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Division of Plastic and Reconstructive Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, People's Republic of China
Division of Plastic and Reconstructive Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, People's Republic of China
The British Journal of Plastic Surgery has had a defining role in bringing the anterolateral thigh (ALT) flap to the plastic surgical community through the publication of Song et al.'s seminal paper in 1984.
Review of this paper, however, does give rise to some confusion regarding the vascular anatomy of this highly versatile flap. Song et al. described the cutaneous artery emerging from ‘the intermuscular septum at a fixed point situated at the junction of the middle and upper thirds of the thigh, where the rectus femoris muscle, vastus lateralis muscle and Fensor fasciae latae muscle meet.’
These surface markings are repeated in two popular surgical atlases.
This contrasts with the anatomical description in Cormack and Lamberty's classic work which places the usual position of the largest perforator infero-lateral to the mid-point of the thigh.
present a thoughtful study of the role of the colour Doppler scanner in planning the ALT flap for head and neck reconstruction in adults. They suggest that the ALT flap is not widely used because the flap elevation is often complicated and the anatomy variable. Our approach to this flap has been somewhat pragmatic.
We began by plotting perforators with the colour Doppler and with time and patience were able to detect multiple perforators (Fig. 1(A)) although these did not always have a precise anatomical correlation probably due to the size (<0.5 mm diameter—Fig. 1(B)). Our standard procedure now is to use the conventional (Cormack and Lamberty) markings and with the hand held Doppler listen for perforators in the region of the intersection of the surface markings of the intramuscular septum and the descending branch of the lateral circumflex femoral artery (LCFA). We do not plot all perforators but aim for at least two (Fig. 2(A)) . The process takes around 5 min. If no perforator is found we examine the contralateral thigh. Peri-operatively we begin by making an incision on the medial aspect of the proposed flap and then extend this distally over the line of the intramuscular septum. We then look for the intramuscular septum, a process aided by observing the orientation of the muscle fibres. Having defined the septum we then explore the depth of the septum and usually have to incise the aponeurotic condensation on the medial side over the vastus lateralis to find the distal extent of the descending branch of the LCFA. Finger dissection sweeps the rectus medially and as we reach the inferior extent of the flap it is obvious, whether, we have a septal or muscular arrangement of perforators. The medial edge of the fascia, in the flap and overlying the rectus femoris is picked up and dissected laterally. As Iida et al. describe, this loose areolar tissue is dissected carefully as we search for a cutaneous perforator(s). The intramuscular septum is then explored proximally with finger dissection to expose the full extent of the descending branch of the LCFA and the origin of perforating vessels. We then begin to dissect out the perforators either by the ‘open-cast’ technique (Fig. 2(B)) or by tunnelling if the perforator is extremely laterally positioned (Fig. 2(C)). This technique is quick and simple for the vast majority of flaps and the question that has to be asked is whether the extensive pre-operative investigations are warranted on every case? We have decided it is not.
Fig. 1(A) Multiple cutaneous perforators marked on the leg after an extensive investigation by the radiologist using the Duplex scanner. (B) The type of perforator difficult to detect. Four musculo-cutaneous vessels all with diameter <0.5 mm in an eight-year-old child.
Fig. 2(A) Two perforators marked in an adult after 5 min with the hand held Doppler. (B) The ‘open-caste’ technique with one short perforator. (C) The tunnelling technique. The flap is on the lower aspect of the dissection with traction being applied to the musculo-cutaneous perforator by the vascular sling. The perforator is travelling diagonally into a long intra-muscular tunnel and small deep muscular branches are now being identified and ligated.
but we suspect that this does not deter surgeons from using the flap as Iida et al. suggest. The flap was first described in the Orient and subsequently very large series have been reported from Mainland,
Valdatta et al. have suggested that there may be anatomical differences to explain the discrepancy in popularity of this flap between oriental and western populations.
We suspect, however, that there are two other factors that have an important role in the pattern of usage. The principle use in the Orient has been in the field of Head and Neck reconstruction. This is because the characteristic Oriental donor site is typified by a paucity of subcutaneous fat and hair. The Western populations have a greater tendency towards obesity and also hair growth (particularly in males) on the antero-lateral thigh. It is of interest to note that whilst Professor Fu Chan Wei's group at Chung Gung now report well over a thousand ALT flaps
In summary then, our impression is that morphology and hirsuitism rather than vascular anatomy per se are responsible for the variation in use of the ALT flap. Our ‘pragmatic’ approach is predicated upon lean, hairless thighs but as the subcutaneous fat increases so the versatility of the colour Doppler scan may become more relevant in pre-operative assessment.
References
Song Y.G.
Chen G.Z.
Song Y.L.
The free thigh flap: a new free flap concept based on the septocutaneous artery.
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