Free anteromedial thigh perforator flap: Complementing and completing the anterolateral thigh flap

Vascular Anatomy of the Anteromedial Thigh Flap: A Systematic Review

While the anterolateral thigh (ALT) flap is the most commonly employed thigh-based flap for microvascular reconstruction, its counterpart, the anteromedial thigh (AMT) flap, is a useful but underdescribed alternative when ALT perforators are absent or lacking. This review aims to assess the existing literature describing the anatomy and vascular territories supplying the AMT flap.

METHODS

A systematic review was performed in accordance with PRISMA guidelines. Ovid MEDLINE, Embase, and Web of Science were queried for records pertaining to the study question using Medical Subject Heading terms such as "anteromedial thigh flap" and "free tissue transfer." Study characteristics and anatomic descriptors (including number and type of perforators, origin, and pedicle course supplying the AMT flap) were collected.

RESULTS

A total of 21 studies representing 723 AMT flaps were identified and included for analysis. Dominant perforators supplying the AMT flap most commonly included the descending lateral circumflex femoral artery (dLCFA; 35%) or the medial branch of the dLCFA (mdLCFA; 33.6%). Average pedicle length ranged from 7.5 to 10.6cm. The majority of AMT perforators were septocutaneous (n = 852, 63.8%) compared with musculocutaneous (n = 483, 36.2%). Perforators to the AMT were absent in 7.6 to 9.1% of clinical cases.

CONCLUSIONS

The variable vascular anatomy of the AMT flap has prevented its widespread adoption in reconstruction. As knowledge regarding pertinent perforator anatomy of the AMT flap increases, so may its utility as an alternative to the ALT flap. This review summarizes the spectrum of anatomy of the AMT vasculature described in the literature to date.

Chimeric ALT Plus TFL Perforator Flap for Breast Reconstruction Post Radical Mastectomy with Large Skin Defect

A 17-year-old girl with large malignant phyllodes tumor of left breast underwent a radical mastectomy with large skin excision resulting in defect of 20 cm × 18 cm. Postoperative radiation therapy necessitated robust cover with flap. The challenge was compounded by her body habitus. Both abdomen and back were deficient as donor sites and a single-island anterolateral thigh (ALT) flap would need skin grafts, volume deficit withstanding. We harvested chimeric ALT plus tensor fascia lata (TFL) perforator free flap sparing all muscles and nerves. Microvascular anastomoses were done to the second internal mammary artery (IMA) perforator artery and vein. The donor site was closed primarily. The TFL flap territory recruited almost three times the volume of ALT territory and allowed us to create a matching breast mound in addition to covering the defect. She tolerated 40 Gy radiation well and doesn’t desire further augmentation. Consistency of ALT and TFL perforators makes this a replicable procedure.

Comparison of the outcomes between free anteromedial thigh flap and anterolateral thigh flap in head and neck cancer reconstruction: Analysis of propensity-score-matched patient cohorts

BACKGROUND

The anterolateral thigh (ALT) flap is a workhorse flap in head and neck cancer reconstruction. The anteromedial thigh (AMT) flap was developed as a rescue or alternative flap whenever the ALT flap is not available; however, the harvest of AMT flap seems to be more challenging in the sense that perforators have multiple variations. This study was designed to compare the outcome of the AMT and ALT flaps in head and neck cancer reconstruction.

METHODS

A total of 1,547 ALT and 57 AMT flaps were used for head and neck cancer reconstruction between March 1, 2008 and February 28, 2017. Differences in patient and operative characteristics were compared between the patients undergoing AMT and ALT flap reconstruction. The primary outcome of the free flap was its survival or failure, while the second outcome was the associated complications.

RESULTS

Compared to those who had ALT flap reconstruction, the patients who underwent AMT flap reconstruction had a higher rate of conditions that required reconstruction after previous cancer ablation and recurrence but a lower rate of primary cancer and deeply located cancer. Analysis of the 40 well-balanced pairs of propensity-score-matched patient cohorts revealed that the AMT flaps were associated with a significantly higher failure rate than the ALT flaps (15.0 vs. 0.0%, respectively; p = .026).

CONCLUSION

This study revealed that AMT flaps were associated with a significantly higher failure rate than ALT flaps in head and neck cancer reconstruction in the cohort of total patients and the propensity-score-matched cohorts.

[Application of anteromedial thigh flap as a alternative flap in maxillofacial soft tissue defects]

Objective:To explore the application value of anteromedial thigh flap（AMT） as alternative flap in repairing maxillofacial soft tissue defects. Method:Sixty patients were scheduled to underwent anterolateral thigh flap（ALT） reconstruction. Preoperative CT angiography were conducted. Imaging workstations were used to locate perforator vessels in the anterolateral and anteromedial areas respectively. Four patients had no suitable perforator during the preparation of AMT flaps. In the same operation area, ALT flaps were prepared to reconstruct the defect according to the location of the perforator vessels in the anteromedial areas. Result:All four AMT flaps survived uneventfully. Flap sizes ranged from 9 cm×6 cm to 7 cm×4 cm. The follow-up period ranged from 6 to 12 months, the functions of recipient and donor sites recovered well. Conclusion:Preoperative CT angiography can improve the accuracy of the preparation of skin flap effectively. When no sizable perforator is available during harvest of the ALT flap, successful reconstruction can be achieved using the ipsilateral AMT flap.