BURN SURGERY AND RESEARCH
Classification and Application of the Distally-Based Thigh Flap
Based on the Lateral Circumflex Femoral Artery System
Yuanbo Liu, MD,* Qiang Ding, MD,* Mengqing Zang, MD,* Shengji Yu, MD,† Shan Zhu, MD,*
Bo Chen, MD,* and Jianhua Zhang, MD*
Background: The lateral circumflex femoral artery system with its anatomical
variations is a common source vessel for numerous thigh flaps. However, the an-
atomic variations of the distally based thigh flaps have not been well classified.
Methods: Between July 2008 and July 2016, 19 patients (13 men and 6 women;
age range, 3–58 years; mean, 27.5 years) underwent reconstruction of defects
around the knee using distally based thigh flaps. Defect etiologies included
malignant neoplasm (6 cases) and post-burn scar contracture (13 cases). The
distally based thigh flaps were raised based on perforating vessels originating
from the descending, oblique, rectus femoris branches of the lateral circumflex
femoral artery.
Results: The average flap size was 17.7  8.4 cm (range, 9–24 cm  6–13 cm),
whereas the mean pedicle length was 16.2 cm (range, 8.5–25 cm). The flap's
perforating vessels originated from the descending branch in 6 patients, the
oblique branch from the descending branch in 7 patients, the rectus femoris
branch in 5 patients, and the oblique branch from the transverse branch in
1 patient. All flaps were pedicle flaps except 1 based on the oblique branch
from the transverse branch that was converted to a free flap. All flaps survived
in its entity.
Conclusions: Our experience demonstrated that a distally based thigh flap can be
reliably raised using perforating vessels from different branches of the lateral
circumflex femoral artery.
Key Words: lateral circumflex femoral artery, distally based thigh flap,
lower extremity reconstruction
(Ann Plast Surg 2017;78: 497–504)
T he anterolateral thigh flap is a workhorse flap in reconstructive
surgery owing to its versatility and well-established advantages.1
The anatomy of the anterolateral thigh flap has also been well docu-
mented. Generally, the lateral circumflex femoral artery originates from
the profunda femoral artery and gives off 3 main branches: the ascend-
ing, transverse, and descending branches. The descending branch first
travels between the rectus femoris and vastus intermedius muscles, then
along the medial margin of the vastus lateralis muscle, and finally
enters into the vastus lateralis muscle.2 Within this muscle, the terminal
branches of the descending branch anastomoses with the superior lat-
eral genicular artery. The reverse flow from this distal anastomosis after
ligation of the proximal lateral circumflex femoral artery descending
branch constitutes the vascular basis of the distally based anterolateral
thigh flap.3–5 The rectus femoris branch originates from the descending
branch proximally and gives rise to cutaneous branches, on which an
anteromedial thigh flap may be based.6 Wong et al7 recently described
a previously unnamed branch as the oblique branch, which travels
between the transverse and descending branches. Both the oblique
Received August 13, 2016, and accepted for publication, after revision October 11, 2016.
From the *Department of Plastic and Reconstructive Surgery, Plastic Surgery Hospital,
and †Department of Orthopedics, Cancer Hospital, Peking Union Medical College
and Chinese Academy of Medical Sciences, Beijing, China.
Conflicts of interest and sources of funding: none declared.
Reprints: Yuanbo Liu, MD, Department of Plastic and Reconstructive Surgery, Plastic
Surgery Hospital, Peking Union Medical College and Chinese Academy of Medical
Sciences, Ba-Da-Chu Road 33, Beijing 100144, China. E-mail: ybpumc@sina.com.
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0148-7043/17/7805–0497
DOI: 10.1097/SAP.0000000000000946
Annals of Plastic Surgery • Volume 78, Number 5, May 2017
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
and descending branches give rise to cutaneous branches, nourish-
ing the skin of the anterolateral thigh region.
Zhang8 first reported the distally based anterolateral thigh flap in
1990, and subsequently the anatomic basis and feasibility of this
nonphysiologic flap have been well demonstrated.3–5,9–11 Although
arterial insufficiency and venous congestion are occasionally encoun-
tered, 10,12 the distally based anterolateral thigh flap is useful for
reconstruction of defects around the knee. Pan et al 3 investigated
the anatomy and hemodynamics of the distally based anterolateral thigh
flap and divided the flap into 4 types, imitating Shieh et al's13 classifi-
cation method regarding the perforating vessels of the anterolateral
thigh flap. Although the type and source vessels of the perforators were
taken into account in this classification method, the lateral circumflex
femoral artery system including the rectus femoris and oblique branches
was not considered as a whole. In this article, we present a classification
method of distally based thigh flaps in which all lateral circumflex
femoral artery branches and our experience in the reconstruction
of lower extremity defects are included.
PATIENTS AND METHODS
All procedures were approved by the institutional review board
of the Chinese Academy of Medical Science and Peking Union Medical
College prior to the execution of the study. Patients and/or direct family
members gave written consent to the procedure. The present study
strictly abides by the Declaration of Helsinki.
Nineteen consecutive distally based thigh flaps in 19 patients
were used to reconstruct defects around the knee and proximal leg after
cancer ablation (32%) and scar removal (68%) between July 2008 and
July 2016 (Table 1). Thirteen patients (68%) were men. The patients'
mean age was 26.5 years (range, 3–58 years).
Surgical Techniques
Preoperative flap design was similar to that of a standard an-
terolateral thigh flap.1,2 All perforators along the line connecting
the anterior superior iliac spine and the superolateral border of the
patella (AP line), particularly near the midpoint of this line, and
the medial margin of the rectus femoris muscle were explored using
a Doppler ultrasound probe and marked on the skin. Using the
perforators explored, the anterolateral and anteromedial flaps
were designed along the AP line and the medial margin of the rec-
tus femoris muscle, respectively, allowing a common incision between
the 2 flaps, allowing the surgeon to explore the existence of the perfo-
rating vessels intraoperatively (Fig. 1). If conditions permitted,
preoperative computed tomographic angiography of the thigh
was performed (Fig. 2). A medial incision over the rectus femoris
muscle was made and carried down to the subfascial plane. Care
was taken not to injure the cutaneous perforators emerging from
the medial border of the rectus femoris muscle. The intermuscular
space between the rectus femoris and vastus lateralis muscles was
identified and opened to expose the main branches of the lateral cir-
cumflex femoral artery. The dissection first proceeded proximally,
and the overall configuration of the lateral circumflex femoral artery
was observed, including the rectus femoris branch, oblique branch,
and relationship to the transverse and descending branches of the lateral
circumflex femoral artery. The dissection then proceeded distally to
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Liu et al Annals of Plastic Surgery • Volume 78, Number 5, May 2017

TABLE 1. Detailed Characteristics of the Patients in This Series*

Pedicle Length,
Pivot Point
Perforator cm
Length to the
of the Superolateral
Sex/Age, Source Flap Size, Length, Relative AP line, Angle of the
No y Side Cause of Defect Defect Location Pattern Vessel Flap Type cm cm Length† cm Patella, cm Outcome
1 M/36 Left Malignant fibrous Lateral knee SCP DB I 87 16 0.47 34 14 Survival
histiocytoma
2 M/13 Left Post-burn scar Popliteal fossa MCP DB I 24  8 13 0.36 36 14 Survival
contracture
3 M/44 Left Post-burn scar Popliteal fossa MCP DB I 22  13 15 0.34 44 16 Venous
contracture congestion
4 F/45 Right Post-burn scar Anteroinferior MCP OB1 IIa 24  8 22 0.57 38 14 Survival
contracture knee
5 F/13 Right Angiofibrolipoma Anteroinferior SCP OB1 IIa 97 19 0.63 30 12 Survival
knee
6 M/11 Left Post-burn scar Anteroinferior MCP OB1 IIa 16  8 17 0.50 34 11 Survival
contracture knee
7 F/4 Left Post-burn scar Lateral knee and MCP DB I 17  11 11 0.42 26 5 Survival
contracture proximal leg
8 F/4 Right Post-burn scar Proximal leg SCP RFB III 18  12 10 0.38 26 12 Survival
contracture
9 M/31 Left Post-burn scar Lateral knee MCP RFB III 24  12 25 0.58 43 12 Survival
contracture
10 M/54 Right Post-burn scar Lateral knee MCP OB2 IIb 20  7 20 0.43 46 11 Free flap,
contracture survival
11 M/30 Left Liposarcoma Popliteal fossa MCP RFB III 20  8 24 0.56 44 12 Survival
12 M/3 Left Post-burn scar Posterolateral MCP OB1 IIa 15  6 15 0.68 22 10 Survival
contracture knee
13 M/6 Right Post-burn scar Posterior knee MCP DB I 20  10 8.5 0.30 28 10 Survival
contracture
14 M/50 Left Post-burn scar Posterior knee SCP REB III 21  6 20 0.47 42 13 Survival
contracture
15 F/54 Left Malignant fibrous Medial knee SCP OB1 IIa 15  8 19 0.48 40 12 Survival
histiocytoma
16 F/38 Right Malignant fibrous Lateral knee MCP DB I 13 7.5 14.5 0.35 41 11 Survival
histiocytoma
17 M/58 Left Soft-tissue sarcoma Superomedial MCP OB1 IIa 15  7 12 0.27 44 14 Survival
knee
18 M/3 Right Post-burn scar Popliteal fossa SCP OB IIa 17 8 12 0.52 23 9.5 Survival
contracture
19 M/6 Left Post-burn scar Inferolateral SCP RFB III 19  7 15 0.48 31 8.5 Survival
contracture knee
*The patients in this table are arranged according to the sequence of the operative time.
†Relative length is a ratio of the pedicle length to the length of the AP line.
SCP, septocutaneous perforator; MCP, musculocutaneous perforator; DB, descending branch; OB1, oblique branch from the descending branch; OB2, oblique branch
from the transverse branch; RFB, rectus femoris branch; AP line, a line is drawn between the anterior superior iliac spine and the upper outer border of the patella; I, type I
flap which is based on the perforator of the descending branch from the lateral circumflex femoral artery; IIa, type IIa flap which is based on the perforator of the oblique
branch from the lateral circumflex femoral artery descending branch; IIb, type IIb flap which is based on perforators of the oblique branch of the lateral circumflex
femoral artery transverse branch or other source arteries; type III flap which is based on the perforator of the rectus femoris branch of the lateral circumflex femoral
artery.

expose the location where the descending branch entered the vastus
lateralis muscle, which serves as the pivot point. Subfascial dissection
then proceeded medially to expose the medial intermuscular septum.
Perforators derived from the rectus femoris branch were explored
and preserved.
The preferred flap pattern was chosen according to the location
and size of the defect, caliber of the arterial perforator and the venae
comitantes, and length of the pedicle needed. The distally based thigh
flap was harvested using perforating vessels from either the descending
branch (Figs. 3A–D), oblique branch from the descending branch
(Figs. 4A–D), rectus femoris branch (Figs. 5A–E), and even oblique
branch from the transverse branch (Figs. 6A–D) of the lateral circum-
flex femoral artery.
Classification of the Distally Based Thigh Flap
We classified the distally based thigh flap into 3 different types
according to the origination of the perforating vessels on which the flap

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Annals of Plastic Surgery • Volume 78, Number 5, May 2017 Defect Reconstruction in the Lower Extremity

FIGURE 1. Preoperative flap design (case 17).

was based (Fig. 7). The type I flap was based on perforating vessels from 6 months to 4 years. Muscle weakness was reported by 1 patient
originating from the lateral circumflex femoral artery descending (case 11), which resolved 6 months postoperatively.
branch, which is similar to types I and III in Pan et al's3 classification
system (Fig. 7A). The type II flap was subdivided into type IIa and type DISCUSSION
IIb, which was based on the perforating vessels of the oblique branch
from the descending and transverse branches of the lateral circumflex The anatomic characteristics of the lateral circumflex femoral
femoral artery, respectively (Figs. 7B, C). The type III flap was based artery and its descending branch have been well documented.1,2,13
on the perforating vessel of the rectus femoris branch from the lateral
circumflex femoral artery descending branch (Fig. 7D).

RESULTS

Clinical Outcomes
Nineteen distally based thigh flaps were transferred for the re-
construction of lower extremity defects. All flaps survived. Moderate
venous congestion occurred in one patient (case 3), which was managed
conservatively and resolved spontaneously one week later. Preoperative
expansion of the flap was performed in 5 cases to obtain sufficient flap
width (cases 7, 8, 9, 12, and 19).
Of the 6 type I flaps, 5 flaps were based on the musculocutaneous
perforator, and 1 was based on the septocutaneous perforator. Among the
7 type IIa flaps, 4 were based on the musculocutaneous perforator and 3
were based on septocutaneous perforator. In 1 patient (case 15), who
underwent type IIa flap reconstruction, the distal portion of the de-
scending branch was found to be severely hypoplastic. The flap was
poorly perfused after clamping the rectus femoris branch and the
proximal descending branch but perfusion was immediately restored
after releasing the rectus femoris branch clamp. Therefore, we ligated
the main trunk of the descending branch, and the flap was raised
based on retrograde flow from the rectus femoris branch. The flap
survived uneventfully.
A type IIb flap was used in 1 case in which the blood supply
derived from the oblique branch that originated from the transverse
branch (case 10) (Fig. 6). The oblique branch was then divided and
anastomosed end-to-end to the descending branch which served as a
retrograde pedicle. Five type III flaps were based on the septocutaneous
perforator in 3 flaps and on the musculocutaneous perforator in the
2 flaps. FIGURE 2. (Case 17) Preoperative computed tomography
The maximum flap size was 24 cm in length and 13 cm in width. angiography showing the left lateral circumflex femoral artery
The pedicle length of all flaps ranged from 8.5 to 25 cm (mean, directly originating from the common femoral artery and
16.2 cm). The donor site was closed primarily in all cases without any sending transverse, descending, and rectus femoris branches.
complications. All flaps survived, and stable soft tissue coverage and An oblique branch can be visualized originating from the
good contour were achieved. The follow-up period after surgery ranged transverse branch.

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Liu et al Annals of Plastic Surgery • Volume 78, Number 5, May 2017

FIGURE 3. A, (case 17) Intraoperative view showing the descending branch sending the rectus femoris branch, musculocutaneous
perforating vessels supplying the anterolateral thigh region. Although the oblique branch also sends a cutaneous perforator supplying
the anterolateral thigh region, it was not chosen as the pedicle because it originates from the transverse branch. B, The motor nerve
accompanying the vascular pedicle was preserved as much as possible. C, The distally based anterolateral thigh flap was raised with
ligation and cut off the proximal portion of the descending branch. D, The flap was transferred to reconstruct the defect through a
subcutaneous tunnel with primary closure of the donor site. The flap survived without any major complications. The patient was
followed up for 6 months without tumor recurrence.

FIGURE 4. A 13-year-old girl (case 5) presented with a recurrent angiofibrolipoma on her right anteroinferior knee. A, Preoperative
flap design and location of the perforators were explored using a Doppler ultrasound probe. B, When the lateral intermuscular septum
was opened, an oblique branch was found to originate from the descending branch proximally and send a septocutaneous branch.
The latter travels through the septum between the vastus lateralis and tensor fascia latae muscles and supplies the anterolateral thigh
region. A common trunk 2.5 cm in length was isolated from the convergence point of the descending and oblique branches.
C, After ligation and cutting of the descending branch proximal to the origination point of the oblique branch, the flap was raised. The
distal portion of the descending branch was dissected until it entered the vastus lateralis muscle. D, The flap was transferred through
a subcutaneous tunnel to reconstruct the defect after tumor removal with direct donor site closure. The flap survived without any
complications. The patient was followed up for 4 years, and tumor recurrence was not observed.

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Annals of Plastic Surgery • Volume 78, Number 5, May 2017 Defect Reconstruction in the Lower Extremity

FIGURE 5. A 6-year-old boy (case 19) presented with severe postburn scar contracture of his inferolateral knee. Preoperative
mapping of perforators using Doppler ultrasound probe revealed the perforator of the rectus femoris branch from the descending
branch of the lateral circumflex femoral artery. A, Preoperative flap design and mapping of perforators in both the anterolateral and
anteromedial regions of the left thigh were performed. Pretransfer tissue expansion technique was used to aid the donor site closure.
B, A septocutaneous perforator originating from the rectus femoris branch was identified and emerged from the medial
intermuscular septum along the medial margin of the rectus femoris muscle. C, With lateral intermuscular septum traction, the rectus
femoris branch was visualized as originating from the descending branch of the lateral circumflex femoral artery. D, A distally based
thigh flap was raised by severing the descending branch proximal to the point where it sends the rectus femoris branch. E, The flap
was transferred to the defect through a subcutaneous tunnel with primary donor site closure. The flap survived postoperatively, and
the scar contracture was corrected.

In Pan et al's3 distally based anterolateral thigh flap classification
system, types I and III flaps were based on the septocutaneous and
musculocutaneous perforators from the descending branch, respec-
tively. Types II and IV flaps were based on the horizontally oriented
musculocutaneous and septocutaneous perforators from the trans-
verse branch, respectively. Although the pattern and source vessel
on which the flap is based are taken into account in this classifica-
tion, the oblique branch is not mentioned, and types II and IV flaps
may only have theoretical significance. In the present study, all poten-
tial branches of the lateral circumflex femoral system were explored
and the distally based thigh flaps were categorized as 3 different types
based on their vascular anatomy. We find that this classification system
is more clinically relevant.
We prefer to choose the point where the lateral circumflex fem-
oral artery descending branch enters the vastus lateralis muscle as the
pivot point to maximally preserve the vascular anastomoses between
the descending branch and genicular artery networks, particularly the
superior lateral genicular artery. Some authors suggested that the
pedicle may be further dissected within the vastus lateralis muscle
so as to improve the pedicle length, lower the pivot point position,
and then increase the reach of the flap.3,10,14 Anatomic variation,
limited pedicle length, and occasional venous congestion constitute

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Liu et al Annals of Plastic Surgery • Volume 78, Number 5, May 2017

FIGURE 6. Type IIb flap. (Case 10). A, A 54-year-old man presented with a burn scar contracture on his right lateral knee.
Perforators in the anterolateral thigh region were explored using a Doppler ultrasound probe and marked on the skin. A distally based
anterolateral thigh flap was chosen for reconstruction of the defect after the contracture release. B, Intraoperatively, the perforator
was found to originate from the oblique branch, while the latter arose from the transverse branch rather than the descending branch
of the lateral circumflex femoral artery. C, Conversion to a free flap. D, The flap survived completely with direct closure of the donor site.

the principal drawbacks of the distally based anterolateral thigh
flap.4,10,12 Superdrainage has been used to relieve venous congestion
of the flap.14,15 In our case series, venous congestion only occurred in
one of our early cases, in which the pedicle was dissected within the
vastus lateralis muscle. We, therefore, choose to avoid intramuscular
pedicle dissection.
Computed tomography angiography is a useful examination in
perforator flap surgery. The overall configuration of the lateral circum-
flex femoral artery can be visualized to guide the surgeon in choosing
the most favorable flap type for each individual patient.16,17 For case 9
in our series, preoperative computed tomography angiography revealed
perforating vessels of the rectus femoris branch in the anteromedial thigh
region. Although the anterolateral thigh donor site was destroyed by a
previous burn injury, a type III flap was successfully elevated for
defect reconstruction.
Harvesting a type I flap based on the perforating vessels from the
lateral circumflex femoral artery descending branch does not require
resection of other proximal lateral circumflex femoral artery
branches, and therefore donor site morbidity is minimal. Neverthe-
less, because the majority of the perforating vessels distributing to
the anterolateral thigh region are musculocutaneous perforators, te-
dious, and time-consuming, intramuscular dissection of the perforator
is sometimes required.1,2 The pedicle length of the type I flap can be
short if only distal perforators (perforator C) were present, although
the more proximally the perforating vessels originate from the descend-
ing branch, the longer the vascular pedicle. Therefore, the type I flap
may be more suitable for the reconstruction of defects of the lateral
aspect of the knee.
The perforators supplying the anterolateral thigh skin may arise
from source vessels other than the descending branch. 13,18,19
Wong et al 7 reported that the oblique branch was present in 34%
of patients. The origin of the oblique branch itself is variable
and may arise from the descending branch (36%), transverse branch
(52%), or the lateral circumflex femoral artery (6%). In rare cases, the
oblique branch may even arise directly from the profunda femoris
(3%) or femoral artery (3%). Although some authors question
whether the oblique branch indeed exists,20 the feasibility of using
the oblique branch in anterolateral thigh flap procedures has been
demonstrated.7,19,21 In our series, 7 flaps were based on the oblique
branch that originated from the descending branch. The origin of the
oblique branch is located distal to that of the rectus femoris branch;
therefore, the vasculature of the rectus femoris muscle can be maxi-
mally preserved when harvesting a type IIa flap. The conditions for
harvesting a type IIa flap include the existence of the oblique branch

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Annals of Plastic Surgery • Volume 78, Number 5, May 2017 Defect Reconstruction in the Lower Extremity

FIGURE 7. Schematic drawings illustrating the three different types of distally based thigh flaps based on the LCFA system. A, Type I
flap is based on perforators from the LCFA descending branch. The pedicle length is composed of the length of the perforator and
length from the originating point of the perforator in the descending branch to the pivot point of the flap where the descending
branch enters the block of the vastus lateralis muscle. Although morbidities after harvest of this kind of flap are probably minimal, the
pedicle is relatively shorter than that of other types of the flap. More proximally, the perforator originates from the descending
branch, longer the vascular pedicle will be. B, Type IIa flap is based on the perforators of the oblique branch from the LCFA descending
branch, when presents. The preconditions for harvesting type IIa flap include that the oblique branch exists and owns a common
trunk with the LCFA descending branch, and the common trunk has a sufficient length facilitating the easy intraoperative ligation. The
pedicle length of type IIa flap is comparatively longer than that of the type I flap because of the more proximal origination point of
the oblique branch in the LCFA descending branch. C, Type IIb flap is based on the perforators of the oblique branch derived from the
transverse branch of the LCFA. Type IIb flap is theoretically feasible. Nevertheless, harvesting this type of the flap necessitates deeply
located vascular dissection and extensive ligation of the muscular branches nourishing the muscles of the thigh. If raising this type of
the flap is mandatory, we recommend to ligate and cut the vascular pedicle and the LCFA descending branch, and then coapts
them using microsurgical anastomosis. A pedicle flap is therefore converted to a free flap so that the donor site morbidities can be
maximally reduced as illustrated in figure 6. D, Type III flap is based on the perforators of the rectus femoris branch from the LCFA
descending branch. A common incision between the anterolateral and anteromedial thigh flaps will enable the surgeon to explore the
existence of these perforators intraoperatively. Type III flap may be used as a backup option when raising a distally-based
anterolateral thigh flap. LCFA, lateral circumflex femoral artery; TB, transverse branch; DB, descending branch; OB, Oblique branch;
RFB, rectus femoris branch; P, perforator.

and a common trunk with the lateral circumflex femoral artery de-
scending branch of sufficient length to facilitate intraoperative ligation.
The pedicle length of the type IIa flap is longer than that of the type I
flap because of the more proximal origin of the oblique branch in the
descending branch. We found that the frequency of a septocutaneous
perforator originating from the oblique branch is higher than that from
the descending branch. Even if a musculocutaneous perforator is pres-
ent, it is often covered by only a small amount of muscle, such that in-
tramuscular dissection and perforator exposure is relatively easy and
straightforward.22 Because of the long length of the pedicle, easy dis-
section of the perforator, and minimal donor site morbidities of the type
IIa flap, it is our preferred flap provided that the oblique branch is
present and originates from the lateral circumflex femoral artery
descending branch.
The nomenclature of the anteromedial thigh flap is a controver-
sial issue owing to the multiple source vessels possibly supplying the
flap.23–25 Yu and Selber26 considered that only a flap based on the rec-
tus femoris branch of the lateral circumflex femoral artery can be a true
anteromedial thigh flap. Although the rectus femoris branch was found
to be consistently present, the perforating vessels from it may be
absent.26–28 To the best of our knowledge, types II and III flaps have
not been previously reported. The type III flap in our study was based
on perforating vessels from the lateral circumflex femoral artery rec-
tus femoris branch and was absolutely different from previously
reported flaps based on the descending genicular and saphenous ar-
teries.29,30 When harvesting a type III flap, the rectus femoris branch
should arise from the lateral circumflex femoral artery descending
branch, send perforating vessels to nourish the anteromedial thigh re-
gion, and form a common trunk of adequate length with the descending
branch facilitating intraoperative ligation. The rectus femoris branch is
considered to be the dominant blood supply to the rectus femoris mus-
cle and is highly recommended to be preserved when performing an an-
terolateral thigh procedure.2 Although major donor site complications,
such as muscle weakness, were not noticed in our 5 patients who
underwent type III flap surgery, the type III flap may only be used when
the perforators in the anterolateral thigh region are absent or too small
to ensure reliable blood supply or the skin of the anterolateral thigh re-
gion is unavailable owing to previous trauma. The type III flap may
serve as a potential backup option for type I and II flaps when raising
a distally based anterolateral thigh flap.

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Liu et al
The type IIb flap is based on the perforating branches from the
lateral circumflex femoral artery transverse branch, which is similar to
the type II and IV flaps in Pan et al's3 classification system. Although
theoretically this type of the flap is feasible and may provide the longest
pedicle length, harvesting a type IIb flap necessitates ligation and tran-
section of almost all the lateral circumflex femoral artery branches,
resulting in severe donor site morbidities, particularly devascularization
of the thigh muscles. As a pedicled distally based anterolateral thigh
flap, the type IIb flap may only have theoretical significance. This ana-
tomic variation is rare. In Yu's31 large series, the ALT flap perforator
originating from the transverse branch only accounts for 2% of the
cases. In our case series, perforating vessels in the anterolateral thigh
region originating from the lateral circumflex femoral artery transverse
branch were present in only 1 case (case 10). The case was finally con-
verted to a free flap with microsurgical anastomosis between the
oblique and descending branches. An alternative approach may be
converting it to a type III flap. As Yu27 has demonstrated, when there
are few or no ALT perforators, AMT perforators are usually present.
CONCLUSIONS
A distally based thigh flap based on the perforating vessels from
the lateral circumflex femoral artery system is a versatile option for
reconstructing defects around the knee. The perforating vessels on
which the flap is based may originate from the descending, oblique,
and rectus femoris branches of the lateral circumflex femoral artery.
Successful transfer of a distally based thigh flap depends on reasonable
preoperative planning, good understanding of the anatomy and physiol-
ogy of the flap, and intraoperative findings. The ideal flap type can be
chosen by taking into consideration the defect location, available donor
site, quality of the perforating vessels, and morbidities after flap harvest.
ACKNOWLEDGMENTS
The authors would like to thank Professor Peirong Yu, MD, of the
Department of Plastic Surgery, University of Texas MD Anderson
Cancer Center, for his invaluable help in writing and editing
this article.
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