Near-Circumferential Musculocutaneous/Perforator Thigh Flap on a Single Arterial Pedicle: A Novel Option for Large Soft-Tissue Defects

Reconstructive microsurgeons continue to be challenged with larger and larger defects requiring quality soft-tissue coverage, especially when the operative field is anticipated to undergo radiation therapy postoperatively. Because soft-tissue flaps covered by skin grafts do not tolerate acute radiation very well, cutaneous flaps are preferred. There are many options available to facilitate closure and coverage of large defects; however, many of these options utilize multiple separate donor sites and may require multiple additional anastomoses to perfuse the individual components. This adds further technical complexity, operative time, and morbidity to a procedure with a high baseline degree of difficulty. In combining the vascular territories of the medial and lateral descending branches of the lateral femoral circumflex artery, the authors described a novel flap that serves to provide quality cutaneous coverage for large soft-tissue defects on a single arterial pedicle. A 45 × 30 cm near circumferential perforator thigh flap was successful transferred to a large shoulder defect with a single arterial (LFC) anastomosis and two venous (LFC and saphenous) anastomoses. The flap included all of the skin from the thigh, leaving behind only a 10-cm strip of skin in the posterior thigh. The patient was placed in lithotomy to facilitate harvesting of the flap. Two teams simultaneously elevated the medial and lateral aspects of the near circumferential thigh flap. The entire flap was perfused by perforators of the medial and lateral branches of the LFC system, as well as muscular perforators arising via the incorporated rectus femoris muscle. A single arterial anastomosis was performed end-to-end using the right external carotid artery. The lateral circumflex vein was anastomosed end-to-side to the external jugular vein and, additionally, the saphenous vein was anastomosed to the transverse cervical vein. The donor site was repaired by centralizing the remaining vastus muscles and covered using skin grafts. There were no flap-related complications, nor were there donor-site complications during the patient's postoperative recovery. This near-circumferential perforator thigh flap provides an additional option to reconstruct truly giant defects with a relatively thin skin flap, in lieu of combination flaps or soft-tissue flaps covered by skin grafts. Morbidity is minimized by using donor tissues from a single location that, when harvested, result in a negligible func