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33 The Groin Flap: TheWorkhorse Flap forUpper Limb Reconstruction
323
• Sabapathy SR, Bajantri B. Indications, Selection and use
of distant pedicled aps in upper limb reconstryction.
Hand Clin 2014;30(2):185–199.
An article which provides all the important technical tips
to obtain good outcomes with the pedicled groin and
abdominal aps.
References
1. McGregor IA, Jackson IT.The groin ap. Br J Plast Surg. 1972
Jan;25(1):3–16.
2. Taylor GI, Daniel RK.The free ap: composite tissue transfer by
vascular anastomosis. Aust N Z J Surg. 1973 Jul;43(1):1–3.
3. Bajantri B, Latheef L, Sabapathy SR. Tips to orient pedicled
groin ap for hand defects. Tech Hand Up Extrem Surg. 2013
Jun;17(2):68–71.
4. Jokuszies A, Niederbichler AD, Hirsch N, Kahlmann D, Herold C,
Vogt PM. The pedicled groin ap for defect closure of the hand.
Oper Orthop Traumatol. 2010 Oct;22(4):440–51.
5. Cobb ARM, Koudstaal MJ, Bulstrode NW, Lloyd TW, Dunaway
DJ.Free groin ap in hemifacial volume reconstruction. Br J Oral
Maxillofac Surg. 2013 Jun;51(4):301–6.
6. Aydin T, Feyzi K, Tayfun T, Berna T. Reconstruction of wide
scrotal defect using groin fasciocutaneous island ap combined
with a strip of deep fascia. J Plast Reconstr Aesthet Surg. 2010
Aug;63(8):1394–5.
7. Zeltzer AA, Anzarut A, Braeckmans D, Seidenstuecker K,
Hendrickx B, Van Hedent E, et al. The vascularized groin lymph
node ap (VGLN): anatomical study and ap planning using multidetector CT scanner. The golden triangle for ap harvesting. J Surg
Oncol. 2017 Sep;116(3):378–83.
8. Hough M, Fenn C, Kay SP.The use of free groin aps in children.
Plast Reconstr Surg. 2004 Apr 1;113(4):1161–6.
9. Chuang DC, Jeng SF, Chen HT, Chen HC, Wei FC.Experience of
73 free groin aps. Br J Plast Surg. 1992 Mar;45(2):81–5.
10. Cormack GC, Lamberty BG. A classication of fascio-cutaneous
aps according to their patterns of vascularisation. Br J Plast Surg.
1984 Jan;37(1):80–7.
11. Sinna R, Hajji H, Qassemyar Q, Perignon D, Benhaim T, Havet
E. Anatomical background of the perforator ap based on the
deep branch of the supercial circumex iliac artery (SCIP ap): a
cadaveric study. Eplasty. 2010 Jan 18;10:e11.
12. Gentileschi S, Servillo M, De Bonis F, Albanese R, Pino V,
Mangialardi ML, etal. Radioanatomical study of the pedicle of the
supercial circumex iliac perforator ap. J Reconstr Microsurg.
2019 Nov;35(9):669–76.
13. Tashiro K, Harima M, Kato M, Yamamoto T, Yamashita S,
Narushima M, etal. Preoperative color Doppler ultrasound assessment in planning of SCIP aps. J Plast Reconstr Aesthet Surg. 2015
Jul;68(7):979–83.
14. Kimura N, Saitoh M, Hasumi T, Sumiya N, Itoh Y. Clinical
application and renement of the microdissected thin groin
ap transfer operation. J Plast Reconstr Aesthet Surg. 2009
Nov;62(11):1510–6.
15. Smith PJ, Foley B, McGregor IA, Jackson IT.The anatomical basis
of the groin ap. Plast Reconstr Surg. 1972 Jan;49(1):41–7.
16. Knutson GH. 7. The groin ap: a new technique to repair traumatic
tissue defects. Can Med Assoc J. 1977 Mar 19;116(6):623–5.
Superficial Circumflex Iliac Artery
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Perforator Flap: AThin andVersatile
Option forLimb andHead andNeck
Reconstruction
JuanEnriqueBerner, DariushNikkhah,
andTiewChongTeo
34.1 Introduction
The supercial circumex iliac artery perforator (SCIP) ap
was rst described by Koshima etal. in 2004 [1], as the evolution of the free groin ap popularised by McGregor and
Jackson [2]. The SCIP ap can be a thin reconstructive
option for most patients, by harvesting skin superior and lateral to the inguinal ligament.
The donor site can be easily closed primarily even when
large aps are designed, leaving a well concealed oblique
scar on the iliac fossa. Dissection of the ap and its pedicle
is relatively supercial, avoiding tedious raising in difcult
anatomical planes. The vascular anatomy of the SCIP ap
allows the raising of multiple skin paddles, lymph nodes [3]
and even small segments of iliac crest bone [4]. This versatility has been the reason for its recent popularity for lower
limb [5], hand [6] and head and neck reconstruction [7].
We have recently proposed a classication system for
SCIP aps based on the contents transferred [6]:
• Type 1: Standard SCIP ap.
• Type 2: Adipofascial SCIP ap.
• Type 3: SCIP ap with multiple skin paddles.
• Type 4: Osteocutaneous SCIP ap.
• Type 5: SCIP ap with vascularised lymph node transfer.
• Type 6: Neurotised SCIP ap.
Supplementary Information The online version contains supplementary
material available at [https://doi.org/10.1007/978- 3- 031- 07678- 7_34].
J. E. Berner (*)
Royal Victoria Inrmary, Newcastle upon Tyne, UK
D. Nikkhah
Royal Free Hospital, London, UK
e-mail: d.nikkhah@nhs.net
T. C. Teo
Queen Victoria Hospital, East Grinstead, UK
34
It has been criticised that its small calibre and short pedicle
limit the applications of this ap. However, adequate planning
and recipient vessel selection can facilitate its execution.
34.2 Anatomy
The supercial circumex iliac artery (SCIA) is a cutaneous
branch arising from the femoral artery close to the origin of
the supercial inferior epigastric artery. The SCIA supplies
skin, tegumentum and supercial lymph nodes in the groin
area. It follows a supero-lateral course branching into a supercial/medial and a deep/lateral branch [8]. The deep branch
runs in the deep fascia, providing muscular perforators to the
sartorius muscle, and the skin and iliac bone lateral to this
muscle. The supercial branch, instead, follows a superior
course crossing the level of the inguinal ligament. It pierces
the supercial fascia to then supply the skin superior and laterally heading towards the anterior superior iliac spine (ASIS).
The SCIP ap can be harvested based on perforators arising from the deep/lateral or supercial/medial branches, or
even both to obtain a chimeric ap [9]. However, if a single
skin paddle is needed, the supercial/medial perforator is
more amenable for dissection. This can be found in the great
majority of patients around a point 4.5cm lateral to the pubic
tubercle and 1.5cm superior to it [10].
The length of the pedicle of the SCIP ap will depend on
the design of its skin paddle. A more laterally placed ap will
therefore have a longer pedicle. The average length of the
SCIP pedicle is 6cm, but can be as long as 8cm, including
vessels of around 1mm calibre [6].
Compared to the traditional groin ap, the SCIP presents
multiple advantages. Its pedicle length can be adjusted as it
can be directly incised along its course. The SCIP is a thinner
ap, as it can be safely raised at the level of Scarpa’s fascia
until the pedicle is reached, compared to the groin ap which
has to include the deep fascia over sartorius. Furthermore,
due to its location inferior to the inguinal ligament, the groin
ap is more likely to include hair bearing skin.
© Springer Nature Switzerland AG 2023
D. Nikkhah et al. (eds.), Core Techniques in Flap Reconstructive Microsurgery, https://doi.org/10.1007/978-3-031-07678-7_34
325
326
ab
J. E. Berner et al.
34.3 Pre-Operative Investigation
In some centres, the use of computed tomography angiography (CTA) has been advocated to facilitate the planning of
the SCIP ap [11]. However, in our experience this is not
routinely required. With the patient lying supine in the operative table, the location of the supercial/medial SCIA perforator can be conrmed using a hand-held Doppler device.
More recently, Pereira etal. have proposed the use of augmented reality for planning SCIP aps. If a CTA has been
performed, smartphone-based technology can combine the
vascular anatomy with the supercial landmarks in order to
ease raising [12]
34.4 Flap Design andMarkings
Considering the dimensions of the defect, the SCIP skin
paddle can be designed as an ellipse, including the nonhair- bearing skin above the inguinal ligament (Fig. 34.1).
Fig. 34.1 Landmarks drawn before SCIP ap transfer. The ASIS is
marked and a line drawn to the pubic tubercle; this illustrates the inguinal ligament. 2cm below this is the SCIA emerging from the femoral
artery. The SCIP perforator is marked emerging superolaterally above
the inguinal ligament
We tend to orientate this ellipse parallel to the supero-lateral
course of the latter. This particular location allows harvesting a thin ap, while allowing a tensionless closure by
mobilising abdominal tissues. As we prefer to raise this ap
in an anterograde manner, we also mark an incision line
over the course of the SCIP pedicle [6]. This is not required
if the ap is raised retrogradely, in other words, from lateral
to medial.
34.5 Flap Raise/Elevation: AStep-by-Step
Guide
1. Incision over SCIP pedicle. An incision over the course of
the previously identied SCIP pedicle is performed using
a number 15 or 10 blade. We routinely prefer using perforators arising from the medial/supercial branch of the
SCIA.Sharp dissection is continued through the supercial ap until the pedicle is visualized (Fig.34.2a, b). We
prefer using the medial to lateral approach as demonstrated here.
2. Pedicle dissection. Using a combination of blunt, sharp
and bipolar dissection the SCIP pedicle is dissected along
its course. Debakey forces are used carefully handling the
vessels. The pedicle is traced to its origin on the SCIA
(Fig.34.3a, b).
3. Pedicle appraisal and ap design adjustment. Once the
pedicle has been exposed it can be appraised before committing to the raising of the skin paddle. If necessary its
design can be adjusted to obtain a longer pedicle
(Fig.34.4).
4. Skin ap raising and incorporation of extra supercial
vein. While protecting the previously dissected pedicle,
the margins of the ap can be incised using a cold
blade. Raising can be done either at the level of the
external oblique muscle fascia, or through Scarpa’s fascia using nger-switch diathermy [13] (Fig.34.5a). We
Fig. 34.2 (a) Landmarks of the SCIP ap before elevation. (b) Medial approach to SCIP ap, showing identication of the supercial perforator
ab
34 Supercial Circumex Iliac Artery Perforator Flap: AThin andVersatile Option forLimb andHead andNeck Reconstruction
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Fig. 34.3 (a) Dissection of SCIP pedicle adjusting desired pedicle length and dissection down to its origin at the SCIA (b)
a
327
Fig. 34.4 The skin paddle is nalised after templating the defect to be
reconstructed
b
also routinely include an extra supercial vein.
(Fig.34.5b).
5. Pedicle division and transfer. The pedicle can be then
clipped in its origin and divided for transfer. By this stage
the recipient vessels should be prepared. If anastomosing
to a perforator on the recipient site, this can be done endto- end. If anastomosing to a named vessel is preferred,
usually it is done end-to-side due to vessel discrepancy
(Fig.34.6).
6. Donor site closure. Abdominal laxity allows tensionless
closure of large aps in the groin area. It is important
not to undermine the abdomen to avoid contour deformities. Closure is obtained by using 2–0 PDS dermal
sutures and 3–0 monocryl subcuticular suture
Fig. 34.5 (a) The ap is raised off the external oblique fascia superi-
orly and (b) an extra supercial vein is incorporated into the skin ap
(Fig.34.7).
328
Fig. 34.6 The pedicle is divided before SCIP transfer. The vein is
marked with blue ink. A pedicle length of 6cm was taken in this case
J. E. Berner et al.
to carefully retract vessels as the pedicle is freed up from
neighbouring tissues.
3. Pedicle appraisal and ap design adjustment. It is advan-
tageous to adjust the ap design to include any supercial veins in its vicinity. This can be later used as a
lifeboat if drainage via the SCIP venae comitans is
inadequate.
4. Skin ap raising. At this point it is convenient to have an
assistant holding Senn-Mueller retractors, especially if
dissection through Scarpa’s fascia is decided.
5. Pedicle division and transfer. If the calibre of the SCIP
artery is too small for a safe anastomosis in the hand of
the operating surgeon, the main trunk of the SCIA can be
taken at its origin from the femoral artery. By doing this
the pedicle can be lengthened to a limited extent.
6. Donor site closure. We do not tend to insert drains on the
donor site for this ap unless a very large ap has been
taken with signicant undermining of the abdominal
wall.
Fig. 34.7 The donor site is closed in layers and a suction drain is
placed
34.6 Core Surgical Techniques inFlap
Dissection
1. Incision over SCIP pedicle. The use of a West self-
retaining retractor provides adequate retraction, easing
sharp dissection. No assistant is needed for raising this
ap.
2. Pedicle dissection. Debakey forceps and tenotomy scis-
sors are our preferred instruments for pedicle dissection,
along with bipolar diathermy. Vessel Loops can be used
34.7 Clinical Scenario
Case Scenario 1 Surgeon TC Teo A 46-year-old female
underwent an excision of a painful leiomyoma on her left
upper arm. A 14× 25cm defect was created that required
reconstruction with a large supercial circumex iliac artery
perforator (SCIP) ap. The anterograde raising of this ap is
shown, rst incising over its pedicle to identify the SCIP vessels to then subsequently complete the whole raising of the
skin paddle. The ap was then inset in the defect while and
the donor site was closed directly. Patient presented an
uneventful recovery. (Figs.34.8, 34.9, 34.10, and 34.11).
Fig. 34.8 Medial approach to the pedicle of SCIP
34 Supercial Circumex Iliac Artery Perforator Flap: AThin andVersatile Option forLimb andHead andNeck Reconstruction
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329
Fig. 34.9 Large 19 by 25 cm SCIP ap raised to reconstruct
Leiomyoma defect
Fig. 34.10 Tensionless donor site closure after large SCIP ap
Fig. 34.12 Patient with signicant wrist exion contracture secondary
to Volkmann’s contracture
Fig. 34.13 Wrist contracture released with resultant defect with
exposed exor tendons. Radial vessels dissected as recipient vessels for
SCIP ap
wrist in to a more functional position, an extensive scar release
was performed, including exor tendon lengthening and a
proximal row carpectomy. The resulting defect was resurfaced
with a 15×7 SCIP ap anastomosed end to side to the radial
artery and end to end to the Venae Comitans. The intraoperative photographs showing the preparation of the radial vessels,
raising of the SCIP pedicle, inset and postoperative results are
shown (Figs.34.12, 34.13, 34.14, 34.15, and 34.16).
Case Scenario 3 Surgeon TC Teo A 49- year- old man sustained a Gustilo 3B open tibial fracture after a motor vehicle
accident, an external xator frame was placed after initial
debridement by the orthopaedic team. An SCIP ap was
Fig. 34.11 Leiomyoma defect closed with SCIP ap
designed to reconstruct the defect. The ap resurfaced the
defect, and anastomosis was made end to side to the poste-
Case Scenario 2 Surgeon TC Teo and D Nikkhah A
37-year- old man was referred to our unit for a long-standing
left forearm and hand Volksmann contracture, following a
missed compartment syndrome years ago. In order to get his
rior tibial artery and end to end to the associated venae commitans. The patient made a full recovery, with bony union
and a healed reconstruction without any long- term sequelae
(Figs.34.17, 34.18, 34.19, and 34.20).
330
Fig. 34.14 Medial approach to SCIP with vessels identied under
Scarpa’s fascia
J. E. Berner et al.
Fig. 34.15 SCIP inset over soft tissue defect at wrist at end of case
Fig. 34.16 Result at 6months
Fig. 34.17 Open tibial fracture in middle third of lower extremity
34 Supercial Circumex Iliac Artery Perforator Flap: AThin andVersatile Option forLimb andHead andNeck Reconstruction
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34.8 Pearls andPitfalls
Pearls
• Place skin paddle over inguinal ligament, incorporating non- hair-bearing skin if possible.
• An incision over the SCIP pedicle allows visualising its calibre and length before committing to raising the whole ap. In rare occasions, raising can be
abandoned and a contralateral SCIP or SIEA ap
raised.
• There are multiple supercial veins running in the
groin region. This should always be included in the
ap if possible. These supercial veins tend to have
a larger calibre than the SCIP vena comitans and are
Fig. 34.18 SCIP ap raised and templated for lower limb defect
particularly useful in small aps to reduce the
chances of venous congestion.
• If the calibre of the SCIP artery is inadequate for
safe anastomosis, a segment of the larger SCIA can
be harvested.
• Avoid undermining of the abdomen prior to closure
to avoid contour deformities or pulling on the
umbilicus.
331
Fig. 34.19 End to side anastomosis onto the PTA and end to end anastomosis onto venae comitans
Pitfalls
• SCIP ap dissection is mostly supercial and therefore raising can be quick in experienced hands. It is
an excellent choice when there are recipient vessels
in the wound or just next to it. If a longer pedicle is
required, another alternative should be sought.
• Small aps are prone to venous congestion.
Incorporating a supercial vein with the ap can
solve this problem.
• It is important to have in mind that the SCIP pedicle
runs through supercial groin lymph nodes. Careful
dissection is key to minimise the risk of seroma and
lymphoedema.
• Surgeons raising this ap should be prepared to
work with vessels of 0.8–1mm calibre. Often it is
necessary to perform an end to side anastomosis in
extremity reconstruction due to the signicant vessel mismatch.
• The artery in the SCIP ap is often smaller than the
vein, it can be simple to confuse the two, and it is
best to mark the vein with blue ink or place a microsurgical clamp over it to help distinguish the two
structures.
Fig. 34.20 Final result at end of case
332
J. E. Berner et al.
34.9 Selected Readings
• Pereira N, Parada L, Kufeke M, Troncoso E, Roa R.A
new planning method to easily harvest the supercial circumex iliac artery perforator ap. J Reconstruct
Microsurg. 2020 Mar;36(03):165–70.
• This recent article presents an anatomy-based planning
strategy using CT-angiography which can be useful for
surgeons familiarising with the SCIP ap
• Koshima I, Nanba Y, Tsutsui T, Takahashi Y, Urushibara
K, Inagawa K, Hamasaki T, Moriguchi T.Supercial circumex iliac artery perforator ap for reconstruction of
limb defects. Plastic and reconstructive surgery. 2004 Jan
1;113(1):233–40.
• Inceptional article by Prof. Koshima, being the rst pub-
lication to present the use of this ap in the literature.
• Goh TL, Park SW, Cho JY, Choi JW, Hong JP.The search
for the ideal thin skin ap: supercial circumex iliac
artery perforator ap—a review of 210 cases. Plastic and
reconstructive surgery. 2015 Feb 1;135(2):592–601.
• Largest case series of SCIP aps to date, demonstrating
its reliability for limb reconstruction as super-thin ap.
The authors describe the lateral to medial approach of
SCIP ap elevation.
• Berner JE, Nikkhah D, Zhao J, Prousskaia E, Teo TC.The
versatility of the supercial circumex iliac artery perforator ap: a single surgeon’s 16-year experience for limb
reconstruction and a systematic review. J Reconstruct
Microsurg. 2020 Feb;36(02):093–103.
• Largest case series in Western population. The SCIP clas-
sication based on the included tissues is presented along
with a description of the anterograde raising technique.
References
1. Koshima I, Nanba Y, Tsutsui T, Takahashi Y, Urushibara K,
Inagawa K, Hamasaki T, Moriguchi T. Supercial circumex
iliac artery perforator ap for reconstruction of limb defects.
Plast Reconstr Surg. 2004;113:233. https://doi.org/10.1097/01.
PRS.0000095948.03605.20.
2. McGregor IA, Jackson IT.The Groin Flap. Br J Plast Surg. 1972;
https://doi.org/10.1016/s0007- 1226(72)80003- 1.
3. Pereira N, Cámbara Á, Kufeke M, Roa R.Post-traumatic lymphedema treatment with supercial circumex iliac artery perforator lymphatic free ap: a case report. Microsurgery. 2019;39:354.
https://doi.org/10.1002/micr.30437.
4. Pan ZH, Jiang PP, Zhao YX, Wang JL. Treatment of complex
metacarpal defects with free chimeric iliac Osteocutaneous aps.
J Plast Surg Hand Surg. 2017;51:143. https://doi.org/10.1080/200
0656X.2016.1205502.
5. Goh TL, Park SW, Cho JY, Choi JW, Hong JP.The search for the
ideal thin skin ap: supercial circumex iliac artery perforator
ap--a review of 210 cases. Plast Reconstr Surg. 2015; https://doi.
org/10.1097/PRS.0000000000000951.
6. Berner JE, Nikkhah D, Zhao J, Prousskaia E, Teo TC. The versatility of the supercial circumex iliac artery perforator ap: a
single Surgeon’s 16-year experience for limb reconstruction and a
systematic review. J Reconstr Microsurg. 2020;36:93. https://doi.
org/10.1055/s- 0039- 1695051.
7. Green R, Rahman KM, Owen S, Paleri V, Adams J, Ahmed
OA, Ragbir M.The supercial circumex iliac artery perforator
ap in intra-Oral reconstruction. J Plast Reconstr Aesthet Surg.
2013;66:1683. https://doi.org/10.1016/j.bjps.2013.07.011.
8. Yoshimatsu H, Steinbacher J, Meng S, Hamscha UM, Weninger WJ,
Tinhofer IE, Harima M, Fuse Y, Yamamoto T, Tzou CHJ.Supercial
circumex iliac artery perforator ap: an anatomical study of the
correlation of the supercial and the deep branches of the artery
and evaluation of perfusion from the deep branch to the Sartorius
muscle and the iliac bone. Plast Reconstr Surg. 2019;143:589.
9. Gentileschi S, Servillo M, De Bonis F, et al. Radioanatomical
study of the pedicle of the supercial circumex iliac perforator ap. J Reconstr Microsurg. 2019;35:669. https://doi.
org/10.1055/s- 0039- 1693144.
10. Suh HS, Jeong HH, Choi DH, Hong JP.Study of the medial supercial perforator of the supercial circumex iliac artery perforator
ap using computed tomographic angiography and surgical anatomy in 142 patients. Plast Reconstr Surg. 2017;139:738. https://
doi.org/10.1097/PRS.0000000000003147.
11. Pereira N, Parada L, Kufeke M, Troncoso E, Roa R.A new planning method to easily harvest the supercial circumex iliac artery
perforator ap. J Reconstr Microsurg. 2020;36:165. https://doi.
org/10.1055/s- 0039- 1698444.
12. Pereira N, Kufeke M, Parada L, Troncoso E, Bahamondes J,
Sanchez L, Roa R. Augmented reality microsurgical planning
with a smartphone (ARM-PS): a dissection route map in your
pocket. J Plast Reconstr Aesthet Surg. 2019;72:759. https://doi.
org/10.1016/j.bjps.2018.12.023.
13. Hong JP, Choi DH, Suh H, Mukarramah DA, Tashti T, Lee K,
Yoon C.A new plane of elevation: the supercial fascial plane for
perforator ap elevation. J Reconstr Microsurg. 2014; https://doi.
org/10.1055/s- 0034- 1369807.
Lateral Circumflex Femoral Artery—
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Anterolateral Thigh Flap: Anterolateral
Thigh Flap
RobertMiller, DariushNikkhah,
EdmundFitzgeraldO’Connor, andJeremyRawlins
35
35.1 Introduction
First published by Song in 1984, the anterolateral thigh (ALT) ap
is one of the key perforator-based workhorse aps for regional or
free tissue transfer reconstruction [1, 2]. Since its inception, it has
been extensively described for reconstruction of defects across the
body. Together with consistently high ap success, minimal donor
site morbidity and the ability to use a two-team approach, this is a
key ap in the reconstructive surgeon’s armament.
Based on work in the late twentieth century on septocutaneous vessels, Song’s original paper described three thigh aps
(anteriolateral, anteriomedial and posterior). They described a
ap thickness between 1 and 3cm, with a total area of 800cm
[2] that could be neurotised [1]. Since then, the ALT ap has
evolved to provide muscle, fascia and skin tissue components in
various combinations, as well as use as a ow-through or chimeric ap. Furthermore, by limiting the ap width dimension,
primary closure of the donor site can be achieved, reducing the
donor site morbidity and improving cosmesis.
Most commonly, the ALT is raised as a free ap for head
and neck and lower limb reconstruction. However, it can also
be used as a pedicled ap, most commonly for lower abdominal wall, groin and perineal reconstruction.
Supplementary Information The online version contains supplementary
material available at [https://doi.org/10.1007/978- 3- 031- 07678- 7_35].
R. Miller
Department of Plastic and Reconstructive Surgery, St George’s
Hospital, London, UK
D. Nikkhah (*)
Department of Plastic, Reconstructive and Aesthetic Surgery,
Royal Free Hospital, London, UK
e-mail: d.nikkhah@nhs.net
E. F. O’Connor
Department of Plastic and Reconstructive Surgery, St. Thomas’
Hospital, London, UK
J. Rawlins
Department of Plastic Surgery, Royal Perth Hospital,
Perth, WA, Australia
© Springer Nature Switzerland AG 2023
D. Nikkhah et al. (eds.), Core Techniques in Flap Reconstructive Microsurgery, https://doi.org/10.1007/978-3-031-07678-7_35
35.2 Anatomy
The ALT ap is centred at the mid-point of a line drawn
between the anterior superior iliac spine (ASIS) superiorly
and the superior lateral aspect of the patella inferiorly. The
arterial supply is derived from the lateral circumex femoral
artery (LCFA) which arises proximally from the profunda
femoris artery and runs deep to the rectus femoris (RF) and
sartorius. The LCFA divides into the ascending, transverse
and descending branches, which most commonly follow an
intramuscular course (87% musculocutaneous vs. 13% septocutaneous [3]) to supply the subcutaneous tissue and skin
of the thigh. This is contrary to Song’s original description of
predominantly septocutaneous vessels [1].
The ALT ap is most commonly based on perforators
from the descending branch. However, other perforator patterns have been described [4]. The descending branch travels
along the medial edge of the vastus lateralis (VL) in the
intra-muscular septum between VL and RF, giving off perforators within a 3 cm radius of the mid-point between the
ASIS– superior lateral patella. In a minority of patients, the
descending branch divides into medial and lateral branches
at this mid-point, with the lateral branch providing perforators to the lateral thigh. Septocutaneous perforators travel
between the RF and VL, traversing the fascia to supply the
skin, while musculocutaneous perforators course through the
VL for approximately 3–5cm, before exiting the fascia to
supply the overlying skin [2]. Studies examining the vascular
territories of the thigh aps have demonstrated that linking
vessels and recurrent ow from the subdermal plexus facilitate perfusion between perforator zones. This allows an
unthinned extended ALT to be raised on a single perforator
[5]. Venous drainage most commonly comes from two venae
comitantes running with the arterial pedicle, which go onto
drain into the femoral vein.
Sensory innervation comes from the lateral femoral cutaneous nerve, which passes under the inguinal ligament just
medial to the ASIS and travels under the tensor fascia lata,
before piercing it. Motor innervation to the VL is derived from
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