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334
R. Miller et al.
a branch of the femoral nerve which travels with the descending branch of the LFCA in the intramuscular septum.
Variations may occur in different ethnic groups. However,
this has not been widely reported or conrmed. One difference
is the thickness of the adipose thigh layer, which is typically
greater in western population and less in Asian populations.
Koshima also reports nding aberrant anatomy with loss of
the RF-VL septum more commonly in Caucasians [6].
35.3 Pre-Operative Investigation
Routine pre-operative imaging is not indicated for ALT ap
harvest. However, CT angiography may be pertinent in
patients with prior upper thigh/ pelvic injury or surgery or
patients with severe arterial atherosclerotic disease.
A standard hand-held doppler is used routinely to map perforators pre-operatively, most commonly found in a 3 cm radius
around the mid-point between the ASIS– superior lateral patella.
Although these devices are cheap and accessible, their accuracy
has been questioned [5] and will often not allow the surgeon to
determine the pedicle course or the site of fascial perforation. For
more accurate perforator mapping, CTA can be used [7, 8].
More recently, colour-coded duplex sonography has
gained popularity. This can be used by the operating surgeon
both pre- and intra-operatively providing both anatomic and
haemodynamic information and has high sensitivity and
specicity values. It has been advocated to facilitate accurate
pre-operative planning and perforator selection, subsequently decreasing ap raise time and allowing potential
complications due to variations in anatomy to be identied
prior to surgery commencing [9].
35.4 Flap Design andMarkings
Flap marking (Fig.35.1):
• Mark the ASIS and superior lateral aspect of the patella.
• Draw a longitudinal line connecting the two landmarks.
This should lie over the groove (septum) between RF and
VL, which can be palpated in thin patients.
• Draw a 3cm circle around the mid-point to dene the
likely exit of perforators (commonly in inferior lateral
quadrant) [2].
• Mark skin perforators with a hand-held Doppler.
Flap design key points:
• Template or measure the defect to design the ap on the
longitudinal axis of the thigh.
• Although, the ap can be successfully raised on one perforator, where possible, incorporate two perforators.
Marking a second backup perforator is helpful in case the
primary perforator is of insufcient size/ calibre.
• Limit the ap width to approximately 8cm to facilitate
primary closure [2].
• Limit the ap length to approximately 22cm for a single
pedicle [2].
35.5 Flap Raise/Elevation: AStep-by-Step
Guide
1. Incise the medial marking of the ap.
2. Incise the subcutaneous tissue down to thigh fascia.
3. At this point:
a. Either stop at the muscle fascia and dissect laterally in
a supra-fascial plane until the skin perforator(s) is
identied and chosen. Isolate the perforator(s) and dissect through the fascia. Supra-fascial aps offer the
advantage of a thinner ap, better suited for dorsal
hand or foot defects.
b. Or incise the fascia over the RF (preserving the epimy-
sium) and dissect laterally in a sub-fascial plane to the
RF-VL septum.
4. Identify the RF-VL septum. Note the yellow fat between
the two muscles to help identify the septum. Additionally,
the VL and RF muscle bres contract in different
directions. Stimulating the muscles can help differentiate
them and identify the septum. Figure35.2.
Fig. 35.1 Pre-op markings. ASIS Anterior Superior Iliac Spine, LP lat-
eral patella, RF rectus femoris, VL Vastus lateralis, Red dot and circle
Mid-point of line around which a 3cm radius circle can be drawn, Blue
dot perforator
5. Retract the RF medially to expose the RF-VL septum and
inspect for the presence of septocutaneous perforators
Fig.35.3.
If septocutaneous perforators are not present, continue
sub-fascial dissection until the perforator is identied passing through the muscle (Fig.35.4). If the perforator is of a
good caliber, there is no need to take a second perforator.
Once the chosen perforator(s) are identied, dissect the
pedicle retrogradely either through a septocutaneous course
35 Lateral Circumex Femoral Artery—Anterolateral Thigh Flap: Anterolateral Thigh Flap
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Fig. 35.2 Tenotomy scissors = RF; black arrow = VL; blue
arrow=RF-VL septum (note the yellow fat)
Fig. 35.5 Black arrow=Retracted RF; tenotomy scissor tips=perforator after VL intramuscular dissection
335
Fig. 35.3 Medial retraction of the RF (black arrow) demonstrates
clearly the RF-VL septum. Green arrow=VL. In this case there are
septocutaneous perforators visible arising from the septum (blue arrow)
Fig. 35.4 Tenotomy scissors highlighting musculocutaneous perforators perforating the fascia
through the RF– VL septum (Fig.35.3) or through the VL
(Fig.35.5) using the deroong technique (g. 35.6) (Video
35.1), heat-sink bipolar technique or ligaclips can be used for
side branches coming off the pedicle
• Dissect the pedicle retrogradely to the descending branch
of the LFCA or until adequate pedicle length is achieved,
at which point the pedicle can be divided. Up to 10–11cm
of pedicle length can be achieved if dissected to rectus
femoris branch [2].
• Incise the lateral marking of the ap down through fascia
to isolate, and then divide, the pedicle (Fig.35.7).
Fig. 35.6 Tenotomy scissors placed on top of the perforator with bipolar used to dissect the muscle off above
Fig. 35.7 Subfascial ALT raised on a single perforator prior to perforator division
35.6 Core Surgical Techniques inFlap
Dissection
General techniques:
• The nal ap design should be reassessed, and modi-
ed if necessary, after identication of the skin
perforators.
336
R. Miller et al.
• For retrograde musculocutaneous perforator dissection,
the anterior muscle bres can be lifted with toothed forceps, the tenotomy scissors spread in a transverse plane
over the vessel and the muscle bres divided [2].
Alternatively, the tenotomy scissors can be passed in a
longitudinal direction over the vessel, creating a tunnel.
Monopolar or Bipolar cautery can then be used to cut onto
the scissors, effectively deroong the vessel [3]. See
Fig.35.6. Video 35.1.
• Intra-muscular branches commonly arise laterally and
posteriorly. Tenotomy scissors can be used to make a window around them, after which they can be ligated.
Alternatively, bi-polar cautery can be used; however, this
increases the risk of thermal damage to the pedicle unless
a heat sink bipolar technique is used [10].
• A cuff of VL muscle can be taken around the pedicle. This
both increases speed of elevation and provides muscle to
ll dead-space if necessary.
• For septocutaneous perforators, dissection is simpler. The
pedicle should again be dissected retrogradely but can
simply be separated from the surrounding tissue until the
desired length is reached. See Fig.35.3.
• The motor nerve to the RF and VL should be protected
during pedicle dissection.
Problem solving:
sary to convert to a tensor fascia lata ap or anteromedial
thigh ap. Failing this, it may be necessary to swap to the
contralateral thigh.
• If donor site closure is not possible, a skin graft might be
needed, although this is cosmetically unsatisfactory.
Alternatively, a modied key-stone ap [10] or V-Y
advancement aps can be used [2].
Considerations for use as a pedicle ap:
• Design and harvest should follow the same steps as outlined above. For a proximally based pedicle ap the pivot
point is approximately 2cm below the inguinal ligament.
The ap can then be rotated medially over the RF or tunneled subcutaneously laterally [2].
Modications:
• Up to the entire length of the VL can be included in the
ap (Fig. 35.9), providing sufcient muscle branches
from the descending branch of the LFCA are preserved.
The VL can also be raised as a stand-alone muscle ap,
based on the descending branch of the LFCA, without the
ALT skin.
• If a perforator is absent or of insufcient size, the same
medial incision can be used with proximal extension to
look for the transverse (Fig.35.8) or ascending branch of
the branch of the LFCA.In these cases, it may be neces-
Fig. 35.8 Medial retraction of the RF (blue arrow) demonstrating the
RF-VL septum (green arrow) with no distal perforator. However, a
proximal transverse LCFA branch perforator supplying the partially
raised ALT ap is demonstrated (black arrow)
Fig. 35.9 ALT ap (black arrow) taken with a segment of VL (blue
arrow). The pedicle is demonstrated in the lower image (green arrow)
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337
• The RF muscle can be incorporated in a chimeric ALT
ap, provided the branches from the descending branch of
the LFCA are preserved.
• The TFL can be raised in conjunction with the ALT if the
ascending branch of the LFCA is included. The TFL can
be used for simultaneous reconstruction of other soft tissue components (such as tendon).
• The ALT ap can be thinned up to a thickness of 3mm.
However, it is advised to keep a 2cm radius around the
skin pedicle [2]. Alternatively, thigh fat can be included
to add bulk to the ap. Placing the skin paddle distally
on the thigh facilitates a thinner ap [4] (almost 50%
thinner) as demonstrated in the two images within
Fig.35.10.
• A fasciocutaneous flap, without the overlying skin,
can also be raised based on the same pedicle. The
approach for raising is the same as for a subfascial
flap but without the need to preserve the skin
perforators.
• The ap can be innervated with the lateral femoral cutaneous nerve to provide sensation or the motor branch to
the VL to provide animation. A nerve stimulator can be
used to check whether the nerve branch is sensory or
motor.
• The ALT ap can also be raised with multiple skin paddles if more than one perforator is identied. This can
be useful in head and neck reconstruction where bipad-
dle ALT aps can be used to reconstruct pharyngooesophageal defects and at the same time to resurface the
neck.
35.7 Clinical Scenario
Case 1 Marine injury propeller injury
Dariush Nikkhah & Jeremy Rawlins
A 35-year-old male was struck by the propeller of a boat
whilst in the sea. He suffered unicortical metatarsal fractures with associated soft tissue defect. He was managed in
line with British Orthopaedic Association / British
Association of Plastic, Reconstructive and Aesthetic Surgery
guidelines. The wound was debrided within 24hours and
reconstructed on day three with a joint ortho-plastics team
approach. A thin subfascial ALT was used and anastomosed
onto the dorsalis pedis vessels. Bony xation was not
required (Fig.35.11).
Case 2 Upper limb exor tenolysis, neurolysis and forearm
defect reconstruction
Dariush Nikkhah & Jeremy Rawlins
A 26-year-old male suffered a forearm crush injury
which had originally been managed by split thickness skin
grafting. He required excision of the skin graft, tenolysis,
neurolysis of the ulnar and median nerves and resurfacing
with a ow through ALT ap (Fig.35.12). He had an excellent outcome with full range of motion achieved at 1year
follow-up (Video 35.2).
Fig. 35.10 Demonstration of the difference in ALT ap thickness
along the thigh. Upper image=proximal; Lower image=distal
Case 3 Orbital exenteration and medical maxillectomy
reconstruction
Graeme Glass & Dariush Nikkhah
A 46-year-old lady presented with an aggressive squamous
cell carcinoma of the maxilla and orbit. She underwent orbital
exenteration and medial maxillectomy. A right sided ALT ap
was raised with a cuff of vastus laterals to ll the dead space in
the right cheek. The ALT was anastomosed to the facial artery
and vein after de-epitheliasing the skin paddle. She had an
uneventful post-operative recovery (Fig.35.13).
The nal video in this chapter provides a summary and
overview of the ALT ap raise (Video 35.3).
338
Fig. 35.11 Upper images
demonstrate pre-operative
defect (left) vs. post-operative
reconstruction (right). The
lower image demonstrates a
subfascial ALT with a single
isolated intra-muscular
perforator
R. Miller et al.
35 Lateral Circumex Femoral Artery—Anterolateral Thigh Flap: Anterolateral Thigh Flap
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Fig. 35.12 Images
demonstrating pre-op deformity
(upper left), intra-op defect post
tenolysis and neurolysis (upper
right), post-op defect
reconstruction with thin
subfascial ATL (lower left) and
follow-up image (lower right)
Fig. 35.13 Upper images
show post orbital exenteration
(left) and post ap inset
(right). The lower image
demonstrates ALT skin paddle
in place within the orbit with
the pedicle tunneled to allow
anastomosis onto the facial
artery. The cuff of VL is
fulling the dead-space of the
maxilla
339
340
35.8 Pearls andPitfalls
Pearls
• Flap design does not need to be centred over the
identied skin vessel. An eccentric design is acceptable and can provide additional pedicle length (particularly for pedicle aps) [2]. Furthermore, using a
distal skin paddle can provide a thinner ap, if
required, as shown in Fig.35.10.
• Distal incision extension can help visualise and
identify the RF/VL septum to prevent confusion
with the septum between the two heads of the RF.
• Proximal extension as a lazy ‘S’ can provide additional exposure to maximise pedicle length [10].
• Identication of the most proximal perforator may
be helpful as this will often have the shortest intramuscular course [11].
• Include a cuff of fascia around the pedicle during
supra-fascial ap harvest.
• After ap raise use a large nylon suture to take the
tension off the donor site and aid subsequent closure (if not being done immediately). See Fig.35.14.
Pitfalls
• Skin colour mismatch between ALT and recipient
site. The thigh may be signicantly paler and provide a poor cosmetic outcome.
• Similar attention should be given to hair growth,
particularly when used for intra-oral
reconstruction.
• Twisting of the pedicle during inset. Lifting the ap
once raised to see the natural lie of the pedicle will
aid placement.
• Not supporting the ap during the raise may cause
tension or traction on the pedicle, which in turn may
cause the vessels to spasm. This is more pertinent in
the supra-fascial raise when both medial and lateral
incision are made prior to pedicle dissection.
• Loss of sensation to the ALT. Patients should be
counselled pre-operatively. This can be reduced by
preserving cutaneous nerves in a supra-fascial
elevation.
R. Miller et al.
Fig. 35.14 Temporary donor site closure using a large dermal silk
suture. This will facilitate subsequent closure
35.9 Selected Readings
• Song YG, Chen GZ, Song YL.The free thigh ap: a new
free ap concept based on the septocutaneous artery.
British journal of plastic surgery. 1984 Apr
1;37(2):149–59.
• The original paper describing the three thigh aps is a
must read for its historic value and the impact it has
had on microsurgical reconstruction. Song et al.,
describe the anteromedial, anterolateral and posterior
thigh aps based on their work on septocutaneous perforators [1].
• Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin
CH.Have we found an ideal soft-tissue ap? An experience with 672 anterolateral thigh aps. Plast Reconstr
Surg. 2002;109(7):2219–26.
• Published in 2002, this was a seminal paper highlight-
ing the versatility and reliability of the ALT flap in
microsurgical reconstruction. It also solidified the
consensus that ALT perforators are predominantly
musculocutanous, in contrast to Song’s original
description [3].
• Kehrer A, Sachanadani NS, da Silva NP, Lonic D,
Heidekrueger P, Taeger C, Klein S, Jung EM, Prantl L,
Hong JP.Step by Step Guide to Ultrasound-Based Design
of Alt Flaps by the Microsurgeon–Basic and Advanced
Applications and Device Settings. Journal of Plastic,
Reconstructive & Aesthetic Surgery. 2019;
73(6)1081–1090.
• The use of ultrasound in ap design is gaining popu-
larity worldwide. This recent publication offers a step-
35 Lateral Circumex Femoral Artery—Anterolateral Thigh Flap: Anterolateral Thigh Flap
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341
wise guide for the use of colour-coded duplex
sonography in identifying and mapping ALT perforators based on the authors experience of 125 ALT aps
over two centres. Although perforator mapping using
ultrasound technology is not routinely necessary for
ALT ap harvest, it offers an excellent opportunity to
learn these skills [9].
• Yu P.Characteristics of the anterolateral thigh ap in a
Western population and its application in head and neck
reconstruction. Head & Neck: Journal for the Sciences
and Specialties of the Head and Neck. 2004
Sep;26(9):759–69.
• This paper balances the experience of the ALT ap from
Asian cohorts with the experience of 72 ALT aps in a
Western population (Texas, USA). It offers excellent illustrations demonstrating the anatomical variations of the
ALT pedicle (Fig.35.3) and the likelihood of encountering these perforators (Fig. 35.1). Familiarising oneself
with these anatomical variations will aid efcient and
effect ap raise [4].
• Saint-Cyr M, Oni G, Lee M, Yi C, Colohon SM.Simple
approach to harvest of the antierloateral thigh ap. Plastic
and reconstructive surgery. 2012; 129 (1):207–11.
• This concise paper from Saint-Cry offers a stepwise
approach to ALT perforator identication, choice and
ALT raise. It highlights the authors’ preference for selecting a proximal perforator to reduce the need for perforator dissection with Fig. 35.6 offering an easy-to-follow
algorithm [11].
References
1. Song YG, Chen GZ, Song YL. The free thigh ap: a new free
ap concept based on the septocutaneous artery. Br J Plast Surg.
1984;37(2):149–59.
2. Wei F-C, Mardini S. Flaps and reconstructive surgery. Elsevier;
2009.
3. Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin CH.Have we
found an ideal soft-tissue ap? An experience with 672 anterolateral thigh aps. Plast Reconstr Surg. 2002;109(7):2219–26. discussion 2227-2230
4. Yu P.Characteristics of the anterolateral thigh ap in a Western
population and its application in head and neck reconstruction.
Head Neck. 2004;26(9):759–69.
5. Saint-Cyr M, Schaverien M, Wong C, et al. The extended anterolateral thigh ap: anatomical basis and clinical experience. Plast
Reconstr Surg. 2009;123(4):1245–55.
6. Koshima I.Free anterolateral thigh ap for reconstruction of head
and neck defects following cancer ablation. Plast Reconstr Surg.
2000;105(7):2358–60.
7. Smit JM, Klein S, Werker PM.An overview of methods for vascular mapping in the planning of free aps. J Plast Reconstr Aesthet
Surg. 2010;63(9):e674–82.
8. Rozen WM, Ashton MW, Pan WR, etal. Anatomical variations in
the harvest of anterolateral thigh ap perforators: a cadaveric and
clinical study. Microsurgery. 2009;29(1):16–23.
9. Kehrer A, Sachanadani NS, da Silva NPB, etal. Step-by-step guide
to ultrasound-based design of alt aps by the microsurgeon- basic
and advanced applications and device settings. J Plast Reconstr
Aesthet Surg. 2019;73(6):1081–90.
10. Nikkhah D, Miller R, Patanis G, Vijayan R, Sadigh P.Five simple
techniques to enable rapid elevation and donor site closure of the
anterolateral thigh ap. J Hand Microsurg. 2019;11(1):54–6.
11. Saint-Cyr M, Oni G, Lee M, Yi C, Colohan SM, Colohon
SM.Simple approach to harvest of the anterolateral thigh ap. Plast
Reconstr Surg. 2012;129(1):207–11.
Transverse Upper Gracilis (TUG) Flap:
AReliable Alternative forBreast
Reconstruction
JuanEnriqueBerner andAdamBlackburn
36
36.1 Introduction
The gracilis muscle has been a common donor site for free
tissue transfer since the 1970s [1]. This expendable muscle
in the adductor compartment of the thigh has demonstrated
to be a reliable alternative, easy to raise and a constant vascular pedicle [2]. Even though its musculocutaneous variant
had been described previously, it was Yousif etal. who introduced the transverse upper gracilis (TUG) ap in 1992 [3].
His anatomical studies demonstrated that musculocutaneous
perforators arising in the proximal portion of the gracilis
muscle follow a transverse course anteriorly and posteriorly.
This is the basis for the transverse design of the TUG skin
paddle, which results in a well concealed donor site scar in
the groin crease [4].
It was a decade after its inception, that Arnez etal. would
popularise the use of this ap for breast reconstruction, as an
alternative to abdominal free aps [5]. In many microsurgical centres, the TUG ap has become the second-best option
for patients undergoing autologous breast reconstruction [6].
This can be particularly useful as a single or stacked ap,
particularly in slim patients [7]. More recently, modications
to the TUG have been proposed, intending to avoid scars in
the gluteal crease while optimising volume harvest. This has
been achieved by modifying the orientation of the skin paddle [8].
pes anserinus conjoint tendon. It acts primarily as a hip
adductor even though it also plays a role in hip exion and
knee extension.
It is perfused by a branch of the medial circumex femoral artery, running between adductor longus and magnus,
entering the gracilis muscle approximately 10cm inferior to
the pubic tubercle [3]. A motor branch of the obturator nerve
pierces into the gracilis muscle close to the entry of its vascular pedicle, usually at a 45° angle. Harvesting the nerve to
gracilis allows transferring this muscle as a functional ap
[9], though this is not indicated for breast reconstruction.
Two anatomical landmarks are important for raising the
skin paddle of the TUG ap. Anteriorly, the long saphenous
vein runs in the femoral triangle towards the saphenofemoral
junction. The TUG ap spares this vein and care should be
taken not to harvest tissues that are deep and lateral to it,
which can disrupt lymphatic drainage to the lower extremity.
Posteriorly, the posterior cutaneous nerve of the thigh arises
from the great sciatic foramen under the piriformis muscle. It
pierces the deep fascia in the posterior midline of the thigh,
from where it travels inferiorly providing sensation to the
skin in the posterior thigh. This structure should be avoided
during the raising of the TUG ap, preserving sensation and
avoiding neuroma formation in a pressure-bearing area [10].
36.3 Pre-Operative Investigation
36.2 Anatomy
The gracilis is the most supercial muscle in the adductor
compartment of the thigh. It originates in the ischiopubic
ramus and inserts in the anteromedial proximal tibia, via the
J. E. Berner (*)
Royal Victoria Inrmary, Newcastle upon Tyne, UK
A. Blackburn
Queen Victoria Hospital, East Grinstead, UK
© 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_36
Given its constant vascular anatomy, no routine preoperative
investigations are used to plan the raising of a TUG ap.
However, for breast reconstruction, careful analysis should
be performed, especially for delayed cases.
The profunda artery perforator (PAP) arises posterior to
the gracilis muscle, approximately 8cm inferior to the gluteal crease [11]. Locating this perforator using computed
tomography angiography in conjunction with hand-held
Doppler can be useful as a lifeboat if the skin paddle over the
gracilis is inadvertently undermined [12].
343
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J. E. Berner and A. Blackburn
36.4 Flap Design andMarkings
Marking of this ap starts with the patient standing, facing
away from the surgeon. The posterior midline of the thigh
is marked rst, as this will be the posterior most point of
the skin ellipse. It is convenient at this stage to mark the
posterior portion of the superior margin of the ap on the
gluteal crease. The patient is then asked to lie down with
the hip abducted and the knee exed. In this position the
adductor longus tendon can be seen and felt and the graci-
lis muscle lies in “the hollow” posterior to it (Fig.36.1).
The anterior marking of the apex of the ap is approximately 2 nger breadths lateral to the lateral border of
adductor longus, at the point where the thin groin skin
becomes thicker thigh skin. The width of the skin paddle
over the gracilis tends to range from 7 to 10cm; however,
this should be routinely checked by means of a “pinchtest” (Fig.36.2). On the operative table markings are templated and re-checked for symmetry in bilateral cases.
(Figs.36.3 and 36.4).
Fig. 36.1 Palpation of the adductor longus muscle. The gracilis muscle is posterior to the adductor longus
Figs. 36.3 and 36.4 Marking of the ap, which should be checked for symmetry if bilateral aps are being harvested
Fig. 36.2 Pinch test to determine the width of skin paddle to be
included with ap
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