Vạt Da Và Phẫu Thuật Tái Tạo (Flaps and Reconstructive Surgery)

686
PART 5 — PERFORATOR-BASED WORKHORSE FL APS
Access Figure 57.16, as well as case example 3
and further reading online at http://
expertconsult.inkling.com
REFERENCES
1. Drever JM. The epigastric island flap. Plast Reconstr Surg 1977;
59(3):343–6.
2. Hartrampf CR, Scheflan M, Black PW. Breast reconstruction with
a transverse abdominal island flap. Plast Reconstr Surg 1982;69(2):
216–25.
3. Holmström H. The free abdominoplasty flap and its use in breast
reconstruction. An experimental study and clinical case report.
Scand J Plast Reconstr Surg 1979;13(3):423–7.
4. Koshima I, Soeda S. Inferior epigastric artery skin flaps without
rectus abdominis muscle. Br J Plast Surg 1989;42(6):645–8.
5. Allen RJ, Treece P. Deep inferior epigastric perforator flap for
breast reconstruction. Ann Plast Surg 1994;32(1):32–8.
6. Blondeel PN, Sgarzani R, Morrison CM. Deep inferior epigastric
artery perforator flap. In: Blondeel PN, Morris SF, Hallock GG,
et al., editors. Perforator flaps: anatomy, technique and clinical
applications. 2nd ed. St Louis, MO: Quality Medical Publishing;
2013. p. 499–526.
7. Boeckx WD, de Coninck A, Vanderlinden E. Ten free flap transfers:
use of intraarterial dye injection to outline a flap exactly. Plast
Reconstr Surg 1976;57(6):716–21.
8. Hester TR Jr, Nahai F, Beegle PE, et al. Blood supply of the
abdomen revisited, with emphasis on the superficial inferior epi­
gastric artery. Plast Reconstr Surg 1984;74(5):657–70.
9. Grotting JC. The free abdominoplasty flap for immediate breast
reconstruction. Ann Plast Surg 1991;27(4):351–4.
10. Koshima I, Moriguchi T, Soeda S, et al. Free thin paraumbilical
perforator-based flaps. Ann Plast Surg 1992;29(1):12–17.
Expert Commentary 
Aldona J. Spiegel, MD and Robert J. Allen, Sr, MD
The composition of the skin and underlying soft tissue of the
lower abdomen is the closest alternative to native breast
tissue that the body has to offer. Thus, the abdominal donor
site has served as the workhorse for breast reconstruction
over the past four decades. Over time, the abundant network
of blood vessels in the region has become better understood
and makes the DIEP and SIEA flaps dependable for recon-
struction with reliable vascularity. The SIEA flap was devel-
oped following vascular injection studies on abdominoplasty
specimens at Louisiana State University Medical Center in
1989. The inconsistency of the SIEA anatomy led to the
development of the DIEP flap for breast reconstruction at
LSUMC in 1992. The biggest advancement since the evolu-
tion of the perforator concept is accurate preoperative
imaging with either the CTA or MRA. By identifying the domi-
nant perforator, most flaps can be based on one perforator.
According to Poiseuille’s law, a single 1 mm perforator has
more blood flow than 15 perforators of 0.5 mm combined.
Applying this mathematical law during the intraoperative per-
forator selection is vital to a well-vascularized flap. Moreover,
the balance between arterial inflow and venous outflow flap
dynamics needs to be considered, especially with superficial
dominant systems. All these factors including perforator
angiosomes, extent of perfusion across the midline, dual
venous system drainage, perforator size and location selec-
tion are kept in mind during flap dissection. Additionally, flap
neurotization can be an advantage to the patient and is per-
formed by coapting a cutaneous branch of T-11 or T-12
donor nerve to a medial or lateral sensory branch of the
intercostal recipient nerve. The focus on minimizing donor
site morbidity drives the refinement of the donor site aesthet-
ics by applying abdominoplasty principles to provide the
most cosmetic benefit to the patient. Finally, efforts to not
only optimize microsurgical flap success, but also to enhance
the ultimate shape and natural result of breast reconstruc-
tion, have led to more emphasis on flap inset to the footprint
of the breast as well as neurotization to improve final
sensation.

CHAPTER 57 — Deep and Superficial I nferior Epigastric Artery Perforator Flaps 686.e1
A young girl was involved in a motor vehicle accident at the age
of 15. She sustained an open fracture of the left femur with
significant soft tissue loss. The wound was treated with debride-
ment and skin grafting. At 5 years later, a residual contour
deformity was still quite apparent and was treated with a free
DIEAP flap. Flap debulking was done using liposuction 10
months after tissue transfer (Fig. 57.16).
CASE 57.3  Lower Limb Post-traumatic Contour Defect Reconstructed with a Free
DIEAP Flap
Figure 57.16  Free DIEAP flap for lower limb post-traumatic contour deformity. (A,B) Preoperative views. (C,D) At 1 year post-flap
transfer after late liposuction.
A
B
C
D

686.e2 PART 5 — PERFORATOR-BASED WORKHORSE FL APS
FURTHER READING
Allen RJ, Heitland AS. Superficial inferior epigastric artery flap for
breast reconstruction. Semin Plast Surg 2002;16(1):35–44.
Allen RJ, Heitland AS. Autogenous augmentation mammaplasty with
microsurgical tissue transfer. Plast Reconstr Surg 2003;112(1):
91–100.
Antia NH, Buch VI. Transfer of an abdominal dermo-fat graft by direct
anastomosis of blood vessels. Br J Plast Surg 1971;24(1):15–19.
Bailey SH, Saint-Cyr M, Wong C, et al. The single dominant medial row
perforator DIEP flap in breast reconstruction: three-dimensional
perforasome and clinical results. Plast Reconstr Surg 2010;126(3):
739–51.
Blondeel PN. One hundred free DIEP flap breast reconstructions: a
personal experience. Br J Plast Surg 1999;52(2):104–11.
Blondeel PN, Arnstein M, Verstraete K, et al. Venous congestion and
blood flow in free transverse rectus abdominis myocutaneous and
deep inferior epigastric perforator flaps. Plast Reconstr Surg 2000;
106(6):1295–9.
Blondeel PN, Beyens G, Verhaeghe R, et al. Doppler flowmetry in the
planning of perforator flaps. Br J Plast Surg 1998;51(3):202–9.
Blondeel PN, Boeckx WD. Refinements in free flap breast reconstruc­
tion: the free bilateral deep inferior epigastric perforator flap anas­
tomosed to the internal mammary artery. Br J Plast Surg 1994;47(7):
495–501.
Blondeel PN, Demuynck M, Mete D, et al. Sensory nerve repair in
perforator flaps for autologous breast reconstruction: sensational or
senseless? Br J Plast Surg 1999;52(1):37–44.
Blondeel PN, Hijjawi J, Depypere H, et al. Shaping the breast in aes­
thetic and reconstructive breast surgery: an easy three-step principle.
Part II–Breast reconstruction after total mastectomy. Plast Reconstr
Surg 2009;123(3):794–805.
Blondeel PN, Vanderstraeten GG, Monstrey SJ, et al. The donor site
morbidity of free DIEP flaps and free TRAM flaps for breast recon­
struction. Br J Plast Surg 1997;50(5):322–30.
Bonde CT, Lund H, Fridberg M, et al. Abdominal strength after breast
reconstruction using a free abdominal flap. J Plast Reconstr Aesthet
Surg 2007;60(5):519–23.
Bottero L, Lefaucheur JP, Fadhul S, et al. Electromyographic assess­
ment of rectus abdominis muscle function after deep inferior epi­
gastric perforator flap surgery. Plast Reconstr Surg 2004;113(1):
156–61.
Boyd JB, Taylor GI, Corlett R. The vascular territories of the superior
epigastric and the deep inferior epigastric systems. Plast Reconstr
Surg 1984;73(1):1–16.
Chang EI, Chang EI, Soto-Miranda MA, et al. Comprehensive analysis
of donor-site morbidity in abdominally based free flap breast recon­
struction. Plast Reconstr Surg 2013;132(6):1383–91.
Cheng MH, Lin JY, Ulusal BG, et al. Comparisons of resource costs and
success rates between immediate and delayed breast reconstruction
using DIEP or SIEA flaps under a well-controlled clinical trial. Plast
Reconstr Surg 2006;117(7):2139–42, discussion 2143–2144.
Chevray PM. Breast reconstruction with superficial inferior epigastric
artery flaps: a prospective comparison with TRAM and DIEP flaps.
Plast Reconstr Surg 2004;114(5):1077–83, discussion 1084–1085.
Damen TH, Timman R, Kunst EH, et al. High satisfaction rates in
women after DIEP flap breast reconstruction. J Plast Reconstr Aesthet
Surg 2010;63(1):93–100.
DellaCroce FJ, Sullivan SK, Trahan C. Stacked deep inferior epigastric
perforator flap breast reconstruction: a review of 110 flaps in 55 cases
over 3 years. Plast Reconstr Surg 2011;127(3):1093–9.
Egeberg A, Rasmussen MK, Sørensen JA. Comparing the donor-site
morbidity using DIEP, SIEA or MS-TRAM flaps for breast reconstruc­
tive surgery: a meta-analysis. J Plast Reconstr Aesthet Surg 2012;
65(11):1474–80.
El-Mrakby HH, Milner RH. The vascular anatomy of the lower anterior
abdominal wall: a microdissection study on the deep inferior epigas­
tric vessels and the perforator branches. Plast Reconstr Surg 2002;
109(2):539–43.
Garvey PB, Salavati S, Feng L, et al. Abdominal donor-site outcomes for
medial versus lateral deep inferior epigastric artery branch perfora­
tor harvest. Plast Reconstr Surg 2011;127(6):2198–205.
Gill PS, Hunt JP, Guerra AB, et al. A 10-year retrospective review of
758 DIEP flaps for breast reconstruction. Plast Reconstr Surg 2004;
113(4):1153–60.
Hamdi M, Blondeel P, Van Landuyt K, et al. Bilateral autogenous breast
reconstruction using perforator free flaps: a single center’s experi­
ence. Plast Reconstr Surg 2004;114(1):83–9.
Hamdi M, Khuthaila DK, Van Landuyt K, et al. Double-pedicle abdomi­
nal perforator free flaps for unilateral breast reconstruction: new
horizons in microsurgical tissue transfer to the breast. J Plast Recon­
str Aesthet Surg 2007;60(8):904–14.
Hamdi M, Van Landuyt K, Monstrey S, et al. A clinical experience with
perforator flaps in the coverage of extensive defects of the upper
extremity. Plast Reconstr Surg 2004;113(4):1175–83.
Hammond DC, Larson DL, Severinac RN, et al. Rectus abdominis
muscle innervation: implications for TRAM flap elevation. Plast
Reconstr Surg 1995;96(1):105–10.
Holm C, Mayr M, Höfter E, et al. Perfusion zones of the DIEP flap
revisited: a clinical study. Plast Reconstr Surg 2006;117(1):37–43.
Holm C, Mayr M, Höfter E, et al. The versatility of the SIEA flap: a clini­
cal assessment of the vascular territory of the superficial epigastric
inferior artery. J Plast Reconstr Aesthet Surg 2007;60(8):946–51.
Holm C, Mayr M, Höfter E, et al. Interindividual variability of the SIEA
Angiosome: effects on operative strategies in breast reconstruction.
Plast Reconstr Surg 2008;122(6):1612–20.
Ireton JE, Lakhiani C, Saint-Cyr M. Vascular anatomy of the deep infe­
rior epigastric artery perforator flap: a systematic review. Plast Recon­
str Surg 2014;134(5):810e–21e.
Itoh Y, Kawakami K, Mizuno H, et al. Combined paraumbilical perfora­
tor skin flap and vascularized pubic bone graft. Ann Plast Surg 1994;
32(2):209–13.
Koshima I, Inagawa K, Urushibara K, et al. Deep inferior epigastric
perforator dermal-fat or adiposal flap for correction of craniofacial
contour deformities. Plast Reconstr Surg 2000;106(1):10–15.
Kroll SS, Sharma S, Koutz C, et al. Postoperative morphine require­
ments of free TRAM and DIEP flaps. Plast Reconstr Surg 2001;
107(2):338–41.
Man LX, Selber JC, Serletti JM. Abdominal wall following free TRAM
or DIEP flap reconstruction: a meta-analysis and critical review. Plast
Reconstr Surg 2009;124(3):752–64.
Munhoz AM, Ishida LH, Sturtz GP, et al. Importance of lateral row
perforator vessels in deep inferior epigastric perforator flap harvest­
ing. Plast Reconstr Surg 2004;113(2):517–24.
Ninkovic M, Holm C. Superficial inferior epigastric artery perforator
flap. In: Blondeel PN, Morris SF, Hallock GG, et al., editors. Perfora­
tor flaps: anatomy, technique and clinical applications. 2nd ed. St
Louis, MO: Quality Medical Publishing; 2013. p. 527–40.
Ochoa O, Chrysopoulo M, Nastala C, et al. Abdominal wall stability and
flap complications after deep inferior epigastric perforator flap
breast reconstruction: does body mass index make a difference?
Analysis of 418 patients and 639 flaps. Plast Reconstr Surg 2012;
130(1):21e–33e.
Peeters WJ, Nanhekhan L, Van Ongeval C, et al. Fat necrosis in deep
inferior epigastric perforator flaps: an ultrasound-based review of
202 cases. Plast Reconstr Surg 2009;124(6):1754–8.
Reardon CM, O’Ceallaigh S, O’Sullivan ST. An anatomical study of
the superficial inferior epigastric vessels in humans. Br J Plast Surg
2004;57(6):515–19.
Rozen WM, Ashton MW, Murray AC, et al. Avoiding denervation of
rectus abdominis in DIEP flap harvest: the importance of medial row
perforators. Plast Reconstr Surg 2008;122(3):710–16.
Rozen WM, Chubb D, Grinsell D, et al. The variability of the Superficial
Inferior Epigastric Artery (SIEA) and its angiosome: A clinical ana­
tomical study. Microsurgery 2010;30(5):386–91.
Rozen WM, Pan WR, Le Roux CM, et al. The venous anatomy of the
anterior abdominal wall: an anatomical and clinical study. Plast
Reconstr Surg 2009;124(3):848–53.
Saint-Cyr M, Wong C, Schaverien M, et al. The perforasome theory:
vascular anatomy and clinical implications. Plast Reconstr Surg
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Sbitany H, Mirzabeigi MN, Kovach SJ, et al. Strategies for recognizing
and managing intraoperative venous congestion in abdominally
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Schaverien MV, Ludman CN, Neil-Dwyer J, et al. Relationship between
venous congestion and intraflap venous anatomy in DIEP flaps using
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CHAPTER 57 — Deep and Superficial I nferior Epigastric Artery Perforator Flaps 686.e3
Selber JC, Nelson J, Fosnot J, et al. A prospective study comparing the
functional impact of SIEA, DIEP, and muscle-sparing free TRAM
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Selber JC, Samra F, Bristol M, et al. A head-to-head comparison between
the muscle-sparing free TRAM and the SIEA flaps: is the rate of flap
loss worth the gain in abdominal wall function? Plast Reconstr Surg
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Teunis T, Heerma van Voss MR, Kon M, et al. CT-angiography prior to
DIEP flap breast reconstruction: a systematic review and meta-
analysis. Microsurgery 2013;33(6):496–502.
Thoma A, Veltri K, Khuthaila D, et al. Comparison of the deep inferior
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774–82.

687
Superior
cluneal
nerves
Skin
island
Inferior
cluneal
nerves
Skin
island
Gluteus
maximus
Inferior gluteal
artery
Deep branch of
superior gluteal artery
Superior gluteal
artery
Inferior gluteal
nerve
Superficial branch of
superior gluteal artery
Iliac crest
Tensor
fasciae
latae
Gluteus
minimus
Superior
gluteal
nerve
Piriformis
Gemellus
inferior
Quadratus
femoris
Sciatic nerve
Descending branch
of posterior femoral
cutaneous nerve
Inferior cluneal
nerves
Posterior femoral
cutaneous nerve
Obturator
internus
Gluteus medius
(cut)
Gluteus maximus
(cut)
Gluteus
maximus (cut)
Superior and Inferior
Gluteal Artery
Perforator Flaps
Robert J. Allen Sr  |  Joshua L. Levine  |  Katherine A. Impastato
58 
INTRODUCTION
The superior gluteal myocutaneous free flap was first
described by Fujino in 1975 for breast reconstruction.1 In
1978, Le Quang performed the first breast reconstruction
with an inferior gluteal myocutaneous free flap.2 Shaw pop­
ularized the myocutaneous superior gluteal artery free flap;
however, a short vascular pedicle often led to additional vein
grafting, thus decreasing enthusiasm.3 The inferior gluteal
myocutaneous flap championed by Paletta et al. was also
abandoned due to sciatic nerve injury.4
In 1993, the superior gluteal artery perforator (SGAP)
flap was first introduced by the authors’ group. This fascio­
cutaneous flap utilizes the upper buttock adipose tissue and
overlying skin leaving the underlying gluteus maximus
muscle intact. However, the donor site is at risk for a bowing
contour deformity, disrupting the superior fullness of the
upper buttock. In early 2004, we developed the inferior
gluteal artery perforator (IGAP) flap. This flap uses excess
lower buttock tissue, preserves the underlying muscle, and
leaves the scar in the natural depression of the inferior
gluteal crease resulting in a more desirable donor site.
Free flaps based on the gluteal artery perforators are an
excellent alternative for breast reconstruction in patients
with inadequate abdominal tissue, a history of extensive
abdominal liposuction, prior abdominoplasty, or otherwise
unavailable abdominal donor tissue. These flaps can also be
used to supplement deep inferior epigastric perforator
(DIEP) flaps in a stacked flap fashion in women with large
breasts desiring large reconstruction who have insufficient
donor tissue from any one site alone. While the profunda
PART 5  —  PERFORATOR-BASED WORKHORSE FLAPS
Figure 58.1  Superior and inferior gluteal artery perforator flaps – buttocks.

688
PART 5 — PERFORATOR-BASED WORKHORSE FLAPS
inferior gluteal and its surrounding vessels from the lower
part of the greater sciatic foramen. The artery accompanies
the greater sciatic nerve, internal pudendal vessels, and the
posterior femoral cutaneous nerve. In this subfascial recess,
the inferior gluteal vein will receive tributaries from other
pelvic veins. The inferior gluteal vasculature continues
towards the surface by perforating the sacral fascia. It exits
the pelvis caudal to the piriformis muscle. Once under the
inferior portion of the gluteus maximus, perforating vessels
are seen branching out through the substance of the muscle
to feed the overlying skin and fat. The course of the inferior
gluteal artery perforating vessels is more oblique through
the substance of the gluteus maximus muscle than the
course of the superior gluteal artery perforators, which
tend to travel more directly to the superficial tissue up
through the muscle. Thus, the length of the inferior gluteal
artery perforator and the resultant pedicle length for the
overlying IGAP flap are greater than that found with an
SGAP flap. Because the skin island is placed inferior to the
origin of the inferior gluteal vessels, a longer pedicle is also
assured.
The direction of the perforating vessels can be superior,
lateral, or inferior. Perforating vessels that nourish the
medial and inferior portions of the buttock have relatively
short intramuscular lengths (4–5 cm), depending on the
thickness of the muscle. Perforators that nourish the lateral
portions of the overlying skin paddle are observed traveling
through the muscle substance in an oblique manner
4–6 cm before turning upwards towards the skin surface.
By traveling through the muscle for relatively long dis­
tances, these vessels are much longer than their medially
based counterparts. The perforating vessels can be sepa­
rated from the underlying gluteus maximus muscle and
fascia and traced down to the parent vessel, forming the
basis for the inferior gluteal artery perforator flap. Between
two and four perforating vessels originating from the inferior
gluteal artery will be located in the lower half of the gluteus
maximus.
After giving off perforators in the buttocks, the inferior
gluteal artery then descends into the thigh accompanied by
the posterior femoral cutaneous nerve and follows a long
course, eventually surfacing to supply the skin of the poste­
rior thigh.
Minor:  none of clinical significance.
The gluteus maximus muscle is classified as a Mathes-
Nahai Type III muscle based on its vascular anatomy with
two major pedicles, the superior and inferior gluteal arter­
ies, and no minor vessels. These arteries also supply the
overlying skin and are the basis of these fasciocutaneous
flaps.
VENOUS DRAINAGE OF THE FLAP (see Fig. 13.19)
SGAP
Primary:  venous comitantes
Length: 7.5 cm (range 6–9 cm)
Diameter: Range 2.5–4.0 mm
Secondary:  there are no known clinically significant
vessels that can be used to either solely drain the flap or to
provide partial or augmented drainage.
artery perforator flap is the first alternative to the DIEP flap
in our practice, the SGAP and IGAP flaps remain superb
options. The decision between a SGAP or an IGAP flap is
primarily based on the patients’ target breast volume, their
anatomic distribution of adipose, quality and location of
perforators, and their scar preference. Gluteal artery perfo­
rator (GAP) flaps are also a common choice for local cover­
age of pressure ulcers because of their bulk, minimal donor
site morbidity, and adaptability of the flap design based on
perforators available and the defect present. Customizing a
posterior thigh fasciocutaneous flap based on the descend­
ing branch of the inferior gluteal artery is an option for
pelvic or perineal reconstruction after cancer ablation,
trauma, or congenital defects.
FLAP ANATOMY (Figs 58.1, 58.2 and
Figs 13.3 and 13.19)
ARTERIAL AND VENOUS SUPPLY OF THE FLAP
(Fig. 58.2, see Fig. 13.3)
SGAP
Dominant:  superior gluteal artery
Length: 7 cm (range 5–10 cm)
Diameter: Range 2.0–3.0 mm
The superior gluteal artery, the largest branch of the
internal iliac artery, is a continuation of the posterior divi­
sion of that vessel. It is a relatively short artery, which runs
dorsally between the lumbosacral trunk and the first sacral
nerve. It emanates from the pelvis above the upper border
of the piriformis muscle, where it immediately divides into
both superficial and deep branches. The superficial branch
continues on to supply the upper portion of the gluteus
muscle and overlying fat and skin. Topographic landmarks
can be used to identify the superior gluteal artery (Fig.
58.3). With the femur slightly flexed and rotated inward, a
line is drawn from the posterior superior iliac spine to the
posterior superior angle of the greater trochanter. The
point of emergence of the superior gluteal artery from the
upper part of the greater sciatic foramen corresponds to the
junction of the upper and middle thirds of this line. Perfo­
rating vessels are given off from the superior branch of
the SGA. An average of three perforators can be found to supply
the skin.
IGAP
Dominant:  inferior gluteal artery
Length: 7.5 cm (range 6–9 cm)
Diameter: Range 2–2.5 mm
The inferior gluteal artery is a terminal branch of the
anterior division of the internal iliac artery and exits the
pelvis through the greater sciatic foramen. Landmarks can
also be used to identify the location of the emergence of
the inferior gluteal artery outside the pelvis. A second line
is drawn from the posterior superior iliac spine to the outer
part of the ischial tuberosity; the junction of its lower-third
with its middle-third marks the point of emergence of the

CHAPTER 58 — Superior and Inferior Gluteal Artery Perforator Flaps
689
maximus muscle in addition to the fascia, fat, and skin (e.g.,
sacral and ischial wounds). (See also Ch. 44.)
ADVANTAGES
• Both: Great options for designing a pedicled perforator
flap for coverage of decubiti and lower back defects
because of their consistently adequate tissue volume and
vasculature. Their adaptable design can accommodate a
large range of local defects while retaining potential for
primary closure without need for skin grafting. They are
good alternative methods for breast reconstruction when
abdominal or posterior thigh donor sites are unavailable
or inadequate, especially with a patients’ pear-shaped
body habitus (Table 58.1). Unlike in some autologous
tissue alternatives, the tissue available is usually adequate
for breast reconstruction without an implant. Even very
thin women often have sufficient tissue for breast recon­
struction. The fat from this location has a firm consistency
contributing to breast projection. The flaps can be rotated
to replicate the patient’s natural footprint and conus.
Both have minimal donor site morbidity and with no
muscle is sacrificed and eliminate the risk of hernia or
abdominal bulge.
• SGAP has a thick flap with adequate pedicle for breast
reconstruction. It is a short easy dissection.
• IGAP also has a thick flap with a long pedicle which, in
breast reconstruction, often supersedes rib cartilage
removal as the IMA recipient need not be as long. The
long pedicle permits the option of use of the thoracodor­
sal system when it is indicated. IGAP is an optimal choice
in patients with excessive saddle-bag tissue, utilizing this
tissue as the donor results in an aesthetically pleasing
body contour at the donor site. Preservation of the supe­
rior buttock fullness results in fewer contour defects than
the SGAP and the scar can be hidden if done in the
gluteal crease.
IGAP
Primary:  venous comitantes
Diameter: Range 2–3 mm
Surgeon must be cognizant of recipient venous diameter
when harvesting donor vessels. Internal mammary vein typi­
cally range at 2–4.5 mm but more commonly 2–2.5 mm.
Secondary:  there are no known clinically significant
vessels that can be used to either solely drain the flap or to
provide partial or augmented drainage
FLAP INNERVATION (Fig. 58.1 and Figs 13.3
and 13.19)
Sensory:  SGAP and IGAP flaps are not typically harvested
as an innervated flap.
However, they can be harvested as sensate flaps when
indicated based on: superior clunial nerves (branches of
posterior rami of lumbar spinal nerves L1-L3), medial
clunial nerves (arise from the posterior rami of sacral spinal
nerves S1-S3), or inferior cluneal nerves (gluteal branches
of the posterior femoral cutaneous nerve); direct branches
off the spinal cord L1–S3.
Motor:  not harvested with motor innervation.
FLAP COMPONENTS
The SGAP and IGAP flaps can be designed and harvested
in variable ways to accommodate different defects and goals.
When harvested as free flaps (e.g., breast reconstruction)
both the SGAP and IGAP flaps are harvested as fasciocuta­
neous flaps (skin, fat, fascia). They can also be designed as
myocutaneous advancement flaps, incorporating the gluteus
Figure 58.2  Variations in the internal iliac artery and its branches: I.G., inferior gluteal; I.I., internal iliac; S.G., superior gluteal; P., internal
pudendal.
Dashed lines mark pelvic floor.
Incidence of pattern given in %.
1a.
4a.
4b.
S. G.
S. G.
I. G.
P.
S. G.
I. G.
P.
I. G.
P.
S. G.
I. G.
P.
S. G.
I. G.
P.
S. G.
I. G.
P.
l. l.
l. l.
l. l.
S. G.
S. G.
I. G.
P.
I. G.
P.
l. l.
l. l.
l. l.
l. l.
l. l.
49%
10%
1.2 %
0.5 %
11.8%
3.5%
22.5%
5.
1b.
2a.
2b.
3.

690
PART 5 — PERFORATOR-BASED WORKHORSE FLAPS
preference of scar location is another important component
in flap choice.
For breast reconstruction, the patient is typically seen in
our office the day before surgery for marking with a perma­
nent marker and a final review of the surgical plan and
discussion of any unanswered question. With the patient in
an upright position, the midline of the chest and the infra­
mammary fold are marked, as well as suggested mastectomy
incision lines.
For all uses of these flaps, the perforator location identi­
fied through angiography is confirmed with a Doppler
probe and marked. The flap design is marked and mea­
sured as described below.
FLAP DESIGN
ANATOMIC LANDMARKS (Fig. 58.3)
With the hip slightly flexed and rotated inward, a line is
drawn from the posterior superior iliac spine to the posterior
superior angle of the greater trochanter; the point of emer­
gence of the superior gluteal artery corresponds to the junc­
tion of the upper- and middle-thirds of this line. Additional
perforators may be located lateral to this line. These lateral
perforators are septocutaneous, passing between the gluteus
maximus and medius, and are reliably longer in length.
A second line is drawn from the posterior superior iliac
spine to the outer part of the ischial tuberosity; the junction
of the lower and middle-third marks the point of emergence
of the inferior gluteal arteries from the lower part of the
greater sciatic foramen.
GENERAL THOUGHTS ABOUT FLAP DESIGN
SGAP (Fig. 58.4A,B)
Markings are placed on the patient in the lateral prone
position.
The skin paddle is marked, beginning at the most inferior
and medial point, 2–3 cm below the intergluteal crease. It
extends superiolaterally in an elliptical pattern, including
the perforators and provide tissue adequate to correct the
defect dimensions. The skin flap can be customized to almost
any orientation as long as the outline contains a perforator.
The scar of an oblique elliptical flap can be designed to be
concealed by swimwear or undergarment. It should be noted
that perforators located laterally will produce longer pedi­
cles and should therefore be incorporated into the flap
design when this characteristic is desirable (Fig. 58.5A,B).
IGAP (Fig. 58.4C,D)
This flap is designed as a horizontal ellipse with the axis
centered above the gluteal crease. The gluteal crease is
marked with the patient in the standing position. The infe­
rior incision is then drawn parallel to the crease and 1–3 cm
inferior to it. Then, with the patient in the lateral decubitus
position, a handheld Doppler probe is used to locate perfo­
rating vessels to the skin. The superior aspect of the skin
island ellipse is then marked to capture these perforators.
The orientation of the skin paddle usually parallels the
inferior gluteal crease. Depending on the amount of skin
needed (less with a skin-sparing mastectomy) and the
amount of excess buttock tissue available, the design of each
DISADVANTAGES
• Both: When used for bilateral breast reconstruction these
flaps require patient repositioning during surgery. They
are typically inappropriate for most arm and head and
neck reconstruction, because of their thickness. Patients
should be aware that there is always the risk of donor site
contour defects, visible scar, and asymmetry, and although
more common following SGAP, there is also a risk after
IGAP.
• SGAP: The short course through muscle makes for a tech­
nically simple procedure but the shorter pedicle limits its
applicability. (Note: perforators located laterally produce
longer pedicles).
• IGAP: A discrepancy of the vein caliber is a potential
problem when using internal mammary vessel as a recipi­
ent. Postoperative pain and discomfort are more common
with the IGAP and it has an increased risk of wound
dehiscence.
PREOPERATIVE PREPARATION
As with all surgeries, a complete history and physical exam
are completed during the initial consultation. Any comor­
bidities are addressed, options and expected outcomes
including scar location are discussed, and risks of surgery
are explained. Patients should be informed about possible
contour deformities and the future location of the scar at
the buttock.
Preoperative imaging with computed tomographic or
magnetic resonance imaging angiograms of the patient in
the prone position is essential for optimal preoperative flap
design. The angiograms identify the key perforator’s course
as being musculocutaneous or septocutaneous, their loca­
tion, and their caliber – thus, influencing the choice between
a SGAP or IGAP flap and providing a map for preoperative
planning.
Other influences on preoperative flap selection are the
patient’s unique body habitus and distribution of fat, the
extent of radiotherapy or trauma to the surrounding tissue
when applicable, ambulatory status, and the tissue compo­
nents that need to be replaced to reach the functional and
structural goal of the reconstruction. The patient’s personal
Table 58.1  The gluteal region as a donor site for
breast reconstruction
Indication
(%)
Thin abdomen with inadequate tissue for desired
breast size
64
Abdominal incisions
14
Previous abdominoplasty
8
Patient preference
7
Nulliparous
6
Failed abdominal flap
1

CHAPTER 58 — Superior and Inferior Gluteal Artery Perforator Flaps
691
length (cm) × height or thickness (cm). For example, an
SGAP flap that is 20 cm long, 10 cm wide, and 4 cm thick
would have an appropriate weight of 400 g. These weights
and estimates are important to avoid over resection.
FLAP DIMENSIONS
SGAP Dimensions
Length: 22 cm (range 20–30 cm)
Width: 8 cm (range 5–12 cm), maximum to be closed pri­
marily for SGAP and IGAP is patient specific and requires
surgeon’s judgment
The flap dimensions are determined by several factors:
the skin requirements to cover the defect; the estimated
flap varies accordingly. In patients with abundant tissue in
the lateral thigh, the flap design can be shifted laterally to
incorporate this saddle-bag tissue and preserve the medial
fat pad over the ischial tuberosity. Preoperative markings are
shown in (Fig. 58.5A–C).
Some patients have more tissue available in the lower
buttock and saddle-bag area. In a patient with relatively
small breasts and large buttocks, the in-the-crease IGAP
(ITC-IGAP) can give an excellent result, particularly with
secondary liposuction of the lateral thighs.
SPECIAL CONSIDERATIONS
When immediate breast reconstruction is being performed,
the mastectomy specimen is weighed to gauge the volume
needed. The flap dimensions are measured and flap weight
(g) is estimated as follows: width (cm) × one half of the
Figure 58.3  Anatomic landmarks. (Reproduced with permission from Lumley JSP. Surface anatomy. 3rd edn. Churchill Livingstone; 2002.)
B
A
1
2
3
4
5
7
6
8
9
10
11
12
13
14
15
16
17
18
19
1. Tensor fascia latae
2. Gluteus maximus
3. Long head of biceps femoris
4. Semitendinosus
5. Semimembranosus
6. Adductor magnus
7. Gracilis
8. Adductor hiatus
9. Sacrotuberous ligament
10. Sacrospinous ligament
11. Gluteus medius
12. Gluteus minimus (deep to medius)
13. Piriformis
14. Quadratus femoris
15. Sciatic nerve
16. Short head of biceps femoris
17. Superior gluteal artery
18. Inferior gluteal artery
19. Internal pudendal artery
1
2
3
4
5
7
6
8
9
10
11
12
13
14
15
16
17
18
19
1. Tensor fascia latae
2. Gluteus maximus
3. Long head of biceps femoris
4. Semitendinosus
5. Semimembranosus
6. Adductor magnus
7. Gracilis
8. Adductor hiatus
9. Sacrotuberous ligament
10. Sacrospinous ligament
11. Gluteus medius
12. Gluteus minimus (deep to medius)
13. Piriformis
14. Quadratus femoris
15. Sciatic nerve
16. Short head of biceps femoris
17. Superior gluteal artery
18. Inferior gluteal artery
19. Internal pudendal artery

692
PART 5 — PERFORATOR-BASED WORKHORSE FLAPS
tissue may be beveled up to 5 cm superiorly and laterally
and 2 cm inferiorly for extra tissue. The exact dimensions
of the flap are dependent on the above mentioned factors.
The pattern can be shifted laterally in pear-shaped women
who wish to utilize the saddle-bag deformity in their flap, in
which case the extent of lateral beveling would be increased.
FLAP MARKINGS (Figs 58.4–58.6)
For the SGAP flap markings, the patient is placed in a lateral
decubitus position. The Doppler probe is used to locate
perforating vessels from the superior gluteal artery. These
are usually located approximately one-third of the distance
volume requirement of the defect; and the thickness of the
tissue at the donor site. The patient can bring underwear
or a swimsuit to help design a flap to keep the scar con­
cealed. In general, the recommended skin design is 8 ×
22 cm. The flap dimensions including beveling are
14–15 × 22–24 cm.
IGAP Dimensions
Length: average 7 cm, maximum 12 cm
Width: average 18 cm, maximum 30 cm
Dimensions are dependent on the amount of skin needed
and the amount of excess buttock tissue available. Adipose
Figure 58.4  (A) SGAP relationship to surrounding structures. (B) End result of SGAP scar. (C) ITC-IGAP relationship to surrounding structures.
(D) End result of ITC-IGAP scar.
B
A
D
C

CHAPTER 58 — Superior and Inferior Gluteal Artery Perforator Flaps
693
reconstruction. The SGA exits the pelvis one-third down
from the posterior iliac spine to the greater trochanter.
There is almost always a perforator at this spot. However,
this will be the shortest pedicle since the perforator goes
straight through the muscle. A more lateral perforator will
pass obliquely back to the point of origin of the SGA, giving
a longer pedicle. All things considered, we select the largest
caliber perforator, as long as it is not on the periphery of
the flap, and are not as concerned with the length. We
on a line from the posterior superior iliac crest to the
greater trochanter. Additional perforators may be found
slightly more lateral from above. The skin paddle is marked
in an oblique pattern from inferior medial to superior
lateral encompassing these perforators.
For marking the day before surgery, the patient is posi­
tioned as she will be on the OR table for flap harvest, usually
lateral decubitus for unilateral breast reconstruction, prone
for bilateral breast reconstruction or sacral or ischial defect
Figure 58.5  (A) SGAP preoperative markings with Doppler-located arterial markings and flap designed to incorporate the most lateral perfora­
tors. Lateral perforators have the longest course and thus produce longer pedicles. (B) SGAP preoperative flap design with estimated perforator
course based on anatomic landmarks.
A
B
A
B
Figure 58.6  ITC-IGAP markings.
C

694
PART 5 — PERFORATOR-BASED WORKHORSE FLAPS
anastomosis safely. The SGAP pedicle is consistently too
short and requires rib cartilage removal to gain the extra
length needed for vessel anastomosis but the IGAP pedicle
is typically of sufficient length, obviating the need for rib
cartilage removal. During harvest of the recipient vessels in
the chest, care must be taken to preserve at least small
lengths of the side branches of the internal mammary artery
and internal mammary vein that may be used for improving
any size mismatch, which may occur with the flap vessels.
This is especially important with the internal mammary vein
because the gluteal vein is often very large and may measure
4–5 mm in diameter.
A second plastic surgeon harvests the GAP flap of choice.
Incisions are made along the previously drawn marks and
electrocautery used to divide the fat down to the gluteal
fascia. In both SGAP and IGAP flap harvest, the dissection
proceeds from lateral to medial in the subfascial plane to
allow easier visualization of the perforators. The fat is bev­
elled superiorly and inferiorly to include the maximum
amount of fat and soft tissue in the flap when deemed neces­
sary. Additional lateral beveling in IGAP harvest can also be
used to obtain more fat from the lateral thigh or saddle-bag
area. In IGAP flap harvest, care is taken to leave sufficient
fat medially over the ischium. The fat in this area is more
dense and slightly lighter in color than the more lateral fat
which is incorporated into the flap.
The subfascial dissection is performed in parallel to the
gluteus maximus muscle bundles. As the fascia is divided
with the bipolar electrocautery, perforators can be seen
emerging between the muscle bundles. Perforators with an
artery of at least 1 mm and venae comitantes are followed
through the muscle between the muscle fascicles, which are
spread apart to allow deeper dissection. The majority of
these perforator flaps are based on one perforator. On occa­
sion, a second perforator is found during the dissection and
included if it is in the same plane and easily joins the first
perforator. The dissection proceeds under the muscle until
a pedicle of sufficient length and vessel caliber is obtained
to allow microsurgical anastomosis with the dissected recipi­
ent vessels. Self-retaining retractors aid in exposure of the
interfascicular pedicle and may be placed incrementally
deeper to allow improved visualization. Once the depth
becomes too great for a regular self-retaining retractor, a
long right-angled version may be used. Excellent exposure
is critically important when ligating tributaries to the supe­
rior gluteal vein; multiple branches are encountered which
can make dissection technically difficult. Without adequate
exposure, the risk of injury to the vein is a significant
problem. To avoid this damage, the authors recommend
placing the retractor so that it holds the piriformis and
gluteus minimus muscle widely apart while an assistant care­
fully supports the flap. Ligation of the venous tributaries is
performed only when the gluteal vein is clearly visualized as
it exits the pelvis. The dissection continues until either the
superior or inferior gluteal artery is reached or until the
pedicle is of adequate length and caliber. Occasionally, ade­
quate vessel size and length are obtained prior to the take-
off from the superior or inferior gluteal artery and vein,
simplifying flap harvest. Dissection proceeds until the artery
diameter is near 2 mm, in order to match the internal
mammary artery. The recipient internal mammary vein is
consistently smaller on the left ranging from 1.5 to 3.5 mm;
prefer the oblique design because, in our experience, the
scar is better concealed by clothing and the contour is
better. A horizontal design may accentuate the concavity
naturally present between the flare of the pelvic bones and
look unattractive.
For the ITC-IGAP, the gluteal fold is noted with the
patient in a standing position. The inferior limit of the flap
is marked 1–3 cm inferior and parallel to the fold. The
patient is then placed in the lateral position with the flap
side up and the Doppler probe is used to find the perforat­
ing vessels from the inferior gluteal artery. An ellipse is
drawn for the skin paddle to include these perforators, with
the final shape having a longer length of the superior limb
than the inferior limb. The final dimensions are 8–10 ×
18–20 cm for both flaps.
PATIENT POSITIONING
Initial positioning is dependent on the intended recipient
site for which this flap is being used.
For decubiti or other dorsally located defects, the patient
is placed in the prone position for the entirety of the
procedure.
In the case of immediate bilateral breast reconstruction,
the patient remains in the supine position following the
mastectomy(s), the recipient vessels are exposed. Once
exposed, the skin over the breast is temporarily stapled
closed and covered with sterile dressings. The patient is then
rolled into the prone position, re-prepped and re-draped
for GAP flap harvest and subsequent closure and sterile
dressing of the donor site(s). The patient is once again
rolled into the supine position, re-prepped and re-draped
for the anastomosis and insetting.
For unilateral breast reconstruction cases, the patient
may be placed in the lateral decubitus for simultaneous
recipient vessel dissection and GAP flap harvest. After flap
harvest and donor site closure, the patient is rolled to the
supine position for optimal inset positioning.
ANESTHETIC CONSIDERATIONS
Flaps can be harvested under local/epidural anesthesia but
due to the delicate nature of flap harvesting and insetting,
even the slightest movements could ruin hours of work. We
recommend general anesthesia for the majority of patients.
TECHNIQUE OF FLAP HARVEST
(Figs 58.7, 58.8)
For breast reconstruction, our patients receive 5000 units of
subcutaneous heparin preoperatively for DVT prophylaxis
in addition to sequential compression devices that are
placed on bilateral lower extremities. After the patient is
anesthetized, re-marked, and positioned, the patient is
prepped and draped in a sterile fashion. When the two-team
approach is used, a recipient site plastic surgeon prepares
the internal mammary artery and vein. This is typically
done within the third intercostal space with removal of the
superior or inferior rib cartilage when the donor pedicle
is of insufficient length to complete the microsurgical

CHAPTER 58 — Superior and Inferior Gluteal Artery Perforator Flaps
695
gluteal vessels. The sciatic nerve is not exposed and has
never been injured in our experience.
Once recipient vessels of adequate diameter are con­
firmed, the pedicle is divided and the flap harvested and
weighed. The superficial fascial system is identified and
closed with sutures before final skin closure. At the end of
the procedure the patient should be placed in a supporting
girdle, which the authors recommend be worn for 2 weeks.
therefore, the surgeon must be cognizant of the inferior
gluteal vein size so as to avoid a large size mismatch. It
should be noted that the vein gets proportionately larger in
diameter than does the artery.
The distal continuation of the inferior gluteal artery and
vein can be transected to aid in mobilization of the pedicle.
Care must be taken to avoid injury to the posterior femoral
cutaneous nerve of the thigh which travels with the inferior
Figure 58.7  (A–E) SGAP progressive flap dissection.
A
B
C
D
E
C
E
Figure 58.8  (A–E) ITC-IGAP flap dissection/final insetting.
A
B
C
D
E

696
PART 5 — PERFORATOR-BASED WORKHORSE FLAPS
We would not recommend trying this as a fascia-only flap.
This fascia is not thick and we do not think a perforator
would perfuse a large sheet of fascia.
A portion of muscle could be taken with the flap either
as local rotation or free flap. We do not like the idea of
taking a block of muscle with this perforator flap. We believe
that this defeats the purpose and advantage of a perforator
skin flap. However, in certain patient populations (e.g., non-
ambulatory with decubitus ulcer), muscle may be taken to
provide augmented blood supply and tissue.
DONOR SITE CLOSURE AND
MANAGEMENT
For standard designs, the donor site is closed primarily in
three layers (superficial fascia, subdermal, and subcuticu­
lar) over a single drain. The incision is dressed in a sterile
fashion based on surgeon preference and a girdle is put
on. Dressings are changed after 3 days and the girdle
remains in place for 2 weeks, except when in the shower.
Patients are allowed to shower on postoperative day 3 but
are not allowed to submerge in water until wounds are
completely healed. If Steri-Strips are placed, they are left
on until they fall off on their own. Patients are taught to
empty and record JP drain output at home twice daily.
They are instructed to return to the clinic for JP removal
when the drain output is <30 cc/day for 2 consecutive
days.
TECHNICAL TIPS TO OPTIMIZE OUTCOMES
AND AVOID COMPLICATIONS
• Efficiency is particularly important when position changes
during surgery. Tips for efficiency:
• Preoperative planning with imaging
• Two-team approach
• Pre-marked perforators, sterile Doppler to periodically
check perforator throughout operation
• Venous coupler
• Marking the anterior side of donor and recipient
vessels with a marking pen prior to microsurgery will
decrease kinking or twisting of vessels
• Careful insetting to avoid kinking this is imperative to
reduce the risk venous thrombosis.
• When large volume reconstructions are desirable, bevel­
ing can accumulate another 100+ g of tissue.
• Bipolar cautery, urologic stays, and large right-angled self-
retaining retractors are all useful surgical tools for flap
harvest and exposure for the anastomosis.
• By designing the SGAP high on the buttock and beveling
mostly superiorly, the revision rate and contour deformi­
ties are low and the scar may be concealed by swimwear.
• To minimize contour deformity, bevel superiorly and may
be beveled in all directions, except medially, and a layered
closure is done
• Techniques to avoid sciatic nerve injury with IGAP
dissection:
• Follow the perforator until its branch from the descend­
ing branch of the IGA. At this point the sciatic nerve
is separate and rarely seen.
The patient is then returned to the supine position and
the microvascular anastomosis and flap insetting are per­
formed, with care to not twist or kink the pedicle. An end-
to-end venous anastomosis using a coupler of appropriate
size is always used in our practice and an end-to-end arterial
anastomosis using either interrupted or running 9-0 nylon
suture by surgeon preference. In combined DIEP/GAP “four
flappers,” we anastomose the GAP perforator into the stump
of the DIEP pedicle making it a flow through stacked flap
on each side. The insetting and closure are performed over
a suction drain, and great care is used to monitor the integrity
of the pedicle during the insetting of the flap. Excess skin
is de-epithelialized superiorly and inferiorly, and the flap
inset with a visible skin paddle is left in place. The external
Doppler probe is used to identify the locations on the flap
with good arterial and venous signals, and these locations
are marked for postoperative monitoring in the ICU and on
the floor with a handheld Doppler. For monitoring it is also
possible to use an implantable Doppler probe.
FLAP MODIFICATION/FLAP HANDLING
We have used free GAP flaps almost exclusively for breast
reconstruction. Our most recent variation of the GAP free
flap for breast reconstruction is the thigh GAP flap (TGAP)
(Fig. 58.9). This flap is based on perforators off the inferior
gluteal artery to the posterior thigh skin and fat. The flap
design on the posterior thigh has an incision in or just below
the inferior gluteal fold with the lower incision 6–7 cm
below. The transverse dimension is 20–26 cm depending on
volume requirement. Preoperative CTA or MRA is helpful
in identifying the key perforator. The perforator(s) usually
emerges from the lateral border of the biceps femoris just
inferior to the gluteus maximus. As it is traced deep and
superior toward the inferior gluteal artery, the posterior
cutaneous nerve of the thigh is encountered and preserved.
After about 6 cm of pedicle length, adequate vessel diame­
ter is obtained for the internal mammary recipient vessels.
The donor site scar is concealed in the inferior fold crease
with no buttock deformity.
Non-free GAP flaps are a great option for pressure ulcer
coverage due to their close proximity and variability of
design. Depending on the location and size of the defect
and the ambulatory status of the patient, the upper-half,
lower-half, or entire gluteus maximus muscle can be used
in a musculocutaneous flap, or the muscle can be spared to
create a fasciocutaneous flap. The method of transfer of
these flaps is also adaptable: V-Y advancement flaps, rota­
tion advancement flaps, island flaps, and propeller flaps,
are a few examples of the potential options for tissue
transfer.
Care should be taken to minimize tension across the
suture line to reduce the risk of dehiscence along the line
of maximal tension.
GAP flaps can be safely thinned. Most are based on one
perforator, protect the perforator and thin the flap, begin­
ning with removal of the deep fat and leaving a little sub­
dermal fat.
These flaps are quite robust and can be de-epithelialized
and folded when additional thickness and less surface area
are needed.

CHAPTER 58 — Superior and Inferior Gluteal Artery Perforator Flaps
697
Postoperative pain at the IGAP donor site is common with
sitting or maximal hip flexion causing increased tension
across the incision. Some complaints of sensory loss at the
donor site after IGAP flaps have been reported due to
damage to branches of the posterior femoral cutaneous
nerve.
OUTCOMES
EXPECTED OUTCOMES
With SGAP and IGAP flaps, 98% success rates are typical.
UNTOWARD OUTCOMES (Table 58.2)
Donor site complications include seroma, hematoma, and
contour abnormalities, including dog ears, scarring, infec­
tion, and wound dehiscence.
Drains can decrease the amount of fluid accumulation
postoperatively. Multiple layer closure with Steri-Strips and
Dermabond can help prevent wound dehiscence. Designing
the IGAP flap in the gluteal fold (ITC-IGAP) can hide the
scar.
Flap complications that can occur include artery or vein
occlusions, venous congestion, hematoma, seroma, partial
necrosis, infection, asymmetry, and scarring.
LONG-TERM OUTCOMES
Long-term outcomes for the recipient site include a flap
that softens with time and scars that fade. For breast recon­
struction, after 3 months, a nipple can be reconstructed.
With time, the flap will adapt to the patient’s body habitus
and gain or lose weight with the patient. Also gravity will
take effect.
Sensory recovery will occur in some patients.
CONCLUSIONS
The gluteal region offers a reliable alternative to the
abdomen for breast reconstruction. This region can provide
an average of 450 g of fat and skin. Even in thin patients,
there is usually adequate tissue to harvest a reasonably sized
breast flap.
• It can be palpated if desired.
• When the free flap is harvested the muscle is left in
place protecting the sciatic nerve.
FLAP USAGE
SGAP and IGAP flaps harvested as free flaps are most com­
monly used as an alternative for breast reconstruction or in
conjunction with a DIEP flap (as a “four flapper”), when no
flap alone would provide adequate tissue for reconstruction.
SGAP and IGAP flaps are excellent options for local flap
reconstruction of decubitus ulcers or lumbosacral defects
after trauma or surgery.
TYPICAL INDICATIONS FOR THE USE OF
THIS FLAP
• Free flaps are used for breast reconstruction – always
harvested as fasciocutaneous flaps.
• Pedicled flaps are used for sacral, trochanteric, and ischial
decubiti, lumbosacral defect, and, less frequently, for
pelvic or perineal reconstruction.
• Note: these flaps can be musculocutaneous or fasciocu­
taneous and their design is highly variable. Examples
of designs:
• Island
• V-Y advancement
• Rotation advancement
• Propeller
POSTOPERATIVE CARE
For free flaps, after discharge from the post-anesthesia care
unit (PACU), the flap is monitored hourly for the first 12 h
then every 4 hours until discharge on postoperative day 3
or 4. Patients get out of bed and ambulate on the first post­
operative day. Many patients feel very well and report little
or no pain on the second postoperative day. Drains are
removed from the breast on postoperative day 3 or when
<30 cc/day from the buttocks. A surgical girdle is worn for
2 weeks postoperatively. All patients are hospitalized until
the 4th postoperative day, for flap monitoring. Patients typi­
cally return to work or normal activity 4 weeks after surgery.
However, many feel well enough to go back to work sooner.
Patients are advised not to engage in vigorous activity or
heavy-lifting for 4 weeks following surgery.
In pressure sore reconstruction, it is best to keep all
pressure off a pedicled GAP flap in the immediate postop­
erative period because there is a danger of shearing off
the pedicle. Complete bed rest is of vital importance, espe­
cially in the cases of pressure ulcers as a consequence of
denervation, since all phases of wound healing are impaired
in that population. The length of bed rest varies from 3
days to 8 weeks. Whether bed rest should take place in an
inpatient facility is also debatable, with the bottom line
being assurance that a patient will follow the protocol
strictly without surveillance. There is also a range of opin­
ions of the degree of bed rest from 3 weeks of flat bed
rest followed by graduated degrees of sitting to only 1 week
of flat bed rest.
Table 58.2  Untoward outcomes
Complication
(%)
Vascular complications
6
Donor site deformity
4
Partial flap necrosis
4
Donor site seroma
2
Breast hematoma
2
Donor site hematoma
1

698
PART 5 — PERFORATOR-BASED WORKHORSE FLAPS
A 28-year-old woman with left breast carcinoma. (A) Preopera-
tive markings left mastectomy and thigh inferior gluteal artery
perforator (TGAP) flap reconstruction. (B) Postoperative
TGAP flap, left breast.
CASE 58.1  Breast Reconstruction with a
Thigh Inferior Gluteal Artery
Perforator (TGAP) Flap
Figure 58.9  (A) Preoperative markings, left mastectomy and thigh
inferior gluteal artery perforator (TGAP) flap reconstruction. (B)
Postoperative TGAP flap, left breast.
A
B
Expert Commentary
Moustapha Hamdi, MD, PhD
The gluteal area provides ample tissue for free flap transfer
to the breast. As was stated by the authors, the buttock
tissue is always adequate for total breast reconstruction,
even in thin patients. Over almost one decade, the superior
gluteal artery perforator flap (SGAP) was our second choice
for autologous breast reconstruction after the abdominal wall
flaps. However, the flap harvesting necessitates a change in
patient position and also it is technically demanding due to
the shortness of the pedicle and the vessels’ diameter
mismatch.
Furthermore, The SGAP flap had several drawbacks. The
buttock fat tissue is quite compact and flap modeling was
not always easy. Therefore, ancillary procedures such as
liposuction/filling with contralateral breast remodeling were
necessary to achieve better breast symmetry. Additionally,
the SGAP flap has smaller skin paddle compared with the
DIEP flap, which makes it more suitable for immediate breast
reconstruction. Finally, harvesting a SGAP flap might result
in a buttock deformity if the flap was harvested from the
central part of the buttock. For all the above-mentioned
reasons, the SGAP flap was not a very popular flap.
Dr Allen later popularized the inferior gluteal artery perfora-
tor (IGAP) flap and the so-called “in-the-crease” gluteal flap,
in order to have a longer pedicle with a better-hidden scar
and less donor site morbidity. However, patients who under-
went IGAP flap breast reconstruction reported long rehabili-
tation times because of the postoperative pain in the sitting
position. Actually, the IGAP flap could improve the buttock
contour in women with sagging lower gluteal folds (banana
deformity), otherwise it is not first-line to choose when other
donor sites are available.
Recently, surgeons move down to the thigh as a donor site
to avoid creating contour deformities to an aesthetic unit
such as the buttock. A new generation of flaps have been
raised from the thigh based perforator from the femoral pro-
funda artery.
Today, the gluteal flaps are rarely indicated for breast
reconstruction.
I still perform SGAP breast reconstruction when the
anatomy of the patient allows harvesting in a highly posi-
tioned skin paddle. A variation of the SGAP flap called a
“septocutaneous flap” provides softer fat tissue with longer
pedicle because the vessels course is between the gluteal
maximus and medium; and enters the skin quite high and
lateral on buttock. Planning such SGAP flap is based on the
findings of a CT angioscan, which will localize such perfora-
tors. The resulting scar is highly located and provides a
buttock/thigh lift effect for the patient as the flap is highly
designed at the junction of the buttock with the lumbar area.
The resulting scar preserves the integrity of the gluteal area
as one aesthetic unit.
Using preoperative CT scan imaging has changed our flap
planning technique. It provides major aesthetic advantages
to our patients in terms of flap design, harvesting, and also
in donor site choice.

CHAPTER 58 — Superior and Inferior Gluteal Artery Perforator Flaps
699
2. Le Quang C. Secondary microsurgical reconstruction of the breast
and free inferior gluteal flap. Ann Chir Plast Esthet 1992;
37:723–41.
3. Shaw WW. Superior gluteal free flap breast reconstruction. Clin
Plast Surg 1998;25:267.
4. Paletta CE, Bostwick J 3rd, Nahai F. The inferior gluteal free flap
in breast reconstruction. Plast Reconstr Surg 1989;84:875–83.
Access Figures 58.10–58.13 as well as case
examples 58.2–58.5 and further reading online
at
REFERENCES
1. Fujino T, Harashina T, Aoyagi F. Reconstruction for aplasia of the
breast and pectoral region by microvascular transfer of a free flap
from the buttock. Plast Reconstr Surg 1975;56:178–81.

CHAPTER 58 — Superior and Inferior Gluteal Artery Perforator Flaps 699.e1
A 55-year-old woman with previous lumpectomy and a right
breast contour deformity. She desired autologous reconstruc-
tion. A right ITC-IGAP flap was chosen due to previous
abdominal surgery. The length of the ITC-IGAP pedicle enabled
use of the thoracodorsal system as recipient vessels.
CASE 58.2  Breast Reconstruction with an ITC-IGAP Flap
Figure 58.10  (A) Right breast, deficient tissue from previous lumpectomy. (B) Flap partially inset and de-epithelialized. Flap vessels
anastomosed to thoracodorsal vessels. (C) Skin island for external visual monitoring of flap viability. (D) Right breast following flap recon­
struction; note volume added and symmetry. (E) Resultant donor scar.
A
B
C
D
E

699.e2 PART 5 — PERFORATOR-BASED WORKHORSE FLAPS
A 38-year-old woman with Poland syndrome involving the left
breast. She underwent implant reconstruction at the age of 18,
with subsequent complication of Grade 4 capsular contracture.
(A) Grade 4 capsular contracture after implant reconstruction.
Preoperative SGAP flap markings shown. (B) Anastomosis
shown. (C) Postoperative left SGAP reconstruction for Poland
syndrome involving the left breast with bilateral implant removal
and right mastopexy for symmetry.
CASE 58.3  Poland Syndrome SGAP Reconstruction
Figure 58.11  Grade 4 capsular contracture after implant reconstruction. (A) Preoperative SGAP flap markings shown. (B) Left chest
arterial and venous anastomoses. (C) Postoperative left SGAP reconstruction for Poland syndrome involving the left breast with bilateral
implant removal and right mastopexy for symmetry.
A
C
B

CHAPTER 58 — Superior and Inferior Gluteal Artery Perforator Flaps 699.e3
Guerra AB, Metzinger SE, Bidros RS, et al. Breast reconstruction with
gluteal artery perforator (GAP) flaps: a critical analysis of 142 cases.
Ann Plast Surg 2004;52:118–25.
Koshima I, Moriguchi T, Soeda S, et al. The gluteal perforator-based
flap for repair of sacral pressure sores. Plast Reconstr Surg
1993;91:678–83.
Roche NA, Van Landuyt K, Blondeel PN, et al. The use of pedicled
perforator flaps for reconstruction of lumbosacral defects. Ann Plast
Surg 2000;45:7.
Shaw WW. Microvascular free flap breast reconstruction. Clin Plast Surg
1984;11:333.
Strauch B, Yu HL, editors. Gluteal region. In: Atlas of microvascular
surgery: anatomy and operative approaches. New York: Thieme
Medical; 1993. p. 102–19.
Verpaele AM, Blondeelm PN, Van Landuyt K, et al. The superior
gluteal artery perforator flap: an additional tool in the treatment of
sacral pressure sores. Br J Plast Surg 1999;52:385–91.
Windhofer C, Brenner E, Moriggl B, et al. Relationship between the
descending branch of the inferior gluteal artery and the posterior
femoral cutaneous nerve applicable to flap surgery. Surg Radiol Anat
2002;24:253–7.
A 40-year-old woman, postoperatively after bilateral nipple
sparing mastectomies for +BRCA genetic mutation, with bilat-
eral IGAP flap reconstruction.
CASE 58.5  Bilateral Breast
Reconstruction with  
IGAP Flaps
Figure 58.13  Anterior and posterior view of patient following
breast bilateral breast reconstruction with IGAP flaps.
A 40-year-old woman with right breast cancer and previous
augmentation mammaplasty. Before and after bilateral mas-
tectomies with combined SGAP/DIEP flap breast reconstruc-
tion bilaterally.
CASE 58.4  Breast Reconstruction with
Bilateral Combined  
SGAP/DIEP Flaps
Figure 58.12  Before and after photographs (a. AP view,
b. oblique view, C. lateral view) of a patient with previous augmen­
tation mammaplasty and right breast cancer. Postoperative pho­
tograph is after bilateral mastectomies with combined SGAP/DIEP
flap breast reconstruction bilaterally.
A
B
C
FURTHER READING
Allen RJ, Tucker C Jr. Superior gluteal artery perforator free flap for
breast reconstruction. Plast Reconstr Surg 1995;95:1207–12.
Allen RJ, Levine JL, Granzow JW. The in-the-crease inferior gluteal
artery perforator flap for breast reconstruction. Plast Reconstr Surg
2006;118:333–9.
Ao M, Mae O, Namba Y, et al. Perforator-based flap for coverage of
lumbosacral defects. Plast Reconstr Surg 1998;101:987.
Benito P, García J, De Juan A, et al. Reconstruction of a perianal defect
by means of a bilateral V-Y advancement flap based on the perforat­
ing arteries of the gluteus maximus shaped over a cicatricial area. J
Plast Reconstr Aesthet Surg 2009;62:412–14.
Blondeel PN. The sensate free superior gluteal artery perforator
(S-GAP) flap: a valuable alternative in autologous breast reconstruc­
tion. Br J Plastic Surg 1999;52:185–93.
Boccola MA, Rozen WM, Ek EW, et al. Inferior gluteal artery myocuta­
neous island transposition flap reconstruction of irradiated perineal
defects. J Plast Reconstr Aesthet Surg 2010;63:1169–75.
Boustred MA, Nahai F. Inferior gluteal free flap breast reconstruction.
Clin Plast Surg 1998;25:275–82.
Codner MA, Nahai F. The gluteal artery free flap breast reconstruction:
making it work. Clin Plast Surg 1994;24:289.
Friedman JD, Reece GR, Eldor L. The utility of the posterior thigh flap
for complex pelvic and perineal reconstruction. Plast Reconstr Surg
2010;126:146–55.

700
Anterolateral and
Anteromedial Thigh Flaps
Samir Mardini  |  Harvey Chim  |  Fu-Chan Wei
59 
INTRODUCTION
In 1984, Song and colleagues introduced the anterolateral
thigh flap based on septocutaneous branches of the descend­
ing branch of the lateral circumflex femoral artery. Since
that time, the anterolateral thigh flap has gained popularity
for use as a soft tissue flap for reconstruction of regional
as well as distant defects. This flap can provide muscle,
fascia, skin, or any of these in combination. Early anatomic
dissections on cadavers noted that the vascular anatomy was
variable and that the majority of skin vessels were septocu­
taneous compared with musculocutaneous in nature. More
recent studies and series indicate the skin vessels are
Figure 59.1  (Left) Anterolateral thigh flap; (Right) Anteromedial thigh flap.
Tensor fascia lata
Rectus femoris
(retracted)
Vastus lateralis
Vastus medialis
Vastus intermedius
Sartorius
Adductor longus
Pubic tubercle
Pectineus
Iliopsoas
Inguinal ligament
Anterior superior iliac spine
Ascending branch
of LFCA
Transverse branch
of LFCA
Descending branch
of LFCA
Superficial femoral
artery
Common femoral artery
Rectus femoris
Vastus medialis
Sartorius
Adductor longus
Pubic tubercle
Pectineus
Inguinal ligament
Anterior superior iliac spine
Common femoral artery
Femoral nerve
Femoral nerve
Lateral femoral
cutaneous nerve
Branch of femoral nerve
to vastus lateralis
Branch of femoral nerve
to vastus intermedius
Saphenous nerve
Nerve to vastus medialis
Anteromedial thigh flap
Anterolateral thigh flap
Lateral femoral
circumflex artery
(LFCA)
Deep femoral artery
Superficial femoral
artery
Deep femoral artery
PART 5  —  PERFORATOR-BASED WORKHORSE FLAPS

CHAPTER 59 — Anterolateral a nd Anteromedial Thigh Flaps
701
vastus lateralis and traverse the fascia to supply the skin of
the anterolateral thigh. At the exit point, musculocutaneous
perforators traverse through the vastus lateralis muscle,
giving off numerous intramuscular branches before pierc­
ing through the fascia and supplying the skin. In 30% of
cases, the descending branch will divide into a medial and
lateral branch, with the latter giving rise to the skin vessels.
In 2% of cases there may be an absence of any skin vessels,
either septocutaneous or musculocutaneous, or the perfora­
tor may be too small in diameter, necessitating exploration
more proximally to determine if perforators are originating
from the transverse branch of the LCFA or if use of an
alternative free flap is required. The artery may also course
without the venae comitantes along its side and turn back
at a more proximal point to join the course of the vein.
Minor:  perforator of transverse branch of LCFA
Length: 11 cm (range 9–13 cm)
Diameter: 2.1 mm (range 1.5–2.5 mm)
Less commonly, the septocutaneous vessel or musculocu­
taneous perforator arises from the transverse branch of the
LCFA and runs parallel with the vastus lateralis muscle.
VENOUS DRAINAGE OF THE FLAP
Primary:  venae comitantes of the lateral circumflex
femoral vessel and its branches
Length: 12 cm (range 8–16 cm)
Diameter: 2.3 mm (range 1.8–3.3 mm)
Two venae comitantes accompany the arterial pedicle of
the anterolateral thigh flap. In rare instances, there may be
no existing veins with the perforator pedicle.
FLAP INNERVATION (Figs 13.2 and 13.19)
Sensory:  The anterolateral thigh flap may be harvested as
a sensate flap by including the lateral femoral cutaneous
nerve proximally with the flap and anastomosing it to a sen­
sory nerve at the recipient site. The sensory nerve branches
pierce the muscle fascia 10 cm below the inguinal ligament
medial to the tensor fascia lata muscle. The nerve in that
area splits into anterior and posterior branches to innervate
the anterolateral aspect of the thigh (see Fig. 13.19).
Motor:  The vastus lateral is innervated by a branch of the
posterior division of the femoral nerve. This branch accom­
panies the descending branch of the lateral femoral circum­
flex artery. This nerve can be included with flap harvest and
anastomosed to a motor nerve at the recipient site for a
functional reconstruction (see Fig. 13.2).
FLAP COMPONENTS
The anterolateral thigh flap can be harvested as a cutaneous
flap consisting of skin and subcutaneous tissue based on
either a septocutaneous vessel or musculocutaneous perfo­
rator. It may also be elevated as a composite flap, consisting
of a fascial (fasciocutaneous anterolateral thigh flap) or
muscular (vastus lateralis myocutaneous anterolateral thigh
flap) component. Furthermore, the flap can be harvested
as a combined flap to include various other tissues (includ­
ing rectus femoris muscle, tensor fascia lata, anteromedial
predominantly musculocutaneous perforators and less com­
monly septocutaneous vessels. In 1991, Zhou et al. evalu­
ated their results of utilizing this flap for the reconstruction
of defects in various regions of the body. In 1993, Koshima
and colleagues reported on 22 cases of head and neck
reconstruction utilizing this flap. This flap has been exten­
sively reported in the literature and has become a workhorse
flap for reconstruction of small or large defects, both simple
and complex, with excellent results and minimal morbidity
at the donor site.
ANTEROLATERAL THIGH FLAP
The anterolateral thigh flap is relatively easy to harvest once
the technique of perforator flap dissection has been learned.
The ALT has a reliable blood supply despite some anatomic
variability, it can provide a long pedicle with large-diameter
vessels, and it is pliable and can be thinned to a significant
degree without compromising blood supply. It can also be
used as a flow-through flap, and, because of its unique posi­
tion, allows for a two-team approach to the reconstruction
of most defects in the body. The flap can also provide dif­
ferent tissue components such as muscle, fascia, and skin in
a variety of combinations. The anterolateral thigh flap does
have disadvantages such as a color mismatch when recon­
structing facial defects, and the presence of hair in some
patients. When large defects are reconstructed, skin grafts
are required at the donor site. In rare instances, there is a
lack of vessels with a reasonable size. The anteromedial
thigh (AMT) flap has similar advantages and disadvantages
to the ALT flap. The harvest of the AMT flap is simple and
many of the same properties of tissues that can be included
are similar. This flap is usually used when the anterolateral
thigh flap vessels are inadequate or cannot be found.
FLAP ANATOMY (see Figs 59.1, 13.1, 13.2, 13.4,
13.19)
ARTERIAL SUPPLY OF THE FLAP (Figs 59.1, 13.1, 13.2
and 13.4)
The anterolateral thigh flap is supplied by either septocuta­
neous vessels or musculocutaneous perforators that usually
arise from the descending branch of the LCFA. The flap is
primarily based on musculocutaneous perforators vs septo­
cutaneous ones (87% vs 13%). Less commonly, the perfora­
tors may originate from other sources such as the transverse
branch of the LCFA.
Dominant:  branches of the descending branch of the
LCFA
Length: 12 cm (range 8–16 cm)
Diameter: 2.1 mm (range 2–2.5 mm)
The descending branch of the LCFA courses obliquely
along the intermuscular septum between the rectus femoris
and vastus lateralis muscles. It exits in the majority of cases
within a circle of 3 cm radius located at the midpoint of a
line drawn between the anterior superior iliac spine and the
superior lateral border of the patella as either a septocuta­
neous vessel or a musculocutaneous perforator, or both.
Septocutaneous vessels run between the rectus femoris and

702
PART 5 — PERFORATOR-BASED WORKHORSE FLAPS
the flap. Important landmarks for the flap include the ante­
rior superior iliac spine (ASIS) and the superior lateral
border of the patella. Taking into account that the perfora­
tors are located either at this line connection, the ASIS to
the lateral patella (septocutaneous perforators), or poste­
rior to this line (musculocutaneous perforators), the skin
paddle is designed either centered over this line or the
design can be shifted slightly posterior. A circle of 3 cm
radius defines the area at which the skin vessels, either sep­
tocutaneous vessels or musculocutaneous perforators, exit.
The skin vessels are often found in the inferior lateral quad­
rant of the circle. The most accurate method to design the
flap is to mark the landmarks mentioned, Doppler the skin
vessels, and design the flap based on the Dopplered skin
vessels. The medial incision is made first, the perforators are
found, and the flap is remarked.
GENERAL THOUGHTS ABOUT FLAP DESIGN
Although a large skin paddle up to 35 cm long and 25 cm
wide can be harvested on a single dominant perforator,
when possible, incorporation of two or more perforators
will ensure greater success.
Limiting the width of the flap to 7–9 cm allows for primary
closure of the donor site without the need for a skin graft.
It is not necessary to design the flap with the skin vessel
at the center. An eccentric flap with the skin vessel entering
thigh skin or vastus lateralis on a separate perforator) based
on blood supply from the descending branch or any other
branches of the lateral femoral circumflex system. These
chimeric flaps consist of multiple tissue combinations, each
with an independent vascular supply. For example, a fascio­
cutaneous anterolateral thigh flap based on a musculocuta­
neous perforator may be harvested with the rectus femoris
muscle that is based on an independent pedicle from the
lateral circumflex femoral system and would be termed a
chimeric fasciocutaneous anterolateral thigh myocutaneous
perforator and rectus femoris muscle flap.
Advantages
• Ease of harvest with relatively constant anatomy
• Long length and large pedicle
• Versatility in design with variable thickness and incorpo­
ration of various tissue components
• Ability to provide sensory innervation
• Lack of significant donor site morbidity
• Decreased operative time with two-team approach.
Disadvantages
• Color
mismatch
in
some
patients
for
facial
reconstruction
• Presence of hair in some male patients
• Skin graft requirement at donor site if >8 cm or 9 cm
width of harvested tissue.
• Lack of vessels with reasonable size in rare cases.
PREOPERATIVE PREPARATION
Preoperative preparation includes functional evaluation of
knee extension as the vastus lateralis muscle is a large com­
ponent of quadriceps function. Patients with impairment in
knee extension or with knee instability may have increased
functional deficit after anterolateral thigh flap harvest and
intramuscular dissection of the vastus lateralis. It is also
important to note any previous scars that may affect flap
design. Prior skin graft donor sites can be incorporated as
part of the flap and would be visible as such at the recipient
site.
The thickness of the thigh tissue should be assessed pre­
operatively. In obese patients, the flap may be very thick and
may require primary thinning as well as subsequent debulk­
ing procedures in order to achieve a reasonable outcome.
Male patients with thick hair may require laser hair removal
or may need to shave the hair for certain types of reconstruc­
tion. Another option is to select a different donor site which
is non-hair bearing. Flaps with hair are not ideal for recon­
structions such as intraoral lining defects.
Patients with significant atherosclerotic disease affecting
the arterial vasculature require preoperative evaluation
using angiography. Previous injury or operations to the
upper thigh require a work-up that will carefully assess the
condition of the leg soft tissues and vasculature supplying
the region of the proposed flap.
FLAP DESIGN
ANATOMIC LANDMARKS (Fig. 59.2)
Markings for the anterolateral thigh flap are based on the
location of the skin vessels that supply the skin territory of
Figure 59.2  Anatomic landmarks and flap marking. (Reprinted
from Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights
Reserved.)
Eccentric flap outline
Superior lateral
aspect of patella
Anterior
superior iliac
spine
Flap outline
Common
site of skin
vessels

CHAPTER 59 — Anterolateral a nd Anteromedial Thigh Flaps
703
tract or tensor fascia lata flap provides an effective
reconstruction.
Upper Extremity Reconstruction
Most upper extremity defects require a relatively thin flap
for coverage. A cutaneous anterolateral thigh flap can be
harvested and trimmed to as little as 5 mm thickness to
facilitate tendon coverage and filling of soft tissue defects.
Alternatively, the anterolateral thigh flap can be elevated as
an adipofascial flap for areas with adequate skin but lack of
soft tissue.
Lower Extremity Reconstruction
Application for lower extremity reconstruction is based on
the general flap design with variation in tissue construct
tailored to the recipient site requirement. Certain areas
such as the foot and ankle will require thin cutaneous flaps,
while other areas will require more tissue bulk. In cases of
trauma with vascular compromise, an anterolateral thigh
flap can be designed as a flow-through flap to preserve the
arterial vasculature at the recipient site. For defects closer
in proximity such as the groin or knee, a pedicled flap can
be elevated with the pedicle based proximally or distally,
respectively. A distal pedicled flap is based on retrograde
blood flow of the descending branch of the LCFA with the
pivot point 3–10 cm above the knee. Longer pedicle length
can be achieved by designing the flap more proximally on
the upper thigh.
Breast Reconstruction
The anterolateral thigh flap may be used as an alternative
tissue flap for breast reconstruction by creation of a fascio­
cutaneous flap with a small skin island and large underlying
fat pad. Subdermal undermining posterior to the medial
flap incision allows for the incorporation of a fat pad ranging
in size from 10 × 12 cm to 14 × 22 cm. The donor site for this
type of reconstruction is unfavorable.
DIFFERENCES IN DESIGN, IF ANY, WHEN
PERFORMING THE FLAP AS PEDICLED OR FREE
Although more commonly used as a free flap, the antero­
lateral thigh flap can be harvested and transferred as a
pedicled flap to cover tissue defects in the groin, lower
abdomen, perineum, and knee. The pedicled anterolateral
thigh flap is elevated in the same manner as its free coun­
terpart and with the same septocutaneous or musculocuta­
neous pedicle based on the descending branch of the LCFA.
Flap boundaries are based on recipient defect requirements
and can be designed eccentrically about a chosen skin vessel
to obtain more length. The most proximal pivot point for
a proximal pedicled flap is 7–10 cm below the ASIS and
the pivot point for a distally-based pedicled flap ranges
from 3 cm to 10 cm above the knee. For local thigh defects
requiring minor rotation, a proximal pedicled flap need not
be designed as an island flap and can instead, preserve a
proximal skin pedicle to insure better venous outflow.
FLAP DIMENSIONS
SKIN ISLAND DIMENSIONS
Length: 21 cm (range 4–35 cm)
Maximum to close primarily: 22 cm
at the proximal portion of the flap will allow for greater
pedicle length. If the flap is to be pedicled in a reverse
fashion for knee reconstruction, the skin island can be
designed so that the skin perpetrator is at the distal end of
the skin paddle. This will allow for further distal reach.
Aside from the variability in flap dimensions, the versatil­
ity of the anterolateral thigh flap in terms of tissue construct
allows it to be tailored to the needs of the recipient site. In
areas requiring a relatively thin flap, such as the foot and
ankle, the anterolateral thigh flap can be elevated as a cuta­
neous flap as thin as 5 mm in thickness.
When extensive soft tissue coverage is needed, and muscle
is believed to be necessary, the anterolateral thigh flap can
be harvested with vastus lateralis muscle as a myocutaneous
flap or rectus femoris muscle as a chimeric flap. Moreover,
in recipient sites with a composite 3-dimensional defect, the
anterolateral thigh flap can be designed with other tissue
components based on separate perforators to more ade­
quately cover the defect.
Sensate flaps can be constructed by including the lateral
femoral cutaneous nerve in the proximal portion of the flap.
SPECIAL CONSIDERATIONS
Head and Neck Reconstruction
The anterolateral thigh flap can be harvested as a thin cuta­
neous perforator flap for defects that need minimal tissue
bulk for coverage, as in tongue reconstruction. This can be
done either by performing a suprafascial dissection or by
thinning the flap after elevation. The flap may also be har­
vested with multiple skin islands, as needed in simultaneous
reconstruction of oral lining and cheek skin, by potentially
dividing the flap into two skin paddles based on separate
perforators or de-epithelializing the flap to create two sepa­
rate skin islands based on a single perforator.
Application of the anterolateral thigh flap for cervical or
thoracic esophageal reconstruction has also been performed
by tubing the flap at the donor site, then transferring to the
defect for reconstruction. This can be performed in two
operations to assure suture line healing after tubing the flap
and prior to transfer. However, this is only indicated if the
defect has not been created. In most cases, surgeons will tube
the flap at the donor site and transfer in the same setting.
For pharyngoesophageal reconstruction, a flap is designed
with a width of approximately 9 cm, to achieve a 3 cm diam­
eter tube. A separate skin paddle based on a separate per­
forator can be used for monitoring of the flap. This is no
longer commonly performed, as the flap can now be moni­
tored using an implantable Doppler.
Abdominal Wall Reconstruction
Flap design for abdominal wall reconstruction is based on
the size and location of the defect and the need for a fascial
component at the recipient site. For lower abdominal wall
and perineal defects, a pedicled fasciocutaneous anterolat­
eral thigh flap with or without incorporation of the iliotibial
tract or vastus lateralis muscle can be harvested with the
pedicle pivot point approximately 7–10 cm below the ASIS,
correlating with the origin of the lateral circumflex femoral
artery. For large defects encompassing both the upper and
lower abdomen, a free myocutaneous anterolateral thigh
flap with a cuff of vastus lateralis along with the iliotibial

704
PART 5 — PERFORATOR-BASED WORKHORSE FLAPS
PATIENT POSITIONING
Generally, the patient is positioned supine on the operating
table to allow for a two-team approach for flap harvest and
recipient site preparation. If necessary because of the loca­
tion of the defect, the flap can be harvested in the lateral
or sloppy lateral position.
ANESTHETIC CONSIDERATIONS
General anesthesia with muscle relaxation is preferred for
flap harvest. For certain reconstructions, regional anesthe­
sia such as spinal block may be used.
TECHNIQUE OF FLAP HARVEST (Figs 59.4–59.8)
The patient is placed in the supine position and the leg is
circumferentially prepared. A line is drawn extending from
the anterior superior iliac spine to the lateral superior
aspect of the patella. At the midpoint of this line a circle
with a radius of 3 cm is drawn, delineating the predominant
location of the skin vessels. Most skin vessels can usually be
found in the inferior, lateral quadrant of this circle. A
Doppler probe is used to establish the skin vessels within the
circle. Additional skin vessels are located by Doppler probe
caudad and cephalad over or slightly posterior to the inter­
muscular septum between the rectus femoris and vastus
lateralis muscles (this septum can be palpated in thin
patients as a groove between these muscles). Flap dimen­
sions are marked based on the size of the recipient defect.
In general, a flap of 8 cm or 9 cm by 22 cm is harvested with
one to three skin vessels. Although experience with the
anterolateral thigh flap has proven the reliability of a large
skin paddle (up to 35 cm in length × 25 cm in width) based
on one dominant perforator, when a large skin flap is to be
harvested, the preference is to include more than one per­
forator. Longitudinal design of the flap allows for better
Width: 8 cm (range 4–25 cm)
Maximum to close primarily: 8–9 cm (at the center of the
thigh)
Thickness: 5 mm (range 3–20 mm)
These dimensions are highly dependent on the patient’s
body habitus and the skin tone and quality. The thickness
of the flap is variable and primary and/or secondary thin­
ning can be performed to achieve a thinness of 5 mm.
Primary closure is more difficult in the proximal and distal
aspect of the thigh.
MUSCLE DIMENSIONS
Length: from 2 cm (cuff) to 20 cm (entire muscle)
The descending branch of the LCFA passes through the
vastus lateralis muscle and a segment of muscle can be har­
vested based on one or more branches. Therefore, the size
and location of the segment of muscle are variable and an
extremely small segment or the entire muscle may be har­
vested with the flap. The tensor fascia lata muscle can be
included if the ascending branch of the LCFA is included
with the flap. The rectus femoris muscle or a portion of it
can be harvested based on the branch from the descending
branch of the LCFA.
FLAP MARKINGS
A line is marked connecting the ASIS with the lateral patella.
The flap is marked over the Dopplered perforators. When
a large flap is harvested, the medial incision is made, the
flap is elevated in the subfascial or suprafascial plane until
sizable perforators are located. The search for perforators
is performed in a free style manner, which allows the surgeon
to have the freedom to change the plan if anatomic varia­
tions are met (Figs 59.2, 59.3).
Figure 59.3  Marking of the anterolateral thigh flap. A line is
drawn from the anterior superior iliac spine to the lateral aspect of
the patella. A circle is drawn with the center of the circle at the mid­
point of the line. Most skin vessels are found in the distal posterior
quadrant of this circle. (from Mardini et al. 2006.)
Figure 59.4  An anterolateral thigh flap elevated in a suprafascial
plane. Note the minimal donor site morbidity visible.

CHAPTER 59 — Anterolateral a nd Anteromedial Thigh Flaps
705
The final design of the flap can be modified after visualizing
and assessing the size and quality of the skin vessels
intraoperatively.
The anterolateral thigh flap can be harvested in either a
subfascial or suprafascial plane, depending on the recipient
site requirements and on the amount of morbidity that is
acceptable at the donor site for that individual patient. For
thin flaps and when preservation of sensory innervation to
parts of the thigh is required, a suprafascial dissection is
preferred (Fig. 59.4). Otherwise, a subfascial dissection is
usually undertaken. The subfascial approach allows for
easier identification of skin vessels and for better exposure
of the intermuscular septum and descending branch of the
LCFA, thereby providing the surgeon with a general map of
donor site closure. In cases when more than one skin vessel
is located intraoperatively, the surgeon has a choice of:
• The largest perforator that takes the shortest intramuscu­
lar course
• All the identified skin vessels (this may add a significant
amount of time to flap harvest)
• More than one skin vessel and subsequently splitting the
flap to fit into a geometrically favorable contour while
allowing for primary closure of the donor site.
The skin vessel does not need to be located in the center
of the flap. If a longer pedicle is required, the flap can
be designed with the skin vessel in an eccentric position.
Figure 59.6  The rectus femoris is retracted medially and the septum
between the rectus femoris and vastus lateralis is clearly visualized.
The descending branch of the LCFA can be seen coursing over the
vastus lateralis muscle and sending perforators to the skin. (from
Mardini et al. 2006.)
Figure 59.7  Two perforators are seen after part of the intramuscular
dissection was performed. Muscle fibers anterior to the perforators
were transected. The flap is then elevated from lateral to medial and
the perforator is dissected off the surrounding tissues. (from Mardini
et al. 2006.)
Figure 59.8  The anterolateral thigh flap after elevation and intra-
muscular dissection of the perforators. The dissection of the descend­
ing branch of the lateral circumflex femoral vessels has yet to be freed
from its surrounding attachments. (from Mardini et al. 2006.)
Figure 59.5  The medial incision of the anterolateral thigh flap is
made down to and through the thigh fascia. The flap is elevated in
the subfascial plate in a lateral direction until the septum between the
rectus femoris and vastus lateralis is visualized. Two perforators are
seen coursing through the muscle and entering the skin. (from Mardini
et al. 2006.)

706
PART 5 — PERFORATOR-BASED WORKHORSE FLAPS
from the descending branch of the LCFA or further until
adequate pedicle length is achieved (Fig. 59.8). The main
nerve and nerve branches supplying the vastus lateralis and
the rectus femoris are carefully dissected away from the
vessels and preserved.
FLAP MODIFICATION/FLAP HANDLING
THIN FLAP
Thin flaps (see Ch. 26) may be suitable for a variety of loca­
tions throughout the body, including defects of the face
and neck, axilla and forearm, anterior tibia and ankle, and
dorsum of the foot and hand, as well as de-epithelialized
flaps for soft tissue augmentation. Thinned flaps have the
advantage of regaining quicker and better sensory innerva­
tion without nerve coaptation.
Flap thinning can be performed after flap elevation and
before transection of the vascular pedicle. The pedicle
entrance into the skin is marked. Preservation of at least a
2 cm radius of tissue around the pedicle is recommended
to ensure adequate perfusion of the flap. The flap is thinned,
beginning with the deep fat tissue (wide and flat fat lobules)
and progressing up to the junction with the more superficial
fat (small and round fat lobules). Usually, the quality of fat
at these two levels is different, with a thin fascia present
between them. Noting this characteristic of the fat lobules
results in uniform defatting. Defatting before vessel ligation
allows for continuous monitoring of flap perfusion through­
out the defatting process and for coagulation of bleeding
points when necessary. The flap can be thinned up to the
dermal plexus without compromise to the blood supply,
provided that the flap is within 9 cm around the perforator.
A more conservative approach towards flap thinning in the
primary procedure is recommended until enough experi­
ence is accumulated, as defatting can be performed easily
and safely as a secondary procedure.
WHEN BULK IS REQUIRED
The anterolateral thigh skin flap can be harvested larger
than the recipient site dimensional requirement and par­
tially de-epithelialized to add bulk (Fig. 59.17). A part or all
of the vastus lateralis or rectus femoris muscle, the tensor
fascia lata or other skin flaps in the thigh can be harvested
along with the anterolateral thigh flap as a chimeric flap to
add bulk or muscle tissue to fill a defect (Fig. 59.9). By inclu­
sion of thigh fat, the anterolateral thigh flap can be used
for breast reconstruction and tailored to create a volume
that can match a medium-sized contralateral breast (Fig.
59.10).
ADIPOFASCIAL FLAP
When a thin flap that does not require skin is desired, an
adipofascial flap can be elevated by using techniques as
described earlier. Once the fascia is exposed and incised, a
subfascial dissection is performed until the perforator is
located. A minimum of 3 mm of fat should be preserved
over the fascia to avoid problems with the vascularity of
the flap. The vascular network runs over the fascia. This
type of flap is useful for covering exposed tendons, provid­
ing a gliding surface, and allowing for easy closure of the
overlying skin and intraoral defects, such as for tongue
repair.
the vascular anatomy of the area before beginning the skin
vessel and pedicle dissection.
Loupe magnification during dissection is recommended
as it aids in locating the skin vessels, avoids unnecessary
injury to the pedicle, and helps to clearly visualize branches
of the vessels. A lower magnification microscope is useful
when dissecting very small perforators in children and
adults.
SUPRAFASCIAL DISSECTION (Figs 59.3, 59.4)
The medial margin of the flap incision is first made through
the skin and subcutaneous tissue, down to the level of the
fascia of the thigh. Dissection proceeds above the fascia in
a lateral direction using tenotomy scissors until the previ­
ously Dopplered skin vessels are reached. Strict hemostasis
allows for less blood staining of the surrounding tissues and
easier visualization of the skin vessels. Cutaneous nerves
overlying the fascia are preserved at the donor site whenever
possible. After identifying a suitable skin vessel and confirm­
ing its course piercing through the fascia and entering the
subcutaneous tissue, the lateral skin flap incision is made
down to the same suprafascial plane and dissection pro­
ceeds in a medial direction until the same skin vessel is
visualized. A fascial incision is made in the direction of the
skin vessel (usually caudad) and the vessel is traced in a
retrograde fashion until adequate vessel length and caliber
are achieved. Inclusion of a cuff of fascia can avoid damage
and twisting of the skin vessel. Dissection then proceeds in
a retrograde fashion with all small branches carefully ligated
or cauterized. Minimal and gentle manipulation of the skin
vessel avoids vessel spasm. Traction on the pedicle is always
avoided, keeping in mind that traction can occur due to the
weight of the flap itself.
SUBFASCIAL DISSECTION (Figs 59.5, 59.6, 59.7, 59.8)
The medial incision is made down to and through the thigh
fascia, exposing the rectus femoris muscle. The epimysium
of this muscle is preserved and the dissection proceeds in a
lateral direction until the septum separating the rectus
femoris from the vastus lateralis is visualized (Fig. 59.5). The
entire septum is exposed by retracting the rectus femoris
medially. At the medial aspect, the descending branch of
the LCFA can be seen coursing over the vastus lateralis
muscle (Fig. 59.6). This exposure provides the operator
with a map of the vascular anatomy of the region. Branches
of the descending branch are observed either perforating
the vastus lateralis muscle or traveling within the septum to
reach the skin of the anterolateral aspect of the thigh. For
septocutaneous vessels, the dissection is performed in a
retrograde fashion and the vessel is dissected away from the
surrounding tissues. If the skin vessel is a musculocutaneous
perforator, then intramuscular dissection is performed in
the following manner: the point of exit of the perforator is
exposed and the muscle fibers anterior to the vessel are
“lifted up” using teeth forceps; the tenotomy scissors are
used to spread in a transverse plane over the perforator, and
the muscle fibers are cut (Fig. 59.7). This same series of
steps is performed throughout the intramuscular course in
a retrograde fashion. Small intramuscular branches, which
generally arise from the lateral and posterior sides of the
perforator and less commonly from the anterior side, are
ligated. Perforator dissection proceeds until its take-off

CHAPTER 59 — Anterolateral a nd Anteromedial Thigh Flaps
707
DEFECTS REQUIRING A WIDE SKIN FLAP
The flap can be harvested in its usual longitudinal pattern,
while maintaining a width that allows for primary closure of
the donor site, and split into two skin islands. The two skin
islands are then placed side by side and used to close a wide
defect.
USE OF FASCIAL COMPONENT
The fascia lata can be included to reconstruct tendon,
fascia, and dura defects, as well as oral commissure defects,
by providing a fascial sling.
MUSCLE COMPONENT ONLY
The vastus lateralis can be harvested independently based
on the muscular perforators arising from the descending
branch of the LCFA. Instead of incorporating a skin paddle
incision, a linear incision is made following the previously
defined landmarks for the anterolateral thigh flap. Dissec­
tion proceeds down to the fascia and the intermuscular
septum is exposed as previously described. Perforators to
the vastus lateralis are identified and a muscle flap of
required size is harvested.
PEDICLED FLAP
Harvest of the pedicled anterolateral flap begins in the same
manner with identification of the skin vessels and flap
design, based on the location of these vessels. The medial
flap incision is made and a subfascial dissection proceeds
with identification of the descending branch of the LCFA.
The pedicled flap can be based proximally, with the most
proximal pivot point located just distal to the origin of the
LCFA off the profunda femoris artery, usually about 2–3 cm
below the inguinal ligament. Medial rotation of the flap
over the rectus femoris muscle allows it to reach 8 cm above
the umbilicus, to the perineum, and even the contralateral
inguinal region. Lateral rotation and passage through a
subcutaneous tunnel allows coverage of the trochanteric
region. The flap can be transferred transmuscular to reach
the posterior thigh. The length of the vascular pedicle
ranges from 16 cm to 19 cm for proximally-based flaps. The
flap may be elevated with a posterior extension of fascia lata
depending on recipient site requirements.
The pedicled flap can also be based distally on retrograde
blood flow, with the pivot point at the anastomotic connec­
tion between the descending branch of the LCFA and the
lateral superior genicular artery or profunda femoral artery
approximately 3–10 cm above the patella, and rotated to
cover defects at the knee joint. The anterolateral thigh per­
forator flap or the vastus lateralis muscle or the combination
may be pedicled, based on retrograde blood supply. The
descending branch of the LCFA must be dissected distally
and the proximal pedicle transected after ensuring ade­
quate distally-based perfusion by temporarily occluding the
proximal blood supply with a vascular clamp. As with proxi­
mal pedicled flap, the arc of rotation radius is determined
by the length of the vascular pedicle, which is about 14 cm
in distally based flaps. For safer transfer of the flap, a 0.5 cm
cuff of vastus lateralis muscle is usually included with the
intramuscular perforator pedicle.
For both proximally- and distally-based pedicled antero­
lateral thigh flaps, the flaps may be designed eccentrically
INNERVATED FLAP (Fig. 13.19)
The lateral femoral cutaneous nerve pierces the fascia
approximately 10 cm caudad to the anterior superior iliac
spine and divides into two or three branches. Some of these
branches are included when an innervated flap is required,
such as for hemi-tongue defects. These nerves are coapted
to sensory nerves at the recipient site. Inclusion of the
motor nerve to the vastus lateralis can provide motor func­
tion to a myocutaneous flap, as would be needed for a facial
defect requiring facial reanimation or for abdominal wall
reconstruction.
FLOW-THROUGH FLAP
The anterolateral thigh flap can be used as a flow-through
flap for a variety of indications. The pedicle can be used to
bridge a vascular gap in the extremity or the distal end can
serve as the blood supply to another free flap.
Figure 59.9  An anterolateral thigh myocutaneous flap used in a
case where bulk was required at the recipient site. (from Mardini et al.
2006.)
Figure 59.10  An anterolateral thigh flap harvested with adequate
bulk to create a breast mound. (from Mardini et al. 2006.)

708
PART 5 — PERFORATOR-BASED WORKHORSE FLAPS
Less commonly, the septocutaneous vessel or musculocu­
taneous perforator arises directly from the superficial
femoral artery. These are short and small and less useful.
VENOUS DRAINAGE OF THE FLAP
Primary:  venae comitantes of the rectus branch of the
lateral circumflex femoral vessel and its branches
Length: 5 cm
Diameter: 2 mm
Two venae comitantes accompany the arterial pedicle of
the anteromedial thigh flap. In rare instances, there may be
no existing veins with the perforator pedicle.
TECHNIQUE OF FLAP HARVEST
The flap is designed over the Dopplered perforator, which
arises inferior to the junction between the sartorius and the
rectus muscles. The medial incision is made first, over the
rectus muscle. A subfascial dissection is performed from
lateral to medial until the perforator is found.
As with the anterolateral thigh flap, the anteromedial
thigh flap can be harvested in either a subfascial or supra­
fascial plane, depending on the recipient site requirements
and on the amount of morbidity that is acceptable at the
donor site for that individual patient. Loupe magnification
during dissection is recommended as it aids in locating the
skin vessels, avoids unnecessary injury to the pedicle, and
helps to clearly visualize branches of the vessels. A lower
magnification microscope is useful when dissecting very
small perforators in children and adults.
The anteromedial thigh flap is often harvested when per­
forators to the anterolateral thigh flap are not found. Hence,
following the anterior incision (for the anterolateral thigh
flap), dissection is carried out further medially, to identify
perforators from the rectus femoris branch. A free style
approach is performed looking for the perforator.
ANTEROLATERAL AND ANTEROMEDIAL
THIGH FLAPS
DONOR SITE CLOSURE AND MANAGEMENT
The anterolateral thigh donor site can be closed primarily,
resulting in a longitudinal linear scar, if the width of the flap
harvested is <8 cm. Wider defects will require closure with
a split-thickness skin graft. Closed suction drainage is not
necessary and is only occasionally placed between the vastus
lateralis and rectus femoris muscles to decrease formation
of seroma and hematoma. In cases requiring intramuscular
dissection of the perforator, the muscle edges can be reap­
proximated to preserve maximal quadriceps function. The
fascia is repaired after elevation of a cutaneous anterolateral
thigh flap (harvested in a suprafascial manner) and for
cases in which the fascia harvest is <2–3 cm.
Primary closure of the donor site without the need for
a skin graft is preferred. Using V-Y advancements of proxi­
mal and distal island flaps based on other perforators, is
an alternative method of donor site management. The
blood supply to the distal island flap is from retrograde
flow of the descending branch of the LCFA via the lateral
about the designated skin vessel to obtain more reach. In
general, proximal pedicled flaps based on orthograde blood
flow are more reliable.
ANTEROMEDIAL THIGH FLAP
When the anterolateral thigh flap has been previously har­
vested or is unavailable, or when, in rare circumstances, no
perforators are found, the anteromedial thigh flap is an
alternative. Perforators to the flap originate from the rectus
femoris branch of the descending branch of the lateral
femoral circumflex artery or the superficial femoral artery.
In an anatomical study by Yu and Selber, 21% of thighs had
no anteromedial thigh perforators, while perforators from
the rectus femoris were present in only 51% of patients,
occurring on average 3.2 cm medial to a line connecting
the anterior superior iliac spine and the superolateral
patella. Yu et al. described similar findings, and found that
18.4% of patients in their series did not have sizable antero­
medial thigh perforators. The presence of reliable perfora­
tors follows an inverse relationship between the anterolateral
and anteromedial thigh, such that patients with AMT per­
forators are unlikely to have sizable ALT perforators, and
vice versa. Hence the anteromedial thigh flap should be
considered as a backup to the anterolateral thigh flap or
when the anterolateral thigh flap is not available for use.
The anteromedial thigh flap can also be harvested as a chi­
meric flap with the anterolateral thigh flap, based on a
single pedicle (the descending branch of the LCFA). This
allows reconstruction of large composite defects.
ARTERIAL SUPPLY OF THE FLAP (Figs 59.1 and 13.1,
13.2, 13.4)
The anteromedial thigh flap is supplied by either septocu­
taneous vessels or musculocutaneous perforators that
usually arise from the rectus femoris branch of the descend­
ing branch of the LCFA (some have termed this the inno­
minate branch) or directly from the superficial femoral
artery.
Dominant:  rectus femoris branch (also termed the
“innominate branch”) of the descending branch of the
LCFA
Length: 8 cm (range 6–10 cm)
Diameter: 2.0 mm
The rectus femoris branch originates from the descend­
ing branch of the LCFA. In a study by Yu et al., perforators
from the rectus femoris branch were present in 51% of
patients. Occasionally, the rectus femoris branch may arise
from the oblique branch of the LCFA, as described by Wong
et al. The rectus femoris branch runs deep to the rectus
femoris muscle, with the anteromedial thigh perforator
exiting medial to the rectus femoris muscle and supplying
branches to the sartorius and vastus medialis muscles.
Minor:  muscular branches of the superficial femoral
artery
Length: 3 cm
Diameter: 1.0 mm

CHAPTER 59 — Anterolateral a nd Anteromedial Thigh Flaps
709
THE MOTOR NERVE BETWEEN THE VESSEL BRANCHES
When including more than one perforator to supply the
flap, the motor nerve often comes between the vessels
branches. In those cases, we usually cut the nerve, harvest
the flap and re-anastomose the nerve.
EXCESS FAT IN OBESE PATIENTS
In obese patients, it may be difficult to adequately defat the
flap safely. The flap can be revised at a later date and made
to better fit the contour of the defect.
FLAP USAGE
PEDICLED
• Lower abdominal wall
• Groin
• Suprapubic
• Perineum and penis
• Trochanteric and lateral gluteal area
• Knee.
FREE FLAP
• Head and neck
• Orofacial
• Esophagus
• Trunk
• Abdominal wall
• Breast reconstruction
• Penile reconstruction
• Upper extremity
• Lower extremity.
TYPICAL INDICATIONS FOR THE USE OF THIS FLAP
Head and Neck Reconstruction
In the majority of cases, a fasciocutaneous flap may be ade­
quate to fill the defect. Intraoral defects may require a cuta­
neous flap using suprafascial dissection to provide a thin
pliable flap such as for reconstruction of the tongue, buccal
mucosa, palate, and pharyngeal wall. Through-and-through
defects requiring both intraoral lining and external facial
skin may be reconstructed with a folded flap with the inter­
vening fold de-epithelialized. If two skin perforators are
present, the flap can be harvested with two separate skin
paddles to fill the defect: one for the external skin and one
for intraoral lining. For intraoral reconstructions, a myocu­
taneous flap is often too bulky and can increase the incidence
of flap failure from venous congestion due to compression
of the pedicle by the muscle bulk. Furthermore, for full-
thickness defects, a myocutaneous flap is not ideal because
the muscle component used for intraoral lining, such as for
buccal mucosa or floor of the mouth, may ultimately atrophy
and lead to functional impairment. In certain situations with
large composite defects, such as following maxillectomy,
added soft tissue bulk is needed for dead space obliteration,
and a myocutaneous flap with vastus lateralis or a chimeric
flap with the skin paddle and muscle component (vastus
lateralis, rectus femoris, tensor fascia lata) raised on separate
perforators provides a better reconstructive outcome. Recon­
struction of extensive composite defects of the mandible may
require two free flaps, both an osteoseptocutaneous flap for
bone reconstruction and an anterolateral thigh flap to fill the
superior genicular artery and the proximal island flap is
supplied by anterograde flow by the descending branch of
the LCFA.
TECHNICAL TIPS TO OPTIMIZE OUTCOMES AND
AVOID COMPLICATIONS
With adequate experience, the success rate for reconstruc­
tion with the anterolateral thigh flap is more than 95%.
Conditions leading to flap failure include twisting or com­
pression of the pedicle, inadequate venous outflow, hema­
toma, and venous or arterial thrombosis. In 2% of cases,
there is lack of or inadequacy of the skin vessels.
LACK OF ADEQUATE SKIN VESSELS
In cases where the vessels supplying the skin island appear
too small to perform the intramuscular dissection comfort­
ably and safely, dissection can be performed using a micro­
scope. Alternatively, the flap can be raised as a myocutaneous
flap by preserving the soft tissue and small vessels between
the vastus lateralis muscle and the overlying skin. If this is
not practical or feasible, if the pedicle lacks a vein or an
artery, or if there is no skin vessel at all, the following algo­
rithm is used:
1. Doppler mapping of the region medial to the incision
is performed and dissection proceeds in a medial direc­
tion until a skin vessel is located. Usually, there is an
inverse correlation between the number and caliber of
vessels in the lateral, anteromedial, and medial thigh
regions. In most cases with absence of skin vessels in
the lateral thigh, good-quality anteromedial and medial
thigh vessels exist.
2. Exposure of the lateral circumflex femoral vessels is per­
formed and the vessels supplying the tensor fascia lata
are dissected and used to harvest a tensor fascia lata flap.
3. A freestyle approach is used to look for skin vessels in the
region of the thigh.
4. The flap is abandoned, the incision is closed primarily,
and the contralateral thigh is explored or another flap
from another region is harvested.
If the perforator is injured during the dissection, it is
better not to use that perforator and to search for a more
suitable one. However, in some situations, the perforator
can be repaired primarily under microscopic visualization
using 11-0 sutures.
An alternative is the anteromedial thigh flap based on a
septocutaneous vessel arising from the medial branch of the
descending branch of the LCFA or the descending branch
itself. The vascular pedicle runs in the medial intermuscular
septum lying between the rectus femoris and sartorius
muscles.
TWISTING OF THE PEDICLE
This can easily occur because the skin vessel does not have
the muscle to keep its proper orientation. For prevention
of pedicle twisting, a cuff of fascia is preserved around the
pedicle, the anterior wall of the pedicle is marked along its
course, and the flap is lifted in the air to allow the pedicle
to fall into its natural orientation before the final inset.

710
PART 5 — PERFORATOR-BASED WORKHORSE FLAPS
required skin dimensions are estimated and sketched using
a template. For areas with exposed bone or extensive soft
tissue loss, a myocutaneous flap or chimeric flap is used. A
chimeric flap with a separate muscular component based on
a separate perforator offers more degrees-of-freedom to
inset the flap. The anterior lateral thigh flap may also be used
as a flow-through flap to reconstruct a defect while maintain­
ing vascularity in a traumatized ischemic lower extremity.
Defects over the knee can be covered with a distally-based
pedicled anterolateral thigh flap. Dissection of the distal
portion of the descending branch of the LCFA is difficult
because of its intramuscular course and harvest of the vessel
with a cuff of vastus lateralis muscle is recommended to
prevent vasospasm. The variability of the pivot point, where
the descending branch communicates with the lateral
superior genicular artery or profundus femoral artery,
poses further difficulty in pedicle dissection. An alternative
method is elevation of a distally-based vastus lateralis muscle
flap with subsequent skin graft application after a second-
look operation to ensure muscle viability.
ATYPICAL INDICATIONS FOR THE USE OF THIS FLAP
Esophageal Reconstruction
Reconstruction of the cervical or thoracic portion of the
esophagus can be undertaken when there are contraindica­
tions to laparotomy. A prefabricated anterior lateral thigh
flap as long as 35 cm in length is rolled onto itself to form
a skin tube (skin on lumen side) and, upon healing of the
skin tube suture line, can be transferred into the retroster­
nal position as an esophagus substitute. For pharyngoesoph­
ageal reconstruction, a fasciocutaneous flap of about 9 cm
width based on two separate skin vessels is harvested to
create a 3 cm tubed flap based on one vessel and a separate
skin paddle based on the other vessel for flap monitoring.
Breast Reconstruction
In cases when lower abdominal flaps are not available, the
anterolateral thigh flap can be used as an alternative with a
small skin island and larger underlying fat pad (Fig. 59.7).
After making the medial incision for flap harvest, subdermal
undermining, predominantly posteriorly, is performed to
obtain a large fat pad and a subfascial elevation proceeds in
the lateral direction. The ability to allow a two-team approach
without the need to re-position from the supine position is
advantageous; however, the donor site scar may not be
acceptable for some patients.
Perineum and Penile Reconstruction
Perineal reconstruction can be completed with a proximal
pedicled fasciocutaneous anterolateral thigh flap by passage
of the flap underneath the rectus femoris muscle and
through a subcutaneous tunnel in the medial thigh to reach
the perineum. A hole is made through the flap to allow
insetting of vaginal and urethral cuffs.
A cutaneous anterior lateral thigh flap can be used as an
alternative for phalloplasty in gender reassignment surgery.
POSTOPERATIVE CARE
GENERAL
It is important to ensure flap viability in terms of flap
color and Doppler signal of the pedicle immediately
soft tissue deficit. Soft tissue augmentation can also be
achieved by insetting a de-epithelialized skin paddle such as
for cheek augmentation.
Because of its long vascular pedicle, the anterolateral
thigh flap is ideal to reach recipient vessels in the neck.
Anastomosis can be performed to various recipient vessels,
including the transverse cervical, superior thyroid, lingual
or facial arteries and the transverse cervical, internal jugular,
external jugular or facial veins.
Hemi-tongue defects can be reconstructed using a thin
sensate cutaneous flap incorporating the lateral femoral
cutaneous nerve and coapting it to the lingual nerve. Sub-
total or total glossectomy defects require added bulk that
can be provided by a myocutaneous flap. Part of the flap
may be de-epithelialized and folded to fill the defect in the
floor of the mouth and the flap is anchored to the gingival
mucosa anteriorly and pharyngeal mucosa posteriorly.
For defects involving the oral commissure, the fascia lata
can be incorporated and split and secured to the upper and
lower orbicularis oris muscle to create a static sling.
Abdominal Wall Reconstruction
Depending upon the location and size of the defect, a proxi­
mal pedicled or free anterolateral thigh flap with fascial or
muscle component is used. For lower abdominal wall defects,
a pedicled flap, either myocutaneous or incorporating the
iliotibial tract, can reach 8 cm above the umbilicus. As previ­
ously mentioned, the most proximal pivot point is about
2 cm below the inguinal ligament. The pedicled flap can be
harvested with a large posterior extension of fascia lata to
cover large fascial defects. Larger defects encompassing the
upper abdomen require a free anterolateral thigh flap with
fascia lata or tensor fascia lata flap. A myocutaneous flap
with a cuff of vastus lateralis muscle is harvested and the
adjoining fascia lata (size up to 14 × 28 cm) is fixed to the
remnant abdominal fascia sheath. Compared with the ped­
icled flap, a greater degree-of-freedom of flap orientation
exists at insetting. Recipient vessels are commonly the infe­
rior epigastric vessels, but the superior epigastric and inter­
nal mammary vessels can also be used. Incorporation of the
motor nerve to the vastus lateralis muscle with recipient site
anastomosis allows for strengthening of the abdominal wall.
Upper Extremity Reconstruction
A thin cutaneous or adipofascial flap may be applied for
defects of the hand and wrist, for coverage of tendons in
the forearm or for tissue coverage after release of contrac­
tures. For acute traumatic cases, primary flap thinning is
avoided and a flap larger than the defect should be used in
anticipation of subsequent wound swelling. For chronic
defects, the flap can be thinned to 3 mm. Harvest as a myo­
cutaneous flap can be used to cover amputation stump
defects. Inclusion of the lateral femoral cutaneous nerve
provides flap sensation. A strip of fascia lata can be incor­
porated with the flap and used for tendon reconstruction.
Lower Extremity Reconstruction
Areas such as the foot and ankle requiring a pliable thin flap
for defect coverage can be covered with a cutaneous flap.
Similar to the upper extremity, a strip of fascia lata can be
incorporated to reconstruct tendon defects such as Achilles
tendon. After debridement of the recipient site and exposure
of recipient vessels, the volume of soft tissue deficit and

CHAPTER 59 — Anterolateral a nd Anteromedial Thigh Flaps
711
series from Wei et al., about two-thirds of the anterolateral
thigh donor sites were closed primarily and the rest closed
with split-thickness skin graft.
UNTOWARD OUTCOMES
General
Successful outcome of reconstruction with anterolateral
thigh flaps is dependent upon adequate knowledge of per­
forator anatomy and meticulous dissection. Inexperience
can lead to inadvertent division of the perforator or injury
of the perforator during intramuscular dissection. Twisting
of the pedicle during flap insetting at the recipient site can
also lead to flap failure. Technical principles leading to a
successful harvest and transfer, include the use of a Doppler
probe for perforator identification prior to flap design, the
use of a low-magnification microscope for intramuscular
dissection of the perforator, and inclusion of a fascial cuff
around the perforator to prevent pedicle twisting. Inclusion
of multiple perforators during flap harvest increases flap
success. It is also important to maintain the position of the
flap during harvest as the weight of the flap itself can stretch
the perforators and result in vasospasm.
Upon insetting at the recipient site, it is important to
insure that there is no compression on or twisting of the
pedicle. Tension at flap edges may also compromise flap
survival.
Different Indications
Aside from the normal complications of flap failure, there
are untoward outcomes specific to different reconstructive
indications. A moderate skin color mismatch and substantial
hair growth in the intraoral skin paddle can occur in head
and neck reconstruction. Excess flap bulk may also lead to
functional impairment requiring secondary flap debulking.
Fistula and stricture rates for pharyngoesophageal recon­
struction from a single series were 13% and 12%, respec­
tively. Fistula formation occurred at about 4 weeks and often
healed spontaneously. Stricture formation at distal anasto­
mosis developed 3–6 months after reconstruction and
responded to endoscopic balloon dilatation.
For breast reconstruction, fat necrosis and wound dehis­
cence can occur and usually respond to debridement and
dressing changes.
Donor Site
Donor site morbidity for the anterolateral thigh flap is
usually minimal. Immediate postoperative complications,
which include hematoma, seroma, and wound infections,
are infrequent. The appearance of the donor site may be
unsatisfactory for some patients, especially for larger defects
requiring a skin graft. Sensation may be decreased along the
anterolateral aspect of the thigh but this is usually well toler­
ated. Sensory nerve preservation by performing a careful
suprafascial dissection of the nerve branches during flap
harvest, may avoid loss of sensation to the thigh.
LONG-TERM OUTCOMES
General
After initial successful reconstruction with the anterolateral
thigh flap, the long-term outcome is generally good because
the versatility of the flap allows it to be tailored to the needs
postoperatively on the table and after transfer to the hospi­
tal bed. Postoperative monitoring continues on a floor or
unit setting allowing for hourly flap checks for the first
24–36 h. In general, no specific medications for the flap are
needed but that may be altered by surgeon preference.
RECIPIENT SITE
Aside from flap monitoring, care must be taken to insure
there is no compression on the flap or the pedicle. For head
and neck reconstruction, patients are positioned with the
head of bed elevated to 30° without the use of pillows.
Patients undergoing pharyngoesophageal reconstruction
are withheld from oral intake for 2 weeks after reconstruc­
tion or 4 weeks if prior history of radiation therapy. A liquid
diet is initiated after a negative swallow study, with advance
to regular diet after 2 days.
In cases of abdominal reconstruction with a large free
flap, prolonged bed rest up to 2 weeks may be necessary, as
early ambulation may cause flap destabilization and traction
on the flap pedicle. A protective abdominal binder is used
for 12 weeks to prevent postoperative herniation.
DONOR SITE
Drain output is monitored postoperatively and the drain is
removed when output is less than 30 mL/day to decrease
the chance of seroma formation. If a skin graft was placed
at the donor site, bed rest is typically instituted until graft
take. Physical therapy rehabilitation of the lower extremity
is initiated once the donor site has healed.
OUTCOMES
EXPECTED OUTCOMES
General
In general, the anterolateral thigh flap success rates are
>96%, as demonstrated by Wei and colleagues in a large
institutional series. Of a total of 439 cutaneous or fascio­
cutaneous flaps based on musculocutaneous perforators,
15 failure cases (eight complete and seven partial) were
reported. A total of 34 flaps were re-explored and 19 were
salvaged (56%).
Different Indications
In the series by Wei et al., which included all types of antero­
lateral thigh flaps, including myocutaneous and chimeric
flaps, the success rate for head and neck reconstructions was
96% (467 of 484 flaps successful); for lower extremity recon­
struction 93% (113 of 121 flaps successful); for upper
extremity reconstruction 93% (54 of 58 flaps successful);
and for trunk reconstruction 100% (nine of nine flaps
successful).
In head and neck reconstruction, secondary debulking
procedures and scar revisions may be required to improve
final aesthetic outcome. The flap skin may be sequentially
excised to improve the initial skin color mismatch or elimi­
nate hair growth. In general, good functional outcome is
achieved in terms of articulation, speech, chewing, and
mouth opening.
Donor Site
There is generally limited morbidity from the anterolateral
thigh donor site, which can be closed primarily if flap width
is less than 8 cm or closed with a skin graft. In the same

712
PART 5 — PERFORATOR-BASED WORKHORSE FLAPS
develop between the skin graft and underlying muscle.
Donor sites with extensive skin grafts may result in decreased
range of motion at the hip and knee compared with donor
sites that are closed primarily. Approximation of muscle
edges after intramuscular dissection and careful preserva­
tion of motor nerves to the muscle help to decrease the
incidence of motor dysfunction. Postoperative rehabilita­
tion facilitates early and complete motor recovery after
anterolateral thigh harvest.
CONCLUSION
Since its first description by Song in 1984, the anterolateral
thigh flap has become a very versatile flap, as evidenced by
its implementation for defects in virtually all areas of the
body. Although its vascular anatomy may be variable at
times, with increased experience in perforator flap surgery,
the reconstructive surgeon can take advantage of the long
pedicle length, the versatility in flap volume and variability
in component construct, and the minimal donor site mor­
bidity for reconstruction of the head and neck, trunk and
abdomen, and upper and lower extremities. These advan­
tages, as well as others previously mentioned, allow the
anterolateral thigh flap to be considered by some recon­
structive surgeons as an ideal soft tissue flap.
of the recipient defect. The aesthetic outcome can be
further improved after initial reconstruction and secondary
procedures may be warranted.
Different Indications
Good aesthetic and functional outcomes for orofacial recon­
struction occur in >90% of cases, although secondary
procedures may be necessary. Evaluation of innervated
anterolateral thigh flaps for oral reconstruction revealed
significant sensory recovery at 6 months with improvement
in functional outcome, compared with non-innervated
flaps. Specifically for tongue reconstruction, sensory recov­
ery in innervated flaps was superior in terms of two-point
discrimination, pain, and temperature testing, and had
superior swallowing function, leading to better overall
patient satisfaction.
Functional assessment of patients 1 year after abdominal
wall reconstruction revealed no abdominal herniations, no
difficulties in daily ambulation, and presence of a mild
abdominal flexion deficit.
Donor Site
Long-term follow-up reveals that patients are able to perform
activities of daily living normally and have minimal weakness
at the donor thigh. Weakness and muscle fatigue may be
exacerbated if the vastus lateralis muscle is severely damaged
during intramuscular perforator dissection, or if adhesions
The patient had a squamous cell cancer of the right tongue. Fol-
lowing resection of the tumor and neck dissection, a suprafascial
anterolateral thigh flap based on a single septocutaneous flap
was used to reconstruct the tongue defect (Fig. 59.11).
CASE 59.1  Tongue Defect Reconstructed with a Suprafascial Anterolateral Thigh Flap
Figure 59.11  (A) Preoperative view showing squamous cell cancer involving right tongue. (B) Intraoperative view showing elevation of
suprafascial anterolateral thigh flap based on a single septocutaneous perforator. (C) Flap completely elevated before division of pedicle.
(D) Suprafascial flap harvest allows complete closure of fascia. (E) The patient at 8 months postoperatively showing well-healed flap.
A
B
C
D
E

CHAPTER 59 — Anterolateral a nd Anteromedial Thigh Flaps
713
A 46-year-old man involved in a motorcycle accident had an open
wound with exposed hardware. An anterolateral thigh flap was
harvested based on perforators and a segment of vastus lateralis
muscle was used to fill in the dead space around the bony
defects. The patient healed without complications (Fig. 59.12).
CASE 59.2  Right Lower Extremity Tibia-Fibula Fracture with Exposed Hardware
Reconstructed with a Free Anterolateral Thigh Flap with Vastus Lateralis Muscle
Figure 59.12  (A) Open tib-fib fracture with exposed hardware. A template of the defect was created. (B) Two perforators were located
in the anterolateral thigh region. (C) The flap was elevated and the perforators were located. The skin was elevated off of the vastus lateralis
muscle based on one perforator. A decision was made to include a segment of muscle that would be used to fill in the dead space around
the bony defects. (D) The flap was harvested. The vastus lateralis muscle and skin are separated and can be used to reconstruct two
separate adjacent defects. (E) The vastus lateralis muscle was used around where more bone was missing and the skin was used to
resurface the defect. (F) Patient well healed postoperatively.
A
B
C
D
E
F

714
PART 5 — PERFORATOR-BASED WORKHORSE FLAPS
A 67-year-old man, who had a recurrent squamous cell carci-
noma, underwent wide local excision of the soft tissue tumor of
the left lower eyelid, orbital exoneration, excision of the cheek,
as well as limited anterior maxillectomy. An anterolateral thigh
flap was harvested and used to reconstruct the nasal, orbital, and
maxillary defect. Several months following the reconstruction,
he underwent a debulking procedure and a cheek advancement
in preparation for placement of osteointegrated implants and a
prosthesis (Fig. 59.13).
CASE 59.3  Orbital, Nasal and Maxillary Defect Reconstructed with a Free Anterolateral
Thigh Flap
Figure 59.13  (A) Orbital, nasal and maxillary defect. (B) An anterolateral thigh flap was marked over three Dopplered perforators. (C) The
flap was harvested based on one of the three perforators. Some muscle was left around the pedicle during the dissection as the pedicle
was going to be exposed to the maxillary sinus and the plan was to avoid denuding the pedicle. (D) Part of the skin island was inset to
reconstruct the nasal defect and the rest of the flap was used to resurface the orbital defect. (E) The patient, several months following
the procedure. He needed a debulking procedure and osteointegrated implants. In order to optimize the result, it was decided to advance
the cheek skin in order to limit the location of the prosthesis to the orbital region. (F) Following a debulking procedure and cheek advance­
ment a prosthesis was placed.
A
B
C
D
E
F

CHAPTER 59 — Anterolateral a nd Anteromedial Thigh Flaps
715
This patient presented with squamous cell cancer involving
the palate. The patient had previously undergone an ALT flap.
The current defect was reconstructed with an AMT flap. Flap
debulking was performed in a second stage procedure. The
donor site was skin grafted (Fig. 59.14).
CASE 59.4  Palate Defect Reconstructed with an Anteromedial Thigh Flap
Figure 59.14  (A) Anteromedial thigh flap marked out on left thigh. Note well-healed scar from previous anterolateral thigh flap harvest.
(B) Flap after division of pedicle. (C) Intraoperative view after flap was inset into palatal defect. (D) Postoperative view showing well-healed
donor site.
A
B
C
D

716
PART 5 — PERFORATOR-BASED WORKHORSE FLAPS
Expert Commentary
Peirong Yu, MD, FACS
The authors provide excellent reviews of the anatomy, tech-
niques, and clinical applications of the anterolateral (ALT) and
anteromedial thigh (AMT) flaps. I agree with the authors
pretty much on everything. The ALT flap has become our soft
tissue flap of choice for nearly all areas of reconstruction
except for breast. The perforator anatomy was not very con-
sistent from initial publications, one of the main reasons for
its slow adaptation. Due to the thicker subcutaneous tissue
in certain populations, the Doppler signals in the 3-cm diam-
eter circle around the mid-point between the anterior supe-
rior iliac spine and supralateral patella (AP line) are difficult
to obtain and often inaccurate. Based on our experience, we
found that the perforators followed a pattern. There are
usually 1–3 perforators in the ALT flap territory in predictable
locations (A, B, and C). In an average person, the perforator
B is located near the midpoint, whereas perforators A and C
are approximately 5 cm proximal and distal to perforator B,
respectively. All three perforators are located approximately
1.4 cm lateral to the AP line. I have found this ABC model is
very reliable and particularly useful for beginners, especially
in thick thighs, where Dopplers can be misleading. For most
applications in our practice, a 6–9 cm wide flap is required.
The medial incision is usually 1.5–2.0 cm medial to the AP
line, roughly corresponding to the anterior midline of the
thigh. With such a design, one should not miss the perfora-
tors. With the ABC perforator locations in mind, surgeons
have a better idea where to look for them.
Our experience showed that 4.3% of the thighs did not
have ALT perforators. We therefore studied the relationship
of the ALT and AMT perforators and found an excellent
inverse relationship between them. It is particularly useful to
know that when there are no ALT perforators, one can almost
always find AMT perforators. Therefore, the AMT flap can be
harvested instead through the same incision, without creat-
ing a new donor site.
Access Figures 59.15, 59.16, 59.17 and 59.18,
as well as case examples 5, 6, 7 and 8 and
further reading online at
.inkling.com

CHAPTER 59 — Anterolateral a nd Anteromedial Thigh Flaps 716.e1
This patient presented with a dorsal foot defect requiring a thin
flap. An anterolateral thigh flap was harvested in the suprafascial
plane, thinned, and used for reconstruction of the foot defect
(Fig. 59.15).
CASE 59.5  Dorsal Foot Defect Reconstructed with a Thin Suprafascial Anterolateral
Thigh Flap
Figure 59.15  (A) Large defect of the right dorsal foot. (B) An anterolateral thigh flap (ALT) was elevated from the side of the right leg on
a single pedicle. (C) Postoperative image following right foot coverage. (D) Well-healed donor site.
A
B
C
D

716.e2 PART 5 — PERFORATOR-BASED WORKHORSE FLAPS
This patient presented with a buccal tumor. Following tumor excision, there was an inner cheek defect, which was resurfaced with
an anteromedial thigh flap (Fig. 59.16).
CASE 59.6  Buccal Mucosa Defect Reconstructed with a Free Anteromedial Thigh Flap
Figure 59.16  (A) The plan was to use an anterolateral thigh flap for reconstructing the defect in the inner cheek. (B) The anterior incision
was made first. The perforators to the ALT were found to be inadequate. The dissection then proceeded in a medial direction until the
perforator to the anteromedial thigh flap was located. (C) The perforator was dissection proximally and the flap was islanded. (D) The
patient well healed with a bulky flap. She did not want a revision.
C
D
A
B
(Courtesy of Seng-Feng Jeng, MD)

CHAPTER 59 — Anterolateral a nd Anteromedial Thigh Flaps 716.e3
A 46-year-old man with a squamous cell cancer of the right
buccal mucosa. Following resection of the tumor and neck dis-
section, he required reconstruction of a right buccal mucosa
defect and augmentation of a soft tissue deficiency in the neck
(Fig. 59.17).
CASE 59.7  Reconstruction of a Buccal Mucosa Defect and Soft Tissue Augmentation of the
Neck with an Anterolateral Thigh Free Flap
Figure 59.17  (A) Intraoperative view following resection of tumor. (B) An anterolateral thigh perforator flap was harvested from the left
thigh. Two perforators were included in the flap. (C) The anterolateral thigh flap was inset into the defect in the buccal region and the
inferior portion was de-epithelialized and tunneled to the neck to fill the soft tissue deficiency that resulted from the neck dissection. (D)
Intraoral view of the patient 1 year postoperatively demonstrating good contour and excellent mouth opening without the need for any
secondary debulking procedures. (E) The patient at 1 year. Note the symmetric contour of the neck without evidence of a soft tissue
deficiency. The de-epithelialized portion of the flap provided long-term soft tissue augmentation. (F) Donor site at 1 year.
A
B
C
D
E
F

716.e4 PART 5 — PERFORATOR-BASED WORKHORSE FLAPS
A 50-year-old man presented with a squamous cell cancer involving the buccal mucosa (Fig. 59.18).
CASE 59.8  Reconstruction of Bilateral Buccal Mucosa Defects with a Split Anterolateral
Thigh Flap
Figure 59.18  (A) Preoperative view of the patient’s lesion following resection the patient ended up with bilateral buccal mucosal defects.
(B) The left thigh was used as the donor site; the skin vessels were mapped using a pencil Doppler, and two skin islands were drawn (see
blue marks) based on at least one perforator each. Both skin islands fell within a large skin island (black marks) that was harvested and
then divided. The two skin islands were separated to allow for the pedicle to traverse the anterior buccal sulcus. (C) A length of 8 cm of
pedicle between the two skin islands was required to allow for reconstruction of two separate distant defects. This figure shows one
perforator being clamped prior to division. The flap was harvested as a large ellipse and separated into two skin islands after all the
perforators were visualized and dissected. (D) Immediately after the reconstruction of both buccal defects with two skin islands based on
one vascular pedicle. (E) The patient 1 year postoperatively.
A
B
C
D
E

CHAPTER 59 — Anterolateral a nd Anteromedial Thigh Flaps 716.e5
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anterolateral thigh flap. Plast Reconstr Surg 2001;108(6):1677–82.
Yu P. Inverse relationship of the anterolateral and anteromedial thigh
flap perforator anatomy. J Reconstr Microsurg 2014;30(7):
463–8.
Yu P. Reinnervated anterolateral thigh flap for tongue reconstruction.
Head Neck 2004;26(12):1038–44.
Yu P, Robb GL. Pharyngoesophageal reconstruction with the anterolat­
eral thigh flap: a clinical and functional outcomes study. Plast Recon­
str Surg 2005;116(7):1845–55.
Yu P, Selber J. Perforator patterns of the anteromedial thigh flap. Plast
Reconstr Surg 2011;128(3):151e–7e.
Yu P, Selber J, Liu J. Reciprocal dominance of the anterolateral and
anteromedial thigh flap perforator anatomy. Ann Plast Surg 2013;
70(6):714–16.
Zhou G, Qiao Q, Chen GY, et al. Clinical experience and surgical
anatomy of 32 free anterolateral thigh flap transplantations. Br J
Plast Surg 1991;44(2):91–6.

e190
INTRODUCTION
The tensor fascia lata (TFL) flap is one of the well-known
flaps with a reliable and constant pedicle. This flap has
served as a workhorse flap for a variety of indications such
as trochanteric pressure ulcers. The TFL muscle has a single
dominant pedicle (Mathes-Nahai type I muscle), which
sends musculocutaneous perforators to supply the overlying
Tensor Fascia Lata Flap
Ömer Özkan  |  O. Koray Coşkunfırat  |  Özlenen Özkan
60 
skin. This flap can be used as a muscle, musculocutaneous,
osteomusculocutaneous, musculo-osseous flap, or skin flap
based on perforator vessels. It can be employed either as a
pedicled flap for neighboring defects to cover pressure
sores, or to reconstruct abdominal wall, groin, and perineum
defects. When necessary, it can be transferred as a free flap
to distant defects utilizing microvascular techniques.
The TFL muscle was first used by Wangensteen in 1934
as a pedicled flap without overlying skin to repair large
hernia defects.1 It was proposed as a musculocutaneous flap
by Bailey in 1967 for the closure of acetabular defects.2 Its
use has gained greater currency following the extensive
clinical application of the flap by Hill et al. in 1978,3 Nahai
et al. in 1978,4 Bostwick et al. in 1979,5 and McGregor and
Buchan in 1980.6 Since then, the TFL flap has found con­
siderable popularity in reconstructive surgery for a variety
of defects. Recently, the perforator vessel based flap with
minimal donor site morbidity has been described by Deiler
et al. in 20007 followed by Koshima et al. in 2001.8
FLAP ANATOMY (Fig. 60.1 and Figs 13.1,
13.2 and 13.19 )
The TFL muscle originates from the outer lip of the ante­
rior iliac crest between the gluteus medius and sartorius
muscles as a broad and flat shaped tendon extending 5 cm
along the crest toward the anterior superior iliac spine. The
muscle, located on the lateral side of the proximal thigh,
continues as a band-like aponeurosis and inserts onto the
iliotibial band by way of the fascia lata at the junction of the
upper and middle thirds of the thigh. The main functions
of the TFL muscle are flexion and abduction of the hip,
extension of the knee, and tightening of the iliotibial tract,
which stabilizes the hip and knee in the standing position
mainly assisting other thigh muscles. It can be considered
as an expendable muscle since there are other muscles that
can serve the same functions.
ARTERIAL SUPPLY OF THE FLAP (see Fig. 60.1
and Figs 13.1, 13.2)
Dominant:  transverse branch of the lateral circumflex
femoral artery
Length: 5 cm (range 4–7 cm)
Diameter: 2.5 mm (range 2–3 mm)
The lateral femoral circumflex artery invariably origi­
nates from the lateral side of the deep branch of the femoral
artery 8–10 cm inferior to the anterior superior iliac spine.
Figure 60.1  Tensor fascia lata perforator flap.
Rectus femoris
Vastus lateralis
Sartorius
Adductor longus
Iliopsoas
Inguinal ligament
Anterior superior
iliac spine
Transverse
branch of LFCA
Descending branch
of LFCA
Superficial
femoral artery
Common femoral
artery
Femoral nerve
Lateral femoral
cutaneous nerve (cut)
Tensor fascia lata
Ascending branch
of LFCA
Tensor fascia lata
perforator flap
Lateral femoral
circumflex artery
(LFCA)
Deep femoral
artery
PART 5  —  PERFORATOR-BASED WORKHORSE FLAPS

CHAPTER 60 — Tensor Fascia Lata Flap
e191
artery, which are not used as blood supply for the flap on
transfer. In order to capture distal thigh skin reliably, a surgi­
cal delay procedure is needed. In most parts of the flap –
especially in the distal part – inclusion of the fascia maximizes
the blood supply of the flap.
All three branches of the transverse branch of the lateral
circumflex femoral artery send perforating branches into
the skin. The perforator vessel runs in a posterolateral direc­
tion in the adipose tissue after penetrating deep fascia, and
divides into several branches in the middle of its course and
runs a straight line to the subdermal plexus. The blood flow
to the skin and lining adipose tissue are supplied mainly by
the perforator, and partially by the capillary network in the
adipose tissue. Aggressive thinning without leaving a large
cuff of fat may sacrifice the blood circulation through this
network, resulting in a less reliable area of skin.
Minor:  the muscle is a type I muscle, so there is no minor
pedicle. However, the distal skin of the thigh is nourished
by perforator vessels arising directly from the profunda
femoris artery.
VENOUS DRAINAGE OF THE FLAP
Primary:  venae comitantes of the transverse branch of
the lateral circumflex femoral artery
Length: 5 cm (range 4–7 cm)
Diameter average 2.5 (range 2–3 mm)
There are usually two venae comitantes traveling with the
accompanying artery.
Secondary:  although there are perforators in the distal
aspect of the skin that drain directly into the deep femoral
vein, these veins could not be considered as secondary
venous drainage for the standard flap.
Length: 7 cm (range 5–12 cm)
Diameter: 2.5 mm (range 2–3 mm)
Theoretically, venae comitantes of the vascular pedicle of
the anterolateral thigh flap, which eventually drain to the
lateral femoral circumflex system, can potentially be used
to drain the flap or to provide partial or augmented drain­
age if needed.
FLAP INNERVATION
Sensory: (see Figs 13.1, 13.2 and 13.19)
1. The lateral cutaneous branch of the 12th thoracic nerve.
This nerve innervates the skin overlying the iliac crest
and superior portion of the TFL muscle. The nerve
pierces the internal and external oblique muscles in the
anterior axillary line, and courses inferior to the iliac
crest and 6 cm posterior to the anterior iliac spine. Proxi­
mally, its diameter varies from 0.5–2 mm and it has 2–3
fascicles.
2. The lateral femoral cutaneous nerve of the thigh (L2–
L3). The lateral femoral cutaneous nerve of the thigh, a
branch of the second and third lumbar nerves, courses
It travels laterally posterior to the femoral nerve divisions,
between the rectus femoris and vastus lateralis muscles and
divides into the ascending, transverse, and descending
branches that nourish the posterior and lateral thigh mus­
culature as well as the overlying fascio-adipocutaneous
tissue. The ascending branch supplies the gluteus medius,
gluteus maximus, and vastus lateralis and upper portion of
the thigh skin; the transverse branch supplies the tensor
fascia lata, the vastus lateralis, and the upper and middle
portions of the thigh skin laterally. The transverse branch
supplies the TFL muscle entering the anteromedial belly of
the muscle 8–10 cm inferior to the anterior superior iliac
spine. The transverse branch supplying the TFL muscle
divides into three branches before entering the muscle at
the hilus: (1) superior, (2) middle, and (3) inferior branches.
The superior branch supplies the upper-third of the muscle,
giving branches to the iliac crest through the origin of the
muscle. The middle branch supplies the middle-third of
the muscle. The inferior branch supplies the lower-third of
the muscle, and then descends caudally superficial to the
fascia lata along the insertion to the iliotibial tract toward
the knee. The main vessel is supplemented by an extra vessel
derived from the ascending branch in 10–15% of cases,
and a vessel derived from the descending branch in 15–20%
of cases.
All vascular divisions send an average of 2–4 musculocu­
taneous perforating branches to the overlying skin, measur­
ing 0.8–1 mm in external diameter. These perforator vessels
arise from the muscle proximally, then course superficial to
the fascia lata in an axial fashion to supply anterolateral
thigh skin. The distal skin of the thigh is nourished by per­
forator vessels that arise directly from the profunda femoris
Figure 60.2  Tensor fascia lata (TFL) flap outline.
TFL flap outline

e192
PART 5 — PERFORATOR-BASED WORKHORSE FLAPS
DISADVANTAGES
• The donor site may be difficult to conceal, and when skin
grafting is needed for closure, it may result in an unaes­
thetic appearance.
• Unless it is harvested as a perforator-based flap, it may be
excessively bulky.
• Sacrifice of the TFL muscle may cause minimal functional
donor site morbidity, such as loss of knee stability. This
seldom occurs and in order to minimize this risk, the skin
flap can be elevated suprafascially as a perforator flap. If
a small flap is needed, the fascia behind can be sutured
back to minimize functional deformity.
PREOPERATIVE PREPARATION
The side of the flap chosen depends on the recipient site,
or the provision of two teams to work simultaneously in
distant tissue transfer. Based on the selection of the flap
type, if a perforator-based flap is to be harvested, a Doppler
probe can be used to determine the most reliable artery
and its course. The thigh is prepared and scrubbed. Shav­
ing the hair is usually optional and depends on the choice
of the surgeon, and on the nature and length of hair and
on the recipient site.
The area of the thigh and hip are prepared down to the
level of the knee. For most cases, it is recommended that
the hip and entire leg be prepared in order to facilitate hip
and knee flexion when needed.
There is no special test that is used prior to surgery. When
a perforator flap is planned, a handheld ultrasound Doppler
device is used to locate the perforators. CT or MRI angiog­
raphy can help in locating perforators.
FLAP DESIGN (Figs 60.2, 60.3, 60.4)
ANATOMIC LANDMARKS
The anatomic landmarks for the flap include the anterior
superior iliac spine (ASIS) and the lateral condyle of the
tibia. A line drawn from the anterior superior iliac spine to
the lateral condyle of the tibia marks the anterior border
of the muscle, and a parallel line drawn 3–4 cm posterior
to the first marks the location of the posterior border of the
muscle. A point marked 8–10 cm (the location of the pedicle
depends on the patient’s height, so it could range between
8 and 12 cm) caudal to the anterior superior iliac spine on
the line extending to the lateral condyle of the tibia, marks
the location of the entrance of the vascular pedicle into the
muscle belly.
GENERAL THOUGHTS ABOUT FLAP DESIGN
• The location where the pedicle enters TFL muscle is not
constant and can be found between 8 and 12 cm caudal
to the ASIS. Therefore, during the dissection, this fact
should be kept in mind.
• For the extended version of the flap, the lower marking
can be extended to the knee, but usually a delay proce­
dure is needed.
in the pelvis beneath the iliac fascia, enters the thigh
below the inguinal ligament about 1–3 cm medial to the
anterior superior iliac spine, lies just above the fascia lata,
and then deep over the sartorius muscle. It enters the
cutaneous territory of the TFL flap 10 cm below the
anterior superior iliac spine. In the distal direction a few
centimeters after reaching the skin territory, it becomes
more superficial and divides into anterior and posterior
branches It measures 2–3 mm proximally and has 3–4
fascicles.
Motor:  the superior gluteal nerve (L4–L5, S1)
This nerve also innervates the gluteus medius and the
gluteus minimus muscles. The nerve is accompanied by the
superior gluteal vessels, descends in an anterior direction
after traveling between the gluteus medius and gluteus
maximus muscles, and enters the muscle in the posterior
surface.
FLAP COMPONENTS
The flap can be harvested as a musculocutaneous flap,
osteomusculocutaneous flap, or musculo-osseous flap, or a
skin flap only. It can include the fascia lata and part of the
iliotibial tract.
1. Lateral thigh skin (LTS) over the TFL
2. TFL muscle
3. LTS + TFL muscle
4. LTS + TFL muscle + iliac crest where TFL muscle
originates
5. TFL muscle + iliac crest
ADVANTAGES
• The flap has a long and large-caliber vascular pedicle that
is suitable for vascular anastomosis.
• It has a wide, reliable, and consistent skin territory. The
variation in vascular anatomy is low and the location of
the pedicle is always between the rectus femoris and
vastus lateralis muscles.
• The skin portion can be transferred as a sensate flap by
including the lateral cutaneous branch of the 12th tho­
racic nerve and/or the lateral femoral cutaneous nerve
of the thigh.
• The TFL muscle can be transferred as a functional unit
by including the motor nerve to the muscle (a branch of
the superior gluteal nerve).
• It can be harvested with iliac bone for composite defects
requiring bone.
• It does not require positional change during surgery for
most recipient sites in the extremities and head and neck
regions.
• It allows a two-team approach most times.
• Reconstruction of defects around the pelvis and lower
extremity can be performed under epidural anesthesia.
• The flap can be harvested as a perforator flap and thinned
to 5 mm, or it can include the entire skin, fascia, muscle,
and bone.
• The donor site can be closed primarily if the skin island
of the flap is <8 cm or if muscle only is harvested.

CHAPTER 60 — Tensor Fascia Lata Flap
e193
dissection of the nerves continues until the desired length
is obtained. Harvesting a relatively wide cuff of subcutane­
ous tissue around the nerve can be useful to protect
neural structures.
• The arc of rotation for the pedicled muscle flap reaches
to the groin, perineum, great trochanter, ischium, and
lower abdominal wall.
• When performing local rotation flaps, the origin of the
muscle proximally may be disinserted to avoid dog-ear
formation.
• For perforator flap harvest, preoperative imaging tech­
niques can be useful.
SPECIAL CONSIDERATIONS
Breast reconstruction: It is not commonly used for breast
reconstruction; however, it can be considered as a secondary
option because of donor site morbidities such as unsightly
thigh scar and thigh asymmetry. The TFL perforator flap is
also a versatile option for breast reconstruction in selected
cases.9
Upper and lower extremities, as well as head and neck
defects requiring soft tissue and bone, can be reconstructed
with this flap, which can include iliac bone.
It can be used as a neurosensorial flap for various soft
tissue defects where sensation is required. Functional muscle
transfer can be achieved by performing a coaptation between
the motor nerve of the TFL muscle (the superior gluteal
nerve) and recipient nerve (i.e., shoulder reconstruction,
facial reanimation).
DIFFERENCE IN DESIGN, IF ANY, WHEN
PERFORMING THE FLAP AS PEDICLED OR FREE
The flap can be designed to rotate anteriorly and superiorly
to reach abdominal, perineal, and inguinal defects, or pos­
teriorly and superiorly to cover ischial, trochanteric, peri­
neal, and sacral defects.
The musculocutaneous flap can be planned as peninsu­
lar, island, and V-Y advancement flap. Although the skin
island of the flap can be designed similarly in both free and
pedicled flaps, there are some differences according to
requirements and the distance to the recipient defects in
pedicled flaps. In pedicled flaps, most of the useful part of
the flap is designed in the area distal to the pedicle of the
flap, which is 8–12 cm inferior to the ASIS. The arc of the
rotation of the flap should be planned considering this loca­
tion prior to dissection. When used as a rotation flap, the
origin of the muscle and its overlying skin can be divided to
form an island flap to add mobility around the axis of the
pedicle (pivot point).
If the flap is designed as a perforator vessel-based skin
flap, it can be rotated more freely.
FLAP DIMENSIONS
Muscle Dimensions
Length: 13 cm average: 12 cm (range 12–15 cm)
Width: average 4 cm (range 3–5 cm)
Thickness: 2 cm (range 1.5–3 cm)
• The anterior and posterior marking for the vertical inci­
sions can be extended in an oblique shape proximally
and distally at the level of this line for the full, proper
exposure of the fascia.
• If a neurosensorial flap is planned, the positions of the
sensory nerves are indicated as described above and
Figure 60.4  Flap design TFL flap.
Figure 60.3  Anatomic landmarks for the TFL flap. (Reprinted from
Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights Reserved.)
Lateral condyle of tibia
Anterior
superior iliac
spine
Location of
the pedicle
Tensor fascia
lata flap outline
8 cm

e194
PART 5 — PERFORATOR-BASED WORKHORSE FLAPS
flap with its entire continuity along the origin of the muscle
proximally (Fig. 60.5).
FLAP MARKINGS (Figs 60.2, 60.3, 60.4, 60.6)
For exposure of the vascular pedicle and fascia, the preop­
erative central axis is marked from the ASIS to the lateral
condyle of the tibia. While a point inferior/caudal to the
iliac crest and 6 cm posterior to the anterior iliac spine
indicates the location for the lateral cutaneous branch of
the 12th thoracic nerve, a line 10 cm below the anterior
superior iliac spine at the anterior border of the flap indi­
cates the location for the lateral femoral cutaneous nerve
of the thigh. A point 8 cm caudal to the ASIS marks the
location where the pedicle enters the muscle. This point
indicates the central axis of the flap.
PATIENT POSITIONING
The best position is the supine position for abdominal,
inguinal, and trochanteric defects and for free flap harvest.
The flap can be harvested in the contralateral lateral decu­
bitus position for reconstruction of hip, ischial, and sacral
defects or it can be harvested with the patient in the prone
position for reconstruction of ischial and sacral decubitus
defects.
ANESTHETIC CONSIDERATIONS
The TFL flap can be harvested either using general anes­
thesia or using a regional block. If the recipient area is in
the head and neck, breast, upper extremity, etc., general
Skin Island Dimensions
Length: average 20 cm (range 15–40)
Width: average 10 cm (range 7–20 cm), maximum to close
primarily 8 cm
Thickness: average 10 mm (range 5–20 mm)
If the length of the flap is extended beyond 10 cm proxi­
mal to the knee or designed longer than 35 cm in an adult
patient, a delay procedure is recommended. Based on the
authors’ experiences, if delay procedure is not performed,
the distal skin of the flap has no chance of survival.
Fascia Dimensions
Length: average 10 cm (range 5–30 cm)
Width: average 10 cm (range 6–20 cm), maximum to close
primarily 7 cm
Thickness: average 2 mm (range 1–2 mm)
The fascia can extend from anterior to the rectus femoris
to posterior to the biceps femoris.
Bone Dimensions
Length: average 5 cm (range 4–8 cm)
Width: average 4 cm (range 2–5 cm)
Thickness: average 12 mm (range 10–17 mm)
A segment of iliac crest 4–8 cm in length and 2–5 cm in
width can be included with the flap. The bone segment is
harvested from the area of origin of the TFL muscle. The
blood supply of the bone is provided by 2–3 small vessels
entering the iliac crest through the origin of the TFL
muscle, which is supplied mainly by an ascending branch of
the main pedicle. The bone segment is included with the
Figure 60.5  Section of iliac bone that can be harvested with the TFL flap. (With permission from Netter, FH, Atlas of Human Anatomy, 5th ed,
Elsevier, Saunders. Copyright 2011.)
Iliac crest
Intermediate zone
Tuberculum
Outer lip
Wing (ala) of ilium (gluteal surface)
Anterior superior iliac spine
Anterior inferior iliac spine
Lateral view
Gluteal
lines
Anterior
Inferior
Posterior
Posterior superior
iliac spine
Posterior inferior
iliac spine
Greater sciatic notch
Body of ilium
Ischial spine
Lesser sciatic notch
Body of ischium
Ischial tuberosity
Ramus of ischium
Obturator
foramen
Acetabulum
Lunate surface
Acetabular notch
Margin (limbus) of acetabulum
Superior pubic ramus
Pubic tubercle
Obturator crest
Inferior pubic ramus
Ilium
Ischium
Pubis
Iliac bone segment harvested with the flap

CHAPTER 60 — Tensor Fascia Lata Flap
e195
proximal part, is exposed and dissected in the posterior
surface and deep plane of the hilus. Vascular branches of
the pedicle to the neighboring muscles, including the
gluteus minimus and vastus lateralis muscles, are identified
and ligated. The TFL muscle is separated from the vastus
lateralis muscle, rectus femoris muscle, sartorius muscle,
and gluteal muscles. The small vascular branches to these
muscles should be ligated and care should be taken to pre­
serve branches of the superior gluteal nerve to the gluteal
muscles. The dissection of the pedicle is continued until the
desired length is obtained, usually 4–6 cm (after freeing the
muscle completely, dissection of the lateral femoral circum­
flex femoral artery can be done up to the profunda femoris
artery to gain extra length when necessary). After pedicle
isolation, the muscle is separated from its origin (ASIS) and
the muscle flap is raised, based on its vascular or neurovas­
cular pedicle (Fig. 60.7).
To reduce the bulk of the flap or to reduce the donor site
morbidity (i.e., contour depression on the upper lateral
thigh region), part of the muscle can be harvested, accord­
ing to the needs for defects. This can be provided including
only the muscle around and inferior to the pedicle to the
flap, preserving superior, anterior, and posterior parts.
FREE MICROVASCULAR TRANSFER OF THE TFL
MUSCLE FLAP
Free TFL muscle flap is also dissected in the same way and
the pedicle is cut after isolation and the flap and is trans­
ferred to the distant recipient site.
TENSOR FASCIA LATA MUSCULOCUTANEOUS
FLAP (Fig. 60.8)
After anterior, inferior, and posterior skin incisions are
extended down through the fascia lata, the flap is elevated
beginning at the inferior border, at the level of the aponeu­
rotic insertion of the muscle to the iliotibial tract. Fixation
sutures between the skin and fascia are useful to prevent
shearing forces between the fascia and skin portions of the
flap. After the circumferential incision of the skin island is
completed, the muscle part of the flap is isolated, based on
anesthesia is used. Although it is not recommended because
of toxic dose level of the anesthetic agent, upper extremity
defects could be reconstructed under two blocks. However,
when the flap is planned to be transferred to the lower
extremity, regional block is selected if no contraindications
are present to this form of anesthesia. Spinal or epidural
block can be used for regional anesthesia. Epidural block
seems to be better because longer operations can be toler­
ated and additional sympathetic blockage may be beneficial
for free tissue transfer as it relieves vascular spasm. We
prefer an epidural block whenever possible and use general
anesthesia for the others. When we perform epidural blocks,
we also recommend IV sedation.
TECHNIQUE OF FLAP HARVEST
TENSOR FASCIA LATA MUSCLE FLAP
The anterior incision is made at the level of the ASIS or
more anterior if need be for increased size. An incision over
the anterior line that is the anterior border of the muscle is
made and the fascia lata is exposed. The entire anterior
component of the vertical incision is made. The fascia lata
at the anterior inferior border of the muscle is incised and
the incision is extended in an inferior direction toward the
knee The fascia lata is separated from the aponeurotic inser­
tion inferiorly and the incision continues posteriorly. The
muscle is isolated and divided from its fascial extension,
which continues as fascia lata. The rectus femoris muscle is
identified and retracted medially; the neurovascular pedicle
of the flap is identified at the level of the middle-third of
the muscle between the rectus femoris and the vastus latera­
lis muscle. If functional muscle transfer is required, a branch
of the superior gluteal nerve, which forms between the
gluteus medius and the gluteus minimus muscles in its
Figure 60.6  Flap markings.
Figure 60.7  Harvest of TFL muscle flap.
Rectus femoris
muscle
Vastus lateralis
muscle
Tensor fascia
lata (TFL) muscle
Vascular pedicle
of TFL muscle
A branch of
superior gluteal
nerve

e196
PART 5 — PERFORATOR-BASED WORKHORSE FLAPS
not exceed 10 cm. The harvest of the flap is similar to the
standard technique. However, the fascia is included with the
flap in order to preserve the blood supply to the distal
aspect of the flap.
TISSUE EXPANSION
This method serves to expand the flap and serves as a delay
procedure. Usually, a rectangular-shaped expander is placed
beneath the fascia lata 2–3 cm away from (inferior) the
pedicle. It is placed through a small incision anteriorly or
posteriorly that will not interfere with the subsequent flap
harvest and donor area closure. Dissection is carried subfas­
cially. After achieving hemostasis, a large size prosthesis
based on the flap size needed is placed. Remote valves are
situated subcutaneously or externally. Inflation of the
expander usually begins after 1 week. Excessive and aggres­
sive inflation should be avoided. The expansion process is
stopped once the surface area is found to be large enough
to create the desired flap to cover the defect or close the
donor area primarily. Over-expansion is usually helpful to
provide satisfactory results.
DELAYED FLAP
Simple delay procedures are also useful for harvesting an
extended flap. The margins of the flap are incised. A delay
procedure is usually performed in the estimated distal
border of flap subfascially. Dividing small perforators from
the descending branch of the lateral femoral circumflex
artery will enhance the final flap survival.
NEUROSENSORIAL FLAP
The lateral cutaneous branch of T12 or the lateral femoral
cutaneous nerve (L2–L3) is included with the flap. The
lateral cutaneous branch of T12 pierces the internal and
external oblique muscles in the anterior axillary line, and
courses inferior to the iliac crest and 6 cm posterior to the
anterior iliac spine. The lateral femoral cutaneous nerve of
the thigh enters the cutaneous territory of the TFL flap
10 cm below the anterior superior iliac spine. One or both
nerves can be included with the flap exposing them supra­
fascially 6 cm posterior to the ASIS for former and 10 cm
inferior to the ASIS for latter.
FUNCTIONAL MUSCLE
The branch of the superior gluteal nerve supplying the TFL
muscle is included with the flap. It can be used as a func­
tional flap, especially for the upper extremity functional
reconstruction including shoulder, elbow, and finger func­
tion reconstruction. The TFL muscle fibers are oriented at
an angle to the direction of muscle contraction. It shortens
about 40% of its average fasicle length. Its maximum excur­
sion is limited to about 3 cm.
CHIMERIC FLAP
An island of skin in the mid- to distal-third of the thigh is
harvested, based on the same vascular axis and raised, based
on the subcutaneous pedicle that is proximally supplied by
its vascular or neurovascular pedicle, depending on the
required flap type, as described for the muscle flap above.
TENSOR FASCIA LATA
OSTEOMUSCULOCUTANEOUS FLAP
MUSCULO-OSSEOUS FLAP
The principle for the dissection is similar to that of the
muscle and musculocutaneous flap, except that a vertical
incision superior to the ASIS may be required to expose the
iliac crest clearly. After isolation of the pedicle, origin of the
muscle is not divided from the iliac bone and a segment
of the bone is harvested performing osteotomies usually
after ligation of the pedicle to expose ASIS and iliac crest
(Fig. 60.5).
FLAP MODIFICATIONS/FLAP HANDLING
TRANSVERSE SKIN ISLAND
An elliptical island designed in a transverse fashion is cen­
tered on the pedicle. Transverse island design is usually used
for breast reconstruction but not preferred because of
unsightly donor area scar and thigh asymmetry.
OSSEO-MUSCLE OR OSSEO-
MUSCULOCUTANEOUS FLAP
A segment of iliac crest (4 × 5 cm) can be included to the
flap. Although an osteotomy could be performed before
the pedicle division, the latter is usually recommended to
expose bone clearly.
EXPANDED SKIN ISLAND
The design of the skin island can be extended to 4 cm above
the knee and the width of the flap at the distal aspect should
Figure 60.8  Harvest of TFL musculocutaneous flap.
Rectus femoris
muscle
Vastus lateralis
muscle
Tensor fascia
lata (TFL) muscle
Cutaneous paddle
of TFL flap
Hilus of
TFL muscle