AAPS, American Association of Plastic Surgeons
AAPS, American Association of Plastic Surgeons
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2008 Annual Meeting Abstracts

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Perforator Patterns of the Anterolateral Thigh (ALT) Flap: from a Single Surgeon’s Experience of 207 Free Flaps in the US
Peirong Yu, M.D., M.S..
University of Texas, M.D. Anderson Cancer Center, Houston, TX, USA.

PURPOSE: In my previous report of 69 ALT flaps, three cutaneous perforators, A, B, and C, were identified based on their predictable locations. The purpose of this study was to analyze and verify the perforator patterns in a larger patient population in the U.S.
METHODS: From 2001 to 2007, 219 thighs on 210 patients were explored and 207 ALT free flaps were performed by the author for oncologic reconstruction. The number, size, and locations of cutaneous perforators and their origins were recorded intraoperatively. Their clinical application and complications were reviewed.
RESULTS:
There were 153 male and 57 female patients with a mean age of 60±12 years (range: 10 to 91). Average body mass index (BMI) was 24.7±4.5 (range: 13.7 to 37.9). There were no perforators on nine thighs. The contralateral thighs were explored in these patients and the flap was successfully raised in 6 patients. Thus there were no perforators on either thigh in 3 patients (1.4%).The average length of the line connecting the anterior superior iliac spine (ASIS) and the superolateral corner of the patella, the AP line, was 46±3 cm. The locations of the cutaneous perforators followed a pattern. The perforator B was found to be most consistent and was present in 87% of the flaps. It was located near the midpoint of the AP line (point 0.51) or 23.5±2.0 cm below the ASIS and 1.4±0.7 cm lateral to the AP line. Perforator A was present in 53% of the flaps and located at point 0.4 or 18.4±2.2 cm below the ASIS and 1.4±0.6 cm lateral to the AP line. Perforator C was present in 59% of the flaps and located at point 0.62 or 28.6±2.3 cm below the ASIS and 1.5±0.6 cm lateral to the AP line. Only 46% of perforator A, 19% of perforator B, and 12% of perforator C were septocutaneous perforators. Twenty-six percent of flaps had a single perforator, 49% had two perforators, and 25% had three perforators. A branch of the motor nerve innervating the vastus lateralis muscle needed to be divided to free the perforators in 24% of flaps. The nerve was repaired in each case. Preoperative hand-held Doppler examination of perforators was performed in the first 120 flaps and was found to have a low specificity. The accuracy of Doppler examination decreased with increasing BMI. The remaining flaps were raised based on the ABC perforator patterns only without Doppler examination. Average flap width was 8.5 cm and the donor site was closed primary in 86% of thighs. Complications included seroma (10%), hematoma (3%), and wound dehiscence (1%). Clinical applications included: pharyngoesophageal (37%), craniofacial (22%), tongue (19%), posterior mandible (10%), double free flap with a fibula (7%), trachea (0.5%), other head and neck soft tissue defects (3%), and trunk (1.5%).
CONCLUSION: The ABC perforator patterns of the ALT flap were verified. The flap can be raised successfully based on this pattern without Doppler examination. The donor site can be closed primarily in most patients and donor site complications are minor.


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