• Archives of Plastic Surgery
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• v.35 no.1
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• pp.20-27
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• 2008

Purpose: The anterolateral thigh flap has many advantages over other conventional free flaps. But the anterolateral thigh flap has yet to enter widespread use because perforating arteries exhibit a wide range of anatomic variations and are difficult to dissect when small. The aim of this study is to identify the vascular variability of perforating arteries and pedicle in the anterolateral thigh free flap. Methods: We studied 12 cadavers and dissected 23 thighs. An anterolateral thigh flap ($12{\times}12cm$) was designed and centered at the midpoint of the line drawn from anterior superior iliac spine to the superolateral border of the patella. After we identifed the perforating arteries we dissected up to their origin from lateral circumflex femoral artery along descending branch of lateral circumflex femoral artery. We then investigated the number and the position of perforating arteries, length and diameter of vascular pedicle and pattern of lateral circumflex femoral arterial system. Results: On average $2.3{\pm}1.1$ perforating arteries per thigh were identified. The musculocutaneous perforators were 63.1%. In those perforators five perforators were arose from transverse branch of lateral circumflex femoral artery and two were arose from rectus femoral artery. Most of the perforators were near the intermuscular septum between rectus femoris muscle and vastus lateralis muscle. The length and diameter of pedicle were $11.9{\pm}3.5cm$ and $3.1{\pm}0.8mm$ on average. Conclusion: This study will be helpful for the success in anterolateral thigh free flap.

• Archives of Plastic Surgery
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• v.37 no.5
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• pp.595-599
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• 2010

Purpose: Trochanteric pressure sores management has been improved through the development of musculocutaneous flaps. But it has many drawbacks such as donor site morbidity and functional muscle sacrifice. With the introduction of perforator flap, it is possible to use in every location where musculocutaneous perforators are present. We have reconstructed trochanteric pressure sores using perforator-based flaps from the ascending branch of lateral circumflex femoral artery. Methods: Between May of 2006 and April of 2008, we performed six cases of perforator-based flap from the ascending branch of lateral circumflex femoral artery for the coverage of trochanteric pressure sores. For identifying perforators, a line was drawn from the anterior superior iliac spine to the superolateral border of the patella as the vertical axis, from the pubis to the trochanteric prominence as the horizontal axis. In the lateral aspect of the intersection of these two axes, various flap were designed according to its defects. The flap was raised in the subcutaneous plane above the fascia and the pedicle was traced by doppler and identified. The pedicle was meticulously dissected not to injure the periadventitial tissues and transposed to the defect. The donor site was closed primarily. Results: The mean age of patients was 56.2 years. Four male and two female patients were studied. Five patients were paraplegic. The mean defect size was $6{\times}4\;cm$. The largest flap dimension was $14{\times}7\;cm$. Donor sites were closed primarily without any complications. All flaps survived completely without necrosis, hematoma or infection. There were no recurrence during the follow-up period. Conclusion: Trochanteric pressure sores using perforator-based flap from the ascending branch of lateral circumflex femoral artery can be performed safely and it would be a reliable option for coverage of trochanteric pressure sores with minimal donor site morbidity.

• Archives of Plastic Surgery
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• v.35 no.4
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• pp.379-384
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• 2008

Purpose: Currently, using perforator artery flaps especially anterolateral thigh flaps are widely used for reconstruction of extremities, head and neck. Obtaining a precise anatomical picture prior to operation will translate to a more accurate, efficient and safe procedure. Authors used 3D-image work up via 64-slice MDCT to make a more precise preoperative plan. Methods: A total of 10 patients underwent soft tissue reconstruction with anterolateral thigh flap from December 2006 to December 2007. The 64-Channel MDCT (LightSpeed VCT, GE, USA) was used and 3D images were reconstructed. Findings from MDCT were applied to the preoperative planning and confirmed with intraoperative findings. Results: The average number of perforator arteries from lateral circumflex femoral artery was 2. The average lengths of vascular pedicle from the origin of lateral circumflex femoral artery to the first and second perforator artery were 11.0 cm and 20.0 cm, respectively. The average diameter of the pedicle artery was 2.2 mm. The locations of the perforator arteries were mapped and localized on the body surface based on the MDCT result. These were confirmed through direct visualization intraoperatively. Conclusion: MDCT has an advantage of obtaining accurate images of the general anatomy and even fine structures like perforator arteries. By using this state-of-the-art diagnostic imaging technique, it is now possible to make an operative plan safely and easily.

• Archives of Reconstructive Microsurgery
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• v.22 no.1
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• pp.13-17
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• 2013

Purpose: Although a fasciocutaneous perforator artery as a vascular pedicle has previously been shown to be predominant in the anterolateral thigh (ALT) flap, recent studies have shown that a myocutaneous perforator artery is predominant. We have attempted to attain a clinical understanding of the vascular variations in the ALT flap. Materials and Methods: We confirmed the origin of a perforator artery in 11 cases of ALT flap. We then reviewed the variations of the descending branch of the lateral femoral circumflex artery, known as the major origin of the flap, and the overall variations associated with an ALT flap. Results: In a total of 11 cases, there were 18 perforator arteries of the ALT flaps. In addition, there were 9 fasciocutaneous perforator arteries and another 9 myocutaneous ones. However, depending on the origin, there was great variability in the perforator artery. That is, there were unique variants in the descending branches of the lateral femoral circumflex artery, the major origin of the perforator artery, in 3 of the total 11 cases. Conclusion: Our results showed that (1) a perforator artery accounts for the high proportion of fasciocutaneous ones, (2) a perforator artery might not originate from the descending branch of the lateral femoral circumflex artery and (3) there might be unique variants in the descending branch. If considering this, surgeons would successfully elevate an ALT flap.

• Journal of the Korean Orthopaedic Association
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• v.56 no.6
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• pp.535-539
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• 2021

Vascular complications following a femoral fracture are rare but can result in serious issues. Several case studies have reported pseudoaneurysms occurring after direct trauma or the insertion of a proximal femoral nail in the case of a proximal femoral fracture. The authors encountered an 85-year-old patient treated with retrograde intramedullary nail fixation for a distal femur fracture and suffered a decrease in the hemoglobin level, swelling, and pain on the 9^th day after surgery. The authors initially attributed the temporary hematoma and pain to ordinary postoperative processes. On the 16^th day after surgery, a pseudoaneurysm originating from the descending branch of the lateral femoral convolutional artery was diagnosed and treated by percutaneous vascular embolization. After the procedure, the hemoglobin level increased, and the swelling and pain decreased.

• Archives of Reconstructive Microsurgery
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• v.16 no.1
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• pp.1-5
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• 2007

The purpose of this article to evaluate the availability of the rectus femoris flap in Korean subjects. Material and Methods is that Cadaveric dissections were done on 51 femoral triangles of 26 cadevers. We measured the length of the direct head of rectus femoris from anterior superior iliac spine to patella upper pole, ASIS to lateral border of femoral nerve, and entry point of femoral nerve and vessel branches to rectus. Usually, there were three terminal branches to rectus femoris from the femoral nerve. The entry point of the first branch was at the proximal $17.5{\sim}31.4%$ portion of the rectus femoris. The second and the third branch entered at the proximal $22.5{\sim}40.7%$ and $26.3{\sim}42.3%$, respectively. The vessel entry was at $20.2{\sim}37.3%$. The length from ASIS to femoral nerve was $3.5{\sim}8.5\;cm$. Among the 51 rectus femoris muscles, 44 had one nutrient artery, and 7 had 2 nutrient arteries. The nutrient artery originated from the descending branch of the lateral femoral circumflex artery in 18(40.9%) cases, directly from the lateral femoral circumflex artery in 8(18.0%) cases, and from proximal(6 cases, 13.6%) and distal(12 cases, 27.3%) portion of the deep femoral artery. The average length of the nutrient artery was 29.8 mm and the width was 2.14 mm. The point where it meets the main feeding artery of the rectus femoris was $9.0{\sim}15.0\;cm$ from the ASIS. In all cases, the main artery's entrance was proximal to the first nerve branch. Conclusion is that rectus femoris has available data for functional flap.

• Archives of Plastic Surgery
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• v.49 no.4
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• pp.543-548
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• 2022

Microvascular reconstruction frequently requires anastomosis outside of the zone of injury for successful reconstruction. Multiple options exist for pedicle lengthening including vein grafts, arteriovenous loops, and arteriovenous bundle interposition grafts. The authors performed a systematic review of arteriovenous bundle interposition grafts to elucidate indications and outcomes of arteriovenous grafts in microvascular reconstruction. A systematic review of the literature was performed using targeted keywords. Data extraction was performed by two independent authors, and descriptive statistics were used to analyze pooled data. Forty-four patients underwent pedicle lengthening with an arteriovenous graft from the descending branch of the lateral circumflex femoral artery. Most common indications for flap reconstruction were malignancy (n = 12), trauma (n = 7), and diabetic ulceration (n = 4). The most commonly used free flap was the anterolateral thigh flap (n = 18). There were five complications, with one resulting in flap loss. Arteriovenous bundle interposition grafts are a viable option for pedicle lengthening when free flap distant anastomosis is required. The descending branch of the lateral circumflex femoral artery may be used for a variety of defects and can be used in conjunction with fasciocutaneous, osteocutaneous, muscle, and chimeric free flaps.

• Maxillofacial Plastic and Reconstructive Surgery
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• v.35 no.4
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• pp.265-275
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• 2013

The anterolateral thigh flap (ALTF) is a versatile fasciocutaneous or myocutaneous flap, which can be harvested incorporating several skin islands and muscle components. The perforator of the ALTF is usually derived from the descending or transverse branch of the lateral circumflex femoral artery, and these vessels are based mainly on musculocutaneous perforators traversing the vastus lateralis muscle, and also based on the septocutaneous vessels running in between the rectus femoris and vastus lateralis muscle. Despite its usefulness for the oral cavity reconstruction, anatomic variations of these nutrient vessels, such as three main branches of ALTF and its relations with sartorius, vastus lateralis, tensor fasciae latae and rectus femoris muscle, have been reconstructive surgeons to be hesitated for the selection of ALTF. For the better understanding of ALTF as a routine reconstructive procedure in oral and maxillofacial surgery, various anatomical findings must be learned and memorized by young doctors in the course of the special curriculum periods for the Korean national board of oral and maxillofacial surgery. This review article will discuss the vascular anatomy and relavant anatomical variations of ALTF with Korean language.

• Archives of Plastic Surgery
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• v.49 no.3
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• pp.444-447
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• 2022

Reconstruction of soft tissue defects around the knee is challenging, and the most common solution is to use various locoregional flaps or, in some difficult cases, a free flap. The distally based anterolateral thigh (dALT) flap is a commonly used flap that relies on reverse blood flow from the descending branch of the lateral circumflex femoral artery (d-LCFA). Here, we present the case of an anteromedial knee reconstruction using a dALT flap after resection of a pleomorphic undifferentiated sarcoma. The tumor resection resulted in a 14 × 7 cm defect, and a dALT flap, measuring 20 × 8 cm was elevated. During the surgery, we found a robust oblique branch of the LCFA (o-LCFA) sending off two sizable perforators to the anterolateral thigh region, whereas the d-LCFA was relatively small with no usable perforators. Therefore, we harvested a dALT flap relying on reverse flow from the o-LCFA. The patient's postoperative course was uneventful, and the flap survived without complications. This report demonstrates that reverse flow from the o-LCFA may be an alternative to nourish a dALT flap in cases where the d-LCFA is hypoplastic or suitable perforators from the d-LCFA are unavailable.

• Korean Journal of Radiology
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• v.23 no.8
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• pp.803-810
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• 2022

Objective: To investigate the clinical application of differential subsampling with Cartesian ordering (DISCO) contrast-enhanced (CE) magnetic resonance angiography for anterolateral thigh (ALT) flap transplantation, using operative findings as a reference. Materials and Methods: Thirty patients (21 males and nine females; mean age ± standard deviation, 45.5 ± 15.6 years) who were scheduled to undergo reconstruction with ALT flaps between June 2020 and June 2021 were included in the prospective study. Before ALT flap transplantation, patients were scanned using CE-DISCO imaging. All acquired DISCO images of the 60 lower limbs (both sides from each patient) were analyzed using maximum intensity projection and volume rendering methods. Two experienced radiologists were employed to examine the patterns of the lateral circumflex femoral artery (LCFA), its branches, and perforators and their skin termini, which were compared with the operative findings. Results: Using CE-DISCO, the patterns of the LCFA and its branches were clearly identified in all patients. Four different origins of the LCFA were found among the 60 blood vessels: type I (44/60, 73.3%), type II (6/60, 10.0%), type III (8/60, 13.3%), and type IV (2/60, 3.3%). Owing to a lack of perforators entering the skin, two patients did not undergo ALT flap transplantation. For the remaining 28 patients, the ALT flaps in 26 patients were successfully operated without flap reselection during the operation, while the remaining two patients underwent other surgical procedures due to the thin diameter of the perforator or injury of the perforator during the operation. The success rate of flap transplantation was 92.8% (26/28). All transplanted flaps exhibited good blood supply and achieved primary healing without infection or delayed healing. Conclusion: CE-DISCO imaging can be an effective method for preoperative perforator imaging before ALT flap transplantation.