Lateral Circumflex Femoral Artery System Research Articles

Individually tailored approach to reconstruction of complex defects using versatility of the lateral circumflex femoral artery system-based pedicled flaps

Lateral circumflex femoral artery (LCFA) system is one of the most versatile donor sites in the body. We present our experience with pedicled flaps from the LCFA system, including different components for a wide variety of etiologies and locations. Twenty-three consecutive pedicled flaps were performed on 22 patients (10 females and 12 males; age 4-71 years) between 2007 and 2015 by a single surgeon. Flap size, type, and composition were tailored according to the requirements of the defects, including (1) location; (2) surface area; (3) depth; (4) number of defects; (5) presence of exposed critical structures; (6) presence of exposed foreign bodies; (7) prior use of other options; (8) history of radiation; and (9) other comorbidities. Defect locations were 10 abdominal wall (including groin and pubis), 9 ischio-gluteo-trochanteric and 4 perineal. Defect sizes ranged from 6×6 to 30×35 cm. Maximum depth of wounds ranged between 7 and 18 cm. The flap sizes ranged from 9×6 to 38×20 cm. Two flaps were fasciocutaneous perforator, 4 were myocutaneous with "muscle sparing" vastus lateralis, 10 were myocutaneous with "segmental" vastus lateralis, 5 were myocutaneous "tri-muscle," 1 was "tri-muscle," and 1 was rectus femoris only. Donor sites were closed primarily in 20 cases and with split thickness skin grafting in 3 cases. All flaps survived completely without any partial loss or congestion. Pedicled flaps from the LCFA system can be tailored individually for a wide variety of etiologies and locations. Muscles can be harvested and used as "muscle sparing," "segmental," and "tri-muscle" to accommodate the requirements of the defects.

Defect Reconstruction Using the Propeller Flaps Based on the Perforators Derived From the Lateral Circumflex Femoral Artery System.

Although propeller flaps are a useful option for soft tissue defect reconstruction, reports based on the perforators of the lateral circumflex femoral artery (LCFA) are rare. We aimed to present our experience in defect reconstruction using the propeller flaps based on perforators from different branches of LCFA and apply these flaps in soft tissue defect reconstruction of the lower extremities. Twenty nine patients (32 flaps) underwent defect reconstruction using propeller flaps based on the perforator of the LCFA. Defects were located from the groin to the proximal leg. According to the source vessels from which the perforator originated, flaps were categorized into types I, II, III and IV, which represented perforators from the transverse, descending, oblique, and rectus femoris branches, respectively. Type II flaps were subdivided into types IIa and IIb flaps based on antegrade and reverse flows of the descending branch. Flap sizes ranged from 12 × 6 cm to 30 × 15 cm (average, 22.69 × 9.19 cm) with the length of the vascular pedicle ranging from 3 to 7 cm (average, 4.86 cm). Flaps were rotated from 60° to 180° (average, 144.06°). There were 3 type I, 10 type IIa, 4 type IIb, 13 type III and, and 2 type IV flaps. Twenty-nine flaps survived after surgery. Total flap necrosis and venous congestion of the distal flap portion occurred in 1 and 2 patients, respectively. Reconstruction using propeller flaps based on perforators of the LCFA is a safe, reliable, and versatile option for defect reconstruction of the lower extremities; however, it requires meticulous surgical dissection and patience.

Internally Fabricated Chimera Anterolateral Thigh-Amputate Flaps for Metachronous Reconstruction.

Background:The chimera flap is a versatile and exciting tissue composition for the reconstruction of complex tissue defects.Methods:Here, we present 2 cases of internally fabricated anterolateral thigh (ALT)-amputate chimera flaps for metachronous transfer.Results:A 22-year-old man (case 1) developed extended soft tissue necrosis in both legs following meningococcal septicemia. Before unilateral amputation, a fasciocutaneous flap based on the posterior tibial artery perforators was saved and ectopically implanted onto the ipsilateral thigh, creating an ALT-amputate chimera flap. Three months later, it was shown that the islanded ALT-amputate chimera flap remained well vascularized on either pedicle alone. Thus, a “true chimera circulation” over the scar between the 2 flaps must have developed. Subsequent free tissue transfer to the remaining right lower leg was performed successfully with uneventful healing. A 57-year-old fisherman (case 2) suffered a traumatic avulsion of his left thumb, which was ectopically replanted onto the contralateral thigh, creating an ALT-amputate chimera flap. After 3 months, the flap was raised and orthotopically replanted successfully with arthrodesis through the metacarpophalangeal joint. The previously coapted radial digital lateral femoral cutaneous nerve was coapted in the palm, and an flexor digitorum superficialis (FDS) ring transfer was performed for flexor pollicis longus (FPL) reconstruction.Conclusions:To the best of our knowledge, these are the first case reports using the descending branch of the lateral circumflex femoral artery system for (1) temporary ectopic implantation of a thumb and (2) temporary implantation of fasciocutaneous tissue based on posterior tibial artery perforators just before below knee amputation to reconstruct the contralateral leg.

Perforator navigation using color Doppler ultrasound and three-dimensional reconstruction for preoperative planning of optimal lateral circumflex femoral artery system perforator flaps in head and neck reconstruction

The authors introduce an algorithm for preoperative planning of optimal lateral circumflex femoral artery system perforator flap (LCFAPF) supplied by the best quality and the easiest dissection of the perforators and the source vessels for simplified and customized strategies in head and neck reconstruction with perforator navigation using color Doppler ultrasound and three-dimensional reconstruction (3D-CDUS PN). Between June 2011 and September 2015, a prospective cohort study was performed with an algorithm based on defect site, perforator type, and pedicle length using 3D-CDUS PN to select optimal perforators arising from the different branches of LCFA in 108 patients. The optimal perforator and flap were determined by perforator caliber and quality, difficulty in flap dissection, and length of the source vessels. Cause and classification of the defect, flap choice, recipient vessels, postoperative course, and complications were analyzed. The source vessels of the perforators were lateral descending branch in 73 cases and oblique branch in 17 cases with ALTPFs, medial descending branch in 12 cases with AMTPFs, and ascending branch in 6 cases with TFLPFs. Straightforward dissection of flaps with septocutaneous (n = 40) and semi-septocutaneous (n = 17) perforators was performed in 52.8% cases. Successful exploration rate and overall flap survival rate were both 100%. Satisfactory functional and esthetic results in both recipient and donor sites with no serious complications were observed in all patients. Our algorithm using 3D-CDUS PN facilitates selection of optimal flap with better caliber and quality of the perforators and sufficient pedicle length for easy dissection.

Feasibility of a bone and soft tissue chimeric anterolateral thigh free flap? Anatomic study and report of two cases for oral cavity reconstruction

The anterolateral thigh flap (ALT) is a workhorse for a spectrum of reconstructive problems including head and neck defects. Its versatility as a chimeric flap employing a variety of soft tissues with a robust pedicle is useful for three-dimensional defects. The authors investigated the anatomical relationship between the vascular supply to the ALT and anterior femur. We studied 16 fresh cadaver limbs to identify the typical branching patterns to the femur off the descending branch of the lateral circumflex femoral artery. These patterns can facilitate dissection of this type of chimeric ALT. The authors have integrated a bone component of vascularised femur in this flap off the lateral circumflex femoral artery system to address oral cancer defects in two patients. A retrospective review of these cases correlating with the anatomic study was undertaken. Both patients had recurrent disease with limited donor site options. Both had extensive floor of mouth and tongue defects as well as small mandible defects of 2 cm. Both went on to heal at the donor and recipient sites at 32 months' follow-up.

Classification and Application of the Distally-Based Thigh Flap Based on the Lateral Circumflex Femoral Artery System

The lateral circumflex femoral artery system with its anatomical variations is a common source vessel for numerous thigh flaps. However, the anatomic variations of the distally based thigh flaps have not been well classified. Between July 2008 and July 2016, 19 patients (13 men and 6 women; age range, 3-58 years; mean, 27.5 years) underwent reconstruction of defects around the knee using distally based thigh flaps. Defect etiologies included malignant neoplasm (6 cases) and post-burn scar contracture (13 cases). The distally based thigh flaps were raised based on perforating vessels originating from the descending, oblique, rectus femoris branches of the lateral circumflex femoral artery. The average flap size was 17.7 × 8.4 cm (range, 9-24 cm × 6-13 cm), whereas the mean pedicle length was 16.2 cm (range, 8.5-25 cm). The flap's perforating vessels originated from the descending branch in 6 patients, the oblique branch from the descending branch in 7 patients, the rectus femoris branch in 5 patients, and the oblique branch from the transverse branch in 1 patient. All flaps were pedicle flaps except 1 based on the oblique branch from the transverse branch that was converted to a free flap. All flaps survived in its entity. Our experience demonstrated that a distally based thigh flap can be reliably raised using perforating vessels from different branches of the lateral circumflex femoral artery.

Free anteromedial thigh perforator flap: Complementing and completing the anterolateral thigh flap.

Objective:Theobjective of this study was to determine the indications, utility, advantages and surgical approach for the anteromedial thigh (AMT) flap.Materials and Methods:We reviewed the records of the patients in whom the AMT flap was used for head and neck reconstruction. We use an anterior approach to harvest the anterolateral thigh (ALT) flap with a non-committal straight line incision. This preserves both ALT and AMT flap territories intact, and further decision is based on the intraoperative anatomy of perforator and pedicle. The ALT flap was usually used as the first choice when available and suitable.Results:Free AMT skin flaps were harvested in 24 patients. All flaps were used for the head and neck reconstruction. Two flaps had marginal flap necrosis. One flap was lost due to venous thrombosis.Discussion:The thigh is an excellent donor site as it has large available skin territory, expendable lateral circumflex femoral artery system and low donorsite morbidity. The ALT flap is the most commonly used flap for reconstruction of soft-tissue defects. However, it is characterised by variable vascular pedicle and perforator anatomy. The AMT flap is an excellent alternative when the ALT flap is not available due to variable perforator anatomy, injury to perforator, when an intermediate thickness is needed between distal and proximal thigh or a chimeric flap is needed.Conclusion:The AMT flap offers all the advantages of the ALT flap without increasing donor-site morbidity. The anterior non-committal approach keeps both the ALT and the AMT flap options viable.

A novel combination flap of anterolateral thigh flap (ALT) and rectus femoris flap for perineal defects

The pedicled anterolateral thigh flap (ALT) has gained importance in perineal reconstruction. Especially, the combination with muscle tissue, in the form of a chimeric flap, has clearly increased its versatility and range of application. Thus, both the skin paddle and the muscle seal, filling the dead space within the small pelvis, can be used to exactly reconstruct the defect. Nevertheless, the lateral circumflex femoral artery system is known for its vascular variability. We report a case, where we planned to close a perineal defect with a combination flap of vastus lateralis muscle and ALT flap. However, the ALT was found perfused by vessels perforating the rectus femoris muscle instead of the vastus lateralis, which gained its main perfusion by the transverse branch of the lateral circumflex femoral artery. Thus, the defect was successfully reconstructed with a combination flap of ALT and rectus femoris muscle tissue. The variable anatomy of the lateral circumflex femoral artery system is one of the main challenges of the ALT flap, frequently demanding creativity and the usage of freestyle flap design. Therefore, it is possible to make a virtue out of necessity.

Lateral Circumflex Femoral Artery System as a Universal Free Flap Donor Area

Introduction: Anterolateral thigh (ALT) flap based on the lateral circumflex femoral artery (LCFA) system has become the ”universal” donor area for many surgeons. It has become by the most utilized donor area for many centers. Many modifications and indications have been described. We present our experience with this versatile donor area, with more modifications and indications than described in the literature.

Versatility of the lateral circumflex femoral arterial (LCFA) system flaps for lower extremity soft tissue reconstruction

Background Complex and extensive limb defects involve difficult reconstructive problems, and lateral circumflex femoral artery (LCFA) system flaps provide an adequate reconstructive answer for these challenging wounds.

Use of Lateral Circumflex Femoral Artery System Free Flaps in Skull Base Reconstruction

We present a 10-year retrospective study at a tertiary center designed to evaluate the advantages, complications, and comparative results using lateral circumflex femoral artery (LCFA) system free flaps for cranial base reconstruction. In this study, a cranial base defect refers to exposed intracranial contents to the skin, paranasal sinuses, nasopharynx, oropharynx, or oral cavity. These defects resulted from resections of primary or recurrent neoplasms or from secondary problems after cranial base surgery. We performed 20 flaps in 20 patients. The selection of flap was as follows: 8 combinations of anterolateral/anteromedial thigh flaps with vastus lateralis muscle or tensor fascia lata flaps, 6 ALT fasciocutaneous flaps, and 6 muscle/myocutaneous flaps. The flap's success rate was 95% (19/20). Early major complications included 1 perioperative death, and there was 1 myocardial infarction. Minor complications included 1 partial (12%) flap loss, 2 temporal cerebrospinal fluid leak, 2 donor-site hematoma, 2 minor wound breakdown, 3 facial nerve weakness, and 4 donor-site numbness. Among 20 patients undergoing LCFA system flap reconstruction, 12 are alive and disease free. Local recurrence occurred in 1 patient. She underwent ablative surgery and a new successful free flap (forearm flap); after 2 years, the patient is disease free. The LCFA system flaps in skull base reconstruction provide versatility in flap design and availability of adequate tissues to fill dead space, and it offers vascularized fascia to augment dural repairs. It also provides a very long pedicle and allows simultaneous flap harvest with low donor-site morbidity.

Reply

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.

Lateral Circumflex Femoral Artery: Not Always Atherosclerosis-Resistant

Sir: We read with great interest the article by Halvorson, Taylor, and Orgill (Plast. Reconst. Surg. 121: 121, 2008) about the radiographic patency of the descending branch of the lateral circumflex femoral artery. The group noted radiographic mean stenosis rates of 10 percent in the descending branch of the lateral circumflex femoral artery and 12.5 percent in the profunda femoris artery, suggesting that the vascular territory supplied by the profunda femoris is largely “atherosclerosis-resistant.” We are submitting a cautionary statement that in the end-stage renal disease patient these findings may not hold true. We recently reconstructed a 13 × 9-cm full-thickness defect of the anterior scalp created after excision of a malignant fibrous histiocytoma. The patient, a 75-year-old man with hypertension and coronary artery disease, underwent a renal transplant 12 years ago. Preoperatively, there was no overt evidence of significant lower extremity vascular disease, as he was noted to have palpable pulses distally. Two lateral thigh perforating vessels were identified on Doppler ultrasonography. We performed an anterolateral thigh flap reconstruction based on a single intramuscular perforator from the lateral circumflex femoral artery to the superficial temporal vessels. Although the flap perforator itself was relatively soft, the entirety of the lateral circumflex femoral artery was extensively and completely calcified. The extensive calcification resulted in a challenging anastomosis, possible only by using a slightly larger needle/suture (8-0) taking bites from the inside aspect of the flap vessels, as coming through the calcified vessel wall from the adventitial side proved impossible. The recipient vessels were soft and had good inflow without evidence of calcification. Postoperatively, the patient did well and the flap survived in its entirety. Pathologic calcification of the vascular system in dialysis patients and transplant recipients has been recognized since the 1960s. In 1973, Tatler and Baillod2 examined plain radiographs and described calcium deposition in a “ring” or “tubular” pattern in 27 percent of patients starting dialysis, with this proportion doubling over a 3- to 4-year period. Using more sophisticated imaging, such as electron beam technology, a 60 to 90 percent prevalence in dialysis patients is noted, with the most consistently associated factors being advanced age and number of years on dialysis.3 The cause of arterial calcification is unclear but may be related to dialysis calcium concentration and the pathologic process of renal osteodystrophy. In dialysis patients, angiographic studies note that arterial calcifications are not necessarily associated with stenotic coronary artery lesions. Although some intimal calcification is present in dialysis patients, the pipe and tubular patterns described by Tatler and Baillod and others are more consistent with calcium deposition in the tunica media. These observations have led to an alternative arterial abnormality occurring in chronic kidney disease, a process called chronic kidney disease–associated arteriopathy.4 Although not causing arterial occlusion, as would be visualized on angiography, medial calcification in these patients leads to extensive arterial thickening and stiffening, making microanastomosis of these vessels extremely difficult. Although Halvorson et al. provide radiographic support for the relative atherosclerosis-sparing of the profunda femoris system, the findings were not correlated with the clinical appearance of the vessels because their patients never went on to surgery. For the surgeon planning any microsurgical reconstruction in patients with a history of end-stage renal disease, we have learned that the lateral circumflex femoral artery system may not be spared from disease. Mehul R. Kamdar, M.D. Christine Rohde, M.D. Jason A. Spector, M.D. Division of Plastic Surgery New York Presbyterian Hospital Columbia University College of Physicians and Surgeons New York, N.Y.

Anatomic Study of the Lateral Circumflex Femoral Artery System Applied to the Anterolateral Thigh Perforator Flap

Anatomic Study of the Lateral Circumflex Femoral Artery System Applied to the Anterolateral Thigh Perforator Flap

Lateral Circumflex Femoral Artery System: Warehouse for Functional Composite Free-Tissue Reconstruction of the Lower Leg

Microsurgical free-flap surgery has progressed from simply providing wound coverage to restoring a high level of function. The concepts and practice of using compound, composite, and chimeric flaps have recently further enhanced the versatility of free flaps in reconstructive surgery. A lateral circumflex femoral arterial (LCFA) system can provide a potential single composite free-tissue transfer for restoration of functional and structural integrity. Between 1997 and 2003, we used 44 free flaps to restore functional and structural defects in the lower limbs. The versatility of the LCFA system allowed utilization of the anterolateral thigh, vastus lateralis, tensor fascia lata, rectus femoris, and iliac crest. Combinations of tissues from this system were employed to restore defects in the patellar tendon (14), Achilles tendon (13), extensor hallucis tendon (2), anterior compartment with/without lateral compartment muscle (11), anterior compartment muscle and segmental tibial bone (3), and composite calcaneus (1). The free-flap success rate was 97.7%. Four re-explorations were performed with one subsequent failure. Eight patients (18.2%) developed wound infections, of which two required secondary amputations, resulting in a limb salvage rate of 95.4%. The LCFA system provides a predictable and versatile surplus of tissue necessary to restore functional and structural integrity of the posttraumatic lower extremity in a single stage.