Lateral Circumflex Femoral Research Articles

Anatomic study of the femur-vastus intermedius muscle-anterolateral thigh osteomyocutaneous free flap

Resection of head and neck malignancy usually causes facial defects and esthetic deformities. Among the wide range of free flaps available for reconstruction, a novel chimeric free flap-the femur-vastus intermedius muscle-anterolateral thigh osteomyocutaneous free flap (FVATLO flap)-has been demonstrated for clinical use. In this study, we illustrate the anatomy and harvest of the FVATLO flap. Eighteen fresh cadavers without damage to either thigh were recruited for dissection. Blood supply to the vastus intermedius muscle and femur were traced and recorded. The diameter, circumference of the middle part of the femur, and thickness of the femoral cortex were measured. The major blood supply to the vastus intermedius muscle showed two patterns of origin. The first arising from the descending branch of the lateral circumflex femoral artery (LCFA-db) accounts for 78% of the cases (28/36), and the second arising from the transverse branch of the lateral circumflex femoral artery (LCFA-tb) accounts for 22% (8/36). Blood supply to the femur consists of two major sources: one from branches penetrating through the nutrient foramen on the posteromedial surface of the femur to the medullary cavity, and the other from the periosteum branches spreading over on the femoral surface. No visible branch from the vastus intermedius muscle to the underlying periosteum was found. The mean diameter, femoral circumference, and mean cortical thickness were 26.30 mm, 85.58 mm, and 6.85 mm, respectively. Considering that there is only one injured donor site, the FVALTO flap is an alternative chimeric flap for cases with a large amount of soft tissue loss together with small bony defects.

Anatomical Study of the Descending Branch of the Lateral Femoral Circumflex Artery and Veins in Vascular Grafting in Japanese Cadavers.

Background:In microsurgery development, autologous vein grafting is necessary when there are no suitable blood vessels for anastomosis around the flap recipient site or when the vascular pedicle of the flap is short. The descending branches of the lateral femoral circumflex artery (LFCA) and vein have been used as a vascular bundle instead of vein grafts, but to our knowledge, there have been no reports on the relationship between thigh length and vessel length. In this study, we performed a macroscopic examination of the LFCA descending branch length required for grafting.Methods:The length of the LFCA descending branches and veins as well as thigh length were measured in 16 preserved cadaveric legs.Results:The average length of the thigh was 42.6 cm. It was possible to harvest a mean length of 14.2 cm of the descending branches of the lateral femoral circumflex vessels. Descending branches of the LFCA and veins were identified in all cases. It was estimated that the length of the LFCA descending branch and veins could be collected in 20% of the thigh length in 98% of cases.Conclusion:When preparing a preoperative plan, it is important to thoroughly consider the required length of blood vessels for grafting and whether it is possible to harvest vessels with sufficient length.

Pelvic collateral pathway during endovascular aortoiliac aneurysm repair with internal iliac artery interruption: a retrospective observational study

BackgroundIpsilateral branches of the deep femoral artery (DFA) are qualitatively identified as collateral arteries based on angiography after internal iliac artery (IIA) interruption. The purpose of this study was to quantitatively identify the major collateral pathway after unilateral IIA interruption during endovascular aortoiliac aneurysm repair to preserve the pelvic circulation and reduce the risk of ischemic complications.MethodsThe study population included 28 patients (mean age 76.3 years) with aortoiliac aneurysm who underwent endovascular aneurysm repair with unilateral IIA interruption from August 2012 to January 2020. The diameters of the bilateral preoperative and postoperative DFA, lateral femoral circumflex artery (LFCA), medial femoral circumflex artery (MFCA) and obturator artery (ObA) were measured on contrast-enhanced computed tomography using a 3-dimensional image analysis system. The measured values were evaluated and analyzed with a repeated measures two-way analysis of variance and Dunnett’s test.ResultsThe postoperative diameters of the MFCA (P = 0.051) and ObA (P = 0.016) were observed to be larger than the preoperative diameters. Such increases in the MFCA (P < 0.001) and ObA (P < 0.001) diameters were only found to be significant on the unilateral side of the IIA interruption, and the diameter of the ipsilateral LFCA (P < 0.001) was also found to have significantly increased in size. However, no significant arterial extension was found on the contralateral side.ConclusionsThe ipsilateral MFCA-ObA pathway might therefore be a major collateral pathway arising from the DFA to preserve pelvic circulation after unilateral IIA interruption.

Anatomical variations in the origins of the lateral circumflex femoral arteries in a South African sample: A cadaver study

BackgroundClinically, the lateral circumflex femoral artery (LCFA) is used in a variety of procedures, these include anterolateral thigh flaps, aortopopliteal bypass, coronary artery bypass grafting and extracranial-intracranial bypass surgeries. Variations in the anatomy of the LCFA, profunda femoris artery (PFA) and their branches have been noted in several studies. There are numerous clinical implications related to the inadequate anatomical knowledge of this region. MethodsThe study sample consisted of 55 cadavers of different ages, ancestry groups and varying body mass index. A total of 90 legs were dissected. The anterior thigh compartment was dissected and the common femoral artery (CFA), superficial femoral artery (SFA), PFA and LCFA further exposed. The course and variations were noted and results documented for further analysis. ResultsThe LCFA was present in all the legs dissected. The origin of the LCFA was found to be the PFA in 75.6% of the left legs and 82.2% of the right legs dissected.In two cases, a male and female limb, the branching of the PFA from the CFA was observed directly from the external iliac artery, deep to the inguinal ligament.A variation was noted in a female cadaver, where the branches of the LCFA on the left limb had different points of origin. Another variation was noted on a male cadaver, the left limb had two different points of branching for the ascending and descending branches of the LCFA, a common trunk was absent. ConclusionThis study indicates that the most common site of origin for the LCFA was the PFA. The branching of the PFA from the CFA was found to be variable in 2.2% of the cases, where the PFA was a direct branch of the external iliac artery. The study also noted variations relating to the origin of the transverse branch of the LCFA, this branch was absent in 4.4% of the limbs dissected.Knowledge of the variations related to the origin of the PFA, LCFA and their branches is important in reducing the chances of intra-operative bleeding, during different surgical procedures.

Individualized design of double skin paddle anterolateral thigh perforator flaps to repair complex soft tissue defects of the extremities: An anatomical study and retrospective cohort study

This study describes our experience using individually designed double skin paddle anterolateral thigh perforator (ALTP) flaps to reconstruct complex soft tissue defects. An anatomical study of double skin paddle ALTP flaps was conducted in six fresh cadavers (12 thighs). We also performed a retrospective cohort study of 36 patients who underwent reconstruction using double skin paddle ALTP flaps from January 2009 to June 2019. The soft tissue defects were large or non-adjacent defects that could not be repaired by a single flap. Three types of double skin paddle ALTP flaps were designed. In type I, separate perforators supplied each flap: one perforator from the transverse branch of the lateral circumflex femoral artery (LCFA) and one from the descending branch of the LCFA (d-LCFA). In type II, both perforators were from the d-LCFA. In type III, a single perforator from the d-LCFA had two branches that each supplied one flap. In the cadaver study, type I was observed in 11 thighs, type II in 10, and type III in six. All patients were successfully treated using double skin paddle ALTP flaps. Four patients received type I flaps, 23 received type II, and nine received type III. Vascular compromise occurred in one patient, and the flap was saved by emergency revascularization. Most patients had satisfactory contours and functional recovery during follow-up. Individually designed double skin paddle ALTP flaps is a reliable option for reconstructing complex soft tissue defects. Moreover, we created an algorithm for microvascular reconstruction of complex soft tissue defects.

TO INVESTIGATE BRANCHED ANATOMICAL FEATURES OF THE LATERAL FEMORAL CIRCUMFLEX ARTERY USED IN THE CONSTRUCTION OF THE COMPOSITE ANTEROLATERAL THIGH (ALT) FLAP

Introduction: The research of the lateral femoral circumflex artery has been studied and applied in many clinical fields. Objectives: To investigate branched anatomical features of the lateral femoral circumflex artery used in the construction of the composite anterolateral thigh (ALT) flap. Patients and research methods: 60 thigh areas of 30 Vietnamese adult cadavers meeting the research standards were conducted cross-sectional descriptive analysis. Result: lateral femoral circumflex artery usually has three branches that are ascending branch, oblique branch and descending branch. Descending branch usually separated independently (11.7%), oblique branch and ascending branch often have common body (83.3%). The majority of ascending branches have origin from lateral femoral circumflex (76.7%). Ascending branche has average of 4.1 branches to supply the anterior thigh muscles. Ascending branches has 2-3 cutaneous perforators were the majority (41.7%). There are 73 descending branch, 75.34% descending branch from the original branch of the lateral femoral circumflex artery, 8.22% lateral femoral circumflex artery from femoral artery and 16.44% descending branch from deep femoral artery. Averaging descending branch has 8.9 ± 0.2 branches to muscles of anteriolateral thigh area and on average had 3.1 ± 0.3 perforators per thigh specimen. The number of branches to lateralis muscles was at most 7.9 ± 0.4 branhes. Conclusion: Anatomical research of the lateral femoral circumflex artery branching as a premise to build a composite ALT flaps with lateralis component or with TFL makes sense in the creation of workhorse materials in clinical application. Key words: lateral femoral circumflex artery

The Anatomic Feasibility of a Functional Chimeric Flap in Complex Abdominal Wall Reconstruction.

Dynamic and functional abdominal wall reconstruction (FAWR) remains a complex challenge. The ideal flap should have a minimal donor-site morbidity and cover a large surface area with motor and sensory capabilities. The goal was to investigate the feasibility of using a free chimeric flap with anterolateral thigh (ALT) and rectus femoris (RF) components pedicled only on the motor nerve branch. Ten fresh cadavers were dissected with a designed chimeric thigh flap including ALT and RF flaps. Anterolateral thigh was designed and raised with the lateral femoral cutaneous nerve integrated, and the descending branch of the lateral circumflex femoral artery was preserved. Rectus femoris was elevated and the common pedicle was dissected up to the femoral origin. Accompanying motor nerve branches were carefully dissected to their femoral origin. Twenty RF flaps were dissected and 9 were harvested as a true chimeric flap with ALT. The mean number of neurovascular bundles associated with RF flap was 2.11 ± 0.47, and the mean primary motor nerve average length was 9.40 ± 2.42 cm. The common vascular bundle in all 9 chimeric flaps was ligated, and the flap was rotated toward the abdomen pedicled only by primary motor nerve of the RF muscle. Nerve length was adequate for reach up to xiphoid area in all 20 flaps. This study demonstrates the feasibility of the chimeric ALT/RF muscle free flap pedicled only by the motor nerve branch, with adequate flap rotation. Even with the limitations in a live patient, this flap would be an excellent option for FAWR in the right patient.

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.

Femoral artery anatomy is a risk factor for limb ischemia in minimally invasive cardiac surgery.

In minimally invasive cardiac surgery (MICS), femoral artery cannulation during cardiopulmonary bypass (CPB) can cause limb ischemia. This study evaluated the association between femoral artery anatomy and the risk of limb ischemia in MICS. Eighty-one patients who underwent MICS with CPB using single femoral artery cannulation between 2010 and 2018 were included. The patients were stratified by their femoral artery diameter and anatomy of ectopic side branch, i.e., medial or lateral femoral circumflex arteries: Type A, deep femoral artery (DFA) ≥ superficial femoral artery (SFA); type B, DFA < SFA with an ectopic side branch of the common femoral artery (CFA); type C, DFA < SFA with an ectopic side branch at the CFA bifurcation; and type D, DFA < SFA without an ectopic side branch. The ratio of the postoperative creatine kinase concentration and the cross-sectional area of the femoral muscles (CK/MA) was used as a surrogate marker of limb ischemia. Predictors of high CK/MA were evaluated. No critical limb ischemia was observed in this study. The median postoperative creatine kinase and CK/MA were 1954 (1305-2872) IU/l and 15.2 (9.2-19.8) IU/l/cm2. Multivariable logistic regression found that anatomical type D (odds ratio 4.19, 95% confidence interval: (1.26-14.0); p = 0.020) and prolonged CPB time (OR 1.01, 95% CI (1.00-1.02); p = 0.045) were independent risk factors of high CK/MA. Anatomical type D and prolonged CPB time were associated with risk of limb ischemia in MICS.

Short-term follow-up of embolization of hip synovitis

BackgroundOsteoarthritis (OA) is the most frequent joint disease, affecting 10% of men and 18% of women older than 60 years worldwide. Traditionally, treatment is based in pain management with joint replacement of end-stage disease. In this setting, transcatheter embolization has emerged as an alternative in reduction of pain in patients with OA.Case presentationA 77 years-old female presenting with two previous deep vein thrombosis and 10 years of hip pain. Magnetic resonance demonstrated a focal area of enhanced pericapsular signal near the superolateral margin of the acetabulum. Embolization of branches of the ascending branch of the lateral femoral circumflex artery was performed, with decrease of the pain and improvement in the image and her walking ability in a four-month follow-up.ConclusionThis case report have shown that embolization of hip synovitis is feasible with early clinical success, in tune with the findings of genicular and shoulder embolization. Studies with more patients and long-term results are necessary to corroborate this finding.Level of evidence4

Perforator Variability of the Anterolateral Thigh Flap Identified on Computed Tomographic Angiography: Anatomic and Clinical Implications.

The anterolateral thigh (ALT) flap is a useful flap with minimal donor site morbidity. Preoperative computed tomographic angiography (CTA) for lower extremity reconstruction can determine vessel integrity and plan for recipient vascular targets. This study reviews lower extremity CTAs to further characterize ALT vascular anatomy and associated clinical implications thereof. Lower extremity CTA studies were retrospectively reviewed, and information on ALT cutaneous perforator location, origin, and course was collected. A total of 58 lateral circumflex femoral artery (LCFA) systems in 31 patients were included. Average age was 38.8 ± 15.9 years with mean body mass index of 27.2 ± 5.7 kg/m2. The majority of patients were females (23, 74.2%). The LCFA most commonly originated from the profunda femoris artery (87.3%), followed by the distal common femoral artery (9.1%). On average, there were 1.66 ± 0.69 cm perforators per extremity, with an average of 5.38 cm between adjacent perforators. Perforators originated from the descending branch of the LCFA in 89.6% of studies. Perforator caliber was <1 mm (29, 30.2%), 1 to 2 mm (55, 57.3%), or >2 mm (12, 12.5%). Mean distance from the most proximal perforator to the anterior superior iliac spine was 20.4 ± 4.82 cm. Perforators were musculocutaneous (46.9%), septocutaneous (34.4%), or septomyocutaneous (18.8%). In 58.1% of patients, only one thigh had easily dissectable septocutaneous and/or septomyocutaneous perforators, in which case preoperative CTA aided in donor thigh selection. ALT flap cutaneous perforator anatomy varies considerably. Using CTA, we report on rates of septocutaneous, myocutaneous, and septomyocutaneous perforators and underscore its utility in perforator selection.

Surgical anatomy of the lateral circumflex femoral artery branches: Contribution to the blood loss control during hip arthroplasty

BackgroundThe lateral circumflex femoral artery (LCFA) branches encountered during anterior and lateral hip approaches; although vessels’ haemostasis is suggested in surgical textbooks, literature is scarce regarding their topography. The current study defines the exact location of the LCFA and its branches, based on osseous landmarks, as well as their size and possible variants, providing helpful information for intraoperative identification and demonstrating the magnitude of potential haemorrhage during hip surgery. MethodsTwenty-three human cadavers (46 lower limbs) were dissected. The LCFA branching pattern was recorded. The distances of the LCFA origin and its first branch from the anterior superior iliac spine (ASIS) were measured. Length and width of the LFCA, LCFA ascending and transverse branches (LCFAab and LCFAtb) were calculated and compared to the ipsilateral ulnar artery (UA) width, which was served as a comparative guide. ResultsThe LFCA origin was located 106.9 ± 17.5 mm distal and 65.6 ± 14.7 mm medial to the ASIS, while the LFCA first branch origin was 115.1 ± 24.3 mm distal and 48.2 ± 14.3 mm medial to the ASIS. The mean lengths of the LCFA, LCFAab and LCFAtb were 23.2 ± 12.6 mm, 44.8 ± 14.9 mm and 42.3 ± 13.6 mm, respectively. Their mean widths were 4.3 ± 1.0 mm, 2.9 ± 0.9 mm and 2.7 ± 0.7 mm, respectively, while the mean UA width was 2.7 ± 0.4 mm. ConclusionThe surgeon may detect the LCFA and its branching, at a mean distance of 110 mm (range 100−126 mm), distal to the ASIS. The LCFAab and LCFAtb widths are similar to the UA width. Meticulous knowledge of the branching pattern topography and vessels’ size may contribute to a successful management of the intraoperative blood loss.

Clinical effect of free anterolateral thigh flap combined with arterial vascular reconstruction on repairing high-voltage electrical burn wound on the wrist

Objective: To explore the clinical effect of free anterolateral thigh flap combined with arterial vascular reconstruction on repairing high-voltage electrical burn wound of type Ⅱ and Ⅲ on the wrist. Methods: From May 2016 to February 2019, 25 patients with deep high-voltage electrical burn wounds on the wrist were admitted to Zhengzhou First People's Hospital, including 23 males and 2 females, aged 11-63 years. Among them, 4 cases had bilateral electrical burns on the wrist, and 21 cases had unilateral electrical burns on the wrist. There were 29 wounds in 29 affected limbs with depth of full-thickness to full-thickness with tendon and bone exposure, and 17 wounds were type Ⅱ and 12 wounds were type Ⅲ. Twenty-four patients underwent CT angiography of the upper extremities before surgery, while the other one patient did not undergo the examination due to seafood allergy. There were no obvious injury to the ulnar and radial arteries in 7 affected limbs, simple ulnar artery injury in 6 affected limbs, simple radial artery injury in 7 affected limbs, and both ulnar and radial arteries injury in 9 affected limbs. The wound areas after debridement were 10 cm×7 cm-36 cm×17 cm, and the free anterolateral thigh flaps were obtained with area of 11 cm×8 cm-37 cm×18 cm for repairing the wounds. For patients with no damage of ulnar artery and radial artery, the trunk of descending branch of lateral circumflex femoral artery of the flap or combined with the thick muscle perforating branch or lateral branch was anastomosed with the ulnar or radial artery of the wound. For patients with simple ulnar artery or radial artery injury, the trunk, lateral branch, or medial branch was anastomosed with the ulnar artery or radial artery of the wound. For patients with long injury of ulnar artery and radial artery, the ulnar artery or radial artery of the wound was reconstructed with one of the above-mentioned methods, the injured artery that was not anastomosed was reconstructed with great saphenous vein, and the transplanted blood vessel was embedded in the lateral femoral muscle. The accompanying vein of the descending branch of the lateral circumflex femoral artery of the flap was anastomosed with the accompanying vein of the ulnar artery or radial artery of the wound and/or the cephalic vein. The donor sites of flaps were sutured directly or repaired with split-thickness skin graft from the thigh. The survival condition of flap and affected limb after operation and during follow-up was observed, and hand function of the affected limb during follow-up was evaluated according to the evaluation standard after repair of peripheral nerve injury in upper limbs. Results: Fifteen affected limb wounds had tissue liquefaction but healed after second debridement on 14-28 days after flap repair operation. All 29 flaps survived in the end. One patient had long ulnar artery and radial artery injuries in affected limbs and the hand was necrotic due to second embolism of the blood vessel in 1 week post operation, and the remaining affected limbs survived. During the follow-up of 6 to 30 months after operation, the flaps were slightly bloated, the affected limbs were warm with normal blood flow, and finger flexion, wrist flexion, and sensory function of hand recovered to varying degrees. The functions of the survived affected limbs were evaluated as excellent in 8 affected limbs, good in 9 affected limbs, medium in 5 affected limbs, and poor in 6 affected limbs, with an excellent and good rate of 60.71%. Conclusions: The clinical effect of free anterolateral thigh flap combined with arterial vascular reconstruction is good for repairing high-voltage electrical burn wound on the wrist, and the patency restoration of the ulnar artery and/or radial artery of the upper limb in stage Ⅰ is helpful for improving the success rate of limb salvage.

Use of Arterial Grafts in Hypothenar Hammer Syndrome: Application of Perforator Flap Anatomy.

Hypothenar hammer syndrome (HHS) is traditionally treated with venous bypass grafting, but controversy has arisen as arterial grafts have become more available. A retrospective review of all patients undergoing ulnar artery bypass grafting for HHS with an arterial graft from 2008 to 2017 was performed. We also review the literature for patency rates and discuss the scenarios that favor different graft choices. Six patients were included in our series. Five had primary surgery and 1 had revision surgery for HHS. Five arterial grafts were from the deep inferior epigastric artery and 1 was from the lateral circumflex femoral artery. The proximal anastomotic site was the ulnar artery for all: n = 6. The distal anastomosis site was the palmar arch and common digital artery (CDA) of the ring/small finger and CDA of the middle/ring finger: n = 3; the palmar arch and the CDA of the ring/small finger: n = 3. All patients were symptom-free at follow-up and had a patent ulnar artery on Allen's testing or angiogram. Patency rates of arterial grafts for HHS appear to be excellent and this small series and may offer an alternative to traditional venous grafts and end-to-end arterial anastomoses. We suggest using arterial perforator grafts from free flap donor sites. These have well-described anatomy, are easily harvested, and carry minimal donor site morbidity. Lateral circumflex femoral artery graft is favored in patients requiring a single distal anastomosis, who have a ventral hernia, or who are obese. Deep inferior epigastric artery graft is preferred when multiple distal targets or versatile configurations are needed, in thin patients, or in female patients.

Repair of Massive Bone Defects of the Proximal Femur Using Iliac Bone Flaps of the Ascending Branch of the Lateral Circumflex Femoral Artery: A Retrospective Report.

The management of bone defects is still a difficult problem. Local vascularized bone grafts represent an efficient and widely used method. In this retrospective report, iliac bone flaps of the ascending branch of the lateral circumflex femoral artery were used for the management of proximal femur bone defects. The hospital information system and clinical data collected by surgeons were retrospectively reviewed. Patients with massive bone defects of the proximal femur reconstructed with iliac bone flaps of the ascending branch of the lateral circumflex femoral artery were included. Relevant data, including general information, perioperative treatment, and imaging data during follow-up, were retrieved for analysis. Five patients (4 males and 1 female) aged 18 to 42 years were included in this report. All patients were diagnosed with proximal femoral bone defects. The sizes of the bone defects ranged from 5 ×4 cm to 8 × 5 cm. Harris hip score was adopted to evaluate the functional outcomes. The adverse events were recorded. The mean follow-up time was 6.3 years. Iliac bone flaps of the ascending branch of the lateral circumflex femoral artery were transferred locally for the 5 patients. Bone flaps were fixed with plates in 4 cases and Kirschner wires in 1 case. The hospital stay was 12 to 27 days, with an average of 19.4 days. All cases achieved bony healing after 3 to 6 months postoperatively. The Harris hip scores ranged from 87 to 95 at final follow-up. All patients achieved good to excellent functional outcomes. One superficial infection occurred. No other adverse events or serious adverse events were noted. Local transfer of iliac bone flaps of the ascending branch of the lateral circumflex femoral artery represents a safe and effective method for the reconstruction of massive bone defects of the proximal femur.

A Prospective Comparative Study of Color Doppler Ultrasound and Infrared Thermography in the Detection of Perforators for Anterolateral Thigh Flaps.

Preoperative localization of the perforators allows precise planning of the flap design and improves surgical efficiency. Recently, infrared thermography is introduced as a reliable alternative, where the perforator corresponds to the "hot spot" on the thermogram. This study aims to compare the application of color Doppler ultrasound (CDU) and infrared thermography in preoperative perforator mapping of the anterolateral thigh (ALT) perforator flap. From September 2017 to January 2019, CDU and infrared thermography were both applied on 20 patients to locate the perforators originated from lateral circumflex femoral artery preoperatively. The perforators identified using each modality were marked on the anterolateral thigh region. The accuracy of both mapping methods was analyzed according to the intraoperative findings. The relation between location bias and the thickness of subcutaneous tissue was analyzed. A total of 20 ALT flaps were included. Fifty-three perforators were detected by CDU, and 51 "hot spots" were identified by infrared thermography, in which 50 "hot spots" corresponded to CDU, and the consistency test showed that the κ index was 0.712 (P < 0.05), representing high consistency. The infrared thermography has a sensitivity of 94.3% and a specificity of 85.7% compared with CDU. The deviation between thermal imaging and CDU was positively correlated with the thickness of the subcutaneous tissue. The Pearson correlation coefficient was 0.84 (R = 0.84). Forty-four perforators marked by CDU were selected for designing the flap. Anatomical findings showed that the accuracy rate of CDU and infrared thermal was 93.2% (41 of 44) and 86.3% (38 of 44), respectively. There was no statistical difference (P > 0.05). Compared with CDU, infrared thermography can be used to locate perforators, in this case, the ALT perforators, with a high degree of consistency. It is portable, economical, noninvasive, and easy to operate. It has higher accuracy in patients with thinner subcutaneous tissue. We believe that infrared thermography can be a useful technique for perforator mapping, especially in patients where the subcutaneous tissue is thinner.

Anatomic Variations of the Deep Femoral Artery and Its Branches: Clinical Implications on Anterolateral Thigh Harvesting.

The deep femoral artery (DFA) is the largest branch of the common femoral artery (CFA), supplying with its branches, the medial circumflex femoral artery (MCFA) and lateral circumflex femoral artery (LCFA), the thigh muscles, the hip joint, and the femur. Their anatomical variations have a great impact on both interventional and surgical procedures. The anterolateral thigh (ALT) flap, a versatile soft tissue with highly increasing use in reconstructive surgery, is noticeably influenced by this variability. A total of 25 articles were incorporated into the review. Studies conducted after the year 2009 were included. After the assessment of all studies included, we concluded that the DFΑ arises from the CFA with a varying site of origin, the posterolateral being the prevalent one found in 51.32% of cases. Of all cases studied, the MCFA and the LCFA most often originated from the DFA in 63.125% and 74.92%, respectively, but the CFA constitutes another frequent source of origin in 27% and 12.12% of cases, respectively. The descending branch of the lateral circumflex femoral artery (dLCFA) is the prominent pedicle in the ALT flap, originating from the LCFA in 83.55% of cases. However, the presence of an oblique lateral circumflex femoral artery (oLCFA) branch with changeable origination was observed. Knowledge of the anatomical variants in the deep femoral artery is imperative both for interventional radiologists and surgeons. Especially in reconstructive surgery, the possibility for different sources supplying the skin and the pedicle compel surgeons to acquire an awareness of this subject.

Preserving the Blood Flow of the Recipient Artery in Cross-Leg Free Flap Procedure for Lower Extremity Reconstruction.

When there is no suitable vessel in the injured leg for microsurgical transfer, cross-leg free flaps can be considered for lower extremity reconstruction. This report describes patients who experienced lower extremity trauma and underwent reconstruction with cross-leg free flaps with preserved blood flow in the recipient artery. Anterolateral thigh flap is preferred for small to moderate defects. The descending branch of the lateral femoral circumflex artery was dissected 2 cm proximally and distally and was prepared in a T-shape. The branches of the T were anastomosed to the recipient artery in the contralateral leg in the first session of the cross-leg free flap procedure. After 3 weeks, the flap artery was separated from the bifurcation. For large defects, the latissimus dorsi flap was chosen. The thoracodorsal artery was anastomosed to the contralateral posterior tibial artery in the first session. After 3 weeks, to provide recipient vessel integrity, the thoracodorsal artery was transected from the flap and anastomosed to the distal stump of the posterior tibial artery. Between January 2017 and January 2019, 8 defects were reconstructed using an anterolateral thigh flap; the remaining 4 defects were reconstructed using a latissimus dorsi flap. All flaps survived without complications. Anterograde flow distal to the anastomosis was confirmed in all recipient arteries via Doppler ultrasound. In cross-leg free flaps, the continuity of the recipient artery can be established to prevent diminished blood flow to the recipient extremity.

Detection of vascularity of femoral head using sub-millimeter resolution steady-state magnetic resonance angiography-initial experience.

The purpose of this study was to use the steady-state (SS) magnetic resonance angiography (MRA) with a sub-millimeter resolution to detect the arteries supplying to the femoral head (FH). SS MRA scanning of hips was performed bilaterally in 15 healthy volunteers. A blood pool contrast agent was used. The scanning protocol included a 0.8-mm3 isotropic T1-fast field echo sequence with spectral fat suppression technique. Two highly qualified radiologists independently evaluated the medial circumflex femoral artery (MCFA), the lateral circumflex femoral artery (LCFA), and the three retinacular arteries including superior retinacular artery (SRA), inferior retinacular artery (IRA), and anterior retinacular artery (ARA). The intraosseous branches of the three retinacular arteries were also evaluated. An orthopaedic surgeon was consulted in case of disagreement. Observation by the two radiologists and support from the orthopaedic surgeon served as the end result. Agreement between the two observer radiologists was evaluated. Interobserver agreement between the two radiologists was found to be substantial to perfect. Of the 30 hips, the LCFA and MCFA were detected in all hips; the SRA and IRA were detected in most hips (100%, 90%), and the ARA was detected in 13 hips (43%). The intraosseous branches of SRA and IRA were detected in 30 and 22 hips (100%, 73%), respectively, while the intraosseous branches of ARA were detected in 11 hips (37%). The main arteries supplying the FH can be detected by the SS MRA, making it a novel method to detect the vascularity of FH.

How To Harvest the Anterolateral Thigh Free Flap

Summary: The anterolateral thigh (ALT) flap is the flap with various components based on perforators from the descending branch of the lateral circumflex femoral artery. This flap has a number of advantages and disadvantages. It can be used to reconstruct defects after oncologic resection and coverage following amputation or to preserve limb length. The contraindications include unsuitable donor sites, inadequately debrided recipient sites, and morbid obesity. Preparations for ALT procedure consist of history taking, physical examinations, and supporting examinations.