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The gracilis assists with hip adduction, knee flexion, and knee internal
rotation. Consequently, loss of this muscle may result in a decrease in
hip adduction strength, but this is often not noticed by patients.23 A
notable portion may also experience numbness in the area of the
obturator nerve.
The scar burden may be adjusted depending on the position of the
skin paddle with more posteriorly and superiorly based flaps being less
visible. In the case of skin paddles close to the gluteal crease, care
must be taken to avoid distorting the crease or causing difficulty with
sitting because of posterior cutaneous nerve dysesthesia. Flap design
must also take into consideration of the lower extremity lymphatic
system, with more medial flaps at higher risk for lymphedema.
Anterolateral Thigh Flap
The thigh is a versatile donor site from which muscle, myocutaneous,
adipofascial, fascial, and fasciocutaneous flaps can be harvested. The
anterolateral thigh (ALT) flap is most commonly known as a perforator
flap supplied by the descending branch of the lateral circumflex femoral
artery via the profunda femoris artery. The flap can be harvested as a
true perforator flap or may include part of or the entire vastus lateralis
muscle if additional bulk is needed. If desired, the lateral femoral
cutaneous nerve can be included for sensory reinnervation.
Indications
The ALT flap is a commonly used flap that can provide large and
pliable coverage anywhere in the body. The skin paddle can be as
large as 8 by 25 cm with primary closure or even larger with skin graft
closure. Like the RFFF, it is a workhorse flap for head and neck
reconstruction and is often chosen over the RFFF if the defect is larger
or if increased bulk is desired. It can be limited by its thickness in more
obese patients; a fascia-only flap or flap thinning may be utilized in
these cases, but alternate flaps may be more beneficial if a thinner flap
is needed. The ALT flap is also beneficial for lower extremity
reconstruction, particularly if patients would like to restrict surgery to
one area of the body.
Surgical Technique
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The most important landmarks for ALT harvest are the supralateral
corner of the patella and the most prominent point of the anterior
superior iliac spine. The line between these two points permits
approximation of the septum between the rectus femoris and the
vastus lateralis, in which the descending branch of the lateral
circumflex femoral pedicle is found. Perforators can typically be found
near and within 5 cm proximally and distally of the midpoint of this line.
A handheld Doppler may be used to detect these perforators. The skin
paddle should be designed over the desired perforators.
The medial incision of the skin paddle is typically made first, down to
the fascia of the rectus femoris muscle, which is also incised. Lateral
subfascial dissection facilitates identification of the septum between the
rectus femoris and the vastus lateralis. Septocutaneous vessels, if
present and notable, are found exiting this septum and can be traced
back to the pedicle. Otherwise, musculocutaneous perforators are
identified with continued exposure of the vastus lateralis and should be
seen piercing the muscle fascia and going into the subcutaneous tissue
and skin. If muscle is not required or desired, the chosen
musculocutaneous perforators are dissected away from the muscle
back to the origin of the descending lateral circumflex femoral pedicle.
Once this is performed, the lateral aspect of the skin paddle is adjusted
as necessary to include the perforators and then incised to complete
the flap harvest.
Donor Site Considerations
Dissection of the flap, even if small, often requires a large incision. If
the amount of skin required is larger than what can permit primary
closure of the thigh, a skin graft may be used, but is often unesthetic
and in an area that is frequently seen by the patient. In addition, a
significant proportion of patients may experience numbness in the
distribution of lateral femoral cutaneous nerve.36 If a notable portion of
the vastus lateralis is taken, patients may experience lower extremity
weakness or instability, but studies have shown that this typically
resolves.
36,37
CONCLUSIONS
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A solid foundation in the principles of flap surgery is an essential tool
for all reconstructive surgeons. Continued advances in the
understanding of anatomy and surgical techniques have made the
possibilities of tissue transfer nearly endless. Ultimate flap selection
should be guided by an informed multidisciplinary discussion between
the patient’s care team and the patient with a focus on how to manage
the patient’s reconstructive needs in the context of their comorbidities
and desires with minimal donor site morbidity and maximal restoration
of form and function.
QUESTIONS
1. You are presented with a 65-year-old woman with a history of
vulvar cancer previously treated with radical vulvectomy and
reconstruction with bilateral pedicled ALT flaps complicated by
recurrence with a large fungating tumor for which a palliative
pelvic exenteration with a left-sided double-barrel wet ostomy
has been performed. The resultant perineal defect is
approximately 10 × 8 cm and significant dead space remains in
the pelvis. Which of the following flaps represents the best
option in this circumstance?
a. Pedicled right transverse rectus abdominis myocutaneous
flap
b. Pedicled right vertical rectus abdominis myocutaneous flap
c. Pedicled diagonal upper gracilis flap
d. Free latissimus dorsi free flap
2. A 35-year-old woman with a BMI of 24 is diagnosed with breast
cancer and is planning on undergoing a unilateral mastectomy.
She is interested in autologous breast reconstruction with a
thigh-based flap. A diagonal upper gracilis (DUG) flap is
planned. When harvesting the flap, the vascular pedicle can be
found between which two muscles?
a. Rectus femoris and vastus lateralis
b. Adductor longus and sartorius
c. Adductor longus and adductor magnus
d. Vastus medialis and semimembranosus
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3. A 48-year-old transgender female-to-male patient is interested in
undergoing phalloplasty using a radial forearm free flap. Which
of the following nerves should be included to provide tactile and
erogenous sensation?
a. Lateral antebrachial cutaneous nerve
b. Radial nerve
c. Medial antebrachial cutaneous nerve
d. Obturator nerve
ANSWERS AND EXPLANATIONS
1. Answer: b. A pedicled right vertical rectus abdominis
myocutaneous (VRAM) is the best option in this case. A vertically
rather than a transversely oriented flap would be better able to
reach the posterior aspect of the defect. A transverse rectus
abdominis myocutaneous (TRAM) flap would also affect the left
side of the abdomen, which would not be ideal given left-sided
ostomy. A gracilis flap could potentially fill the defect, but the
additional bulk from a rectus abdominis muscle would better fill the
dead space left behind by the pelvic exenteration. A free flap
would result in unnecessary morbidity when pedicled options are
available, particularly in the case of a palliative procedure.
2. Answer: c. The gracilis muscle is a Mathes and Nahai type II
muscle with a dominant blood supply from the descending branch
of the medial circumflex femoral artery via the profunda femoris
artery. The pedicle can be identified approximately 10 cm distal to
the pubic symphysis between the adductor longus and adductor
magnus muscles.
3. Answer: a. The radial forearm free flap should be neurotized
using the lateral antebrachial cutaneous nerve. Care must be
taken to preserve the sensory branches of the radial nerve when
harvesting the flap. The obturator nerve innervates the gracilis
muscle and can be used when a functional free flap is required.
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REFERENCES
1. McGregor IA, Morgan G. Axial and random paern flaps. Br J Plast
Surg. 1973;26(3):202-213.
2. Taylor GI, Palmer JH. The vascular territories (angiosomes) of the
body: experimental study and clinical applications. Br J Plast Surg.
1987;40(2):113-141.
3. Ghali S, Butler PEM, Tepper OM, Gurtner GC. Vascular delay
revisited. Plast Reconstr Surg. 2007;119(6):1735-1744.
4. Hamilton K, Wolfswinkel EM, Weathers WM , et al. The delay
phenomenon: a compilation of knowledge across specialties.
Craniomaxillofac Trauma Reconstr. 2014;7(2):112-118.
5. Mathes SJ, Nahai F. Classification of the vascular anatomy of
muscles: experimental and clinical correlation. Plast Reconstr Surg.
1981;67(2):177-187.
6. Pontén B. The fasciocutaneous flap: its use in soft tissue defects of the
lower leg. Br J Plast Surg. 1981;34(2):215-220.
7. Cormack GC, Lamberty BG. A classification of fascio-cutaneous flaps
according to their paerns of vascularisation. Br J Plast Surg.
1984;37(1):80-87.
8. Wei FC, Jain V, Suominen S, Chen HC. Confusion among perforator
flaps: what is a true perforator flap? Plast Reconstr Surg.
2001;107(3):874-876.
9. Koshima I, Soeda S. Inferior epigastric artery skin flaps without
rectus abdominis muscle. Br J Plast Surg. 1989;42(6):645-648.
Surg. 2020;34(3):133-138.
Br J Plast Surg. 1991;44(1):53-54.
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perforator flap for coverage of ischial or trochanteric pressure sores.
Ann Plast Surg. 2006;56(5):540-542.
reconstructive surgery. ANZ J Surg. 2003;73(3):112-120.
in clinical use. Clin Plast Surg. 2003;30(3):457-467.
2004;114(4):910-916.
flaps: clinical results and vascular anatomy. Plast Reconstr Surg.
2010;126(5):1589-1603.
supermicrosurgery. J Reconstr Microsurg. 2014;30(1):53-58.
microsurgery and perforator flaps. Paper presented at. First
International Course on Perforator Flap and Arterialized Skin Flaps
(Special Invited Lecture). 1997.
applications. J Surg Oncol. 2018;118(5):832-839.
Surg. 1971;38(1):61-63.
for reconstruction in the head and neck. Plast Reconstr Surg.
1979;63(1):73-81.
disability following reconstruction with the pectoralis major pedicled
flap. Laryngoscope. 2010;120(6):1129-1134.
pectoralis major myocutaneous flap harvest. Laryngoscope.
2002;112(3):467-471.
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morbidity of free DIEP flaps and free TRAM flaps for breast
reconstruction. Br J Plast Surg. 1997;50(5):322-330.
epigastric artery flaps: a prospective comparison with TRAM and
DIEP flaps. Plast Reconstr Surg. 2004;114(5):1077-1083; discussion
1084-1085.
Superficial Inferior Epigastric Artery (SIEA) and its angiosome: a
clinical anatomical study. Microsurgery. 2010;30(5):386-391.
thoracodorsal artery perforator flap: anatomic basis and clinical
application. Ann Plast Surg. 2003;51(1):23-29.
reconstruction. J Adv Pract Oncol. 2014;5(3):181-187.
transplantation: a report of 56 cases. 1981. Br J Plast Surg.
1997;50(3):162-165.
the radial forearm flap really the standard technique? Plast Reconstr
Surg. 2009;124(2):510-518.
flap. Plast Reconstr Surg Glob Open. 2017;5(4):e1287.
donor-site complications and morbidity: a prospective study. Plast
Reconstr Surg. 1997;99(1):109-115.
Upper Gracilis (DUG) flap: a safe and improved alternative to the
TUG flap. Plast Reconstr Surg. 2013;132(4S-1):33-34.
femoris artery perforator flap: a new option for autologous breast
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reconstruction—a cadaveric and computer tomography angiogram
study. J Reconstr Microsurg. 2012;28(6):381-386.
perforator flaps for breast reconstruction. Plast Reconstr Surg Glob
Open. 2019;7(10):e2463.
morbidity after anterolateral thigh fasciocutaneous and
myocutaneous free flap harvest in 220 patients. Plast Reconstr Surg.
2010;125(1):209-214.
found an ideal soft-tissue flap? An experience with 672 anterolateral
thigh flaps. Plast Reconstr Surg. 2002;109(7):2219-2226; discussion
2227-2230.
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CHAPTER 8 Principles of Nerve Repair and Reconstruction
and Neuroma Management
Lisa Gfrerer and Kyle R. Eberlin
KEY POINTS
Nerve injuries can result in motor weakness, numbness, chronic pain, and phantom
sensations depending on the nerve affected and injury grade. Surgeons should consider all
four domains in the treatment of affected patients.
The diagnostic workup for nerve injury may include a history and physical examination,
imaging with ultrasound and magnetic resonance imaging, as well as electrodiagnostic
studies and diagnostic nerve blocks.
The most important aspect of nerve repair is coaptation without tension after debridement of
unhealthy neural tissue. Based on this principle, several surgical techniques including direct
coaptation, repair with conduits, as well as autograft and allograft reconstruction are
available to achieve optimal clinical outcomes.
Treatment of neuropathic pain is multidisciplinary. The role of the surgeon is to identify and
treat nerve compression, nerve injury (neuroma), and musculoskeletal injury/inflammation.
The most common surgical techniques to treat neuropathic pain include burying in muscle,
regenerative peripheral nerve interface, targeted muscle reinnervation, and relocation nerve
grafting.
PRINCIPLES OF NERVE INJURY
Peripheral nerve injuries occur through different mechanisms including sharp or blunt trauma, stretch
injury, and compression. The degree of nerve injury influences the severity of the resulting deficits, the
chances of recovery, and the treatment approach (see Table 8.1 and Figure 8.1).1 Functionally,
disruption of nerve tissue results in varying degrees of motor weakness, numbness, chronic pain, and
phantom sensations. Therefore, surgeons should consider all four of these domains in the treatment of
affected patients.
TABLE 8.1. CLASSIFICATION OF PERIPHERAL NERVE INJURIES IS BASED ON THE LEVEL
OF ANATOMIC DISRUPTION
Seddon
Classification
Sunderland
Classification
a
Nerve Anatomy
b
Myelin Axon Endoneurium Perineurium Epineuriu
Neurapraxia First degree − + + + +
Axonotmesis Second
degree
− − + + +
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Third degree − − − + +
Fourth degree − − − − +
Neurotmesis Fifth degree − − − − −
Sixth degree − ± ± ± ±
a
Degree of nerve injury determines likelihood of spontaneous recovery and/or need for surgical intervention.
b
+ Indicates structure is intact; − indicates structure is injured.
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