Neurovascular Anatomy at the “Box Junction”: Considerations in the Anterolateral Thigh Flap

Abstract

Our study confirms that the BxJn is a site of potentially complex and challenging neurovascular anatomy for the surgeon. Based on these results, we propose an algorithm to guide inexperienced surgeons in negotiating this area.

Anatomical Relations of the Perforators from the Descending Lateral Femoral Circumflex Artery and Vastus Lateralis Motor Nerve Branches

“…Although there have been several anatomical studies on the lateral femoral circumflex artery 2 , 8 – 10 and motor nerve of the vastus lateralis muscle 7 , 11 , 12 on their own, the anatomical relationship between them has rarely been reported. 13 – 15 …”

“… 14 Stewart et al reported the neurovascular anatomy at the “box junction,” the point at which the perforator arose from the source vessel. 15 However, the overall anatomy of these two were not assessed in previous studies, and their detailed anatomical relationship is still unclear. This study aimed to investigate the overall anatomic locations of the perforators from the descending branch of the lateral femoral circumflex artery and the motor nerve branches of the vastus lateralis muscle using fresh-frozen cadaveric specimens and to determine which branches of the motor nerve are at a higher risk of injury.…”

“…Although there have been several anatomical studies on the lateral femoral circumflex artery 2,8-10 and motor nerve of the vastus lateralis muscle 7,11,12 on their own, the anatomical relationship between them has rarely been reported. [13][14][15] Donor-site morbidities associated with the ALT flap have attracted increasing attention owing to its widespread use. Donor-site morbidity is as important as flap survival at the recipient site because it can affect a patient's quality of life.…”

“…23 Musculoskeletal dysfunction is caused not only by direct injury to the vastus lateralis muscle, but also by injury to the motor nerve of the vastus lateralis muscle during harvesting of the ALT flap. 7,13,15,17,22 Only three anatomical studies have investigated the relationship between the lateral femoral circumflex artery and the motor nerve of the vastus lateralis muscle. [13][14][15] Casey et al reported the running pattern of the descending branch of the lateral femoral circumflex artery and motor nerve of the vastus lateralis muscle from clinical cases to assess injury rates.…”

“…7,13,15,17,22 Only three anatomical studies have investigated the relationship between the lateral femoral circumflex artery and the motor nerve of the vastus lateralis muscle. [13][14][15] Casey et al reported the running pattern of the descending branch of the lateral femoral circumflex artery and motor nerve of the vastus lateralis muscle from clinical cases to assess injury rates. 13 Rozen et al performed anatomical studies on embalmed cadavers and examined the running patterns of the two largest perforators and the motor nerve of the vastus lateralis to assess injury rates.…”