Lateral Thigh Flap

Pil-Young Yun, D.D.S., M.S.D.

Dept. of Oral & Maxillofacial Surgery, College of Dentistry,
Seoul National University

Lateral Thigh Flap

Introduction
Fasciocutaneous flap from the lower limb
Versatile, reliable alternative in the reconstruction of specific head and neck

History
1983 Baek S.M. Two new cutaneous free flaps : the medial and lateral thigh flap
1994 Richard E. Hayden Reconstruction of pharyngoesphageal defects
1995 Miller M.J. Lateral thigh free flap in head and neck reconstruction
1998 Turelson J.M. Lateral thigh flap reconstruction in the head and neck

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

Blood supply : cutaneous branches of the perforators from the profunda femoris a.
principal supply is 3rd perforator (in a very small minority of patients - 4th perforator)
secondary blood supply - 2nd and 4th perforator
cf.) Anterolateral thigh free flap (Koshima et al) : lateral circumflex femoral system

Femoral a. - 3.5cm below the inguinal ligament - profunda femoris a.

Profunda femoris a. - deep to the adductor longus - perforators
3rd perforator - piercing the fascia through the linea aspera - branches to the vastus lateralis    and
biceps femoris
pass over, through or the under the short head of the biceps femoris - intermuscular septum
Miller et al
57 of 61 cases pass through the short head of the biceps femoris
Terminal cutaneous branch - subcutaneous fat overlying posterolateral intermuscular septum

Cormack et al
Primary blood supply of the lateral thigh skin came from the underlying muscle or fascia
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 dissection in 2 fresh and 61 preserved cadaver extremities followed    by 10 clinical cases
involving defects after tumor ablation
Vessel came to skin level : 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

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 derection to anastomose with branches of the other perforators
fasciocutaneous branches

The first perforator

The primary blood supply to the adductors(brevis, longus, and magnus)
Terminal branch : the main vascular pedicle of the gracilis muscle
Cutaneous branch : the upper medial thigh
Branches to the gluteus maximus and the greater trochanter

The second perforator

Muscular branches
to the semimembranosus
the long and short heads of the biceps femoris
the 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. : 3-5mm
the origin of the 3rd perforator : 2-3mm
terminal cutaneous branch : 1-2mm

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 cuteneous nerve
originate from the first three lumbar nerve
sometimes from the femoral nerve
passing under the inguinal ligament and anterior, posterior or through the satorius m.
divide into anterior and lateral branch - subdivide into the subdermal fat

Anatomic Variations
the major source of the blood supply - fourth perforator
the center of the skin paddle - more distally

The major problem : the major arterial supply - second perforator

ensure the vascular supply to the muscles and the femur

Hayden
15% incidence of vascular variations
Recommend to include a large fourth perforator to augment the cutaneous blood supply
even when the third perforator is the dominant

Baek
one cadaver : the dominant vascular supply - from a branch of the superficial femoral artery
the redimentary profunda femoris without third or fourth cutaneous branch

Clinical application
1. Near-total and total pharyngectomy defects
- The thin, pliable quality of skin and subcutaneous tissue
- allows tubing of the flap to provide an epithelialized conduit
- de-epithelization : skin island for monitoring flap viability
2. very long pharyngeal defects from nasopharynx to thoracic inlet
3. for both total and near-total glossectomy defects.
- Bulkier thigh flaps with more subcutaneous fat can provide sufficient tissue
- subdermal fat : less atrophy associated with denervated muscle

Clinical application
4. sensory reinnervation for oral cavity reconstrucions
5. severe cervical burn contractures - suboptimal color match
6. large scalp defects - with underlying fascia flap
7. facial augmentation - vacularized 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 any issues that disqualify surgery
Evaluate previous injury or surgery to the thigh
Prepare the patient for a 1-2 week hospital stay with a suction drain in the thigh.
No specific lab studies or imaging studies
Pinch test : to determines the amount of fat
Using a Doppler device to locate the main perforating vessel

Draping and Flap design

Slight flexion of hip and knee
Inward rotation of leg(location of pillow under the hip for rotation)
No tourniquet
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 the long axis along the line

Landmark of femur
Greater trochanter
greater trochanter of the femur is a large, somewhat rectangular projection from the junction of the
neck and the body. It provides an insertion for several muscles of the gluteal region.
Condyle
the medial and lateral condyle of the femur are subcutaneous and easily palpable. Palpate them as
you flex and extend your knee joint. At the center of each condyle is a prominent epicondyle, to which
the tibial and fibular collateral ligaments of the knee joint are attached. The medial and lateral
epicondyles are easily palpable.

Flap Harvest
Incision at the anterior aspect of the ellipse
through the skin and subcutaneous fat
down to the level of the fascia overlying the vastus lateralis m

Easy approach to the intermuscular septum at the distal part

- proximal : overlying fascia lata

3rd perforator identification

- near the superior border of the 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 the vastus lateralis m.
trace the vessel toward the femur
careful ligation of the muscular perforators to the vastus lateralis and biceps femoris
- prior to the junction of the adductor musculature with the linea aspera
Demonstration of the vascular pedicle piercing the adductor fascia through a small semilunar hiatus
Releasing adductor attachment from the linea aspera
identification of the profunda femoris a.
proximal dissection until the 2nd perforator level

Flap harvest
skin paddle mobilization
release from the short head of biceps femoris
- avoid direct dissection
- two finger breadth section of biceps femoris m.
posterior skin incision down to the long head level and proximal dissection
protection of the sciatic n. during the flap elevation
hemostasis

Staple back of the flap until transfer

- further practical test of flap viability
- limits ischemia time for the flap
- placement of the flap in the cool siline bath

Donor site
Hemostasis & Insertion of the suction drain
Primary closure - wide undermining of skin flap
Skin graft
- parallel relaxing incision on the anterior thigh area
- primary closure at the intermuscular septum and medial relaxing wound is closed with a split-
thickness skin graft
- this avoids 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 the sartorius m. level in the anteromedial thigh
- lateral tracing from the main nerve trunk
- section of the branch to the anterior thigh
- halt the further dissection and harvest with subcutaneous fat
- subdermal dissection and underlying fascia elevation

Aid Tips Details

1. Proper positioning
2. Sufficient exposure of anatomic landmarks and postlateral thigh
3. Remember the exit of the perforating artery between landmarks
4. Planned ellipse - center on intermuscular septum
5. Relation of the vascular pedicle to the short head of the biceps femoris until securing the posterior
compartment of the thigh
6. Most challenging aspect of the dissection - adductor hiatus level

Advantage
1. Vascular pedicle : 8-10cm Large vessel diameter : 2-5mm
2. Large available surface Thin pliable flap - pharyngeal reconstruction
thicker flap - glossal reconstruction
3. Two team approach 4. Minimal donor site morbidity
5. Favorable alternative - to the more accepted fasciocutaneous free flap
cf.) Forearm flap - linear scar Scapular/parascapular flap

Disadvantage 1. bulkness in Obese patients

2. hear-bearing skin - in male - permanent depilatory effects of post-operative radiation therapy

Complications
1. Flap death
Success rate approaches 90-95% Arteriosclerotic plaque
2. 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.
3. Donor site skin graft loss Seroma have a tendency to develop in this area
To avoid - Anterior relaxing incision and posterior shift and the skin of the secondary area can be
grafted.
Future And Controversies
Controversies 1. PFA itself Vs the third perforator Short pedicle length
2. PFA proximal to the second perforator Muscular weakness

Future Tissue engineering and tissue culture The free lateral thigh flap has stood the test of time