Title: Reconstruction of Extensive Groin Defects with Contralateral Anterolateral Thigh–Vastus Lateralis Muscle Flaps
Abstract: Sir: Inguinal lymphadenectomy is commonly performed for treatment of nodal metastases of primary malignancies of the lower limb, abdomen, and pelvis, often necessitating en bloc excision and producing extensive wounds with exposure of femoral vessels. The pedicled vertical rectus abdominis myocutaneous or anterolateral thigh fasciocutaneous and vastus lateralis muscle flaps are first choices for reconstruction of ipsilateral groin defects.1 We report our experience using contralateral pedicled anterolateral thigh–vastus lateralis flaps for immediate reconstruction of radical inguinal defects when other options are unavailable. Two patients initially presented with recurrent rectal cancer treated with chemoirradiation, abdominoperineal resection, and pelvic exenteration, followed by inguinal metastasis that was further treated with wide local excision and irradiation to the groin. Both patients' abdomens and ipsilateral anterolateral thigh–vastus lateralis donor sites had been previously used for pelvic and groin reconstruction. They subsequently presented with further groin recurrence and underwent radical resection in the groin and upper thigh involving the lower abdominal wall with exposed irradiated femoral vessels (Figs. 1 and 2). Both patients underwent reconstruction with contralateral anterolateral thigh–vastus lateralis flaps. Hospital stay in both cases was less than 5 days, and they had maintained stable wound coverage.Fig. 1.: A 64-year-old woman presented with groin recurrence of anal squamous cell cancer. (Above) After resection, the patient has exposed femoral vessels and acellular dermis for abdominal wall repair. (Below) A contralateral anterolateral thigh–vastus lateralis flap is raised, brought under the rectus femoris muscle, and passed through a subcutaneous tunnel over the suprapubic area.Fig. 2.: (Left) The vastus lateralis muscle covers the femoral vessels and acellular dermis and fills the dead space, and the anterolateral thigh flap resurfaces the skin defect. (Right) The patient at 2-year follow-up.The techniques for anterolateral thigh and vastus lateralis flap harvest are described elsewhere.2,3 The following steps are important to increase the flap's arc of rotation to the contralateral groin. First, the skin paddle is extended distally to approximately 5 cm above the patella. Once satisfactory perforators are identified, the skin paddle and the vastus lateralis muscle are raised together without separating them, to maximize the perfusion to the distal skin paddle. The proximal flap skin, which is to be buried in the tunnel, is deepithelialized. The vastus lateralis muscle is also divided at approximately 5 cm above the patella. Second, the descending branch is completely islanded and the vascular branch to the rectus femoris muscle is divided to lengthen the pedicle for another 1 or 2 cm. Third, the flap is passed under the rectus femoris muscle proximally. Depending on the anatomy, the anterolateral thigh–vastus lateralis flap may be brought above or below the sartorius muscle. If it is brought above the sartorius, the sartorius muscle is split perpendicular to its longitudinal axis to release tension on the flap's vascular pedicle. The flap is then brought through a subcutaneous tunnel in the suprapubic area to the contralateral groin. In both patients, repeated groin dissections and radiation therapy resulted in mild lower extremity lymphedema, which could be worsened with more extensive dissection in the ipsilateral thigh for flap harvesting. The contralateral anterolateral thigh–vastus lateralis flap is an excellent option, with minimal donor-site morbidity,4 in selected patients who would otherwise require free flap reconstruction with unfavorable recipient vessel options. In obese patients, tunneling an anterolateral thigh–vastus lateralis flap to the contralateral side may not be possible. Vastus lateralis muscle alone with skin grafting, if necessary, may be a better option. Finally, patients with short legs may not have a sufficient arc of rotation to reach the contralateral groin. Jon Ver Halen, M.D. Peirong Yu, M.D. Department of Plastic Surgery University of Texas M. D. Anderson Cancer Center Houston, Texas DISCLOSURE The authors have no commercial associations or financial disclosures regarding any product involved in this article.