University of Cambridge, Cambridge, United Kingdom.
Human Anatomy Teaching Group, Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, United Kingdom.
J Reconstr Microsurg. 2019 May;35(4):254-262. doi: 10.1055/s-0038-1670649. Epub 2018 Sep 15.
The anterolateral thigh (ALT) perforator flap is one of the most widely used flaps in reconstructive microsurgery. This study investigated a previously unexplored and clinically relevant aspect of perforator anatomy: the "box junction" (BxJn), the point at which the perforator arises from its source vessel. Negotiating the BxJn can be a challenging and time-consuming step in flap harvest, due to the neurovascular structures in the area which must be protected from injury. However, as the presence and location of these structures have yet to be clearly defined, painstaking exploration is necessary on each occasion. Knowledge of BxJn anatomy could allow surgeons to harvest the ALT flap more rapidly and safely.
We dissected 20 cadaveric thighs and identified perforators to the ALT region and investigated the neurovascular anatomy at their BxJns.
In 51 BxJns, two clinically relevant vascular structures were identified: an intramuscular artery arising from the perforator (23, 45% of cases) and a "deep" artery to the underlying muscle arising from the source vessel (29, 57% of cases). We confirmed the consistent presence of motor nerve branches and describe one previously unreported, clinically significant variation, in which the nerve to vastus lateralis crosses the BxJn (12, 24% of cases); 36, 71% of BxJns contained at least one vascular and one neural structure.
Our study confirms that the BxJn is a site of potentially complex and challenging neurovascular anatomy for the surgeon. Based on these results, we propose an algorithm to guide inexperienced surgeons in negotiating this area.
股前外侧穿支皮瓣是重建显微外科中最广泛应用的皮瓣之一。本研究探讨了穿支解剖学中一个以前未被探索过但具有临床相关性的方面：“盒交接点”（BxJn），即穿支从其源血管发出的点。由于该区域存在的神经血管结构必须避免损伤，因此在皮瓣采集时，通过 BxJn 进行操作可能是一个具有挑战性和耗时的步骤。然而，由于这些结构的存在和位置尚未明确界定，因此每次都需要进行艰苦的探索。了解 BxJn 解剖结构可以使外科医生更快、更安全地采集股前外侧皮瓣。
我们解剖了 20 具尸体大腿，确定了到股前外侧区域的穿支，并研究了其 BxJn 处的神经血管解剖结构。
在 51 个 BxJns 中，确定了两个具有临床相关性的血管结构：一个发自穿支的肌内动脉（23 例，占 45%）和发自源血管的深部动脉（29 例，占 57%）。我们证实了运动神经分支的一致存在，并描述了一种以前未报道的、具有临床意义的变异，即股外侧肌神经穿过 BxJn（12 例，占 24%）；36 例（71%）BxJn 至少包含一个血管和一个神经结构。
我们的研究证实，BxJn 是外科医生在处理该区域时可能面临复杂和具有挑战性的神经血管解剖结构的部位。基于这些结果，我们提出了一种算法，以指导经验不足的外科医生在该区域进行操作。
