The Lateral Thigh Perforator Propeller Flap: A Reliable Backup Plan for Locoregional Reconstruction in Case of Missing or Unreliable Anterolateral Thigh Perforators.

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Sir: We read with great interest the article by Tuinder and colleagues, and we congratulate the authors for having shown the reliability of the septocutaneous tensor fasciae latae or lateral thigh perforator flap in the setting of microsurgical breast reconstruction.1 The lateral thigh perforator flap, based on septocutaneous perforators originating from the ascending branch of the lateral circumflex femoral artery, presents a robust vascularization, allowing the reconstructive surgeon to design it in different shapes and orientations, according to the features of the donor and the recipient sites, respectively. Dissection of septocutaneous perforators is relatively easy. As recommended by Tuinder and colleagues, perforators of the dorsal septum (the one between the tensor fasciae latae and the gluteus medius) have to be chosen when harvesting the flap in microsurgical reconstruction, because of the increased length of the pedicle.2 In our experience, the anterolateral thigh flap represents the first choice to reconstruct defects of different causes in the lower abdominal and proximal thigh region; however, when no sizable perforators from the descending branch of the lateral circumflex femoral artery are encountered, a “plan B” procedure should be chosen intraoperatively to avoid exploring a second distant donor site. Some authors have reported on the use of the tensor fasciae latae flap as a backup plan in case of unreliable, missing, or damaged anterolateral thigh perforators, especially in case of microsurgical reconstruction.3,4 The branching pattern of the main pedicle of the anterolateral thigh flap and perforators’ number, size, and location are extremely variable. A thorough review reported the absence of anterolateral thigh cutaneous perforators in up to 5.4 percent in some series of patients.5 In our opinion, the lateral thigh perforator flap can be used with the same salvage indication (absence or damage to the anterolateral thigh perforators) when a locoregional reconstruction with a pedicled anterolateral thigh flap has been planned. We report a case of a lateral thigh perforator propeller flap used to accomplish reconstruction of the left pubic and inguinal region after resection of recurring soft-tissue sarcoma (Fig. 1): a medial approach was used to explore the anterolateral thigh flap region, which showed no sizable cutaneous perforators from the descending branch of the lateral circumflex femoral artery. Then, intraoperative dissection proceeded laterally, showing a valid cutaneous perforator from the ascending branch of the lateral circumflex femoral artery, running through the ventral septum between the tensor fasciae latae and the rectus femoris–vastus lateralis muscles. The skin paddle was redesigned on the above-mentioned perforator (Fig. 2), according to the propeller concept.6 The harvested flap was rotated in a propeller fashion 135 degrees to accomplish full coverage of the defect, whereas the extension of the skin paddle (minor blade of the propeller flap) was used to obtain primary closure of the donor site at its tightest cranial part. The postoperative course was uneventful, as no flap necrosis or donor-site dehiscence or seroma occurred.Fig. 1.: (Left) Preoperative planning (notice that a vertical deep inferior epigastric artery perforator flap had been considered as a possible option for reconstruction). (Right) Outcome at 3 months postoperatively.Fig. 2.: Original anterolateral thigh skin paddle is marked in red. The blue lines show the extension of the skin paddle required to include the tensor fasciae latae perforator, which is marked with a blue cross.The lateral thigh perforator flap represents a nice new option for microsurgical breast reconstruction; in our opinion, its use as a pedicled propeller flap should be considered in case of abdominal wall, groin, perineum, and thigh defects. Furthermore, the same flap, with an ascending oblique design, could be useful to close an anterolateral thigh donor site, when direct suture is not possible or is at high risk of dehiscence because of excessive tension. When the flap is harvested as a locoregional option, if no suitable anterolateral thigh perforators are found, the dissection proceeds from medial to lateral and the perforators running through the ventral septum are first encountered, so they should be considered if their size is adequate. For all these reasons, we support the use of the lateral thigh perforator propeller flap as a valid alternative option when the anterolateral thigh flap is not suitable. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Beniamino Brunetti, M.D., Ph.D.Marco Morelli Coppola, M.D.Stefania Tenna, M.D., Ph.D.Paolo Persichetti, M.D., Ph.D.Plastic, Reconstructive and Aesthetic Surgery DepartmentCampus Bio-Medico UniversityRome, Italy