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Functional Reconstruction of a Large AnteriorThigh Defect Using
Contralateral AnterolateralThigh Flap with Tensor Fasciae Latae
andMotorized Vastus LateralisAlexander B. Dillon, BA1 Sammy Sinno,
MD1 Keith Blechman, MD1 Russell Berman, MD2Pierre Saadeh, MD11
Institute of Reconstructive Plastic Surgery, New York
UniversitySchool of Medicine, New York2Department of Surgery, New
York University School of Medicine,New YorkJ Reconstr Microsurg
2015;31:7982.
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Reconstructive surgeons strive to return to their patients what
fate has taken away, a mission particularly evident in limb salvage
surgery (LSS). Patients with soft tissue sarcomas, aggressive
tumors that require wide resections or amputation, have
particularly benefited from strides in this field that has been
made possible by cross-sectional imaging, adjuvant therapy, and
microsurgery. With equal to or greater than 5- year survival
outcomes compared with amputation, this multimodal approach has
become the standard of care
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The anterior thigh, the most common location of soft tissue
sarcomas,2 has become a focus of LSS efforts. Here, we reveal a
novel approach to a massive anterolateral thigh (ALT) deficit,
including the use of a neuromotor, neurosensory, composite
myocutaneous ALT graft from the contralateral thigh.
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Case StudyA 73-year-old man presented with an 8-month history of
left thigh pain and swelling. MRI and biopsy revealed a
near-circumferential myxoid liposarcoma measuring 31 X 50 cm. The
patient underwent 5 weeks of neoadjuvant radiation and preoperative
tumor embolization before aggressive surgical resection and
immediate reconstruction. Preoperatively, he ambulated with walker
and cane.
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Operative Resection
Oncologic surgeons performed a wide skin excision and
nearcomplete resection of the quadriceps compartment, iliotibial
tract, and femur periosteum. En bloc removal of the 7-pound
specimen left a 40 X 15 cm defect with exposed bone(Fig. 1).
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Fig. 1 The intraoperative defect.
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Reconstructive Approach
The reconstructive surgery team harvested a 35 X 15 cm
musculocutaneous free flap from the contralateral ALT including
tensor fascia latae and vastus lateralis muscles with preserved
motor nerve branches, iliotibial tract, and a dominant vascular
pedicle from the lateral femoral circumflex system (Fig. 2).
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Fig. 2 The donor flap on its pedicle.
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The donor site was closed primarily.
The lateral femoral circumflex artery and two accompanying venae
comitantes supplying the graft were anastomosed end-to-end with
those of the recipient site, followed by reapproximation of the
flaps motor supply to the contralateral posterior division of the
femoral nerve.
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The vastus lateralis and iliotibial tract fascia were tenodesed
proximally to the anterior superior iliac spine and pubis, and
distally to the patella tendon.
The lateral femoral Cutaneous nerves of the flap and recipient
site were then coapted to grant sensation to the skin island.
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Both motor and sensory nerve reapproximations were performed as
close to the donor tissue as possible to minimize the distance
required for nerve regeneration. A deep wound drain was placed, and
the skin flap secured in place to achieve complete wound coverage
(Fig. 3).
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Fig. 3 The closed recipient site
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The reconstructive procedure, including harvest and implant of
the free flap took a total of 5.5 hours, with a 200 ml estimated
blood loss. The graft showed signs of perfusion once
revascularized, and no signs of ischemia
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Postoperative Course
The postoperative course was uncomplicated and included knee
immobilization for 6 weeks and outpatient physical rehabilitation.
After 6 months of the surgery, the patient was fully healed and
able to extend his left knee 45 degrees from the seated
position
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There were no notable limitations of active knee flexion or hip
flexion or extension. The patient used a cane, and he ambulated
without assistance at home. The graft was sensate to light touch,
pain, and temperature and yielded 8-mm two-point discrimination.
There was no notable donor site morbidity
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DiscussionDebilitating soft tissue deficits, including loss of
entire muscle compartments not uncommon postsarcoma resection, have
prompted the use of innervated grafts to actively maintain function
in addition to restoring form.
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Optimal motorized donor flap considerations include the size,
strength,excursion of the muscle, the availability of overlying
skin, the functional role and redundancy of donor site musculature,
ease of access and dissection, and sustainability including blood
supply and innervation.
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At present, no level I or level II evidence exists to support
specific treatment options for anterior thigh muscle defects, due
to small case numbers and retrospective study designs
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We replaced likewith like, namely, our patients resected thigh
tissue with that of his contralateral thigh, ensuring an optimal
muscle and skin match.
We used the vastus lateralis :the largest, most powerful head of
the quadriceps, minimal donor site impairment. 3
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The noninnervated tensor fasciae latae muscle transfer
conveniently restored bulk to the recipient site, due to its close
proximity, with low cost, given its nonessential role in knee
stabilization. The partial iliotibial band transfer helped
stabilize the lateral knee and assist in hip mobility, while the
generous ALT skin island easily covered the large surface area of
the defect, and availability of its sensory nerve, the lateral
femoral cutaneous, allowed it to be reinnervated, maximizing the
chance of resensitization
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Though comparison across the small studies49 of various
approaches to similar defects is difficult, functional outcomes
appear most favorable when there is residual musculature to
accompany that transferred, and when local, pedicled muscle
transfers augment free muscle grafts. Whether or not the latter
combination represents the ideal treatment for functional ALT
deficits, the optimal free flap remains to be determined.7,10
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Our technique allowed allmissing tissue components to be
replaced with a single flap.
Our patient required no intraoperative repositioning, and his
supine position allowed for an expedited two-team approach.
Moreover, our flap lends more coverage than the others
described, with minimal donor site morbidity. Its long pedicle
length and large caliber artery help ensure its survival and
sustainability at the recipient site
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Summarywe report the first successful use of a composite,
sensate ALT flap with tensor fasciae latae and motorized vastus
lateralis muscles to reconstruct the anterior thigh and quadriceps
compartment, representing what we believe to be the optimal free
flap for this defect