An unusual anatomical variant of the vascular anatomy in the anterolateral thigh free flap

Abstract

The anterolateral thigh flap is a fasciocutaneous flap based on the descending branch of the lateral circumflex femoral artery. The vascular pedicle and its perforators have a varied anatomical course that has led to difficulties in flap harvest. Many papers have described the anatomical variation in the origin and path of this vessel, but they all show one artery and two accompanying venae commitantes. The authors report the first case of duplication of the descending branch of the lateral circumflex femoral artery. They discuss whether this variation requires two arterial anastomoses.

The anterolateral thigh flap is a fasciocutaneous flap based on the perforators of the descending branch of the lateral circumflex femoral artery. First described in 1984, the anterolateral thigh flap is becoming popular for head and neck reconstruction as it has a number of advantages over other conventional free flaps. Many anatomical variations of the vascular pedicle have been described that make this free flap technically difficult to raise. The authors present another variation in the vascular pedicle anatomy.

Case Report

A 50-year-old male was referred to a tertiary referral centre with a T4N2b squamous cell carcinoma of the anterior floor of the mouth. He underwent tumour resection, bilateral selective neck dissections and reconstruction with a left anterolateral thigh free flap. Using a Doppler ultrasound probe, two septocutaneous perforators were identified and marked preoperatively.

Following tumour resection, a septocutaneous perforator flap with a 10 cm x 6 cm skin paddle was harvested ( Fig. 1 ). During pedicle dissection, duplication of the descending branch of the lateral circumflex femoral artery was noted. Both arteries were patent and positioned adjacent to each other anteroposteriorly in the intermuscular septum. The duplicated pedicle vessels were of equal length and their diameters were 2 mm and 2.5 mm ( Fig. 2 ). Two normal venae commitans were found in the correct position accompanying these aberrant pedicle arteries. A decision was made to utilise the larger diameter artery for microvascular anastomosis. Using an operating microscope and interrupted 9.0 monofilament suture, an end-to-end anastomosis of the larger pedicle artery to the facial artery and end-to-side anastomosis with the venae commitans to the internal jugular vein was performed. Good venous outflow was noted with bleeding from the free skin edges of the flap and the remaining pedicle artery was ligated.

Fig. 1
Anterolateral thigh flap skin paddle.

Fig. 2
Duplication of descending branch of the lateral circumflex artery (a) and (b) with accompanying venae commitans (c) and (d).
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Feb 8, 2018 | Posted by in Oral and Maxillofacial Surgery | Comments Off on An unusual anatomical variant of the vascular anatomy in the anterolateral thigh free flap
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