Anterolateral Thigh/Vastus Lateralis Flap

Abstract

In 1984, Song and coworkers described the thigh as a donor site for three new flaps, which they raised from its posterior, anteromedial, and anterolateral aspect [500]. Of these three flaps, the anterolateral thigh flap became most popular, especially in head and neck reconstruction. Although originally described as a fasciocutaneous flap which is nourished by a septocutaneous perforator of the descending branch of the lateral circumflex femoral artery, the design of the flap significantly depends on the course and location of the cutaneous vessels, the anatomy of which can vary considerably. Because of the fact that the perforator often takes its course through the vastus lateralis muscle instead of running strictly along the intermuscular septum, parts of the vastus lateralis muscle have to be included into the flap in these cases. Besides the possibility of raising large skin paddles on a single perforating vessel, the vastus lateralis muscle can be transferred as a muscle-only flap, being safely perfused by the descending branch. Thus, a number of flap raising possibilities arise at the anterolateral thigh, offering a wide spectrum of flaps to be harvested. In one of the first large clinical series, Zhou et al. described successful transplantation of this flap in 32 patients, most of them having defects in the region of the face and scalp [623]. Based on a single perforator, a flap design was described reaching in length from the distal end of the tensor fasciae latae muscle to a level 7 cm above the patella and in width from the medial edge of the rectus femoris muscle to the lateral intermuscular septum. According to Koshima and coworkers, who reported on 22 reconstructions of head and neck defects, the flaps can have up to 25 cm in length and 18 cm in width [282]. Two years later, the same author combined the anterolateral thigh flap with neighboring skin-, myocutaneous-, and bone flaps using the lateral circumflex femoral system to treat massive composite defects of the head and neck, performing an additional anastomosis at the distal end of the descending branch [293]. In 1995, the usefulness of the anterolateral thigh flap to cover defects in the lower extremity was demonstrated by Pribaz and coworkers, especially because of the possibility to harvest and transfer the flap in epidural anesthesia [411]. An important variation of designing the anterolateral thigh flap was introduced by Kimura et al. in 1996, who performed a primary radical thinning procedure, only leaving a small cuff of fatty tissue around the perforator [276]. With this procedure, ultrathin flaps could be created, being very useful to cover superficial skin defects [72, 276, 575, 609]. To improve intraoral defect coverage, Wolff et al. performed additionally de-epithelialization of the thinned flaps to create a mucosa-like flap surface [595]. In the following years, the exceptional wide spectrum of indications and the high reliability of the flap were reported especially from authors of the Asian countries. In 2002, Wei et al. published a series of 672 anterolateral thigh flaps with a total flap failure in only 12 patients [575]. An even larger number of 1284 patients were presented by Gedebou and Wei in the same year, who described the anterolateral thigh flap as one of the most useful soft tissue flaps, especially in head and neck reconstruction [161].