FREE FLOW-THROUGH ANTEROLATERAL THIGH FLAP FOR COMPLEX KNEE DEFECT INCLUDING THE POPLITEAL ARTERY SHIMPEI MIYAMOTO, M.D.,1* MASAHIDE FUJIKI, M.D.,1 FUMIHIKO NAKATANI, M.D.,2 MASANOBU SAKISAKA, M.D.,1 and MINORU SAKURABA, M.D.3
Reconstruction of complex knee defects including the popliteal artery presents a challenging problem in reconstructive microsurgery. Reconstruction of the popliteal artery and soft-tissue coverage should be performed simultaneously for limb salvage. We present the onestage reconstruction of a complex knee defect including the popliteal artery using a free flow-through anterolateral thigh (ALT) flap as a bypass flap in two patients with sarcomas. In both patients, the popliteal artery and vein were reconstructed using branches of the lateral circumflex femoral arterial system. The flaps survived without vascular compromise and the limbs were preserved successfully. Free flowthrough ALT flap enables simultaneous leg revascularization and soft-tissue coverage with a single free flap. The lateral circumflex femoral C 2015 arterial system has many branches with large diameters, making it suitable for reconstruction of multiple infrapopliteal arteries. V Wiley Periodicals, Inc. Microsurgery 35:485–488, 2015.
Limb-salvage
surgery has become the standard for local control of aggressive soft-tissue sarcomas arising around the knee.1 Soft-tissue sarcomas located in the knee region could easily invade surrounding neurovascular structures because of the absence of any natural barrier around the tumors. The popliteal artery is critical for limb salvage, and its resection thus requires vascular reconstruction. In addition, the lack of expandable muscle in this region makes primary closure difficult, thus necessitating tissue transfer for wound closure.2 Traditionally, complex knee defects have been reconstructed using a combination of local transposition of a gastrocnemius muscle with a vein graft.3 To the best of our knowledge, there have been no reports of the simultaneous reconstruction of the popliteal artery and softtissue defects with a single free flap. We describe two patients who underwent one-stage reconstruction of complex knee defects including the popliteal artery using a free flow-through anterolateral thigh (ALT) flap as a bypass flap. CASE 1
A 30-year-old woman presented with osteosarcoma of her left fibular head. She underwent wide excision of the tumor including the fibular head and the popliteal vessels 1 Division of Plastic and Reconstructive Surgery, National Cancer Center Hospital, Tokyo, Japan 2 Division of Orthopedic Surgery, National Cancer Center Hospital, Tokyo, Japan 3 Division of Plastic and Reconstructive Surgery, National Cancer Center Hospital East, Kashiwa, Japan *Correspondence to: Shimpei Miyamoto, M.D., Division of Plastic and Reconstructive Surgery, National Cancer Center Hospital, 5-1-1, Tsukiji, Chuo-ku, Tokyo 104-0045, Japan. E-mail: [email protected] and [email protected]. or.jp Received 28 January 2015; Revision accepted 9 March 2015; Accepted 10 April 2015 Published online 25 April 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22421
Ó 2015 Wiley Periodicals, Inc.
with a 13.5 cm 3 11 cm skin defect. The superficial peroneal nerve was sacrificed but the deep peroneal nerve was preserved. The distal limit of vessel transection was at the level of the anterior tibial artery and tibioperoneal trunk. The length of the vascular defect was approximately 6 cm. A 19 cm 3 8 cm free ALT flap was harvested from the ipsilateral thigh. The skin island was based on the musculocutaneous perforator of the descending branch of the lateral circumflex femoral artery (LCFA). The distal continuities of the descending branch and the ascending branch of the LCFA were harvested in preparation for flow-through anastomosis (Fig. 1). The proximal stump of the popliteal artery (6.0 mm diameter) was anastomosed to the LCFA of the flap (5.0 mm), the descending branch of the LCFA (3.5 mm) was anastomosed to the tibioperoneal trunk (4.5 mm), and the ascending branch of the LCFA (3.0 mm) was anastomosed to the anterior tibial artery (4.0 mm). The veins were reconstructed in the same configuration as in the arteries using the comitant flap veins (Fig. 2). After revascularization, the skin defect was closed with the flap, in layers. The wounds healed uneventfully. Ten months after the operation, the patient was able to walk with an ankle prosthesis (Fig. 3). Computed tomographic angiography (CTA) obtained 11 months after the operation showed patency of the popliteal vessels and their bifurcation (Supporting Information Video 1). CASE 2
A 60-year-old woman presented with undifferentiated pleomorphic sarcoma of her right popliteal fossa. She underwent wide excision of the tumor including the popliteal vessels with a 14 cm 3 9 cm skin defect. The length of the vascular defect was 10 cm. An 18 cm 3 6-cm free ALT flap was harvested from her ipsilateral
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Miyamoto et al.
Figure 1. Case 1. Harvested flap. LCFA: lateral circumflex femoral artery, DB: descending branch, AB: ascending branch.
Figure 3. Case 1. Appearance after 10 months.
Figure 2. Case 1. Intraoperative appearance after flap transfer. Right side is cephalad. PA: popliteal artery, LCFA: lateral circumflex femoral artery, DB: descending branch, AB: ascending branch, ATA: anterior tibial artery, TPT: tibioperoneal trunk.
Figure 4. Case 2. Harvested flap. LCFA: lateral circumflex femoral artery, DB: descending branch, AB: ascending branch.
thigh. The skin island was based on the musculocutaneous perforator of the descending branch of the LCFA. The ascending branch of the LCFA was harvested in preparation for flow-through anastomosis (Fig. 4). The ascending branch was not long enough to reach the distal stump of the popliteal artery, and the great saphenous vein (GSV) was therefore harvested from the same incision as a vein graft. The proximal stump of the popliteal artery (6.0 mm diameter) was anastomosed to the LCFA of the flap (5.0 mm), and the ascending branch of the LCFA (3.5 mm) was anastomosed to the distal stump of the popliteal artery (5.0 mm) with an interpositional GSV graft 6 cm in length. The proximal stump of the popliteal vein and distal stump of the anterior tibial vein were bypassed using the comitant vein of the flap and its descending branch (Fig. 5). After revascularization, the skin defect was closed with the ALT flap, in layers. Microsurgery DOI 10.1002/micr
Figure 5. Case 2. Intraoperative appearance after flap transfer. Left side is cephalad. PA: popliteal artery, LCFA: lateral circumflex femoral artery, DB: descending branch, AB: ascending branch, GSV: great saphenous vein, dPA: distal stump of popliteal artery.
The wounds healed uneventfully. Five months after the operation, she was able to walk with a cane (Fig. 6), and CTA demonstrated patency of the
Popliteal Artery Reconstruction With ALT
Figure 6. Case 2. Appearance after 2 months.
reconstructed popliteal vessels (Supporting Information Video 2). DISCUSSION
The popliteal artery is known to be a true end artery with a tenuous collateral supply. Simple ligation of the artery results in a 73% amputation rate,4 and reconstruction of the popliteal artery is therefore essential for limb salvage when the popliteal vessels are resected during tumor resection. Defects of the popliteal artery after tumor resection are usually reconstructed using an interpositional GSV graft.5 Adequate coverage of the reconstructed conduit is considered necessary to ensure graft patency and wound healing. Rudiger et al. reported combined use of a gastrocnemius muscle transposition with a GSV graft for the reconstruction of complex knee defects3; however, in our cases, this option was exhausted because the nutrient vessels of the gastrocnemius muscle were sacrificed with the popliteal vessels. The distally based ALT flap has been used for soft-tissue coverage around the knee.6 The flap is fed by the retrograde flow of the descending branch of the LCFA from the vascular network around the knee. However, this flap cannot be used in patients whose popliteal vessels have been transected, because the vascular network is sacrificed. Free flaps can also be used in combination with a vein graft; however, the popliteal artery and its branches represent the only suitable recipient vessels in the knee region, and it is difficult to find alternative recipient ves-
487
sels. Hallock reported the use of a deep epigastric artery perforator flap for knee coverage; however, this is usually too bulky for reconstruction of this region.7 A flow-through ALT flap is the best choice in these situations, because it can provide simultaneous arterial reconstruction and soft-tissue coverage, as a bypass flap.8 In addition to its simplicity, a bypass flap has hemodynamic advantages over conventional vein grafts, because it can function as a self-modulating arteriovenous fistula and maintain a high flow rate through the conduit.9,10 The use of radial forearm and serratus anterior muscle flaps as bypass flaps has also been reported. However, the ALT flap has several advantages over these; it can be harvested from the ipsilateral thigh in either the supine or lateral decubitus position, without positional change. If the distal resection reaches beyond the popliteal bifurcation, multiple infrapopliteal arteries can be reconstructed using branches of the LCFA, as in case 1 here. In addition, the popliteal and infrapopliteal veins can be reconstructed simultaneously using the comitant veins of the LCFA, which are relatively large in diameter and more suitable for popliteal vein reconstruction than the comitant veins of the radial or thoracodorsal artery. To the best of our knowledge, this is the first report of the simultaneous reconstruction of popliteal artery and soft-tissue defects with a single free flap. To date, the use of flow-through ALT flaps has been limited to distal limb reconstruction, involving the radial, ulnar, and tibial arteries.11 In most reported cases, the distal stump of the descending branch was used as a distal run off. The use of a flow-through ALT flap for popliteal artery reconstruction is a concern, because of the size discrepancy between the popliteal artery and flap artery. This is not a problem at the proximal anastomosis, because the diameter of the proximal LCFA is comparable to that of the popliteal artery; however, the distal stump of the descending branch of LCFA is usually much smaller (0.9–1.8 mm) and direct anastomosis to the popliteal artery is impossible.8,12 There are two possible solutions to this problem. One involves using the proximal branches of the LCFA system, such as the ascending and transverse branches; although these branches are usually shorter than the descending branch, they are a better match for the diameter of the distal stump of the popliteal artery.13 The other solution involves interposition of a GSV graft, as in the current case 2. The ipsilateral GSV can be harvested from the same incision as the ALT donor site. Use of the GSV does not achieve complete arterial revascularization, but counterbalances the size discrepancy and ensures acute patency. Complex knee defects including the popliteal artery may be reconstructed using a flow-through ALT flap, which may represent an ideal bypass flap for reconstruction of complex popliteal vessel defects. Microsurgery DOI 10.1002/micr
488
Miyamoto et al.
REFERENCES 1. Sim IW, Tse LF, Ek ET, Powell GJ, Choong PF. Salvaging the limb salvage: Management of complications following endoprosthetic reconstruction for tumours around the knee. Eur J Surg Oncol 2007; 33:796–802. 2. Alektiar KM, McKee AB, Jacobs JM, McKee BJ, Healey JH, Brennan MF. Outcome of primary soft tissue sarcoma of the knee and elbow. Int J Radiat Oncol Biol Phys 2002;54:163–169. 3. Rudiger HA, Beltrami G, Campanacci DA, Mela MM, Franchi A, Capanna R. Soft tissue sarcomas of the popliteal fossa: Outcome and risk factors. Eur J Surg Oncol 2007;33:512–517. 4. Klineberg EO, Crites BM, Flinn WR, Archibald JD, Moorman CT III. The role of arteriography in assessing popliteal artery injury in knee dislocations. J Trauma 2004;56:786–790. 5. Baxter BT, Mahoney C, Johnson PJ, Selmer KM, Pipinos II, Rose J, Neff JR. Concomitant arterial and venous reconstruction with resection of lower extremity sarcomas. Ann Vasc Surg 2007;21:272– 279. 6. Lin CH, Zelken J, Hsu CC, Wei FC. The distally based, venous supercharged anterolateral thigh flap. Microsurgery 2015 Feb 4. doi: 10.1002/micr.22380. [Epub ahead of print]
Microsurgery DOI 10.1002/micr
7. Hallock GG. Abdominoplasty as the patient impetus for selection of the deep inferior epigastric artery perforator free flap for knee coverage. Microsurgery 2014;34:102–105. 8. Sananpanich K, Tu YK, Kraisarin J, Chalidapong P. Flow-through anterolateral thigh flap for simultaneous soft tissue and long vascular gap reconstruction in extremity injuries: Anatomical study and case report. Injury 2008;39 (Suppl 4):47–54. 9. Chun JK, Marin ML. Radial artery flow-through flap for distal lower-extremity arterial bypass for limb salvage. Plast Reconstr Surg 2003;111:361–365. 10. Teodorescu VJ, Chun JK, Morrisey NJ, Faries PL, Hollier LH, Marin ML. Radial artery flow-through graft: A new conduit for limb salvage. J Vasc Surg 2003;37:816–820. 11. Hsiao YC, Yang JY, Chang CJ, Lin CH, Chang SY, Chuang SS. Flowthrough anterolateral thigh flap for reconstruction in electrical burns of the severely damaged upper extremity. Burns 2013;39:515–521. 12. Fabbrocini M, Fattouch K, Camporini G, DeMicheli G, Bertucci C, Cioffi P, Mercogliano D. The descending branch of lateral femoral circumflex artery in arterial CABG: Early and midterm results. Ann Thorac Surg 2003;75:1836–1841. 13. Gurunluoglu R. The ascending branch of the lateral circumflex femoral vessels: Review of the anatomy and its utilization as recipient vessel for free-flap reconstruction of the hip region. J Reconstr Microsurg 2010;26:359–366.
Reconstruction of complex knee defects including the popliteal artery presents a challenging problem in reconstructive microsurgery. Reconstruction of the popliteal artery and soft-tissue coverage should be performed simultaneously for limb salvage. We present the onestage reconstruction of a complex knee defect including the popliteal artery using a free flow-through anterolateral thigh (ALT) flap as a bypass flap in two patients with sarcomas. In both patients, the popliteal artery and vein were reconstructed using branches of the lateral circumflex femoral arterial system. The flaps survived without vascular compromise and the limbs were preserved successfully. Free flowthrough ALT flap enables simultaneous leg revascularization and soft-tissue coverage with a single free flap. The lateral circumflex femoral C 2015 arterial system has many branches with large diameters, making it suitable for reconstruction of multiple infrapopliteal arteries. V Wiley Periodicals, Inc. Microsurgery 35:485–488, 2015.
Limb-salvage
surgery has become the standard for local control of aggressive soft-tissue sarcomas arising around the knee.1 Soft-tissue sarcomas located in the knee region could easily invade surrounding neurovascular structures because of the absence of any natural barrier around the tumors. The popliteal artery is critical for limb salvage, and its resection thus requires vascular reconstruction. In addition, the lack of expandable muscle in this region makes primary closure difficult, thus necessitating tissue transfer for wound closure.2 Traditionally, complex knee defects have been reconstructed using a combination of local transposition of a gastrocnemius muscle with a vein graft.3 To the best of our knowledge, there have been no reports of the simultaneous reconstruction of the popliteal artery and softtissue defects with a single free flap. We describe two patients who underwent one-stage reconstruction of complex knee defects including the popliteal artery using a free flow-through anterolateral thigh (ALT) flap as a bypass flap. CASE 1
A 30-year-old woman presented with osteosarcoma of her left fibular head. She underwent wide excision of the tumor including the fibular head and the popliteal vessels 1 Division of Plastic and Reconstructive Surgery, National Cancer Center Hospital, Tokyo, Japan 2 Division of Orthopedic Surgery, National Cancer Center Hospital, Tokyo, Japan 3 Division of Plastic and Reconstructive Surgery, National Cancer Center Hospital East, Kashiwa, Japan *Correspondence to: Shimpei Miyamoto, M.D., Division of Plastic and Reconstructive Surgery, National Cancer Center Hospital, 5-1-1, Tsukiji, Chuo-ku, Tokyo 104-0045, Japan. E-mail: [email protected] and [email protected]. or.jp Received 28 January 2015; Revision accepted 9 March 2015; Accepted 10 April 2015 Published online 25 April 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22421
Ó 2015 Wiley Periodicals, Inc.
with a 13.5 cm 3 11 cm skin defect. The superficial peroneal nerve was sacrificed but the deep peroneal nerve was preserved. The distal limit of vessel transection was at the level of the anterior tibial artery and tibioperoneal trunk. The length of the vascular defect was approximately 6 cm. A 19 cm 3 8 cm free ALT flap was harvested from the ipsilateral thigh. The skin island was based on the musculocutaneous perforator of the descending branch of the lateral circumflex femoral artery (LCFA). The distal continuities of the descending branch and the ascending branch of the LCFA were harvested in preparation for flow-through anastomosis (Fig. 1). The proximal stump of the popliteal artery (6.0 mm diameter) was anastomosed to the LCFA of the flap (5.0 mm), the descending branch of the LCFA (3.5 mm) was anastomosed to the tibioperoneal trunk (4.5 mm), and the ascending branch of the LCFA (3.0 mm) was anastomosed to the anterior tibial artery (4.0 mm). The veins were reconstructed in the same configuration as in the arteries using the comitant flap veins (Fig. 2). After revascularization, the skin defect was closed with the flap, in layers. The wounds healed uneventfully. Ten months after the operation, the patient was able to walk with an ankle prosthesis (Fig. 3). Computed tomographic angiography (CTA) obtained 11 months after the operation showed patency of the popliteal vessels and their bifurcation (Supporting Information Video 1). CASE 2
A 60-year-old woman presented with undifferentiated pleomorphic sarcoma of her right popliteal fossa. She underwent wide excision of the tumor including the popliteal vessels with a 14 cm 3 9 cm skin defect. The length of the vascular defect was 10 cm. An 18 cm 3 6-cm free ALT flap was harvested from her ipsilateral
486
Miyamoto et al.
Figure 1. Case 1. Harvested flap. LCFA: lateral circumflex femoral artery, DB: descending branch, AB: ascending branch.
Figure 3. Case 1. Appearance after 10 months.
Figure 2. Case 1. Intraoperative appearance after flap transfer. Right side is cephalad. PA: popliteal artery, LCFA: lateral circumflex femoral artery, DB: descending branch, AB: ascending branch, ATA: anterior tibial artery, TPT: tibioperoneal trunk.
Figure 4. Case 2. Harvested flap. LCFA: lateral circumflex femoral artery, DB: descending branch, AB: ascending branch.
thigh. The skin island was based on the musculocutaneous perforator of the descending branch of the LCFA. The ascending branch of the LCFA was harvested in preparation for flow-through anastomosis (Fig. 4). The ascending branch was not long enough to reach the distal stump of the popliteal artery, and the great saphenous vein (GSV) was therefore harvested from the same incision as a vein graft. The proximal stump of the popliteal artery (6.0 mm diameter) was anastomosed to the LCFA of the flap (5.0 mm), and the ascending branch of the LCFA (3.5 mm) was anastomosed to the distal stump of the popliteal artery (5.0 mm) with an interpositional GSV graft 6 cm in length. The proximal stump of the popliteal vein and distal stump of the anterior tibial vein were bypassed using the comitant vein of the flap and its descending branch (Fig. 5). After revascularization, the skin defect was closed with the ALT flap, in layers. Microsurgery DOI 10.1002/micr
Figure 5. Case 2. Intraoperative appearance after flap transfer. Left side is cephalad. PA: popliteal artery, LCFA: lateral circumflex femoral artery, DB: descending branch, AB: ascending branch, GSV: great saphenous vein, dPA: distal stump of popliteal artery.
The wounds healed uneventfully. Five months after the operation, she was able to walk with a cane (Fig. 6), and CTA demonstrated patency of the
Popliteal Artery Reconstruction With ALT
Figure 6. Case 2. Appearance after 2 months.
reconstructed popliteal vessels (Supporting Information Video 2). DISCUSSION
The popliteal artery is known to be a true end artery with a tenuous collateral supply. Simple ligation of the artery results in a 73% amputation rate,4 and reconstruction of the popliteal artery is therefore essential for limb salvage when the popliteal vessels are resected during tumor resection. Defects of the popliteal artery after tumor resection are usually reconstructed using an interpositional GSV graft.5 Adequate coverage of the reconstructed conduit is considered necessary to ensure graft patency and wound healing. Rudiger et al. reported combined use of a gastrocnemius muscle transposition with a GSV graft for the reconstruction of complex knee defects3; however, in our cases, this option was exhausted because the nutrient vessels of the gastrocnemius muscle were sacrificed with the popliteal vessels. The distally based ALT flap has been used for soft-tissue coverage around the knee.6 The flap is fed by the retrograde flow of the descending branch of the LCFA from the vascular network around the knee. However, this flap cannot be used in patients whose popliteal vessels have been transected, because the vascular network is sacrificed. Free flaps can also be used in combination with a vein graft; however, the popliteal artery and its branches represent the only suitable recipient vessels in the knee region, and it is difficult to find alternative recipient ves-
487
sels. Hallock reported the use of a deep epigastric artery perforator flap for knee coverage; however, this is usually too bulky for reconstruction of this region.7 A flow-through ALT flap is the best choice in these situations, because it can provide simultaneous arterial reconstruction and soft-tissue coverage, as a bypass flap.8 In addition to its simplicity, a bypass flap has hemodynamic advantages over conventional vein grafts, because it can function as a self-modulating arteriovenous fistula and maintain a high flow rate through the conduit.9,10 The use of radial forearm and serratus anterior muscle flaps as bypass flaps has also been reported. However, the ALT flap has several advantages over these; it can be harvested from the ipsilateral thigh in either the supine or lateral decubitus position, without positional change. If the distal resection reaches beyond the popliteal bifurcation, multiple infrapopliteal arteries can be reconstructed using branches of the LCFA, as in case 1 here. In addition, the popliteal and infrapopliteal veins can be reconstructed simultaneously using the comitant veins of the LCFA, which are relatively large in diameter and more suitable for popliteal vein reconstruction than the comitant veins of the radial or thoracodorsal artery. To the best of our knowledge, this is the first report of the simultaneous reconstruction of popliteal artery and soft-tissue defects with a single free flap. To date, the use of flow-through ALT flaps has been limited to distal limb reconstruction, involving the radial, ulnar, and tibial arteries.11 In most reported cases, the distal stump of the descending branch was used as a distal run off. The use of a flow-through ALT flap for popliteal artery reconstruction is a concern, because of the size discrepancy between the popliteal artery and flap artery. This is not a problem at the proximal anastomosis, because the diameter of the proximal LCFA is comparable to that of the popliteal artery; however, the distal stump of the descending branch of LCFA is usually much smaller (0.9–1.8 mm) and direct anastomosis to the popliteal artery is impossible.8,12 There are two possible solutions to this problem. One involves using the proximal branches of the LCFA system, such as the ascending and transverse branches; although these branches are usually shorter than the descending branch, they are a better match for the diameter of the distal stump of the popliteal artery.13 The other solution involves interposition of a GSV graft, as in the current case 2. The ipsilateral GSV can be harvested from the same incision as the ALT donor site. Use of the GSV does not achieve complete arterial revascularization, but counterbalances the size discrepancy and ensures acute patency. Complex knee defects including the popliteal artery may be reconstructed using a flow-through ALT flap, which may represent an ideal bypass flap for reconstruction of complex popliteal vessel defects. Microsurgery DOI 10.1002/micr
488
Miyamoto et al.
REFERENCES 1. Sim IW, Tse LF, Ek ET, Powell GJ, Choong PF. Salvaging the limb salvage: Management of complications following endoprosthetic reconstruction for tumours around the knee. Eur J Surg Oncol 2007; 33:796–802. 2. Alektiar KM, McKee AB, Jacobs JM, McKee BJ, Healey JH, Brennan MF. Outcome of primary soft tissue sarcoma of the knee and elbow. Int J Radiat Oncol Biol Phys 2002;54:163–169. 3. Rudiger HA, Beltrami G, Campanacci DA, Mela MM, Franchi A, Capanna R. Soft tissue sarcomas of the popliteal fossa: Outcome and risk factors. Eur J Surg Oncol 2007;33:512–517. 4. Klineberg EO, Crites BM, Flinn WR, Archibald JD, Moorman CT III. The role of arteriography in assessing popliteal artery injury in knee dislocations. J Trauma 2004;56:786–790. 5. Baxter BT, Mahoney C, Johnson PJ, Selmer KM, Pipinos II, Rose J, Neff JR. Concomitant arterial and venous reconstruction with resection of lower extremity sarcomas. Ann Vasc Surg 2007;21:272– 279. 6. Lin CH, Zelken J, Hsu CC, Wei FC. The distally based, venous supercharged anterolateral thigh flap. Microsurgery 2015 Feb 4. doi: 10.1002/micr.22380. [Epub ahead of print]
Microsurgery DOI 10.1002/micr
7. Hallock GG. Abdominoplasty as the patient impetus for selection of the deep inferior epigastric artery perforator free flap for knee coverage. Microsurgery 2014;34:102–105. 8. Sananpanich K, Tu YK, Kraisarin J, Chalidapong P. Flow-through anterolateral thigh flap for simultaneous soft tissue and long vascular gap reconstruction in extremity injuries: Anatomical study and case report. Injury 2008;39 (Suppl 4):47–54. 9. Chun JK, Marin ML. Radial artery flow-through flap for distal lower-extremity arterial bypass for limb salvage. Plast Reconstr Surg 2003;111:361–365. 10. Teodorescu VJ, Chun JK, Morrisey NJ, Faries PL, Hollier LH, Marin ML. Radial artery flow-through graft: A new conduit for limb salvage. J Vasc Surg 2003;37:816–820. 11. Hsiao YC, Yang JY, Chang CJ, Lin CH, Chang SY, Chuang SS. Flowthrough anterolateral thigh flap for reconstruction in electrical burns of the severely damaged upper extremity. Burns 2013;39:515–521. 12. Fabbrocini M, Fattouch K, Camporini G, DeMicheli G, Bertucci C, Cioffi P, Mercogliano D. The descending branch of lateral femoral circumflex artery in arterial CABG: Early and midterm results. Ann Thorac Surg 2003;75:1836–1841. 13. Gurunluoglu R. The ascending branch of the lateral circumflex femoral vessels: Review of the anatomy and its utilization as recipient vessel for free-flap reconstruction of the hip region. J Reconstr Microsurg 2010;26:359–366.
