lambeau antero‐latéral de cuisse · 1 lambeau antero‐latéral de cuisse altf ou de la lente et...

1

Lambeau Antero‐latéral De CuisseALTF

Ou de la lente et longue évolution des lambeaux cutanés

• Lambeau antero-latéral de cuisse (ALTF) =– première description 1984 (Song)

– Popularisation mondiale 20 ans après

Lambeau antero‐latéral de cuisse

• Song Y.G. and al. The free thigh flap: a new free flap concept based on

the septo-cutaneous artery. Br J Plast Surg. 1984; 37: 149-159

Nombre de publications sur le lambeau antero-latéral de cuisse

Le ALTF est naît trop tôt

• Lambeau antero-latéral de cuisse (ALT)=première description 1984 (Song)– première description 1984 (Song)

– Popularisation mondiale 20 ans après

• Les raisons de ce délai résulte de la lente diffusion du concept des lambeaux perforants résumée par :

« une longue maturation et une lente digestion »

1000 19861972- 500 2008

Design of a cutaneous flap

Superficial = random flaps

-700

Nasolabial Sushruta

The indian flap

The Tagliocozzi flap

2


• For 3000 years = superficialsuperficial– random flap

• 2/1 ratio• Arc of rotation• 4 basic drawings

ADVANCEMENT TRANSLATION

TRANSPOSITION ROTATION

1000 19861972- 500 2008

Planning of cutaneous flap


Deep = axial flaps

-700

Nasolabial Sushruta

1972

Mc GregorGroin flap

Axial flow flap


• 1972 = deep, following source vessel– Axial flap

• 1972 Mc Gregor = the conceptg p

• The era of musculo-cutaneous flaps

1000 19861972- 500 2008

Planning of a cutaneous flap


Deep = axial flaps

Superficial = perforator flaps

-700

Nasolabial Sushruta

1972

Mc GregorGroin flap

Axial flow flap

Taylor

1980

NakajimaClassification of vessels

for the skin

1986


• 1990 = superficial – According with the anatomy of vessels for the

skin• The result of fundamental and clinical work on skin

vascularisation

• The era of perforator flaps

– Result during this last century of :• fundamental anatomical work

• Clinical evolution

3

1890

Manchot 1889Spalteholz 1893

1 century of fundamental work on skin vascularization

1800 1900 19501850 2000

1890


1936

Salmon


1800 1900 19501850 2000

1890


1936

Salmon

1980

Taylor


1800 1900 19501850 2000

4

1890


1936

Salmon

1980

Taylor

1986

NakajimaClassification of vessels

assuring skin vascularization


1800 1900 19501850 2000

Nakajima (1986)A new concept of vascular supply to the skin and classification of skin flaps according

to their vascualrizationAnn. Plast Surg. 1986

A- Direct cutaneous arteryB- Direct septo-cutaneous arteryC- Direct muscular artery for the skinD- Skin perforator from muscular arteryE- Skin perforator from septal arteryF- Musculo-cutaneous perforator artery

Arteries for the skin

What did we learn from all this work ?

• Stratification of the skin vascularization in 5 plexus

5


• Stratification of the skin vascularization in plexus

• 3D organization = Angiosome concept– 61 territories = based on 61 main source vessels

– 442 perforators over 0 5 mm442 perforators over 0.5 mm



• 3D organization = Angiosome concept

– 61 territories = based on 61 main source vessels

– 442 perforators over 0.5 mm

• Skin paddle design = survival of the entire flap

What did we learn from all this work ?Survival of the entire skin paddle

The skin territory

The source vessel

The Perforator






• Skin paddle design = survival of the entire flap– The subcutaneous network

Sub-cutaneous network

• Long running sub-cutaneous vessels (limbs)

6

Sub-cutaneous network• Long running sub-cutaneous vessels (limbs)

• Sensitive nerves accompanied by pedicle = neuro-cutaneous flap







– The capture rule

The capture rule• Interconnection of all angiosomes by:

– Choke arteries

– Oscillating veins

Choke arteries & oscillating veins

The capture rule• Interconnection of all angiosomes by:

– Choke arteries

– Oscillating veins

• Responsible for the Capture phenomena:p p p– Anatomic Cutaneous Arterial & Venous Territory

– Hemodynamic Cutaneous Arterial & Venous Territory

– Potential Cutaneous Arterial & Venous Territory

Vascular territories

7

Survival of the entire skin paddleThe sub-cutaneous network

IV

Survival of the entire skin paddleThe capture rule

IVIIII II


• Stratification of plexus in the skin






– The perforasome concept

Perforasome conceptSaint-Cyr PRS 124 2009

• 1 principle = each perforator is linked with adjacent through direct & indirect communication



• 2 principle = Flap design according with connecting vesselsconnecting vessels– Limbs = longitudinal

– Trunk = perpendicular



• 2 principle = Flap design according with connecting vessels

– Limbs = longitudinal

Trunk = perpendicular– Trunk = perpendicular

• 3 principle = preferential filling within the same angiosome

8



• 2 principle = Flap design according with connecting vessels

– Limbs = longitudinal

– Trunk = perpendicular

• 3 principle = preferential filling within the same angiosome

• 4 principle = – direction of vascularization of a joint perforator

is away from the joint

– Intermediate perforator is multidirectional


• Stratification of plexus in the skin




Ski ddl d i i l f h i fl• Skin paddle design = survival of the entire flap

– The subcutaneous network


– The perforasome concept

• Classification of vessels for the skin

Vessels for the skin

• 3 types of vessels vascularising the skin:1. Direct path to the skin

2. Perforating vessels but dissectable

3. Perforating vessels but undissectable A- Direct cutaneous arteryB- Direct septo-cutaneous arteryC- Direct muscular artery for the skin

Direct

A- Direct cutaneous artery

Ex: groin flap vascularized by superficial circonflexe iliac pedicle

B- Direct septo-cutaneous

Forearm flap vascularized by radial pedicle

9

A- Direct cutaneous arteryB- Direct septo-cutaneous arteryC- Direct muscular artery for the skin

F- Musculo-cutaneous perforator artery

Direct

Undirectundissectable


Pectoralis major flap vascularized by acromio-thoracic pedicle

A- Direct cutaneous arteryB- Direct septo-cutaneous arteryC- Direct muscular artery for the skin

D- Skin perforator from muscular arteryE- Skin perforator from septal artery


Direct

Undirectundissectable

Undirectdissectable

D- Skin perforator from muscular artery

DIEP flap vascularized by the deep inferior epigastric pedicle

D & E- Skin perforator from muscular & septal artery

Antero-lateral thigh flap vascularized by the anterior lateral circonflexe

femoral artery

To concludeThe history of skin flaps can be

summarized by A l t ti d d t i th• A longue maturation needed to acquire the fundamental bases of blood circulation and skin vascular anatomy and an long digestion by the practitioner for their application in the medical practice of flap surgery

10

Manchot, 1889 Salmon, 1936 Morris & Taylor, 2006

Manchot, 1889Whetzel, Plast. Reconstr. Surg., 1992

Morris,Perforator flaps, 2006

1984 1986 1989-1994 1993-1998

Pourquoi le lambeau antero‐latéral de cuisse est‐il né trop tôt ?

Articlede Song

Classificationde Nakajima

1989 - Concept de lambeau perforant DIEP flap (Koshima)

1994 – DIEP flap et reconstruction mammaire (Allen)

Travaux de Kimata et Koshima

Lambeau antero‐latéral de cuisse:Travaux fondamentaux sur son anatomie vasculaire

• Les articles à retenir:– Xu. Applied anatomy of the antero-lateral femoral flap. 1988– Koshima. The anterolateral thigh flap: variations in its vascular pedicle. 1989– Zhou. Clinical experience and surgical anatomy of 32 free anterolateral thigh flap

transplantation. 1991– Koshima. Free combined composite flaps using the lateral circonflex femoral system for

repair of massive defects of the head and neck regions: an introduction to chimeric flap

principle. 1993– Kimata. Versatility of the free anterolateral thigh flap for reconstruction of head and neck defects.

1997– Kimata. Anatomic variations and technical problems of the anterolateral thigh flap: A report of 74

cases. 1998

Lambeau antero‐latéral de cuisse:Travaux fondamentaux sur son anatomie vasculaire

• Les articles à retenir:– Xu,1988; Koshima,1989; Zhou, 1991, Koshima,1993; Kimata, 1997;

Kimata, 1998

• Les rectifications principales des approximations de Song:– Variations de l’origine de la perforante septo-cutanée directe (type B):

• Naît de la branche descendante de la LCFA 25 %

• Naît directement de la fémorale profonde 30 %

• N’existe pas 45 %

– Variations du type de perforantes cutanées:• Septo-cutanée directe (type B) 18 %

• Musculaire (type C & D) et septo-cutanée indirecte (type E) 82 %

11

Lambeau antero‐latéral de cuisseNotions anatomiques fondamentales

Intermuscular septum LCFA

Branchedescendante

Rectus femoris

Vastus lateralis


Origine de la perforante cutanée

84.5 % 14 % 1.5 %

98.5 %

Naissance des perforantes cutanées: principalement à la moitié de la cuisse


Lambeau antero‐lateral de cuisseTechnique chirurgicale

Variation dans la technique de fermeture cutanée

Lambeau antero‐latéral de cuisseTechnique chirurgicale

12

Lambeau antéro‐latéral de cuisseClassification

1- Zone donneuse: peau de la région antero-latérale de la cuisse2- Composition du lambeau: Fascio-cutané

– Fascio-cutané : fin et plastique +/- dépend du patient et du sexe. Utilisé comme un lambeau ultra-fin

• Taille de la palette cutanée: 20 x 12 pour une fermeture directe– Musculo-cutané avec le muscle vaste externe– Composite ou chimérique avec tissus du voisinage (rectus antérieur, TFL,

crête iliaque)


Lambeau antero-latéral composite


1- Zone donneuse: peau de la région antero-latérale de la cuisse2- Composition du lambeau: Fascio-cutané

– Fascio-cutané : fin et plastique +/- dépend du patient et du sexe. Utilisé comme un lambeau ultra-fin

• Taille de la palette cutnée: 20 x 12 pour une fermeture directe– Musculo-cutané avec le muscle vaste externe– Composite ou chimérique avec tissus du voisinage (rectus antérieur, TFL, crête

iliaque)3- Type de vascularisation: pédicule LCFA, branche descendante

– Direct septo-cutanée (type B) ou perforante septo-cutanée (type E)– Direct cutanée d’une artère musculaire (type C) ou perforante d’une artère

muusculaire (type D)4- Type de transfère :

– Pédiculé en îlôt vasculaire (longueur du pédicule de 10 à 20 cm) à flux antérograde (reconstruction abdominale) ou à flux rétrograde (reconstruction du genou)

– Libre (reconstruction de la tête et cou, autres régions ayant de besoin d’une vaste palette cutanée

5- Préparation préopératoire: aucune

• Couverture de pertes de substance cutanée:– Joue et larges pertes de substance cervico-faciale

– Abdomen

Lambeau antéro‐latéral de cuisseIndications

– Membres

• Reconstruction de la cavité buccale:– Reconstruction de la langue

• Reconstruction complexe tridimentionnelle de la tête et du cou comme lambeau composite

Lambeau antéro‐latéral de cuisseExemples de cas cliniques

Sarcome radio‐induit de la joue: exérèse transfixiante

13

Composite flap with rectus femoris

Type E perforator

Collateral for rectus femoris

Métastase pariétale cancer du col de l’utérus

• F 45 ans

• PDS 7 x 14 cmabdomenabdomen

• Lambeau musculo-cutané de vaste externe

• Pédiculé

14

1 an post-opératoire

Adénocarcinome récidivant de la tempe

• F 63 ans

• PDS 8 x 13 cmfosse temporale

• Comblement et couverture

15

• F 33 ans

• PDS abdominale

8 x 10 cm

Tumeur de Darrier Ferrand aine droite

• Lambeau sensible (nerf cutané fémoral latéral controlatéral)

lambeau antero‐latéral de cuisse · 1 lambeau antero‐latéral de cuisse altf ou de la lente et...

Documents