Surgical Highlights

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To harvest this flap the knee is flexed and internally rotated to expose the postero-

lateral aspect of the thigh. The midpoint of the thigh is marked (halfway between the greater trochanter and the lateral femoral condyle) along the intermuscular septum between the vastus lateralis muscle and biceps femoris muscle. The width of the flap can be up to 15 cm while still allowing for primary closure of the donor site. More of the flap should be designed anterior to the intermuscular septum because the skin is thinner in this area. The flap can extend along the entire thigh, if needed. Dissection proceeds from anterior to posterior in a subfascial plane (over the thick iliotibial tract) down to the intermuscular septum. The lateral femoral cutaneous nerve can be included in flap design, if desired. The posterior portion of the flap is dissected to the intermuscular septum as well. The vastus lateralis must be retracted anteriorly to expose the vessels along the septum. The third perforator passes superior, through, or posterior to the short head of the biceps and there is a wide variation in its vertical position along the intermuscular septum, ranging from 8 to 32 cm ^

d above the lateral femoral condyle (75). The adductor magnus and the short head >3

of the biceps must be sharply incised to follow the profunda femoris vessels superiorly. The profunda femoris artery and its accompanying venae comitantes are trans- o ected just distal to the second perforator. Dividing the profunda femoris artery proximal to the second perforator (usually the largest of the perforators) may cause

Anatomie Pferdebein Vorne
Figure 67 The third perforator of the profunda femoris artery is the dominant blood supply to the lateral thigh free flap.

muscular weakness. The second perforator is identified clinically by noting its close relationship to the insertion of the gluteus and the iliotibial tract (76). The dissection within the intermuscular groove is tedious and difficult. It may be best to leave the posterior portion of the flap attached and if the feeding vessels are transected accidentally the flap can be replaced intact. According to Hayden et al., the most difficult part of the dissection is freeing the third perforator as it exits the hiatus through the origin of the adductor magnus muscle along the posterior border of the femur (74). Multiple branches to the vastus lateralis must be carefully ligated and the hiatus |

enlarged superiorly and inferiorly. Once this is accomplished, the profunda femoris vessels are uncovered and relatively easily dissected to the second perforator. The flap is release by dividing the artery and vein and a layered closure of the donor site over a large suction drain is performed.

Advantages o

In thin individuals, the lateral thigh flap is well suited for a variety of defects in the head ยง

and neck. The supplying artery is nonessential to the vascularity of the thigh and the @

donor site scar is quite acceptable to most patients. Functional morbidity is minimal after harvest. A two-team simultaneous harvest is possible, reducing operative time. The vascular pedicle is relatively lengthy and the vascular pedicle is large in terms of microvascular surgery. There is a potential for sensory innervation. Good-quality tracheoesophageal voicing is possible after routine placement of a speaking valve. Disadvantages

Contraindications include local obesity (so-called saddle-bag thighs), previous trauma, severe peripheral vascular disease, or prior hip replacement surgery that may have disrupted the perforating vessels. The donor site may leave a slight contour defect with primary closure or require skin grafting when an excessively wide flap is taken. The principal disadvantage is the difficulty in harvesting the flap. It is a tedious and arduous dissection that can take up to 3.5 h to perform. However, an experienced surgeon should take no more than 2-2.5 h to raise the flap. Accidental division of the vascular pedicle, especially as the third perforator passes through the adductor magnus muscle, is a realistic possibility. The flap skin is quite pale in most individuals, making it a poor color match with the cervicofacial region. There is a small risk of wound dehiscence and compartment syndrome, especially if the donor site is closed under excessive tension. When used for pharyngeal reconstruction, stenosis at the distal anastomosis may occur. This is avoided by designing the inferior circumference of the flap with a "V" type extension to break up the scar.

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