Download PDF
J Reconstr Microsurg 2019; 35(04): 254-262
DOI: 10.1055/s-0038-1670649
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Neurovascular Anatomy at the “Box Junction”: Considerations in the Anterolateral Thigh Flap

Max Stewart
1   University of Cambridge, Cambridge, United Kingdom
,
Cecilia Brassett
2   Human Anatomy Teaching Group, Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, United Kingdom
,
Ahid Abood
3   Department of Plastic and Reconstructive Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
› Author Affiliations
Further Information

Publication History

05 June 2018

09 August 2018

Publication Date:
15 September 2018 (online)

    Permissions and Reprints

Abstract

Background The anterolateral thigh (ALT) perforator flap is one of the most widely used flaps in reconstructive microsurgery. This study investigated a previously unexplored and clinically relevant aspect of perforator anatomy: the “box junction” (BxJn), the point at which the perforator arises from its source vessel. Negotiating the BxJn can be a challenging and time-consuming step in flap harvest, due to the neurovascular structures in the area which must be protected from injury. However, as the presence and location of these structures have yet to be clearly defined, painstaking exploration is necessary on each occasion. Knowledge of BxJn anatomy could allow surgeons to harvest the ALT flap more rapidly and safely.

Methods We dissected 20 cadaveric thighs and identified perforators to the ALT region and investigated the neurovascular anatomy at their BxJns.

Results In 51 BxJns, two clinically relevant vascular structures were identified: an intramuscular artery arising from the perforator (23, 45% of cases) and a “deep” artery to the underlying muscle arising from the source vessel (29, 57% of cases). We confirmed the consistent presence of motor nerve branches and describe one previously unreported, clinically significant variation, in which the nerve to vastus lateralis crosses the BxJn (12, 24% of cases); 36, 71% of BxJns contained at least one vascular and one neural structure.

Conclusion Our study confirms that the BxJn is a site of potentially complex and challenging neurovascular anatomy for the surgeon. Based on these results, we propose an algorithm to guide inexperienced surgeons in negotiating this area.

Keywords

anterolateral thigh flap - anatomy - approach - safety - vasculature
 

  • References

  • 1 Song YG, Chen GZ, Song YL. The free thigh flap: a new free flap concept based on the septocutaneous artery. Br J Plast Surg 1984; 37 (02) 149-159
    CrossrefPubMedGoogle Scholar
  • 2 Wong CH, Wei FC. Anterolateral thigh flap. Head Neck 2009; 32 (04) 529-540
    PubMedGoogle Scholar
  • 3 Ali RS, Bluebond-Langner R, Rodriguez ED, Cheng MH. The versatility of the anterolateral thigh flap. Plast Reconstr Surg 2009; 124 (6, Suppl): e395-e407
    CrossrefPubMedGoogle Scholar
  • 4 Blondeel PN, Morris SF, Hallcock GG, Neligan PC. Perforator Flaps: Anatomy, Technique, & Clinical Applications, 2nd ed. St Louis: Quality Medical Publishing; 2013
    Google Scholar
  • 5 Agostini T, Lazzeri D, Spinelli G. Anterolateral thigh flap: systematic literature review of specific donor-site complications and their management. J Craniomaxillofac Surg 2013; 41 (01) 15-21
    CrossrefPubMedGoogle Scholar
  • 6 Collins J, Ayeni O, Thoma A. A systematic review of anterolateral thigh flap donor site morbidity. Can J Plast Surg 2012; 20 (01) 17-23
    CrossrefPubMedGoogle Scholar
  • 7 Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin CH. Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps. Plast Reconstr Surg 2002; 109 (07) 2219-2226 , discussion 2227–2230
    CrossrefPubMedGoogle Scholar
  • 8 Chen H, Zhou N, Huang X, Song S. Comparison of morbidity after reconstruction of tongue defects with an anterolateral thigh cutaneous flap compared with a radial forearm free-flap: a meta-analysis. Br J Oral Maxillofac Surg 2016; 54 (10) 1095-1101
    CrossrefPubMedGoogle Scholar
  • 9 Kimata Y, Uchiyama K, Ebihara S. , et al. Versatility of the free anterolateral thigh flap for reconstruction of head and neck defects. Arch Otolaryngol Head Neck Surg 1997; 123 (12) 1325-1331
    CrossrefPubMedGoogle Scholar
  • 10 Lin DT, Coppit GL, Burkey BB. Use of the anterolateral thigh flap for reconstruction of the head and neck. Curr Opin Otolaryngol Head Neck Surg 2004; 12 (04) 300-304
    CrossrefPubMedGoogle Scholar
  • 11 Kaplan JL, Allen RJ, Guerra A, Sullivan SK. Anterolateral thigh flap for breast reconstruction: review of the literature and case reports. J Reconstr Microsurg 2003; 19 (02) 63-68
    Article in Thieme ConnectPubMedGoogle Scholar
  • 12 Zhang ZY, Feng SM, Zhou MM, Tao YL, Wang AG. Clinical application of anterolateral thigh perforator flap for the reconstruction of severe tibia exposure. Eur Rev Med Pharmacol Sci 2015; 19 (24) 4707-4714
    PubMedGoogle Scholar
  • 13 Shieh SJ, Chiu HY, Yu JC, Pan SC, Tsai ST, Shen CL. Free anterolateral thigh flap for reconstruction of head and neck defects following cancer ablation. Plast Reconstr Surg 2000; 105 (07) 2349-2357 , discussion 2358–2360
    CrossrefPubMedGoogle Scholar
  • 14 Saint-Cyr M, Oni G, Lee M, Yi C, Colohon SM. Simple approach to harvest of the anterolateral thigh flap. Plast Reconstr Surg 2012; 129 (01) 207-211
    CrossrefPubMedGoogle Scholar
  • 15 Yu P, Youssef A. Efficacy of the handheld Doppler in preoperative identification of the cutaneous perforators in the anterolateral thigh flap. Plast Reconstr Surg 2006; 118 (04) 928-933 , discussion 934–935
    CrossrefPubMedGoogle Scholar
  • 16 Lakhiani C, Lee MR, Saint-Cyr M. Vascular anatomy of the anterolateral thigh flap: a systematic review. Plast Reconstr Surg 2012; 130 (06) 1254-1268
    CrossrefPubMedGoogle Scholar
  • 17 Strauch B, Yu HL. Atlas of Microvascular Surgery, 2nd ed. New York: Thieme; 2006
    Google Scholar
  • 18 Celik N, Wei FC, Lin CH. , et al. 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 2002; 109 (07) 2211-2216 , discussion 2217–2218
    CrossrefPubMedGoogle Scholar
  • 19 Luo S, Raffoul W, Luo J. , et al. Anterolateral thigh flap: a review of 168 cases. Microsurgery 1999; 19 (05) 232-238
    CrossrefPubMedGoogle Scholar
  • 20 Deng C, Nie K, Wei Z. , et al. Is the oblique branch a preferable vascular pedicle for anterolateral thigh free flaps?. J Reconstr Microsurg 2018; 34 (07) 478-484
    Article in Thieme ConnectPubMedGoogle Scholar
  • 21 Wong CH, Wei FC, Fu B, Chen YA, Lin JY. Alternative vascular pedicle of the anterolateral thigh flap: the oblique branch of the lateral circumflex femoral artery. Plast Reconstr Surg 2009; 123 (02) 571-577
    CrossrefPubMedGoogle Scholar
  • 22 Rozen WM, le Roux CM, Ashton MW, Grinsell D. The unfavorable anatomy of vastus lateralis motor nerves: a cause of donor-site morbidity after anterolateral thigh flap harvest. Plast Reconstr Surg 2009; 123 (05) 1505-1509
    CrossrefPubMedGoogle Scholar
  • 23 Revenaugh PC, Knott D, McBride JM, Fritz MA. Motor nerve to the vastus lateralis. Arch Facial Plast Surg 2012; 14 (05) 365-368
    CrossrefPubMedGoogle Scholar
  • 24 Casey III WJ, Rebecca AM, Smith AA, Craft RO, Hayden RE, Buchel EW. Vastus lateralis motor nerve can adversely affect anterolateral thigh flap harvest. Plast Reconstr Surg 2007; 120 (01) 196-201
    CrossrefPubMedGoogle Scholar
  • 25 Lakhiani C, DeFazio MV, Han K, Falola R, Evans K. Donor-site morbidity following free tissue harvest from the thigh: a systematic review and pooled analysis of complications. J Reconstr Microsurg 2016; 32 (05) 342-357
    Article in Thieme ConnectPubMedGoogle Scholar
  • 26 Hanasono MM, Skoracki RJ, Yu P. A prospective study of donor-site morbidity after anterolateral thigh fasciocutaneous and myocutaneous free flap harvest in 220 patients. Plast Reconstr Surg 2010; 125 (01) 209-214
    CrossrefPubMedGoogle Scholar
  • 27 Yu P. Characteristics of the anterolateral thigh flap in a Western population and its application in head and neck reconstruction. Head Neck 2004; 26 (09) 759-769
    CrossrefPubMedGoogle Scholar
  • 28 Lim S, Atwi N, Long S, Toshav A, Lau FH. Variations in the anterolateral thigh flap's vascular anatomy in African Americans. J Reconstr Microsurg 2018; 34 (04) 300-306
    Article in Thieme ConnectPubMedGoogle Scholar
  • 29 Namgoong S, Yoon YD, Yoo KH, Han SK, Kim WK, Dhong ES. Alternative choices for anterolateral thigh flaps lacking suitable perforators: a systematic review. J Reconstr Microsurg 2018; 34 (07) 465-471
    Article in Thieme ConnectPubMedGoogle Scholar