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Anterolateral Thigh/Vastus Lateralis Flap

  • Klaus-Dietrich Wolff
  • Frank Hölzle

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].

Supplementary material

Video 5.1

Anterolateral thigh-VL flap (MPG 115128 kb)

References

  1. 1.
    Abu Jamra FN, Afeiche N, Sumrani NB (1983) The use of a vastus lateralis muscle flap to repair a gluteal defect. Br J Plast Surg 36(3):319–321. doi:S0007-1226(83)90052-8 [pii]Google Scholar
  2. 6.
    Alkureishi LW, Shaw-Dunn J, Ross GL (2003) Effects of thinning the anterolateral thigh flap on the blood supply to the skin. Br J Plast Surg 56(4):401–408. doi:S0007122603001255 [pii]Google Scholar
  3. 17.
    Ao M, Uno K, Maeta M, Nakagawa F, Saito R, Nagase Y (1999) De-epithelialised anterior (anterolateral and anteromedial) thigh flaps for dead space filling and contour correction in head and neck reconstruction. Br J Plast Surg 52(4):261–267. doi:S0007-1226(99)93107-7 [pii] 10.1054/bjps.1999.3107
  4. 59.
    Bovet JL, Nassif TM, Guimberteau JC, Baudet J (1982) The vastus lateralis musculocutaneous flap in the repair of trochanteric pressure sores: technique and indications. Plast Reconstr Surg 69(5):830–834CrossRefGoogle Scholar
  5. 65.
    Burd A, Pang P (2003) The antero-lateral thigh (ALT) flap: a pragmatic approach. Br J Plast Surg 56(8):837–839. doi:S0007122603004089 [pii]Google Scholar
  6. 73.
    Celik N, Wei FC, Lin CH, Cheng MH, Chen HC, Jeng SF, Kuo YR (2002) Technique and strategy in anterolateral thigh perforator flap surgery, based on an analysis of 15 complete and partial failures in 439 cases. Plast Reconstr Surg 109(7):2211–2216; discussion 2217–2218Google Scholar
  7. 87.
    Chen WF, Kung YP, Kang YC, Lawrence WT, Tsao CK (2014) An old controversy revisited-one versus two venous anastomoses in microvascular head and neck reconstruction using anterolateral thigh flap. Microsurgery 34(5):377–383. doi:10.1002/micr.22214CrossRefPubMedGoogle Scholar
  8. 105.
    Collins J, Ayeni O, Thoma A (2012) A systematic review of anterolateral thigh flap donor site morbidity. Can J Plast Surg 20(1):17–23CrossRefGoogle Scholar
  9. 124.
    Dowden RV, McCraw JB (1980) The vastus lateralis muscle flap: technique and applications. Ann Plast Surg 4(5):396–404CrossRefGoogle Scholar
  10. 127.
    Drimmer MA, Krasna MJ (1987) The vastus lateralis myocutaneous flap. Plast Reconstr Surg 79(4):560–566CrossRefGoogle Scholar
  11. 162.
    Gedebou TM, Wei FC, Lin CH (2002) Clinical experience of 1284 free anterolateral thigh flaps. Handchir Mikrochir Plast Chir 34(4):239–244. doi:10.1055/s-2002-36290CrossRefPubMedGoogle Scholar
  12. 172.
    Gong ZJ, Wang K, Tan HY, Zhang S, He ZJ, Wu HJ (2015) Application of thinned anterolateral thigh flap for the reconstruction of head and neck defects. J Oral Maxillofac Surg 73(7):1410–1419. doi:10.1016/j.joms.2015.01.006CrossRefPubMedGoogle Scholar
  13. 208.
    Hauben DJ, Smith AR, Sonneveld GJ, Van der Meulen JC (1983) The use of the vastus lateralis musculocutaneous flap for the repair of trochanteric pressure sores. Ann Plast Surg 10(5):359–363CrossRefGoogle Scholar
  14. 277.
    Kimata Y, Uchiyama K, Ebihara S, Nakatsuka T, Harii K (1998) Anatomic variations and technical problems of the anterolateral thigh flap: a report of 74 cases. Plast Reconstr Surg 102(5):1517–1523CrossRefGoogle Scholar
  15. 278.
    Kimata Y, Uchiyama K, Ebihara S, Sakuraba M, Iida H, Nakatsuka T, Harii K (2000) Anterolateral thigh flap donor-site complications and morbidity. Plast Reconstr Surg 106(3):584–589CrossRefGoogle Scholar
  16. 281.
    Kimura N, Satoh K (1996) Consideration of a thin flap as an entity and clinical applications of the thin anterolateral thigh flap. Plast Reconstr Surg 97(5):985–992CrossRefGoogle Scholar
  17. 288.
    Koshima I, Fukuda H, Utunomiya R, Soeda S (1989) The anterolateral thigh flap; variations in its vascular pedicle. Br J Plast Surg 42(3):260–262CrossRefGoogle Scholar
  18. 290.
    Koshima I, Inagawa K, Urushibara K, Moriguchi T (1998) Paraumbilical perforator flap without deep inferior epigastric vessels. Plast Reconstr Surg 102(4):1052–1057CrossRefGoogle Scholar
  19. 299.
    Koshima I, Yamamoto H, Hosoda M, Moriguchi T, Orita Y, Nagayama H (1993) Free combined composite flaps using the lateral circumflex femoral system for repair of massive defects of the head and neck regions: an introduction to the chimeric flap principle. Plast Reconstr Surg 92(3):411–420CrossRefGoogle Scholar
  20. 308.
    Kuo YR, Seng-Feng J, Kuo FM, Liu YT, Lai PW (2002) Versatility of the free anterolateral thigh flap for reconstruction of soft-tissue defects: review of 140 cases. Ann Plast Surg 48(2):161–166CrossRefGoogle Scholar
  21. 314.
    Lee YC, Chen WC, Chou TM, Shieh SJ (2015) Anatomical variability of the anterolateral thigh flap perforators: vascular anatomy and its clinical implications. Plast Reconstr Surg 135(4):1097–1107. doi:10.1097/PRS.0000000000001103CrossRefPubMedGoogle Scholar
  22. 316.
    Lethaus B, Loberg C, Kloss-Brandstätter A, Bartella AK, Steiner T, Modabber A, Hölzle F, Teichmann J (2017) Color duplex ultrasonography versus handheld Doppler to plan anterior lateral thigh flaps. Microsurgery. doi:10.1002/micr.30177. [Epub ahead of print]CrossRefGoogle Scholar
  23. 318.
    Lichte J, Teichmann J, Loberg C, Kloss-Brandstätter A, Bartella A, Steiner T, Modabber A, Hölzle F, Lethaus B (2016) Routine preoperative colour Doppler duplex ultrasound scanning in anterolateral thigh flaps. Br J Oral Maxillofac Surg 54(8):909–913. doi:10.1016/j.bjoms.2016.06.008. [Epub 2016 Jun 25]CrossRefPubMedGoogle Scholar
  24. 346.
    Mathes SJ, Nahai F (1979) Clinical atlas of muscle and musculocutaneous flaps. C. V. Mosby, St. LouisGoogle Scholar
  25. 347.
    Mathes SJ, Nahai F (1981) Classification of the vascular anatomy of muscles: experimental and clinical correlation. Plast Reconstr Surg 67(2):177–187CrossRefGoogle Scholar
  26. 371.
    Minami RT, Hentz VR, Vistnes LM (1977) Use of vastus lateralis muscle flap for repair of trochanteric pressure sores. Plast Reconstr Surg 60(3):364–368PubMedGoogle Scholar
  27. 393.
    Murakami R, Fujii T, Itoh T, Tsutsui K, Tanaka K, Lio Y, Yano H (1996) Versatility of the thin groin flap. Microsurgery 17(1):41–47. doi:10.1002/(SICI)1098-2752(1996)17:1<41::AID-MICR8>3.0.CO;2-Z [pii] 10.1002/(SICI)1098-2752(1996)17:1<41::AID-MICR8>3.0.CO;2-Z
  28. 420.
    Pribaz JJ, Orgill DP, Epstein MD, Sampson CE, Hergrueter CA (1995) Anterolateral thigh free flap. Ann Plast Surg 34(6):585–592CrossRefGoogle Scholar
  29. 433.
    Ribuffo D, Cigna E, Gargano F, Spalvieri C, Scuderi N (2005) The innervated anterolateral thigh flap: anatomical study and clinical implications. Plast Reconstr Surg 115(2):464–470. doi:00006534-200502000-00014 [pii]Google Scholar
  30. 444.
    Rojviroj S, Mahaisavariya B, Sirichativapee W, Suibnugarn C (1989) Vastus lateralis myocutaneous flap: the treatment for trochanteric pressure sores in paraplegic patient. J Med Assoc Thail 72(11):629–632Google Scholar
  31. 445.
    Romanes GJ (1981) Cunningham’s textbook of anatomy, 12th edn. Oxford University Press, Oxford/New York/TorontoGoogle Scholar
  32. 447.
    Ross GL, Dunn R, Kirkpatrick J, Koshy CE, Alkureishi LW, Bennett N, Soutar DS, Camilleri IG (2003) To thin or not to thin: the use of the anterolateral thigh flap in the reconstruction of intraoral defects. Br J Plast Surg 56(4):409–413. doi:S0007122603001267 [pii]Google Scholar
  33. 497.
    Shieh SJ, Chiu HY, Yu JC, Pan SC, Tsai ST, Shen CL (2000) Free anterolateral thigh flap for reconstruction of head and neck defects following cancer ablation. Plast Reconstr Surg 105(7):2349–2357; discussion 2358–2360Google Scholar
  34. 509.
    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(2):149–159CrossRefGoogle Scholar
  35. 522.
    Swartz WM, Ramasastry SS, McGill JR, Noonan JD (1987) Distally based vastus lateralis muscle flap for coverage of wounds about the knee. Plast Reconstr Surg 80(2):255–265CrossRefGoogle Scholar
  36. 573.
    von Lanz T, Wachsmuth W (1972) Teil 4: Bein und Statik. Praktische Anatomie Bd. 1, 2nd edn. Springer, Berlin/Heidelberg/New YorkGoogle Scholar
  37. 584.
    Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin CH (2002) Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps. Plast Reconstr Surg 109(7):2219–2226; discussion 2227–2230Google Scholar
  38. 588.
    Williams LP, Warwick R (1980) Grey’s anatomy, 36th edn. Churchill Livingston, Edinburgh/London/Melbourne/New YorkGoogle Scholar
  39. 591.
    Wolff KD (1998) Indications for the vastus lateralis flap in oral and maxillofacial surgery. Br J Oral Maxillofac Surg 36(5):358–364CrossRefGoogle Scholar
  40. 595.
    Wolff KD, Dienemann D, Hoffmeister B (1995) Intraoral defect coverage with muscle flaps. J Oral Maxillofac Surg 53(6):680–685; discussion 686. doi:0278-2391(95)90170-1 [pii]Google Scholar
  41. 598.
    Wolff KD, Grundmann A (1992) The free vastus lateralis flap: an anatomic study with case reports. Plast Reconstr Surg 89(3):469–475; discussion 476–467Google Scholar
  42. 602.
    Wolff KD, Howaldt HP (1995) Three years of experience with the free vastus lateralis flap: an analysis of 30 consecutive reconstructions in maxillofacial surgery. Ann Plast Surg 34(1):35–42CrossRefGoogle Scholar
  43. 605.
    Wolff KD, Metelmann HR (1992) Applications of the lateral vastus muscle flap. Int J Oral Maxillofac Surg 21(4):215–218CrossRefGoogle Scholar
  44. 606.
    Wolff KD, Plath T, Frege J, Hoffmeister B (2000) Primary thinning and de-epithelialization of microsurgical transplants from the lateral thigh. Mund Kiefer Gesichtschir 4(2):88–94. doi:10.1007/s100060050176CrossRefPubMedGoogle Scholar
  45. 616.
    Xu Z, Zhao XP, Yan TL, Wang M, Wang L, Wu HJ, Shang ZJ (2015) A 10-year retrospective study of free anterolateral thigh flap application in 872 head and neck tumour cases. Int J Oral Maxillofac Surg 44(9):1088–1094. doi:10.1016/j.ijom.2015.06.013CrossRefPubMedGoogle Scholar
  46. 620.
    Yang JY, Tsai FC, Chana JS, Chuang SS, Chang SY, Huang WC (2002) Use of free thin anterolateral thigh flaps combined with cervicoplasty for reconstruction of postburn anterior cervical contractures. Plast Reconstr Surg 110(1):39–46CrossRefGoogle Scholar
  47. 635.
    Zhou G, Qiao Q, Chen GY, Ling YC, Swift R (1991) Clinical experience and surgical anatomy of 32 free anterolateral thigh flap transplantations. Br J Plast Surg 44(2):91–96CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG 2018

Authors and Affiliations

  • Klaus-Dietrich Wolff
    • 1
  • Frank Hölzle
    • 2
  1. 1.Department of Oral and Maxillofacial SurgeryKlinikum rechts der Isar, Technische Universität MunichMunichGermany
  2. 2.Department of Oral and Maxillofacial SurgeryUniversity Hospital of RWTH Aachen UniversityAachenGermany

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