Atlas Phẫu Thuật Vi Phẫu Mạch Máu (Atlas of Microvascular Surgery)

Figure 5–24
Anatomy of the DCIA.
1. Spermatic cord
2. DCIA
3. Inguinal ligament
4. Ascending branch of DCIA
5. External iliac a.
6. External oblique aponeurosis
7. ASIS
8. Transversus m.
9. Internal oblique m.
VASCULARIZED ILIAC BONE GRAFT
Anatomy of the Deep Circum ex Iliac
Artery (Fig. 5–24)
The DCIA (2) arises from the posterolateral aspect of the
external iliac artery (5), just above the inguinal liga-
m ent (3). It runs parallel to the ligam ent toward the
ASIS (7) in the fascial sheath formed by the junction of
the transversalis and iliac fascia.
Approxim ately 1 cm m edial to the ASIS, the artery
gives off a large ascending branch (4) that pierces the
transversus abdom inis m uscle and then runs superi-
orly along the undersurface of the internal oblique
m uscle.
After giving off the ascending branch, the DCIA
penetrates the transversalis fascia and passes along the
inner lip of the iliac crest, 2 cm below the surface of
the crest in the line of fusion between the iliacus and
the transversalis fascia, ending at about the midpoint
of the crest 6 to 9 cm beyond the ASIS, where it reenters
the transversus abdom inis to anastom ose with the
iliolumbar and superior gluteus arteries. In its course
along the iliac crest, the DCIA gives off perforators to
the adjacent muscles and skin.
Venous Drainage
A vena com itans accom panies the artery. Usually, it
diverges upward from the artery before draining into
the external iliac vein.
VASCULARIZED ILIAC BONE GRAFT
179
Measurements
Diameter (mm)
Length of
Range
Average
Pedicle (cm)
Deep
Artery
1.5–3.0
2.0
5–6
circum ex
Vein
2.0–4.0
3.0
5–6
iliac
Ascending
~ 1.0
branch

Figures 5–25
Variations in the ascending branch of the DCIA (see text for details).
Variations in the Ascending Branch of the
Deep Circum ex Iliac Artery (Fig. 5–25)
A. The branch originates w ithin 1 cm m edial to the
ASIS (65%).
B. The branch originates 2 to 4 cm from the ASIS (15%).
C. There is no single vessel but two to three sm all
branches near the ASIS (20%).
180
II.5 LOWER EXTREMITY: GROIN REGION

Figure 5–26
Anatomy of the iliac bone.
A. Lateral view of ilium
3. Tubercle of crest
B. Medial view of ilium
4. Posterior superior iliac spine
1. ASIS
5. Posterior inferior iliac spine
2. Anterior inferior iliac spine
6. Iliac fossa
Anatomy of the Iliac Bone (Fig. 5–26)
The iliac crest, the upper border of the ilium, is convex
above but sinuously curved and concave inward in its
front part; it is concave outward in its posterior part.
The entire length of the crest is 23 cm; the anterior 14 cm
can usually be applied clinically for bone graft. The
average thickness of the iliac crest is indicated below.
Measurements
Thickness (cm)
Anterior Superior Iliac Spine
1.4
Tubercle of the Crest
1.7
Midpoint of the Crest
0.8
Posterior Superior Iliac Spine
2.2
VASCULARIZED ILIAC BONE GRAFT
181
This has been one of the most common donor sites for
vascularized bone graft because the consistent vascular
anatomy, long pedicle length, and adequate vessel diam-
eter make the procedure reliable and safe. A good quality
of iliac bone is provided in suf cient amounts. The natu-
ral curvature of the iliac bone is ideally suited for
mandibular reconstruction, using the ipsilateral or con-
tralateral crest, depending on which segment of the
mandible needs rebuilding. The bone can also be used for
certain bone defects in the extremities. In extraordinary
circumstances, this vascularized bone graft is indicated
for a bony defect after complete removal of juxta-articular
giant cell tumor of the long bone in the upper and lower
extremities. However, for large, long-bone defects, a
vascularized bula graft would be the better choice.
The donor defect should be carefully closed because
a potential for abdominal herniation still remains.
The DCIA dom inantly supplies the inner lip and
cortex of the iliac crest and body; the SCIA supplies the
overlying skin; the superior gluteal artery supplies the
outer lip and cortex of the iliac crest and body.
Among the vessels, the DCIA is the m ost reliable in
supplying the iliac bone; it is therefore the preferred
choice in vascularized iliac bone graft procedures.
COMMENT AND INSIGHTS

Figure 5–27
Incision.
1. External iliac a. and v.
2. External oblique aponeurosis
3. Inguinal ligament
4. Internal oblique m.
5. DCIA
6. Transversus abdominis m.
7. Lateral cutaneous n. of thigh
8. Iliac crest
9. Iliacus m.
10. Ascending branch
11. Gluteus m. and tensor
fasciae latae (TFL) m.
VASCULARIZED ILIAC BONE GRAFT
(BASED ON THE DEEP CIRCUMFLEX
ILIAC ARTERY)
Incision (Fig. 5–27)
The patient is placed in a supine position with a sandbag
under the buttock. The incision runs along the upper
border of the inguinal ligament and iliac crest, extending
for the required distance.
182
II.5 LOWER EXTREMITY: GROIN REGION

Figure 5–28
Approach to the DCIA pedicle
in the groin.
1. External iliac a. and v.
2. External oblique aponeurosis
3. Inguinal ligament
4. Internal oblique m.
5. DCIA
Approach to the DCIA Pedicle in the
Groin (Fig. 5–28)
Through the m edial incision, the external oblique
aponeurosis (2) is split parallel with and 1 cm above
the upper edge of the inguinal ligam ent (3) from
the midpoint of the ligament to the ASIS. Retracting the
sperm atic cord or round ligam ent m edially and
upward, the posterior wall of the inguinal canal,
consisting of the transversalis fascia at this point, is
exposed and the external iliac artery (1) can then be
palpated.
VASCULARIZED ILIAC BONE GRAFT (BASED ON THE DEEP CIRCUMFLEX ILIAC ARTERY)
183

Figure 5–29
Dissection of DCIA in the groin.
4. Internal oblique m.
5. DCIA
6. Transversus abdominis m.
7. Lateral cutaneous n. of thigh
9. Iliacus
10. Ascending branch
Dissection of DCIA in the Groin
(Fig. 5–29)
Following the dissection of the external iliac artery, the
vascular bundle of the DCIA (5) is identi ed and
dissected laterally in the sheath of the transversalis
fascia, while the arching bers of the internal oblique
and transversus m uscles (4,6) are detached from the
inguinal ligament. Finding the ascending branch (10) at
a point 1 cm above and medial to the ASIS between the
internal oblique and transversus muscles and tracing it
down usually makes identi cation and dissection of the
vascular pedicle easier and faster.
Meanwhile, the lateral femoral cutaneous nerve (7)
is found in this region. In some cases when it is under
the vessels, its continuity can be preserved. In other
cases, it must be divided and repaired if it is super cial
to the vessels.
184
II.5 LOWER EXTREMITY: GROIN REGION

Figure 5–30
Dissection of the DCIA in
the inner space of the ilium.
5. DCIA
8. Iliac crest
9. Iliacus m.
Dissection of the DCIA in the Inner
Space of the Ilium (Fig. 5–30)
Following the dissection of the vascular pedicle, the
incision is extended on the iliac crest (8). In the upper
lateral dissection, the three layers of abdom inal
m uscles are detached from the crest. The ascending
branch is ligated and the DCIA (5) is traced laterally by
dividing the transversalis fascia and separating
extraperitoneal fat from the iliacus (9), keeping this
vascular bundle intact with the iliacus m uscle.
The iliacus fascia and muscle are divided at least
1 cm below the course of the DCIA (5) onto them, to
expose the inner surface of the ilium. The distal end of
this vessel is ligated.
VASCULARIZED ILIAC BONE GRAFT (BASED ON THE DEEP CIRCUMFLEX ILIAC ARTERY)
185

Figure 5–31
Exposure of the outer ilium.
8. Iliac crest
11. Gluteus m. and TFL m.
Exposure of the Outer Ilium
(Fig. 5–31)
For aps requiring the full thickness of iliac crest, the
lower lateral dissection requires the TFL and gluteus
m edius (11) to be detached from the outer lip and
cortex of the iliac crest and body subperiosteally.
186
II.5 LOWER EXTREMITY: GROIN REGION

Figure 5–32
Osteotomy for whole layer of iliac
crest.
5. DCIA
8. Iliac crest
9. Iliacus m.
Osteotomy for Whole Layer of Iliac
Crest (Fig. 5–32)
According to the requirem ents of size and shape, a
segment of the iliac bone (8) is divided with an oscillating
saw. For a better appearance at the donor site postoper-
atively, it is advisable to leave the ASIS in situ.
VASCULARIZED ILIAC BONE GRAFT (BASED ON THE DEEP CIRCUMFLEX ILIAC ARTERY)
187

Figure 5–33
Osteotomy for the inner lip of iliac
crest.
5. DCIA
8. Iliac crest
9. Iliacus m.
Osteotomy for the Inner Lip of Iliac
Crest (Fig. 5–33)
More commonly, the inner lip of the iliac crest alone is
needed clinically. It can be isolated on the DCIA (5)
independently, providing a less bulky ap and less
deform ity at the donor site.
188
II.5 LOWER EXTREMITY: GROIN REGION

Figure 5–34
Suturing between the iliacus and transversalis
for inner layer.
2. External oblique aponeurosis
4. Internal oblique m.
6. Transversus abdominis m.
9. Iliacus m.
Donor Closure
Suturing Between the Iliacus and
Transversalis for Inner Layer
(Fig. 5–34)
The closure of this donor site m ust be perform ed
meticulously to prevent postoperative herniation. The
iliacus m uscle (9) and fascia should be sutured to the
transversus abdominis muscle (6) and fascia.
VASCULARIZED ILIAC BONE GRAFT (BASED ON THE DEEP CIRCUMFLEX ILIAC ARTERY)
189

Figure 5–35
Suturing for the middle and outer layers.
2. External oblique aponeurosis
11. Gluteus m. and TFL m.
Suturing for the Middle and Outer Layers
(Fig. 5–35)
The internal and external oblique muscle (2) should be
sutured to the gluteal and TFL muscles (11). The inguinal
canal and ligam ent should also be repaired if they have
been divided.
190
II.5 LOWER EXTREMITY: GROIN REGION

Figure 5–36
Flap design (anteroposterior view).
1. External iliac a. and v.
2. DCIA
3. Inguinal ligament
4. Iliacus m.
5. Iliac bone
6. Glutei m. and TFL m.
7. Fringe of three layers of abdominal m.
ILIAC OSTEOCUTANEOUS FLAP (BASED ON THE DEEP CIRCUMFLEX ILIAC ARTERY)
191
Figure 5–37
Flap design in oblique view.
ILIAC OSTEOCUTANEOUS FLAP
(BASED ON THE DEEP CIRCUMFLEX
ILIAC ARTERY)
Flap Design (Figs. 5–36, 5–37)
The axial line of the skin ap is placed along the
upper border of the anterior part of the iliac crest.
The largest skin area reported for this osteocuta-
neous ap is 20
16 cm.

Figure 5–38
Exposure and dissection of DCIA.
1. External iliac a. and v.
2. DCIA
3. Inguinal ligament
4. Iliacus m.
5. Iliac bone
7. Fringe of three layers of abdominal m.
Exposure and Dissection of DCIA
(Fig. 5–38)
The vascular pedicle of the DCIA (2) in the inguinal
region is dissected as previously described. The upper
border of the skin ap is incised. The three layers of the
abdominal muscle (7) are divided, leaving a 2 to 3 cm
fringe with the skin ap to attach to the bone. Dividing
the transversalis fascia, the continuation of the DCIA in
the line of fusion between the iliacus and the transver-
salis fascia is identi ed.
192
II.5 LOWER EXTREMITY: GROIN REGION

ILIAC OSTEOCUTANEOUS FLAP (BASED ON THE DEEP CIRCUMFLEX ILIAC ARTERY)
193
Figure 5–39
Elevation of the lower
portion of the ap.
5. Iliac bone
6. Glutei m. and TFL m.
Elevation of the Lower Portion of the
Flap (Fig. 5–39)
The lower border of the skin ap is incised. The TFL and
gluteal muscles (6) are detached from the ilium (5).

Figure 5–40
Osteotomy for whole layer of ilium.
2. DCIA
5. Iliac bone
7. Fringe of three layers of abdominal m.
Osteotomy for Whole Layer of
Ilium (Fig. 5–40)
The required segment of the ilium (5) is divided and the
osteocutaneous ap is raised.
194
II.5 LOWER EXTREMITY: GROIN REGION

ILIAC OSTEOCUTANEOUS FLAP (BASED ON THE DEEP CIRCUMFLEX ILIAC ARTERY)
195
Figure 5–41
Osteotomy for the inner table of
ilium
1. External iliac a. and v.
2. DCIA
5. Iliac bone
7. Fringe of three layers of abdominal m.
Osteotomy for the Inner Table of
Ilium (Fig. 5–41)
Clinically, the inner table alone is used for the iliac
osteocutaneous ap.

Figure 5–42
Anatomy of the internal oblique muscle
and its blood supply.
1. Internal oblique m.
2. External oblique m.
3. DCIA
INTERNAL OBLIQUE FLAP
Anatomy (Fig. 5–42)
The origins of the m uscle are the lateral half of the
inguinal ligament, the anterior iliac crest, and the lum-
bodorsal fascia. Insertion includes the costal cartilage
of the lower three or four ribs, the rectus sheath, and
the pubis. The shape of the muscle is broad and at,
and its functions include compression of the abdominal
contents. Innervation is segmentally from the eighth to
twelth intercostals, iliohypogastric, and ilioinguinal
nerves.
Blood Supply
The DCIA (3) (see section on vascularized iliac bone
graft) gives off an ascending branch (5), usually at a
point 1 cm medial to the ASIS. After piercing the trans-
versus muscle, the branch ascends between it and the
internal oblique m uscle (1), eventually to anastomose
with the inferior epigastric artery. The ascending
branch is often more than 1 mm in diameter. (For vari-
ations of this branch, also see the section on the vascu-
larized iliac bone graft.)
196
II.5 LOWER EXTREMITY: GROIN REGION
This ap provides a thin and broad muscle, with a thick-
ness of 0.5 to 1.0 cm and a maximum dimension of 10
15 cm reported. Because the DCIA and its ascending
branch are anatomically constant, length and diam eter
of the vascular pedicle are quite adequate for microvas-
cular anastomosis. The procedure is thus very reliable
and safe. The ascending branch has no cutaneous blood
supply and cannot be used in a myocutaneous ap;
however, by combining the DCIA vessels, the iliac bone
can be com bined with its overlying skin in an iliac
osteocutaneous ap. All donor sites can be closed pri-
m arily, and the scar is inconspicuous and acceptable.
Sequelae to use of this ap include the potential for
abdominal wall weakness or herniation. Also, this muscle
flap cannot be transferred for functional repair because
of its segm ental innervation.
COMMENT AND INSIGHTS
4. External iliac a.
5. Ascending branch
6. ASIS

INTERNAL OBLIQUE MUSCLE FLAP
197
INTERNAL OBLIQUE MUSCLE FLAP
Incision (Fig. 5–43)
An incision is made above and parallel to the
lateral two thirds of the inguinal ligam ent,
extending for a short distance toward the tip of
the scapula.
Exposure of the Muscle
(Fig. 5–44)
The external oblique aponeurosis and muscle
(1) are incised to expose the internal oblique
muscle (2).
Figure 5–43
Incision
1. External oblique m.
2. Internal oblique m.
3. Transversus abdominis m.
4. DCIA
5. Ascending branch
6. ASIS
7. External iliac a. and v.
Figure 5–44
Exposure of the muscle.
1. External oblique m.
2. Internal oblique m.
6. ASIS

198
II.5 LOWER EXTREMITY: GROIN REGION
Figure 5–45
Elevation of muscle and
identi cation of ascending branch of DCIA.
1. External oblique m.
2. Internal oblique m.
3. Transversus abdominis m.
5. Ascending branch
6. ASIS
Elevation of Muscle Flap and
Identi cation of Ascending
Branch of DCIA (Fig. 5–45)
The internal oblique muscle (2) is divided transversely,
just below the costal margin and elevated by dissection
in a plane between it and the transversus abdominis
muscle (3).
The ascending branch (5) is identi ed on the un-
dersurface of the internal oblique m uscle (2); this is
then detached from the rectus sheath, freeing the
muscle from the transversus abdom inis and leaving the
ascending branch (5) attached to the undersurface of
the muscle.

INTERNAL OBLIQUE MUSCLE FLAP
199
Figure 5–46
Pedicle dissection.
3. Transversus abdominis m.
4. DCIA
5. Ascending branch
7. External iliac a. and v.
Pedicle Dissection (Fig. 5–46)
The internal oblique muscle is detached from the iliac
crest, and the ascending branch (5) is traced to identify
the DCIA (4) that lies in a sheath formed by the junction
of the transversalis and iliacus fascia. (This can be
dissected following the procedure described in the
section on vascularized iliac bone graft.)
The distal continuation of the DCIA is ligated and
the muscle ap is raised, with a pedicle length of 6 to
7 cm.

200
II.5 LOWER EXTREMITY: GROIN REGION
Figure 5–47
Composite pattern
of this osteomuscular ap.
4. DCIA
5. Ascending branch
6. ASIS
7. External iliac a. and v.
INTERNAL OBLIQUE
OSTEOMUSCULAR FLAP
Composite Pattern of This
Osteomuscular Flap (Fig. 5–47)
A com bination of m uscle ap with vascularized iliac
bone (6) can be designed for particular clinical purposes
by utilizing the DCIA (4) and its supply, as well.

BIBLIOGRAPHY
201
BIBLIOGRAPHY
Ao M, Mae O, Namba Y, Asagoe K. Perforator-based ap
for coverage of lum bosacral defects. Plast Reconstr
Surg 1998;101:987
Arnez ZM, Khan U, Pogorelec D, Planinsek F. Breast
reconstruction using the free super cial inferior epi-
gastric artery (SIEA) ap. Br J Plast Surg 1999;52:276
Chuang DC-C, Jeng S-F, Chen H-T, et al. Experience of
73 free groin aps. Br J Plast Surg 1992;45:81
Cooper TM, Leewis N, Baldw in MA. Free groin ap
revisited. Plast Reconstr Surg 1999;103:918
Forrest C, Boyd B, Manktelow R, et al. The free vascu-
larised iliac crest tissue transfer: donor site complica-
tions associated with eighty-two cases. Br J Plast Surg
1992;45:89
Franklin JD, Shack RB, Stone JD, et al. Single-stage
reconstruction of m andible and soft tissue defects
using a free osteocutaneous groin ap. Am J Surg
1980;140:492
Graf P, Biemer E. Morbidity of the groin ap transfer:
are we getting som ething for nothing? Br J Plast Surg
1992;45:86
Harpf C, Gabl M, Reinhart C, et al. Small free vascular-
ized iliac crest bone grafts in reconstruction of the
scaphoid bone: a retrospective study of 60 cases. Plast
Reconstr Surg 2001;108:664
Hayashi A, Maruyama Y, Okajima Y, Motegi M. Vascu-
larized iliac bone graft based on a pedicle of upper
lumbar vessels for anterior fusion of the thoraco-lum-
bar spine. Br J Plast Surg 1994;47:425
Huang G-K, Hu R-Q, Hua M, et al. Microvascular free
transfer of iliac bone based on the deep superior
branches of the superior gluteal vessels. Plast Reconstr
Surg 1985;75:68
Igawa HH, Minakawa H, Sugihara T. Functional alveolar
ridge reconstruction with prefabricated iliac crest free
ap and osseointegrated implants after hemimaxillec-
tomy. Plast Reconstr Surg 1998;102:2420
Kato H, Hasegawa M, Takada T, Torii S. The lum bar
artery perforator based island ap: anatom ical study
and case reports. Br J Plast Surg 1999;52:541
Kimata Y, Uchiyam a K, Sakuraba M, et al. Deep circum-
ex iliac perforator ap with iliac crest for mandibular
reconstruction. Br J Plast Surg 2001;54:487
Kum ta SM, Leung PC, Yip K, et al. Vascularized bone
grafts in the treatm ent of juxta-articular giant-cell
tum ors of the bone. J Reconstr Microsurg 1998;
14:185
Kuzbari R, Worseg A, Burggasser G, et al. The external
oblique muscle free ap. Plast Reconstr Surg 1997;
99:1338
McCrabb DJ. The prevention of hernia and numbness of
the thigh following deep circum ex iliac artery free
groin ap. Plast Reconstr Surg 1980;66:477
Mialhe C, Brice M. A new compound osteo-myocuta-
neous free ap: the posterior iliac artery ap. Br J Plast
Surg 1985;38:30
Murakami R, Tanaka K, Kobayashi K, et al. Free groin
ap for reconstruction of the tongue and oral oor.
J Reconstr Microsurg 1998;14:49
Ram asastry SS, Granick MS, Futrell JW. Clinical
anatomy of the internal oblique m uscle. J Reconstr
Microsurg 1986;2:117
Ramasastry SS, Tucker JB, Swartz WM, Hurwitz DJ. The
internal oblique m uscle ap: an anatomic and clinical
study. Plast Reconstr Surg 1984;73:721
Safak T, Klebuc MJA, Kecik Ab, Shenaq S. Closure of
upper extrem ity soft-tissue defects using the new
“supra-crest” fasciocutaneous free ap. Plast Reconstr
Surg 1997;99:1154
Safak T, Klebuc MJA, Mavili E, Shenaq S. A new design
of the iliac crest m icrosurgical free ap without
including the “obligatory” muscle cuff. Plast Reconstr
Surg 1997;100:1703
Sasaki K, Nozaki M, Katahira J. Beard restoration using
a free puboinguinal hair-bearing ap. J Reconstr Micro-
surg 1998;14:445
Sasaki K, Nozaki M, Okagaki M, et al. Variants in the
deep circum ex iliac artery: clinical considerations in
raising iliac osteocutaneous free aps. J Reconstr
Microsurg 1999;15:527
Satoh T, Tsuchiya M, Harii K. A vascularised iliac
m usculo-periosteal free ap transfer: a case report. Br
J Plast Surg 1983;36:109
Stern HS, Nahai F. The versatile super cial inferior
epigastric artery free ap. Br J Plast Surg 1992;45:270
Taylor GI, Corlett RJ. Microvascular free transfer of a
compound deep circum ex groin and iliac crest ap to
the mandible. In: Strauch B, Vasconez LO, Hall-Findlay,
eds. Grabb’s Encyclopedia of Flaps. Vol 1. Boston: Little,
Brown, 1990:589
Taylor GI, Corlett RJ. Microvascular free transfer of a
compound deep circum ex groin and iliac crest p to
the upper extremity. In: Strauch B, Vasconez LO, Hall-
Findlay, eds. Grabb’s Encyclopedia of Flaps. Vol 2.
Boston: Little, Brown, 1990:1197

202
II.5 LOWER EXTREMITY: GROIN REGION
Taylor GI, Corlett RJ. Microvascular transfer of a com-
pound deep circum ex groin and iliac crest ap. In:
Strauch B, Vasconez LO, Hall-Findlay, eds. Grabb’s
Encyclopedia of Flaps. Vol 3. Boston: Little, Brown,
1990:1786
Taylor GI, Townsend P, Corlett RJ. Superiority of the
deep circum ex iliac vessels as the supply for free
groin aps. Plast Reconstr Surg 1979;64:595
Taylor GI, Townsend P, Corlett RJ. Superiority of the
deep circum ex iliac vessels as the supply for free
groin aps: clinical work. Plast Reconstr Surg 1979;
64:745
Ueda K, Inoue T, Harada T, et al. Dura and cranial base
reconstruction by external oblique fascia and rectus
abdom inis m uscle ap. J Reconstr Microsurg 1992;
8:427
Urken ML, Vickery C, Weinberg H, et al. The internal
oblique-iliac crest osseomyocutaneous m icrovascular
free ap in head and neck reconstruction. J Reconstr
Microsurg 1989;5:203

GRACILIS FLAP
Anatomy (Fig. 6–1)
The origin of the gracilis m uscle (1) is the body of
the pubis and its inferior ram us, and the adjacent
ram us of the ischium . Insertion is at the m edial
upper surface of the tibia below the condyle. The
m uscle functions as an accessory adductor of the
thigh and exor of the leg.
This is a thin, at, strap-shaped muscle, broad
above and narrow and tapering below. Its total
length is 42 cm (muscle belly, 32 cm; tendon portion,
10 cm). Average width and thickness are 4 and 1 cm,
respectively.
Blood Supply
The dominant nutrient vessels (8) arise mostly from
the profunda fem oris vessels (7), and occasionally
from the m edial circum ex fem oris vessels. They
pass inferom edially between the adductor longus
(3) and brevis, and enter the upper third of the
muscle, 8 to 10 cm below the pubic tubercle.
Although there are several additional branches
from the femoral vessels to the distal portion of the
muscle, the dominant vessels alone can nourish the
entire muscle belly, but they barely supply the distal
third of overlying skin.
There are commonly two venae comitantes.
6
Thigh Region
Figure 6–1
Anatomy of the gracilis ap.
1. Gracilis m.
2. Sartorius m.
3. Adductor longus m.
4. Rectus femoris m.
5. Pectineus m.
6. Femoral a.
7. Deep femoral a.
8. Branch to the gracilis

Innervation
The anterior branch of the obturator nerve runs
between the adductor longus and brevis and divides
into the motor and sensory nerves in the vicinity of the
main vascular pedicle. The motor nerve enters the muscle
with the vessels and bifurcates into two branches,
whereas the sensory nerve descends, then crosses the
gracilis muscle at its central part to serve the skin.
Measurements
Length (from
origin to
Diameter (mm)
entrance) (cm)
Dominant
Artery
1.2–1.8
6.0
Vein
1.5–2.0
Anterior branch of
1.0–2.0
5.0
obturator nerve
204
II.6 LOWER EXTREMITY: THIGH REGION
Despite the fact that the origin of the dominant artery
varies occasionally, its course and entrance into the
m uscle are anatom ically consistent. It can be easily
elevated and reliably transferred, with adequate vessel
diam eter. The gracilis therefore rem ains one of the
most useful muscles in microvascular repair.
The donor site provides a thin, strap-shaped func-
tional m uscle of m edium size, especially suitable for
functional reconstruction in the forearm.
The distal third of skin overlying the gracilis does
not receive suf cient blood supply from the m uscle.
Only the upper two thirds of overlying skin can be used
as a component in the musculocutaneous ap.
In addition to motor function, the anterior branch
of the obturator nerve also supplies sensibility to the
overlying skin and, a few months postoperatively, the
m usculocutaneous ap m ay have fair pressure and
COMMENT AND INSIGHTS
touch sensibility; however, sensation is not always
good.
The donor defect can always be closed directly,
and the linear scar on the m edial aspect of the
thigh does not present serious cosm etic problem s.
Nor does the loss of the gracilis produce any obvious
m orbidity.
Splitting the muscle longitudinally will allow for
the possibility of differential contraction or the ability
to harvest small segments for facial reanimation.
Currently, this is still one of the com m on donor
sites in reconstructive microsurgery. In addition, it has
been used for reanim ation of facial paralysis in
reconstruction of the total tongue, and also for exor
substitutes in the upper extrem ity. Using island
transfer, it is commonly applied in vulvoperineal and
inguinal reconstruction.

GRACILIS MUSCLE FLAP
Incisions (Fig. 6–2)
The patient is placed in a supine position with the thigh
abducted.
The anterior border of the gracilis muscle (1) corre-
sponds to a line drawn between the posterior border of
the tendon of the adductor longus (2) at the pubic
tubercle, and the distal end of the incision may extend
over the tendon of the sem itendinosus m uscle (9).
Usually, the incision is placed over the proximal 10 cm
of the line; a second incision may be based distally if
the entire muscle is to be harvested. The position of the
dom inant vessels is m arked 8 cm below the pubic
tubercle.
GRACILIS MUSCLE FLAP
205
Figure 6–2
Incisions.
1. Gracilis m.
6. Anterior branch of obturator n.
2. Adductor longus m.
7. Semimembranosus m.
3. Adductor brevis m.
8. Sartorius m.
4. Adductor magnus m.
9. Semitendinosus m.
5. Branch from deep femoral a. and v.

Vascular Pedicle Approach (Fig. 6–3)
At the rst incision, the fascia over the adductor longus
(2) and gracilis (1) is divided to identify its interspace.
After retracting the adductor longus (2) laterally, the
dominant vascular pedicle (5) and the anterior branch
of the obturator nerve (6) can easily be found on the
anterior surface of the adductor brevis (3), near the
predicted point marked previously.
206
II.6 LOWER EXTREMITY: THIGH REGION
Figure 6–3
Vascular pedicle approach.
1. Gracilis m.
2. Adductor longus m.
3. Adductor brevis m.
4. Adductor magnus m.
5. Branch from deep femoral a. and v.
6. Anterior branch of obturator n.

Exposure of the Distal Gracilis (Fig. 6–4)
At the second incision, the distal m usculotendinous
portion of the gracilis muscle (1) will lie between the
sartorius (8) anteriorly and the sem imembranosus (7)
posteriorly. After further veri cation by traction, the
distal portion of the gracilis (1) is divided and bluntly
dissected proximally from the surrounding tissue, ligat-
ing the small branches from the fem oral vessels.
GRACILIS MUSCLE FLAP
207
Figure 6–4
Exposure of the distal gracilis.
1. Gracilis m.
7. Semimembranosus m.
2. Adductor longus m.
8. Sartorius m.

Completion of the Muscle Flap
(Fig. 6–5)
The distal portion of the gracilis (1) is drawn into the
proximal incision through a subcutaneous tunnel, and
the origin of the gracilis is detached. The dom inant
pedicle (5) can be dissected toward its origin to obtain
as long a pedicle as possible.
208
II.6 LOWER EXTREMITY: THIGH REGION
Figure 6–5
Completion of the muscle
ap.
1. Gracilis m.
2. Adductor longus m.
3. Adductor brevis m.
4. Adductor magnus m.
5. Branch from deep femoral a. and v.
6. Anterior branch of obturator n.

GRACILIS MYOCUTANEOUS FLAP
Flap Design (Fig. 6–6)
A line is drawn to serve as the anterior border of the
gracilis, as mentioned previously. The anterior perime-
ter of the skin ap can extend 2 or 3 cm beyond the line,
and the posterior limitation is 6 to 9 cm beyond. The
skin ap should be centered over the gracilis muscle.
However, the skin over the distal third of the gracilis is
not supplied from the underlying muscle, and it should
be excluded from the ap. Maximal reported ap size is
11
27 cm. In patients with very lax or redundant skin,
this skin paddle is not reliable.
GRACILIS MYOCUTANEOUS FLAP
209
Figure 6–6
Flap design.
1. Gracilis m.
5. Branch from deep femoral a. and v.
2. Adductor longus m.
6. Anterior branch of obturator n.
3. Adductor brevis m.
7. Semimembranosus m.
4. Adductor magnus m.
8. Sartorius m.

Vascular Pedicle Approach and Distal
Dissection (Fig. 6–7)
In the procedure to raise the muscle ap, the proximal
anterior margin of the skin ap is incised to expose the
dominant vessels (5) and nerve. Under traction of the
distal m uscle portion (1), the skin territory can be accu-
rately outlined.
210
II.6 LOWER EXTREMITY: THIGH REGION
Figure 6–7
Vascular pedicle approach and distal dissection.
1. Gracilis m.
5. Branch from deep femoral a. and v.
2. Adductor longus m.
7. Semimembranosus m.
3. Adductor brevis m.
8. Sartorius m.
4. Adductor magnus m.

Flap Elevation and Completion
(Fig. 6–8)
All the skin margins of the ap are incised and the mus-
cle is divided proximally and distally. Several tacking
stitches should be used in this procedure.
The musculocutaneous ap is elevated, based on
the dominant neurovascular pedicle (5,6).
GRACILIS MYOCUTANEOUS FLAP
211
Figure 6–8
Flap elevation and completion.
1. Gracilis m.
4. Adductor magnus m.
2. Adductor longus m.
5. Branch from deep femoral a. and v.
3. Adductor brevis m.
6. Anterior branch of obturator n.

TENSOR FASCIAE LATAE (TFL) FLAP
Anatomy (Fig. 6–9)
The origin is the anterior 5 cm of the outer lip of the
iliac crest and anterior superior iliac spine (ASIS). Inser-
tion is at the iliotibial band at a level a little below the
greater trochanter; the iliotibial band is, in turn,
attached below to the lateral condyle of the tibia. The
212
II.6 LOWER EXTREMITY: THIGH REGION
Figure 6–9
Anatomy of tensor fasciae latae (TFL) ap.
1. TFL
2. Rectus femoris m.
3. Sartorius m.
4. Femoral a.
5. Deep femoral a.
6. Lateral circum ex femoral a. (LCFA)
7. Ascending branch
8. Descending branch
main function of the muscle is as an accessory exor
and m edial rotator of the thigh. The muscle is sm all,
broad, at, and sh-shaped. The average length is
17 cm, width is 5 cm, and thickness is 1.5 cm.

TENSOR FASCIAE LATAE (TFL) FLAP
213
Blood Supply
The lateral circum ex femoral artery (LCFA) (6) com -
m only arises from the lateral side of the deep femoral
artery (5), passes laterally between the divisions of the
fem oral nerve behind the sartorius and rectus femoris
m uscles (3,2), and divides into three major branches.
The ascending branch is the dominant pedicle to
the tensor fasciae latae (TFL) (7,1). It passes up between
the rectus femoris and vastus lateralis muscles to reach
the TFL 8 cm below the ASIS. Im m ediately before
entering the muscle, this branch divides into superior,
m iddle, and inferior twigs. The superior twig feeds the
upper muscle and a segment of iliac crest; the middle
twig nourishes the m ain belly of the muscle; and the
inferior twig supplies the distal fascia lata and an
extensive skin territory of the thigh.
There are ve to seven m usculocutaneous perfora-
tors from the muscle into the overlying skin and iliac
crest, and the lower perforator runs longitudinally
above the fascia to supply the cutaneous territory over
the distal iliotibial band.
There are commonly two venae comitantes.
Measurements
Length of
Diameter (mm)
Pedicle (cm)
Ascending branch
Artery
1.1
4–5
Vein
1.3
Ascending branch
Artery
0.8–1.5
10 (by ligating
(after descend-
Vein
0.7–2.0
the descending
ing branch)
branch)
Lateral circum ex
Artery
1.5–2.5
femoral vessels
Vein
2.5–4.0
(at its origin)
Innervation
Motor. The inferior branch of the superior gluteal nerve
courses between the gluteus medius and minimus, enter-
ing the undersurface of the TFL near the vascular pedicle.
Sensory. The branch of T12 pierces the external
oblique muscle just above the iliac crest in the anterior
axillary line, innervating the upper third of the skin ap.
The lateral cutaneous nerve of the thigh emerges 1
to 2 cm inferom edial to the ASIS and runs over the
Measurements
Diameter (mm)
Cutaneous branch of T12
0.5–2.0
Lateral cutaneous nerve of thigh
2.0–3.0
Inferior branch of superior gluteal nerve
0.5–2.0
sartorius, piercing the deep fascia, to supply the distal
two thirds of the anterolateral aspect of the thigh.
This ap is one of the m ost reliable and com m only
acceptable myocutaneous aps because of its constant
anatomy and the adequate length and diam eter of the
vascular pedicle. Even though the TFL muscle itself is
quite sm all, its m usculocutaneous perforators can
nourish almost all the skin of the anterolateral thigh,
providing an enormous skin territory. The ap under
discussion is a sensory myocutaneous ap and has been
widely applied clinically, but it has not been reported as
a functional m uscular ap.
The widest donor defect that can be closed primarily
is 6 cm, and wider aps require skin grafting. Any over-
tight closure may result in a compartment syndrome.
The TFL muscle is expendable and not of primary
functional im portance. There is m inim al donor-site
morbidity postoperatively. The donor scar may cause
some cosmetic problems.
The entrance of the vascular pedicle is located at
the center of the undersurface of the m uscle; this
should be considered during ap design so that the
recipient defect and vessels can be adequately matched.
Also of some signi cance is the fact that the proximal
part of the ap is thicker and the distal part somewhat
thinner.
Caution needs to be advised because the distal skin
paddle m ay be unreliable if extended too far. A safer
limit is advised in this chapter.
Over the past decade, this donor has remained in
the arm am entarium of the reconstructive m icrosur-
geon, though used less frequently. Reportedly, it can be
used in pharyngoesophageal and penile reconstruction
as well as in functional reconstruction of a paralytic
deltoid. Using island transfer, it can be applied in
reconstruction of the abdominal wall.
COMMENT AND INSIGHTS

TFL MYOCUTANEOUS FLAP
Flap Design (Fig. 6–10)
In the surface anatomy of the m uscle, its anterior
border corresponds to a line between the ASIS and the
lateral edge of the patella. Its posterior border is a line
from the iliac crest 5 cm posterior to the ASIS through
the anterior edge of the greater trochanter to the lateral
condyle of the femur.
Its skin territory can be harvested to a size as large
as 20
30 cm, three times the size of the muscle. The
superior border can exceed the iliac crest for a few cen-
tim eters, the inferior border can reach a level 15 cm
above the knee, and the anterior and posterior borders
can be extended for at least 2 cm on either side of the
muscle.
The vascular pedicle is m arked on the anterior
border of the muscle 8 cm below the ASIS.
214
II.6 LOWER EXTREMITY: THIGH REGION
Figure 6–10
Flap design.
1. TFL
2. Rectus femoris m.
3. Vastus lateralis m.
4. Ascending branch
5. Iliotibial band
6. Lateral cutaneous n. of thigh
7. Cutaneous branch of T12 n.
8. Gluteus m.
9. Iliac bone

Distal Elevation of the Flap (Fig. 6–11)
Flap elevation begins from distal to proxim al subfas-
cially to raise the fascia lata with the skin ap. Several
tacking stitches are applied to protect the m usculocuta-
neous perforator. The vascular pedicle (4) is visualized
on the undersurface, 8 cm below the ASIS.
TFL MYOCUTANEOUS FLAP
215
Figure 6–11
Distal elevation of the ap.
1. TFL
2. Rectus femoris m.
3. Vastus lateralis m.
4. Ascending branch
5. Iliotibial band

Identifying the Sensory Nerves
(Fig. 6–12)
If a sensory ap is required, the cutaneous branch of
T12 (7) is identi ed above the iliac crest in the anterior
axillary line, and the lateral cutaneous nerve of the
thigh (6) is dissected at a point 1 to 2 cm inferomedial
to the ASIS. For a functional musculocutaneous ap, the
inferior branch of the superior gluteal nerve should be
carefully sought out at the posterior border of the
muscle, 4 to 5 cm below the iliac crest.
216
II.6 LOWER EXTREMITY: THIGH REGION
Figure 6–12
Identifying the sensory nerves.
6. Lateral cutaneous n. of thigh
7. Cutaneous branch of T12 n.

Vascular Pedicle Dissection and Flap
Elevation (Fig. 6–13)
The vascular pedicle (4) is dissected by m edial
retraction of the rectus femoris (2). The muscle (1) is
detached, dividing all the nerves to the TFL with mark-
ers. The musculocutaneous ap is raised based on the
ascending branch (4) of the LCFA. This can be dissected
further to obtain a pedicle as long as 10 cm by ligating
all the branches, including the descending branch.
During the dissection of the pedicle, care should be
taken under the rectus femoris (2) where the vessel is
intim ately related to the m uscular branches of the
femoral nerve.
TFL MYOCUTANEOUS FLAP
217
Figure 6–13
Vascular pedicle dissection and
ap elevation.
1. TFL
2. Rectus femoris m.
4. Ascending branch
8. Gluteus m.

TFL OSTEOMYOCUTANEOUS FLAP
Elevation of Osteomyocutaneous Flap
(Fig. 6–14)
An anterior segm ent of the iliac crest (9), connected
with the origin of the TFL and adjacent tissue, can be
taken with the ap as a vascularized bone graft.
218
II.6 LOWER EXTREMITY: THIGH REGION
Figure 6–14
Elevation of osteomyocutaneous ap.
8. Gluteus m.
9. Iliac bone

RECTUS FEMORIS FLAP
Anatomy (Fig. 6–15)
The origin of the muscle (6) is the anterior inferior iliac
spine and the groove above the acetabulum . Insertion is
in the upper border of the patella as a central portion of
the quadriceps tendon. The m uscle is fusiform and
bipennate in shape. Its complete length is 36 cm (mus-
cle belly, 30 cm), its thickness is 1.5 cm, and its width is
5.5 cm. The function of the muscle is leg extension and
thigh exion.
Blood Supply
The dom inant blood supply usually comes from the de-
scending branch (4) of the LCFA (3). There is a double
grouping of the neurovascular bundle, which enters the
posterior surface of the muscle 10 and 15 cm below the
ASIS, respectively. Each group has two venae com i-
tantes. The length of the pedicle is 4 cm.
Innervation
There are two motor branches from the femoral nerve
that enter the m uscle, accompanying the vascular
pedicle.
Measurements
Diameter
Length of
(mm)
Pedicle (cm)
Group 1
Artery
1.5
Veins 1
0.7
3 – 4
2
0.7
Nerve
1.0
10 – 12
Group 2
Artery
2.0
Veins 1
1.2
3 – 4
2
0.5
Nerve
1.0
10 – 12
Descending branch
Artery
2.5
of lateral circum ex
Vein
3.4
femoral a.
COMMENT AND INSIGHTS
The neurovascular anatomy of the rectus fem oris is
consistent and its vessel diameter adequate for micro-
surgical transfer in functional reconstruction or wound
coverage. Compared with other muscle aps, the rectus
femoris, as a strong portion of the quadriceps, has an
important function. Removal of the muscle will decrease
the strength of knee extension, especially in the last
20 degrees.
RECTUS FEMORIS FLAP
219
Figure 6–15
Anatomy of rectus femoris ap.
1. Femoral a.
2. Deep femoral a.
3. LCFA
4. Descending branch
5. Ascending branch
6. Rectus femoris m.

RECTUS FEMORIS MUSCLE FLAP
Incision (Fig. 6–16)
The incision for harvesting the muscle ap is made in
an S-shaped fashion along a line drawn from the ASIS to
the midpoint of the upper border of the patella.
Exposure of the Muscle and
Identi cation of the Pedicle (Fig. 6–17)
The medial and lateral borders of the rectus femoris (1)
are exposed at the lower part of the muscle. Retracting
the sartorius (2) medially, the LCFA (5) and their descend-
ing branch (4) are identi ed 10 cm below the ASIS.
220
II.6 LOWER EXTREMITY: THIGH REGION
Figure 6–17
Exposure of the muscle and identi cation of the pedicle.
1. Rectus femoris m.
5. LCFA
2. Sartorius m.
6. Deep femoral a.
3. TFL
7. Femoral n.
4. Descending branch
Figure 6–16
Incision.
1. Rectus femoris m.
2. Sartorius m.
3. TFL
4. Descending branch
5. LCFA
6. Deep femoral a.
7. Femoral n.
8. Vastus intermedialis m.

Elevation of the Muscle Flap
(Fig. 6–18)
The muscle (1) is separated from the vastus lateralis in-
termedialis and medialis, ligating the branches to these
muscles. The vascular pedicle (5) and muscular branches
of the femoral nerve are further identi ed and dissected.
The m uscle is then isolated on its pedicle (5), after
detaching its origin and insertion.
RECTUS FEMORIS MUSCLE FLAP
221
Figure 6–18
Elevation of the muscle ap.
1. Rectus femoris m.
5. LCFA
7. Femoral n.
8. Vastus intermedialis m.

RECTUS FEMORIS MYOCUTANEOUS FLAP
Flap Design (Fig. 6–19)
A line is drawn from the ASIS to the midpoint of the up-
per border of the patella as an axis of the musculocuta-
neous ap. The skin territory is lim ited to the area
between the sartorius and TFL at the upper third. The
ap can measure as much as 10 cm in width by 30 cm in
length, but the lower third is less reliable.
Flap Elevation (Fig. 6–20)
Keeping the skin territory intact with tacking stitches,
the m usculocutaneous ap (1) is raised, based on its
neurovascular pedicle (5). The procedure then follows
that of the muscle ap described above.
222
II.6 LOWER EXTREMITY: THIGH REGION
Figure 6–19
Flap design.
1. Rectus femoris m.
5. LCFA
2. Sartorius m.
6. Deep femoral a.
3. TFL
7. Femoral n.
4. Descending branch
8. Vastus intermedialis m.
Figure 6–20
Flap elevation.
1. Rectus femoris m.
5. LCFA
2. Sartorius m.
7. Femoral n.

MEDIAL THIGH FLAP
Anatomy (Fig. 6–21)
An unnam ed branch (7) arises from the m edial aspect
of the super cial fem oral artery (6), just proxim al to
the adductor canal (5) at the apex of the fem oral
triangle that is form ed by the m edial borders of the
sartorius (1) and adductor longus (2), and inguinal
ligam ent. The branch continues as a cutaneous artery,
em erging near the apex of the fem oral triangle to
supply the skin of the m edial thigh. The diam eter at its
origin is 2.0 to 4.0 m m , and its venae com itantes
provide venous drainage.
Innervation
The m edial fem oral cutaneous nerve runs from the
fem oral nerve, crossing super cially to the fem oral
vessels at the apex of the femoral triangle.
MEDIAL THIGH FLAP
223
Figure 6–21
Anatomy of the medial thigh ap.
1. Sartorius m.
2. Adductor longus m.
3. Gracilis m.
4. Vastus medialis m.
5. Adductor canal
6. Femoral a.
7. Unnamed branch of femoral a.
Experience with this ap is lim ited, and cadaver dissec-
tion of these vessels is recommended prior to clinical
application.
The skin of the medial thigh is generally uniformly
thin and hairless, and it could be provided with sensi-
bility through the m edial fem oral cutaneous nerve.
Therefore, this ap can be considered for use in the
reconstruction of the head, neck, and hand.
The common size of the ap is reported as 6
12
cm, and the donor defect can be closed primarily. Donor-
site morbidity is minimal, but a resulting linear scar or
skin graft may create some cosmetic problems in females.
COMMENT AND INSIGHTS

Harvesting Technique
Flap Design (Fig. 6–22)
The course of the super cial fem oral artery is traced
from the m idpoint of the inguinal ligam ent to the
adductor tubercle. The vascular pedicle is marked on
the apex of the femoral triangle approximately at the
midpoint of the line, and the upper border of the ap is
placed at the level of this apex. Flap outline is in the
m edial aspect of the thigh, and its area has been
reported as 6
12 cm.
Identifying the Vascular Pedicle
(Fig. 6–23)
A straight incision is made at the proximal course of the
femoral artery, and the femoral vessel (5) is identi ed,
dissected, and traced toward the adductor canal (4).
Retracting the sartorius (1) laterally, the unnam ed
vascular pedicle (7) is located just proxim al to the
adductor canal. The branch to the sartorius is ligated.
The m edial fem oral cutaneous nerve (6) appears
super cial to the fem oral vessels if a sensory ap is
desired.
224
II.6 LOWER EXTREMITY: THIGH REGION
Figure 6–22
Flap design.
1. Sartorius m.
2. Adductor longus m.
3. Adductor magnus m.
4. Adductor canal
5. Femoral a. and v.
6. Medial femoral cutaneous n.
7. Unnamed a. and v.
8. Vastus medialis m.
9. Gracilis m.
Figure 6–23
Identifying the vascular pedicle.
1. Sartorius m.
2. Adductor longus m.
3. Adductor magnus m.
4. Adductor canal
5. Femoral a. and v.
6. Medial femoral cutaneous n.
7. Unnamed a. and v.

Flap Elevation (Fig. 6–24)
The m edial thigh ap is raised from the deep fascia,
leaving the saphenous vein intact. The average length of
the vascular pedicle of medial thigh aps is 5 cm.
MEDIAL THIGH FLAP
225
Figure 6–24
Flap elevation.
5. Femoral a. and v.
6. Medial femoral cutaneous n.
7. Unnamed a. and v.
8. Vastus medialis m.
9. Gracilis m.

226
II.6 LOWER EXTREMITY: THIGH REGION
LATERAL THIGH FLAP
Anatomy (Fig. 6–25)
This ap is based on the third perforating branch of the
profunda femoris artery (1). The vessel arises from the
fem oral artery 3.5 cm below the inguinal ligam ent
and then runs in front of the pectineus (9) and adductor
brevis (7) and magnus (8) behind the adductor longus
(6), near the linea aspera of the femur. It terminates as
the fourth perforating artery (5).
Figure 6–25
Anatomy of the lateral thigh ap.
1. Deep femoral a.
2. First perforator
3. Second perforator
4. Third perforator
5. Fourth perforator
6. Adductor longus m.
7. Adductor brevis m.
8. Adductor magnus m.
9. Pectineus m.

LATERAL THIGH FLAP
227
The third perforating artery (4) begins below the
adductor brevis (7) and pierces the insertion of the
adductor m agnus (8). After giving off branches to
the muscles, the third perforator traverses between the
biceps femoris and the vastus lateralis and then pierces
the deep fascia. It then emerges at about the m idpoint
between the greater trochanter and the lateral
epicondyle of the femur.
Measurements
Arterial Diameter
Vessel Landmarks
(mm)
At the piercing of the adductor magnus
3 – 5
Between the biceps femoris and vastus lateralis
2
At its emergence as a cutaneous branch
1.0 – 1.5
The venae com itantes term inate in the profunda
femoris vein. Occasionally, the cutaneous branch may
originate from the super cial femoral branch.
Innervation
Sensibility is provided by the lateral cutaneous nerve of
the thigh.
COMMENT AND INSIGHTS
There have been several cases of free lateral thigh aps
reported. This ap is a typical septofasciocutaneous ap
based on the perforating branches of the deep femoral
artery in the lateral septum of the thigh.
The vascular anatomy of the ap is quite constant,
and the diameter and length of pedicle vessels are quite
suf cient for anastomosis at the recipient site. If the pa-
tient is properly positioned, the harvesting procedure
should not be dif cult.
Thigh skin is generally uniformly thin, but the skin
of the lateral side of the thigh is hairy in males. The ap
may be somewhat bulky and stiff because of the thick
dermis and fascia lata if the fascia layer is included in the
ap, even though there is less subcutaneous tissue there.
The skin territory of this ap should be quite large,
especially when the deep fascia is included. A ap size
of 8
25 cm has been reported.
Flap sensibility can be provided through the lateral
cutaneous nerve of the thigh. If the width of the ap is
less than 8 cm, the donor defect can be closed primarily.
Donor-site morbidity is minimal, but a resulting linear
scar or skin graft may create some cosmetic problems
in females.