2. History by Song et al
1984 - 1st introduced
1986 - for head & neck reconstruction 1st described by
Koshima et al
1992 – 1st microvascular transfer of VL muscle flap –
Wolff
1995 – for lower extremity defect
1996 – ultrathin flap (3-4 mm) preserving subdermal
plexus – Kimura et al
Very popular reconstructive flap in Asia
Limited use in West –
vascular anatomy variations
difficult dissection
thick thigh fat
3. Indications
Head & neck reconstructions
Buccal mucosa defect
Buccal through & through defect
Pharyngo-oesophageal reconstruction
Lower lip
Tongue
Lateral & anterior skull base
Scalp
Combined with free fibula flap
Extremity reconstruction
4. Contraindications
Previous surgeries
Injury to upper thigh
Morbid obesity – too thick flap – Difficult
intramuscular dissection
Severe peripheral disease
5. Types
Free flap
Pedicled flap
Distally based (on distal minor pedicle) – for knee defect
Proximally based –
Trochanteric bed sore
Lower abdominal defects
Perineal reconstruction
Gluteal defect
6. Types
Type B/C Fasciocutaneous flap (type B - septocutaneous
perforator) or ( type C - musculocutaneous perforator )
Musculocutaneous flap
Fascial flap
Adipo fascial flap – for Romberg disease
Sensate flap(include lateral femoral cutaneous nv.)
Osteo fascio cutaneous flap
Chimeric flap ( 2 or more separate defect)
2 small independent flaps
Muscle only flap
Flow through flap (to salvage extremity, where proximal &
distal ends of pedicle anastomosed to recipient vessel)
7. Pre-Op preparation
Exclude previous trauma/surgery to thigh
Doppler study over
lateral intermuscular septum
2-3 cm lateral to lateral intermuscular septum(over
medial part of VL)
Angiography - not helpful
Check for popliteal pulsation
Consent for - failure/risk/alternate (RFFF)
Donor site morbidity, knee instability / limping gait
No IV line in flap leg
8. Landmarks
Line drawn between ASIS & supero-lateral border of
patella
Corresponds to the septum between RF & VL.
Skin perforators mapped by Doppler
Accuracy of Doppler decreases as BMI increases.
9.
10. Flap dimensions
Maximum length – 30 cm
Maximum width – 15 cm
For direct closure –
maximum width – 8 - 10 cm or < 16% of thigh
circumference
15. Flap harvesting
Initial skin incision on medial flap aspect over RF , 2-3
cm medial to lateral inter-muscular septum.
Proximal incision between TFL & RF
Sub-fascial – incision through deep fascia with lateral
dissection until perforators identified
Supra-fascial - for thin flap carried laterally until
perforators identified
16.
17. Flap harvesting
Skin incision completed after perforator identification
Retrograde dissection of pedicle to descending
branch
May involve dissection of VL. A cuff of muscle may be
left to protect perforating branches.
Advantage of taking a part of VL
easy harvest – no intramuscular dissection
pedicle twisting will be less
Lateral femoral cutaneous nerve – sensate flap
Thinning performed in deep fat layer to avoid pedicle
injury.
18.
19.
20. Pedicle
1 Artery, 2 Venae commitantes, motor branch of
femoral nerve to VL
Based on perforators from descending branch of
lateral circumflex femoral artery (90%).
From transverse branch of LCFA (4%).
From profunda femoris (4%) – pierces through RF.
Descending branch
Can be safely dissected proximally to its major
branch to RF, which should be preserved
Runs in inter-muscular space b/w RF & VL.
Terminates by anastomosing with superior lateral
genicular artery.
21. Dimensions of vascular pedicle
Average length of pedicle – 12 cm
Diameter ( DLCFA )
Artery - 1.5 – 2.5 mm ( Avg - 2.1 mm )
Veins – 1.8 – 3.3 mm ( Avg - 2.3 mm )
23. Perforators
Mapping – A (most proximal),B, C (most distal)
Musculocutaneous perforator (80-90%) - traverse
VL (close to medial edge) & deep fascia to supply skin
Septocutaneous perforator (10-20%) –
runs in-between RF & VL
pierces the fascia lata to supply skin
24. Perforator classification
Type 1 (50 %) –
Perpendicularly to subdermal
plexus.
Type 2 (35%) –
Branch in adipose & extends into
subdermal plexus.
Type 3 (15%) –
Extends along deep fascia &
gradually into adipose .
25. Sensory innervations
Lateral femoral cutaneous nerve(L2-L3)
Direct branch of lumbar plexus
Enters thigh deep to IL near ASIS.
Follows path of deep circumflex iliac artery & vein
Lies along line connecting ASIS to lateral patella.
Pierces fascia lata 10 cm distal to IL.
Travels in deep subcutaneous layer immediately
superficial to deep fascia.
46. Advantages
Minimal long term donor site morbidity
Long,reliable,larger pedicle
Large skin paddle
Can cover complex wound
Good pliability
No major artery is sacrificed
Ability to tailor the thickness of flap.
47. Disadvantages
Bulky flap
Hair bearing flap in male
Primary closure of donor site is not possible in most
cases.
48. Post operative care
Removal of drain - output < 30 ml/day, with sero
sanguinous discharge.
Encourage to walk on 3rd post op day.
49. Post op complications
Recipient site
Flap necrosis
Fistula (head & neck
reconstruction )
Haemorrhage
Arterial occlusion
Local abscess
Exposed bone/plate
Donor site
STSG loss
Wound infection
Dog ears
Pain & weakness in thighinjury to nerve to VL.
Seroma/haematoma
Partial necrosis of foot &
calf –
in a case of DLCFA act as a
critical collateral for an
obstructed superficial
femoral artery.
50. Outcome & prognosis
Minimal long term donor site complications
Allowed to walk after 3 days
No significant decrease in strength or range of motion
51. ALT vs Radial forearm free flap
ALT
Increased learning curve
Primary closure
Morbidity related to vastus
lateralis damage
Potential dysfunction –
Quadriceps
Pain
Disto-lateral thigh
anaesthesia /paraesthesia
Radial forearm free
flap
Potential tendon exposure
Sacrifice of dominant
distal blood supply
Closure with STSG
Potential dysfunctions Hand stiffness
Pain
Anaesthesia / paraesthesia
52. Anatomical Variations
Absence of cutaneous perforator – in 5.4 %
Absence of descending branch – in 22.6 %
replaced by medial descending branch
( inominate branch )
Ascending branch can supply a perforator to upper
part of ALT, which can be used when normal ALT
perforators are inadequate
Other leg can be used
53. ALT Failure Etiology
Inadvertent perforator divison at fascial plane
Inadvertent perforator injury during intramuscular
dissection
Pedicle twisting during inset
54. Follow up – recipient area
Aesthetic
Sagging of flap
Hair growth on flap
Contour defect
Flap bulkiness – need of debulking ( shoe wearing)