One-Stage Reconstruction of Large Midline Abdominal Wall Defects Using a Composite Free Anterolateral Thigh Flap With Vascularized Fascia Lata

Kuo, Yur-Ren; Kuo, Mei-Hui; Lutz, Barbara S.; Huang, Yu‐Chi; Liu, Yi-Tien; Wu, Shih-Chi; Hsieh, Kun-Chou; Hsien, Ching-Hua; Jeng, Seng‐Feng

doi:10.1097/01.sla.0000114229.89940.e8

Cited by 87 publications

(88 citation statements)

References 31 publications

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“…Uncertainty regarding the DBLCFA and its role in the genicular arterial anastomosis should be resolved if this vessel is to be used as a graft in bypass or free flap surgery. 4 It was our hope, undertaking this research, that anatomic knowledge of the genicular anastomosis would assist the development of non-surgical treatments of traumatic interruption of SFA flow that might be useful in combat situations.…”

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confidence: 99%

Absence of the genicular arterial anastomosis as generally depicted in textbooks

Sabalbal

Johnson

McAlister

2013

annals

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Introduction Textbook representations of the genicular arterial anastomosis show a large direct communication between the descending branch of the lateral circumflex femoral artery (DBLCFA) and a genicular branch of the popliteal artery but this is not compatible with clinical experience. The aim of this study was to determine whether the arterial anastomosis at the knee is sufficient, in the event of traumatic disruption of the superficial femoral artery, to infuse protective agents or to place a stent to restore flow to the lower leg. Methods Dissection of ten cadaveric lower limbs was performed to photograph the arterial anatomy from the inguinal ligament to the tibial tubercle. Anastomosis with branches of the popliteal artery was classified as: ‘direct communication’, ‘approaching communication’ or ‘no evident communication’. Results A constant descending artery in the lateral thigh (LDAT) was found to have five types of origin: Type 1 (2/10 limbs) involved the lateral circumflex femoral branch of the femoral artery, Type 2 (3/10 limbs) the lateral circumflex femoral branch of the profunda femoris artery, Type 3 (1/10 limbs) the femoral artery, Type 4 (3/10 limbs) the superficial femoral artery and Type 5 (2/10 limbs) the profunda femoris artery. In one limb, there were two descending arteries (Types 4 and 5). Collateral circulation at the knee was also variable: direct communicating vessels (3/10 limbs); approaching vessels with possible communication via capillaries (5/10 limbs); no evident communication (2/10 limbs). Communicating vessels, if present, are too small to provide immediate collateral circulation. Conclusions Modern representations of the genicular arterial anastomosis are inaccurate, derived commonly from an idealised image that first appeared Gray’s Anatomy in 1910. The afferent vessel is not the DBLCFA. The majority of subjects have the potential to recruit collateral circulation via the LDAT following gradual obstruction to normal arterial flow, which may be important if the LDAT is removed for bypass or flap surgery. A direct communication is rarely present and is never as robust as generally depicted in textbooks.

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mentioning

confidence: 99%

Absence of the genicular arterial anastomosis as generally depicted in textbooks

Sabalbal

Johnson

McAlister

2013

annals

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“…[21,[24][25][26] Although the tensor fascia lata flap has been used for the reconstruction of the pelvis following hemipelvectomy, [27] its application for the reconstruction of pelvic floor defects has not yet been clinically documented.…”

Section: Discussionmentioning

confidence: 99%

Reconstruction of a pelvic floor defect using a pedicled tensor fascia lata flap: a new technique to prevent radiation injury for pediatric patients with advanced pelvic tumors

Ohno¹,

Tanaka²,

Kobayashi³

et al. 2008

Journal of Pediatric Surgery

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“…It may be used for reconstruction of the chest wall (9), oropharynx (10-13), head and neck (14,15), hand (16)(17)(18), lower extremity (19)(20)(21), phallus (22) and abdominal wall (23). Use of the flap for breast reconstruction was originally described by Wei et al (1) …”

Section: Discussionmentioning

confidence: 99%

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

Krochmal¹,

Rebecca

Casey

et al. 2011

J Plast Surg

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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...

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One-Stage Reconstruction of Large Midline Abdominal Wall Defects Using a Composite Free Anterolateral Thigh Flap With Vascularized Fascia Lata

Abstract: The free composite ALT myocutaneous flap with vascularized fascia lata provides an alternative option for a stable repair in complex abdominal wall defects.

Cited by 87 publications

References 31 publications

Absence of the genicular arterial anastomosis as generally depicted in textbooks

Absence of the genicular arterial anastomosis as generally depicted in textbooks

Reconstruction of a pelvic floor defect using a pedicled tensor fascia lata flap: a new technique to prevent radiation injury for pediatric patients with advanced pelvic tumors

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

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