Lateral Thigh Flap

YUN XX, D.D.S., M.S.D.
Dept. of Oral & Maxillofacial Surgery, College of Dentistry, XXXXX National University

History
1983 Baek S.M.
Two new cutaneous free flaps : the medial and lateral thigh flap

1984 Richard E. Hayden
Reconstruction of pharyngoesphageal defects

1995 Miller M.J.
Anatomical study of the lateral thigh free flap

1998 Turelson J.M.
Lateral thigh flap reconstruction in head and neck

Anatomy
Encompassing skin and subcutaneous tissue of posterolateral thigh Ellipse, with the long axis resting over intermuscular septum between vastus lateralis and the long head of biceps femoris Skin island size : 27.0 ×14.0 cm 27. 14.

Blood supply
Cutaneous branches of the perforators from the profunda femoris a. Principal supply : Third perforator
very small minority of patients - fourth perforator

Secondary supply : Second or fourth perforator
Cf. Cf.) Anterolateral thigh free flap (Koshima et al)
Lateral circumflex femoral system

Profunda femoris a.
Femoral a.
3.5 cm below inguinal ligament

Profunda femoris a.
Deep to the adductor longus

Third perforator

Piercing the fascia through linea aspera Branches to vastus lateralis and biceps femoris Pass the short head of the biceps femoris Intermuscular septum

Cormack et al
(Plast. Reconstr. Surg. 75:342, 1985)

Primary blood supply of the lateral thigh skin came from the perforators of the profunda femoris a. Not dependent on perforators from underlying muscle or fascia Can be harvested with the flap to repair complex defects skull base

Michael J. Miller et al
(Plast. Reconstr. Surg. 96:334, 1995)

Anatomic cadaver dissection
Vessel came to skin level
14. 14.5cm ±3.5cm above the lateral femoral epicondyle

Pedicle length from superficial fascia level to the origin of the 3rd perforator
6.1cm ±0.9cm

57 of 61 cases pass through the short head of the biceps femoris

Perforators
An understanding of these four branches is critical to the safe harvest of the lateral thigh flap

Each perforator gives off three types branches
Muscular branches to the hamstrings Branches that run in a cephalocaudal direction to anastomose with branches of the other perforators Fasciocutaneous branches

The first perforator
Primary blood supply to the adductors
Brevis, longus, and magnus

Terminal branch
main vascular pedicle of the gracilis muscle

Cutaneous branch
upper medial thigh

Branches to gluteus maximus and greater trochanter

The second perforator
Muscular branches
Semimembranosus Long and short heads of biceps femoris Vastus lateralis

The nutrient artery of the femur

The third perforator
Dominant nutrient supply to the lateral thigh flap Muscular branches to the biceps femoris and vastus lateralis
The short head of the biceps femoris : A flexor of the knee Pulsations within the filmy short head of the biceps femoris

The fourth perforator
Terminal portion of the profunda femoris Occasionally provide the dominant vascular supply to the lateral thigh skin Sacrificed in the process of harvesting a lateral thigh flap

Arterial diameter
Profunda femoris a. : 3 to 5 mm Origin of the 3rd perforator : 2 to 3 mm Terminal cutaneous branch : 1 to 2 mm

Venous drainage
Venae comitantes
Always two venae comitantes Traveling with the arterial perforator Join to become one large vein that ultimately accompanies the profunda femoris artery The diameter of the parent vein : 4 to 5 mm

Sensory supply
Lateral femoral cutaneous nerve
Originate from the first three lumbar nerve
Sometimes from the femoral nerve

Passing under the inguinal ligament and anterior, posterior or through sartorius m. Divide into anterior and lateral branch
Subdivide into the subdermal fat

Anatomic Variations
Major arterial supply - fourth perforator
The center of the skin paddle - more distally

The major problem
Major arterial supply - second perforator
Ensure the vascular supply to the muscles and the femur

Anatomic Variations
Hayden
15% 15% incidence of vascular variations Recommend to include a large fourth perforator to augment the cutaneous blood supply

Baek
One cadaver : the dominant vascular supply - from a branch of the superficial femoral artery The rudimentary profunda femoris

Clinical applications
Total pharyngectomy defects
Thin, pliable flap quality
Tube formation an epithelialized conduit

DeDe-epithelization
Skin island for monitoring flap viability

Very long pharyngeal defects
From nasopharynx to thoracic inlet

Clinical applications
NearNear-total glossectomy defects
Bulkier thigh flaps
with more subcutaneous fat can provide sufficient tissue

Advantages of the subdermal fat
less atrophy associated with denervated muscle

Clinical applications
Sensory reinnervation for oral cavity reconstructions Severe cervical burn contractures - suboptimal color match Large scalp defects with underlying fascia flap Facial augmentation with vascularized fat flap

Patient Selection
Body habitus and specific defect requirement No tourniquet
Limiting worries of extremity eschemia

Minimal donor site morbidity No specific preoperative workup

Workup
Question about issues that disqualify surgery Evaluate previous injury or surgery to the thigh No specific lab studies or imaging studies Pinch test to determines the amount of fat Doppler device to locate the main perforator

Draping and Flap design
Slight flexion of hip and knee Inward rotation of leg
location of pillow under the hip for rotation

Exposure of thigh
From the greater trochanter to the lateral epicondyle

Palpation and marking of intermuscular septum
Center of the line - Third perforator

Design : Ellipse with long axis along the line

Landmarks of femur
Greater trochanter
greater trochanter of the femur is a large, somewhat rectangular projection from the junction of the neck and the body. body. It provides an insertion for several muscles of the gluteal region. region.

Condyle
the medial and lateral condyle of the femur are subcutaneous and easily palpable. Palpate them as you flex and extend your palpable. knee joint. At the center of each condyle is a prominent joint. epicondyle, to which the tibial and fibular collateral ligaments of the knee joint are attached. The medial and lateral attached. epicondyles are easily palpable. palpable.

Flap harvest
Incision at the anterior aspect of ellipse
Through the skin and subcutaneous fat Down to the level of fascia overlying vastus lateralis

Easy distal approach to intermuscular septum
Proximal : overlying fascia lata

Third perforator identification
Near superior border of short head of biceps femoris Vessel may run on, under, or through the muscle This area is preserved for later dissection

Flap harvest
Medial retraction of vastus lateralis m.
Trace the vessel toward the femur Careful ligation of muscular perforators
To the vastus lateralis and biceps femoris

Demonstration of vascular pedicle piercing adductor fascia through a semilunar hiatus
Releasing adductor attachment from linea aspera

Identification of profunda femoris a.
Proximal dissection until the 2nd perforator level

Flap harvest
Skin paddle mobilization
Release from short head of biceps femoris
Avoid direct dissection Two finger breadth section of biceps femoris m.

Posterior skin incision down to long head level and proximal dissection
Sciatic n. protection during flap elevation

Flap harvest
Staple back of flap until transfer
Further practical test of flap viability Limits ischemia time for the flap Placement of flap in cool siline bath

Donor site
Hemostasis & Suction drain insertion Primary closure - wide undermining of skin flap Occasional skin graft
Parallel relaxing incision on the anterior thigh area Primary closure at intermuscular septum and with splitsplit-thickness skin graft at medial relaxing wound To avoid potential skin graft loss at the intermuscular septum

Sensate lateral thigh flap
Lateral femoral cutaneous nerve
Arborize from the subcutaneous fat proximal to the anterior incision of ellipse Retrograde dissection : tedious and unsatisfying Second longitudinal incision at sartorius level
Lateral tracing from the main nerve trunk Section of the branch to the anterior thigh Halt further dissection and harvest with subcutaneous fat Subdermal dissection and underlying fascia elevation

Aid Tips Details
Proper positioning Sufficient exposure
Anatomic landmarks and postlateral thigh

Remember the exit of perforating artery Planned ellipse
Center on intermuscular septum

Relation of vascular pedicle
To the short head of biceps femoris

Most challenging aspect of the dissection
Adductor hiatus level

Advantages
Vascular pedicle : 8-10cm 10cm Large vessel diameter : 2-5mm Large available surface
Thin pliable flap - pharyngeal reconstruction Thicker flap - glossal reconstruction

Advantages
Two team approach Minimal donor site morbidity Favorable alternative
More accepted fasciocutaneous free flap
Forearm flap - linear scar Scapular/parascapular flap

Disadvantages
Bulkness in Obese patients HairHair-bearing skin
Esp. Esp. in male Permanent depilatory effects of postpost-operative radiation therapy

Complications
Flap death
Success rate approaches 90-95% 90-95% Arteriosclerotic plaque Accidental vessel transection during dissection
The posterior skin attachment may be left intact until the time of anastomosis The posterior subdermal and dermal vessels provide adequate blood flow to the skin flap. flap.

Donor site skin graft loss
Seroma have a tendency to develop in this area

Future and Controversies
Controversies
PFA itself Vs third perforator
Short pedicle length

PFA proximal to second perforator
Muscular weakness

Future
Tissue engineering and tissue culture Lateral thigh flap has stood the test of time