Anterolateral thigh flap salvage following failed deep inferior epigastric artery perforator breast reconstruction

Abstract

T he transverse rectus abdominis myocutaneous and deep inferior epigastric artery perforator (DIEP) flaps are currently the workhorses for autologous tissue breast reconstruction following mastectomy. However, situations may arise in which these flaps are not available. Contraindications to abdominal flaps include soft tissue inadequacy, previous abdominoplasty, scar presence and, controversially, plans for future pregnancy (1). Approximately 15% of women are not candidates for abdominal flap reconstruction (2). The gluteal artery perforator flap is often the second choice; however, the flap has inferior fat quality compared with abdominal flaps, offers short pedicles and necessitates an intraoperative position change (1). In these situations, the anterolateral thigh (ALT) flap has been used in breast reconstruction with satisfactory results (1-3). Simultaneous harvest of the bilateral flaps is possible, intraoperative position change is unnecessary, and the flap is soft and pliable (1,3).Wei et al (1) described five cases using ALT flaps in women with failed DIEP flaps or inadequate abdominal bulk. Overall, outcomes were rated as 'good'. Kaplan et al (2) described three cases in which women did not have adequate abdominal flaps (previous DIEP, abdominoplasty and obesity-related contraindication for DIEP). Bernier et al (3) presented a case report of bilateral breast reconstruction using bilateral ALT flaps, also with good results. We present our experience using the ALT flap for failed DIEP flap salvage. AnAtomyThe ALT flap is of moderate thickness, with a large cutaneous area, and provides a long vascular pedicle. The flap area may be up to 21 cm × 35 cm (4), with a vascular pedicle of up to 20 cm (5). Innervation is via the anterior branch of the lateral femoral cutaneous nerve (L2-3).The lateral femoral circumflex system usually originates from the profunda femoral artery and divides into the ascending, transverse and descending branches. The descending arterial branch is typically accompanied by two veins. This branch courses between the rectus femoris and vastus intermedius muscles. The first cutaneous perforator is usually the largest. It may be located near the midpoint of a line linking the anterior superior iliac spine and the superolateral patellar border. Approximately 90% of the perforators are found within 3 cm of this point, mostly inferolaterally (6).Luo et al (6) detailed pedicle variations of the ALT flap. Musculocutaneous perforators course through the vastus lateralis in 80.4% of cases. Perforator arteries run intermuscularly, between the rectus femoris and the vastus lateralis, in 9.5% of cases. In 8.3% of patients, the perforator is a direct cutaneous branch from a transverse branch of the lateral circumflex femoral artery or originates directly from the lateral circumflex femoral vessel proximal to the take-off of the descending branch. Tiny cutaneous perforators with diameters of 0.2 mm to 0.3 mm are found in 1.8% of patients (6). CAse presentAtions Case 1A 45-year-old woman presented wit...