Cigna, Emanuele M.D., Ph.D.; Chen, Hung-Chi M.D., Ph.D.; Ozkan, Omer M.D., Ph.D.; Sorvillo, Valentina M.D.; Maruccia, Michele M.D.; Ribuffo, Diego M.D.
Free vascularized tissue transfer has become a well-accepted standard in the treatment of tissue loss.1 It has the advantage of providing a wider choice of flaps for a reliable one-stage reconstruction.1,2 Currently, perforator flaps have become the choice of most reconstructive surgeons as they have a decreased donor-site morbidity compared with nonperforator flaps.3–8 Among these, the free anteromedial thigh flap, first described by Song and colleagues,9 has yet to become a frequently used flap. One of the main problems in harvesting this flap is the inconstant anatomy of the pedicle.
This study aimed to describe the anatomy of 108 cases to highlight common patterns and the flap’s clinical applications. The origin and the type of the perforators are listed and have been statistically evaluated. The cases reviewed for anteromedial thigh flap anatomy belong to three different groups: clinical experience, anatomical findings, and previous reports in the literature.
PATIENTS AND METHODS
The study began in 2004 and took nine years to complete. It was performed in two Departments of Plastic Surgery in two countries (Italy and Taiwan), first in 12 clinical anteromedial thigh flap cases and then in 48 clinical anterolateral thigh flap cases in which the vascular anatomy of the anteromedial thigh flap was studied. The final part of the study involved the Department of Anatomy, where 48 anteromedial thigh flaps from anatomical cadavers were dissected.
In the 12 clinical cases, the anteromedial thigh flap was harvested following Song et al.’s description9 (Fig. 1). There were 10 male and two female patients, and their ages ranged from 30 to 61 years, with an average age of 50 years (Table 1).
Between 2005 and 2010, to expand the anatomical value of the study and clarify the vascular anatomy of the anteromedial thigh flap pedicle, the location and type of the anteromedial thigh flap perforators were investigated in 48 thighs of patients undergoing reconstruction with the anterolateral thigh flap (39 male and nine female patients ranging in age from 38 to 67 years; mean age, 54 years). Every patient gave signed informed consent specifying the dissection of the anteromedial thigh flap pedicle and the flap’s possible use.
A third study was carried out between 2009 and 2011 on 24 cadaver dissections (a total of 48 thighs). In these cases, a large anteromedial thigh flap of about 10 × 20 cm was harvested using the same technique applied in clinical cases. Its vascular pedicle was dissected and compared with that of the other perforators entering the flap that were dissected and spared.
Anatomy of the Anteromedial Thigh Flap: The Oblique Branch
The cutaneous perforators of the anteromedial thigh flap, as previously described,8–12 commonly originate from the lateral circumflex femoral artery system, which gives off three branches: the ascending, the transverse, and the descending branches. The descending branch gives off several perforators both laterally and medially. Lateral perforators are located mainly in the middle half of the thigh, while medial perforators are fewer in number and proximally located. The pedicle of the anteromedial thigh flap, which we call the oblique branch of the lateral circumflex femoral artery, arises near the base of the lateral circumflex femoral artery or in the proximal third of the descending branch of the artery (Fig. 2, left). Less frequently, the pedicle may arise from other vessels (Fig. 2, second from left, second from right, and right, and Table 2). The oblique branch ends as a cutaneous perforator of the anteromedial thigh skin. This vessel is commonly septocutaneous and runs medially between the overlying rectus femoris muscle and the vastus intermedius muscle proximally and laterally. It then emerges in the triangle formed by the rectus femoris muscle, the sartorius muscle, and the vastus medialis muscle. Along its course, it gives off small branches to the neighboring muscles and then perforates the deep fascia and supplies the skin of the overlying region.
One or two venae comitantes accompany the artery during its course. Superficial tributaries of the great saphenous vein are also present and represent a second venous system. Sensorial nerves of this region are cutaneous branches of the femoral nerve, as the median perforator nerve.8,9,13–15
Clinical Cases Group
Eleven anteromedial thigh flaps were successfully harvested and transferred. Septocutaneous perforators were found in 10 (83.3 percent) of 12 cases (Table 2). Of these 10 flaps, seven were nourished by the septocutaneous perforator only (five flaps had one perforator, one flap had two perforators, and one flap had three very small perforators on the septum) and three were based on two perforators (one septocutaneous and one musculocutaneous) (Table 3). In one (8.3 percent) of 12 cases, the flap was based on a musculocutaneous perforator only. In one case (8.3 percent), the perforator of the flap was not found.
The flap ranged from 10 to 29 cm long and from 5 to 11 cm wide (average size, 16.75 cm long and 7.5 cm wide). The origin of the pedicle was from the lateral circumflex femoral artery system in 10 (83.3 percent) of 12 cases (the descending branch in seven cases and directly from the artery in three cases). In one case (8.3 percent), the origin was from the superficial femoral artery (Table 4).
The diameter of the pedicle ranged from 0.5 to 2.5 mm for the artery and from 1 to 3 mm for the vein (average, 1.63 mm and 1.97 mm, respectively). The average length of the pedicle was 7.72 cm (range, 6 to 10 cm).
Anatomical Anteromedial Thigh Flap Pedicle Study Group in Patients Undergoing Reconstruction with the Anterolateral Thigh Flap
Anteromedial thigh flap perforators were investigated during anterolateral thigh flap surgery. The perforators were found mainly in the superomedial and inferomedial quadrants of the preoperative circle marking. Septocutaneous perforators were found in 38 thighs (79 percent); 30 were nourished by the septocutaneous perforator only (25 flaps had one perforator, four flaps had two perforators, and one flap was supplied by multiple tiny perforators on the septum), and eight were based on two perforators (one septocutaneous and one musculocutaneous). Musculocutaneous perforators only were found in six cases (12.5 percent). No perforators were found in four cases (8.5 percent).
Thirty-nine perforators (81 percent) originated from the descending branch of the lateral circumflex femoral artery system (Fig. 3). Of these, 24 (61.5 percent) were “oblique” branches, 15 (38.5 percent) were from the lateral circumflex femoral artery itself, four (8.5 percent) were from the superficial femoral artery, and one was from the profunda femoris (2 percent). In four cases, no perforator was found (8.5 percent).
Cadaveric Anatomical Study
In this group, septocutaneous perforators were found in 26 thighs (54 percent) (Fig. 4). Of these, 24 were nourished by the septocutaneous perforator only (22 flaps had one perforator, one flap had two perforators, and one flap was supplied by multiple tiny perforators on the septum), and two were based on two perforators, one septocutaneous and one musculocutaneous. Musculocutaneous perforators only were found in four flaps (8.5 percent). No perforators were found in 18 cases (37.5 percent).
Concerning the origin of the pedicle, 26 perforators (54.5 percent) originated from the descending branch of the lateral circumflex femoral artery system. Of these, 15 (58 percent) were “oblique” branches, 11 (42 percent) were from the lateral circumflex femoral artery itself, two (4 percent) were from the superficial femoral artery, and two were from the profunda femoris (4 percent).
The chi-square test was rated between the first two groups (living patients) and among all three groups to show the homogeneity of the sample. An almost total consistency was observed between the first two groups; on the other hand, in the third group inserted in the test, homogeneity was minimal. Using “type of perforator” (septocutaneous or musculocutaneous) as the parameter, we highlighted an almost total consistency between groups 1 and 2 (χ2 = 0.164 and p = 0.92), while the third group was minimally homogeneous (χ2 = 13.7 and p = 0.0082). Using the parameter “origin of perforators,” we noticed the same trend, with a clear alignment between the first two groups (χ2 = 1.84 and p = 0.87) and a strong inhomogeneity in relation to the third group (χ2 = 19.8 and p = 0.03).
In the past, mere coverage of the defect was the goal of reconstructive surgery.16–20 In the present scenario, reconstructive surgeons, as well as their patients, do consider the final aesthetic result of the reconstruction and simultaneously weigh the donor-site morbidity. Free perforator flaps offer an adequate amount of tissue with reduced donor-site morbidity.3–6,21–25
Among them, the anteromedial thigh flap was first described by Song et al.9 in 1984, but even though it was reported more than 20 years ago, there are few descriptions concerning its clinical use.8–11,26–28 These described indications for anteromedial thigh flap use are generally related to chimeric flaps8,28 or, as an alternative procedure in case of a lack of or intraoperative damage to perforators, during anterolateral thigh flap harvest.6,29 Following these first descriptions, other studies described the origin of the pedicle of the anteromedial thigh flap,9–12,30–33 and only more recent studies34–37 focused on the number, position, caliber, and type of anteromedial thigh perforators.
Anteromedial Thigh Flap Surgical Anatomy
Part 1: Flap Pedicle
The restricted use of the anteromedial thigh flap is due to the anatomical variations in the pedicle of the flap. Its vascular anatomy, concerning the point of origin of the pedicle, the perforator, and its nomenclature, is still a debated issue. Initially, in 1984, Song et al.9 described an “innominate” branch of the lateral circumflex femoral artery that arises from the descending branch. They also described the point of exit of the perforator, located in the midsection of the thigh (in the narrow triangle formed by the sartorius muscle, rectus femoris muscle, and vastus medialis muscle), its length (up to 12 cm), and its caliber (>2 mm).
Subsequently, in 1988, Koshima et al.10 reported three anteromedial thigh flap cases in which the origin of the perforator was from the lateral circumflex femoral artery and not from the descending branch.
Shimizu et al.,12 in an anatomical study, included the anteromedial region of the thigh and found the perforators of this flap in 46 percent of the dissections only. In their drawings, the authors represented a division of the descending branch into two branches, where the medial one was considered the pedicle of the anteromedial thigh flap.
Ao et al.11 reported an anatomical review of four anteromedial thigh flap cases. They defined a lateral and a medial descending branch of the lateral circumflex femoral artery and six more branching points where the cutaneous perforator for the anterolateral thigh flap arises. While the lateral branch supplied the anterolateral thigh region, the medial branch supplied the anteromedial skin of the thigh. This study introduced for the first time the term “medial” descending branch as a branch of the descending branch of the lateral circumflex femoral artery.
The division of the descending branch into lateral and medial branches was first reported in 1988 by Xu et al.33 On the basis of their cadaver study, they stated that the descending branch divides into medial and lateral branches. They named lateral branch the perforator that supplies the skin, and medial the one that is usually named the descending branch, which runs distally until its connection with the lateral geniculate network. Between these two studies (Xu et al.’s 1988 study on the anterolateral thigh flap and Ao et al.’s 1999 study on the anteromedial thigh flap), the nomenclature is the same (medial and lateral descending branches of the lateral circumflex femoral artery) but the vessels clearly differ. In 2002, Valdatta et al.,30 following Ao and Xu’s nomenclature, described the vascular anatomy of the lateral circumflex femoral artery system. In their work on cadavers, they found in seven (43.75 percent) of 16 thighs a division of the descending branch of the lateral circumflex femoral artery laterally and medially. In one case, the medial descending branch arose directly from the lateral circumflex femoral artery. As a result, the medial branch of the artery (which was considered the pedicle of the anteromedial thigh flap)12 was absent in the 50 percent of cases (54 percent following the previous anatomical study).12
In our opinion, the nomenclature of the descending branches of the lateral circumflex femoral artery system as medial and lateral branches is incorrect.7,25 The descending branch of the artery is not normally divided into medial and lateral vessels, but gives off several branches to the neighboring muscles and has a well-defined course following the vastus lateralis medial edge.
Even though in 2004 Schoeller and associates,26 as well as others,8–10,22,28 reported a 100 percent reliability of the pedicle of this flap and found that its branching point, as well as the point of exit of the perforator, corresponds to the first description,9 we found different results concerning pedicle origin and flap perforator and between cadaveric and “in vivo” studies. In our clinical findings, the origin of the anteromedial thigh flap pedicle was from the descending branch in seven (58.3 percent) of 12 cases, from the lateral circumflex femoral artery in three (25 percent) of 12 cases, and from the superficial femoral artery in one (8.3 percent) of 12 cases. In this last case, the perforator ran inferolaterally to the sartorius muscle, thus differentiating this flap from the medial thigh flap described by Baek,31 in which the perforator arose superomedially to that muscle. In two cases we did not find a dominant perforator, and in only one case (8.3 percent) could we not harvest the anteromedial thigh flap.
According to our experience,6,25,38,39 and previous large clinical reports7,21,40 on anterolateral thigh flap anatomy as well as on recent selective radiological studies of the descending branch,41–43 we then suppose that the so-called medial descending branch is at the same time the artery, and the innominate perforator described by Song supplying the anteromedial thigh skin is the vessel that we call the “oblique” branch of the lateral circumflex femoral artery. Anyway, it is clear that its reliability is much more than the 46 percent described in the anatomical study as being a branch of the lateral circumflex femoral artery—in our combined clinical and dissection groups, a total of 75 of 108 cases (70 percent), with 10 clinical cases (83.3 percent), 39 cases in the anatomical study (81 percent), and 26 cases in the cadaver study (54.5 percent).
The difference between the anatomical studies and the clinical reports probably follows the high variability of the caliber of the anteromedial thigh flap pedicle and the different point at which it originates that we also encountered in our cases. The authors who named the anteromedial thigh flap pedicle the “medial” descending branch reported a limited presence of this vessel. The anteromedial thigh flap pedicle was probably considered to exist when a large vessel originating from the descending branch, named the medial descending branch, similar in size to the “lateral” descending branch, was present. As shown by our clinical “in vivo” findings, the anteromedial thigh flap pedicle caliber can be small (0.5 mm for the artery and 1 mm for the veins; Table 2), and was probably considered, in the previous anatomical studies, to be one of the branchlets of the descending branch,8–12,26–30,32,38,41 or it can be larger, as in cases in which the origin of the vessel is common to the branch vascularizing the rectus femoris, as shown by Hupkens et al.35
Moreover, an anteromedial thigh flap pedicle arising directly from the lateral circumflex femoral artery or from the femoral artery was not considered to be the pedicle of the flap. If we include flaps with more than 1.5 mm of arterial diameter pedicle, we conclude that an anteromedial thigh flap was possible in just 50 percent of cases.
Part 2: Flap Perforators
We all know the variability of the pedicle of several flaps but, as with the anterolateral thigh flap, from a surgical point of view, this does not change the surgical plan. Correspondingly, the variability of perforator size and location is constant, especially for the thigh area, and the anatomical studies may simply give a “gross” indication to the surgeon.34,44
Recently, a remarkable study showed a 21 percent total absence of cutaneous perforators in 100 thighs undergoing an anteromedial thigh flap dissection during anterolateral thigh flap harvest, reporting a single perforator in 62 thighs and a double perforator in 17.36 In our study, the cadaver dissection confirmed the difficulty of finding a proper perforator in almost half of the cases (18 cases, 37.5 percent) when compared with the clinical group of 12 anteromedial thigh flaps (one case, 8.3 percent) and the 48 clinical dissections (four cases, 8.5 percent) during anterolateral thigh flap harvest. We can assume an increased difficulty of finding perforators of small caliber in cadaver dissections when compared with the clinical dissections.
We believe that the differences between our “in vivo” dissection group (91.5 percent of anteromedial thigh flap perforator reliability) and the study by Yu and Selber36 (79 percent of anteromedial thigh flap perforator reliability) are based on a limited dissection on the medial side of the rectus femoris area. If the more lateral perforators coming from the superficial and the deep femoral artery (10.5 percent) are excluded, the results are similar to ours.
Nevertheless, these results seem to be in contrast with another study that showed 2.8 suitable large perforators per cadaver.35 However, this study investigated the perforator area between the sartorius and the gracilis muscles up to the inguinal ligament,35,37 a very large area indeed, if compared with the anteromedial thigh flap harvest area, giving a large amount of biased information for clinical practice.35
In addition, with the experience in flap and anatomical dissections, during an anteromedial thigh flap harvest, the surgeon has to look for a perforator located in the triangle formed by the rectus femoris, the sartorius, and the vastus medialis muscles. If not, according to other authors,35–37 one may harvest a flap based on a perforator coming from the superficial femoral artery because they are distally located, with a smaller and shorter caliber. In fact, proximal perforators from the deep or common femoral arterial system have a longer pedicle with a larger caliber and only if they originate from the “oblique” branch can a chimeric free flap with the anterolateral thigh flap be harvested.
The anteromedial thigh flap has several advantages. (1) Compared to other free fasciocutaneous flaps, it provides a large amount of tissue. (2) The anteromedial thigh flap does not require a change of position during the majority of reconstructive procedures. (3) The donor site allows for simultaneous flap harvest and tumor resection, thus reducing the operating time. (4) The donor region allows the scar to be hidden in a concealed area. (5) The donor region allows for primary closure of the defect. (6) The vascular pedicle is generally longer than 7.5 cm. (7) Sacrifice of the vascular pedicle does not harm blood circulation. (8) Two different venous systems can be used, one comitant and one superficial, coming from the great saphenous network. (9) Adipofascial flaps, nourished by the vascular network of the deep fascial plexus, and (10) neurosensorial flaps, by means of nerve coaptation, are also possible. (11) Harvest of the anteromedial thigh flap is easy and does not require long intramuscular dissection, as with the anterolateral thigh flap. (12) This flap provides adequate reconstruction for complex defects, can be bilobed if based on two perforators, and can be combined with the fascia lata, the rectus femoris muscle, and/or with the iliac bone as a chimeric flap using the lateral circumflex femoral artery.8,10,11,28 (13) The thinness and pliability of the anteromedial thigh flap skin (better than that of the anterolateral thigh flap)12 allow surgeons to tailor the skin in the desired fashion, thanks to the dense plexus network.31–45 (14) As with the anterolateral thigh flap,47 (compared with which it seems to have a more dense dermal plexus),32 it can be trimmed to the subdermal fat level, except for a limited area around the pedicle entry to the flap.
The disadvantages of this flap are minimal. (1) The flap skin contains, in some patients, a moderate amount of hair. (2) The donor-site scar in female patients may not be concealable and may require skin grafting.6,7,25,29 (3) Thus, in our opinion, the only real disadvantage of the anteromedial thigh flap is the variability in the caliber of its pedicle. Although this problem can be solved by more expert microsurgeons with the use of supramicrosurgery techniques (0.5- to 0.8-mm caliber)45 (Fig. 5), and by beginners harvesting the vessel from which the oblique branch of the lateral circumflex femoral artery originates, angio-computed tomographic scanning might show the anatomy of the pedicle preoperatively (Fig. 6), as our extensive studies clearly showed.42,43
In conclusion, even though we applied, in selected cases, the anteromedial thigh flap as a primary reconstructive option, in agreement with Yu and Selber,35 we think its current role is one of a counterpart to the anterolateral thigh flap when it has already been used, and as a complement in cases when multiple skin islands are required for three-dimensional reconstructions. If anatomic variations or unexpected events are encountered during anteromedial thigh flap harvest, alternative flaps (such as the anterolateral thigh flap or the tensor fasciae latae flap) can be elevated through the same incision, or more easily, by applying the concept of a free-style free flap, an alternative flap can fulfill the reconstructive requests.24
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