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

Christopher M. Schneider; Patrick A. Palines; Daniel J. Womac; Charles T. Tuggle; Hugo St Hilaire; Mark W. Stalder

doi:10.1055/s-0041-1740122

Journal of Reconstructive Microsurgery, Table of Contents

J Reconstr Microsurg 2022; 38(06): 491-498
DOI: 10.1055/s-0041-1740122

Original Article

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

Christopher M. Schneider

¹Division of Plastic and Reconstructive Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana

,

Patrick A. Palines

¹Division of Plastic and Reconstructive Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana

,

Daniel J. Womac

¹Division of Plastic and Reconstructive Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana

²Department of Plastic and Reconstructive Surgery, University Medical Center, LCMC Health, New Orleans, Louisiana

,

Charles T. Tuggle

¹Division of Plastic and Reconstructive Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana

²Department of Plastic and Reconstructive Surgery, University Medical Center, LCMC Health, New Orleans, Louisiana

,

Hugo St Hilaire

¹Division of Plastic and Reconstructive Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana

²Department of Plastic and Reconstructive Surgery, University Medical Center, LCMC Health, New Orleans, Louisiana

,

Mark W. Stalder

¹Division of Plastic and Reconstructive Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana

²Department of Plastic and Reconstructive Surgery, University Medical Center, LCMC Health, New Orleans, Louisiana

› Author Affiliations

Abstract

Background Computed tomography angiography (CTA) has been widely used for perforator mapping in abdominal-based reconstruction, but it is less widespread in the anterolateral thigh (ALT) flap. However, CTA may be quite useful for ALT planning, as this flap has demonstrated substantial variability in intrapatient bilateral vascular anatomy. This study investigated whether standard use of preoperative CTA resulted in selection of the donor extremity with preferential perforator anatomy, and whether this affected operative time and postoperative outcomes.

Methods A retrospective review of 105 patients who underwent proposed ALT flap reconstruction was performed. Seventy-nine patients received bilateral lower extremity CTAs, which were evaluated for dominant perforator anatomy (septocutaneous, musculoseptocutaneous, or musculocutaneous). Donor extremity selection was noted, and predicted perforator anatomy was compared with that encountered intraoperatively.

Results Among the 73 patients who received bilateral imaging and ultimately received an ALT, congruent findings between imaging and surgical exploration were observed in 51 (69.8%) patients. Thirty (37.9%) patients had asymmetric perforator anatomy between their bilateral extremities on imaging. Among these, the leg with optimal perforator anatomy was selected in 70% of cases. There were no significant reductions among postoperative complication rates, but selection of the donor site with preferential anatomy was associated with a decrease in operative time (p = 0.049) among patients undergoing extremity reconstruction.

Conclusion CTA is a useful tool for optimizing donor site selection for ALT flaps and reducing operative time. We believe that standard use of preoperative CTA in ALTs warrants further consideration.

Keywords

CTA - ALT flap - perforators

Full Text

References

References
1 Song R, Gao Y, Song Y, Yu Y, Song Y. The forearm flap. Clin Plast Surg 1982; 9 (01) 21-26
2 Koshima I, Fukuda H, Yamamoto H, Moriguchi T, Soeda S, Ohta S. Free anterolateral thigh flaps for reconstruction of head and neck defects. Plast Reconstr Surg 1993; 92 (03) 421-428 , discussion 429–430
3 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
4 Zhang Q, Qiao Q, Yang X, Wang H, Robb GL, Zhou G. Clinical application of the anterolateral thigh flap for soft tissue reconstruction. J Reconstr Microsurg 2010; 26 (02) 87-94
5 Shen Y, Huang J, Dong MJ, Li J, Ye WM, Sun J. Application of computed tomography angiography mapping and located template for accurate location of perforator in head and neck reconstruction with anterolateral thigh perforator flap. Plast Reconstr Surg 2016; 137 (06) 1875-1885
6 De Beule T, Van Deun W, Vranckx J, de Dobbelaere B, Maleux G, Heye S. Anatomical variations and pre-operative imaging technique concerning the anterolateral thigh flap: guiding the surgeon. Br J Radiol 2016; 89 (1063): 20150920
7 Artero GE, Ulla M, Neligan PC, Angrigiani CH. Bilateral anatomic variation of anterolateral thigh flap in the same individual. Plast Reconstr Surg Glob Open 2018; 6 (05) e1677
8 Lu D, Chan P, Ferris S, Shayan R, Angliss M, Bruscino-Raiola F. Anatomic symmetry of anterolateral thigh flap perforators: a computed tomography angiographic study. ANZ J Surg 2019; 89 (05) 584-588
9 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
10 Kim EK, Kang BS, Hong JP. The distribution of the perforators in the anterolateral thigh and the utility of multidetector row computed tomography angiography in preoperative planning. Ann Plast Surg 2010; 65 (02) 155-160
11 Zhou H, Tan Q, Liu S. et al. Improved location technology of perforators of anterolateral thigh flap for Chinese patients. J Reconstr Microsurg 2013; 29 (05) 317-324
12 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
13 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
14 Smit JM, Klein S, Werker PM. An overview of methods for vascular mapping in the planning of free flaps. J Plast Reconstr Aesthet Surg 2010; 63 (09) e674-e682
15 Ribuffo D, Atzeni M, Saba L, Milia A, Guerra M, Mallarini G. Angio computed tomography preoperative evaluation for anterolateral thigh flap harvesting. Ann Plast Surg 2009; 62 (04) 368-371
16 Rozen WM, Ashton MW, Stella DL. et al. Developments in perforator imaging for the anterolateral thigh flap: CT angiography and CT-guided stereotaxy. Microsurgery 2008; 28 (04) 227-232
17 Chen SY, Lin WC, Deng SC. et al. Assessment of the perforators of anterolateral thigh flaps using 64-section multidetector computed tomographic angiography in head and neck cancer reconstruction. Eur J Surg Oncol 2010; 36 (10) 1004-1011
18 Seth R, Manz RM, Dahan IJ. et al. Comprehensive analysis of the anterolateral thigh flap vascular anatomy. Arch Facial Plast Surg 2011; 13 (05) 347-354
19 Yang JF, Wang BY, Zhao ZH, Zhou P, Pang F, Sun WD. Clinical applications of preoperative perforator planning using CT angiography in the anterolateral thigh perforator flap transplantation. Clin Radiol 2013; 68 (06) 568-573
20 Garvey PB, Selber JC, Madewell JE, Bidaut L, Feng L, Yu P. A prospective study of preoperative computed tomographic angiography for head and neck reconstruction with anterolateral thigh flaps. Plast Reconstr Surg 2011; 127 (04) 1505-1514
21 Lin SJ, Rabie A, Yu P. Designing the anterolateral thigh flap without preoperative Doppler or imaging. J Reconstr Microsurg 2010; 26 (01) 67-72
22 Cohen OD, Abdou SA, Nolan IT, Saadeh PB. Perforator variability of the anterolateral thigh flap identified on computed tomographic angiography: anatomic and clinical implications. J Reconstr Microsurg 2020; 36 (08) 616-624
23 Ulas Bali Z, Keçeci Y, Pabuşcu Y, Yoleri L. Anterolateral thigh flap design by using suprafascial course of the perforator. Ann Plast Surg 2020; 84 (05) 550-553
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
25 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
26 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
27 Ross GL, Dunn R, Kirkpatrick J. et al. To thin or not to thin: the use of the anterolateral thigh flap in the reconstruction of intraoral defects. Br J Plast Surg 2003; 56 (04) 409-413
28 Kimura N, Satoh K. Consideration of a thin flap as an entity and clinical applications of the thin anterolateral thigh flap. Plast Reconstr Surg 1996; 97 (05) 985-992
29 Alkureishi LW, Shaw-Dunn J, Ross GL. Effects of thinning the anterolateral thigh flap on the blood supply to the skin. Br J Plast Surg 2003; 56 (04) 401-408
30 Haddock NT, Dumestre DO, Teotia SS. Efficiency in DIEP flap breast reconstruction: the real benefit of computed tomographic angiography imaging. Plast Reconstr Surg 2020; 146 (04) 719-723
31 Wang Z, Yi X, He J. et al. Catheter-based computed tomography angiography in anterolateral thigh perforator mapping of Chinese patients. J Reconstr Microsurg 2019; 35 (03) 221-228
32 Bhattacharya V, Agrawal NK, Chaudhary GR, Arvind S, Bhattacharya S. CT angiographic evaluation of perforators in the lower limb and their reconstructive implication. Indian J Plast Surg 2012; 45 (03) 494-497
33 Singh J, Daftary A. Iodinated contrast media and their adverse reactions. J Nucl Med Technol 2008; 36 (02) 69-74 , quiz 76–77
34 Rao QA, Newhouse JH. Risk of nephropathy after intravenous administration of contrast material: a critical literature analysis. Radiology 2006; 239 (02) 392-397
35 Hall EJ, Brenner DJ. Cancer risks from diagnostic radiology: the impact of new epidemiological data. Br J Radiol 2012; 85 (1020): e1316-e1317
36 Rozen WM, Ashton MW, Whitaker IS, Wagstaff MJ, Acosta R. The financial implications of computed tomographic angiography in DIEP flap surgery: a cost analysis. Microsurgery 2009; 29 (02) 168-169