Lateral Thigh Flap

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

Transcript of Lateral Thigh Flap

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Lateral Thigh FlapLateral Thigh Flap

YUN XX, D.D.S., M.S.D.YUN XX, D.D.S., M.S.D.

Dept. of Oral & Maxillofacial Surgery, College of Dentistry,Dept. of Oral & Maxillofacial Surgery, College of Dentistry,

XXXXX National UniversityXXXXX National University

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HistoryHistory

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

1984 Richard E. Hayden1984 Richard E. Hayden Reconstruction of pharyngoesphageal defectsReconstruction of pharyngoesphageal defects

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

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

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AnatomyAnatomy

Encompassing skin and subcutaneous Encompassing skin and subcutaneous tissue of posterolateral thightissue of posterolateral thigh

Ellipse, with the long axis resting over Ellipse, with the long axis resting over intermuscular septum between intermuscular septum between vastus vastus lateralislateralis and and the long head of biceps the long head of biceps femorisfemoris

Skin island size : 27.0 ×14.0 cmSkin island size : 27.0 ×14.0 cm

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Blood supplyBlood supply

Cutaneous branches of the perforators Cutaneous branches of the perforators from the profunda femoris a.from the profunda femoris a.

Principal supplyPrincipal supply : : Third perforatorThird perforatorvery small minority of patients - fourth perforatorvery small minority of patients - fourth perforator

Secondary supply : Second or fourth perforatorSecondary supply : Second or fourth perforator

Cf.) Anterolateral thigh free flap (Koshima et al) Cf.) Anterolateral thigh free flap (Koshima et al) Lateral circumflex femoral systemLateral circumflex femoral system

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Profunda femoris a.Profunda femoris a.

Femoral a.Femoral a.

Profunda femoris a.Profunda femoris a.

Third perforatorThird perforator

3.5 cm below inguinal ligament3.5 cm below inguinal ligament

Deep to the adductor longusDeep to the adductor longus

Piercing the fascia through linea aspera Piercing the fascia through linea aspera

Branches to vastus lateralis and biceps femorisBranches to vastus lateralis and biceps femoris

Pass the short head of the biceps femoris Pass the short head of the biceps femoris

Intermuscular septumIntermuscular septum

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

Primary blood supply of the lateral thigh Primary blood supply of the lateral thigh skin came from the perforators of the skin came from the perforators of the profunda femoris a.profunda femoris a.

Not dependent on perforators from Not dependent on perforators from underlying muscle or fasciaunderlying muscle or fascia

Can be harvested with the flap to repair Can be harvested with the flap to repair complex defects skull basecomplex defects skull base

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

Anatomic cadaver dissectionAnatomic cadaver dissection

Vessel came to skin levelVessel came to skin level14.5cm ±3.5cm above the lateral femoral epicondyle14.5cm ±3.5cm above the lateral femoral epicondyle

Pedicle length from superficial fascia level to Pedicle length from superficial fascia level to the origin of the 3rd perforatorthe origin of the 3rd perforator

6.1cm ±0.9cm6.1cm ±0.9cm

57 of 61 cases57 of 61 cases pass through the short head of pass through the short head of the biceps femoristhe biceps femoris

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PerforatorsPerforators

An understanding of these four branches is critical to An understanding of these four branches is critical to

the safe harvest of the lateral thigh flapthe safe harvest of the lateral thigh flap

Each perforator gives off three types branchesEach perforator gives off three types branchesMuscular branchesMuscular branches to the hamstrings to the hamstrings

Branches that run in a cephalocaudal direction to Branches that run in a cephalocaudal direction to anastomoseanastomose with branches of the other with branches of the other perforatorsperforators

Fasciocutaneous branchesFasciocutaneous branches

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The first perforatorThe first perforator

Primary blood supply to the Primary blood supply to the adductorsadductorsBrevis, longus, and magnusBrevis, longus, and magnus

Terminal branchTerminal branchmain vascular pedicle of the main vascular pedicle of the gracilisgracilis muscle muscle

Cutaneous branchCutaneous branchupper medial thighupper medial thigh

Branches to Branches to gluteus maximusgluteus maximus and and greater greater trochantertrochanter

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The second perforatorThe second perforator

Muscular branchesMuscular branchesSemimembranosusSemimembranosus

Long and short heads of Long and short heads of biceps femorisbiceps femoris

Vastus lateralisVastus lateralis

The nutrient artery of the The nutrient artery of the femurfemur

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The third perforatorThe third perforator

Dominant nutrient supplyDominant nutrient supply to the lateral to the lateral thigh flapthigh flap

Muscular branches to the biceps femoris Muscular branches to the biceps femoris and vastus lateralisand vastus lateralis

The short head of the biceps femoris : A The short head of the biceps femoris : A flexor of the kneeflexor of the knee

Pulsations within the filmy short head of the Pulsations within the filmy short head of the biceps femorisbiceps femoris

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The fourth perforatorThe fourth perforator

Terminal portion of the profunda femorisTerminal portion of the profunda femoris

Occasionally provide the dominant Occasionally provide the dominant

vascular supply to the lateral thigh skinvascular supply to the lateral thigh skin

SacrificedSacrificed in the process of harvesting a in the process of harvesting a

lateral thigh flaplateral thigh flap

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Arterial diameterArterial diameter

Profunda femoris a. : 3 to 5 mmProfunda femoris a. : 3 to 5 mm

Origin of the 3rd perforator : 2 to 3 mmOrigin of the 3rd perforator : 2 to 3 mm

Terminal cutaneous branch : 1 to 2 mmTerminal cutaneous branch : 1 to 2 mm

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Venous drainageVenous drainage

Venae comitantesVenae comitantes

Always Always twotwo venae comitantes venae comitantes

Traveling withTraveling with the arterial perforator the arterial perforator

Join to become one large veinJoin to become one large vein that ultimately that ultimately accompanies the profunda femoris arteryaccompanies the profunda femoris artery

The diameter of the parent vein : 4 to 5 mmThe diameter of the parent vein : 4 to 5 mm

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Sensory supplySensory supply

Lateral femoral cutaneous nerveLateral femoral cutaneous nerve

Originate from the first three lumbar nerveOriginate from the first three lumbar nerveSometimes from the femoral nerveSometimes from the femoral nerve

Passing under the Passing under the inguinal ligamentinguinal ligament and and

anterior, posterior or through anterior, posterior or through sartoriussartorius m. m.

Divide into anterior and lateral branchDivide into anterior and lateral branchSubdivide into the subdermal fatSubdivide into the subdermal fat

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Anatomic VariationsAnatomic Variations

Major arterial supply - Major arterial supply - fourth perforatorfourth perforatorThe center of the skin paddle - more distallyThe center of the skin paddle - more distally

The major problemThe major problemMajor arterial supply - Major arterial supply - second perforatorsecond perforator

Ensure the vascular supply to the muscles Ensure the vascular supply to the muscles

and the femurand the femur

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Anatomic VariationsAnatomic Variations

HaydenHayden15% incidence of vascular variations15% incidence of vascular variationsRecommend to include a large fourth perforator to Recommend to include a large fourth perforator to augment the cutaneous blood supplyaugment the cutaneous blood supply

BaekBaekOne cadaver : the dominant vascular supply - from a One cadaver : the dominant vascular supply - from a branch of the superficial femoral arterybranch of the superficial femoral arteryThe rudimentary profunda femorisThe rudimentary profunda femoris

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Clinical applicationsClinical applications

Total pharyngectomy defectsTotal pharyngectomy defects

Thin, pliable flap quality Thin, pliable flap quality Tube formation an epithelialized Tube formation an epithelialized

conduitconduit

De-epithelizationDe-epithelizationSkin island for monitoring flap viabilitySkin island for monitoring flap viability

Very long pharyngeal defects Very long pharyngeal defects From nasopharynx to thoracic inletFrom nasopharynx to thoracic inlet

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Clinical applicationsClinical applications

Near-total glossectomy defectsNear-total glossectomy defectsBulkier thigh flaps Bulkier thigh flaps

with more subcutaneous fat can provide with more subcutaneous fat can provide

sufficient tissuesufficient tissue

Advantages of the subdermal fatAdvantages of the subdermal fatless atrophy associated with denervated less atrophy associated with denervated

musclemuscle

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Clinical applicationsClinical applications

Sensory reinnervation for oral cavity Sensory reinnervation for oral cavity

reconstructionsreconstructions

Severe cervical burn contractures - suboptimal Severe cervical burn contractures - suboptimal

color matchcolor match

Large scalp defects with underlying fascia flapLarge scalp defects with underlying fascia flap

Facial augmentation with vascularized fat flapFacial augmentation with vascularized fat flap

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Patient SelectionPatient Selection

Body habitus and specific defect Body habitus and specific defect requirementrequirement

No tourniquet No tourniquet Limiting worries of extremity eschemiaLimiting worries of extremity eschemia

Minimal donor site morbidityMinimal donor site morbidity

No specific preoperative workupNo specific preoperative workup

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WorkupWorkup

QuestionQuestion about issues that disqualify surgery about issues that disqualify surgery

Evaluate previous Evaluate previous injury injury or surgery to the thighor surgery to the thigh

No specific No specific lab studies or imaging studieslab studies or imaging studies

Pinch testPinch test to determines the amount of fat to determines the amount of fat

Doppler deviceDoppler device to locate the main perforator to locate the main perforator

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Draping and Flap designDraping and Flap design

Slight flexion of hip and kneeSlight flexion of hip and knee

Inward rotation of legInward rotation of leglocation of pillow under the hip for rotationlocation of pillow under the hip for rotation

Exposure of thighExposure of thighFrom the greater trochanter to the lateral epicondyleFrom the greater trochanter to the lateral epicondyle

Palpation and marking of intermuscular septumPalpation and marking of intermuscular septumCenter of the line - Third perforatorCenter of the line - Third perforator

Design : Ellipse with long axis along the lineDesign : Ellipse with long axis along the line

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Landmarks of femurLandmarks of femur

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

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

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Flap harvestFlap harvest

Incision at the anterior aspect of ellipseIncision at the anterior aspect of ellipseThrough the skin and subcutaneous fatThrough the skin and subcutaneous fatDown to the level of fascia overlying vastus lateralisDown to the level of fascia overlying vastus lateralis

Easy distal approach to intermuscular septumEasy distal approach to intermuscular septum Proximal : overlying fascia lataProximal : overlying fascia lata

Third perforator identificationThird perforator identificationNear superior border of short head of biceps femorisNear superior border of short head of biceps femorisVessel may run on, under, or through the muscleVessel may run on, under, or through the muscleThis area is preserved for later dissectionThis area is preserved for later dissection

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Flap harvestFlap harvest

Medial retraction of vastus lateralis m.Medial retraction of vastus lateralis m.Trace the vessel toward the femurTrace the vessel toward the femurCareful ligation of muscular perforators Careful ligation of muscular perforators

To the vastus lateralis and biceps femorisTo the vastus lateralis and biceps femoris

Demonstration of vascular pedicle piercing Demonstration of vascular pedicle piercing adductor fascia through a semilunar hiatusadductor fascia through a semilunar hiatus

Releasing adductor attachment from linea asperaReleasing adductor attachment from linea aspera

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

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Flap harvestFlap harvest

Skin paddle mobilizationSkin paddle mobilizationRelease from short head of biceps Release from short head of biceps femorisfemoris

Avoid direct dissectionAvoid direct dissectionTwo finger breadth section of biceps Two finger breadth section of biceps femoris m.femoris m.

Posterior skin incision down to long head Posterior skin incision down to long head level and proximal dissectionlevel and proximal dissection

Sciatic n. protection during flap Sciatic n. protection during flap elevationelevation

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Flap harvestFlap harvest

Staple back of flap until transferStaple back of flap until transferFurther practical test of flap viabilityFurther practical test of flap viability

Limits ischemia time for the flapLimits ischemia time for the flap

Placement of flap in cool siline bathPlacement of flap in cool siline bath

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Donor siteDonor site

Hemostasis & Suction drain insertionHemostasis & Suction drain insertionPrimary closure - wide undermining of skin flapPrimary closure - wide undermining of skin flap

Occasional skin graftOccasional skin graftParallel relaxing incision on the anterior thigh areaParallel relaxing incision on the anterior thigh area

Primary closure at intermuscular septum and with Primary closure at intermuscular septum and with split-thickness skin graft at medial relaxing wound split-thickness skin graft at medial relaxing wound

To avoid potential skin graft loss at theTo avoid potential skin graft loss at theintermuscular septumintermuscular septum

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Sensate lateral thigh flapSensate lateral thigh flap

Lateral femoral cutaneous nerveLateral femoral cutaneous nerveArborize from the subcutaneous fat proximal to the Arborize from the subcutaneous fat proximal to the

anterior incision of ellipseanterior incision of ellipse

Retrograde dissection : tedious and unsatisfyingRetrograde dissection : tedious and unsatisfying

Second longitudinal incision at sartorius level Second longitudinal incision at sartorius level Lateral tracing from the main nerve trunkLateral tracing from the main nerve trunk

Section of the branch to the anterior thighSection of the branch to the anterior thigh

Halt further dissection and harvest with subcutaneous Halt further dissection and harvest with subcutaneous fatfat

Subdermal dissection and underlying fascia elevationSubdermal dissection and underlying fascia elevation

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Aid Tips DetailsAid Tips DetailsProper positioningProper positioning

Sufficient exposureSufficient exposureAnatomic landmarks and postlateral thighAnatomic landmarks and postlateral thigh

Remember the exit of perforating arteryRemember the exit of perforating artery

Planned ellipsePlanned ellipseCenter on intermuscular septumCenter on intermuscular septum

Relation of vascular pedicle Relation of vascular pedicle To the short head of biceps femoris To the short head of biceps femoris

Most challenging aspect of the dissectionMost challenging aspect of the dissectionAdductor hiatus levelAdductor hiatus level

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AdvantagesAdvantages

Vascular pedicle : 8-10cm Vascular pedicle : 8-10cm

Large vessel diameter : 2-5mmLarge vessel diameter : 2-5mm

Large available surface Large available surface Thin pliable flap - pharyngeal reconstructionThin pliable flap - pharyngeal reconstruction

Thicker flap - glossal reconstructionThicker flap - glossal reconstruction

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AdvantagesAdvantages

Two team approachTwo team approach

Minimal donor site morbidityMinimal donor site morbidity

Favorable alternative Favorable alternative More accepted fasciocutaneous free flapMore accepted fasciocutaneous free flap

Forearm flap - linear scarForearm flap - linear scar

Scapular/parascapular flapScapular/parascapular flap

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Disadvantages Disadvantages

Bulkness in Obese patientsBulkness in Obese patients

Hair-bearing skin Hair-bearing skin Esp. in male Esp. in male

Permanent depilatory effects of Permanent depilatory effects of

post-operative radiation therapypost-operative radiation therapy

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ComplicationsComplications

Flap deathFlap deathSuccess rate approaches 90-95% Success rate approaches 90-95% Arteriosclerotic plaqueArteriosclerotic plaqueAccidental vessel transection during dissectionAccidental vessel transection during dissection

The posterior skin attachment may be left intact until The posterior skin attachment may be left intact until the the

time of anastomosistime of anastomosisThe posterior subdermalThe posterior subdermal and dermal vessels provide and dermal vessels provide adequate blood flow to the skin flap.adequate blood flow to the skin flap.

Donor site skin graft lossDonor site skin graft lossSeromaSeroma have a tendency to develop in this area have a tendency to develop in this area

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Future and ControversiesFuture and Controversies

Controversies Controversies PFA itself Vs PFA itself Vs third perforatorthird perforator

Short pedicle lengthShort pedicle length

PFA proximal to PFA proximal to second perforatorsecond perforator Muscular weaknessMuscular weakness

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