HOI CHAN THUONG CHINH HINH VIET NAM - HOI NGHI KHOA HOC TOAN QUOC LAN T H U IX
CAC DAC DIEM GIAI P H A U IJffJG DUNG CUA VAT OA CAN DUI TRlTCTC NGOAI
Pham Thi Viet Dung*, Tran Dang Khoa**, Tran Thilt Son*** va Cong su
TOM TAT
Vat diii trUdc ngoai (DTN) dugc Song phat hien nam 1984 va den nay da cd rat nhieu nghien cii'u ve giai phau va irng dung tren lam sang. Bai bao nay trinh bay ket qua nghien cu'u giai phau vat DTN tren 30 tieu ban xac ngUdi Viet va tren 50 trUdng hgp lam sang. Nghien cu'u tren xac va tren benh nhan cho thay nhanh xudng ciia dgng mach mu diii ngoai gap trong 100% sd trUdng hdp. Mac dii nguyen iiy nhanh xudng khdng hang djnh nhUng sU tdn tai hang dinh ciia nhanh xudng va nhanh xuyen khang dinh vai trd ciia no tren lam sang. Chieu dai trung binh nhanh xudng 9.43cm. Chieu dai nay dii de thiet ke chuyen vat cd cudng lien xuoi dong hoac vat tu do. 100% nhanh xudng cd vdng ndi thdng vdi mang mach tren gdi bang nhanh tan ciia nhanh xudng vdi dgng mach gdi tren ngoai. Day la cd sd giai phau de sir dung vat dUdi dang ngUdc dong. Tir nhanh xudng cho ft nhat mgt nhanh xuyen ra da viing trUdc ngoai diii. Vi tri ra da cua cac nhanh xuyen dUdc ddi chieu vdi khdang 16 ciia dill. Cac nhanh xuyen trong khoang 8,9 va 11,12 kha hang dinh. Nhd sU phan chia phong phu ciia nhanh xudng cho da va cd rdng ngoai, sU tUdng doi hang djnh ciia vj trf nhanh xuyen, vat DTN dUdc thiet ke dUdi nhieu hinh thirc, da dang ve thanh phan de phuc vu cho cac muc dfch tao hinh khac nhau.
Tit khoa: Giai phau u'ng dung, mach xuyen, vat diii trUdc ngoai.
SUMMARY
Surgical Anatomical Aspects of Anterolateral Thigh Flap in Vietnameses
Since the discovery in 1984, Alterolateral thigh flaps are increasingly widely used. Many researchs were be performed on many different aspects. The authors present result on anatomic study on 30 thighs of Vietnamese cadavers and on 50 clinical cases. 100% of the cases have descending branches. Although the anatomic variations of the origin of the descending branch, but the constant existence of descending branch and perforator confirm their role on the clinic.
Average length of descending branches is 9.43cm. Length is sufficient to design pedicle alterolateral thigh island flap or free flaps. 100%
descending branch is connected with vascular network of knee joint. This is the basis of recontraction for soft tissue defect of knee and third lower extremity. Length of thigh is divided into 16 spaces. There is at least one perforator at the alterolateral thigh area. Position of the perforator on skin is often at 8*, 9"^ space and 11*, 12'" space. Clinically, all of 50 cases are designed on space 8'" and 9'". Depending on the variation of the descending branch and perforator, ALT flaps are desinged and used with the diversity for many clinical purposes.
Keyword: Surgical anatomy, perforators, anterolateral thigh flap. , . , ,,
* B6 mdn Phdu thudt Tgo hinh, Truang Dgi hoc Y Hd ndi
** Khoa Phdu thudt tgo hinh Benh vien Xanh Pdn Hd ndi
*** Bd mdn Gidiphdu, Truang Dgi hoc YKhoa Phgm Ngoc Thgch
Y HOC VIET NAM THANG 10-SO 2/2010
I. O A T V A N O E 1 - * ; >
Nhiing khuyit hdng ldn, phiic tap ciia co the do cac nguyen nhan khac nhau (chin thuang, bdng, khdi u)...rit thudng gap.
Trong khi dd viec phuc hdi hinh the va chiic nang do tdn khuyet gay ra, tra lai cugc sdng binh thudng cho benh nhan vin dang la tbach thiic ldn ddi vdi cac phiu thuat vien. Mdt trong nhiing chat lieu dang dugc nghien ciiu ling dung trong tao hinh hien nay la vat diii trudc ngoai. Day la vat da can dua tren nhanh xuong cua ddng mach mii diii ngoai. Vat dugc Song md ta lan dau tien nam 1984. Tir do den nay, nhd cd nhieu uu diem nen vat ngay cang dugc sir dung rdng rai tren the gidi. Ci trong nudc ciing da cd mdt sd co sd tao hinh budc dau sir diing vat. Tir thang 1 nam 2007 den thang 2 nam 2010, khoa Phau Thuat Tao Hmh benh vien Saint Paul da tiln hanh nghien eim sir dung vat did trudc ngoai tu do tao hinh cho nhiing khuyet ldn ciia co the.
Muc tiiu nghiin cieu:
1. Tim hieu dac diem giai phau ciia vat diii trudc ngoai 1^^ ,^^3t"i n
2. Ung dung nhiing dac diem ciia vat tren lam sang
II. 001 TUpNG VA PHUONG PHAP NGHIEN COU 1. Doi tuang nghiin cieu " ' ^
Nghien ciiu dugc tien hanh tren 15 xac khd (30 mau xac) dugc phau tich tai bd mdn Giai Phiu trudng Dai Hgc Y khoa Pham Nggc Thaeh va 50 benh nhan cd khuyet phan mlm ldn tai cac viing cua co the do cac nguyen nhan khac nhau dugc phau thuat tai khoa Phiu Thuat Tao Hinh benh vien Saint Paul. 45/50 trudng hgp vat dugc sir dung dudi dang tu do trong dd cd 13 trudng hgp tao hinh viing diu mat cd, 15 trudng hgp che phu khuyit phin mem chi tren, 17 trudng hgp khuyit phin mlm cing ban chan. Ivat duoc sir dung dudi dang cudng liln xudi
ddng de tao hinh am dao va 4 vat dugc sii dimg dudi dang cudng lien ngugc ddng che phii khuyet phan mem gdi va 1/3 tren cang chan cimg ben.
2. Phuang phdp nghiin cieu
- Tren xac: Phau tich vat da viing trudc ngoai diii, khao sat nguyen uy nhanh xudng, do chieu dai, vi tri ra da va loai nhanh xuyen.
- Tren benh nhan: Vat diii trudc ngoai dugc chuyen tdi noi tdn thuong de tao hinh che phii, ddn hoac dimg hinh trong nhung trudng hgp khuyet phan mem ldn. Vat dugc sir dung vdi cac thanh phan khac nhau cho cac muc dich khac nhau. Vat dugc sir dung dudi dang vat tu do hoac cuong liln. Tit ca cac benh nhan deu dugc kham danh gia tdn thuang, xac dinh sd lugng, vi tri nhanh xuyen bang sieu am Doppler va tren co sd dd thilt ke vat trudc phau thuat.
III. KET QUA NGHIEN CQU
1. Dgc diim gidiphdu vgt diii tru&c ngodi Tren xac, nghien ciiu cho thay 100%) sd trudng hgp cd nhanh xudng trong dd 33.3%
cd nhanh xudng phu. Nguyen uy ciia nhanh xudng kha thay ddi. Trong 30 vat, gap nhieu nhat la nhanh xudng xuat phat tir DM mii diii ngoai (80%)), cac trudng hgp cdn lai nhanh xudng tach ra tir ddng mach dui hoac ddng mach diii sau. Nhanh xuyen xuat phat tir nhanh xudng cd mat trong tat ca cac trudng hgp. Nhanh xuyen can da chiem 38,24%, va nhanh xuyen co da, chiem 61,76%. Trung binh cd 2.83 nhanh/vat (2-4 nhanh). Cac nhanh xuyen phan bd dgc theo true mach la dudng ndi gai chau trudc tren vdi diem giiia bd ngoai xuong banh che. 25/30 vat (83.33%)) cd mat nhanh xuyen can hoac xuyen co trong vdng trdn trung tam (vdng trdn ban kinh 3 cm tam la trung diem cua true vat). Chia chieu dai diii lam 16 khoang thi vdng trdn nay tuong iing khoang thii 8,9.
HOI CHAN THUONG CHINH HINH VIET NAM - HOI NGHj KHOA HOC TOAN QUOC LAN T H U IX
23/30 vat (76.67%)) cd nhanh xuyen co di ra da d khoang diii thii 11,12.
2. Kit qud lam sdng
Tren 50 benh nhan gap 93 nhanh xuyen trong dd cd 57(61.3% nhanh xuyen can da, 36(38.7%) nhanh xuyen co da. 40/50 trudng hgp cd nhanh xuyen nam trong vdng trdn tnmg tam (tuong iing khoang diii thii 8,9), nhiing trudng hgp cdn lai nhanh xuyen nam cao ban d phia tren vdng trdn (tuong iing khoang dui thir 6,7 hoac khoang diii thir 10).
85% nhanh xuyen nay dugc phat hien tren sieu am Doppler . Gia tri chan doan dung ciia phuang phap la 76%), gia tri chan doan duong tinh la 87.5%). Chieu dai cudng mach trung binh la 9.34cm, ngan nhat la 5 cm, dai nhit la 15 cm. Dudng kinh cudng mach trung binh la 1.57cm. Kich thudc vat trung binh
17.6x9.6cm vdi do day trmig binh la 1.24cm.
45 trong sd 50 trudng hgp noi cho vat ddng true tilp. 15 trudng hgp cdn lai ghep da thi 2.
Theo ddi ket qua cd 5 trudng hgp vat bi hoai tir toan bd trong dd 4 trudng hgp vat tu do bi tac tinh mach, 1 trudng hgp vat cudng lien xudi ddng cudng vat khdng dugc giai phdng het gay keo cang mach va hematome d dudng ham gay tac ddng mach, 2 trudng hgp vat hoai tir ban phan. 43 trudng hgp cdn lai vat sdng tdt, dap ung dugc cac yeu cau ve chiic nang che phu, tram d loet, dimg hiiih...ve mat tham my, nhin chung, benh nhan kha hai ldng tuy vat hoi khac mau so vdi da viing lan can. Tat ca cac trudng hgp noi cho vat lien tdt, khdng anh hudng tdi chirc nang van ddng diii.
IV. BANLUAN
1. Dgc diim cuong mgch
Nguyen uy nhanh xudng bien ddi kha da dang: trong nghien eim 30 miu xac cd 25 mau nhanh xudng xuat phat tir ddng mach mQ diii ngoai, cac trudng hgp khac nhanh
xudng xuit phat tir ddng mach diii chung, ddng mach dui ndng hoac diii sau. Tuy vay, ludn tim thiy nhanh xuyen xuit phat tir nhanh xudng chay ra ciing trudc ngoai dui.
Viec cip mau cho vat dua vao nhanh xuyen can da, ca da hoac ca 2. Nhanh xuyen can da hay CO da chi cd y nghia trong qua trinh bdc vat. Vdi nhiing nhanh xuyen co da, khi phiu tich nhanh xuyen de bi tdn thuong hon, yeu cau phau thuat vien phai ti mi. Do do thdi gian bdc vat lau hon. Ngugc lai, loai nhanh xuyen khdng anh hudng tdi siic sdng va su cap mau cho vat.
Theo sd lieu ciia chiing tdi, sd nhanh xuyen trung binh mdi vat tren benh nhan la
1.86, it nhat la 1 nhanh, nhieu nhat la 3 nhanh cac ket qua tuong tu cua Kimata la 2.31, Luigi la 2.1, nhd hon cua Sung Weon Choi la 4.2 (tir 0 den 8 nhanh). Nghien cuu tren xac gap nhieu ban tren lam sang khoang 1 nhanh mdi vat do tien hanh khao sat tren toan bg chieu dai diii. Nhu vay, khi lay vat cang ldn, kha nang gap nhanh xuyen cang cao. Thuc te tren 50 trudng hgp ciing khdng gap trudng hgp nao that bai do khdng tim thay nhanh xuyen phu hgp.
Hon niia, theo nghien ciiu tren xac, cac nhanh nay kha thudng gap d vi tri khoang diii thii 8,9 va 11,12. Tren lam sang lai cd the xac dinh sd lugng vi tri va sd lugng nhanh xuyen mdt each dang tin cay nhd sieu am Doppler trudc md. Nhd dd nhdm nghien ciiu da thiet ke vat tuong ddi phii hgp vdi tdn thuong:
chia vat thanh 2 dao da tuong ddi tach biet dua tren 2 nhanh xuyen khac nhau xuat phat tir cimg 1 cudng mach, lay nhanh xuyen xa hoac gan tiiy yeu cau chieu dai cudng mach...
2. Dgc diem vgt diii tru&c ngodi trin lam sdng
Tren thuc te, so vdi cac vat khac, vat diii trudc ngoai la ngudn cung cip sd lugng da.
Y HOC VIET NAM THANG 10 • SO 2/2010
can rat ldn. Trung binh kich thudc vat 17.6x9.6 cm. Vat ldn nhit la 18xl4cm chi dua tren 1 nhanh xuyen vin sdng rat tdt sau khi chuyen tdi noi nhan. Dilu nay chiing td cd the lay vat ldn hon niia khi can thiet. Tren thuc te 50 benh nhan, vat du ldn de che phii nhiing khuyit hdng phin mem ldn tren khap cac vimg ciia co the, tham chi la dii ldn de dimg hinh khdng gian 3 chieu ciia ca mdt phiic hgp CO quan miii, ma va mdt ben mdi tren. Trong sd eac benh nhan chiing tdi gap tir thang 1 nam 2007 den nay, vat dap iing nhu cau ve khdi lugng cho tao hinh trong hau bet cac trudng hgp tdn thuong trir 3 trudng hgp khuyet phan mem ldn hau nhu chiem 2/3 cang ban chan do chan thuong. Trong 3 trudng hgp nay vat dugc sir dimg uu tien cho vimg Id xuong, nhiem trimg va chiu ti de. Vimg tdn thuong cdn lai dugc ghep da bd sung.
Chieu day trung binh vat la 1.24cm (tir 1 din 2 cm). Vdi chieu day nay vat kha phii hgp cho viec tao hinh viing dau mat cd ciing nhu vimg ban chan. Ngoai ra cd the thay ddi chilu day vat bing each liy them dao co rdng ngoai hoac lam mdng vat dudi kinh hiln vi phau thuat tiiy theo tdn thuong. Trong nhdm nghien ciiu cd 18 vat dugc lam mdng. Nhiing vat sau lam mdng song tdt, kha mlm mai de cd thi udn theo khdng gian 3 chilu tao hinh CO cam, che phu mdm cut ban tay, tao hinh thay thi phin mlm ngdn tay, tham chi t^o hinh ke ngdn. Sau 6 thang theo ddi nhan thiy vat van giii dugc do mlm, mdng, tao dudng viin kha tdt. Chilu day vat trung binh 1.24 Cling rit thuan lgi cho tao hinh ddn. Dac biet la nhiing tdn thuong teo lep viing mat. Khi dd vat dugc liy bd thugng bi tao thanh chat ligu ddn chi bao gdm trung bi va mo. Chiing tdi dung vat ddn cho 3 benh nhan teo lep vimg mat va thai duong. 1 trudng hgp vat bi hoai tu do hematome chen ep gay tic tinh mach. 2 trudng hgp cdn lai vat van giu nguyen khoi lugng sau 6 thang theo ddi.
Theo bao cao ciia Guelinck qua 2 trudng hgp tai tao dudng vien mat trong hdi chiing Barraquer- Simon (dac tnmg bdi su loan dudng teo lep md md dudi da d nira tren co the, bat dau tir mat rdi lan den than minh) va ciia Xiancheng Wang qua 7 trudng hgp teo lep nira mat trong hdi chiing Parry- Romberg (dac trung bdi su teo lep tien trien cham ciia md mem va xuong d 1 ben mat). Tac gia sir dung vat trung bi md ALT dem lai ket qua tdt trong viec ddn tai tao dudng vien mat. Cac tac gia nay ciing nhan xet vat dn dinh sau 1 nam theo ddi.
Nhd cau tnic giai phau vdi sd nhanh xuyen xuat phat tir nhanh xudng trung binh 2.83 nhanh lai cd sieu am Doppler xac dinh vi tri va sd lugng nhanh xuyen trudc phau thuat vat cd the tach lam 2 phan tuong ddi ddc lap dua tren 2 nhanh xuyen khac nhau cimg tach ra tir nhanh xudng (vat phiic hgp).
Dieu nay lam cho viec sir dung vat trd nen linh boat hon trong cac trudng hgp cd 2 vi tri tdn thuong gan nhau nhung tuong ddi tach biet. Chiing tdi da sir dung vat dang nay cho 2 benh nhan. Trong dd, 1 benh nhan bi hoai tir toan bd da, niem mac ma cimg xuong ham dudi. Vat dugc chia thanh 2 dao da up ngugc vao nhau de ddng thdi tao hinh thay the da va niem mac ma. Mdt trudng hgp benh nhan bi bdng nguc va cam cd. 2. viing tdn thuong nay ngan each nhau bang mdt dai da lanh vimg hdm ire. De bao tdn tdi da viing da nay each thich hgp nhat la diing vat phiic hgp. Khdng phai noi cho nao ciing dam bao yeu cau nay.
Chi cd nhiing vat dua tren he thdng DM nguc lung va DM mii diii ngoai mdi cd kha nang cho day dii cac thanh phan ciia vat: can, da, CO va tham chi ca xucng. Hon niia, cac thanh phin ciia vat tuong ddi ddc lap. Tuy vay, cd nhugc diem la phai hi sinh nhilu d noi cho vat va ddi hdi cac phau thuat vien phai cd ky nang phau tich. Mdt sd tac gia nhu Wei Chao Huang, Ju te Lin ciing da bao cao sir dung
HOI CHAN THUONG CHJNH HINH VIET NAM - HOI NGHI KHOA HOC TOAN QUOC L A N T H U I X
thanh cdng vat phiic hgp cho tao hinh viing ban tay va ban chan.
Tren lam sang, cd the bdc vat vdi cudng dai (tir 5 den 15 cm, trung binh la 9.34cm), khiu kinh ldng mach kha ldn (dudng kinh mach trung binh la 1.57cm) phii hgp vdi mach mat, mach thai duong, mach quay, tru... Hon nira, nhd cd cudng dai, khi d dang tu do, vat cd the chuyen den tao hinh bat ki viing nao ciia co the. Khi d dang cudng lien, vat cd the vuon tdi tan vimg ben, day chau.
Mdt sd tac gia: Muhmet Mutaf, Perong Ju, Seng Kang Luo ciing da sir dung dudi dang cudng lien tao hinh duong vat, am dao va tang sinh mdn.
Va mdt yeu td thuan lgi niia khi sir dung vat ALT d vimg nay la su da dang va linh boat trong hinh thiic sir dung. Vat cd the dugc chuyen vdi cudng ngugc ddng che phii viing gdi. Khao sat tren xac thay rang 100%
nhanh xudng tan bet bang each ndi vdi ddng mach gdi tren ngoai va trudc khi tan hit nhanh xudng cdn phan rat nhilu nhanh cho CO thang diii va co rdng ngoai. Day chinh la CO sd dam bao cap mau phong phii cho vat ngugc ddng. Trong sd 50 benh nhan cd 4 trudng hgp khuyet viing gdi va 1/3 tren cang chan vat dugc sir dung dudi dang vat dao ngugc ddng. Ca 4 trudng hgp nay vat diu sdng hoan toan. Thep ddi ket qua xa vet md lien tdt, mau sac, do day vat kha phu hgp.
Benh nhan di lai binh thudng va hai ldng vl ket qua phiu thuat. Mat khac, nlu liy vat cimg vdi nhanh xuyen d cao, dac biet trong trudng hgp nhanh xuyen xuit phat tir nhanh ngang, cudng mach cd thi vuon tdi 1/3 tren, tham chi la 1/3 giiia cing chan.
Tuy vay, vat cd mdt nhugc dilm khi tao hinh phu ma khdng thiy cac tac gia nhic tdi, dd la su bien ddi mau sic tren vat. Dac biet khi sir dung vat tao hinh che phii vimg mat.
Trong 13 vat vimg mat cua chiing tdi, 1 vat bi
"bach bien", 1 vat tang dam sic to gay ra su
tuong phan rd ret. Day la khd chiu duy nhat ciia benh nhan sau tao hinh ma khdng the khic phuc dugc. Vl phuong dien nay, cd le vat plastyma, vat thugng ddn, vat Trung Qudc... cd uu thi hon. Mac dii vay,
V. KET LUAN
Vat diii trudc ngoai bien ddi da dang ve nguyen uy nhanh xudng nhung su cd mat cua cac nhanh xuyen la tuong ddi hang dinh.
Nhin chung vat cd kich thudc ldn, do day thich hgp de ddn, phii hay dimg hinh va la chat lieu cd the bien ddi thanh phan phii hgp theo timg trudng hgp, phuc vu cho cac muc dich tao hinh khac nhau, tren khip cac viing ciia CO the. Vat cd cudng dai, dudng kinh ldng mach ldn thich hgp vdi chuyen vat tu do Cling nhu sir dung dudi dang cudng liln ...
Mac dil cd nhugc diem hoi khac mau khi tao hinh phu viing dau mat cd song hien nay, khi cac phau thuat vien van dang tren dudng di tim chit lieu ly tudng cho tao hinh, vat ALT van la lua chgn xung dang trong nhiing trudng hgp tdn khuyet ldn.
TAI UEU THAM KHAO
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Chung(2006), "Reconstmction of Thumb Loss Complicated by Skin Defects in the Thumb-index Web Space by Combined, Transplantation of Free Tissues", The Journal of Hand Surgery, 31A (2), pp. 236-245 2. Derrick T. Lin, George L. Coppit and
Brian B. Burkey(2004), " Use of the anterolateral thigh flap for reconstmction of the head and neck". Current Opinion in Otolaryngology & Head and Neck Surgery,
12,pp. 300-304
3. Felici.N, Felici.A (2006), "A new phalloplasty technique: the free anterolateral thigh flap phalloplasty", Joumal of Plastic,
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Reconstructive & Aesthetic Surgery, 59, pp.
153-157
4. Goulinckx.P.J. and Sinsel. N.K.(2000), "
Facial contour restoration in Barraquer- Simon syndrome using two free Anterolateral Thigh Flap", Plastic and Recontructive Surgery, 105(5), pp. 1730-1736
5. Hopman G.A.J, Jongh G.J, Hartman E.H.M, Spauwen P. H.M(2003), "Flow- through anterolateral thigh flap reconstruction as a salvage procedure", Eur J Plast Surg, 26, pp. 363-366
6. Isao Koshima, Misako Fujitsu, Shigeko Ushio, Narushi Sugiyama, and Shuji Yamashita(2005), "Flow-Through Anterior Thigh Flaps with a Short Pedicle for Reconstmction of Lower Leg and Foot Defects", Plast. Reconstr. Surg, 115, pp. 155-161
7. Javaid. M and Cormack. G. C(2003),
"Anterolateral Thigh free flap for complex soft tissue hand reconstructions", Joumal of Hand Surgery (British and European), 288(1), pp. 21-27
8. Luigi Valdatta, Stefania Tuinder, Mara Buoro, Alessandro Thione, Angela Faga, Reinhard Putz(2002), "Lateral Circumflex Femoral Arterial System and Perforators of the Anterolateral Thigh Flap: An Anatomic Study", Annals of Plastic Surgery, 49 (2), pp.
145-150
9. Mehmet Mutaf, Dag'han I_sik, O" mer Bulut and Berker Bu"yu"kgu"ral (2006), "Tme One- Stage Nonmicrosurgical Technique for Total Phallic Reconstmction", Annals of Plastic Surgery, 57(1), pp. 100-106
10. Robert H. Caulfield, Atoussa Maleki- Tabrizi, Jeremy Birch and Venliat Ramakrishnan(2008), "Salvage of Finger Length in Septicemic Necrosis Using 3 Free Flaps From a Single Anterolateral Thigh Donor Site", Annals of Plastic Surgery, 60 (6), pp. 623-625
11. Roberto Adani, Luigi Tarallo, Ignazio Marcoccio, Riccardo Cipriani, Chiara Gelati,
and Marco Innocenti(2005), "Hand Reconstmction Using the Thin Anterolateral Thigh Flap", Plast. Reconstr. Surg, 116, pp. 467-173 12. Peirong Yu, James R. Sanger, Hani S.
Matloub, Arun Gosain and David Larson(2002), "Anterolateral Thigh Fasciocutaneous Island Flaps in Perineoscrotal Reconstruction", Plast.
Reconstr. Surg, 109, pp. 610-616
13. Shengkang Luo, Wassim R affoul, Piaget.
F and Daniel V. Efloff(2000). "Anterolateral Thigh Fasciocutaneous Flap in the Difficuh Perineogenital Reconstruction", Plastic and Reconstructive Surgery, 105 (1), pp. 171-173 14. Shyh-Jou Shieh, Haw-Yen Chiu, Jui-Chin
Yu, Shin Chen Pan, Sen-Tien Tsai, and Ching-Liang Shen(2000), "Free Anterolateral Thigh Flap for Reconstruction of Head and Neck Defects following Cancer Ablation", Plastic and Reconstructive Surgery, 105 (7), pp. 2349-2357
15. Sung-Weon Choi, Joo-Yong Park, Mi-Sun Hur, Hyun-Do Park, Hyun-Joo Kang, Kyung-Seok, Hee-Jin Kim(2007), "An Anatomic Assessment on Perforators of the Lateral Circumflex Femoral Artery for Anterolateral Thigh Flap", The Joumal of Craniofacial, 18 (4), pp. 866-871
16. Wei-Chao Huang, Hung-Chi Chen, Vivek Jain, Morten Kilda, Yu-De Lin, Ming- Huei Cheng, Shye-Horng Lin, Yi-Chieh Chen, Feng-Chou Tsai and Fu-Chan Wei(2002), "Reconstruction of Through-and- Through Cheek Defects Involving the Oral Commissure, Using Chimeric Flaps from the Thigh Lateral Femoral Circumflex System", Plast. Reconstr. Surg, 109, pp. 433-441 17. Yoshihiro Kimata, Kiyotaka Uchiyama,
Satoshi Ebihara, Takashi Nakatsuka, Kiyonori Harii(1998), "Anatomic Variations and "Technical Problems of the Anterolateral Thigh Flap: A Report of 74 Case", Plastic Recontruction Surgery, 102, pp. 1517
