PMC4174101_01
A coronal illustration of the anterior thigh with a pedicled ALT flap dissected to its origin, with creation of a transmuscular tunnel through the vastus intermedius.
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F1
The lack of padded tissue was very painful for her in the sitting position, and she had dealt with a chronic wound within the skin grafted wound for years (see Supplemental Digital Content Fig. 1, which demonstrates a chronic nonhealing wound in the skin graft and cancer recurrence, http://links.lww.com/PRSGO/A18).
An axial illustration of the proximal thigh demonstrating the anatomy of the transmuscular tunnel through which the pedicled ALT flap is passed to decrease the distance to the defect, allowing greater flexibility with insetting of the flap in the posterior thigh secondary to an increase in effective pedicle length. AB indicates Adductor Brevis; AL, Adductor Longus; ALT flap, Anterolateral thigh flap; Am, Adductor Minimus; AM, Adductor Magnus; BF, Biceps Femoris; G, Gracilis; GM, Gluteus Maximus; RF, Rectus Femoris; S, Sartorius; ST, Semitendinosus; VI, Vastus Intermedius; VL, Vastus Lateralis; VM, Vastus Medialis.
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F2
She recovered uneventfully from the surgery (see Supplemental Digital Content Figs. 2 and 3, which show the healed flap and donor site at 8 wk, http://links.lww.com/PRSGO/A18), although with substantial lower extremity morbidity from the oncologic sacrifice of a long segment of her sciatic nerve.
Photograph showing a large defect in the posterior thigh after tumor extirpation. The defect measured 20 x 25 cm, even with partial primary closure medially and inferiorly.
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F3
The oncologic team performed the extirpative portion of the operation, which included en bloc resection of a 24-cm portion of her sciatic nerve that left a large 24 x 25 cm wound (Fig. 3). She recovered uneventfully from the surgery (see Supplemental Digital Content Figs. 2 and 3, which show the healed flap and donor site at 8 wk, http://links.lww.com/PRSGO/A18), although with substantial lower extremity morbidity from the oncologic sacrifice of a long segment of her sciatic nerve.
View of the dissected pedicled ALT flap with exposure of the transmuscular tunnel through to the posterior thigh. Note that even though the donor site is from the lateral thigh, the pedicle origin is medial to the femur.
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F4
The sciatic nerve was exposed for a length of 10 cm with significant dead space and inflammation (see Supplemental Digital Content Fig. 4, which shows an intraoperative photograph of the posterior thigh after debridement of the shotgun wound with an exposed segment of sciatic nerve, http://links.lww.com/PRSGO/A18).
Final intraoperative view of the flap inset. Because of an increase in the effective pedicle length, the flap was inset longitudinally, making the most of flap volume to fill the entire defect. The majority of the lateral thigh flap epidermis is a healed split thickness skin graft donor site from her previous operation.
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F5
The flap was then directed through the tunnel (See Supplemental Digital Content Fig. 5, which shows the pedicled ALT flap being directed through the transmuscular tunnel to the posterior thigh, http://links.lww.com/PRSGO/A18).
PMC4174101_02
View of the dissected pedicled ALT flap with exposure of the transmuscular tunnel through to the posterior thigh. Note that even though the donor site is from the lateral thigh, the pedicle origin is medial to the femur.
gox-1-e81-g004.jpg
PMC4174101_02_gox-1-e81-g004.jpg
F4
The sciatic nerve was exposed for a length of 10 cm with significant dead space and inflammation (see Supplemental Digital Content Fig. 4, which shows an intraoperative photograph of the posterior thigh after debridement of the shotgun wound with an exposed segment of sciatic nerve, http://links.lww.com/PRSGO/A18).
Final intraoperative view of the flap inset. Because of an increase in the effective pedicle length, the flap was inset longitudinally, making the most of flap volume to fill the entire defect. The majority of the lateral thigh flap epidermis is a healed split thickness skin graft donor site from her previous operation.
gox-1-e81-g005.jpg
PMC4174101_02_gox-1-e81-g005.jpg
F5
The flap was then directed through the tunnel (See Supplemental Digital Content Fig. 5, which shows the pedicled ALT flap being directed through the transmuscular tunnel to the posterior thigh, http://links.lww.com/PRSGO/A18).