Functional Reconstruction of a Large AnteriorThigh Defect Using Contralateral AnterolateralThigh Flap with Tensor Fasciae Latae andMotorized Vastus LateralisAlexander B. Dillon, BA1 Sammy Sinno, MD1 Keith Blechman, MD1 Russell Berman, MD2Pierre Saadeh, MD11 Institute of Reconstructive Plastic Surgery, New York UniversitySchool of Medicine, New York2Department of Surgery, New York University School of Medicine,New YorkJ Reconstr Microsurg 2015;31:7982.

Reconstructive surgeons strive to return to their patients what fate has taken away, a mission particularly evident in limb salvage surgery (LSS). Patients with soft tissue sarcomas, aggressive tumors that require wide resections or amputation, have particularly benefited from strides in this field that has been made possible by cross-sectional imaging, adjuvant therapy, and microsurgery. With equal to or greater than 5- year survival outcomes compared with amputation, this multimodal approach has become the standard of care

The anterior thigh, the most common location of soft tissue sarcomas,2 has become a focus of LSS efforts. Here, we reveal a novel approach to a massive anterolateral thigh (ALT) deficit, including the use of a neuromotor, neurosensory, composite myocutaneous ALT graft from the contralateral thigh.

Case StudyA 73-year-old man presented with an 8-month history of left thigh pain and swelling. MRI and biopsy revealed a near-circumferential myxoid liposarcoma measuring 31 X 50 cm. The patient underwent 5 weeks of neoadjuvant radiation and preoperative tumor embolization before aggressive surgical resection and immediate reconstruction. Preoperatively, he ambulated with walker and cane.

Operative Resection

Oncologic surgeons performed a wide skin excision and nearcomplete resection of the quadriceps compartment, iliotibial tract, and femur periosteum. En bloc removal of the 7-pound specimen left a 40 X 15 cm defect with exposed bone(Fig. 1).

Fig. 1 The intraoperative defect.

Reconstructive Approach

The reconstructive surgery team harvested a 35 X 15 cm musculocutaneous free flap from the contralateral ALT including tensor fascia latae and vastus lateralis muscles with preserved motor nerve branches, iliotibial tract, and a dominant vascular pedicle from the lateral femoral circumflex system (Fig. 2).

Fig. 2 The donor flap on its pedicle.

The donor site was closed primarily.

The lateral femoral circumflex artery and two accompanying venae comitantes supplying the graft were anastomosed end-to-end with those of the recipient site, followed by reapproximation of the flaps motor supply to the contralateral posterior division of the femoral nerve.

The vastus lateralis and iliotibial tract fascia were tenodesed proximally to the anterior superior iliac spine and pubis, and distally to the patella tendon.

The lateral femoral Cutaneous nerves of the flap and recipient site were then coapted to grant sensation to the skin island.

Both motor and sensory nerve reapproximations were performed as close to the donor tissue as possible to minimize the distance required for nerve regeneration. A deep wound drain was placed, and the skin flap secured in place to achieve complete wound coverage (Fig. 3).

Fig. 3 The closed recipient site

The reconstructive procedure, including harvest and implant of the free flap took a total of 5.5 hours, with a 200 ml estimated blood loss. The graft showed signs of perfusion once revascularized, and no signs of ischemia

Postoperative Course

The postoperative course was uncomplicated and included knee immobilization for 6 weeks and outpatient physical rehabilitation. After 6 months of the surgery, the patient was fully healed and able to extend his left knee 45 degrees from the seated position

There were no notable limitations of active knee flexion or hip flexion or extension. The patient used a cane, and he ambulated without assistance at home. The graft was sensate to light touch, pain, and temperature and yielded 8-mm two-point discrimination. There was no notable donor site morbidity

DiscussionDebilitating soft tissue deficits, including loss of entire muscle compartments not uncommon postsarcoma resection, have prompted the use of innervated grafts to actively maintain function in addition to restoring form.

Optimal motorized donor flap considerations include the size, strength,excursion of the muscle, the availability of overlying skin, the functional role and redundancy of donor site musculature, ease of access and dissection, and sustainability including blood supply and innervation.

At present, no level I or level II evidence exists to support specific treatment options for anterior thigh muscle defects, due to small case numbers and retrospective study designs

We replaced likewith like, namely, our patients resected thigh tissue with that of his contralateral thigh, ensuring an optimal muscle and skin match.

We used the vastus lateralis :the largest, most powerful head of the quadriceps, minimal donor site impairment. 3

The noninnervated tensor fasciae latae muscle transfer conveniently restored bulk to the recipient site, due to its close proximity, with low cost, given its nonessential role in knee stabilization. The partial iliotibial band transfer helped stabilize the lateral knee and assist in hip mobility, while the generous ALT skin island easily covered the large surface area of the defect, and availability of its sensory nerve, the lateral femoral cutaneous, allowed it to be reinnervated, maximizing the chance of resensitization

Though comparison across the small studies49 of various approaches to similar defects is difficult, functional outcomes appear most favorable when there is residual musculature to accompany that transferred, and when local, pedicled muscle transfers augment free muscle grafts. Whether or not the latter combination represents the ideal treatment for functional ALT deficits, the optimal free flap remains to be determined.7,10

Our technique allowed allmissing tissue components to be replaced with a single flap.

Our patient required no intraoperative repositioning, and his supine position allowed for an expedited two-team approach.

Moreover, our flap lends more coverage than the others described, with minimal donor site morbidity. Its long pedicle length and large caliber artery help ensure its survival and sustainability at the recipient site

Summarywe report the first successful use of a composite, sensate ALT flap with tensor fasciae latae and motorized vastus lateralis muscles to reconstruct the anterior thigh and quadriceps compartment, representing what we believe to be the optimal free flap for this defect