Perforator Variability of the Anterolateral Thigh Flap Identified on Computed Tomographic Angiography: Anatomic and Clinical Implications

Abstract

<jats:title>Abstract</jats:title><jats:p> Background The anterolateral thigh (ALT) flap is a useful flap with minimal donor site morbidity. Preoperative computed tomographic angiography (CTA) for lower extremity reconstruction can determine vessel integrity and plan for recipient vascular targets. This study reviews lower extremity CTAs to further characterize ALT vascular anatomy and associated clinical implications thereof.</jats:p><jats:p> Patients and Methods Lower extremity CTA studies were retrospectively reviewed, and information on ALT cutaneous perforator location, origin, and course was collected.</jats:p><jats:p> Results A total of 58 lateral circumflex femoral artery (LCFA) systems in 31 patients were included. Average age was 38.8 ± 15.9 years with mean body mass index of 27.2 ± 5.7 kg/m2. The majority of patients were females (23, 74.2%). The LCFA most commonly originated from the profunda femoris artery (87.3%), followed by the distal common femoral artery (9.1%). On average, there were 1.66 ± 0.69 cm perforators per extremity, with an average of 5.38 cm between adjacent perforators. Perforators originated from the descending branch of the LCFA in 89.6% of studies. Perforator caliber was &lt;1 mm (29, 30.2%), 1 to 2 mm (55, 57.3%), or &gt;2 mm (12, 12.5%). Mean distance from the most proximal perforator to the anterior superior iliac spine was 20.4 ± 4.82 cm. Perforators were musculocutaneous (46.9%), septocutaneous (34.4%), or septomyocutaneous (18.8%). In 58.1% of patients, only one thigh had easily dissectable septocutaneous and/or septomyocutaneous perforators, in which case preoperative CTA aided in donor thigh selection.</jats:p><jats:p> Conclusion ALT flap cutaneous perforator anatomy varies considerably. Using CTA, we report on rates of septocutaneous, myocutaneous, and septomyocutaneous perforators and underscore its utility in perforator selection.</jats:p>

Preoperative Computed Tomography Angiography for ALT Flaps Optimizes Design and Reduces Operative Time

“…This muscle represents the largest component of the quadriceps femoris, and functional loss is more likely if greater than half the muscle is sacrificed. 22,[24][25][26] At worst, if the ALT cannot be salvaged or successfully converted, it could lead to total flap failure. Preoperative CTA minimizes the risk of encountering these undesirable scenarios.…”

“…Another secondary benefit of preoperative imaging is that it provides an appraisal of predicted flap thickness. 6,18,22 The ALT can demonstrate significant variation in subcutaneous fat based on body habitus and ethnic and regional populations. 18,27 This is a factor that must be considered in flap design, and thus as the subcutaneous tissue becomes significantly thinner with distal progression, perforators can be actively selected based on subcutaneous course and corresponding reconstructive needs.…”

“…However, despite many anecdotal reports of preoperative ALT perforator mapping with CTA, there are surprisingly few empirical studies that have directly attempted to assess the impact of this approach on donor extremity selection. 5 15 17 20 22 Garvey et al performed one such study, reporting CTA guidance to alter leg selection in 19% of cases. 20…”

Premature Fusion of the Posterior Intraoccipital Synchondrosis, A Minor Suture Mimic of Lambdoid Craniosynostosis

“…24 From this point of view, free osseous myocuta-neous flap was not considered the best choice for reconstruction after maxillary malignant tumor resection.The scar of ALTF has minimal impact on the function of the donor site compared with other free flaps. 28 In addition, ALTF is superior in terms of being an adequately sized flap, sparing major vasculature, and having better cosmesis at both donor and recipient sites. 29 Other studies reported that the donor site complications of the anterolateral thigh valve are rare compared with radial forearm free flap.…”

Color Doppler Ultrasound versus Computed Tomography Angiography for Preoperative Anterolateral Thigh Flap Perforator Imaging: A Systematic Review and Meta-Analysis

“…The CTA offers the advantage of improved perforator location sensitivity and specificity, but this technique does have contrast and radiation-related morbidity. 10 CDU is a potentially faster, cheaper option for the experienced surgeon or radiographer that also provides information related to vessel flow patterns and tissue characteristics. 11,12 Additionally, CDU offers intraoperative and postoperative flap monitoring due to its portability and vessel flow evaluation capabilities.…”