Accepted Manuscript Application of Thinned Anterolateral Thigh Flap for the Reconstruction of Head and Neck Defects Zhao-Jian Gong, MD, Resident, Kai Wang, MD, Visting Doctor, Hong-Yu Tan, Visting Doctor, Sheng Zhang, MD, Associate Professor, Zhi-Jing He, MD, Resident, HanJiang Wu, MD, Professor, Department Head PII:
S0278-2391(15)00060-9
DOI:
10.1016/j.joms.2015.01.006
Reference:
YJOMS 56623
To appear in:
Journal of Oral and Maxillofacial Surgery
Received Date: 17 October 2014 Revised Date:
5 January 2015
Accepted Date: 5 January 2015
Please cite this article as: Gong Z-J, Wang K, Tan H-Y, Zhang S, He Z-J, Wu H-J, Application of Thinned Anterolateral Thigh Flap for the Reconstruction of Head and Neck Defects, Journal of Oral and Maxillofacial Surgery (2015), doi: 10.1016/j.joms.2015.01.006. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Title of the article: Application of Thinned Anterolateral Thigh Flap for the Reconstruction of Head and Neck Defects.
Zhao-Jian Gong, MD, Resident; Kai Wang, MD, Visting Doctor; Hong-Yu Tan,
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Visting Doctor; Sheng Zhang, MD, Associate Professor; Zhi-Jing He, MD, Resident; Han-Jiang Wu, MD, Professor, Department Head. Department of Stomatology, the Second Xiangya Hospital, Central South University, Changsha 410011, China.
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This work was supported by the National Natural Science Foundation of China (Grant No. 81301757) and the Hunan Province Natural Science Foundation of China (Grant
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No. 2015JJ2191 and 12JJ5067).
First author: Zhao-Jian Gong, MD, Resident. Department of Stomatology, the Second Xiangya Hospital, Central South University, Changsha, China.
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E-mail:[email protected]
Corresponding author: Han-Jiang Wu, MD, Professor, Department Head. Department
China.
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of Stomatology, the Second Xiangya Hospital, Central South University, Changsha,
Address: 139 Renmin Road, Changsha, Hunan 410011, China
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Tel: 86-13873196061; 86-0731-85292108 Fax: 86-0731-85292108 E-mail: [email protected]
ACCEPTED MANUSCRIPT
Application of Thinned Anterolateral Thigh Flap for the Reconstruction of Head and Neck Defects
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Zhao-Jian Gong, MD, Kai Wang, MD, Hong-Yu Tan, Sheng Zhang, MD, Zhi-Jing He, MD, Han-Jiang Wu, MD. Department of Stomatology, the Second Xiangya Hospital,
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Central South University, Changsha 410011, China.
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This work was supported by the National Natural Science Foundation of China (Grant No. 81301757) and the Hunan Province Natural Science Foundation of China (Grant
ABSTRACT:
To evaluate the feasibility and reconstructive efficacy of the thinned
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Purpose:
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No. 2015JJ2191 and 12JJ5067).
anterolateral thigh (ALT) flap for the reconstruction of head and neck defects.
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Patients and Methods: A retrospective review was performed on 43 patients who underwent reconstruction of head and neck defects with thinned ALT flaps from January 2009 through December 2013 in the Second Xiangya Hospital. The methods for flap thinning and defect reconstruction, as well as reconstructive efficacy, are reported. Results: The flaps were 5 cm × 7 cm to 9 cm × 14 cm, and all of them were harvested from a single cutaneous perforator. Postoperatively, 40 flaps survived
ACCEPTED MANUSCRIPT completely and 3 flaps experienced partial necrosis. Venous compromise occurred in 2 cases, and both of them were salvaged after the operative exploration. Of the 43 donor sites, 41 were closed directly and resulted in only linear scars, while 2 were
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closed using full-thickness skin grafts owing to larger defects. All patients were followed for approximately 6 to 36 months, and they were satisfied with the esthetic and functional results of the donor and recipient sites after the reconstruction.
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Conclusions: Because of the high success rate of flap transplantation, satisfactory
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functional and esthetic results, and lower complication rates at the donor and recipient sites, the use of thinned ALT flaps is a good choice for the reconstruction of head and neck defects in obese patients.
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Key Words
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anterolateral thigh flap, flap thinning, reconstruction, head and neck, defect
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The reconstruction of substantial head and neck defects resulting from malignant tumor resection or injury has always been a challenging problem because of their extremely visible location, as well as limited local tissue supply.1 There are several options for treating such defects, which include reconstruction with the pectoralis major flap,2 radial forearm flap,3 latissimus dorsi flap 4 and anterolateral thigh (ALT) flap.1,5 The ALT flap was first reported by Song et al
6
in 1984. It has gained
widespread popularity in recent years, especially for the reconstruction of head and
ACCEPTED MANUSCRIPT neck defects, because of its versatility in design, long pedicle with a suitable vessel diameter, abundant cutaneous perforators, large skin territory, ability for a 2-team approach, minimal donor site morbidity, high success rate of flap transplantation, and
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other reasons.7-10 However, for obese patients who have thicker subcutaneous fat in the thigh, the ALT flaps are usually excessively bulky and the achievement of satisfactory functional and esthetic results is often difficult.9 Although secondary
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debulking procedures can be performed, they impose additional burdens and stress on
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the patients.11,12 Reports have described that the ALT flap could be thinned by removing excess subcutaneous fat as a one-stage procedure.13 Therefore, it would not only be beneficial to the reconstruction of the defects, but would also avoid the requirement for a secondary defatting procedure. Here, we report our experience with
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43 patients who underwent reconstruction of head and neck defects with a thinned ALT flap from January 2009 through December 2013.
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Patients
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Patients and Methods
A retrospective case series was performed in patients who underwent reconstruction of head and neck defects with a thinned ALT flap from January 2009 through December 2013 in the Second Xiangya Hospital of Central South University (Changsha, China). This study was approved by the ethics committee of Second Xiangya Hospital, Central South University and all participants signed an informed consent agreement. This study followed the guidelines set forth in the Declaration of
ACCEPTED MANUSCRIPT Helsinki. Of the 43 patients, 17 were men and 26 were women, with an average age of 52.1 years (range, 37 to 63 yr). Thirty-seven patients presented with head and neck defects
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that resulted from cancer ablation, and the defects were located in the tongue in 14 cases, the buccal mucosa in 7 cases, the soft palate in 6 cases, the floor of the mouth
other 6 patients were caused by injury. Surgical technique
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in 5 cases, the upper lip in 3 cases, and the forehead in 2 cases. The defects of the
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The elevations of the flaps were performed simultaneously with neck dissection and tumor resection or debridement by two surgical teams.
The incisions for the flaps were designed based on the classic ALT flap.9 A line from the anterior superior iliac spine to the lateral border of the patella was drawn, and the
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incision was made approximately 3 cm (depending on the width of the flaps) medial to this line, down to the plane immediately below the fascia lata. The lateral fascia lata was turned open and the cutaneous perforators were explored. Once sizable
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cutaneous perforators arising from the lateral circumflex femoral artery (LCFA) system were found, the ALT flap could be raised for the reconstruction. The
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cutaneous perforators were dissected and traced until an adequate pedicle length and a satisfactory pedicle size for safe anastomosis were achieved. Muscle tissue and fat flaps of various sizes were cut off accordingly to fill the dead spaces. Thinning of all of the flaps was performed before ligation of the vascular pedicles (Figs 1 to 3). The position of the cutaneous perforators was marked, and a circle with a radius of 2 cm was drawn around these perforators. The entire flap was thinned with tissue scissors to an appropriate thickness, except for approximately 2 cm around the
ACCEPTED MANUSCRIPT entry of the perforator to the flap. To preserve subdermal plexus circulation, the superficial adipose layer, composed of the small and tight small fat lobules, was preserved. The area within 2 cm around the location of the perforator was also thinned microscopically in cases in which thinner flaps were required for the reconstruction.
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In these cases, the fat lobules were meticulously peeled off with microforceps. During the thinning around the perforator, irrigation with a heparin-containing saline solution was continued to prevent desiccation and vasospasm.
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Postoperative follow-up was performed for all of the 43 patients, and the follow-up time varied from 6 to 36 months. Basic information for all patients, including defect
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sites, flap size and pedicles, recipient vessels, donor and recipient complications, and postoperative quality of life, was recorded and assessed.
Results
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The flaps were 5 cm × 7 cm to 9 cm × 14 cm. All flaps were harvested from a single dominant cutaneous perforator, including the musculocutaneous perforators in 34 cases, and septocutaneous perforators in 9 cases. The flaps were pedicled with the
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descending branch of the LCFA in 31 cases and with the transverse branch of the
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LCFA in 12 cases. Arterial anastomosis of the flaps was performed in 20 cases to the superior thyroid artery, in 12 cases to the facial artery, in 8 cases to the superficial temporal artery, in 2 cases to the lingual artery, and in 1 case to the external carotid artery. Venous anastomosis of the flaps was performed to the internal jugular vein, internal jugular vein branches, the external jugular vein, or the superficial temporal vein. Double venous anastomoses were performed in 28 cases, and single venous anastomosis was performed in 15 cases. Of the 43 flaps, 40 flaps survived completely and 3 experienced partial necrosis,
ACCEPTED MANUSCRIPT resulting in a success rate of 93.0 percent. Venous compromise occurred in 2 cases, and both of them were salvaged after the operative exploration (Figs 4 to 6). Wound effusion caused by salivary fistula occurred in 1 patient with buccal mucosa defects,
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and fistulas in the floor of the mouth occurred in 2 patients, 1 patient with a tongue defect and the other with a floor of the mouth defect. Gradual wound healing was observed after daily wound dressings in these 3 patients. Of the 43 donor sites, 41
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were closed directly, leaving only linear scars, and 2 were closed using full-thickness
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skin grafts, owing to larger defects. The skin grafts were harvested from the upper part of the donor sites. All donor sites healed well, without significant morbidity. No remarkable donor site hematoma or seroma was observed.
All patients were followed for approximately 6 to 36 months. The UW-QOL
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(University of Washington quality of life questionnaire) version 4, oral evaluation, or other methods were used to assess the patients’ quality of life and obtain information about their speech, chewing, swallowing, and appearance (Table 1). For patients with
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intraoral defects, the reconstructed tongues (Fig 7A), buccal mucosa (Fig 7B), soft
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palates (Fig 7C) and floor of the mouth were satisfactory, and the linguistic, chewing and swallowing functions recovered well. For patients with facial defects, their appearance was acceptable (Fig 7D). The scars of all of the donor sites were not readily visible, and no thigh motor dysfunctions were observed.
Discussion With the advancement of microsurgery, free flaps have become the first choice for the
ACCEPTED MANUSCRIPT reconstruction of head and neck defects.14 The radial forearm flap, first described by Yang and colleagues in 1981,15 is one of the most commonly used free flaps in reconstruction. In spite of its usefulness and feasibility, at the receiving site,
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harvesting the radial forearm flap implies a conspicuous esthetic deformity in the forearm, the sacrifice of an important vessel, namely the radial artery, and a high rate of donor site morbidity.16 The latissimus dorsi flap is also commonly used for the
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reconstruction of head and neck defects because of its obvious advantages relative to
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other donor sites.4 The unfavorable location of the donor site, which prohibits a 2-team approach, is considered to be a major disadvantage for the widespread use of the latissimus dorsi flap. In contrast, the ALT flap is a good choice for head and neck soft-tissue reconstruction.
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Although the ALT flap is sometimes too thick for the reconstruction of head and neck defects, the thickness and the volume of the flap can be adjusted according to the individual extent of defects.12 The thinning of the flap can be performed accordingly
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before ligation of the vascular pedicle, and the ALT flap can be harvested as thin as a
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radial forearm flap, with the additional advantage of reduced donor site morbidity. In the present series, all of the 43 ALT flaps were thinned by removing excess subcutaneous fat, and 17 of them were also thinned microscopically. The use of these thinned ALT flaps for the head and neck defects resulted in reconstructions with good functional results, acceptable esthetic outcomes, and a high level of patient satisfaction (Fig 7). Thinning of the ALT flap may extend its usefulness to situations requiring less bulk;
ACCEPTED MANUSCRIPT however, the disruption of the blood supply remains controversial. Reports from Asia have described successful cases of thinning of the ALT flap.13,17 In contrast, similar results have not yet been produced in the West.18,19 The necrosis of thinned flaps may
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occur more frequently in the Western population, owing to the generally greater volume of subcutaneous fat present, which requires more extensive fat dissection to achieve the desired thickness.19 In the present series, no complete flap failure resulted
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from the process of trimming. All of the 43 thinned ALT flaps survived, and only 3
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cases of partial necrosis occurred. The result indicated that one-stage thinning of the ALT flap is a reliable and safe option for reconstruction of head and neck defects. However, the flaps of the present series were relatively small, with flap sizes ranging from 5 cm × 7 cm to 9 cm × 14 cm. For larger ALT flaps, the effects of the disruption
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of the blood supply to the flap skin caused by flap thinning require further study. Because of potential disruption of the blood supply caused by flap thinning, the edge of the flap, especially for larger flaps, may not have a sufficient blood supply from the
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perforator. Thus, the location of the perforator in the flap should be carefully designed.
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In addition, the blood supply of the most distal part of the flap could be affected and, consequently, the distal necrosis rate of the flaps would increase while the flaps were folded. In the 3 patients in the present series with partial flap necrosis, the perforators were not properly designed and were located close to the edge of the flaps. Of them, 2 flaps (3.5 cm × 12 cm and 4 cm × 14 cm) were elevated to reconstruct through-and-through upper lip defects, and the flaps were bi-paddled to provide external as well as oral lining. The intervening area was de-epithelized and superiorly
ACCEPTED MANUSCRIPT sutured to the inner and outer edge of the defect. A 1.5 cm × 1.5 cm and a 1.5 cm × 2 cm area of the distal parts of the flaps were necrotized. Another flap was harvested to reconstruct a tongue defect. Taking into consideration the inappropriate perforator
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location, the side of the flap that was distal to the perforator was designed to reconstruct the dorsal lingual defect. Though a 1.5 cm × 2 cm area of the distal part of the flap was necrotized, the occurrence of a fistula in the floor of the mouth was
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effectively avoided.
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In the 35 patients of the present series, thinned ALT flaps were harvested to reconstruct intraoral defects resulting from tumor resection. They were different from those used for the reconstruction of other parts. On the one hand, the ALT flaps that are used to reconstruct intraoral defects need not be harvested as thin as those used for
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hand or foot reconstruction, which may reduce the disruption of the blood supply caused by flap thinning. On the other hand, the ALT flaps that are used to reconstruct intraoral defects are usually compressed by intraoral organs and may suffer from
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some pressure and/or tension. This may increase the occurrence of flap compromise.
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In the present series, venous compromise occurred in 2 cases with tongue defects. Intriguingly, no cervical hematoma, twisting of the perforator, or arterial or venous thrombosis of the anastomotic stomas was observed during the re-exploration. In addition, the local tissues were not excessively bulky and compression from the mandible was not apparent. Based on our experience, the flaps were unlikely to be compressed. However, both of them were salvaged after the relaxation of the local tissues. It is our opinion that thinning of the ALT flap may lead to a decline in its
ACCEPTED MANUSCRIPT anti-extrusion/tension capacity. Studies have revealed that most venous compromise of free flaps occurred within the first 72 h after surgery. 20-22 In the present series, both of the incidences of venous
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compromise occurred within the first 12 h, specifically at 5 h and 6 h postoperatively. This may be related to flap thinning, which could have led to the earlier occurrence of flap compromise. Thus, the flaps should be carefully monitored postoperatively,
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especially within the first 12 h.
In conclusion, because of the high success rate of flap transplantation, satisfactory
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functional and esthetic results, and lower complication rates at the donor and recipient sites, the use of thinned ALT flaps is a good choice for the reconstruction of head and neck defects in obese patients. However, for larger ALT flaps, this notion requires
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further validation.
References
Liu ZM, Wu D, Liu XK, et al: Reconstruction of through-and-through cheek
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1
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defects with folded free anterolateral thigh flaps. J Oral Maxillofac Surg 71: 960, 2013
2
Gadre KS, Gadre P, Sane VD, et al: Pectoralis major myocutaneous flap--still a workhorse for maxillofacial reconstruction in developing countries. J Oral Maxillofac Surg 71: 2005.e1, 2013
3
Zhou W, He M, Liao Y, et al: Reconstructing a complex central facial defect with a multiple-folding radial forearm flap. J Oral Maxillofac Surg 72: 836.e1, 2014
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Janus JR, Carlson ML, Moore EJ: The scapular, parascapular, and latissimus dorsi flap as a single osteomyocutaneous flap for repair of complex oral defects. Clin Anat 25: 120, 2012
5
Kekatpure VD, Trivedi NP, Shetkar G, et al: Single perforator based
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anterolateral thigh flap for reconstruction of large composite defects of oral cavity. Oral oncol 47: 517, 2011 6
Song YG, Chen GZ, Song YL: The free thigh flap: a new free flap concept
Gong ZJ, Zhang S, Wang K, et al: Chimeric flaps pedicled with lateral circumflex
femoral
vessel
for
individualised
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7
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based on the septocutaneous artery. Br J Plast Surg 37: 149, 1984
reconstruction
of
through-and-through oral and maxillofacial defects. Br J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.bjoms.2014.10.017 8
Gong ZJ, Wang K, Zhang S, et al: Anatomy on chimeric flaps of lateral
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circumflex femoral vessel and application for the reconstruction of complex oral and maxillofacial defects. Chinese J of Microsurgery 37: 436, 2014 9
Gong ZJ, Wu HJ: Measurement for subcutaneous fat and clinical applied
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anatomic studies on perforators in the anterior thigh region. J Oral Maxillofac
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Surg 71: 951, 2013 10
Gong ZJ, Zhang S, Ren ZH, et al: Application of Anteromedial Thigh Flap for the Reconstruction of Oral and Maxillofacial Defects. J Oral Maxillofac Surg 72: 1212, 2014
11
Huang SH, Wu SH, Chang KP, et al: Contour refinements of free flaps for optimal outcome in oral reconstruction: combination of modified liposuction technique and w-plasty in one-stage procedure. J Craniomaxillofac Surg 37: 201, 2009
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Sun G, Lu M, Hu Q, et al: Clinical application of thin anterolateral thigh flap in the reconstruction of intraoral defects. Oral Surg Oral Med Oral Pathol Oral Radiol 115: 185, 2013
13
Kimura N, Satoh K, Hasumi T, et al: Clinical application of the free thin
1197, 2001 14
Hurvitz KA, Kobayashi M, Evans GR: Current options in head and neck
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reconstruction. Plast Reconstr Surg 118: 122e, 2006 15
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anterolateral thigh flap in 31 consecutive patients. Plast Reconstr Surg 108:
Yang GF, Chen PJ, Gao YZ, et al: Forearm free skin flap transplantation: a
16
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report of 56 cases. 1981. Br J Plast Surg 50: 162, 1997
Gupta M, Allen M, Corsten M: Reduction of donor site morbidity in the radial forearm free flap by use of topical tissue expanders. J Otolaryngol Head Neck Surg 38: 628, 2009
Kimura N, Satoh K: Consideration of a thin flap as an entity and clinical
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17
applications of the thin anterolateral thigh flap. Plast Reconstr Surg 97: 985, 1996
Alkureishi LW, Shaw-Dunn J, Ross GL: Effects of thinning the anterolateral
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18
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thigh flap on the blood supply to the skin. Br J Plast Surg 56: 401, 2003 19
Ross GL, Dunn R, Kirkpatrick J, et al: To thin or not to thin: the use of the anterolateral thigh flap in the reconstruction of intraoral defects. Br J Plast Surg 56: 409, 2003
20
Yu P, Chang DW, Miller MJ, et al: Analysis of 49 cases of flap compromise in 1310 free flaps for head and neck reconstruction. Head neck 31: 45, 2009
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Liu Y, Zhao YF, Huang JT, et al: Analysis of 13 cases of venous compromise in 178 radial forearm free flaps for intraoral reconstruction. Int J Oral Maxillofac Surg 41: 448, 2012
22
Yang Q, Ren ZH, Chickooree D, et al: The effect of early detection of
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anterolateral thigh free flap crisis on the salvage success rate, based on 10
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years of experience and 1072 flaps. Int J Oral Maxillofac Surg 43: 1059, 2014
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Table 1.
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Tables The postoperative scores of UW-QOL version 4 of patients presented with head and neck cancer (n=37, 6 months postoperatively) Appearance
Activity
Recreation
Swallowing
Chewing
95.95
75.00
77.03
79.05
78.92
67.57
Tongue (n=14)
92.86
82.14
76.79
78.57
73.57
64.29
Buccal mucosa (n=7)
96.43
64.29
75.00
82.14
82.86
Soft palate (n=6)
100.00
79.17
79.17
75.00
73.33
Floor of the mouth (n=5) Upper lip and forehead (n=5)
95.00
75.00
70.00
75.00
74.00
100.00
65.00
85.00
85.00
100.00
Taste
Saliva
Mood
Anxiety
Total
74.32
79.46
75.68
81.76
82.16
941.49
68.57
70.71
70.00
75.00
80.36
82.14
915.00
71.43
78.57
72.86
82.86
72.86
82.14
81.43
942.86
66.67
68.33
73.33
85.00
73.33
79.17
85.00
937.50
50.00
74.00
62.00
74.00
60.00
85.00
74.00
868.00
90.00
94.00
100.00
100.00
100.00
85.00
88.00
1092.00
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Shoulder
74.59
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Total (n=37)
Speech
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Pain
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Figure legends FIGURE 1. Elevation of the anterolateral thigh flap.
FIGURE 3. Thinned anterolateral thigh flap.
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FIGURE 2. Thinning of the anterolateral thigh flap.
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FIGURE 4. Venous compromise of the thinned anterolateral thigh flap.
flap after operative exploration.
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FIGURE 5. The recovery of blood supply of the thinned anterolateral thigh
thigh flap.
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FIGURE 6. Reconstruction of the tongue defect with salvaged anterolateral
FIGURE 7. Esthetic and functional outcomes after the reconstruction.
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(A), (B) and (C) One year postoperatively, with defects resulting from cancer
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resection; (D) Three months postoperatively, with defect resulting from injury.
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S0278-2391(15)00060-9
DOI:
10.1016/j.joms.2015.01.006
Reference:
YJOMS 56623
To appear in:
Journal of Oral and Maxillofacial Surgery
Received Date: 17 October 2014 Revised Date:
5 January 2015
Accepted Date: 5 January 2015
Please cite this article as: Gong Z-J, Wang K, Tan H-Y, Zhang S, He Z-J, Wu H-J, Application of Thinned Anterolateral Thigh Flap for the Reconstruction of Head and Neck Defects, Journal of Oral and Maxillofacial Surgery (2015), doi: 10.1016/j.joms.2015.01.006. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Title of the article: Application of Thinned Anterolateral Thigh Flap for the Reconstruction of Head and Neck Defects.
Zhao-Jian Gong, MD, Resident; Kai Wang, MD, Visting Doctor; Hong-Yu Tan,
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Visting Doctor; Sheng Zhang, MD, Associate Professor; Zhi-Jing He, MD, Resident; Han-Jiang Wu, MD, Professor, Department Head. Department of Stomatology, the Second Xiangya Hospital, Central South University, Changsha 410011, China.
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This work was supported by the National Natural Science Foundation of China (Grant No. 81301757) and the Hunan Province Natural Science Foundation of China (Grant
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No. 2015JJ2191 and 12JJ5067).
First author: Zhao-Jian Gong, MD, Resident. Department of Stomatology, the Second Xiangya Hospital, Central South University, Changsha, China.
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E-mail:[email protected]
Corresponding author: Han-Jiang Wu, MD, Professor, Department Head. Department
China.
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of Stomatology, the Second Xiangya Hospital, Central South University, Changsha,
Address: 139 Renmin Road, Changsha, Hunan 410011, China
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Tel: 86-13873196061; 86-0731-85292108 Fax: 86-0731-85292108 E-mail: [email protected]
ACCEPTED MANUSCRIPT
Application of Thinned Anterolateral Thigh Flap for the Reconstruction of Head and Neck Defects
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Zhao-Jian Gong, MD, Kai Wang, MD, Hong-Yu Tan, Sheng Zhang, MD, Zhi-Jing He, MD, Han-Jiang Wu, MD. Department of Stomatology, the Second Xiangya Hospital,
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Central South University, Changsha 410011, China.
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This work was supported by the National Natural Science Foundation of China (Grant No. 81301757) and the Hunan Province Natural Science Foundation of China (Grant
ABSTRACT:
To evaluate the feasibility and reconstructive efficacy of the thinned
EP
Purpose:
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No. 2015JJ2191 and 12JJ5067).
anterolateral thigh (ALT) flap for the reconstruction of head and neck defects.
AC C
Patients and Methods: A retrospective review was performed on 43 patients who underwent reconstruction of head and neck defects with thinned ALT flaps from January 2009 through December 2013 in the Second Xiangya Hospital. The methods for flap thinning and defect reconstruction, as well as reconstructive efficacy, are reported. Results: The flaps were 5 cm × 7 cm to 9 cm × 14 cm, and all of them were harvested from a single cutaneous perforator. Postoperatively, 40 flaps survived
ACCEPTED MANUSCRIPT completely and 3 flaps experienced partial necrosis. Venous compromise occurred in 2 cases, and both of them were salvaged after the operative exploration. Of the 43 donor sites, 41 were closed directly and resulted in only linear scars, while 2 were
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closed using full-thickness skin grafts owing to larger defects. All patients were followed for approximately 6 to 36 months, and they were satisfied with the esthetic and functional results of the donor and recipient sites after the reconstruction.
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Conclusions: Because of the high success rate of flap transplantation, satisfactory
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functional and esthetic results, and lower complication rates at the donor and recipient sites, the use of thinned ALT flaps is a good choice for the reconstruction of head and neck defects in obese patients.
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Key Words
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anterolateral thigh flap, flap thinning, reconstruction, head and neck, defect
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The reconstruction of substantial head and neck defects resulting from malignant tumor resection or injury has always been a challenging problem because of their extremely visible location, as well as limited local tissue supply.1 There are several options for treating such defects, which include reconstruction with the pectoralis major flap,2 radial forearm flap,3 latissimus dorsi flap 4 and anterolateral thigh (ALT) flap.1,5 The ALT flap was first reported by Song et al
6
in 1984. It has gained
widespread popularity in recent years, especially for the reconstruction of head and
ACCEPTED MANUSCRIPT neck defects, because of its versatility in design, long pedicle with a suitable vessel diameter, abundant cutaneous perforators, large skin territory, ability for a 2-team approach, minimal donor site morbidity, high success rate of flap transplantation, and
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other reasons.7-10 However, for obese patients who have thicker subcutaneous fat in the thigh, the ALT flaps are usually excessively bulky and the achievement of satisfactory functional and esthetic results is often difficult.9 Although secondary
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debulking procedures can be performed, they impose additional burdens and stress on
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the patients.11,12 Reports have described that the ALT flap could be thinned by removing excess subcutaneous fat as a one-stage procedure.13 Therefore, it would not only be beneficial to the reconstruction of the defects, but would also avoid the requirement for a secondary defatting procedure. Here, we report our experience with
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43 patients who underwent reconstruction of head and neck defects with a thinned ALT flap from January 2009 through December 2013.
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Patients
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Patients and Methods
A retrospective case series was performed in patients who underwent reconstruction of head and neck defects with a thinned ALT flap from January 2009 through December 2013 in the Second Xiangya Hospital of Central South University (Changsha, China). This study was approved by the ethics committee of Second Xiangya Hospital, Central South University and all participants signed an informed consent agreement. This study followed the guidelines set forth in the Declaration of
ACCEPTED MANUSCRIPT Helsinki. Of the 43 patients, 17 were men and 26 were women, with an average age of 52.1 years (range, 37 to 63 yr). Thirty-seven patients presented with head and neck defects
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that resulted from cancer ablation, and the defects were located in the tongue in 14 cases, the buccal mucosa in 7 cases, the soft palate in 6 cases, the floor of the mouth
other 6 patients were caused by injury. Surgical technique
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in 5 cases, the upper lip in 3 cases, and the forehead in 2 cases. The defects of the
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The elevations of the flaps were performed simultaneously with neck dissection and tumor resection or debridement by two surgical teams.
The incisions for the flaps were designed based on the classic ALT flap.9 A line from the anterior superior iliac spine to the lateral border of the patella was drawn, and the
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incision was made approximately 3 cm (depending on the width of the flaps) medial to this line, down to the plane immediately below the fascia lata. The lateral fascia lata was turned open and the cutaneous perforators were explored. Once sizable
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cutaneous perforators arising from the lateral circumflex femoral artery (LCFA) system were found, the ALT flap could be raised for the reconstruction. The
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cutaneous perforators were dissected and traced until an adequate pedicle length and a satisfactory pedicle size for safe anastomosis were achieved. Muscle tissue and fat flaps of various sizes were cut off accordingly to fill the dead spaces. Thinning of all of the flaps was performed before ligation of the vascular pedicles (Figs 1 to 3). The position of the cutaneous perforators was marked, and a circle with a radius of 2 cm was drawn around these perforators. The entire flap was thinned with tissue scissors to an appropriate thickness, except for approximately 2 cm around the
ACCEPTED MANUSCRIPT entry of the perforator to the flap. To preserve subdermal plexus circulation, the superficial adipose layer, composed of the small and tight small fat lobules, was preserved. The area within 2 cm around the location of the perforator was also thinned microscopically in cases in which thinner flaps were required for the reconstruction.
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In these cases, the fat lobules were meticulously peeled off with microforceps. During the thinning around the perforator, irrigation with a heparin-containing saline solution was continued to prevent desiccation and vasospasm.
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Postoperative follow-up was performed for all of the 43 patients, and the follow-up time varied from 6 to 36 months. Basic information for all patients, including defect
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sites, flap size and pedicles, recipient vessels, donor and recipient complications, and postoperative quality of life, was recorded and assessed.
Results
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The flaps were 5 cm × 7 cm to 9 cm × 14 cm. All flaps were harvested from a single dominant cutaneous perforator, including the musculocutaneous perforators in 34 cases, and septocutaneous perforators in 9 cases. The flaps were pedicled with the
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descending branch of the LCFA in 31 cases and with the transverse branch of the
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LCFA in 12 cases. Arterial anastomosis of the flaps was performed in 20 cases to the superior thyroid artery, in 12 cases to the facial artery, in 8 cases to the superficial temporal artery, in 2 cases to the lingual artery, and in 1 case to the external carotid artery. Venous anastomosis of the flaps was performed to the internal jugular vein, internal jugular vein branches, the external jugular vein, or the superficial temporal vein. Double venous anastomoses were performed in 28 cases, and single venous anastomosis was performed in 15 cases. Of the 43 flaps, 40 flaps survived completely and 3 experienced partial necrosis,
ACCEPTED MANUSCRIPT resulting in a success rate of 93.0 percent. Venous compromise occurred in 2 cases, and both of them were salvaged after the operative exploration (Figs 4 to 6). Wound effusion caused by salivary fistula occurred in 1 patient with buccal mucosa defects,
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and fistulas in the floor of the mouth occurred in 2 patients, 1 patient with a tongue defect and the other with a floor of the mouth defect. Gradual wound healing was observed after daily wound dressings in these 3 patients. Of the 43 donor sites, 41
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were closed directly, leaving only linear scars, and 2 were closed using full-thickness
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skin grafts, owing to larger defects. The skin grafts were harvested from the upper part of the donor sites. All donor sites healed well, without significant morbidity. No remarkable donor site hematoma or seroma was observed.
All patients were followed for approximately 6 to 36 months. The UW-QOL
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(University of Washington quality of life questionnaire) version 4, oral evaluation, or other methods were used to assess the patients’ quality of life and obtain information about their speech, chewing, swallowing, and appearance (Table 1). For patients with
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intraoral defects, the reconstructed tongues (Fig 7A), buccal mucosa (Fig 7B), soft
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palates (Fig 7C) and floor of the mouth were satisfactory, and the linguistic, chewing and swallowing functions recovered well. For patients with facial defects, their appearance was acceptable (Fig 7D). The scars of all of the donor sites were not readily visible, and no thigh motor dysfunctions were observed.
Discussion With the advancement of microsurgery, free flaps have become the first choice for the
ACCEPTED MANUSCRIPT reconstruction of head and neck defects.14 The radial forearm flap, first described by Yang and colleagues in 1981,15 is one of the most commonly used free flaps in reconstruction. In spite of its usefulness and feasibility, at the receiving site,
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harvesting the radial forearm flap implies a conspicuous esthetic deformity in the forearm, the sacrifice of an important vessel, namely the radial artery, and a high rate of donor site morbidity.16 The latissimus dorsi flap is also commonly used for the
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reconstruction of head and neck defects because of its obvious advantages relative to
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other donor sites.4 The unfavorable location of the donor site, which prohibits a 2-team approach, is considered to be a major disadvantage for the widespread use of the latissimus dorsi flap. In contrast, the ALT flap is a good choice for head and neck soft-tissue reconstruction.
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Although the ALT flap is sometimes too thick for the reconstruction of head and neck defects, the thickness and the volume of the flap can be adjusted according to the individual extent of defects.12 The thinning of the flap can be performed accordingly
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before ligation of the vascular pedicle, and the ALT flap can be harvested as thin as a
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radial forearm flap, with the additional advantage of reduced donor site morbidity. In the present series, all of the 43 ALT flaps were thinned by removing excess subcutaneous fat, and 17 of them were also thinned microscopically. The use of these thinned ALT flaps for the head and neck defects resulted in reconstructions with good functional results, acceptable esthetic outcomes, and a high level of patient satisfaction (Fig 7). Thinning of the ALT flap may extend its usefulness to situations requiring less bulk;
ACCEPTED MANUSCRIPT however, the disruption of the blood supply remains controversial. Reports from Asia have described successful cases of thinning of the ALT flap.13,17 In contrast, similar results have not yet been produced in the West.18,19 The necrosis of thinned flaps may
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occur more frequently in the Western population, owing to the generally greater volume of subcutaneous fat present, which requires more extensive fat dissection to achieve the desired thickness.19 In the present series, no complete flap failure resulted
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from the process of trimming. All of the 43 thinned ALT flaps survived, and only 3
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cases of partial necrosis occurred. The result indicated that one-stage thinning of the ALT flap is a reliable and safe option for reconstruction of head and neck defects. However, the flaps of the present series were relatively small, with flap sizes ranging from 5 cm × 7 cm to 9 cm × 14 cm. For larger ALT flaps, the effects of the disruption
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of the blood supply to the flap skin caused by flap thinning require further study. Because of potential disruption of the blood supply caused by flap thinning, the edge of the flap, especially for larger flaps, may not have a sufficient blood supply from the
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perforator. Thus, the location of the perforator in the flap should be carefully designed.
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In addition, the blood supply of the most distal part of the flap could be affected and, consequently, the distal necrosis rate of the flaps would increase while the flaps were folded. In the 3 patients in the present series with partial flap necrosis, the perforators were not properly designed and were located close to the edge of the flaps. Of them, 2 flaps (3.5 cm × 12 cm and 4 cm × 14 cm) were elevated to reconstruct through-and-through upper lip defects, and the flaps were bi-paddled to provide external as well as oral lining. The intervening area was de-epithelized and superiorly
ACCEPTED MANUSCRIPT sutured to the inner and outer edge of the defect. A 1.5 cm × 1.5 cm and a 1.5 cm × 2 cm area of the distal parts of the flaps were necrotized. Another flap was harvested to reconstruct a tongue defect. Taking into consideration the inappropriate perforator
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location, the side of the flap that was distal to the perforator was designed to reconstruct the dorsal lingual defect. Though a 1.5 cm × 2 cm area of the distal part of the flap was necrotized, the occurrence of a fistula in the floor of the mouth was
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effectively avoided.
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In the 35 patients of the present series, thinned ALT flaps were harvested to reconstruct intraoral defects resulting from tumor resection. They were different from those used for the reconstruction of other parts. On the one hand, the ALT flaps that are used to reconstruct intraoral defects need not be harvested as thin as those used for
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hand or foot reconstruction, which may reduce the disruption of the blood supply caused by flap thinning. On the other hand, the ALT flaps that are used to reconstruct intraoral defects are usually compressed by intraoral organs and may suffer from
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some pressure and/or tension. This may increase the occurrence of flap compromise.
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In the present series, venous compromise occurred in 2 cases with tongue defects. Intriguingly, no cervical hematoma, twisting of the perforator, or arterial or venous thrombosis of the anastomotic stomas was observed during the re-exploration. In addition, the local tissues were not excessively bulky and compression from the mandible was not apparent. Based on our experience, the flaps were unlikely to be compressed. However, both of them were salvaged after the relaxation of the local tissues. It is our opinion that thinning of the ALT flap may lead to a decline in its
ACCEPTED MANUSCRIPT anti-extrusion/tension capacity. Studies have revealed that most venous compromise of free flaps occurred within the first 72 h after surgery. 20-22 In the present series, both of the incidences of venous
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compromise occurred within the first 12 h, specifically at 5 h and 6 h postoperatively. This may be related to flap thinning, which could have led to the earlier occurrence of flap compromise. Thus, the flaps should be carefully monitored postoperatively,
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especially within the first 12 h.
In conclusion, because of the high success rate of flap transplantation, satisfactory
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functional and esthetic results, and lower complication rates at the donor and recipient sites, the use of thinned ALT flaps is a good choice for the reconstruction of head and neck defects in obese patients. However, for larger ALT flaps, this notion requires
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further validation.
References
Liu ZM, Wu D, Liu XK, et al: Reconstruction of through-and-through cheek
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1
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defects with folded free anterolateral thigh flaps. J Oral Maxillofac Surg 71: 960, 2013
2
Gadre KS, Gadre P, Sane VD, et al: Pectoralis major myocutaneous flap--still a workhorse for maxillofacial reconstruction in developing countries. J Oral Maxillofac Surg 71: 2005.e1, 2013
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Zhou W, He M, Liao Y, et al: Reconstructing a complex central facial defect with a multiple-folding radial forearm flap. J Oral Maxillofac Surg 72: 836.e1, 2014
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Janus JR, Carlson ML, Moore EJ: The scapular, parascapular, and latissimus dorsi flap as a single osteomyocutaneous flap for repair of complex oral defects. Clin Anat 25: 120, 2012
5
Kekatpure VD, Trivedi NP, Shetkar G, et al: Single perforator based
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anterolateral thigh flap for reconstruction of large composite defects of oral cavity. Oral oncol 47: 517, 2011 6
Song YG, Chen GZ, Song YL: The free thigh flap: a new free flap concept
Gong ZJ, Zhang S, Wang K, et al: Chimeric flaps pedicled with lateral circumflex
femoral
vessel
for
individualised
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7
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based on the septocutaneous artery. Br J Plast Surg 37: 149, 1984
reconstruction
of
through-and-through oral and maxillofacial defects. Br J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.bjoms.2014.10.017 8
Gong ZJ, Wang K, Zhang S, et al: Anatomy on chimeric flaps of lateral
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circumflex femoral vessel and application for the reconstruction of complex oral and maxillofacial defects. Chinese J of Microsurgery 37: 436, 2014 9
Gong ZJ, Wu HJ: Measurement for subcutaneous fat and clinical applied
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anatomic studies on perforators in the anterior thigh region. J Oral Maxillofac
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Surg 71: 951, 2013 10
Gong ZJ, Zhang S, Ren ZH, et al: Application of Anteromedial Thigh Flap for the Reconstruction of Oral and Maxillofacial Defects. J Oral Maxillofac Surg 72: 1212, 2014
11
Huang SH, Wu SH, Chang KP, et al: Contour refinements of free flaps for optimal outcome in oral reconstruction: combination of modified liposuction technique and w-plasty in one-stage procedure. J Craniomaxillofac Surg 37: 201, 2009
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Sun G, Lu M, Hu Q, et al: Clinical application of thin anterolateral thigh flap in the reconstruction of intraoral defects. Oral Surg Oral Med Oral Pathol Oral Radiol 115: 185, 2013
13
Kimura N, Satoh K, Hasumi T, et al: Clinical application of the free thin
1197, 2001 14
Hurvitz KA, Kobayashi M, Evans GR: Current options in head and neck
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reconstruction. Plast Reconstr Surg 118: 122e, 2006 15
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anterolateral thigh flap in 31 consecutive patients. Plast Reconstr Surg 108:
Yang GF, Chen PJ, Gao YZ, et al: Forearm free skin flap transplantation: a
16
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report of 56 cases. 1981. Br J Plast Surg 50: 162, 1997
Gupta M, Allen M, Corsten M: Reduction of donor site morbidity in the radial forearm free flap by use of topical tissue expanders. J Otolaryngol Head Neck Surg 38: 628, 2009
Kimura N, Satoh K: Consideration of a thin flap as an entity and clinical
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17
applications of the thin anterolateral thigh flap. Plast Reconstr Surg 97: 985, 1996
Alkureishi LW, Shaw-Dunn J, Ross GL: Effects of thinning the anterolateral
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18
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thigh flap on the blood supply to the skin. Br J Plast Surg 56: 401, 2003 19
Ross GL, Dunn R, Kirkpatrick J, et al: To thin or not to thin: the use of the anterolateral thigh flap in the reconstruction of intraoral defects. Br J Plast Surg 56: 409, 2003
20
Yu P, Chang DW, Miller MJ, et al: Analysis of 49 cases of flap compromise in 1310 free flaps for head and neck reconstruction. Head neck 31: 45, 2009
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Liu Y, Zhao YF, Huang JT, et al: Analysis of 13 cases of venous compromise in 178 radial forearm free flaps for intraoral reconstruction. Int J Oral Maxillofac Surg 41: 448, 2012
22
Yang Q, Ren ZH, Chickooree D, et al: The effect of early detection of
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anterolateral thigh free flap crisis on the salvage success rate, based on 10
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years of experience and 1072 flaps. Int J Oral Maxillofac Surg 43: 1059, 2014
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Table 1.
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Tables The postoperative scores of UW-QOL version 4 of patients presented with head and neck cancer (n=37, 6 months postoperatively) Appearance
Activity
Recreation
Swallowing
Chewing
95.95
75.00
77.03
79.05
78.92
67.57
Tongue (n=14)
92.86
82.14
76.79
78.57
73.57
64.29
Buccal mucosa (n=7)
96.43
64.29
75.00
82.14
82.86
Soft palate (n=6)
100.00
79.17
79.17
75.00
73.33
Floor of the mouth (n=5) Upper lip and forehead (n=5)
95.00
75.00
70.00
75.00
74.00
100.00
65.00
85.00
85.00
100.00
Taste
Saliva
Mood
Anxiety
Total
74.32
79.46
75.68
81.76
82.16
941.49
68.57
70.71
70.00
75.00
80.36
82.14
915.00
71.43
78.57
72.86
82.86
72.86
82.14
81.43
942.86
66.67
68.33
73.33
85.00
73.33
79.17
85.00
937.50
50.00
74.00
62.00
74.00
60.00
85.00
74.00
868.00
90.00
94.00
100.00
100.00
100.00
85.00
88.00
1092.00
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Shoulder
74.59
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Total (n=37)
Speech
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Pain
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Figure legends FIGURE 1. Elevation of the anterolateral thigh flap.
FIGURE 3. Thinned anterolateral thigh flap.
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FIGURE 2. Thinning of the anterolateral thigh flap.
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FIGURE 4. Venous compromise of the thinned anterolateral thigh flap.
flap after operative exploration.
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FIGURE 5. The recovery of blood supply of the thinned anterolateral thigh
thigh flap.
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FIGURE 6. Reconstruction of the tongue defect with salvaged anterolateral
FIGURE 7. Esthetic and functional outcomes after the reconstruction.
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(A), (B) and (C) One year postoperatively, with defects resulting from cancer
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resection; (D) Three months postoperatively, with defect resulting from injury.
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