Tensor Fascia Lata Flap Research Articles

Modification of the tensor fasciae latae flap for reconstruction of the abdominal wall: a case report

Full-thickness periumbilical wounds after extensive abdominal surgery present a major challenge. In this case report the traditional tensor fasciae latae flap was modified, improving flap mobility while also facilitating donor defect repair.

Penile resurfacing with vascularized fascia lata

Penis resurfacing is a challenging procedure, and should simultaneously ensure erectile function, tactile sensibility, sexual satisfaction, and aesthetic integrity. This article presents three cases with penile skin defects treated by means of a pedicled fascia lata attached either to the tensor fascia lata (one case) or an anterolateral thigh flap (two cases). The cause of the wounds included electrical burn, Fournier's gangrene, and self-mutilation. The size of flaps ranged from 10-13 cm in width and 15-30 cm in length. All flaps included vascularized fascia lata, which covered part or the circumference of the penis. All flaps survived completely. The lateral cutaneous nerve of the thigh was included in the designed flaps in all instances, and normal protective sensation was recorded postoperatively. The patients reported normal erectile function and ability to perform intercourse. The flaps, though relatively bulky and hairy, had a good color and texture match with the penis and suprapubic region. Based on our limited experience, we believe that the anterolateral thigh flap has greater dimensions with a longer pedicle, and allows for greater flexibility in flap design compared to the tensor fascia lata flap. An anterolateral thigh flap can be safely thinned in a second stage, and it is our flap of choice for penis resurfacing.

Anatomic analysis of the vascular network and vascular pedicle of the tensor fascia lata flap (angiographic and cadaver study)

Knowing the vascular network and properties of the vascular pedicle is of crucial importance for elevation of the tensor fascia lata (TFL) transpositional or free flap; therefore, the origin of the lateral circumflex femoral artery (LCFA), its diameter at the site of origin, the length of the vascular pedicle, the number of lateral branches, the number of terminal branches and the anastomosis of the LCFA ascending branch are of utmost importance for successful elevation and clinical application of this flap. The study was conducted on clinical (100 angiographic images of the femoral artery) and autopsy (48 preparations) material. The first part of the study comprised analysis of the angiographic images that were used to obtain the information on LCFA. The diameter of LCFA at its origin was measured to be 0.44 cm, while it was 0.33 cm at the origin of ascending branch. The mean value of the diameter at the bifurcation of the terminal branches of ascending branch (inside tensor fascia lata muscle) was 0.24 cm. It has been established that the vascular pedicle of the tensor fascia lata flap (ascending branch of LCFA) is anastomosed with the superior gluteal artery in all cases. Measurement of the tensor fascia lata muscle revealed an average length of 15.91 cm, width of 3.55 cm and thickness of 1.98 cm. Injection of colour-ink into the ascending branch LCFA that enters directly into the TFL muscle was used to measure the extent of the TFL flap vascularization and on the average, the TFL flap was 20.32 cm long and 16.57 cm wide while the surface was 17.52 cm3.

Radio-recurrent spermatic cord leiomyosarcoma requiring radical surgery and reconstruction using a myocutaneous (tensor fascia lata) flap: a case report and review of the literature

Leiomyosarcomas (LMS) of the spermatic cord are exceedingly rare tumours. Radical inguinal orchiectomy and high ligation of the cord is the standard primary procedure. The extent of soft tissue excision required, including margins, and the precise role of adjuvant radiotherapy (RT), however, remains unclear. A 58-year-old male underwent excision of a large inguinoscrotal mass and orchiectomy. Histological examination revealed the mass to be a LMS of the spermatic cord with the tumour extending to one of the resection margins. Further surgery was nevertheless withheld for fear of creating a significant anatomical defect and hence the patient was referred for radiation therapy. He developed locoregional recurrence 2.5 years later which necessitated radical excision of soft tissues in the lower–anterior abdominal wall and inguinal region, and reconstruction using a tensor fascia lata flap. This report emphasizes the need for primary radical surgery until negative histological margins are achieved even if it involves sacrificing some adjacent normal anatomy. If margins are positive after primary surgery, re-excision should be the rule rather than the exception. Adjuvant RT, though useful, should not be considered as a substitute for complete surgical clearance. To the authors’ knowledge, this is the first report in medical literature of a case of spermatic cord LMS recurring after surgery and RT, requiring further radical surgery. The pathophysiology and the management of this complex and rare tumour are also reviewed.

The Use of Anteromedial Thigh Flap in Head and Neck Reconstruction

Anterolateral Thigh (ALT) flap was well known and used worldwide. Although the anatomy and variation was well studied and presented in literature, some cases without any perforator were found during ALT flap harvesting. Tensor Fascia Lata (TFL) flap, Anteromedial Thigh (AMT) flap and Medial Thigh flap (MT) were alternative flaps for the condition of lack of perforator when harvesting ALT flap. Although the length and diameter of pedicle of AMT is shorter than ALT flap, this flap could be used primarily for head and neck cancer reconstruction instead of alternative flap. Mostly the perforator is septocutaneous type which renders shorter harvesting time without tedious intramuscular dissection. Also it could be combined with including the adjacent tissue such as the rectus femoris (RF) muscle and iliac bone. Between July 2003 and October 2003, 15 flaps were harvested as free AMT flaps and prospectively reviewed. Perforators from medial branch of Lateral circumflex femoral artery were found along subfascial dissection. There were eleven males and four females with ages ranging from 34 to 72 years (mean 56). The size of the flaps ranged from 10 to 29 cm in length and 5 to 11 cm in width. Twelve flaps had 1 perforator, two flaps had 2 perforators and one flap had 3 perforators. Among nineteen perforators, 14 perforators were septocutaneous type which ran through the intermuscular septum (74%); and the other 5 were all musculocutaneous type (26%). All flaps survive well without any complication. The AMT flap is a safe and reliable flap as primary flap in the reconstruction of head and neck cancer.

Die Therapie des fortgeschrittenen Peniskarzinoms

Skin infiltration and locoregional lymph node extension in metastatic penile cancer leads to destruction in the inguinal and perineal region. Efficacy of systemic polychemotherapy based on cisplatin, methotrexate, and bleomycin (CMB scheme) is limited with an objective remission rate up to 30% only. The obligatorily superinfected defects require tension-free and extended coverage with immediate myocutaneous flaps after surgical resection. Pedicle flaps, consisting of skin, fascia, muscle, and the supplying vessels, are used to cover the post-resection defects. In the field of surgical uro-oncology the following myocutaneous flaps listed with the supplying vessels have proved themselves: M. tensor fasciae latae flap (A. circumflexa femoris lateralis), M. rectus abdominis flap (A. epigastrica inferior), M. gluteus maximus flap (A. glutea inferior). Data concerning a prospective study for neoadjuvant chemotherapy with CMB followed by surgical tumor resection with immediate myocutaneous flap reconstruction are presented. In 15 patients (median age: 69.7 years) suffering from squamous cell carcinoma of the penis (Tx, N3, M1 cutis), a surgical excision of the tumor was performed after neoadjuvant chemotherapy (median:2.4 cycles) and antibiotic pretreatment. All patients received coverage of the femoral vessels with a musculus sartorius transfer on both sides. An extended (up to 45x30 cm) tension-free coverage of groin defects was performed in two patients with a unilateral M. tensor fasciae latae flap (TFL) and in eight patients with a bilateral TFL. One patient received a M. gluteus maximus flap (GMFL) on both sides, three patients were treated with a combination of M. rectus abdominis flap (RFL) and TFL, and one patient received a combination of two TFL, one GMFL as well as one RFL. Of 31 myocutaneous pedicle flaps, 2 developed distant necrosis of the flap, in which one GMFL and one TFL were affected. No complete necrosis of the pedicle flap occurred. Primary wound healing was found in 29 of 31 myocutaneous flaps. The covering of groin defects by the use of myocutaneous flaps, such as the M. tensor fasciae latae, M. rectus abdominis, and M. gluteus maximus flap, is a method of first choice in the primary treatment of even bacterially contaminated wounds or after radiation therapy. The techniques of pedicle flaps are comparably applied in oncology and traumatology.

The vascular supply of the extended tensor fasciae latae flap: how far can the skin paddle extend?

The vascular supply of the tensor fasciae latae flap and of the lateral thigh skin was studied in 10 cadavers to evaluate whether the lateral thigh skin toward the knee could be incorporated into an extended tensor fasciae latae flap. Within each cadaver, vascular injection of radiopaque material preceded flap elevation in one limb and followed flap elevation in the contralateral limb. Flaps raised after vascular injection were examined radiographically to evaluate the vascular anatomy of the lateral thigh skin independent of flap elevation. When vascular injection was made into the profunda femoris, the upper two-thirds of the flaps was better visualized than the distal third. When the injection was made into the popliteal artery, the vasculature of the distal third of the flaps was better visualized. Flaps raised before vascular injection were examined radiographically to delineate the anatomical territory of the vascular pedicle that had been injected. In these flaps, consistent cutaneous vascular supply was only seen in the skin overlying the tensor fasciae latae muscle, confirming that musculocutaneous perforators are the predominant means by which the pedicle of the tensor fasciae latae flap supplies the skin of the lateral thigh. Extended tensor fasciae latae flaps were elevated bilaterally in one cadaver, and selective methylene blue injections were made into the lateral circumflex femoral artery on one side and into the superior lateral genicular artery on the contralateral side. Methylene blue was observed in the proximal and distal thirds of the skin paddles, respectively, leaving unstained midzones. The vascular network of the lateral thigh skin could be divided into three zones. The lateral circumflex femoral artery and the third perforating branches of the profunda femoris artery perfuse the proximal and middle zones of the lateral thigh skin, respectively. The superior lateral genicular artery branch of the popliteal artery perfuses the distal zone. The middle and distal zones meet 8 to 10 cm above the knee joint, where the skin paddle of the tensor fasciae latae flap becomes unreliable. These data indicate that if the aim is to incorporate the skin over the distal thigh in an extended tensor fasciae latae flap without resorting to free-tissue transfer, then either a carefully planned delay procedure or an additional anastomosis to the superior lateral genicular artery is required.

The Vascular Supply of the Extended Tensor Fasciae Latae Flap: How Far Can the Skin Paddle Extend? by Arun K. Gosain, M.D. Ji-Geng Yan, M.D. Mustafa A. Aydin, M.D. Dilip K. Das, M.D. James R. Sanger, M.D.

Received for publication April 12, 2002. Foad Nahai, M.D. PACES Plastic Surgery and Recovery Center The Palisades Suite 640 3200 Downwood Circle Atlanta, Ga. 30327 [email protected]

The Vascular Supply of the Extended Tensor Fasciae Latae Flap: How Far Can the Skin Paddle Extend?

The Vascular Supply of the Extended Tensor Fasciae Latae Flap: How Far Can the Skin Paddle Extend?

Repair of a giant inguinoscrotal hernia

We present a case of a long-standing, giant inguinoscrotal hernia extending to the patient's knees, complicated by intestinal obstruction. Initial management involved conservative treatment of the intestinal obstruction and optimising the patient's general condition. Surgical treatment included debulking the contents of the hernia sac by performing a right hemicolectomy and a small bowel resection, and reconstruction of the abdominal wall using Marlex mesh and a tensor fasciae latae flap. Although abdominal wall reconstruction for massive ventral or incisional herniae is well reported, inguinoscrotal herniae of this magnitude are much rarer and pose additional problems, which are discussed in this paper.

Tensor fasciae latae perforator flap for reconstruction of composite Achilles tendon defects with skin and vascularized fascia.

The surgical management of large defects of the Achilles tendon and overlying skin is very demanding and necessitates, as a rule, a free vascularized graft. The ideal characteristics of a thin layer of skin and a strong tendon component, combined with a reliable blood supply and minimal morbidity at the donor site, have only been partially met by all previous grafts used in this situation. The authors performed reconstructions in five patients with large defects of the Achilles tendon and overlying skin by using a perforator flap derived from the tensor fasciae latae flap. A vascularized skin-subcutis-fascia lata flap could be raised by dissecting out two to three perforating arteries through the tensor fasciae latae muscle to the ascending branch of the lateral circumflex femoral artery; the muscle was left in situ in the process. All the flaps took well without complications. At final examination after an average of 20 months, the reconstructed Achilles tendon showed good functional results, although there was a 50 to 70 percent reduction in power during plantar flexion when compared with the normal side. A very good aesthetic result could be obtained after a debulking operation was performed on the skin flap.

Abdominoperineal electrical injury involving urogenital organs

Although the incidence of electrical burns is not very high this incidence is rising in India. The residual effects of electrical burns are sometimes very severe and long lasting, if not managed properly. This case report is of a patient who sustained severe electrical burns over his left arm, lower abdomen and perineal area. The injuries were so severe that life-saving disarticulation of the limb together with excision of the involved pubic bone and genitalia and suprapubic urinary diversion was done. During follow up an unusual finding was noticed. There was a peritubal leak with no drainage from the catheter and on removal of the catheter, a manual examination of the urinary bladder revealed a stone which was removed at the same time. Following removal of the stone two ureteric openings with the trigone were seen and it was concluded that the granulating tissue was actually the posterior wall of the bladder. This was then mobilized and reposited into the abdomen. The deficient lower abdomen was reconstructed with a tensor fascia lata flap. A penile reconstruction for the patient is under consideration.

Neophalloplasty in female-to-male transsexuals with the island tensor fasciae latae flap.

In the past 60 years, several different procedures have attempted to achieve a postoperative neophallus that is as aesthetic and as functional as possible after penile amputation or sex reassignment. Recently, with improvements in free tissue transfer and microvascular technique, many free flap procedures have been developed with the goal of an aesthetically acceptable neophallus of adequate bulk that enables urination in a standing position and sexual intercourse, with minimal functional and aesthetic donor-site defects. Most authors currently agree that the method of choice for penile reconstruction is microsurgical free tissue transfer, although it does not always fulfill all of the aforementioned goals in a predictable manner. In fact, complete urethroplasty, penile rigidity, and donor-site disfigurement remain challenges, thus making this operation one of the most difficult in plastic surgery. The vascular anatomy of the lateral circumflex femoral artery, which we studied in 1991 with the anatomic dissection of 27 cadavers, gave us the idea to use a long tensor fasciae latae neurovascular island flap as a donor source for neophalloplasty. Grounds for the procedure and its surgical planning have been carefully evaluated with 10 additional fresh cadaver dissections. Since 1991, we have performed five neophalloplasties using this procedure; all patients were female-to-male transsexuals. In four cases, the healing was uneventful; in one case, there was a marginal necrosis of the flap because of poor venous drainage, probably from a twisting of the pedicle. The island tensor fasciae latae provides a safe and sensate flap for phalloplastic procedure and leaves a less conspicuous donor scar.

Reconstruction of large abdominal wall defects

Reconstruction of a large abdominal defect is a technically demanding procedure. A single flap is sometimes insufficient for cover. Compound procedures play an important role in solving this problem. The case of a 35-year-old man with a large abdominal hernia as a result of a traumatic defect on the right abdomen, previously covered by a skin graft, is presented. The reconstructive method was initially expansion of posterior and upper parts of the defect and also of the tensor fascia lata in situ and then deepithelization of the previous skin graft over the intestinal serosa. The defect was covered by Prolene mesh, the upper and dorsal expanded skin was approximated, and an expanded tensor fascia lata flap was transposed to complete the cover. During follow-up examinations, there were no complications such as infection or recurrence of the hernia.

Anterolateral thigh flap for abdominal wall reconstruction.

The free or pedicled anterolateral thigh flap was introduced for the reconstruction of large abdominal wall defects. This flap is superior to the tensor fasciae latae musculocutaneous flap in several respects. These include the wide, reliable skin territory (which can reach the level of the knee) and the long pedicle. Therefore, a pedicled anterolateral thigh flap with reliable blood circulation can easily be positioned above the umbilicus. In addition, the free anterolateral thigh flap has greater freedom of orientation and can be used to repair larger abdominal wall defects than can the tensor fasciae latae flap. Seven patients in whom abdominal wall defects had been reconstructed with pedicled or free anterolateral thigh flaps were reviewed. Their average age was 47.1 years (range, 21 to 74 years), and the average follow-up period was 10.7 months (range, 2 to 21 months). The size of the abdominal wall defects ranged from 12 x 12 cm to 18 x 24 cm, and the size of the transferred flap ranged from 10 x 20 cm to 20 x 20 cm. Three flaps were pedicled and four were free, of which three incorporated the tensor fasciae latae flap. All flaps survived completely, and no postoperative abdominal hernias developed. Despite some variations in vascular anatomy and technical difficulties in elevating the anterolateral thigh flap, the authors conclude that the pedicled or free anterolateral thigh flap is superior to the tensor fasciae latae flap for reconstruction of large abdominal wall defects.

TWO CASES OF ABDOMINAL WALL RECONSTRUCTION USING TENSOR FASCIA LATA MUSCLE AND MUSCULOCUTANEOUS FLAPS AFTER RESECTION OF ABDOMINAL-WALL-INVADING MALIGNANT TUMORS

Today various kinds of musculocutaneus flaps have been introduced and used for defects after resection of malignant tumors which invade the abdominal wall. We experienced two cases of abdominal malignant tu-mor which invaded their abdominal wall, including a neuroendocrine carcinoma arisen from the transverse colon in case 1 and a mucinous adenocarcinoma right above the pubic bone in case 2. After the resection of the tumor, we used the tensor fascia lata (TFL) muscle and musculocutaneus flaps as muscle pedicle flaps. Though one patient of them died due to a rapid progression of the original malignant disease 3 months after the surgery, both patients had no trouble with their abdominal wall such as infection or hernia. So we think that the TEL flaps can be used safely and fairly easily to reconstruct the defect of the ab-dominal wall even for general surgeons. And the TFL flap method would be recommended for cases of ab-dominal reconstruction with a high risk of infection or with a probable retardation of cure.

Island V-Y tensor fasciae latae fasciocutaneous flap for coverage of trochanteric pressure sores.

The distal fasciocutaneous portion of the lateral thigh is supplied by the direct cutaneous branch of the lateral descending branch of the lateral circumflex femoral artery and the third perforating artery of the deep femoral artery. This consistent vascular anatomy allows raising a distal skin island based on both arteries on the lateral thigh, and this flap can be advanced into a trochanteric defect according to the V-Y technique. Based on anatomic and clinical study, a new design has been developed of the tensor fasciae latae fasciocutaneous flap, which is supplied by two pedicles. Seven island V-Y tensor fasciae latae fasciocutaneous flaps have been used for the coverage of trochanteric pressure sores in six patients. It is believed that the island V-Y tensor fasciae latae fasciocutaneous flap could overcome the traditional drawbacks of the conventional tensor fasciae latae flap and its modifications, and this is an ideal flap for covering trochanteric pressure sores without any donor site deformity and morbidity, which greatly improves the aesthetic result.

V-Y Tensor Fascia Lata for Trochanteric Pressure Sore Treatment

There are several alternatives for pressure sore reconstruction, but it is of utmost importance that an appropriate surgical technique be adopted, because although treatment is successful, recurrence of these ulcers is frequent. The purpose of this study was to conduct a precise evaluation of the V-Y tensor fascia lata flap, pointing out its advantages compared with the classical flap and with other possibilities described in the literature. The author employed 20 V-Y tensor fascia lata flaps to correct 20 trochanteric ulcers. The use of the classical tensor fascia lata flap to cover trochanteric ulcers is unquestionable. However, primary closure for flaps wider than 10 cm is difficult, necessitating an eventual skin grafting of the donor site. The V-Y tensor fascia lata allows a covering similar to the classical flap, simplifies primary closure and essentially presents the possibility of numerous reutilizations.

Flap selection as a determinant of success in pressure sore coverage.

To establish a treatment algorithm for the long-term surgical management of pressure sores. Retrospective case series. University-based teaching hospital. From March 1979 to July 1995, 280 unselected pressure sore reconstructions (113 ischial, 94 sacral, and 73 trochanteric sores) were performed in 201 patients (130 men and 71 women; age range, 16-90 years; mean, 50 years). Of the patients, 90% had severe spinal cord injuries (paraplegia or quadriplegia). Forty-one percent of the wounds were chronic (present longer than 3 months). Length of stay, postoperative morbidity and mortality, and flap success (defined as a completely healed wound). Overall, 89% of the flaps healed primarily (ischium, 83% [94/113]; sacrum, 91% [86/94]; trochanter, 93% [68/73]). Three fourths of cases were treated in a single stage (debridement and reconstruction). The inferior gluteus maximus island flap (ischium) (94% [32/ 34]), the V-Y gluteus maximus advancement flap (sacrum) (97% [36/37]), and the tensor fascia lata flap (trochanter) (95% [42/44]) had the highest success rates. Flap success was not significantly affected by the size of the pressure sore or the number of previous flaps used. Postoperative hospital stays averaged 20 days. The overall complication rate was 28%, most commonly from a slight wound edge dehiscence. Flap selection and the appropriate short- and long-term sequence of flap use significantly improve success rates for pressure sore coverage. Reconstruction can be reliably performed in a single stage with a relatively short hospitalization.

Ischial pressure sore coverage: a rationale for flap selection

The role of wound debridement and flap coverage in treating pressure sores is clearly established. However, criteria and supportive clinical data for specific flap selection and the sequence of flaps for coverage of the ischium remain ill-defined. From 1979–1995, 114 consecutive patients underwent flap coverage of 139 ischial pressure sores. Preoperative risk factors, prior flap history, defect size, flap success, complication rates, and the length of hospitalization were retrospectively evaluated and compared for 112 flaps in 87 patients. Flap success was defined as a completely healed wound. Average follow-up was 10 months (range: 1 month–9 years). Overall, 83% (93/112) of the flaps healed. In the majority of cases (75%, 84/112), wound debridement and flap reconstruction was achieved in a single stage. However, there were significant differences in the healing rates among the various flaps used. The inferior gluteus maximus island flap and the inferior gluteal thigh flap had the highest success rates, 94% (32/34) and 93% (25/27), respectively, while the V-Y hamstring flap and the tensor fascia lata flap had the poorest healing rates, 58% (7/12) and 50% (6/12), respectively. Flap success was not significantly affected by the age of the patient or the prior number of flaps used and preoperative risk factors were equally distributed across all types of flaps. The overall complication rate was 37% (41/112), most commonly from a slight wound edge dehiscence ( n = 16) that healed with local wound care within one month postoperatively. Results of this study show that proper flap selection and the appropriate sequence of flap use significantly improve success rates for ischial pressure sore coverage in both the short- and long-term. Based upon flap reliability (successful healing rates), reusability, and the need to preserve as many future flap options as possible, a rationale for flap selection is presented which can be individualized to any patient.