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

2018 ◽  
Vol 35 (04) ◽  
pp. 254-262
Author(s):  
Max Stewart ◽  
Cecilia Brassett ◽  
Ahid Abood
Keyword(s):  
Motor Nerve ◽  
Vastus Lateralis ◽  
Perforator Flap ◽  
Anterolateral Thigh Flap ◽  
Neural Structure ◽  
Anterolateral Thigh ◽  
Reconstructive Microsurgery ◽  
Clinically Significant ◽  
A Site ◽  
Neurovascular Anatomy

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.

Vastus Lateralis Motor Nerve Can Adversely Affect Anterolateral Thigh Flap Harvest

2007 ◽  
Vol 120 (1) ◽  
pp. 196-201 ◽  
Author(s):  
William J. Casey ◽  
Alanna M. Rebecca ◽  
Anthony A. Smith ◽  
Randall O. Craft ◽  
Richard E. Hayden ◽  
...  
Keyword(s):  
Motor Nerve ◽  
Vastus Lateralis ◽  
Anterolateral Thigh Flap ◽  
Anterolateral Thigh

scholarly journals Revisited Anterolateral Thigh Free Flaps For Reconstructive Microsurgery : One Year Evaluation

1970 ◽  
Vol 1 (2) ◽  
Author(s):  
Parintosa Atmodiwirjo ◽  
Siti Handayani ◽  
Shelly Madona Djaprie
Keyword(s):  
Soft Tissue ◽  
Free Flaps ◽  
Soft Tissue Defect ◽  
Anterolateral Thigh Flap ◽  
Soft Tissue Defects ◽  
Anterolateral Thigh ◽  
Wide Range ◽  
Reconstructive Microsurgery ◽  
One Year ◽  
Tissue Defects

Extensive soft tissue defects present a dif!cult problem to the plastic surgeon as they are usually associated with exposed important structures such as vessels, nerves, tendons, joint cavity or bone. Reconstruction of soft tissue defects have a wide range of therapeutic options. We reconstructed soft tissue defect in many areas using free anterolateral thigh flap (ALTF). From Februari 2009 - 2010, 9 cases of soft tissue defects in the face, neck, leg and foot of various etiologic factors were admitted to the plastic and reconstructive surgery unit, Cipto Mangunkusumo general hospital. Trauma is the commonest cause of soft tissue defects of the lower extremity, followed by tumours. The cruris was the commonest site (4 cases, 44,4%). Flap success rate was 66,67 %. Failure was reported 1 cases in this study due to vein compromise. In our hospital, we are quite familiar with Anterolateral thigh flap (ALTF) even though the case is limited. Anterolateral thigh flap (ALTF) is used for reconstruction of various simple and complex soft tissue defects, for big and small defects with cavity (orbita).

scholarly journals Secondary reconstruction of below knee amputation stump with free anterolateral thigh flap

2010 ◽  
Vol 43 (01) ◽  
pp. 108-110
Author(s):  
Dinesh Kadam
Keyword(s):  
Soft Tissue ◽  
Vastus Lateralis ◽  
Pressure Effects ◽  
Tissue Loss ◽  
Anterolateral Thigh Flap ◽  
Vastus Lateralis Muscle ◽  
Knee Amputation ◽  
Amputation Stump ◽  
Anterolateral Thigh ◽  
Soft Tissue Loss

ABSTRACTBelow knee stump preservation reduces ambulatory energy expenditure and improves the quality of life. Reconstruction of soft tissue loss around the stump is a challenging task. Below knee stump reconstruction demands stable skin with sufficient soft tissue to allow weigh bearing. Microsurgical tissue transfer is increasingly being used as a salvage option. Anterolateral thigh flap with additional vastus lateralis muscle provides extra cushioning effect. We report two cases of amputation below knee successfully salvaged. The anterolteral flap with abundant tissue and stable skin offers a reliable option for cover. Two patients with below knee amputation were reconstructed secondarily. After 6 to 20 months of follow -up, stumps showed no signs of pressure effects. Patients are able to bear 50-70 hours of weight per week.

scholarly journals A neglected problem in the utilization of free anterolateral thigh flap toward reconstructing complicated wounds of extremities: the obliteration of deep dead space

2020 ◽  
Vol 15 (1) ◽  
Author(s):  
Gao-hong Ren ◽  
Da-yong Xiang ◽  
Xiao-hu Wu ◽  
Yun-biao Chen ◽  
Runguang Li
Keyword(s):  
Clinical Application ◽  
Dead Space ◽  
Skin Flap ◽  
Perforator Flap ◽  
Muscle Flap ◽  
Sinus Tract ◽  
Thigh Muscle ◽  
Anterolateral Thigh Flap ◽  
Anterolateral Thigh ◽  
Complex Wounds

Abstract Background Deep dead space may be thought as an independent risk factor of the poor infection control after flap reconstruction in complex limb wounds. But it can be easily neglected. The conventional skin flap and musculocutaneous flap are difficult to obliterate the deep dead space in irregular shape effectively. It was investigated that the clinical application of chimeric anterolateral thigh perforator flap in the treatment of complex wounds complicated with deep dead space of the extremities in the paper. Methods Fifty-six cases complicated with deep dead space wounds were registered in group. Following thorough debridement and treatment with VSD, the granulation tissues grew with well-controlled infection. And then the chimeric anterolateral thigh perforator flap was used to obliterate the deep dead space and repair the wounds. The postoperative flap survival and infection conditions were evaluated. Results Overall, the infection was effectively controlled, without persistent exudation or sinus tract formation after wound healing. While 5 cases lost to follow-up, the remaining 51 cases were followed up until 15 months on average. Generally, the affected extremities recovered satisfactorily with normal appearances and texture of the flaps, along with normal functions. Importantly, no recurrence of infection was observed. Conclusion During the grafting of chimeric perforator flap pedicled with lateral thigh muscle flap, the muscle flap is recommended to obliterate the deep dead space while the skin flap is being used to cover the wound. The combination of these two technologies performed well in the repair and reconstruction of the complex wounds of the extremities, possessing potential for broader clinical application.

Challenges of Setting up a Lower Extremity Reconstruction Practice in a Constrained Environment

2020 ◽  
Author(s):  
Asli Datli ◽  
Ismail Karasoy ◽  
Yucel Genc ◽  
Ozgur Pilanci
Keyword(s):  
Lower Extremity ◽  
Administrative Support ◽  
Tertiary Care ◽  
Perforator Flap ◽  
Operation Time ◽  
Anterolateral Thigh Flap ◽  
Anterolateral Thigh ◽  
Lower Extremity Reconstruction ◽  
Extremity Reconstruction ◽  
Set Up

Abstract Background Microsurgical lower extremity reconstruction remains challenging, especially when resources are limited such as lack of proper equipment, human resources, administrative support, and located in a remote area far from tertiary care. Nevertheless, reconstructive solutions are required, especially when in urgent trauma situations. In this article, we evaluate ways of overcoming challenges and issues that should be considered in a newly established unit by sharing our initial lower extremity reconstruction experience. Methods We report a local hospital's initial lower extremity reconstruction experience in February 2017 to January 2018. Through a total of seven patients, we tried to enhance the environment, instruments, nurses' contribution, and perspective of the peers and community in terms of factors related to the surgeon, hardware, environment, supporting faculty, reimbursement, and patients. Results Four patients underwent reconstruction with a freestyle propeller flap and three with an anterolateral thigh flap; in one case, a superficial circumflex iliac artery perforator flap was chosen to salvage partial flap necrosis. Increased experience of the surgeon, new equipment, continuing nurse/patient education, and collaborating with other departments allowed us to choose more challenging flaps and be more meticulous while decreasing the operation time and hospital stay. Conclusion To start a lower extremity reconstruction practice in a resource-poor environment, the surgeon needs to evaluate the relevant factors; moreover, he or she should continuously improve them until a working methodology is achieved. Despite all the challenges, the adaptations learned at this center can be applied to other local hospitals around the world to set up a lower extremity reconstruction practice and improve its outcomes.

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