Anterolateral Thigh Free Flap

1
Anterolateral Thigh Free Flap

• Garrett Hauptman M.D.
• Vicente A. Resto, M.D., Ph.D.
• University of Texas Medical Branch
• Department of Otolaryngology
• Grand Rounds Presentation
• April 2, 2008

2
Head Neck Reconstruction Goals

• 1 Wound healing
• 2 Function
• 3 Cosmesis

3
Reconstructive Ladder

• Secondary intention
• Primary closure
• Skin grafting
• Local flaps
• Distant pedicled flaps
• Free tissue transfer

4
Overview

• Anatomy
• Flap Design
• Literature Review
• Comparisons
• Complications
• Applications

5
Anatomy of the Leg
6
Muscular Anatomy
7
Vascular Anatomy
8
Sensory Innervation
9
History and Emergence
10
Nomenclature Clarification

• ALT
• 1984 - Song
• Anterolateral thigh skin
• Lateral circumflex femoral ? Descending branch
• No repositioning

• Lateral Thigh
• 1983 - Baek
• Posterolateral thigh skin
• Profunda femoris ? 3rd cutaneous perforator
• Repositioning or flexed internally rotated hip
  with flexed knee

11
Emergence of the ALT

• Very popular reconstructive flap in Asia
• Limited reports of use in Western countries,
  particularly United States
• Possible reasons
• Vascular anatomy variations
• Difficult dissection
• Thick thigh fat

12
Creatures of Habitus
13
Workhorse Attributes

• No repositioning
• Remote from defect
• Long pedicle

14
Flap Design
15
Tale of the Tape

• Maximum size
• From horizontal line at greater trochanter to
  horizontal line 3cm above patella
• 25cm X 40cm
• Vascular pedicle
• Length 16cm
• Diameter
• Artery 2.1mm
• Vein 2.6mm
• Donor site defect can be closed primarily if
  width lt 8cm

16
Vascular Pedicle

• Lateral circumflex femoral a. ? Descending branch
  ? Perforators
• Descending branch
• Runs superior to inferior in intramuscular space
  between rectus femoris and vastus lateralis
• Terminates in vastus lateralis just above knee
• Perforators 2 types
• Septocutaneous run between rectus femoris and
  vastus lateralis and traverse the fascia lata to
  skin
• Musculocutaneous traverse vastus lateralis and
  deep fascia to skin
• Details
• 8 16cm
• 2 venae commitantes

17
Landmarks

• Line drawn between anterior superior iliac spine
  (ASIS) and lateral border of patella
• Approximates septum between rectus femoris and
  vastus lateralis
• Skin perforators mapped by Doppler
• Accuracy decreases as BMI increases

Yu P. Plast Reconstr Surg 2006
18
Perforator Mapping
70 pts.
Kimata Y. Plast Reconstr Surg 1998
19
Perforator Mapping
72 pts.
Yu P. Head Neck 2004
20
Perforator Mapping

• Most consistently present perforator midway
  between ASIS and superolateral patella
• Another perforator may be found more distally and
  more proximally
• All within 5cm apart from each other
• Perforators labeled A, B, and C
• A most proximal
• C most distal
• Perforators range between 0 and 3 per patient
  with 2.04 being the mean per patient
• 0 2
• 1 22
• 2 54
• 3 22

Yu P. Head Neck 2004
21
Cutaneous Perforator Origin

• 3 Different Origins
• Type I descending branch of lateral circumflex
  femoris artery (90)
• Type II single cutaneous perforator originates
  from the transverse branch of lateral circumflex
  femoris artery and travels longitudinally in
  vastus lateralis (4)
• Type III single perforator from profundus
  femoris artery pierces through rectus femoris (4)

Yu P. Head Neck 2004
22
Cutaneous Perforator Origin
Yu P. Head Neck 2004
23
Type I
Right Thigh
Yu P. Head Neck 2004
24
Type II
Left Thigh
Yu P. Head Neck 2004
25
Type III
Right Thigh
Yu P. Head Neck 2004
26
Perforator Classification

• Type 1 (50) extends perpendicularly to
  subdermal plexus
• Type 2 (35) branch in adipose and extends to
  subdermal plexus
• Type 3 (15) extend along deep fascia and
  gradually into adipose

Kimura N et al. Plast Reconstr Surg 2001
27
Flap Harvesting

• Initial skin incision on medial flap aspect
• Lateral dissection
• Suprafascial technique for thin flap carried
  laterally until perforators identified
• Fasciocutaneous flap (subfascial) involves
  incision through deep fascia with lateral
  dissection until perforators identified

28
Flap Harvesting
29
Flap Harvesting
30
Flap Harvesting

• Skin incisions completed upon perforator
  identification
• Retrograde dissection of pedicle to descending
  branch
• May involve dissection of vastus lateralis- cuff
  of muscle may be left to protect perforating
  branches
• Lateral femoral cutaneous nerve of thigh may be
  used for sensation
• Thinning performed in deep fat layer to avoid
  pedicle injury

31
Sensory Innervation

• Lateral femoral cutaneous nerve
• Direct branch of lumbar plexus (L2-L3)
• Enters thigh deep to lateral aspect of inguinal
  ligament near anterior superior iliac spine
• Follows path of deep circumflex iliac artery and
  vein
• Lies along line connecting ASIS to lateral
  patella
• Travels in deep subcutaneous layer immediately
  superficial to deep fascia

32
Sensory Innervation
Yu P. Head Neck 2004
33
Flap Composition

• Subcutaneous
• Fasciocutaneous
• Myocutaneous
• Adipofascial

34
Modifications
35
Two Independent Flaps
Chou EK. Plast Recostr Surg 2006
36
Use of Tissue Expander to Allow Primary Closure
Hallock G. Ann Plast Surg 2004
37
The Survey Says
38
RFs Big Brother

• 34 consecutive cases
• 2 flaps with partial necrosis
• No flap failures
• No significant donor morbidity
• Skin
• Large 40cm X 25cm
• Moderately thick
• Uniform
• Sensate potential
• Multipaddle skin potential

Lueg E. Arch Otolaryngol Head Neck Surg 2004
39
Largest Case Series

• 672 ALTs in 660 pts.
• 87 musculocutaneous perforators 13
  septocutaneous perforators
• 439 flaps cutaneous/fasciocutaneous based on
  musculocutaneous perforators
• Flap failure (15)
• Total 1.8
• Partial 2.5

Wei F. Plast Reconstr Surg 2002
40
Septocutaneous vs- Musculocutaneous
41
Septocutaneous vs- Musculocutaneous
42
ALT Versus
43
ALT vs- RF for Intraoral Defects

• No functional difference with speech or swallow
  in
• 20 pts. 10 ALT, 10 RF

• RF
• Potential tendon exposure
• Sacrifice dominant distal forearm blood supply
• Usually close with STSG
• Potential dysfunction
• Hand stiffness
• Pain
• Anesthesia/parasthesia

• ALT
• Increased learning curve
• Primary closure
• Morbidity related to vastus lateralis damage
• Potential dysfunction
• Quadriceps
• Pain
• Disto-lateral thigh anesthesia/parasthesia

Farace F. J Plast Reconstr Aesth Surg 2007
44
Advanced Tongue Cancer Reconstruction Functional
Outcome
Chien C. J Cancer Surg 2006
45
Advanced Tongue Cancer Reconstruction Functional
Outcome
Chien C. J Cancer Surg 2006
46
Reconstruction Trends Pharyngectomy

• 153 pharyngectomy pts.
• 85 partial
• 68 circumferential

Clark J. Laryngoscope 2006
47
Reconstruction Trends Pharyngectomy
Clark J. Laryngoscope 2006
48
Pharyngoesophageal Reconstruction ALT vs-
Jejunal Flaps

• 57 circumferential reconstructions
• 26 ALT 31 FJT
• Results
• Better function
• Quicker recovery
• More cost-effective
• Similar complication rates

Yu P. Plast Reconstr Surg 2006
49
Complications ALT vs- FJT
Yu P. Plast Reconstr Surg 2006
50
TEP Speech ALT vs- FJT

• ALT 89 FJT 22

Yu P. Plast Reconstr Surg 2006
51
Swallowing ALT vs- FJT
Yu P. Plast Reconstr Surg 2006
52
Hospital Course ALT vs- FJT
Yu P. Plast Reconstr Surg 2006
53
New Sensation
54
Implications of Sensory Innervation
Yu P. Head Neck 2004
55
Implications of Sensory Innervation

• Superior sensory recovery in all testing
  modalities
• 2 point discrimination
• Monofilament testing
• Pain
• Temperature
• Improves swallow function
• Improves patient satisfaction
• Post-op XRT may delay sensory recovery

Yu P. Head Neck 2004
56
Complications
57
ALT Failure Etiology

• Inadvertent perforator division at fascial plane
• Inadvertent perforator injury during
  intramuscular dissection
• Pedicle twisting during inset
• Vessel size mismatch

Celik N. Plast Reconstr Surg 2002
58
ALT Failure Rates
59
Donor-Site Morbidity

• 37 pts. with free or pedicled ALT
• 32 primary closure 5 STSG closure
• Results
• Primary closure
• All normal ADLs
• 87.5 appearance satisfaction
• 1 pt. with ? ROM
• STSG
• 3/5 with ? ROM
• Less appearance satisfaction
• Sensation deficit in 87.5 of entire group

Kimata Y. Plast Reconstr Surg 2000
60
Donor-Site MorbidityALT vs- RF

• 37 pts. 18 ALT, 19 RF
• Telephone questionnaire
• Results
• Bothered by cold
• RF 26 -vs- ALT 0
• Shape difference bothersome
• RF 32 -vs- ALT 11

Novak C. Microsurgery 2007
61
Complications

• Necrosis of lower limb- case report
• Obstructed superficial femoral artery by
  angiography
• Lateral circumflex femoral artery supplied
  critical collaterals
• Importance of checking popliteal pulsations
• Absence necessitates angiography

Hage J. Ann Plast Surg 2004
62
Post-Operative Complications
23 patients
Mureau M. Plast Reconstr Surg 2005
63
Objective Functional and Aesthetic Follow-up
Recipient Site
14 patients
Mureau M. Plast Reconstr Surg 2005
64
Objective Functional and Aesthetic Follow-up
Donor Site
14 patients
Mureau M. Plast Reconstr Surg 2005
65
Post-Op Scar
66
Flap Smorgasbord
67
AVM

• Pre-operative selective embolization
• Resection ALT reconstruction 6 months
  post-embolization

Koshima I. Ann Plast Surg 2003
68
Buccal Mucosa Defects

• Mouth opening and oral intake preserved

Chuang HC. Otolaryngol Head neck Surg 2007
69
Buccal Through-and-Through
70
Lower Lip
Yildirim S. Plast Reconstr Surg 2006
71
Pharyngoesophageal Reconstruction
Genden E. Arch Otolaryngol Head Neck Surg 2005
72
Lateral Skull Base Defects
Malata C. Ann Plast Surg 2006
73
Tongue and FOM
Agostini V. Brit J Plast Surg 2003
74
Anterior Skull Base
75
Scalp
Calikapan G. Microsurgery 2006
76
Scalp
77
Combined with Fibula Free Flap
78
How About Us?
79
Were Doing em
80
Anterior Skull Base
81
Total Glossectomy-Total Laryngectomy
82
Total Glossectomy Total Laryngopharyngectomy
83
Questions
84
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85
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