Reconstruction: Review of the Literature and Case Reports

Robert J. Allen, MD
Aldo Guerra, MD
Scott K. Sullivan, MD

Abstract
More women than ever before are undergoing mastectomies secondary to increased awareness and screening. This has also caused a corresponding increase in the number of breast reconstructions requested each year. The demand for improved results has fueled recent advances in new techniques. Aside from implant reconstruction, the methods now being employed are related to autogenous donations and reconstruction. Currently, the most commonly used techniques for autogenous breast reconstruction are the DIEP (deep inferior epigastric perforator) and TRAM (transverse rectus abdominis myocutaneous) flaps from the lower abdomen.

The anterolateral thigh flap is a type of perforator flap usually described for use in head and neck reconstruction. The authors have discovered this flap's utility as an alternative in autogenous breast reconstruction when the abdomen is not available as a donor site. A review of the literature reveals a dearth of experience in using the anterolateral thigh flap for breast reconstruction. The artide reviews the literature with regard to current uses of the anterolateral thigh flap, and then reports three case studies which highlight the thigh flap as an excellent alternative for breast reconstruction in selected patients.

KEYWORDS: Autogenous breast reconstruction, thigh flap, perforator flap

With mammography screening guidelines to include women aged 40 years and above, more women are undergoing rnastectomies than ever before. After these procedures, women often choose to undergo breast reconstruction partly for restoration of their self-images. The need for better results and muscle-sparing alternatives for autogenous reconstruction have fueled research and the development of newer techniques. Through its evolution, breast reconstruction has come to include several modalities. Most familiar are those modalities dealing with silicone and, currently, saline implants. The latter are advantageous because they are simple to insert and relatively safe. However, they appear less natural than the normal breast, and often result in capsular contraction. After 4 years, the incident or capsular contraction is at least 30 percent, and increases in subsequent years. Additionally, implants tend to become more expensive than other techniques over several years. This is usually due to the need for removal of implants or capsulectomy secondary to contractures.

Because of the disadvantages of implant reconstruction, and the advantages of muscle-sparing techniques using perforator flaps, better results for patients have evolved over the last decade. This is clearly advantageous for women, because they are now provided with several alternatives in the type of reconstruction they prefer. With the disadvantages stated above, research and development have now encouraged newer micro- vascular techniques, including the perforator flaps and the free TRAM flaps.

Autogenous breast reconstruction is useful in areas where implant-based reconstruction is lacking. Silicone shell implants, by definition, cause capsular contracture. Additionally, muscle, fat, and skin without implants create a more natural feeling breast.³ Common to all autogenous breast reconstruction is the much longer initial surgical procedure. An added disadvantage with TRAM flaps is the morbidity associated with abdominal hernias and restricted range of motion.⁴

Anterolateral Thigh Flap

Perforator artery flaps are being performed in increasing numbers. Koshima and Soeda⁵ first described parauxnbilical perforator flaps in 1989. This technique involves the harvesting of free flaps based on dissection of the myocutaneous perforators, using fat and skin alone, while avoiding the use of muscle that can result in functional deficits. These perforator and muscle-sparing flaps can be based on the deep inferior epigastric perforator (DIEP), the superficial inferior epigastric artery (SIEA), the thorncodorsal artery perforator (T-DAP), or the superior gluteal artery perforator (S-GAP).6 Allen and Treece⁷ first introduced perforator flaps for breast reconstruction. Over 1000 perforator flaps for breast reconstruction have been successfully performed at the Louisiana State University Health Sciences Center since 1992. Based on our experience, there were fewer donor-site complications with the perforator flaps, especially complications involving abdominal hernias, bulges, and muscle weakness, when compared to the TRAM flaps.

The authors' most recent technique in breast reconstruction involves the use of the anterolateral thigh flap when abdominal tissue is not available. The thigh flap is not necessarily better or more advantageous than other types of perfurator flaps, but provides an additional donor site when traditional donor Sites are not available. Although there is some variation, the anterolateral thigh flap is usually based on the descending branch of the lateral circumflex femoral artery.⁸⁹ This flap was first reported by Baekin 1983, and soon after by Song et al. in 1984. The flap has a long vascular pedicle, moderate thickness, and a large cutaneous area. The donor site can be closed primarily or covered with a split- thickness skin graft.

Prior to its recent use in breast reconstruction, the thigh flap has been used for other types of reconstruction. Specifically, the anterolateral free flap has been used for coverage and reconstruction of the lower eyelid after excision of malignant melanoma, full thickness defects of the mandible or cheek,'³ and for pharyngoesophageal defects after radical resection of malignancy). The above procedures were all free flaps, but the anterolateral thigh flap can also be used as a pedicled flap. This was done for coverage of defects resulting from resection of abdominal tumors that extended to the anterior abdominal wall.'⁵ The anterolateral thigh flap has also been combined with a vascularized fibula graft for two patients with wide through-and-through oromandibular defects, as described by Koshima et al.¹⁶

Anatomy

In most cases, the descending branch of the lateral circumflex femoral artery (LCFA) supplies the anterolatcmi thigh flap. A Doppler probe can delineate the surface projection of the perforating artery from the LCFA. This area of projection is estimated to be at the midpoint of a line linking the anterior superior iliac spine and the superolateral border of the patella. The descending branch runs downward through the intermuscular space between the rectus femons and the vastus lateralis, and terminates in the vastus lateralis muscle near the knee joint. The cutaneous branches supply the skin overlying the vastus lateralis.

The cutaneous branches are classified into four types by Luo et al. First are the musculocutaneous perforators that penetrate the vastus lateralis muscle. These are the most common types. Second are the septocutaneous peforators that run between the rectus femoris and the vastus lateralis before entering the skin. Third, there are the direct cutaneous branches that arise from the transverse branch of the LCFA and pass through the fascia lata. Finally, there are the tiny cutaneous branches found on the surface of the vastus lateralis. If a sensate flap is desired, the lateral femoral cutaneous nerve (L2-3) must be included with the harvested flap. The largest branch of this nerve traverses downward along the previously mentioned line that extends from the antenor superior iliac spine down to the lateral border of the patella.

Anatomic Variations of the Pedicle

The major advantage of the thigh flap can also be its major disadvantage. While the length of the vascular pedicle can be helpful, it also has a great deal of vanation in its course along the thigh. In a 13-patient series reported by Koshima et al.~ in 1989, two vascular patterns of the septocutaneous perforator are described. In type 1, the septocutaneous perforator derives from the descending branch of the lateral circumflex femoral artery. However, only 3 of 13 patients demonstrated this type. In type 2, the septocutaneous perforators emerge directly from the profnnda femoris and not the LCFA. Five cases of 13 were of the type 2 variation. The five remaining cases were not included in either type because no septocutaneous perforating artery could be found,

Anatomic variation of the branching pattern of the perforators. The nutrient perforating artery of the anterolateral thigh flap is indicated by the asterisk. L. lateral circumflex femoral artery; D. descending branch of the lateral circumflex femoral artery; P. profunda femoris artery. In types 1, 2, and 3, the perforators arise from the descending branch. In types 4, 5, and 6, they arise from the lateral circumflex femoral artery. In type 7, they arise independently from the profunda femoris artery, and in type 8, they arise from the trunk of the femoral artery.

Figure 1 Anatomic variation of the branching pattern of perforators in anterolateral thigh flaps. (Reprinted with permission from Kimata Y, Uchiyama K, Ebihara S, et aI. Anatomical variations and technical problems of the anterolateral thigh flap: A report of 74 cases. Plast Reconstr Surg 1998;102:15172523). and the procedure was converted to a tensor fasciae latae or anteromediai thigh flap.

In a more extensive series that included 74 patients, Kimata et al.⁹ found a total of 171 perforators. There were 31 septocutaneous perforators and 140 muscuiocutaneous perforators. Only 70 of the 74 patients had any recognizable pcrforators at all. Therefore, of these 70 patients with perforators, Kimata and his team mapped out eight different types of anatomic variations. Figure 1 shows a schematic diagtam of those eight variations.⁹ This disadvantage of anatomic variation will be highlighted in the following case reports in which an anterolateral thigh flap is used for breast reconstruction. After doing a thorough literature review, these three case reports appear to be the only reported instances of an anterolateral thigh flap for the purpose of breast reconstruction, other than the five described by Wei et al.18.t9

CASE REPORTS

Case 1 A 43-year-old woman had a right modified radical mastectomy in 1998 for carcinoma of the right breast. She had immediate reconstruction with a DIEP flap. Her post-operative radiation caused progressive shrinking and fibrosis of the reconstructed right breast. To obtain better symmetry, an attempt was made to rotate an intercostal perforator flap to the right anterior chest wall. Although the rotated flap survived, the radiated breast flap then underwent partial necrosis at the site of insetting and subsequent infection that would not heal, even after 2 months of aggressive wound care (Fig. 2). Because her abdominal donor site was not available, the patient was scheduled for an anterolateral thigh flap to reconstruct the breast.

After placing the patient on the operating room table in the supine position, a two-team approach was used for the procedure. The recipient area on the tight anterior chest wall was prepared by excising the radiated right breast flap. Following removal, the second costal cartilage was removed to expose the right internal mammary artery and vein as recipient vessels, since these had previously been used at the third costal cartilage area for the DIEP flap.

At the same time another surgeon incised a vertical ellipse on the left anterior lateral thigh (Fig. 3). The area incised encompassed Doppler determined perforating vessels. Small perforators were found coming through the vastus lateralis and rectus femoris muscles, but no large subcutaneous perforator. Rather than convert to a tensor fasciae latae or anteromedial flap, the decision was made to suture the healthy flap back into place. A similar flap design and exploration was then performed on the right anterior thigh. This time, a large septocutaneous perforator was found coming off the descending branch of the lateral femoral circumflex artery The flap was harvested with this single perforator and had excellent perfusion (Fig. 4).

An end-to-end anastomosis was performed between the flap vessels and the right internal mammary artery and vein. Excellent perfusion was noted by Doppicr exam and capillary refill. After contouring, the flap was inset over a suction drain and sutured with a subcuticular closure. Thereafter, the donor site on the right anterior thigh was closed primarily. The total operative time was approximately 6 hr. Her postoperative picture several months later is shown in Figure 5. She is awaiting nipple reconstruction and a reduction mamxnoplasty on the contralateral breast for symmetry.

Case 2 A 56-year-old woman with a history of invasive carcinoma of the right breast was previous1y treated with a lumpectomy and axillary dissection. Follow-up mammography revealed a suspicious lesion that was confirmed as ductal carcinoma in situ. Following preoperative counseling, she elected to undergo a right cornpletion mastectomy and left prophylactic mastectomy with immcdiatc bilateral reconstruction with autogcnous tissue. The patient had a significant medical history that consisted of a fill abdominoplasty 15 years prior, and severe obesity After lengthy discussion, the patient elected to undergo a bilateral anterolaterat thigh perforator flap.

After patient placement on the operating room table in the supine position, the general surgeon proceeded with bilateral skin-sparing mastectomies. At the same time₁ the preoperatively marked anterolaterai thigh flaps were elevated in the medial to lateral direction (Fig. 6). The muscular septum between the rectus femoris and vastus lateralis was identified and the rectus was then mobilized medially. A large perforating vessel was noted to be coming from between the rectus femoris and vastus lateralis, with some branches perforating through the most medial border of the vastus lateralis and continuing into the subcutaneous tissue of the anterolateral thigh flap (Fig. 7). The remainder of the pedicle was meticulously dissected out and ligated at its origin from the profunda femoris. The contralateral side was elevated in a similar maimer.

Following the mastectomies, the third costal cartilage was removed from both sides to expose the internal mammary vessels. Each flap subsequently underwent an end-to-end anastomosis and was inset into the recipient sites. The donor sites were closed primarily. A postoperative view is seen several months later in Figure 8.

Case 3 The third anterolateral thigh flap in our series was performed on a 55-year-old woman who was diagnosed with left breast cancer one year prior to her breast reconstruction. She underwent a modified radical mastectomy followed by postoperative chemotherapy and radiation. The patient came to the plastic surgery clinic requesting breast reconstruction. Due to her obesity (die patient was 5'3 tall and weighed 242 pounds), she would be very susceptible to wound breakdown and infection at her abdominal incision. Obesity is a relative contraindication for using an abdominal flap. Obese patients have a high incidence of abdominal wound cornplications, as well as pulmonary complications. Postoperatively, patients can reduce their tidal volume due to increased abdominal pain. Therefore, an anterolateral thigh flap was suggested to the patient rather than a DIEP flap.

As in the other cases, a two-team approach was used. While one surgeon located the internal mammary vessels beneath the left third costal cartilage, another team elevated the anterolateral thigh flap. Preoperatively, the perforators to the right thigh were mapped out with the hand-held Doppler. After the patient was prepped and draped, an incision was made medial to the vastus lateralis over the rectus femoris and extended down to the muscle fascia. The flap was elevated superficial to the fascia, and two perforators were found: one from the descending branch of the lateral circumflex femoral artery (LCFA) and one from the transverse branch of the lateral femoral circumflex femoral artery. The former perforator was larger, and was selected as the pedicle on which to base the flap. The pedicle was dissected free from the muscular septum between the rectus femoris and vastus lateralis. An anastomosis of the donor and recipient vein and artery were performed under the operating microscope. After the anastomosis, the flap was inset onto the left chest wall between the superior and inferior skin flaps of the previous mastectomy. An indwelling Doppler cuff was placed around the venous anastomosis for postoperative monitoring. The donor site was closed primarily.

DISCUSSION

The unpredictable anatomic variations are very apparent in these case reports. In the first case, no adequate perforator was found in the left thigh. This is consistent with some patients in Koshima'sand Kimata's experience. While Koshima and Kimata salvaged the flap by converting to a musculocutaneous tensor fasciae latae or anteromedial thigh flap, there is a distinct effort to avoid musculocutaneous flaps in our institution. Because musculocutaneous flaps harvest musde, they may leave more residual functional defects. Therefore, in case 1, the patient underwent an anterolateral perforator thigh flap on the contralateral side, since no adequate perforator was found on the ipsilateral side.

In the second case, the large perforator was not the descending branch of the LCFA, but rather the perforator caine directly off the proflmda femoris. Finally, in the third case, the main perforator was located in the expected anatomic position, but there was a second perforator from a diflhrent vessel. These cases highlight the potential variation and subsequent difficulty in performing anterolateral thigh flaps.

Since this can be a relatively difficult flap, the indications for performing it should be dearly defined. The abdominal flap has become the standard autogenous tissue for breast reconstruction. However, approximately 15 percent of patients in our experience are not good candidates for use of the abdomen as a donor site for one reason or another. Donor sites then include the buttock, thigh, and back. The anterolateral thigh flap can be considered advantageous over a gluteal artery perforator flap, because it does not require repositioning of the patient between the harvesting and insetting of the flap. Bilateral simultaneous reconstruction is more feasible than with the gluteal artery perforator flap, also because of positioning. Body fat distribution varies in patients, making those with lipodystrophy of the thighs candidates for this procedure. In our institution, we would rank our donor-site preferences as abdomen, buttock, thigh, and back. In the hands of an experienced reconstructive surgeon, the anterolateral thigh flap is an excellent source of autogenous tissue fur breast reconstruction in selected circumstances.

REFERENCES

1. Handel N,Jenson JA, Black Qct aiThe fate of breast implants: a critical analysis of complications and outcomes. Plast Reconstr Surg 1995;%:1521
2. Kroll SS, Evans GRD, Reece GP, Ct a!. Comparison of resource costs between implant-based and TRAM flap breast reconstruction. Plast Reconstr Surg 1996;97:364
   
3. Kid! SS. Why autologous tissue? Clin Plast Surg 199%25~.2
4. Suominen 5, Asko.-Seljavaara 5, von Smitten K, et aL Scquelae in the abdominal wall after pedicalcd or free TRAM flap surgery. Ann Plast Surg 1996;36:629-36
5. Koshima I, Soeda S. Inferior epigastric artery skin flap without rcctus abdomjnis muscle. BrJ Plast Sing 1989;42:645-48
6. Allen RI. The superior glutcal artery perforator flap. Clin Plast Surg 1998;25:2
7. Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg 1994;32:32
8. Koshima I, Soeda S, Fulwda H, eta!. The anterolatcral thigh flap; variations in its vascular pedide. BrJ Plast Sing 1989;42:
   260-262
9. Kimata Y, Uchiyama K, Ebihara S, eta!. Anatomic variations and technical problems of the antemlateral thigh flap: a report of 74 cases. Plast Reconstr Surg 1998,102:15172523
10. Back S. Two new cutaneous free flaps: the media! and lateral thigh flaps. Plast Reconstr Surg 1983;71:354-363
11. Song YG, Chen G, Song YL. The free thigh flap: a new free flap concept based on the septocutaneous artery. Br J Plast Surg 1984;37:149259
    
12. Ogawa T, Nakayama B, Hasegawa Y, eta!. Treatment of malignant melanoma of the lower eyelid using anterolateral thigh flap. Antis Nasus Larynx 2000,27:79-82
    
13. Demirkan F, Chen HC, Wei Fe, Ct aL The versatile anterolateral thigh flap: a musculocutaneous flap in disguise in head and neck reconstruction. BrJ Plast Surg 200053:30-36
    
14. Kim HG, Ha B, Back CH, et al. The short head of the biceps femoris as a monitor for the free lateral thigh flap in pharyngocsophageal reconstruction. Br J Plast Surg 200154:62-66
    
15. Kimata Y, Uchiyama K, Sckido M, Ct a!. Anterolatcrsl thigh flap for abdominal wall reconstruction. Plaat Reconstr Surg
    1999103:11912197
16. Koshima 1, Hosoda S. Inagawa K, et a!. Free combined anterolateral thigh flap and vascularized fibula for wide, through- and-through oromandibular defects. J Reconstr Microsuxg
    1998;14:529-534
17. Luo S. Raffoul W, LuoJ, Ct a!. Axsterolateral thigh flap: a review of 168 cases. Microsurgery 1999,19:232-238
18. Cclik N, Wei FC, Suominen 5, eta!. Antemlateral thigh flap for poatmastectomy breast reconstruction. In: Shenaq SM, Homer LH, Allen RJ (eds.). Seminars in Phzstic Surgery~Adssznces in Breast Reco,ustyuction, vol. 16, no. 1. New Yorlc
    Thieme, 2002.
19. Wei FC, Suomincn 5, Cheng MM, et a!. Anterolateral thigh flap for postmastectomy breast reconstruction. Plast Reconstr Surg 2002;110:82-88