Versatility of the Free Vastus Lateralis Muscle Flap

Versatility of the Free Vastus Lateralis Muscle FlapPetros K. Spyriounis, MD, PhD, EBOPRAS, and Barbara S. Lutz, MD, PhD

Background: A flap that carries suf-ficient tissue with satisfactory pediclelength or diameter and with minor donorsite morbidity is an ideal option for thereconstructive surgeon. Many flaps havebeen described with each one having spe-cific advantages. The vastus lateralis(VL)-muscle flap is among them, but nospecial attention has been given to its valu-able use. To evaluate and to propagate theversatility of the free VL-muscle flap, thisflap was used in different pathology and indifferent anatomic areas.

Methods: Twenty-three patients withvarious defects after trauma and cancertherapy underwent reconstruction with 24free VL-muscle flaps.

Results: The flap provided excellentreconstruction in all cases. All flaps weresuccessful. Secondary operations includedtwo debulking procedures, respectively,and one regrafting of parts of the flapbecause of partial skin graft loss. The do-nor site morbidity was minimal and nopatient suffered from permanent partiallimb dysfunction.

Conclusions: The free VL-muscleflap is a versatile flap that offers specificadvantages such as constant anatomy, easeof dissection in supine position, long pediclelength, large vessel diameter, good estheticoutcome, and minor donor site morbidity.This flap has proven to be most valuablealso in difficult cases, including head andneck and lower limb reconstruction.

Key Words: Free vastus lateralismuscle flap, Versatility, Low donor-sitemorbidity.

J Trauma. 2008;64:000–000.

The use of free microvascular flaps has become routine inplastic surgery. Many donor areas have been describedand new flap concepts, especially the perforator flaps,

became popular. This was mainly because of their reduceddonor site morbidity. However, a certain degree of expertiseis required to dissect a perforator flap. The first author(P.K.S.) noted the potentials of the vastus lateralis (VL)-muscle flap during the harvest of the anterolateral thighperforator flap in both clinical and laboratory settings.1 Itsoon became obvious that a safer and easier dissection withina much shorter operative time was needed for preparingsolely the VL-muscle. Furthermore, the surgeon does not faceunpleasant surprises, as it can be the case with the variableanatomy of the perforator arteries, when dissecting the an-terolateral thigh perforator flap. An accidental damage to theperforator arteries can “burn” the perforator flap. In suchsituation, the VL-muscle flap is the ideal back up plan as thesame incision allows the harvest of the muscle based on thesame major pedicle.

No matter which flaps are used, some basic prerequisitesare desired. In general, flaps that offer adequate tissue amountwith minimum donor site morbidity are preferred. Additionalcharacteristics such as a large and long pedicle, feasibility of

a simultaneous two-team approach, consistent anatomy, and asafe and quick dissection are appreciated. The free VL-muscle flap is a flap that fulfils all of these desired criteria.

Though the free VL-muscle flap has been successfullydescribed for head and neck reconstructions2,3 and alsoshowed promising results after having been applied for lowerlimb reconstruction,4 this flap did not yet gain the popularityit deserves. We applied the free VL-muscle flap in 24 casesat different recipient sites with good results. The aim of thispresentation is to show and to popularize the versatility of theVL-muscle flap and its application as a valuable reconstruc-tive tool in various recipient sites with minimal donor sitemorbidity.

ANATOMYThe VL-muscle originates from the greater trochanter,

the gluteal tuberosity, and the lateral intermuscular septum.Along with the other muscles of the quadriceps group ends inthe patella as the strong tendinus patellar ligament. It is astrong extensor of the leg, but it also contributes in externalrotation and adduction of the leg as the “vasogluteal musclesling” that forms with the gluteus maximus muscle.

The muscle’s dimension is about 10 � 25 cm, the inner-vation comes from a motor branch of the femoral nerve and itsvascular supply comes from the descending branch of the lateralcircumflex femoral artery and two accompanying veins. Theartery has a diameter of 1.8 mm to 2.5 mm and the veins havea diameter of 1.8 mm to 3.3 mm in average. The muscle receivesadditional blood supply by the transverse branch of the lateralcircumflex femoral artery proximally and by the lateral superiorgenicular artery distally, thus it is considered a type 2 accordingto Mathes and Nahai classification.

The vascular pedicle takes of the lateral circumflex fem-oral artery and descends along the medial rim of the VL-

Submitted for publication July 31, 2007Accepted for publication December 6, 2007.Copyright © 2008 by Lippincott Williams & WilkinsFrom the NIMTS, Veteran’s Hospital (P.K.S.), Athens, Greece; and

Highgate Hospital (B.S.L.), London N6 4DJ, United Kingdom.Presented at the 4th World Congress of Reconstructive Microsurgery,

June 23–26, 2007, Athens, Greece and in the 14th IPRAS (InternationalCongress of the International Confederation for Plastic, Reconstructive andAesthetic Surgery), June 26–30, 2007, Berlin, Germany.

Address for reprints: Petros Spyriounis, MD, PhD, Athens, Karneadou16, 10675 Greece; email: [email protected].

DOI: 10.1097/TA.0b013e3181647c61

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muscle in a discreet plane between the VL and the rectusfemoris muscle, till about the middle one-third of the muscle,giving different perforating branches to the muscle and theoverlying skin. Then it dives within the muscle and coursedistally to meet the superior genicular artery. The nerveenters the muscle at the junction between the superior and themiddle one-third and follows the vascular pedicle’s course.

Depending on the amount of muscle tissue and the de-sired pedicle length, the surgeon chooses which part of theVL-muscle is going to use (Fig. 1). If a thinner muscle flap isdesired, a cross-section part of the muscle is prepared. In ourexperience, a pedicle length of even 20 cm is achievable, if adistal muscle segment is used. It may be necessary to dissectthe pedicle intramuscularly in its distal one-third, to gain thedesired extra length.

PATIENTS AND METHODSFrom August 2001 to December 2006, 23 patients, aged

32 years to 85 years were operated on and 24 free VL-muscleflaps were used for reconstruction. Details of the patients,pathology, flap’s dimension, and the involved sites are shownin Table 1. In all operations, a simultaneous two-team ap-proach was possible. The anastomoses were performed withthe aid of either the microscope or the varioscope AF35

according to surgeon’s preference. In 14 cases, the musclewas covered with split thickness skin grafts and in 10 casesfull thickness skin grafts were used depending on the sizeof the flap and the preference of the surgeon. An activerehabilitation program was initiated in all patients postoper-atively. This included leg press exercises, unilateral kneeextension, and descending and elevating step exercises. Dur-

Fig. 1. A raised vastus lateralis muscle attached only to its vascularpedicle. Note the very long pedicle one of the major flap’s advantages.

Table 1 Patients’ Demographic Data

Patient No. Sex Age Nature of Defect Flap Size (cm2) Special Procedures

1 M 73 SCC parotid gland VL � FTSG 30 —2 F 84 SCC buccal mucosa VL � FTSG 48 —3 F 85 SCC maxilla VL � FTSG 25 No bone reconstruction4 M 80 SCC maxilla VL � FTSG 24 No bone reconstruction5 M 73 SCC ear or parotid gland VL � FTSG 54 —6 M 83 SCC mandible VL � FTSG 45 Reconstruction plate for mandible,

3 postoperative d deathbecause of heart attack

7 M 43 Adeno-Ca maxilla or midfaceeye socket

VL � STSG 30 Exenteratio orbit, maxilla or floorof the orbit reconstruction withfree vascular iliac crest boneand two consecutive VL-flaps

VL � FTSG 40

8 F 82 SCC maxilla VL � FTSG 25 No bone reconstruction9* M 54 SCC forehead VL � STSG 36 Previously kidney transplanted

10 F 72 Basaliom forehead VL � STSG 225 Exenteratio orbit11 F 45 SCC scalp VL � STSG 50 —12 M 55 SCC scalp VL � STSG 162 —13 M 32 Trauma heal or foot sole VL � STSG 75 Debulking after 20 mo14 M 55 Chronic infection lower leg VL � STSG 162 —15 M 39 Infratemporal infection VL � FTSG 56 —16 M 60 Chronic osteitis tibia VL � STSG 48 Debulking after 8 mo17 M 57 Salvage BK amputation stump VL � STSG 200 —18 M 39 Chronic calcaneal osteomyelitis VL � STSG 60 Partial regraft after 1 mo19 M 54 Salvage BK amputation stump VL � STSG 220 —20 F 57 Open No. lower tibia-malleolus VL � FTSG 90 —21 M 48 Salvage BK amputation stump VL � STSG 220 022 M 57 Salvage BK amputation stump VL � STSG 200 023 M 50 Chronic infection tibia VL � STSG 42 —

* Patient 9 had been irradiated preoperatively.SCC indicates squamous cell cancer; VL, vastus lateralis muscle flap; STSG, split thickness skin graft; FTSG, full thickness skin graft; BK,

below knee.



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ing the follow-up period, the overall outcome regarding re-cipient and donor sites was evaluated by the two surgeons.

RESULTSTwenty-four free VL-flaps with either split thickness

skin grafts or full thickness skin grafts were used for recon-struction in head and neck, cranial, and lower limb areas. Thefollow-up ranged from 3 months to 48 months. All flapswere successful. No patient suffered any vascular compro-mise; no revision of anastomoses was necessary. Twopatients underwent a secondary debulking procedure andone necessitated a partial skin regraft procedure. In allcases, the VL-muscle flap provided a good reconstructionfunctionally and cosmetically with the flaps adapting wellto the contour of the surrounding tissue after the primaryswelling period. Cosmetic outcome of the donor site wasjudged as good in all cases, although in five patients contourirregularities at the respective thighs were visible. No hyper-trophic scar was noted. Functionally no patient, except one,

suffered any obvious limitation, following evaluation ofwalking, climbing and descending stairs, and lifting theirknee joint extended against gravity. One patient (patient 21)suffered some 20 degrees of extension lag at the knee jointearly postoperatively. However, there is constant improve-ment with the rehabilitation program after a 6-months follow-up. He had sustained a below knee traumatic amputation andalmost the whole contralateral VL-muscle was used for sal-vaging the knee joint. This should not have caused the post-operative extension lag, but because the popliteal recipientartery had retracted proximally, the surgeon ligated themain pedicle of the rectus femoris muscle on the donor siteto gain two more centimeters pedicle length for achievingtension-free vascular anastomoses. Thus, it is assumed thatthe induced morbidity might rather be due to the createdrectus femoris weakness. Retrospectively, the ipsilateralmuscle should have been used in first place and same,ligature of the main pedicle of the rectus femoris muscleshould have been avoided.

Fig. 2. A, a large basalioma at the left forehead, which included the eye. B, intraoperative defect following radical resection. C, result 9months post-op with free vastus lateralis muscle and split skin grafts. D, profile post-op view.


Free Vastus Lateralis Muscle Flap


DISCUSSIONAlready in 1977, the surgical technique for using the

pedicled VL-muscle in trochanteric pressure sores wasoutlined.6 However, so far the free VL-muscle flap did notreally find popularity, but was mentioned in the literaturemostly in single case reports. It has been reported as apedicled flap in gluteal defect reconstruction7 and as a dis-tally based flap for coverage of defects around the knee.8,9

Other reports include its harvesting technique as a muscleflap and its use for treatment of femur or hip infections.10,11

A single case employing a free VL-muscle flap for coverageof a diabetic ulcer was published recently.12 The VL-muscleflap has also been used for closure of chronic thoracic em-pyema mostly because of its long vascular pedicle and fortrunk wall reconstruction as a whole muscle transplantationproviding a large flap with a long pedicle.13 The vascularanatomy of the VL-muscle has been studied in detail byWolff14 in 100 cadavers. It was employed as a free flap forhead and neck reconstruction, either as a pure muscle flap, or asa thinned myocutaneous flap (anterolateral thigh flap). Wolffused the VL-muscle flap also for glossectomy reconstructionand the subsequent epithelialization gave a satisfactory result,which was confirmed by Tsai et al.,15 who reconstructed amaxilla defect also with a “pure” VL-muscle flap (no skingrafts). Chana et al.16 described the successful employment ofthe VL-muscle flap for skull base reconstruction in a series ofseven patients. We used the flap successfully in a similar case(patient 1, Fig. 2A–D) for providing infratemporal dead spacefilling and forehead skin replacement. The same accounts for itsuse in scalp and midface reconstruction (see Table 1; patient 7,who received two consecutive VL-muscle flaps because of sub-sequent origin tissue necrosis). The ability of the VL-muscle tocarry vascularized fascia lata proved very useful in the durareconstruction. An additional advantage of the VL-muscle flap isthe possibility to convert the flap to a conjoint combined flapas it has been described with the gracilis perforator flap.17

This flap can include muscle, adiposal tissue, and fascia lata asa conjoint flap with each component receiving distinct vascularsupply by the same main pedicle (descending branch of thelateral circumflex femoral artery). This can be ideal for complexthree-dimensional reconstructions, keeping in mind that differ-ent independent skin paddles can also be harvested. Superioresthetic results (as compared with skin flaps) were found whenusing pure muscle flaps, including the VL-muscle free flapcombined with split or full thickness skin grafts for head andneck reconstruction. Donor site morbidity was negligible andparticularly the patients who received full thickness skin graftson the muscle flaps showed an adequate texture and colormatch.3 We agree with Jackson18 that this flap will become aworkhorse in craniofacial surgery after tumor resection and intrauma cases.

In this study, the flap was also used in 10 patients forlower limb reconstruction. In four cases, the flap was used forlower tibia reconstruction (Fig 3A–C), in two cases for heel

reconstruction, and in another four cases for salvaging belowknee amputation stumps (Fig. 4A and B). In all cases, goodfunctional and cosmetic results were achieved. This confirmsthe excellent results that were reported recently by Cavadasand Sanz-Jimenez-Rico,4 who published a series of nine pa-

Fig. 3. A, chronic distal one-third tibial osteitis. B, postoperativeresult at 9 months after a minor debulking procedure. C, view of thedonor site at the same time.



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tients who received lower limb reconstruction with the use ofthe VL-muscle flap. Cavadas and Sanz-Jimenez-Rico4 em-phasize the advantages of the flap including a short dissectiontime and a constant anatomy. They mostly used a cross-section part of the muscle with the rest remaining intact andinnervated. No functional impairment was found postopera-tively. Although in five occasions, we used almost the entiremuscle (75–80%), except the most proximal and distal ten-dinous insertions, no functional limitation was noted regardingthe knee extension mechanism, except in the case that the rectusfemoris pedicle was ligated for extra pedicle length (see Resultsection). Our findings confirm other’s considerations regardingthe donor site morbidity of the musculocutaneous anterolateralthigh flap harvest.19–21 The general consensus is that an activerehabilitation program is the key element in reducing morbiditytogether with other factors such as, e.g., the patient’s age, pre-operative mobility, or kind of reconstruction.

Comparing the VL-muscle flap with numerous other fre-quently used free flaps for reconstruction such as the radialforearm flap, or muscle or musculocutaneous flaps such as the

anterior lateral thigh (perforator) flap, the rectus abdominis myo-cutaneous flap, the gracilis flap, and the latissimus dorsi flapproves that the VL-muscle flap is indeed an attractive choice.

Compared with the radial forearm flap, the VL-muscleflap proved clearly superior regarding donor site morbidity.The main advantage of the radial forearm flap is its longpedicle and the thin and pliable skin paddle. However, thelength of the VL-muscle flap pedicle reaches 20 cm, whichalso allows anastomosis to be performed, e.g., on the con-tralateral neck if need arises. Additionally, if a cross sectionof the muscle is used, a thin flap can be obtained (Fig. 5A–B).Another advantage comparing with the radial forearm flap isthe ability to easily combine a skin island with differentorientation (perforator-based island), if it is necessary.

Possible problems regarding the anterior lateral thighperforator flap were already mentioned in the introductionsection. The rectus abdominis flap is not as large as the VLand its pedicle is not as long. In addition, the donor sitemorbidity can be substantial, including hernia development

Fig. 4. A, below knee amputation stump necrosis. B, 8-month post-operative view of the salvaged amputation stump with an ipsilateralfree vastus lateralis muscle and SSG.

Fig. 5. A, radical resection for squamous cell cancer treatment of rightparietal and inner ear. B, the result 17-months postoperative after freevastus lateralis flap, full thickness skin graft, and irradiation.


Free Vastus Lateralis Muscle Flap


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and deterioration of pulmonary function in some patients.22,23

The gracilis muscle is relatively small and the vascular pedi-cle is shorter and of smaller caliber comparing with theVL-muscle. The latissimus dorsi muscle usually demandschange of the patient’s position making a simultaneous two-team approach difficult. Postoperative seroma at the donorsite are rather frequent. Thus, this flap is regarded as firstchoice only in cases that need a very large flap.

Another muscle belonging to the quadreps femoris mus-cle group, the rectus femoris flap, does not seem to be a realalternative yet especially due to different results consideringthe donor site’s functional impairment.24,25

CONCLUSIONSThe free VL-flap has been used for reconstruction in

different clinical situations and in different recipient sites. Inall cases, good functional and esthetical results wereachieved. The long and large pedicle allowed easy anasto-moses. The flexibility in terms of design is an additionalpositive asset. The constant anatomy, the harvest in supineposition (simultaneous two-team approach!) and finally thelow donor site morbidity (fast rehabilitation!) are furtheradvantages of the VL-flap. In addition, the dissection is easyto master and teach, thus improving the safety of the proce-dure. Its specific advantages make VL-muscle flap very use-ful, for head and neck and lower limb reconstruction.

REFERENCES1. Spyriounis PK. The extended approach to the vascular pedicle of the

anterolateral thigh perforator flap: anatomical and clinical study.Plast Reconstr Surg. 2006;117:997–1001.

2. Wolff KD, Grundmann A. The free vastus lateralis flap: an anatomicstudy with case reports. Plast Reconstr Surg. 1992;89:469–475.

3. Lutz BS. Beauty of skin-grafted free muscle flaps in head and neckreconstruction. Microsurgery. 2006;26:177–181.

4. Cavadas PC, Sanz-Jimenez-Rico JR. Use of the extended pediclevastus lateralis free flap for lower extremity reconstruction. PlastReconstr Surg. 2005;115:1070–1076.

5. Spyriounis PK. Use of Varioscope in free microvascular tissuetransplants. Microsurgery. 2005;25:187–190.

6. Minami RT, Hentz VR, Vistnes LM. Use of vastus lateralis muscleflap for repair of trochanteric pressure sores. Plast Reconstr Surg.1977;60:364–368.

7. Schmidt AB, Fromberg G, Ruidisch MH. Applications of thepedicled vastus lateralis flap for patients with complicated pressuresores. Spinal Cord. 1997;35:437–442.

8. Wang Y, Beguet T, Masquelet AC. Anatomic study of the distallybased vastus lateralis muscle flap. Plast Reconstr Surg. 1999;103:101–103.

9. Swartz WM, Ramasastry SS, McGill JR, Noonan JD. Distally basedvastus lateralis muscle flap for coverage of wounds about the knee.Plast Reconstr Surg. 1987;80:255–265.

10. Necmioglu S, Askar I, Lok V, Subasi M. Useof the vastus lateralismuscle flap with a grooving procedure in the surgical treatment ofchronic osteomyelitis of the femur. Ann Plast Surg. 2004;53:570–576.

11. Huang KC, Peng KT, Li YY, et al. Modified vastus lateralis flapin treating a difficult hip infection. J Trauma. 2005;59:665– 671.

12. Vega SJ, Sbitany H, Bossert RP. Vastus lateralis free flap for softtissue coverage of a lower diabetic ulcer. J Reconstr Microsurg.2007;23:51–54.

13. Chen HC, Sanatamaria E, Chen HH, et al. Microvascular vastuslateralis muscle flap for chronic empyema associated with a largecavity. Ann Thorac Surg. 1999;67:866–869.

14. Wolff KD. Indications for the vastus lateralis flap in oral andmaxillofacial surgery. Br J Oral Maxillofac Surg. 1998;36:358–364.

15. Tsai CY, Wei FC, Chang YL, Chen YY, Chen CT. Vastus lateralismuscle flap used for reconstruction of the maxilla after radical resectionof recurrent ameloblastoma. Chang Gung Med J. 2006;29:331–335.

16. Chana JS, Chen HC, Sharma R, Hao SP, Tsai FC. Use of the freevastus lateralis flap in skull base reconstruction. Plast Reconstr Surg.2003;111:568–574.

17. Lykoudis E, Spyropoulou G, Vlastou C. The conjoint medialcircumflex femoral perforator and gracilis muscle free flap:anatomical study and clinical use for complex facial paralysisreconstruction. Plast Reconstr Surg. 2005;116:1589–1595.

18. Jackson IT. Discussion in use of the free vastus lateralis flap in skullbase reconstruction. Plast Reconstr Surg. 2003;111:575.

19. Kimata Y, Uchiyama K, Ebihara S. Anterolateral thigh flap donor-sitecomplications and morbidity. Plast Reconstr Surg. 2000;106:584–589.

20. Kuo YR, Jeng SF, Kuo MH. Free anterolateral thigh flap forextremity reconstruction: clinical experience and functionalassessment of donor site. Plast Reconstr Surg. 2001;107:1766–1771.

21. Mureau MAM, Posch ASN, Meeuwis GA, Hofer SO. Anterolateralthigh flap reconstruction of large external facial skin defects: afollow up study on functional and aesthetic recipient and donor siteoutcome. Plast Reconstr Surg. 2005;115:1077–1086.

22. Nakatsuka T, Harri K, Yamada A, Asato H, Ebihara S. Versatility ofa free inferior rectus abdominis flap for head and neck reconstruction.Analysis of 200 cases. Plast Reconstr Surg. 1994;93:762–769.

23. Kroll SS, Baldwin BJ. Head and neck reconstruction with the rectusabdominis free flap. Clin Plast Surg. 1994;21:97–105.

24. Daigeler A, Dodic T, Awiszus F, Schneider W, Fansa H. Donor sitemorbidity of the pedicled rectus femoris muscle flap. Plast ReconstrSurg. 2005;115:786–792.

25. Gardetto A, Raschner CH, Schoeller T, Pavelka ML, WechselbergerG. Rectus femoris muscle flap donor-site morbidity. Br J Plast Surg.2005;175–182.



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Versatility of the Free Vastus Lateralis Muscle Flap