Clinical application of computed tomographic angiography in predicting the vascular pedicle length of the proximally-based anterolateral thigh flap_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

WANG Danying ¹ ,  LIU Yuanbo ¹ , CHEN Weiwei ² , ZANG Mengqing ¹ , ZHU Shan ¹ , CHEN Bo ¹ , LI Shanshan ¹

1. Scar Comprehensive Treatment Center, Plastic Surgery Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100144, P. R. China;
2. Radiology Department, Plastic Surgery Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100144, P. R. China;

Corresponding author：

LIU Yuanbo, Email: ybpumc@sina.com

Keywords：

Proximally-based anterolateral thigh flap; computed tomography angiography; vascular pedicle length; defect repair

DOI：

10.7507/1002-1892.202111002

Video：

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Objective To explore the reliability and effectiveness of prediction of the pedicle length of the proximally-based anterolateral thigh (pALT) flap which was used to repair the defects following the resection of various malignant tumors using computed tomographic angiography (CTA). Methods The clinical data of 12 patients who met the selection criteria by using pALT flap to repair wounds left after malignant tumor resection between June 2015 and December 2020 were retrospectively analyzed. There were 5 males and 7 females; the age ranged from 16 to 80 years, with an average age of 54.4 years. After tumor resection, the soft tissue defect ranged from 15 cm×5 cm to 30 cm×12 cm; defect sites included 4 cases of lower abdomen, 3 cases of groin, 2 cases of thigh, and 3 cases of buttocks. Preoperative CTA was used to obtain the location information of the descending branch of the lateral femoral circumflex artery and its perforators by maximum density projection, and the length of the pedicle of pALT flap was estimated. Fasciocutaneous flap (5 cases) or myocutaneous flap (7 cases) were cut during operation to repair the defect, and the size of flap ranged from 20 cm×7 cm to 30 cm×12 cm. The donor site of thigh was directly sutured (11 cases) or repaired with skin graft (1 case). Bland-Altman analysis was used to detect the consistency between the pALT flap vascular pedicle length estimated by CTA and the pALT flap vascular pedicle length actually obtained during operation. Results One case had distal blood supply disturbance of the flap and was repaired with skin graft after debridement; the remaining 11 flaps survived. All donor and recipient incisions healed by first intention. All 12 cases were followed up 1-12 months, with an average of 4.3 months. One patient died of pelvic tumor recurrence at 6 months after operation, and no tumor recurrence was found in the other patients. Preoperative CTA estimated that the length of pALT flap vascular pedicle was 9.3-24.7 cm, with an average of 14.7 cm; the actual length of pALT flap vascular pedicle was 9.5-25.0 cm, with an average of 14.8 cm. Bland-Altman analysis showed that there was no significant difference between the pALT flap vascular pedicle length estimated by CTA before operation and the pALT flap vascular pedicle length actually obtained during operation, and the average difference was 0.1 (95% consistency limit: –0.89, 0.74), indicating that they had good consistency. Conclusion CTA can be accurately used to localize the perforator and predict the possible pedicle length of the pALT flap. When performing a pALT flap surgery, preoperative CTA is helpful for surgeons to make a preliminary assessment of the difficult of the operation. The time for exploration of perforators and dissection of the vascular pedicle, and complications can be reduced, and the safety of the operation can be improved.

Citation： WANG Danying, LIU Yuanbo, CHEN Weiwei, ZANG Mengqing, ZHU Shan, CHEN Bo, LI Shanshan. Clinical application of computed tomographic angiography in predicting the vascular pedicle length of the proximally-based anterolateral thigh flap. Chinese Journal of Reparative and Reconstructive Surgery, 2022, 36(3): 322-328. doi: 10.7507/1002-1892.202111002 Copy

1.	Koshima I, Tai T, Yamasaki M. One-stage reconstruction of the penis using an innervated radial forearm osteocutaneous flap. J Reconstr Microsurg, 1986, 3(1): 19-26.
2.	Vijayasekaran A, Gibreel W, Carlsen BT, et al. Maximizing the utility of the pedicled anterolateral thigh flap for locoregional reconstruction: technical pearls and pitfalls. Clin Plast Surg, 2020, 47(4): 621-634.
3.	D’Arpa S, Claes K, Lumen N, et al. Urethral reconstruction in anterolateral thigh flap phalloplasty: A 93-case experience. Plast Reconstr Surg, 2019, 143(2): 382e-392e.
4.	Shen Y, Huang J, Dong MJ, et al. Application of computed tomography angiography mapping and located template for accurate location of perforator in head and neck reconstruction with anterolateral thigh perforator flap. Plast Reconstr Surg, 2016, 137(6): 1875-1885.
5.	Łuczewski Ł, Machczyński P, Marszałek S, et al. Colour Doppler sonography in the preoperative assessment of the vascular pedicle from the anterolateral thigh flap: proposal for a mathematical formula to predict pedicle length. Eur Arch Otorhinolaryngol, 2019, 276(3): 815-819.
6.	Powers JM, Martinez M, Zhang S, et al. A description of the vascular anatomy of the tensor fascia lata perforator flap using computed tomography angiography. Ann Plast Surg, 2018, 80(6S Suppl 6): S421-S425.
7.	Friji MT, Suri MP, Shankhdhar VK, et al. Pedicled anterolateral thigh flap: a versatile flap for difficult regional soft tissue reconstruction. Ann Plast Surg, 2010, 64(4): 458-461.
8.	Bharath SP, Madhusudan G, Manjunath S. Pedicled anterolateral thigh flap for contralateral groin composite defect. Indian J Plast Surg, 2010, 43(1): 103-105.
9.	Lannon DA, Ross GL, Addison PD, et al. Versatility of the proximally pedicled anterolateral thigh flap and its use in complex abdominal and pelvic reconstruction. Plast Reconstr Surg, 2011, 127(2): 677-688.
10.	刘元波, 朱珊, 臧梦青, 等. 穿支皮瓣研究领域的新技术、新方法. 中华整形外科杂志, 2019, 35(9): 835-846.
11.	González Martínez J, Torres Pérez A, Gijón Vega M, et al. Preoperative vascular planning of free flaps: comparative study of computed tomographic angiography, color doppler ultrasonography, and hand-held doppler. Plast Reconstr Surg, 2020, 146(2): 227-237.
12.	Malhotra A, Chhaya N, Nsiah-Sarbeng P, et al. CT-guided deep inferior epigastric perforator (DIEP) flap localization-better for the patient, the surgeon, and the hospital. Clin Radiol, 2013, 68(2): 131-138.
13.	Chen SY, Lin WC, Deng SC, et al. Assessment of the perforators of anterolateral thigh flaps using 64-section multidetector computed tomographic angiography in head and neck cancer reconstruction. Eur J Surg Oncol, 2010, 36(10): 1004-1011.
14.	Yang JF, Wang BY, Zhao ZH, et al. Clinical applications of preoperative perforator planning using CT angiography in the anterolateral thigh perforator flap transplantation. Clin Radiol, 2013, 68(6): 568-573.
15.	Fuse Y, Yoshimatsu H, Karakawa R, et al. Pedicled anterolateral thigh flap transfer for the reconstruction of a large gluteal defect assisted by preoperative computed tomographic angiography and intraoperative indocyanine green angiography: A case report. Microsurgery, 2021, 41(8): 777-781.
16.	Teo TC. The propeller flap concept. Clin Plast Surg, 2010, 37(4): 615-626.
17.	Tamai M, Nagasao T, Miki T, et al. Rotation arc of pedicled anterolateral thigh flap for abdominal wall reconstruction: How far can it reach? J Plast Reconstr Aesthet Surg, 2015, 68(10): 1417-1424.
18.	Collins J, Ayeni O, Thoma A. A systematic review of anterolateral thigh flap donor site morbidity. Can J Plast Surg, 2012, 20(1): 17-23.
19.	Kimata Y, Uchiyama K, Sekido M, et al. Anterolateral thigh flap for abdominal wall reconstruction. Plast Reconstr Surg, 1999, 103(4): 1191-1197.
20.	Kim S, Lee KT. Abdominal wall reconstruction using anterolateral thigh flap with microsurgical pedicle lengthening technique: a case report. Microsurgery, 2020, 40(6): 700-703.

1. Koshima I, Tai T, Yamasaki M. One-stage reconstruction of the penis using an innervated radial forearm osteocutaneous flap. J Reconstr Microsurg, 1986, 3(1): 19-26.
2. Vijayasekaran A, Gibreel W, Carlsen BT, et al. Maximizing the utility of the pedicled anterolateral thigh flap for locoregional reconstruction: technical pearls and pitfalls. Clin Plast Surg, 2020, 47(4): 621-634.
3. D’Arpa S, Claes K, Lumen N, et al. Urethral reconstruction in anterolateral thigh flap phalloplasty: A 93-case experience. Plast Reconstr Surg, 2019, 143(2): 382e-392e.
4. Shen Y, Huang J, Dong MJ, et al. Application of computed tomography angiography mapping and located template for accurate location of perforator in head and neck reconstruction with anterolateral thigh perforator flap. Plast Reconstr Surg, 2016, 137(6): 1875-1885.
5. Łuczewski Ł, Machczyński P, Marszałek S, et al. Colour Doppler sonography in the preoperative assessment of the vascular pedicle from the anterolateral thigh flap: proposal for a mathematical formula to predict pedicle length. Eur Arch Otorhinolaryngol, 2019, 276(3): 815-819.
6. Powers JM, Martinez M, Zhang S, et al. A description of the vascular anatomy of the tensor fascia lata perforator flap using computed tomography angiography. Ann Plast Surg, 2018, 80(6S Suppl 6): S421-S425.
7. Friji MT, Suri MP, Shankhdhar VK, et al. Pedicled anterolateral thigh flap: a versatile flap for difficult regional soft tissue reconstruction. Ann Plast Surg, 2010, 64(4): 458-461.
8. Bharath SP, Madhusudan G, Manjunath S. Pedicled anterolateral thigh flap for contralateral groin composite defect. Indian J Plast Surg, 2010, 43(1): 103-105.
9. Lannon DA, Ross GL, Addison PD, et al. Versatility of the proximally pedicled anterolateral thigh flap and its use in complex abdominal and pelvic reconstruction. Plast Reconstr Surg, 2011, 127(2): 677-688.
10. 刘元波, 朱珊, 臧梦青, 等. 穿支皮瓣研究领域的新技术、新方法. 中华整形外科杂志, 2019, 35(9): 835-846.
11. González Martínez J, Torres Pérez A, Gijón Vega M, et al. Preoperative vascular planning of free flaps: comparative study of computed tomographic angiography, color doppler ultrasonography, and hand-held doppler. Plast Reconstr Surg, 2020, 146(2): 227-237.
12. Malhotra A, Chhaya N, Nsiah-Sarbeng P, et al. CT-guided deep inferior epigastric perforator (DIEP) flap localization-better for the patient, the surgeon, and the hospital. Clin Radiol, 2013, 68(2): 131-138.
13. Chen SY, Lin WC, Deng SC, et al. Assessment of the perforators of anterolateral thigh flaps using 64-section multidetector computed tomographic angiography in head and neck cancer reconstruction. Eur J Surg Oncol, 2010, 36(10): 1004-1011.
14. Yang JF, Wang BY, Zhao ZH, et al. Clinical applications of preoperative perforator planning using CT angiography in the anterolateral thigh perforator flap transplantation. Clin Radiol, 2013, 68(6): 568-573.
15. Fuse Y, Yoshimatsu H, Karakawa R, et al. Pedicled anterolateral thigh flap transfer for the reconstruction of a large gluteal defect assisted by preoperative computed tomographic angiography and intraoperative indocyanine green angiography: A case report. Microsurgery, 2021, 41(8): 777-781.
16. Teo TC. The propeller flap concept. Clin Plast Surg, 2010, 37(4): 615-626.
17. Tamai M, Nagasao T, Miki T, et al. Rotation arc of pedicled anterolateral thigh flap for abdominal wall reconstruction: How far can it reach? J Plast Reconstr Aesthet Surg, 2015, 68(10): 1417-1424.
18. Collins J, Ayeni O, Thoma A. A systematic review of anterolateral thigh flap donor site morbidity. Can J Plast Surg, 2012, 20(1): 17-23.
19. Kimata Y, Uchiyama K, Sekido M, et al. Anterolateral thigh flap for abdominal wall reconstruction. Plast Reconstr Surg, 1999, 103(4): 1191-1197.
20. Kim S, Lee KT. Abdominal wall reconstruction using anterolateral thigh flap with microsurgical pedicle lengthening technique: a case report. Microsurgery, 2020, 40(6): 700-703.

Chinese Journal of Reparative and Reconstructive Surgery

Clinical application of computed tomographic angiography in predicting the vascular pedicle length of the proximally-based anterolateral thigh flap

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