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Tuinder et al. Plast Aesthet Res 2024;11:38 https://dx.doi.org/10.20517/2347-9264.2024.40 Page 3 of 10

volume of tissue that can be harvested for reconstruction, but the test frequently overestimates the amount
of tissue that can be safely taken while still attaining adequate donor site closure. Accordingly, caution
should be taken during preoperative markings and the reconstructive surgeon should be cautious when
choosing the specific flap size based solely on clinical examination, as relying only on the pinch test may
increase the chance of wound dehiscence.

For preoperative markings, the following steps can be followed [Figure 1]:

1. A straight vertical line is drawn from the anterior superior iliac spine (ASIS) to the lateral border of the
patella: this indicates the anterior border of the flap and also the course of the lateral femoral cutaneous
nerve (LFCN).

2. A second line is drawn horizontally, perpendicular to the first line and at the height of the pubic bone.

3. These lines can be used as guidance to indicate the location of the perforators, as they can usually be
identified lateral to the vertical line, surrounding the horizontal line, and therefore located on the lateral
thigh.

4. A handheld Doppler ultrasound is used to preoperatively identify suitable perforators, guided by previous
perforator mapping through radiological imaging. The distance of the perforator from the SIAS is then
noted.

The perforator is often located more anteriorly than the preoperatively marked location due to the
curvature of the thigh [Figure 2]. As such, this should be kept in mind during flap dissection as the pedicle
will be encountered earlier than expected.

RELEVANT VASCULAR ANATOMY
[9]
Initially, the TFL flap was based on musculocutaneous perforators . Following more investigation of its
clinical anatomy, septocutaneous perforators have been introduced for microsurgery. These septocutaneous
perforators are located either in the anterior septum or in the posterior septum between the TFL and the
surrounding muscles. The anterior septum is located between the rectus femoris/vastus lateralis muscle and
the TFL. The posterior septum is located between the TFL and the gluteus medius muscle. The
septocutaneous perforators originate from the ascending branch of the lateral circumflex femoral artery. In
our clinic, we use the septocutaneous perforators located in the posterior septum.

Previous studies have found the mean number of septocutaneous perforators to be approximately 1.5-1.8,
ranging from 1-3 perforators per thigh. More than half of the perforators were found between 8-12 cm from
[8,9]
the ASIS on imaging . The perforators are considered suitable when they have a sufficient caliber, and
their length is a minimum of 6 cm. This is feasible, as the pedicle length often ranges between 6-12.4 cm [8-10] .
The mean diameter of the septocutaneous perforators is approximately 1.5 mm, ranging between 0.5-3
mm [11-14] .

OPERATIVE TECHNIQUE
Throughout the entire procedure, the patient is positioned in the supine position with the arms tucked. A
two-team approach is advisable. In this way, the plastic surgeon can harvest the flap while the resident or
the second plastic surgeon performs dissection of the internal mammary vessels in the meantime. In