Surgical 2 Radiologlc Anatomy
Surg Radiol Anat (1990) 12 : 311-313
Journal of Clinical Anatomy
© Springer-Verlag 1990
Report of the Socidtd Anatomique de Paris *
Anatomical basis of the anterolateral thigh flap (25.05.1990) T Brgur, AC Masquelet, JY Nordin Service de Chirurgie orthoprdique et traumatologique, Hrpital Avicenne, 125, route de Stalingrad, 93000 Bobigny, France
First described by Song [3], the anterolateral thigh flap is a fasciocutaneous flap [2]. Its pattern of vascular anatomy is axial and specific [2]. Its origin is the lateral circumflex artery of the thigh, or the descending branch of this artery [4]. The authors present an anatomical study of this flap done to establish the exact anatomy of the flap and the reliable possibilities it offers for c o v e r i n g cutaneous defects. Method
Results Arteries
The arterial supply is sustained by the descending branch of the lateral circumflex artery of the thigh. It is a myocutaneous branch. From the origin, the descending branch moves down and laterally. Then, it crosses between the vastus lateralis muscle posteriorly and the rectus femoris muscle anteriorly. In this space between the two muscles, the myocutaneous branch
divides into a muscular artery for the quadriceps, and a specific cutaneous artery. This continues transv e r s e l y b e t w e e n the f o r m e r muscles, reaches the aponeurosis and goes through it. Then, the cutaneous branch separates in two small subcutaneous arteries lying along the longitudinal axis of the thigh. The blood supply for the skin comes from a subcutaneous network arising from the terminal branches. The specific pedicle of the flap is 5 cm long (minimum 3 cm, maximum 8 cm). The diameter of
Thirty-two anatomical studies have been done on sixteen adult cadavers, eleven men and five women. Twenty-two of these were done without any specific vascular opacification. Six were examined after arterial and venous injection with colored gelatin. Four specific injections of the cutaneous branch with methylene blue defined the cutaneous area s u p p o r t e d by the pedicle.
Offprint requests : Dr T Brgu6 -* The full text of these communications is published each year in the Bulletin de la Socidt6 Anatomique de Paris, Laboratoire d'Anatomie, UFR Biomddicale des SaintsP~res, 45, rue des Saints-Prres F-75270 Paris Cedex 06.
Fig. 1 Arterial anatomy of the anterolateral thigh flap. t Femoral artery 2 Descending branch of the lateral circumflex artery 3 Sartorius muscle 4 Rectus femoris muscle Anatomic artrrielle du lambeau ant6ro-latdral de cuisse. Dissection rdtrograde du prdicule (les muscles droit de la cuisse 4 et sartorius 3 ont 6t6 sectionnds). 1 A. fdmorale 2 R. descendant de l'art~re circonflexe latrrale de la cuisse
312
T Bdgu6 et al: The anterolaterat thigh flap
Veins The specific cutaneous perforating artery is followed by one or two veins down to the intermuscular space between the vastus lateralis muscle and the rectus femoris muscle.
Design of the flap The flap can be designed on the anterolateral aspect of the thigh. The longitudinal axis of the flap goes from the anterosuperior iliac spine to the lateral border of the patella. The perforating cutaneous vessels are found at the junction of the proximal third and distal two thirds of this line (Fig. 1). The methylene blue injections allow a maximal size for the flap of 30 cm long and 15 cm wide (length/width = 2/1). Discussion
Fig. 2 A burn of the dorsum of the foot. Metatarsus and joint exposed B Localisation of the perforating vessels (doppler) C Final state A Brfilure dorsale du pied et exposition du squelette m6tatarsien (pr6-opdratoire) B Repdrage de l ' a r t ~ r e du lambeau au doppler C Etat final
the artery is 1 mm wide. The length of the pedicle can be increased by ligature of the branches for the vastus lateralis muscle, after the origin of the specific cutaneous artery. In these cases, the pedicle
has an average length of 10 cm (minimum 7 cm, maximum 12 cm). The diameter of the origin of the descending branch of the lateral circumflex artery varies from 1,8 to 2,5 ram.
The origin of the descending branch of the lateral circumflex artery may vary [4]. In three cases, this branch took its origin directly from the profunda artery of the thigh. These variations are more frequent in the Japanese study [1]. Williams [4] emphasized usual differences in anatomy of the large vessels in the Japanese population. The venous drainage can reach the femoral or the great saphenous vein [5]. In our study, ten cases used the saphenous system by the lateral superficial femoral vein. In these cases, the vein did not follow the descending branch of the lateral circumflex artery. The flap pedicle was constant in this study, as also for Song [3], but Koshima [1] denied this. In two of our cases, the cutaneous branch of the flap crossed the muscular fibers of the vastus lateralis muscle. The vascular pedicle was still a specific cutaneous axial bundle, but the distal part goes through a muscle without any participation in its vascularisation. Only Song [3]
T Bdgu6 et al: The anterolateral thigh flap
encountered this kind of distribution. In one of our case, this anatomy would have prevented the surgical approach without any muscular sacrifice. For song [3], the cutaneous pedicle is a septocutaneous pattern. In our study, it always lay in an intermuscular space filled with fatty tissue, with vastus lateralis in front and rectus femoris behind. We never found an intermuscular septum. So, we consider the pedicle of the flap as an intermuscular specific cutaneous axial one [2]. It differs from the perforating myocutaneous vessels even in the cases where the branch goes through the vastus lateralis muscle.
313
foot, After excision, the metatarsus and the tarso-metatarsal joints were exposed. Covering was done by using a free anterolateral thigh flap ( 1 7 x l 0 c m ) . The position of the perforating vessels was obtained by using a Doppler system. The artery (diameter 1,5 mm) was anastomosed on the anterior tibial artery, and the vein of the flap to the great saphenous vein. Other surgical procedures were needed for correction of the toe deformities (Fig. 2).
Acknowledgments: The authors are very
References 1. Koshima I, Kukuda H, Utunomiya R, Soeda S (1989) The anterolateral thigh flap; variations in its vascular pedicle. Br J Plast Surg 42 : 260-262 2. Masquelet AC, Romana MC (1988) V a s c u l a r i s a t i o n t ~ g u m e n t a i r e des membres et applications chirurgicales. Rev Chir Orthop 74 : 669-675 3. Song YG, Chen GZ, Song YL (1984) The free thigh flap: a new free flap concept based on the septocutaneous artery. Br J Plast Surg 37 : 149-159 4. Williams GD, Martin CH, McIntire LR (1934) Origin of the deep and circumflex femoral group of arteries. Anat Rec 60 : 189-196 5. Xu DC, Zhong SZ, Kong JM, Wang GY, Liu M, Luo LS, Gao JH (1988) Applied anatomy of the anterolateral femoral flap. Plast Rec Surg 82 : 305-310
grateful to Marc Donon for the original drawing
Clinical case
A fifty-five year old man burned himself on the dorsal aspect of the
The anatomical study was carried out at the Department of Anatomy, UFR Biom6dicale des Saints-P~res, Universit6 Paris V
Received September 18, 1990~Accepted September 26, 1990
Surg Radiol Anat (1990) 12 : 311-313
Journal of Clinical Anatomy
© Springer-Verlag 1990
Report of the Socidtd Anatomique de Paris *
Anatomical basis of the anterolateral thigh flap (25.05.1990) T Brgur, AC Masquelet, JY Nordin Service de Chirurgie orthoprdique et traumatologique, Hrpital Avicenne, 125, route de Stalingrad, 93000 Bobigny, France
First described by Song [3], the anterolateral thigh flap is a fasciocutaneous flap [2]. Its pattern of vascular anatomy is axial and specific [2]. Its origin is the lateral circumflex artery of the thigh, or the descending branch of this artery [4]. The authors present an anatomical study of this flap done to establish the exact anatomy of the flap and the reliable possibilities it offers for c o v e r i n g cutaneous defects. Method
Results Arteries
The arterial supply is sustained by the descending branch of the lateral circumflex artery of the thigh. It is a myocutaneous branch. From the origin, the descending branch moves down and laterally. Then, it crosses between the vastus lateralis muscle posteriorly and the rectus femoris muscle anteriorly. In this space between the two muscles, the myocutaneous branch
divides into a muscular artery for the quadriceps, and a specific cutaneous artery. This continues transv e r s e l y b e t w e e n the f o r m e r muscles, reaches the aponeurosis and goes through it. Then, the cutaneous branch separates in two small subcutaneous arteries lying along the longitudinal axis of the thigh. The blood supply for the skin comes from a subcutaneous network arising from the terminal branches. The specific pedicle of the flap is 5 cm long (minimum 3 cm, maximum 8 cm). The diameter of
Thirty-two anatomical studies have been done on sixteen adult cadavers, eleven men and five women. Twenty-two of these were done without any specific vascular opacification. Six were examined after arterial and venous injection with colored gelatin. Four specific injections of the cutaneous branch with methylene blue defined the cutaneous area s u p p o r t e d by the pedicle.
Offprint requests : Dr T Brgu6 -* The full text of these communications is published each year in the Bulletin de la Socidt6 Anatomique de Paris, Laboratoire d'Anatomie, UFR Biomddicale des SaintsP~res, 45, rue des Saints-Prres F-75270 Paris Cedex 06.
Fig. 1 Arterial anatomy of the anterolateral thigh flap. t Femoral artery 2 Descending branch of the lateral circumflex artery 3 Sartorius muscle 4 Rectus femoris muscle Anatomic artrrielle du lambeau ant6ro-latdral de cuisse. Dissection rdtrograde du prdicule (les muscles droit de la cuisse 4 et sartorius 3 ont 6t6 sectionnds). 1 A. fdmorale 2 R. descendant de l'art~re circonflexe latrrale de la cuisse
312
T Bdgu6 et al: The anterolaterat thigh flap
Veins The specific cutaneous perforating artery is followed by one or two veins down to the intermuscular space between the vastus lateralis muscle and the rectus femoris muscle.
Design of the flap The flap can be designed on the anterolateral aspect of the thigh. The longitudinal axis of the flap goes from the anterosuperior iliac spine to the lateral border of the patella. The perforating cutaneous vessels are found at the junction of the proximal third and distal two thirds of this line (Fig. 1). The methylene blue injections allow a maximal size for the flap of 30 cm long and 15 cm wide (length/width = 2/1). Discussion
Fig. 2 A burn of the dorsum of the foot. Metatarsus and joint exposed B Localisation of the perforating vessels (doppler) C Final state A Brfilure dorsale du pied et exposition du squelette m6tatarsien (pr6-opdratoire) B Repdrage de l ' a r t ~ r e du lambeau au doppler C Etat final
the artery is 1 mm wide. The length of the pedicle can be increased by ligature of the branches for the vastus lateralis muscle, after the origin of the specific cutaneous artery. In these cases, the pedicle
has an average length of 10 cm (minimum 7 cm, maximum 12 cm). The diameter of the origin of the descending branch of the lateral circumflex artery varies from 1,8 to 2,5 ram.
The origin of the descending branch of the lateral circumflex artery may vary [4]. In three cases, this branch took its origin directly from the profunda artery of the thigh. These variations are more frequent in the Japanese study [1]. Williams [4] emphasized usual differences in anatomy of the large vessels in the Japanese population. The venous drainage can reach the femoral or the great saphenous vein [5]. In our study, ten cases used the saphenous system by the lateral superficial femoral vein. In these cases, the vein did not follow the descending branch of the lateral circumflex artery. The flap pedicle was constant in this study, as also for Song [3], but Koshima [1] denied this. In two of our cases, the cutaneous branch of the flap crossed the muscular fibers of the vastus lateralis muscle. The vascular pedicle was still a specific cutaneous axial bundle, but the distal part goes through a muscle without any participation in its vascularisation. Only Song [3]
T Bdgu6 et al: The anterolateral thigh flap
encountered this kind of distribution. In one of our case, this anatomy would have prevented the surgical approach without any muscular sacrifice. For song [3], the cutaneous pedicle is a septocutaneous pattern. In our study, it always lay in an intermuscular space filled with fatty tissue, with vastus lateralis in front and rectus femoris behind. We never found an intermuscular septum. So, we consider the pedicle of the flap as an intermuscular specific cutaneous axial one [2]. It differs from the perforating myocutaneous vessels even in the cases where the branch goes through the vastus lateralis muscle.
313
foot, After excision, the metatarsus and the tarso-metatarsal joints were exposed. Covering was done by using a free anterolateral thigh flap ( 1 7 x l 0 c m ) . The position of the perforating vessels was obtained by using a Doppler system. The artery (diameter 1,5 mm) was anastomosed on the anterior tibial artery, and the vein of the flap to the great saphenous vein. Other surgical procedures were needed for correction of the toe deformities (Fig. 2).
Acknowledgments: The authors are very
References 1. Koshima I, Kukuda H, Utunomiya R, Soeda S (1989) The anterolateral thigh flap; variations in its vascular pedicle. Br J Plast Surg 42 : 260-262 2. Masquelet AC, Romana MC (1988) V a s c u l a r i s a t i o n t ~ g u m e n t a i r e des membres et applications chirurgicales. Rev Chir Orthop 74 : 669-675 3. Song YG, Chen GZ, Song YL (1984) The free thigh flap: a new free flap concept based on the septocutaneous artery. Br J Plast Surg 37 : 149-159 4. Williams GD, Martin CH, McIntire LR (1934) Origin of the deep and circumflex femoral group of arteries. Anat Rec 60 : 189-196 5. Xu DC, Zhong SZ, Kong JM, Wang GY, Liu M, Luo LS, Gao JH (1988) Applied anatomy of the anterolateral femoral flap. Plast Rec Surg 82 : 305-310
grateful to Marc Donon for the original drawing
Clinical case
A fifty-five year old man burned himself on the dorsal aspect of the
The anatomical study was carried out at the Department of Anatomy, UFR Biom6dicale des Saints-P~res, Universit6 Paris V
Received September 18, 1990~Accepted September 26, 1990
