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The Anterolateral Thigh Flap Introduction The anterolateral thigh flap is a fasciocutaneous flap whose blood supply is derived from cutaneous perfoartors of the descending branch of the lateral femoral circumflex vessels. Anatomy The fasciocutaneous branches are of 2 types: muscle branches to the vastus lateralis muscle and direct cutaneous branches. Flap Dimensions A flap that is 38 cm long and 12 cm wide can be elevated (average 8 to 10 cm in lenght). Preoperative Design The central axis of the flap is indicated by a line drawn from the anterior superior iliac spine to the superolateral border of the patella. At the midpoint of this line, a circle with a 3 cm radius is drawn. A transcutaneous doppler probe is used to locate the perforators (1 to 8), especially in the lower outer quadrant. The skin paddle is drawn with its base overlying these perforators. Combinations Most of the time, this flap is used as a fasciocutaneous flap but a segment of the vastus lateralis muscle can be included. Indications This flap is indicated whenever a relatively thin and large flap is required. A neurosensory flap can be used based on the anterior branches of the lateral femoral cutaneous nerve of the thigh. Flap Dissection 1. Incision of the skin paddle over the rectus femoris muscle down to the deep fascia. 2. Flap elevation proceeds in the subfascial plane from an anterior to a posterior direction. 3. A posterior caudal incision facilitates flap elevation and exposure the intermuscular septum between the rectus femoris and the vastus lateralis muscles. 4. By retracting the rectus femoris muscle medially, the perforators are traced to the descending branch of the lateral femoral cutaneous artery and venae comitantes. 5. The vascular pedicle is dissected from the nerve to the vastus lateralis muscle (lateral to the artery) 6. The pedicle is elevated along with its septocutaneous perforators and segment of intermuscular septum.
Introduction
The superior gluteal artery perforator (S-GAP) flap is a fasciocutaneous flap with ample amount of fat.Anatomy
The superior and inferior gluteal artery, dominant pedicles of the gluteus maximus muscle, give 20 to 25 cutaneous perforators. The superior gluteal artery exits the pelvis through the suprapiriform foramen. The larger perforator varies from 3 to 8 cm in length and 1 to 1.5 mm in diameter. Superior gluteal artery perforators (at least 3) reach the superolateral region of the buttock.Flap Dimensions
The skin paddle can reach 12 cm in width and 32cm in length.Preoperative Design
The position of the piriformis muscle is located by drawing a line between the middle of a line connecting the posterior superior iliac spine with the coccyx and the superior edge of the greater trochanter of the femur. Another line is drawn from the posterior superior iliac spine to the greater trochanter. The superior gluteal vessels are marked one third down this line. A transcutaneous Doppler probe is used to identify the position of the perforators, mainly above the piriformis muscle and parallel to the second line. A skin paddle is designed over the perforators in an elliptical fashion and parallel to the bikini line (drawn in supine position).Indications
This flap is mainly used for breast reconstruction. As an island flap, it can be used to cover sacral pressure sores.Flap Dissection
1. Incision of the skin paddle down to the gluteus maximus muscle. At the most lateral end, the gluteus medius muscle can be identified by the more vertical course of its fibres.
2. Incision of the fascia of the gluteus maximus muscle. Dissection below the fascia allows quicker identification of perforators.
3. The flap is elevated from the lateral side to the medial side avoiding injury to the preoperatively identified perforators.
4. The perforators are dissected spliting the gluteus maximus muscle in the direction of its fibers.
5. Upon reaching the superior gluteal vessels, the dissection is complete and the pedicle length should mesure approximately 8 cm in length, one or two veins accompanying the artery.
Introduction
The radial forearm flap is one of the most common fasciocutaneous flap.Anatomy
The radial forearm flap is based on septocutaneous perforating vessels following the course of the radial artery. A segment of radial artery up to 20 cm in length can be obtained, depending on the place of the skin paddle. Venous drainage can be provided by the cephalic vein or the paired venae comitantes of the radial artery, or both.Flap Dimensions
Flap dimensions may vary from 2 to 3 cm in width and 2 to 3 cm in length to 5 to 8 cm in width and 8 to 10 cm in length.Preoperative Design
Adequate flow to the hand and digits via the ulnar artery is confirmed preoperatively by an Allen test. The flap can be designed and placed proximally, centrally, or more distally on the forearm. The course of the brachial artery and approximate location of the medial and lateral antebrachial cutaneous nerves are marked. The flap is designed so that the lateral third of the flap is located lateral to the course of the radial artery.Combinations
The radial forearm flap can also be used as a fascial flap, or as a fascial-fasciocutaneous flap with an osseous segment , or as a fascial-fasciocutaneous flap including vascularized superficial radial nerve.Indications
The flap is useful when a thin flap with a lengthy pedicle of large external diameter is required. It has been used in many reconstructions such as the floor of the mouth, the neck, the face, the plantar aspect of the foot or the hand. This flap has also been employed in penile reconstruction.Flap Dissection
1. Skin incision on the ulnar flap margin to include the deep fascia of the forearm.
2. The distal flap margin is also incised to the radial artery.
3. The proximal flap margin is similarly incised to the radial artery, avoiding injury to the cephalic or median vein as well as to the medial and lateral antebrachial cutaneous nerves.
4. Dissection continues from an ulnar to a radial location beneath the deep fascia.
5. Paratenon of the palmaris longus tendon, of the flexor tendons and of the flexor carpi radialis tendon is preserved. The median nerve is observed between flexor carpi radialis and palmaris longus tendons.
6. The lateral intermuscular septum is identified on the lateral aspect of the flexor carpi radialis muscle.
7. The radial artery is visible within the septum.
8. Skin incision on the proximal radial flap margin to include the deep fascia of the forearm which is elevated from the brachioradialis muscle.
9. The brachioradialis muscle is retracted laterally to expose the radial artery, venae comitantes and the superficial branch of the radial nerve. The distal radial flap margin is incised avoiding injury to the supercial branch of the radial nerve.
10. The lateral intermuscular septum and the pedicle are elevated from the radius from a distal to a proximal direction.
11. When an osseous segment of the radius is to be included, the radius is first exposed lateral to the attachment of the lateral intermuscular septum. The pronator quadratus and the flexor pollicis longus muscle bellies are incised down to the radius, 1 to 1.5 cm medial to the septum. Longitudinal osteotomies are performed to isolate an osseous segment 10 to 12 cm long and 1 to 1.5 cm wide.
Introduction
The gracilis muscle is a long muscle with a dominant neurovascular pedicle as well as a secondary pedicle or pedicles (Class II).Anatomy
A single artery and 2 venae comitantes enter the muscle on its deep and anterior surface at the junction of the proximal and middle thirds 6 to 12 cm distal to the pubic tubercle. A single musculocutaneous perforator is usually present opposite the dominant vascular pedicle supplying the proximal skin. The gracilis muscle is innervated by the anterior branch of the obturator nerve (L2-L4).Flap Dimensions
The gracilis muscle is 5 to 6 cm wide, 2 to 3 cm thick and 30 to 32 cm long . The skin paddle centered over the proximal muscle belly measures 6 to 8 cm in width and 10 to 15 cm in length.Preoperative Design
The knee and hip are flexed. The lower extremity is then abducted so the adductor longus muscle becomes apparent. A line is drawn from the pubic tubercle to the medial femoral condyle along the prominence of the adductor longus muscle, demarcating the superior border of the gracilis muscle. The skin paddle is centered over the proximal gracilis muscle belly and the vascular pedicle. The superior margin of the paddle correspond to the line along the adductor longus muscle.Combinations
The gracilis flap can be used as a muscle or a musculocutaneous flap.Indications
The gracilis flap to perform obturation of soft tissue defects, especially in the head and neck region and lower extremities. It can be employed to treat localized areas of osteomyelitis in the lower extremities and to restore
unilateral facial palsy or loss of motion of foot or fingers.Flap Dissection
1. Incision of the skin paddle down to and including the fascia lata.
2. Skin incision along the proximal and middle third of the thigh, 2cm inferior to the adductor longus line and parallel to it. The superficial fascia is incised and the juncture of the adductor longus and gracilis muscles is identified.
3. The fascia lata is incised and dissected from the gracilis muscle.
4. Distally, the gracilis muscle is dissected from the adductor longus muscle anteriorly and the adductor magnus posteriorly.
5. Dissection proceeds from a distal to a proximal direction, separating the gracilis muscles from the adductor longus and adductor magnus muscles.
6. The adductor longus muscle is retracted anteriorly to increase the exposure of the dominant pedicle.
7. The nerve to the adductor longus muscle and the medial cutaneous nerve of the thigh are identified on the deep surface of the adductor longus muscle.
8. Small branches to the adductor muscles are ligated, increasing the pedicle length to 6 to 7 cm.
9. The anterior branch of the obturator nerve is seen entering the deep surface of the gracilis muscle 2 to 3 cm proximal to the vascular hilus. It can be traced from a distal to a proximal direction.
10. Transverse skin incision on the medial aspect of the knee over the hamstrings. Tendinous insertion of the gracilis muscle is palpated by placing tension on the proximal muscle. The tendon is cut and the origin of the the muscle is then detached from the pubis.
