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Case Report/Case Series |

Auto Flow-Through Technique for Anterolateral Thigh Flaps

Timothy M. Haffey, MD1; Eric D. Lamarre, MD1; Michael A. Fritz, MD1
[+] Author Affiliations
1Department of Otolaryngology—Head and Neck Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio
JAMA Facial Plast Surg. 2014;16(2):147-150. doi:10.1001/jamafacial.2013.2263.
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Importance  The vascular supply of anterolateral thigh (ALT) free flaps is variable, and the pedicle length and ability to capture perforators to the flap may be limited by the anatomic configuration. We describe the reasoning behind performing the auto flow-through procedure, as well as the steps to carry this procedure out.

Observations  A retrospective medical chart review was performed within our health care system database to identify patients in whom the auto flow-through technique was used during reconstruction with an ALT free flap. The auto flow-through technique was applied to 3 separate ALT free flaps to incorporate perforators from 2 separate vascular systems. This technique allowed for more robust vascularity of the flap and/or optimized pedicle length that would have otherwise necessitated vein grafts. All patients had successful ALT free flap reconstruction and went on to have good functional results.

Conclusions and Relevance  The auto flow-through technique is an adaptation of the flow-through flap, which allows for capture of vascular perforators from separate sources when this configuration is present in the ALT free flap. This technique is especially useful when operating in a vessel-depleted neck or when maximizing pedicle reach is necessary. This technique allows the ALT to be used in challenging reconstruction cases regardless of the vascular branching pattern of the pedicle.

Level of Evidence  4

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Figures

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Figure 1.
Femoral Muscular and Vascular Anatomy

A, Relevant muscular anatomy in an anterolateral thigh flap dissection. B, Vascular anatomy of the lateral thigh, including the lateral circumflex femoral artery (LCFA) and its branches. Outlined box signifies area of flap harvest and separate perforator supply from the transverse branch of the LCFA and the descending branch of the LCFA. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2013. All Rights Reserved.

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Figure 2.
Correction of Unfavorable Perforator Anatomy With the Auto Flow-Through Technique

A, Figure demonstrating unfavorable perforator anatomy, with the proximal perforator coming off of the transverse branch of the lateral circumflex femoral artery (LCFA) and the more distal perforator arising from the descending branch of the LCFA. A flap incorporating both perforators cannot be harvested without sacrificing the nutrient vessel to the rectus femoris. Dotted lines show the ligation points for incorporating both perforators using the auto flow-through technique. B, The perforator distal to the nutrient vessel to the rectus femoris becomes the axis of rotation. C, Anastomosis of the (former) proximal perforator to the distal end of the descending branch of the LCFA, increasing the pedicle length and vascular supply to the flap and requiring only 1 donor vessel at the recipient site. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2013. All Rights Reserved.

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Figure 3.
Pleomorphic Adenoma: Intraoperative and Postresection Photographs

A, Intraoperative photograph showing a large pleomorphic adenoma involving the entire palate and extending into the nasal cavity. B, Same patient after resection of the pleomorphic adenoma sacrificing the entire hard palate and inferior septum. The posterior soft palate and entire alveolar arch was preserved.

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Figure 4.
First and Second Anastomosis for the Auto Flow-Through

A: Intraoperative photograph showing minimal access (4-cm) incision under the facial notch used to access the facial vessels where the descending system was anastomosed. B, Photograph showing the second anastomosis (arrow) of the distal descending system to the proximal transverse system (adjacent to tooth #6), completing the auto flow-through.

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Figure 5.
Postoperative Photograph Showing Healed Flap After Mucosalization
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