Reply

Abstract

Sir: We thank Drs. Hubmer and Feigl for their comments. We are well aware of the classic description of branches of the lateral circumflex femoral artery system. We agree that, based on these descriptions, the oblique branch could perhaps have been a low-lying transverse branch. In fact, that was our initial conclusion when we first noticed this vessel many years ago. However, with careful analysis and experience, it is quite clear that this vessel is not the transverse branch but a new vessel that we have called the oblique branch of the lateral circumflex femoral artery.1 As demonstrated in our article, from the standpoint of the use of the anterolateral thigh fasciocutaneous or myocutaneous flap, it is a vessel of profound clinical significance.2 The description of a “new” branch of the lateral circumflex femoral system is a responsibility that we do not take lightly. Accordingly, we have performed cadaver dissections to meticulously study the lateral circumflex femoral system before performing the clinical series (Fig. 1). Having performed the anatomical study and with the benefit of an extensive experience with the anterolateral thigh flap, a prospective clinical study was performed. The benefits of a clinical study over a cadaver study are that in addition to noting its prevalence, the reliability of the oblique branch as the flap pedicle and adequacy for microsurgical anastomoses can be evaluated conclusively. We found in our study that the oblique branch is present in 35 percent of cases and originates most commonly from the descending or the transverse branch (88 percent). The transverse branch, in contrast, is always present and identified when we traced the flap pedicle to its origin at the lateral circumflex femoral artery (i.e., it is never missed as the authors erroneously suggested).1 Finally, one only has to note the occasional “extreme” cases encountered to be convinced that the oblique branch exists (Figs. 2 and 5).1Fig. 1.: Photograph of a cadaver specimen showing an oblique branch arising from the descending branch of the lateral circumflex femoral artery. As demonstrated here, the oblique branch is an additional vessel that may be present in the lateral circumflex femoral system. The transverse branch, which is always present, is limited to the proximal thigh and runs in a more transverse and cephalic direction. LCFA, lateral circumflex femoral artery; TFL, tensor fasciae latae.Multiple types of the so-called anatomical variation of the anterolateral thigh flap have been described.3–5 Much of the past confusion regarding the surgical anatomy and failure of the anterolateral thigh flap could now be attributed to the unrecognized presence of the oblique branch of the lateral circumflex femoral artery. The description of the oblique branch is a certainly a step forward in our understanding of the surgical anatomy of the anterolateral thigh flap. To question its existence would take us back into the confusion that was so pervasive before. From a surgical standpoint, knowing that either the descending or the oblique branch of the lateral circumflex femoral artery can be used as the flap pedicle is a psychological breakthrough and liberates one from the need to base the flap on the descending branch in every case. It encourages the move away from the conventional approach to flap harvest to one that embraces the free-style approach.6 Chin-Ho Wong, M.R.C.S.(Ed.), F.A.M.S.(Plast. Surg.) Department of Plastic, Reconstructive, and Aesthetic Surgery Singapore General Hospital Singapore Fu-Chan Wei, M.D. Department of Plastic Surgery Chang Gung Memorial Hospital Taoyuan, Taiwan DISCLOSURE Neither of the authors has a financial interest in any of the products, devices, or drugs mentioned in this reply or the article being discussed.