Anteromedial Thigh Flap Research Articles

The Anteromedial Thigh Free Flap Anatomy

Perforator flaps have become the choice of most reconstructive surgeons because they have decreased donor-site morbidity. Among these flaps, the free anteromedial thigh flap has not yet become a first-choice flap because of the inconstant anatomy of its pedicle. This study aimed to describe the anatomy from different perspectives to highlight common patterns and simplify the flap's application in clinical cases. The study started in 2004 and took 9 years to complete. It was performed on 12 clinical anteromedial thigh flap cases, 48 clinical cases of anterolateral thigh flap in which the vascular anatomy of the anteromedial thigh flap was studied, and 48 cadaver dissections. In "type of perforators," the authors found an almost total consistency between clinical cases (group 1) and dissections in patients (group 2) (χ = 0.164 and p = 0.92), whereas the cadaver dissections (group 3) were minimally homogeneous (χ = 13.7 and p = 0.0082). Then, taking into account the parameter "origin of perforators," they noticed the same trend with a clear alignment between the first two groups (χ = 1.84 and p = 0.87) and a strong inhomogeneity in relation to the third group (χ = 19.8 and p = 0.03). Anatomical study of the anteromedial thigh flap pedicle showed a marked variability that makes preoperative planning difficult, and thus more stressful to realize. This evidence confirms that the flap can be used as a second choice or simultaneously with the anterolateral thigh flap. In addition, the authors strongly suggest a preoperative radiological study to minimize the possible anatomical variabilities during surgery.

Application of Anteromedial Thigh Flap for the Reconstruction of Oral and Maxillofacial Defects

To discuss the vascular anatomy of the anteromedial thigh (AMT) flap and to evaluate the feasibility of the AMT flap for the reconstruction of oral and maxillofacial defects. A retrospective review was performed of 18 patients who underwent reconstruction of oral and maxillofacial defects with AMT flaps from January 2009 through December 2011 in the Second Xiangya Hospital. Eleven unifoliate AMT flaps were elevated to reconstruct defects of the tongue, soft palate, and floor of the mouth and 7 chimeric anterolateral thigh (ALT) and AMT flaps were harvested to reconstruct through-and-through cheek defects. The flaps were 4 × 6 to 9 × 11 cm(2). All the AMT flaps were nourished by the descending branch (DB) of the lateral circumflex femoral artery. The cutaneous perforators were derived from the rectus femoris branch of the DB in 15 cases and directly from the DB in the other 3 cases. Postoperatively, all flaps survived completely, without major complications. Of the 18 donor sites, 14 were closed directly, leaving only linear scars, and 4 were closed using full-thickness skin grafts owing to larger defects. All patients were followed for approximately 6 to 30 months, and they were satisfied with the esthetic and functional results of the donor and recipient sites after the reconstruction. Because of easy perforator dissection, the AMT flap can be used as an alternative to the ALT flap or harvested with the ALT flap as chimeric ALT and AMT flaps for the reconstruction of oral and maxillofacial defects.

Use of Anteromedial Thigh Flaps as an Alternative to Anterolateral Thigh Flaps for Reconstruction of Head and Neck Defects in Cancer Patients

To determine whether anteromedial thigh (AMT) flaps are a good choice for reconstruction in cases in which no sizable skin perforator is found in anterolateral thigh (ALT) flap dissection or ALT flaps have been previously harvested. From February 2006 to August 2008, 17 free AMT flaps were used to reconstruct soft tissue defects of the head and neck. We recorded the age and sex of the patients, sites of primary tumor, tumor stage, size of defect, previous operative conditions, results of flap transfer, and donor-site complications. Of the 17 AMT flaps, 1 flap failed and 1 showed partial necrosis. Venous insufficiency developed in 2 cases, and the flaps were successfully salvaged in both the cases. The success rate was 94.1%. The AMT flaps were 6 to 20 cm long and 4 to 9 cm wide. The mean length of the pedicle was 7.5 ± 1.0 cm (range, 5-12 cm). Of the 17 donor sites, 6 were closed directly, 9 were closed using split-thickness skin grafts, and 2 were closed using full-thickness skin grafts. Complications and morbidity of the donor site were minimal. Cases in which no sizable perforator is found or an ALT flap has been previously harvested pose an aesthetic challenge, and an AMT flap is a good alternative for performing successful reconstruction in such cases.

Reconstruction of Perineoscrotal and Vaginal Defects With Pedicled Anterolateral Thigh Flap

To present a series of perineoscrotal and vaginal defects reconstruction with the use of anterolateral thigh flap. We present a series of 11 patients in whom we used pedicled thigh flaps (10 anterolateral thigh flaps and 1 anteromedial thigh flap) to cover defects of perineum, scrotum, and vagina. Ten patients had perineoscrotal defects and 1 patient had vaginal agenesis. Age group ranged from 26 to 79 years. The size of the flaps ranged from 105 cm² to 220 cm². The vascular pedicle length ranged from 10 cm to 12 cm. Stable closure was achieved in every patient. There were no complications from the donor site. In 1 patient, we found only 1 perforator at the superomedial edge of the flap that originated from the medial circumflex femoral artery; hence, in this patient, we used an anteromedial thigh flap as a salvage procedure. With versatility in their design and low donor site morbidity, these flaps present an option in the armamentarium of the reconstructive surgeon for the coverage of defects at the perineoscrotal and vaginal area.

Anteromedial thigh perforator free flap: Report of 41 consecutive flaps and donor-site morbidity evaluation

The anterolateral thigh (ALT) flap is a workhorse flap in free tissue transfer but an alternative is needed in case of failure, no sizable perforators and for those cases where the ALT flap has already been used. The anteromedial thigh (AMT) flap provides a good amount of soft tissues, not increasing the number of donor sites. In this study, we reviewed a single-centre series of AMT flaps, evaluated the donor-site morbidity and discussed the indications for head and neck reconstruction. From 2006 to 2010, 41 consecutive AMT flaps in 39 patients were done. Donor-site morbidity was evaluated with subjective and functional assessment. At least 6 months after surgery, patients received a standard questionnaire and a bilateral kinetic test was performed to compare the AMT donor leg and the contralateral leg. In every case, a sizable perforator was found and an AMT flap was harvested and revascularised. The average size of the flaps was 14.0±5.5×6.2±1.5 cm. The mean pedicle length was 8 cm (6-10 cm) and 30 of the perforators (73.2%) were true myocutaneous perforators. Two flaps were lost postoperatively and the assessed success rate was 95%. Donor-site morbidity evaluation showed very good subjective perception and good kinetic functional tests. No impairment in daily activity was found. The AMT flap is a very good and reliable option whenever the ALT flap is not available. It does not increase the number of donor sites, preserving a good lower-limb function. Therapeutic study: level III.

An alternative option to overcome difficult venous return in head and neck free flap reconstruction

The frozen neck secondary to prior neck irradiation and surgery is not uncommon in head and neck surgery. Identifying the optimal and alternative recipient vein in patients with difficult necks is one of most important steps in preceding a free flap for head and neck reconstruction. This is a retrospective study. From January 2006 to October 2011, the authors performed 544 cases of free flap reconstruction for head and neck cancer. The indications for choosing the retrograde limb of the superficial temporal vein as recipient vein were: (1) the flap pedicle contained only one vein 'and' (2) the patient had frozen neck or vessel-depleted neck from surgery. Amongst them, 10 patients with difficult neck where the retrograde limb of the superficial temporal vein was used as the only recipient vein for outflow were collected for the study. The mean age was 51.7 years. The types of flaps included the anterolateral thigh (ALT) flap (n=6), anteromedial thigh (AMT) flap (n=1), medial sural perforator flap (n=1) and trapezius perforator flap (n=1). One flap needed take-back due to haematoma compression of the pedicle. All nine flaps survived completely. The retrograde limb of the superficial temporal vein used as the only recipient vein served as an alternative option for venous return to precede a successful free flap reconstruction in difficult neck cases. The presence of valves in the vein system in the head and neck does not seem to preclude the use of retrograde flow anastomosis in patients with frozen neck.

Nearby perforator flaps as alternative choices for anterolateral thigh flap when lacking useful perforator

To explore the proposal using nearby perforator flaps as alternative reconstructive choices for anterolateral thigh (ALT) flap when lacking useful perforator. From August 2010 to August 2012, 8 cases with head and neck cancer were found lacking reliable perforator during ALT flap elevation, a tensor fascia latae (TFL) flap or an anteromedial thigh (AMT) flap was used to complete the reconstruction. All 8 alternative flaps were successfully harvested, other donor sites were not needed. Flap harvest time was 50-85 min. Of 5 TFL flaps, pedicle lengths were 6-10 cm, and the diameters of the arteries and veins were 2.5-3.0 mm and 2.5-3.5 mm respectively. Of 3 AMT flaps, pedicle lengths were 10-15 cm, the rectus femoris branch was used as pedicle in 1 flap, with artery and vein more than 1.0 mm in diameter, and the descending branch of the lateral circumflex femoral artery was used as pedicle in other 2 flaps, the diameters of the arteries were 3.5 and 3.0 mm respectively, the diameters of the veins were 3.5 mm. The donor sites were directly closed in 7 cases and skin graft was performed in another case. All the flaps were alive and no complication was found in the donor sites. TFL or AMT flap is an good alternative to ALT flap lacking useful perforator.

Reciprocal Dominance of the Anterolateral and Anteromedial Thigh Flap Perforator Anatomy

When anterolateral thigh (ALT) perforators are inadequate, exploration of the contralateral thigh may be required. If anteromedial thigh (AMT) perforators were useable in these instances, harvest could proceed from a single donor site. A prospective cohort study was performed examining 100 consecutive thighs. Anterolateral and anteromedial thigh skin territories were surgically explored, and perforator size and number were documented. The relationship between ALT and AMT size and number was examined using Fisher exact test, logistic regression, and linear regression. Patients with small or no ALT perforators usually had a large AMT perforator. Patients with large or medium ALT perforators usually had medium or small AMT perforators (P = 0.029). Patients with small or no ALT perforators had a 6-fold increased chance of large/medium AMT perforators (odds ratio, 6.18; 95% confidence interval [CI], 1.23-30.91; P = 0.026). Patients without ALT perforators usually had 1 or more AMT perforators. Patients with 3 ALT perforators usually had no AMT perforators (P < 0.001). Patients with 1 or fewer ALT perforators had a 4-fold increased chance of an AMT perforator (odds ratio, 3.77; 95% CI, 1.34-10.65; P = 0.012). After assigning numeric values to perforators based on size, the total scores for ALT and AMT regions were analyzed using a linear regression model. Lower ALT perforator scores were significantly related to higher AMT scores (slope, -0.33; 95% CI, -0.46 to -0.20; P < 0.001). The Spearman test showed a similar relationship (ρ = -0.43, P < 0.001). There is an inverse relationship between size and number of ALT and AMT perforators, that is, when ALT perforators are inadequate, AMT perforators are typically useable.

Easier and Safer Harvesting of the Anterolateral and Anteromedial Thigh Flap

Easier and Safer Harvesting of the Anterolateral and Anteromedial Thigh Flap

Commentary on the paper “Cervicothoracic reconstruction with an anteromedial thigh flap: A novel flap concept”

This is a commentary on the paper “Cervicothoracic reconstruction with an anteromedial thigh flap: a novel flap concept”. It is an excellent case. The method to use a segment of SFA to replace the carotid artery is great and the defect of SFA could be reconstructed with a Gore-Tex prosthesis. This method has the following advantages: (1) When the cancer has invaded the carotid artery with encasement, this method provides a more radical way of ablating the malignancy. (2) In the presence of potential infection, this method provides an autogenous tissue graft for the carotid artery instead of an artificial graft which has more chance of infection and blow-out. (3) In addition to a segment of SFA, it carries soft tissue and skin for simultaneous reconstruction of defects of large vessel and soft tissue. However, the author should be careful about the anatomical variations of perforators at the medial thigh region. Secondly, the territory of the skin paddle is still not clearly defined with individual difference, so that partial loss can happen if the skin paddle is too large. Even CT angiography has proved the presence of perforators, the area of complete survival for medial thigh flap is not so clear as the anterolateral thigh flap. The venous return of the flap should also be watched for a large anteromedial thigh flap. I would suggest using a smaller anteromedial

Free fasciocutaneous flaps for reconstruction of complete circumferential degloving injury of digits

Complete circumferential degloving injury of the digits usually results in a large cutaneous defect with tendinous structure and bone and joint exposure. When revascularization is not possible, a thin and adequately sized flap is required to resurface the defect, restore finger function, and prevent amputation. In this report, we present our experience with reconstruction of the entire circumferential degloving injury of the digits using free fasciocutaneous flaps. Between February 2006 and January 2011, 9 male patients with circumferential degloving injury of 9 digits underwent reconstruction using free fasciocutaneous flap transfer with the posterior interosseous artery flap, medial sural artery flap, anteromedial thigh flap, or radial forearm flap. The average flap size was 14.2 × 6.9 cm. Donor sites were closed primarily or covered with split-thickness skin graft. All flaps survived completely and the donor sites healed without complications. The mean follow-up period was 34.8 months. A maximum Kapandji score (10/10) was seen in 2 cases with crushed thumbs. All patients could achieve good key pinch and grasping functions. All skin flaps showed acceptable static 2-point discrimination and adequate protective sensation. Patient satisfaction for resurfaced digits averaged 9 on a 10-points visual analogic scale. In conclusion, the free fasciocutaneous flaps used were thin and did not interfere with finger movements. The patient's finger formed a smooth contour and acceptable functional results were obtained after reconstruction. This method may be a valuable alternative for reconstruction of entire circumferential avulsion injury of the digits.

Cervicothoracic reconstruction with an anteromedial thigh flap: A novel flap concept

The anteromedial thigh region is more popular as a donor site for skin graft than for flap. It is an extended area whose limits are poorly defined. This explains why flaps vascularised by different source arteries but described under the same name can be found in the literature introducing confusion and misunderstanding. This confusion was introduced since the primary descriptions as Baek presented in 1983 an anteromedial skin flap whose source artery was the superficial femoral artery and Song published a year later, under the same name, a flap vascularised by the innominate descending branch of the lateral circumflex femoral artery. Whatever the name and the source artery, the anteromedial thigh region is an under-exploited region which can be useful in the case of composite and complex defects. Anteromedial thigh flaps, either as pedicled or as a microvascular free-tissue transfer, were used in reconstructive surgery. We here describe a chimeric flap of the anteromedial thigh region and used as a flow-through flap.

Nearly Circumferential Pharyngoesophagectomy Reconstruction with a Double–Skin Paddle Anteromedial Thigh and Sartorius Muscle Free Flap

Nearly Circumferential Pharyngoesophagectomy Reconstruction with a Double–Skin Paddle Anteromedial Thigh and Sartorius Muscle Free Flap

Clinical anatomical study and evaluation of the use of the free anteromedial thigh perforator flaps in reconstructions of the head and neck

The anteromedial thigh (AMT) perforator flap is usually thin, pliable, and nearly hairless, making it particularly suitable to repair defects of the head and neck. We studied the topography and outcomes of AMT perforator flaps in such defects after excision of tumours. We retrospectively reviewed the casenotes of 11 consecutive patients who had had reconstructions of the head and neck with the initial intent of using an AMT perforator flap from January 2010 to July 2011. For each patient we recorded the size and thickness of the flap; the length of the pedicle; and the number, external diameters, anatomical types, source vessels, and sites of the sizeable perforators. Of the 11 patients, 10 had successful reconstruction using AMT perforator flaps, but one had no AMT perforator big enough. The mean (range) number of sizeable perforators/flap was 1.3 (1–2), length of pedicle 10.6 (7–13) cm, and diameter of the artery 1.1(1.0–1.5) mm. Of the 13 sizeable perforators, 3 were direct and septocutaneous. The remaining ones were all musculocutaneous. Most of them were located in the middle third of the thigh. Primary closure of the donor site was achieved in all patients. One flap was successfully revised after compression of the perforator. All flaps survived with good functional and aesthetic outcomes. The free AMT perforator flap is suitable for reconstructions of the head and neck if a sizeable perforator can be found. The AMT flap may be used as a primary flap rather than as an alternative to the anterolateral thigh flap or a component of a chimeric flap.

Perforator Patterns of the Anteromedial Thigh Flap

The vascular anatomy of the anteromedial thigh flap has not been well defined. The purpose of this study was to determine the perforator patterns and vascular anatomy of this flap. The perforators of the anteromedial thigh flaps and their origins were prospectively explored, documented, and mapped. Twenty-one of 100 thighs had no anteromedial thigh perforators. For the remaining thighs, there were two sources of perforators: the rectus femoris branch of the descending branch of the lateral circumflex femoris artery, and the superficial femoral artery. Perforators from the latter were short and small and thus less useful. Anteromedial thigh flaps based on rectus femoris branch perforators shared the same vascular pedicle as the anterolateral thigh flap and were thus clinically useful. These rectus femoris branch perforators, however, were present in only 51 percent of the patients. Their surface locations follow a similar pattern as the anterolateral thigh flap, with the majority of perforators near the midpoint, but an average of 3.2 cm medial to a line connecting the anterior superior iliac spine and the superolateral patella. Forty-three thighs had a single rectus femoris branch perforator and eight had two perforators. Sixty-six percent were septocutaneous and the rest traversed a thin layer of the rectus femoris muscle. The perforator patterns of the anteromedial thigh flap were examined and defined. It is best to plan the anteromedial thigh flap to complement the anterolateral thigh rather than to be the primary flap.

The Anteromedial Thigh Fasciocutaneous Flap Pedicled on the Supragenicular Septocutaneous Perforator

Skin defects around the knee remain a challenge for the reconstructive surgeons. Choosing appropriate flaps for coverage is crucial to preserve the knee joint or to restore its function. On the basis of anatomic results in 20 cadaveric specimens, we found a constant supragenicular fasciocutaneous perforator within 3 cm above the adductor tubercle, which arose from the saphenous branch of the descending genicular artery. Based on it, the distally pedicled anteromedial thigh fasciocutaneous flap can be harvested from the anteromedial thigh. Between 2003 and 2009, we performed the distally pedicled anteromedial thigh flaps in 11 patients. The site of skin defects included the popliteal fossa, proximal ⅓ leg, and amputation stump below knee. The size of skin defects ranged from 15 × 6 cm to 27 × 9 cm, and the corresponding size of the flaps ranged from 15 × 10 cm to 32 × 9 cm. Of 11 flaps, 10 flaps survived unevently, except 1 flap which suffered partial necrosis due to venous congestion. The patients were followed up for 3 weeks to 12 months. The donor site healed uneventfully without complications in all patients. Additionally, the skin paddle matched with the recipient in terms of skin color, texture, and thickness. The anteromedial thigh fasciocutaneous flap pedicled on the supragenicular perforator is a reliable and versatile alternative to cover skin defects around the knee.

Salvage of compromised free flaps in trauma cases with combined modalities

Using the microsurgical technique for reconstruction in trauma cases represents a challenge for the reconstructive surgeon. Several methods of salvaging of a compromised free flap have been reported, among them: intravenous heparin washing, thrombolitic therapy, thrombectomy, use of grafts and others. Here, we present our experience from nine cases and a review of the literature regarding the use of various modalities for free flap salvage in trauma cases, and their results. Data was collected from trauma cases in our institutions over a period of 2 years, where reconstruction was performed using microsurgical techniques, and where subsequent complications required some type of salvage procedure. The techniques that were used for the salvage included: intravascular irrigation with heparin, papaverine and lidocaine; administration of continuous intravenous heparin, use of the Fogarty catheter, flap washing with streptokinase, and adventitia stripping. The free flaps used were latissimus dorsi, serratus anterior, and the anteromedial thigh flap. Either vein or artery thromboses were identified during the procedure or immediately after surgery in seven patients. Two patients had prolonged spasms of the recipient artery with low flow. In all cases, the No. 2 Fogarty catheter was used for thrombectomy and also for release of the vessel spasm. There was only one complete failure among these patients, and partial necrosis was encountered in three. From our experience and review of the literature, we offer an algorithm for determining treatment strategies in a range of flap salvage situations.

前外側および内側大腿皮弁採取の際のカラードプラ法の有用性

Donor site morbidity must be considered when harvesting conventional flaps. Perforator flaps such from the anterolateral or anteromedial thigh minimize donor morbidity and let the flap be harvested simultaneously in head and neck reconstruction. We reconstructed defects using anterolateral and anteromedial thigh flaps in 7 oropharyngeal cancer cases between January 2008 and March 2010. Using color Doppler ultrasonography to detect anterolateral and anteromedial thigh flap perforators, we completed reconstruction after oropharyngeal cancer ablation without complications. Preoperative color Doppler ultrasonography has thus aided in detecting the perforator in such organ harvesting.

Perforating arteries of the anteromedial aspect of the thigh: an anatomical study regarding anteromedial thigh flap

Because the skin of anteromedial thigh region usually is thinner, pliable, hairless it can be preferred based on the requirements of the recipient site. In this way more information is necessary about the perforators of anteromedial thigh region. The aim of this cadaveric study was described to provide useful knowledge about localizations and number of anteromedial thigh perforators. Study was carried out on 16 lower extremities of 9 cadavers. The area in anteromedial aspect of the thigh searched for perforators was defined between the anterolateral border of sartorius and the posterior border of gracilis. The diameters of the dissected perforators were measured and the locations were documented. A total of 204 perforators were dissected in 16 lower extremities. The majority of musculocutaneous perforators were from gracilis (24 of 37) and there were at most 3 musculocutaneous perforators arising from gracilis muscle. 167 septocutaneous perforators were identified. Origin of all perforators was determined as 52 from deep femoral artery, 25 from proximal part of femoral artery and 127 from distal part of femoral artery and their branches. Perforators with the largest diameter were the ones arising from the intermuscular septa between the adductor (longus and magnus) and sartorius muscles. The mean diameter of the perforators was 0.75 ± 0.11 mm and ranged between 0.61 and 0.96 mm. The septocutaneous perforators of the anteromedial aspect of the thigh are as much important as the musculocutaneous perforators and all they are with adequate to perform anteromedial thigh flap. This study provides numerical overview, useful perception about the localization of the perforators of the anteromedial aspect of the thigh and detailed anatomical basis for anteromedial thigh flap to be an important alternative.

The chimeric perforator flap pedicled with descending branch of lateral circumflex femoral artery for reconstruction of oromaxillary soft tissue defect

To report the application of the chimeric perforator flap pedicled with descending branch of lateral circumflex femoral artery for large and complicated oromaxillary soft tissue defect. Based on the anatomic study of descending branches and cutaneous perforators of lateral circumflex femoral artery, the perforator vessels were found and used as flap pedicle. The perforator flap was made as chimeric flap for repairing the oromaxillary soft tissue defect in 8 cases. The chimeric perforator flaps were divided into three types as anterolateral thigh flaps and anteromedial thigh flaps, anterolateral thigh flaps and rectus femoris perforator flaps, and anterolateral thigh flaps and anterolateral thigh flaps. All the 16 flaps in 8 cases survived completely with no complication. The wounds in donor sites were all primarily closed with no skin graft. The patients were followed up for 1-9 months with good functional and esthetic results. There was no morbidity in donor sites. The chimeric perforator flap has a large tissue volume for large and complicated oromaxillary defect. There is no need for extra donor site and extra blood vessel anastomosis.