The Rich Get Richer: Osseous Chimeric Versatility to the Anterolateral Thigh Flap
Jason W. Yu, D.M.D., M.D., Jordan D. Frey, M.D., Vishal D. Thanik, M.D., Eduardo D. Rodriguez, M.D., D.D.S., Jamie P. Levine, M.D..
NYU Langone Health, New York, NY, USA.
Background: The lateral femoral circumflex system (LFCA), which supplies the anterolateral thigh (ALT) flap territory, offers a plethora of tissue types for composite, functional reconstruction. However, the ability to include a reliable and flexible osseous component is limited. Based on cadaveric dissections, we describe an isolated LFCA branch to the femur separate from the vastus intermedius that can be included in ALT flap harvest in cases requiring bony reconstruction.
Methods: Cadaveric dissection was undertaken to define the LFCA vascular system with specific dissection of the proximal branches of the descending branch of the LFCA (db-LFCA)to define any muscular, periosteal, and/or osseous branches to the femur.
Results: Six thighs in four cadavers were dissected. After elevation of a standard fasciocutaneous skin paddle based on perforators from the db-LFCA, all branches at the plexus were carefully dissected. Consistent in all specimens (6), we were able to identify a trifurcation at the plexus: 1) the superficial lateral system supplying the traditional anterolateral thigh flap 2) the superficial medial system supplying the rectus femoris muscle 3) the deep system consisting of usually two myo-osseous branches found on the undersurface of plexus. The deep major branch was the larger and lateral of the two, providing multiple branches within the VI parenchyma while the deep minor branch perforated through VI more medially with a clear supply to the anteromedial portion of the femur. In five specimens, the minor branch was reliably located within one centimeter distal to the rectus femoris branch and approximately one centimeter proximal to a separate branch entering and supplying the vastus intermedius. In one specimen (16.7%), there was a common trunk that split into the familiar orientation with a myo-osseous branch extending into the femur medially and another supplying the vastus intermedius more laterally. The length of the minor branch from the plexus to insertion into the femoral periosteum was approximately 6-8 centimeters. The length of the major branch extending into the vastus intermedius muscle from its origin was approximately 2-3 centimeters.
Conclusions: There appears to be a consistent and reliable branch to the femur based on the proximal LFCA that may be included in ALT flap harvest, adding even more versatility as another option in complex cases requiring composite reconstruction, including bone.
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