Comprehensive Analysis of the Anterolateral Thigh Flap Vascular Anatomy

ABSTRACT The anterolateral thigh (ALT) flap has become a frequently used free flap for head and neck reconstruction. Widespread use has been based on literature of ALT flap thickness performed primarily in Asian populations. To our knowledge, to date there has not been a comprehensive analysis of the anthropomorphic parameters of this flap in the Western population, in which it is often much thicker, thereby potentially limiting its utility.
Computed tomographic angiograms of 106 patients were assessed, yielding 196 lower-extremity scans examined for volumetric characteristics and vascular anatomical variations.
Perforator vessels were located in 88.8% of scans, and most commonly located were a hybrid musculoseptocutaneous vessel (52.3%) followed by septocutaneous (33.9%) and musculocutaneous (13.8%) vessels. The midpoint perforator was located within ±2% of the midpoint of the total thigh length in only 47% of legs. The proximal and distal perforators were located 52.7 and 58.6 mm from the midpoint, respectively. Subcutaneous fat thickness differed significantly by sex, with mean male and female thicknesses of 9.9 mm and 19.9 mm (P < .001), respectively. Thickness increased with increasing body mass index, especially in women.
This study used computed tomographic angiography to characterize the ALT flap vasculature and thickness, providing a degree of predictability to these 2 highly variable flap characteristics.

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    ABSTRACT: : The most untoward aspect of the anterolateral thigh is the complexity of the local vasculature. Failure to understand its variability can lead to vascular flap embarrassment and tissue loss. The authors present a comprehensive summary of the vascular anatomy of the anterolateral thigh. : A MEDLINE search was performed for articles published between 1948 and 2012 on the anterolateral thigh flap. Two levels of screening and manual reference check identified 44 relevant studies. : The descending branch of the lateral circumflex femoral artery was variably found to originate from the deep femoral (6.25 to 13 percent) or common femoral artery (1 to 6 percent), instead of the lateral circumflex femoral artery. Dominant perforator supply to the anterolateral thigh was most commonly from the descending (57 to 100 percent), transverse (4 to 35 percent), oblique (14 to 43 percent), or ascending (2.6 to 14.5 percent) branch. Septocutaneous perforators were present in 19.8 percent (0 to 61.5 percent) of cases overall (n = 2486). No perforators were found in 1.8 percent of cases overall (n = 2895). The majority of perforators were found in the central third of the thigh. The previously undescribed musculoseptocutaneous perforator was observed in 21 to 52.3 percent of vascular mapping or anatomic studies, but not in clinical studies. : As knowledge of pertinent vascular anatomy for the anterolateral thigh flap has increased, so has insight into the amount of existing variation. This systematic review summarizes the wide spectrum of normal and variant anatomy described in the literature to date. : Therapeutic, IV.
    Plastic and Reconstructive Surgery 12/2012; 130(6):1254-68. DOI:10.1097/PRS.0b013e31826d1662 · 3.33 Impact Factor
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    ABSTRACT: Anterolateral thigh (ALT) flap is one of the most common flaps in the reconstruction armamentarium of plastic surgeons, but there is no published data about the flap characteristics in the Indian population. The aim of this study is to analyse the anthropomorphic characteristics of the ALT flap and the perforator details in Indian population. ALT flap details were studied in 65 patients of Indian origin comprising 45 males and 20 females. The study period is from August 2011 to July 2012. A prospective database of the Doppler findings, perforator and pedicle details and the flap morphology were maintained. The variables are analysed by using the SPSS, PASW statistics 18 software IBM(®). In nearly 75% of cases, the perforator was found within 4 cm of the pre-operative Doppler markings. The percentage of musculocutaneous and septocutaneous perforators was 61.8% and 38.2% respectively. The pedicle variation was found in 6 cases (9.23%). The average thickness of the thigh skin in Indians is similar to the western people, but thicker than the other Asian people. Flap thinning was performed in nine patients without any major complications. The perforator details and type in the Indian population are similar to the published reports from other parts of the world. We advise pre-operative Doppler examination in possible cases. The variation in pedicle anatomy should not be overlooked to avoid complications. The thickness of subcutaneous tissue of the flap is higher in Indians, but still can be safely thinned. The data of this study will serve as a guide for the ALT flap characteristics in Indian patients.
    Indian Journal of Plastic Surgery 03/2013; 46(1):59-68. DOI:10.4103/0970-0358.113709
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    ABSTRACT: Objective To provide a description of a minimally invasive, video-assisted technique (VAT) to identify the cutaneous perforators of the anterolateral thigh (ALT). The objective of the study was to compare this technique with standard open exploration of the thigh and to describe the learning curve for the procedure.Study DesignCase series with chart review.SettingAcademic tertiary institution.Subjects and Methods Twenty-six cases operated between December 2009 and June 2012. In all of these cases, an open thigh exploration, considered the gold standard, was performed immediately after the VAT. Data retrieved included surgical findings, demographics, and outcomes.ResultsThere were 17 men and 9 women with a mean age of 60 years. The average flap size was 91 cm(2) (range, 39-264 cm(2)), and a chimeric double skin paddle flap was harvested in 6 cases. Forty-nine of 53 total perforators were successfully identified endoscopically. Findings on endoscopic and open exploration were highly correlated (r = 0.92, P = .000). The overall sensitivity for the technique was 92.4% (confidence interval, 80.9-97.5) but reached 100% for perforators located at the midpoint of the anterior-superior iliac spine-patella line. All flaps survived, and there were no technique-related complications. The learning curve plateaued after 15 cases, with a mean endoscopic operative time of 18.2 minutes for the last 10 procedures.Conclusion This VAT is a safe and reliable method to identify cutaneous perforators of the lateral thigh. The procedure is straightforward and has a moderate learning curve. This approach has a role in minimizing donor site morbidity and assisting in flap design.
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