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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  Lateral Thigh

 1984 - Song  1983 - Baek

 Anterolateral thigh skin  Posterolateral thigh skin

 Lateral circumflex  Profunda femoris → 3rd
femoral → Descending cutaneous perforator
branch
 Repositioning or flexed
 No repositioning 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

70 pts.

Kimata Y. Plast Reconstr Surg 1998

Perforator Mapping

72 pts.

Yu P. Head Neck 2004

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

Cutaneous Perforator Origin

Yu P. Head Neck 2004

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

Song 1984 Amount & Type Septocutaneous (%) Musculocutaneous (%)
Xu 1988 9 flaps 100 0
Koshima 1989 40 60
Zhou 1991 42 cadavers 61.5 38.5
Wolff 1992 13 flaps 37 63
Pribaz 1995 32 flaps 10 90
Shimizu 1997 36 64
Kimata 1997 100 cadavers 49 51
Sheih 1998 44 flaps 26.3 73.7
Kimata 1998 16.2 83.8
Luo 1999 41 cadavers 18 82
Demirkan 2000 38 flaps 18 82
Wei 2002 37 flaps 12 88
Makitie 2003 70 flaps 13 87
152 flaps 23 77
59 flaps
672 flaps
39 flaps

Septocutaneous –vs-
Musculocutaneous

Song 1984 Amount & Type Septocutaneous (%) Musculocutaneous (%)
Xu 1988 9 flaps 100 0
Koshima 1989 40 60
Zhou 1991 42 cadavers 61.5 38.5
Wolff 1992 13 flaps 37 63
Pribaz 1995 32 flaps 10 90
Shimizu 1997 36 64
Kimata 1997 100 cadavers 49 51
Sheih 1998 44 flaps 26.3 73.7
Kimata 1998 16.2 83.8
Luo 1999 41 cadavers 18 82
Demirkan 2000 38 flaps 18 82
Wei 2002 37 flaps 12 88
Makitie 2003 70 flaps 13 87
152 flaps 23 77
59 flaps
672 flaps
39 flaps

ALT Versus

ALT –vs- RF for Intraoral Defects

 No functional difference with speech or swallow in

20 pts. – 10 ALT, 10 RF

 ALT  RF

 Increased learning curve  Potential tendon exposure
 Sacrifice dominant distal
 Primary closure
forearm blood supply
 Morbidity related to  Usually close with STSG
vastus lateralis damage  Potential dysfunction

 Potential dysfunction  Hand stiffness
 Pain
 Quadriceps  Anesthesia/parasthesia
 Pain
 Disto-lateral thigh Farace F. J Plast Reconstr Aesth Surg 2007

anesthesia/parasthesia

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