Adductor Magnus Perforator Flap Revisited: An Anatomical Review and Clinical Applications
Zachary M. Hurwitz, M.D., Richard Montilla, M.D., Mustafa Akyurek, M.D., PhD.
University of Massachusetts, Worcester, MA, USA.
The adductor magnus musculocutaneous perforator flap is a medial thigh flap that is often overshadowed by its anatomical neighbor, the gracilis flap. It has been shown to have a large, reliable pedicle and associated skin paddle. Few reports have been published describing the use of this flap as a local or free tissue transfer. The purpose of this study is to revisit and further characterize the anatomy of this extremely versatile and underutilized flap.
Twelve cadavers (n=24 thighs) were dissected to identify the musculocutaneous perforators from the adductor magnus muscle that supply the skin of the posteriomedial thigh. The vascular anatomy was studied using multiple modalities. Latex injection demonstrated the configuration of the perforators and their respective origins. Dye injection into the perforating vessel was performed to delineate the cutaneous territories. Three-dimensional CT angiogram was performed to visualize the arborization and anastomoses of the musculocutaneous perforators. Based on the anatomic data, a local V-Y advancement flap supplied by the underlying perforating vessels was designed. A total of eight patients (n=10 flaps) underwent reconstruction of locoregional defects.
Anatomical studies confirmed the presence of multiple musculocutaneous perforators that travel through the adductor magnus muscle and course in parallel obliquely in a posterior-inferior direction. We confirmed that the previously described perforator (Angrigiani) is reliably found approximately 8 cm distal to the groin crease and 2 cm posterior to the posterior border of the gracilis muscle. We discovered that it is consistently accompanied by a separate perforator located 2 cm distally. Minimal dissection into the muscle revealed a Y-configuration of these two perforators (Image 1). This configuration was present in 100% of the cadaveric dissections and is supplied by the first medial branch of the profunda femoris artery. CT angiograms depicted vascular architecture and arborization of the perforators supplying the flap. Clinical experience showed that complete flap survival was noted in all of the cases.
The adductor magnus perforator flap is a reliable flap, offering robust blood supply, consistent vascular pedicle with an extensive skin territory. Our anatomic work revealed the consistent presence of two proximal perforators in the medial thigh that are linked by a Y- configuration intramuscularly which provides enhanced blood supply to a local V-Y advancement flap design. We also found that there are several slightly smaller distal perforators that originate from the profunda femoris and the superficial femoral artery. Their length and parallel posterior-inferior course are ideal for their preservation when designing a local advancement flap to cover regional defects. The location of the skin paddle on the proximal medial thigh allows for minimal donor site morbidity as it can be closed primarily with a V-Y advancement flap design, obviating the need for skin grafting.
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