Nghiên cứu đặc điểm giải phẫu và ứng dụng lâm sàng của vạt đùi trước ngoài tự do dạng chùm tt tiếng anh

In oder to clarifying the anatomical features of the descending branch of the lateral femoral circumflex artery and the application of ALT flap, we study the subject: “Research anatomica

DUONG MANH CHIEN

RESEARCH ANATOMICAL

CHARACTERISTICS AND CLINICAL APPLICATON OF FREE CHIMERIC ANTEROLATERAL THIGH FLAP

Speciality: Orthopedic and Plastic Surgery

Code: 62720129

MEDICAL DOCTORAL THESIS

Scientific supervisor:

Assoc Prof Nguyen Bac Hung

Opponent 1: Assoc Prof Le Van Doan

Opponent 2: Assoc Prof Vu Quang Vinh

Opponent 3: Prof Vu Duc Moi

The thesis has been defended at University-level Thesis Evaluation Council held in Hanoi Medical University

At, (hour), / /2019 (date)

The common causes of large and complex defects for differentareas of the body are trauma, burns, tumors The biggest difficulty isfinding the right material for each type of damage The AnterolateralThigh Flap with its own texture, blood supply is considered anappropriate material in complex defect reconstruction Song Y.G hasfirst reported the Anterolateral Thigh (ALT) flap in 1984 to head andneck reconstruction A special using of ALT flap is chimeric flap.The chimeric flap is compounded from multiple different flaps, butconsists of only a single different tissue form Each of the flaps isusually supplied by different branches from the same source vessel

In oder to clarifying the anatomical features of the descending branch

of the lateral femoral circumflex artery and the application of ALT

flap, we study the subject: “Research anatomical characteristics and clinical application of free chimeric Anterolateral Thigh flap” for purposes of:

1 Describting the anatomical characteristics of the descending branch of the lateral femoral circumflex artery.

2 Evaluating the results of using the free chimeric Anterolateral Thigh flap.

New contributions from the thesis:

- Described the anatomical characteristics of the descending of thelateral circumflex femoral artery to creating chimeric anterolateralthigh flap: with 60 thighs, the dissertation given the description of thenumber, original and size of the descending and the number, size andtype of the perforator of the lateral circumflex femoral artery Fromthe results of the research, satisfactory discussions and conclusionswere made

- In the clinical application, the causes, positions and composition ofdamages of patients were very various Patients were reconstructed

by chimeric flap which have thickness and suitable size The near andfar results have proven that using the free chimeric anterolateral thighflap was effective and reliable New contributions of the dissertation

is reflected in the creation of theoretical and practical basis for theconstruction of the process of using free chimeric anterolateral thighflap in various complex defects reconstruction

Thesis outline:

This thesis covers 126 pages, including: preamle (2 pages), theoverview (37 pages), materials and method (16 pages), outcomes (33pages), discussion (36 pages), conclusion (2 pages), recommendation(1 page) It consists of 29 tables, 57 figures There are 101 references,

in Vietnamese and English

Chapter 1: OVERVIEW 1.1 THE ANATOMICAL CHARACTERISTICS OF THE DESCENDING BRANCH

1.1.1 The anatomical characteristics of the lateral femoral circumflex artery.

According to the classic anatomy, the lateral femoral circumflex

artery is the first branch of profunda femoris artery - a major branch

of femoral artery From the origin, the artery goes between the vastusmedialis muscle and the pelvic lumbar muscles and divided into 3branches: ascending, transverse and descending branch

1.1.2 The anatomical characteristics of the descending branch.

1.1.2.1 The origin

The descending branch usually is one of three branches of the

lateral femoral circumflex artery However, there are some

anatomical changes, some cases the descending branch is dividedfrom femoral or profunda femoris artery.

1.1.2.2 The relation

From the origin, the descending branch running along thecalibrated line which is connected from anterior inferior iliac spine tolateral patella Descending branch length is about 8-15 cm The outerdiameter of artery average 3 mm (2.2-4.0 mm) depeding on the study

1.1.2.3 The branching muscles

On the way, the descending branch divides many small, shortbranches to supply to the rectus femoris, vastus medialis and vastuslateralis muscles The branching muscles are rarely described inanatomical studies

1.1.3 The characteristics of perforators from the descending

branch

1.1.3.1 The origin of perforator

According to the most of research papers, the perforators inanterior thigh are mainly separated from the descending branch.However, some studies also found that the perforators of ascendingand transverse branches involves blood supply to the anterior thigh

1.1.3.2 The number of perforator

The number of perforator varies according to each report SungW.C noticed an average of 4.2 perforators originating from the

lateral femoral circumflex artery Of which about 68% from thedescending branch Kimata Y reported an average of 2,3 perforatorsfrom the descending, while Kawai K was 3,8.

1.1.3.3 The outer diameter at the origin

The outer diameter at the origin of perforator of the descendingbranch varies according to each report According to Sung W.C theaverage diameter of perforator is 0,9 mm, proportion of perforatorwith diameter bigger than 0,5mm accounts for 68,1% Yu P reported64,3% of cases have diameter greater than 0,5mm

1.1.3.4 The length of perforator

The length of perforator and the length of descending branch willdetermine the length of pedicle of flap The domestic and foreign studiesthat we have read there are no researches describing this detail

1.1.3.5 The type of perforator

According to Song Y.G the perforator supply for ALT flap isseptocutaneous perforator, this type accounts for 100% In 1999, Lou S.K.studied more about the types of perforator, he classified into four typesbased on the way to skin of perforator: musculocutaneous (type M),septocutaneous (type S), direct cutaneous (type D) and small perforator

1.1.3.6 Distribution of perforator through the skin

In the most of the studied, the perforator through the skin can befound in a circle with a radius of 3 cm at the center of the calibrated linewhich is connected from anterior inferior iliac spine to lateral patella

1.2 THE PERFORATOR FLAP IN RECONSTRUCTION 1.2.1 A brief history of flaps

In the beginning, the flaps were used in random flaps, as the skinwas raised without regard to any known blood supply other than tomaintain the presence of the subdermal vascular plexus Because ofthe inherent limited blood supply, random flaps had to be restricted torigid length to width ratios to assure viability The important mark inthe development of flap is when Mc Gregor and Morrgan discoveredthat some regions of the body had discrete and relatively largesubcutaneous vessels that pierced the deep fascia to follow apredictable course Comparatively huge cutaneous flaps, if orientedalong the axis of that vascular pathway, consistently maintainedcomplete viability, and appropriately were called axial flaps Theconcept of musculocutaneous flap was first used in 1906 by Tanzini.Pontén deserves credit for reintroducing fasciocutaneous flaps,although he was not quite sure why the inclusion of the deep fasciawith his “superflaps” resulted in a longer flap survival length thancould be predicted for random flaps of comparable width

1.2.2 Types of perforator flaps are used clinically

1.2.2.1 Conjoined flaps

Harii et al first introduced the concept of combined flaps when theydescribed a "combined myocutaneous flaps and microvascular free flap"

The purpose of using conjoined flap is to increase the ability to rotate, theextent of reaching while increasing the vitality of the flap In essence, flap

is a combination of at least 2 flaps with different anatomical regions, eachregion has an independent source

1.2.2.2 Chimeric flap

The chimeric flap is compounded from multiple different flaps,but consists of only a single different tissue form Koshima I firstintroduced the concept of chimeric flap Hallock G.G divided thechimeric flap into three subtypes based on the special blood supply ofeach type In 2015, Kim và CS divided the chimeric flap into foursubtypes

1.3 CHIMERIC FLAP FROM THE DESCENDING BRANCH 1.3.1 The concepts of the chimeric ALT flap

1.3.1.1 The chimeric perforator flap

a The chimeric fasciocutaneous - fasciocutaneous flap

The chimeric fasciocutaneous - fasciocutaneous flap with two ormore fasciocutaneous flap with each of the flaps is usually supplied bydifferent branches from the same source vessel (usually are descendingand transverse branch of the lateral femoral circumflex artery)

b The chimeric fasciocutaneous – fascia flap

The chimeric fasciocutaneous - fascia flap with fasciocutaneousflap and fascia flap, each of the flaps is usually supplied by differentbranches from the same source vessel

c The chimeric fasciocutaneous – adipose flap

The flap is used to recover the skin defects and to fill the tissuedefect due to parry - romberg syndrome or sequelae caused byradiotherapy

1.3.1.2 The chimeric perforator - branching muscles flap

The chimeric flap with many component flap that this flap is

supplied by perforator and the other flap is supplied by branching

muscles

1.3.2 The advantages of the chimeric ALT flap

1.3.2.1 Purpose of reconstruction

a The covering reconstruction

The chimeric ALT flap has many advantages in coveringreconstruction, when it is necessary to reconstruct defects in a distantposition or need to cover different aspects of an organ

b The filled and covering reconstruction

The large, complex defects need a special material to filled andcovering reconstruction The chimeric perforator - branching musclesflap is used to filled and covering reconstruction

c The 3D reconstruction

Toal penile reconstruction requires forming the urethra and penis.Mehmet M reported a case of reconstructing a penis with a pediclechimeric ALT flap.

1.3.2.2 Microsurgical anastomosis

The chimeric flap is compounded from multiple different flaps,but consists of only a single different tissue form Each of the flaps isusually supplied by different branches from the same source vessel.Therefore, only by an anastomosis (artery and vein) has enoughblood supply for all flaps

1.3.2.3 The donor site

Another advantage of ALT flap is that with flexible design, flapcan be used to reconstruct larger defects while still being able toprimary close the donor site

Chapter 2: MATERIALS AND METHOD

2.1 MATERIALS

2.1.1 The anatomical research

The Anatomical research was performed on 30 human cadaverswith 60 thighs From January 2nd, 2010 to June 1st, 2011

2.1.2 The clinical research

Selecting a convenient pattern, all patients suffered fromreconstructive surgery by free chimeric ALT flap, 35 patients with 37free chimeric anterolateral thigh flap From June 2007 to Januany 2016

2.2 METHOD

2.2.1 The anatomical research

The method of study is a cross-sectional descriptive study oncadavers

2.2.1.1 The indexes need to collect: The descending branch, the

perforator, the branching muscles

2.2.1.2 The tools to collect the data

Nikon D90 camera, Surgical kits, marker kits, measuring kits

2.2.1.3 The descending branches were exposed and dataes were collected

a The descending branches were exposed: the incision along the

medial side of Sartorius muscle from anterior inferior iliac spine tomedial patella Tracing the pathway of femoral and profunda femoris

arteries to find the descending branches of the lateral femoral circumflex artery The branches of the descending were exposed.

b Dataes were collected

- Qualitative indexes: the origin, relation of descending branches

of the lateral femoral circumflex artery, type of the perforator, thedirection of the perforator, distribution of perforator through the skin

- Quantitative indexes: length of standard line, length of arteries, Theouter diameter at the origin

2.2.2 The clinical research

The study describes clinical, retrospective and prospective,statistical, synthesized then draw general remarks and conclusions

2.2.2.1 Characteristics of lesions need to be reconstructed by chimeric flap.

Preoperative evaluation: Time of disease Number of previoussurgery, surgery method Causes, location of lesions, size of lesions,injury status: clean damage or infection, good blood supply or not

2.2.2.2 The process of creating the chimeric flap.

Team 1: Harvesting flap

- Harvesting flap: the incision along the anterior flap, through the

fascia, the descending branches of the lateral femoral circumflex

artery were finded and exposed Peforators were preserved

- Chimeric flap design: the first characteristics of the descending

branches, perforators and the branching muscles were evaluated.Combined with the characteristics of demanges, the chimeric ALTflap were designed

- Cutting the pedicle: Cutting the pedicle and transferred to the

receiving place

Team 2: Prepare the receiving place

- Prepare the receiving place: clean the wound, Preparation of

2.2.2.3 The result evaluation

a The early outcomes

The chimeric ALT flap: The survival of flaps, and condition ofwound healing The donor site: condition of wound healing,postoperative complications and functional effects in the area ofdonor site

b The distant outcomes

The chimeric ALT flap: Evaluate each area based on criteria andscoring (select evaluation criteria depending on each region) Thedonor site: Evaluate scarring condition for donor site

Chapter 3: STUDY RESULTS 3.1 ANATOMICAL RESEARCH RESULTS

3.1.1 The anatomical characteristics of the descending branch

3.1.1.1 The number of the descending branch

We studied on 30 human cadavers with 60 thighs had a total of 73

the descending branches, of which 47 specimens had one descending

branch (78,3%) and 13 specimens with 2 descending branches (21,7%)

3.1.1.2 The origin of the descending branch

In 73 descending branches, there were 55 branches with theoriginal from the lateral femoral circumflex artery, 6 branches fromfemoral and 12 branches from profunda femoris artery

3.1.1.3 The outer diameter at the origin of the descending branch

The outer diameter at the origin of the descending branches incase there are one was an average 2,9 ± 0,1mm in case there are twowas an average 2,5 ± 0.2mm

3.1.1.4 The length of the descending branch

The average length of outer descending branches was 262,7 ± 4,3mm,the average length of inner descending branches was 196,9± 17,5mm

3.1.2 The branching characteristics of the descending branch

3.1.2.1 The characteristics of the branches

The branches of the descending branch are divided into two types:The branching muscles and perforators

Table 3.1 The average number of a descending branch

The branches Number Average/1 descending branch Branching muscles 654 8,9 ± 0,2

The total number of branches of descending branches was 880,including 654 branching muscles and 226 perforators Average, eachdescending branch had 12,1 ± 0,2 branches, including 8,9 ± 0,2 8,9 ±0,2 branching muscles and 3,1 ± 0,3 perforators

Table 3.2 Correlation between the branching muscles and

perforators in a descending branch (n=73)