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The Lateral Circumflex Femoral Artery System and Perforators of the Antero Lateral Thigh Flap: An Anatomical Study pattern of the anterolateral thigh flap is considered septocutaneous, but it is primarily musculocutaneous.4,10 In fact, in our study only five septocutaneous perforators were found out of a total number of 34 perforators. This causes us to think that their number is less than that of the musculocutaneous perforators in the anterolateral thigh region. This new consideration of anterolateral thigh flap perforators makes it possible to elevate a vital flap in a greater number of cases, but it requires a longer and more difficult surgical technique (to dissect perforators through the muscle)2-4that is already impaired by the variable vascular pattern of the anterolateral thigh flap pedicle.1,2,9 We found that the variability of perforating vessels concerned not only their type, but also their number, caliber, and location, with data similar to that reported in literature.9 Unlike Shieh and associates,2 we found that the perforators originated consistently from the descending branch or the lateral descending branch when it was present. In seven of the thighs examined, we found a lateral descending branch and a medial descending branch. These two branches derived from the division of the descending branch, with the exception of Cadaver 10, in which the medial descending branch arose directly from the lateral circumflex femoral artery. Moreover, in Cadaver 7 we found a descending branch placed in a more medial position than seen normally, and it ran between the rectus femoris and the vastus intermedius muscles. This seemed to depend on an uncommon shortness of the lateral circumflex femoral artery, and could have important considerations in clinical practice, making the individuation of the anterolateral thigh flap main pedicle more difficult. In fact, the descending branch could not be found in the intermuscular septum between the rectus femoris and the vastus lateralis muscles, where it usually runs in the distal part.14 With regard to the ascending branch, it originated in two of the examined thighs from the transverse branch rather than from the lateral circumflex femoral artery.13 The popularity of the anterolateral thigh flap in the West is inferior to that in the East.1-14The most cited reason for which western surgeons seem to prefer other flaps to the anterolateral thigh flap for postoncological recon- struction of head and neck defects appears to be the anatomic variability of the anterolateral thigh flap vascular pedicle and the consequent difficulties in elevating that flap. Our anatomic study demonstrated the presence of an increased number of changes, even in a limited number of cadavers. Some anatomic differences between whites and Asians have been detected 26


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