16,17 In this study, the ALT flap, based onperforators from the descending branch of thelateral circumflex femoral (LCF) vessels, washarvested as a chimera flap. Varying sizes of VLmuscle were harvested with the flap in specificfashions for optimal reconstruction of variousdefects. It was hypothesised that this flapwould offer adequate tissue stock combiningmaximal freedom in planning with minimaldonor site morbidity. In addition, patientsatisfaction and cosmetic outcome wereevaluated.

Patients and methods

Patient characteristics

From November 2001 to February 2003 a free partialVL with ALT perforator flap was used in 11 whitepatients (8 male, 3 female) with an average age of55 years (range 10–77 years). In 10 patients thedefect was cancer related in the head and neck areaand in one patient with spina bifida a lumbosacraldefect resulted after failed local flap coverage ofosteosynthesis material. Eight patients receivedpostoperative radiotherapy (70 Gy). Four patientshad been previously operated one to four times inthe same area. Reasons for adding a muscular partto the flap were skull base exposure (nZ6), duralexposure (nZ2), exposed osteosynthesis material(nZ1), or partial tongue base muscle replacement(nZ2). All patients except those with intraoraldefects had extensive exposure of bone. No func-tional muscle transfers were performed by reanas-tomosing a motor nerve. In Table 1 defect detailsand operation indications are presented.

Measurements

Patient satisfaction with the functional and cos-metic outcome of their reconstruction and donorsite was obtained from patient files kept duringregular outpatient visits at follow-up using five-point scales (1Zvery dissatisfied; 5Zvery satis-fied). Cosmetic and functional outcome was alsoassessed by the surgeon (S.H.) scoring the presenceof flap bulkiness, colour mismatch, contour defect,flap contracture and flap sagging as indicated.

Surgical technique

All flaps were planned as standard ALT flaps.Dissection of these (fascio) cutaneous flaps hasbeen described in detail previously.18 In short, aline was drawn between the anterosuperior iliacspine and the superolateral aspect of the patella,indicating the intramuscular septum between rec-tus femoris and VL muscles. A Doppler probe wasused to identify skin perforators along the intra-muscular septum region. A skin flap was outlinedaround marked perforators. A medial exploringincision was first made down to the fascia overthe rectus femoris muscle. Suprafascial or subfas-cial dissection was performed depending on thereconstructive need for fascia lata in the flap. Insubfascial dissection the fascia was incised anddissection proceeded laterally towards the intra-muscular septum between rectus femoris and VL

Table 1 Defect details and operation indications

Case Sex Age Indication operation Location defect Indication muscle part of flap

1 M 56 Recurrent SCC Frontoparietal/orbita R Bone/open sinus/orbitalexenteration

2 M 69 Recurrent BCC Frontoparietal/orbita R Bone/open sinus/orbitalexenteration

3 M 63 Recurrent SCC Fronta/orbita/cheek R Bone/open sinus/orbitalexenteration

4 M 50 BCC Temporal/zygoma/N VII R Bone/exposed dura5 F 77 BCC Frontoparietal R Bone/exposed dura6 M 65 Angiosarcoma Cheek/orbit R Bone/open sinus/orbital

exenteration7 M 51 BCC Frontal/nose/orbit L Open sinuses/orbital

exenteration8 F 61 BCC Entire midface/orbit L Open sinuses/orbital

exenteration9 F 10 Skin defect area T8-L5

after spondylodesisLumbar spine Bone/osteosynthesis

material10 M 48 SCC Tongue base/mobile tongue L No bulk tongue base11 M 62 SCC Tongue base/mobile tongue L No bulk tongue base

Indications for ALT skin were large external skin defects (cases 1–9) or missing mobile tongue (cases 10 and 11); SCC, squamous cellcarcinoma; BCC, basal cell carcinoma.

Combined vastus lateralis with anterolateral thigh perforator flap 1097

muscles. Perforators, with both dissection tech-niques, were identified and classified as septocuta-neous or musculocutaneous perforators. Beforeperforator dissection the descending branches ofthe LCF vessels were identified to clarify theirspecific course. From this point on dissection wastailored to the specific need of muscle in the flap. Inthis study three different muscular requirementswere dissected. First, dissection was performed asa large musculocutaneous flap. This type does notdiffer much from a standard musculocutaneous VL–

Figure 1 Schematic representation of a musculocuta-neous vastus lateralis with anterolateral thigh skin flapwith a skin island based on multiple perforators on top ofthe vastus lateralis muscle.

ALT flap, except that the skin island washarvested on its perforators. The skin partcould be left on a few perforators as its positionon top of the muscle was adequate (Figs. 1–4).Second, dissection was performed as a flapwhere muscle with a highly mobile skin islandwas needed. The skin island was raised as anALT flap on one perforator. This perforator wasdissected free into the muscle so that itobtained the necessary freedom of movement.This skin island could then be rotated up to 1808(Figs. 5–8). Third, dissection was performed as aflap where muscle with a separate skin island

Figure 2 Lumbar defect in a 10-year-old spina bifidapatient with exposed osteosynthesis material after T8-L5spondylodesis and failed local flap coverage.

Figure 3 Musculocutaneous partial vastus lateralis withanterolateral thigh skin flap in right donor leg.

Figure 5 Schematic representation of a musculocuta-neous vastus lateralis with anterolateral thigh skinperforator flap with a skin island based on a single skinperforator enabling maximal rotation of the skin inrelation to the muscle.

N.A.S. Posch et al.1098

was needed. The skin island was raised until itsorigin from the descending branch of the LCFvessels. The muscle was harvested based on aside branch of the perforator of the skin islandor based on a separate perforator from thedescending branch as a chimera type flap (Figs.

Figure 4 Reconstructed lumbar area showing musculo-cutaneous partial vastus lateralis with anterolateral thighflap at 7 months follow-up.

9–12). In all types of dissection, once the bloodsupply had been determined, the remainder ofthe skin flap and the final amount of musclerequired were dissected. The vascular pedicle

Figure 6 Right temporal defect after extensive resec-tion of a basal cell carcinoma with transdural growth.

Figure 7 Musculocutaneous partial vastus lateralis withanterolateral thigh skin perforator flap, where the skinpart was harvested on a single perforator enabling liberalindependent movement of muscle and skin.

Figure 9 Schematic representation of a chimeramusculocutaneous vastus lateralis with anterolateralthigh skin perforator flap with a muscular part on itsindividual vascular pedicle.

Combined vastus lateralis with anterolateral thigh perforator flap 1099

was finally dissected from distal to proximaluntil its origin from the deep femoral vessels.Motor innervation to the remaining VL musclewas preserved meticulously.

Figure 8 Reconstructed temporal defect showingmusculocutaneous partial vastus lateralis with anterolat-eral thigh skin perforator flap at 1 year follow-up.

Results

Flap characteristics and complications

The skin parts of the myocutaneous ALT flaps variedfrom 6 to 14!9–15 cm2 (mean 131 cm2). Themuscular parts of the myocutaneous ALT flapsvaried from 12 to 640 cm3 (mean 268 cm3). Themuscular part was custom designed to meet thespecific requirement of the defect. No total orpartial flap failures were encountered. One com-plication deserves special mentioning, whereas alladverse events are listed in Table 2. In one case(case 9) the musculocutaneous ALT flap wasanastomosed to the thoracodorsal vessels withvein grafts. Rupture of the pedicle occurred afterraising the arm above the head at postoperative day12. Revision was only performed 6 h after thesupposed event. New vein grafts were

Figure 10 Defect after resection of 70% of the base ofthe tongue while leaving the anterior mobile tonguemostly intact.

Figure 11 Chimera musculocutaneous partial vastuslateralis with anterolateral thigh skin perforator flap withthe muscular part on its individual vascular pediclebranching of the perforator vessels to the skin part ofthe flap.

Figure 12 Intraoperative result of base of tonguereconstruction after inset of a chimera musculocutaneouspartial vastus lateralis with anterolateral thigh skinperforator flap.

N.A.S. Posch et al.1100

interpositioned and the following postoperativecourse was uneventful.

Cosmetic and functional outcome

Mean follow-up was 16.6 months (range, 10–24months). In all patients the myocutaneous ALTperforator flap solved the reconstructive challenge.Cosmetic acceptor site evaluation by the surgeonshowed that colour mismatch was the most com-mon problem encountered (6 of 8 patients) whenthe skin was used in the facial area in this all whitepopulation. Flap bulkiness was also observed underclose scrutiny. In this study, group excessive flapbulk was observed in 8 of 11 patients at 6 weekspostoperatively. At an average follow-up of 16.6months, however, flap bulkiness was only observedin 2 of 11 patients. Patients were (very) satisfied(score four or five) with the functional result oftheir reconstructions (8 of 11 patients) as well asthe cosmetic result of their reconstruction (7 of 11patients). All four moderately and nonsatisfiedpatients (score one to three) had received theirflap for external facial skin reconstruction. Themusculocutaneous ALT flap provided an adequateflap for both intraoral defects treated (cases 10 and

Table 2 Early postoperative complications

Complication Number Case Time

Total flap necrosis 0Partial flap necrosis 0Haematoma 1 5 !3 hArterial occlusion 1 7 !3 hVenous insufficiency 1 9 Day 1

11). Both patients had excellent oral function at 14and 16 months follow-up as judged by normalspeech, swallowing, and tongue mobility.

Donor site closure was performed by skin graftingin seven patients with flap width sizes of 9–14 cm.Donor sites with flap width sizes of 6–10 cm could beclosed primarily. The cosmetic aspect of the donorsite was less favourable when skin grafted, how-ever, all but two patients were (very) satisfied withthe appearance.

Discussion

The application of the combined free partial VLmuscle with ALT perforator flap for reconstructionof extensive composite defects was evaluated. Itwas hypothesised that this site would offer avaluable myocutaneous perforator flap that couldbe harvested as a perforator chimera flap in a veryliberal, free style fashion while minimizing donorsite morbidity.

The reasons for choosing a myocutaneous flap inthe current patient group were two-fold. On theone hand there was a need for coverage of bone,dura, skull base or osteosynthesis material which

of occurrence Treatment Outcome

Evacuation UneventfulRevision artery Uneventful

2 Vein graft inter-position

Uneventful

Combined vastus lateralis with anterolateral thigh perforator flap 1101

has been shown tobenefit frommuscle coverage.19–21

On the other hand, muscle was used to fill thetongue base after subtotal resection. Increasedneurotisation of transplanted muscle tissue posi-tioned adjacent to remaining muscle after recon-struction of (sub) total glossectomy defects hasbeen reported.22,23 In this study, no objectiveevidence (EMG) for this phenomenon was investi-gated, however, tongue function in two cases wasjudged excellent.

The free partial VL muscle with ALT perforatorflap is a very versatile flap because differentpossibilities for dissection are feasible. The muscu-locutaneous ALT flap has been reported previouslywith an emphasis on the ease of dissection whenadding muscle.16,17 The true benefit of muscleaddition, however, which should be emphasised, isa tailor-made flap.16 The current description ofdifferent approaches in dissection of the musculo-cutaneous ALT flap provides three types of muscu-locutaneous flaps, which further facilitateimplementation of these flaps for specific recon-structive challenges. The musculocutaneous ALTflap can be a standard musculocutaneous flap like amusculocutaneous latissimus dorsi or transverserectus abdominis muscle flap. In this case the skinperforators are identified to ensure the optimalposition of the skin island on top of the VL muscle. Arefinement of musculocutaneous ALT flap dissec-tion allows the skin island to be dissected on oneperforator. This design enables skin island rotationup to 1808 in relation to the muscle. A similarfreedom of rotation can be achieved in othermusculocutaneous flaps when the skin island isisolated on an individual perforator. In our experi-ence this technique is more straightforward in theALT donor site compared to for instance thelatissimus dorsi flap donor site.23,24 A furtherrefinement in flap dissection enables the skin islandand muscle to be completely independent. This isachieved by dissecting muscle and skin on separateperforators of the same source vessel. The advan-tage of this approach is the complete freedom insize and position of tissue parts. Small or largeblocks of muscle can be added to small or large,single or multiple skin islands. This freedom ofdesign is hard to match in such a subtle andconsistent manner by other flaps. Chimera flapsbased on the subscapular system can offer similartissue combinations for larger size tissue require-ments,3 however, are less suited for harvest of verysmall flaps. Another drawback is that lateral patientpositioning is mandatory for latissimus dorsi flapharvest.

Although inconsistent anatomy hampering easyand safe flap dissection of the (fascio) cutaneous

ALT flap has been reported,17,25 the anatomy of themusculocutaneous ALT flap is mostly straightfor-ward. The skin island is usually based on aperforator from the descending branch of the LCFvessels and the muscle can then be harvested onthese vessels. However, in one of our first 50 skin-only ALT flaps there were no perforators on theentire lateral side, which would have made simul-taneous VL harvest impossible and an anteromedialflap needed to be harvested.26 This absence of skinperforators has been reported previously,25 how-ever, in some cases where a skin-only ALT flapwould be a high-risk option due to a tiny perforator,a musculocutaneous ALT flap is still a safe optionbecause of incorporation of a few of these tinyperforators. In one case (case 1) the dominant skinisland perforator was based on the transversebranch of the LCF vessels, which did not perfusethe distal VL muscle. Subsequently, the vessels ofthe descending branch of the LCF system thatbranched off the femoral artery individually had tobe anastomosed separately to perfuse the distal VLmuscle.

Acceptor site outcome was satisfactory in allcases. In patients who were moderately or notsatisfied with their functional result, this wasrelated to functional loss due to extensive resectionrather than to insufficient flap reconstruction. Thetwo main issues of objective acceptor site outcomewere related to flap colour and bulk. Strictevaluation of long-term flap colour outcome inthis all white population showed poor colour match,which is a problem to be considered especiallywhen using this flap for external facial reconstruc-tion.15 The other issue is flap bulkiness. Flap bulk isrelated to skin and subcutaneous volume ratherthan muscle bulk as previously suggested.17 In aprevious report by our group flap bulk in skin onlyfacial ALT flap reconstructions was excessive in 50%of patients.15 In the current study 8 of 11 patientshad excessive tissue bulk at 6 weeks, however, only2 of 11 had excessive bulk left at an average follow-up of 16.6 months. Defects reconstructed in thesepatients were deeper allowing settling in of thicker(sub) cutaneous parts after muscular atrophy. Thismuscular atrophy is in accordance with facialmuscle-skin graft reconstructions, which in ourexperience often result in a skeletonised appear-ance at long-term follow-up and fail to maintaintheir original bulk, even when overcorrected. Thismuscular atrophy works well for scalp reconstruc-tions27 but is less favourable for midface and lowerfacial reconstructions. On the other hand, flap bulkcan be an advantage for various reconstructivechallenges. In a white population, we favour ALTflaps for those defects that require more bulk such

N.A.S. Posch et al.1102

as for example tongue base and soft palate defects.For external facial defects we now reserve the ALTflap for larger volume defects requiring bulk. Flapthinning is used for additional refinement.

Harvesting a musculocutaneous ALT flapobviously defeats one of the perforator flapprinciples, which is muscle preservation. Unless amajor part of VL muscle is harvested, partial muscleharvest with meticulous motor nerve preservationwill maintain part of VL muscle function. On theother hand, VL is an expendable muscle which hasbeen pointed out previously: no significantdecrease in strength or range of motion was foundbetween musculocutaneous or regular ALT flapharvest compared to nonoperated opposite legs.15

The other parameter of donor site morbidity in ALTflaps is the ability for primary donor site closure. Instandard ALT flaps skin islands larger than 8 cm orvery proximal skin islands based on the perforatorsof the transverse branch of the LCF vessels areunlikely to permit primary closure. The possibilityof donor site closure, however, often additionallydepends on individual skin laxity. In case of largerVL muscle harvest, slightly larger skin islands can beclosed primarily. For larger skin islands donor siteclosure with adjacent VY skin advancement,28

adipofascial harvest beyond the 8 cm skin island14

or skin grafting are necessary for donor site closure.Although musculocutaneous ALT flap harvest gavesensory disturbances in 86% of distal thighs,15,29

most patients did not seem to be bothered about it.In conclusion, the combined free partial VL with

ALT perforator flap proved valuable as a (chimeratype) musculocutaneous flap with maximal freedomof planning to meet specific reconstructivedemands. Donor site morbidity was minimal usingthis flap. In a white population colour mismatch isan issue to be considered when using the ante-rolateral thigh skin for external facial defects.

References

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