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The anterolateral thigh (ALT) flap has achieved popularity recently for free-flap reconstruction of intraoral defects following excision of squamous cell carcinoma. We have assessed the feasibility of the ALT flap as a free flap for oral lining and the potential use of the thinned ALT flap in a one-stage reconstruction. We used the ALT flap to reconstruct the oral cavity in 18 consecutive patients between December 2000 and December 2001 following intraoral resection of squamous cell carcinoma. Twelve patients underwent reconstruction using a standard ALT flap, four patients received a thinned ALT flap in a one-stage procedure, one patient received a standard ALT flap in combination with a fibula flap and one patient received a combination of a standard ALT flap and vascularised iliac bone. There were no complications in any of the 14 cases in which a standard ALT flap was used. Two of these flaps were thinned subsequently as secondary procedures. Of the four thinned ALT flaps, one flap failed completely and two flaps experienced partial necrosis. In all but one case the donor site was closed directly with minimal donor-site morbidity. The ALT flap is a versatile flap that can be used in combination with other flaps for more complex defects with minimal donor-site morbidity and is a useful alternative in the armamentarium of the head and neck surgeon. Thinning of the flap is best performed as a secondary procedure, should it be required.
Subsequent reports confirmed the variations in the vascular anatomy, and it was found that the blood supply of the ALT is based on the septocutaneous or myocutaneous perforators or both.
Free combined composite flaps using the lateral circumflex femoral system for repair of massive defects of the head and neck regions: an introduction to the chimeric flap principle.
It may also be combined with neighbouring tissues, such as vascularised vastus lateralis, ilium and tensor fascia lata, which is particularly important in reconstructing large composite defects in the head and neck.
Free combined composite flaps using the lateral circumflex femoral system for repair of massive defects of the head and neck regions: an introduction to the chimeric flap principle.
Free combined composite flaps using the lateral circumflex femoral system for repair of massive defects of the head and neck regions: an introduction to the chimeric flap principle.
The use of the thinned ALT flap as a one-stage intraoral reconstruction has not been assessed previously.
1. Patients and methods
Between December 2001 and December 2002, we used the ALT flap to reconstruct the oral cavity in 18 patients following intraoral resection of squamous cell carcinoma. There were six women and 12 men, with a mean age of 66 years (range: 47–81 years). Nine patients had tumours of the anterior floor of the mouth or anterior tongue (Fig. 1) and nine had posterior tumours of the retromolar area, palate or posterior tongue; 17 patients had reconstruction following surgery for primary disease and one had recurrent disease. The pathological staging was T1 in four patients, T2 in six patients, T4 in seven patients and Tx in one patient. Twelve patients had reconstruction with a standard ALT flap, four patients received a thinned ALT flap, one patient received a standard ALT flap in combination with a vascularised fibula and one patient received a standard ALT flap in combination with vascularised iliac bone.
Fig. 1(A) Intraoral reconstruction with a standard ALT flap following resection of a T2 anterior-tongue tumour. (B) Postoperative result at three months showing a bulky flap that required thinning as a secondary procedure. (C) Appearance of the ALT flap three months after thinning.
In dissecting the standard ALT flap, a line was drawn from the anterior superior iliac spine to the midpoint of the lateral border of the patella. An incision was made medial to this in the middle third of the line, down to the plane immediately below the deep fascia. The flap was then undermined medially until rectus femoris was visible beneath the fascia. The fascia was then incised over rectus femorus and raised laterally toward the intermuscular septum between the rectus femoris and the vastus lateralis muscles (Fig. 2) . Medial displacement of the rectus femoris muscle allowed exploration of the intermuscular space, to expose either the septocutaneous perforator (if present) or the beginning of the myocutaneous perforator. All branches from the perforators were clipped, using an Ethicon Ligaclip MCA staple gun, and divided. Terminal branches of the descending or transverse branch of the lateral circumflex femoral artery (LCFA) were divided by the same method, distal to the most distal perforating branch. The main pedicle was traced to the origin of the descending or transverse branch of the LCFA and divided as close as possible to the origin from the main vessel. The lateral border of the skin paddle was cut once the pedicle had been completely dissected. Cutting the skin paddle at this time allowed consideration of the defect and positioning of the pedicle for the anastomosis. In all cases the flaps were designed so as to facilitate donor-site closure (Fig. 3) . In the last four cases a stealth pattern was used (Fig. 4) . The wings of the stealth flap were designed according to the orientation and position of the defect and were predominantly used in reconstruction of floor-of-the-mouth defects. All thin flaps were thinned to within 3 mm of the subdermal plexus, and, in all cases, a cuff of fascia 2 cm from the main perforator was preserved. Any perforators visualised deep to the fascia, outwith this cuff of tissue, within the subcutaneous tissue were preserved.
Fig. 2Anatomical relations of the lateral circumflex femoral artery.
The cutaneous perforators of the ALT flap usually arise from the descending branch of the LCFA. These cutaneous perforators can be classified as either septocutaneous or myocutaneous. In our series, 10 flaps had one perforator, seven flaps had two perforators and one flap had three perforators (average: 1.5 perforators); 14 perforators (52%) were myocutaneous and 13 (48%) were septocutaneous.
There were no complications in any of the 14 cases in which a standard ALT flap was used. Of the thinned ALT flaps, one flap failed completely and two flaps experienced partial necrosis that required no further reconstruction. In both patients in whom larger complex defects were reconstructed with a standard ALT flap in combination with either iliac bone or fibula there were no complications, although the patient with the fibular graft had a delay in return of function secondary to swelling. Two of the 14 patients (14%) in whom standard ALT flaps were used for reconstruction have subsequently undergone thinning of the flap (Fig. 1). There were no significant differences in preoperative status, including smoking status, between patients with thinned flaps and those with standard ALT flaps.
All patients have continued to make functional improvement postoperatively, and 17 patients are alive and well with an average follow-up of seven months. In 17 patients, including all those in whom the stealth pattern was used, the donor site was closed directly; in one patient split-skin grafting was used to close the donor defect. In patients, whom the donor-site was closed directly there has been no donor-site morbidity.
Free combined composite flaps using the lateral circumflex femoral system for repair of massive defects of the head and neck regions: an introduction to the chimeric flap principle.
that the ALT flap is relatively safe and easy to raise, with a vascular pedicle of 10 cm or more in all cases. All flaps were anastomosed to neck vessels without tension and without the need for vein grafts. In the combined ALT-fibular flap separate arterial inputs were used for the ALT and the fibula, with the fibula being used as a flow through for the venous drainage of the ALT flap. The proportion of flaps with septocutaneous perforators in our series was 48%, which is similar to other reported series.
Although there are many variations in the vascular pedicle, we found that in 16/18 cases (89%) the perforators originated from the descending branch of the LCFA. In the remaining cases the vascular pedicle originated directly from the profunda femoris.
We have not experienced any problems with hair follicles on the flap as previously described,
Free combined composite flaps using the lateral circumflex femoral system for repair of massive defects of the head and neck regions: an introduction to the chimeric flap principle.
although all our male patients received postoperative radiotherapy to the flap.
There have been no problems with donor-site morbidity in any case in which the donor site was closed directly, even though in two cases the branch to the vastus lateralis muscle was sacrificed. In both these cases there were two perforators, and the nerve passed between the two. The nerve was subsequently repaired following flap elevation. One patient, in whom a skin graft was applied to the donor defect, had a decreased range of motion as a result of adhesion between the meshed graft and the underlying muscle.
The design of the stealth flap in the shape of the wing of a stealth bomber allows the donor defect to be closed directly by reducing tension in the middle of the wound. It is especially beneficial in filling defects such as the floor of the mouth that are rarely elliptical in shape.
Thinning of the ALT flap caused significant problems in our series. Although thinning of the flap, as a one-stage procedure is possible, we had significant problems. Our technique of thinning was less radical than that described previously for the use of the thinned flap on nonmucosal sites,
and yet our success rate was significantly reduced. Out of four thinned ALT flaps, one failed completely and two experienced partial necrosis. In both cases the necrosis occurred in the portion of the flap that was thinned. It is our opinion that a portion of the thinned flap most distal to the pedicle may not have a sufficient blood supply from the main pedicle. It may be that this portion of the flap acquires a blood supply during the first 24–48 h by recruitment via the subdermal plexus from the adjacent tissue supplied by the main pedicle. There may also be neovascularisation from the adjacent recipient tissues, similar to that seen in graft take. The salivary secretions may prevent the neovascularisation of the thinned portion of the flap within the oral cavity. Thus, the thinned flap may not be as successful within the oral cavity as it is at nonmucosal sites. Although the thinned flap has been used on the limbs with considerable success, the reliability of the thinned ALT flap for intraoral reconstruction has to be reconsidered.
Of the 14 standard ALT flaps used, only two (14%) have required subsequent thinning because of difficulty in swallowing in one case and difficulty with speech in the other. Both standard ALT flaps thinned as secondary procedures were in patients treated for anterior tongue tumours. No retromolar, palatal or posterior-tongue reconstructions have required subsequent thinning of the flap. The standard ALT flap decreases in size postoperatively, partly through a reduction in the subcutaneous fat and partly because of fibrosis secondary to radiotherapy. The simple ALT flap is reliable, and its extra bulk provides a better size match than other fasciocutaneous flaps for resections in the retromolar area, thus leading to better functional results.
When selecting a flap for intraoral reconstruction the ALT flap is an excellent option with a more aesthetic donor site than its main rival, the radial forearm flap. We do not recommend the use of the thinned flap for intraoral reconstruction as a one-stage procedure owing to the associated morbidity and because the majority of flaps will not require further thinning anyway. In the Western population the ALT flap may occasionally be too bulky and in these cases the radial forearm flap remains a better option.
In conclusion, the ALT flap is a versatile flap that can be used in combination with other flaps for more complex defects with minimal donor-site morbidity and is a useful alternative for intraoral reconstruction in the armamentarium of the head and neck surgeon.
References
Song Y.G
Chen G.Z
Song Y.L
The free thigh flap: a new free flap concept based on the septocutaneous artery.
Free combined composite flaps using the lateral circumflex femoral system for repair of massive defects of the head and neck regions: an introduction to the chimeric flap principle.
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