Epoxy injection with 3D virtual dissection reveals the complexity of ALT perforasome.

75 % of the links between ALT flap perforasomes are within the suprafascial plexus.

ALT flaps cannot be safely defatted without including the suprafascial plexus arteries.

The aim of this study was to specify the morphology and relative importance of the types of arterial anastomoses between the different perforasomes constituting the anterolateral thigh (ALT) flap vascular tree.

15 ALT flaps were injected on a single perforator with epoxy resin and then analyzed via 3D CT microangiography. Data were processed using a broad binary threshold based on the Hounsfield density of the various contrast-enhanced arteries. A virtual dissection of the 3D images associated with a virtual segmentation of the flap's vascular tree was then performed, enabling direct visualization of the various means of connection between the different perforasomes.

The average surface area of the flap's vascular territory was 190.5 cm2.

40 % of mixed anastomoses including both arteries from the subdermal plexus AND the suprafascial plexus, 35 % of exclusively suprafascial anastomoses, 25 % of exclusively subdermal anastomoses. Some connections via the dermal plexus could be identified, but their relative importance could not be established. No subcutaneous plexus connections were identified.

This study demonstrates that ALT constitutive perforasomes are mostly linked with each other via anastomosing arteries located in the suprafascial plexus.

The debulking of ALT flaps must take this data into account in order to preserve the supra fascial plexus linking arteries as much as possible to avoid loss of vascular territory and marginal necrosis of the flap in vivo.

Flap thinning

3D CT

Microvascularization

Perforasome

Reconstructive surgery

Linking vessels

ALT flap

Perforator anatomy

Flap perfusion

Anterolateral thigh flap

Perforasome theory

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