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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%
Yu P. Head Neck 2004
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%)
Yu P. Head Neck 2004
Yu P. Head Neck 2004
Cutaneous Perforator Origin
Type I
Right Thigh
Yu P. Head Neck 2004
Type II
Left Thigh
Yu P. Head Neck 2004
Type III
Right Thigh
Yu P. Head Neck 2004
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
Yu P. Head Neck 2004
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
Yu P. Plast Reconstr Surg 2006
Complications: ALT –vs- FJT
Yu P. Plast Reconstr Surg 2006
TEP Speech: ALT –vs- FJT
ALT = 89% FJT = 22%
Yu P. Plast Reconstr Surg 2006
Swallowing: ALT –vs- FJT
Yu P. Plast Reconstr Surg 2006
Hospital Course: ALT –vs- FJT
Yu P. Plast Reconstr Surg 2006
New Sensation
Implications of Sensory Innervation
Yu P. Head Neck 2004
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
Yu P. Head Neck 2004
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
Mureau M. Plast Reconstr Surg 2005
14 patients
Objective Functional and Aesthetic
Follow-up: Donor Site
Mureau M. Plast Reconstr Surg 2005
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
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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.
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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.
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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.
Bibliography
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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.
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