Journal of Cranio-Maxillo-Facial Surgery 42 (2014) 2041e2044
Contents lists available at ScienceDirect
Journal of Cranio-Maxillo-Facial Surgery journal homepage: www.jcmfs.com
Double anterior (anterolateral and anteromedial) thigh flap for oral perforated defect reconstruction W.H. Wang a, *, J.Y. Deng b, B. Xu a, J. Zhu a, B. Xia a, B.J. Zhang a a b
Department of Oral and Maxillofacial Surgery, Affiliated Stomatology Hospital of Kunming Medical University, Kunming 650031, China Department of Computer Tomography, Second Affiliated Hospital of Kunming Medical University, Kunming 650101, China
a r t i c l e i n f o
a b s t r a c t
Article history: Paper received 14 July 2014 Accepted 25 September 2014 Available online 5 October 2014
Objective: The purpose of this study was to assess the therapeutic efficacy of oral perforated defect reconstruction with a double anterior (anterolateral and anteromedial) thigh flap through the modified lateral lip-submandibular approach. Materials and methods: From July 2010 to August 2013, eight patients with oral perforated defects secondary to oral cancer ablation involving the superior partial mandible or the posterior partial maxilla, with immediate reconstruction by double anterior (anterolateral and anteromedial) thigh flaps, were retrospectively enrolled into this study. Results: All double anterior flaps were musculocutaneous flaps. Seven double flaps resulted in good functional and aesthetic outcomes with complete flap survival. One patient required operative exploration in the postoperative period due to thrombosis in the external jugular vein. After the salvage, one of the double flaps in the intraoral region resulted in partial failure of the superficial skin of the flap. No functional impairment at the donor sites occurred in any of the cases. Conclusion: The double anterior (anterolateral and anteromedial) thigh flap is a feasible and acceptable technique for reconstruction of an oral perforated defect involving the mandible or the maxilla through the modified lateral lip-submandibular approach. It presents a very acceptable aesthetic and functional result with the additional advantage of low morbidity at the donor site. © 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
Keywords: Double anterior (anterolateral and anteromedial) thigh flap Oral perforated defect Reconstruction Modified lateral lip-submandibular approach
1. Introduction An oral perforated defect always results in substantial aesthetic and functional sequelae such as malformation of the facial contour, impairment of speech, and difficulty swallowing, which in turn impacts on the quality of life of the affected patients if reconstruction is not carried out immediately. It is widely accepted that simultaneous restoration of the oral perforated defect is now the standard protocol. For the primary repair of a full-thickness oral perforated defect, several techniques have been demonstrated in previous studies, for instance, double-skin paddled superficial temporofascial flap (Kilinc et al., 2013) and folded radial forearm flap (Kang et al., 2009; Katou et al., 1996; Savant et al., 1995; Valentini et al., 2008). Although these techniques can result in functionally satisfactory outcomes, several disadvantages, such as * Corresponding author. Department of Oral and Maxillofacial Surgery, Affiliated Stomatology Hospital of Kunming Medical University, China. Tel.: þ86 0871 65330099; fax: þ86 0871 65330116. E-mail address: [email protected] (W.H. Wang).
hyperpigmentation and temporal alopecia at the temporal site (Kilinc et al., 2013); numbness and poor aesthetic outcome of the forearm; and sacrificing the radial artery, which may have an association with the depression of pinch and grip strength, could not be overcome (Kang et al., 2009; Katou et al., 1996; Savant et al., 1995; Valentini et al., 2008). Moreover, these procedures frequently fail to provide enough tissue, especially for large, fullthickness oral perforated defects involving the mandible or maxilla. The bipaddle pectoralis major myocutaneous flap can offer an alternative method for the reconstruction of large and fullthickness cheek defects (Ahmad et al., 2006). However, the drawbacks of this method include loss of the nipple and limitation of applicability in females or in patients who do not need a radical neck dissection. In this study, we have developed a double anterior (anterolateral and anteromedial) thigh flap to restore oral perforated defects involving the superior mandible or the posterior maxilla. The method achieved a satisfactory appearance and functional speech in all patients, and resulted in only slight complications.
http://dx.doi.org/10.1016/j.jcms.2014.09.011 1010-5182/© 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
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W.H. Wang et al. / Journal of Cranio-Maxillo-Facial Surgery 42 (2014) 2041e2044
2. Materials and methods Between July 2010 and August 2013, eight male patients with oral perforated defects secondary to oral squamous cell carcinoma ablation, with immediate reconstruction by double anterior (anterolateral and anteromedial) thigh flaps (ALT flap and AMT flap) at the Department of Oral and Maxillofacial Surgery, Affiliated Stomatology Hospital of Kunming Medical University, were retrospectively enrolled into this study. No approval was needed from The Human Subjects Committee at Kunming University of Medical Science. All patients had advanced stage IV squamous cell carcinoma in the buccal mucosa which also involved part of the mandible or maxilla. Five patients presented with restricted mouth opening. The mean age of the patients was 50.4 years (range 42e61). Only one patient had a history of previous surgery, which involved an upper lip defect repaired by a nasolabial flap secondary to upper lip squamous cell carcinoma ablation. Prior to the reconstructive surgery, all patients received a spiral CT scan in which the data of the upper legs were acquired during a single arterial phase with the following scan parameters: 0.625 mm collimation; 1.0 mm slice thickness; and a slice reconstruction interval of 0.625 mm, and then imported into the commercial software program SimPlant Pro (version 11.04, Materialise NV, Leuven, Belgium). The lateral circumflex femoral artery (LCFA) was visually reconstructed on a computer and the points at which the lateral and medial branches arise from the LCFA and its perforator vessels were located in the horizontal and vertical plane (Fig. 1). Under general anaesthesia using nasoendotracheal intubation, all patients were operated on simultaneously by two teams. Using the modified lateral lip-submandibular approach, the initial incision began from the lower lip vermilion approximately 0.5 cm from the ipsilateral cheilion and then descending downward and backward along the nasolabial sulcus to about 1.5 cm beneath the inferior edge
Fig. 1. The lateral and medial branch of the LCFA was visually reconstructed.
of the mandible (Fig. 2). The cheek flap was raised along the surface of the marginal mandibular branch of the facial nerve, the lesion was exposed, and then the posterior partial maxillectomy and/or the superior partial mandibulectomy were performed along with the total excision of the lesion. In cases with involvement of the adjoining infratemporal fossa, the mandibular coronoid process and temporal muscle were included in the resection. The location of the perforator and the course of the artery were delineated onto the patient's thigh based on the preoperative reconstruction of the LCFA and the incision was made along the lateral branch of the LCFA (Fig. 3). After the ALT flap was harvested, the vascular pedicle of the ALT flap was dissected upward to its point of emergence from the branch of the descending LCFA, in which the medial branch of the descending LCFA was dissected downward to its perforator, and then the AMT flap including the partial rectus femoris muscle component was harvested on the basis of the lines drawn (Figs. 3 and 4). After the double anterior thigh flap was harvested for microscopic anastomoses, the donor wound was closed by primary intention in all cases. A functional neck dissection was performed in all patients. Finally, a suction drain was placed routinely for five days after the operation. Adjuvant radiotherapy was given postoperatively at a mean dose of 50.0 Gy. 3. Results All patients had combined bone and extensive soft-tissue defects. The area of the double anterior thigh flap with skin cover ranged from 4 7 cm to 8 12 cm. The musculocutaneous flaps were used to reconstruct the oral perforated defects as well as the partial mandible and the partial maxilla. Seven double flaps resulted in good functional and aesthetic outcomes with complete flap survival. One patient required operative exploration in the postoperative period due to thrombosis of the external jugular vein. After the salvage, one of the double flaps in the intraoral region suffered partial loss of the superficial skin. No functional impairment at the donor sites occurred in any patient. The patients were followed up for 8e30 months without evidence of local recurrence or postoperative trismus (Fig. 5).
Fig. 2. The modified lateral lip-submandibular approach.
W.H. Wang et al. / Journal of Cranio-Maxillo-Facial Surgery 42 (2014) 2041e2044
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Fig. 3. The design of the double anterior thigh flap.
4. Discussion The anterolateral thigh flap has gained in popularity in head and neck reconstructive surgery over other commonly used flaps, such as the radial forearm flap, scapular flap, parascapular flap, latissimus dorsi flap and abdominal perforator flap, because of its longer pedicle length, large surface area and the ability to tailor variable amounts of skin, muscle, fat, or fascia, as well as an associated low morbidity at the donor site (Agostini et al., 2013; Nasajpour and Steele, 2011; Park and Miles, 2011). Moreover, its versatility allows for the harvest of two independent flaps based on two individual musculocutaneous perforators or septocutaneous vessels from one donor site. This means the ALT flap can be folded for the reconstruction of both the inner and outer lining of through-andthrough cheek defects (Liu et al., 2013; Sun et al., 2014) and harvested with two small flaps for bilateral buccal mucosa reconstruction (Huang et al., 2010). However, in this situation with a large, full-thickness oral perforated defect involving partial mandibulectomy or partial maxillectomy, the free flaps should firstly contain the correct components and amount of tissue required to restore the intraoral and external defects and fulfil the functional and cosmetic requirements of the recipient defect. Secondly, two independent flaps with longer vessel pedicles should be considered as this allows for greater adjustment and for the flaps to be positioned smoothly.
Fig. 4. The harvested double anterior thigh flap.
Fig. 5. The frontal view four months after the operation.
The anteromedial thigh flap was first described by Song et al. in 1984. Over the last few decades, the AMT flap has been well described (Gong et al., 2014; Koshima et al., 1988; Xu et al., 2013). The AMT flap mostly shares the same grand vessel pedicle with the ALT flap, the former based on the medial branch of the descending LCFA which supplies the rectus femoris, and the latter based on the lateral branch of the descending LCFA which supplies the vastus lateralis, each with an isolated long vessel pedicle. Both own the common vessel, namely the LCFA, which arises from the branches of the profunda femoris artery. The branch of the descending LCFA runs inferolaterally behind the rectus femoris and then through the intermuscular space between the rectus femoris and vastus lateralis. According to different studies, the AMT flap can sometimes originate from the femoral artery or from the deep femoral artery (Ao et al., 1999; Cigna et al., 2014; Comert et al., 2011; Riva et al., 2013). Therefore, in this study all cases received a preoperative spiral CT scan, and the points at which the lateral and medial branches of the LCFA arise were visually located. Although the AMT flap presents some variation in vascular anatomy, it is a very good, reliable option for head and neck reconstruction when the ALT flap has already been used or in case of intraoperative failure or no sizable perforator (Liang et al., 2013). The AMT flap may even be used as a primary flap rather than as an alternative to the ALT flap or a component of a chimeric flap (Xu et al., 2013). A study by Ao et al. (1999) showed that deepithelialized anterior (anterolateral and anteromedial) thigh flaps could be used to fill space and for contour correction in head and neck surgery. Based on these studies, we have developed the technique of harvesting both the ALT and the AMT flaps with two independent long vessel pedicles from one donor site in the thigh region at the same time, which therefore can contribute to reducing the total operation time. Additionally, as demonstrated in our study, two
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W.H. Wang et al. / Journal of Cranio-Maxillo-Facial Surgery 42 (2014) 2041e2044
independent flaps can be used to reconstruct two soft-tissue defects, especially those involving partial mandibulectomy or partial maxillectomy and the temporal fossa. With the use of double anterior thigh flaps for defect reconstruction, all patients had good functional and aesthetic outcomes and only one patient had partial skin loss from one of the flaps in the intraoral region. Moreover, the five patients with advanced buccal carcinomas who preoperatively had restricted mouth opening regained satisfactory mouth opening after the coronoidectomy was performed. In addition, no trismus occurred in this series even after postoperative radiation. This may be attributed to the removal of the temporal muscle along with the complete obliteration of the resultant dead space and using adequate soft tissue thereby reducing fibrosis (Kekatpure et al., 2013). Furthermore, the incision at the donor site can be closed primarily, and the obvious scar can be concealed by clothing more easily than the other two donor sites (Huang et al., 2010). The split-lip incision and its modified incision have previously been used to perform a mandibulectomy in head and neck cancer patients (Nair et al., 2011; Sun et al., 2009). The satisfactory outcomes in our study supported the modified lateral lipsubmandibular approach. The symmetrical lower lip and the normal sensation of the lower lip contribute to the preservation of the marginal mandibular branch of the facial nerve and the mental nerve. The incision, which starts at about 0.5 cm from the ipsilateral cheilion, rather than the cheilion, can lead to normal mouth opening shortly after the operation. In addition, the modified incision has the advantages of wide exposure, low morbidity, and the recipient and supplying vessels can easily be adjusted and anastomosed in the same buccal region. 5. Conclusions In conclusion, this study suggests that the double anterior (anterolateral and anteromedial) thigh flap is a feasible and acceptable technique for the reconstruction of an oral perforated defect involving the mandible or maxilla through the modified lateral lip-submandibular approach. However, this technique has some disadvantages including texture mismatch with facial skin, bulkiness, and limitation of applicability in obese and female patients. Moreover, if a major full-thickness cheek defect is involved following extensive surgical resection, then an extensive pedicled supraclavicular fasciocutaneous island flap combined with an extended vertical lower trapezius island myocutaneous flap is the preferred technique (Chen et al., 2012). Also, if the defect involves a segmental mandibular defect or total maxillary defect, other techniques including osseocutaneous free tissue should be considered such as the fibula osteomyocutaneous flap flowthrough from radial forearm (He et al., 2009) or the scapular osseous free flap (Usami et al., 2014). Ethical approval Not required. Funding This work was supported by research grant D-201233 from the Health Department of Yunnan province. Conflict of interest All authors declare no conflict of interest. Acknowledgement This work was supported by the Department of Health, Yunnan Province under research grants D-201233.
References Agostini T, Lazzeri D, Spinelli G: Anterolateral thigh flap: systematic literature review of specific donor-site complications and their management. J Craniomaxillofac Surg 41: 15e21, 2013 Ahmad QG, Navadgi S, Agarwal R, Kanhere H, Shetty KP, Prasad R: Bipaddle pectoralis major myocutaneous flap in reconstructing full thickness defects of cheek: a review of 47 cases. J Plast Reconstr Aesthet Surg 59: 166e173, 2006 Ao M, Uno K, Maeta M, Nakagawa F, Saito R, Nagase Y: De-epithelialised anterior (anterolateral and anteromedial) thigh flaps for dead space filling and contour correction in head and neck reconstruction. Br J Plast Surg 52: 261e267, 1999 Chen WL, Yang ZH, Zhang DM, Huang ZQ, Fan S, Wang L: Reconstruction of major full cheek defects with combined extensive pedicled supraclavicular fasciocutaneous island flaps and extended vertical lower trapezius island myocutaneous flaps after ablation of advanced oral cancer. J Oral Maxillofac Surg 70: 1224e1231, 2012 Cigna E, Chen HC, Ozkan O, Sorvillo V, Maruccia M, Ribuffo D: The anteromedial thigh free flap anatomy: a clinical, anatomical, and cadaveric study. Plast Reconstr Surg 133: 420e429, 2014 Comert A, Altun S, Unlu RE, Orbay H, Tekdemir I: Perforating arteries of the anteromedial aspect of the thigh: an anatomical study regarding anteromedial thigh flap. Surg Radiol Anat 33: 241e247, 2011 Gong ZJ, Zhang S, Ren ZH, Zhu ZF, Liu JB, Wu HJ: Application of anteromedial thigh flap for the reconstruction of oral and maxillofacial defects. J Oral Maxillofac Surg 72: 1212e1225, 2014 He Y, Hg Zhu, Zy Zhang, He J, Sader R: Three-dimensional model simulation and reconstruction of composite total maxillectomy defects with fibula osteomyocutaneous flap flow-through from radial forearm flap. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 108: 6e12, 2009 Huang JJ, Wallace C, Lin JY, Tsao CK, Kao HK, Huang WC, et al: Two small flaps from one anterolateral thigh donor site for bilateral buccal mucosa reconstruction after release of submucous fibrosis and/or contracture. J Plast Reconstr Aesthet Surg 63: 440e445, 2010 Kang SH, Nam W, Cha IH, Kim HJ: Double continuous radial forearm flap for the reconstruction of full-thickness buccal cheek defect. J Plast Reconstr Aesthet Surg 62: 95e96, 2009 Katou F, Shirai N, Kamakura S, Ohki H, Motegi K: Full-thickness reconstruction of cheek defect involving oral commissure with forearm tendinocutaneous flap. Br J Oral Maxillofac Surg 34: 26e27, 1996 Kekatpure V, Manjula B, Mathias S, Trivedi N, Selvam S, Kuriakose M: Reconstruction of large composite buccal defects using single soft tissue flapeanalysis of functional outcome. Microsurgery 33: 184e190. http://dx.doi.org/10.1002/ micr.22063, 2013 Epub 22012 Dec 22019 Kilinc H, Geyik Y, Aytekin AH: Double-skin paddled superficial temporofascial flap for the reconstruction of full-thickness cheek defect. J Craniofac Surg 24: 92e95, 2013 Koshima I, Soeda S, Yamasaki M, Kyou J: The free or pedicled anteromedial thigh flap. Ann Plast Surg 21: 480e485, 1988 Liang CC, Jeng SF, Yang JC, Chen YC, Hsieh CH: Use of anteromedial thigh flaps as an alternative to anterolateral thigh flaps for reconstruction of head and neck defects in cancer patients. Ann Plast Surg 71: 375e379, 2013 Liu ZM, Wu D, Liu XK, Liu WW, Li H, Li Q, et al: Reconstruction of through-andthrough cheek defects with folded free anterolateral thigh flaps. J Oral Maxillofac Surg 71: 960e964, 2013 Nair S, Sridhar KR, Shah A, Kumar B, Nayak K, Shetty P: Maxillectomy through mandibulotomydA retrospective clinical review. J Oral Maxillofac Surg 69: 2040e2047, 2011 Nasajpour H, Steele MH: Anterolateral thigh free flap for “head-to-toe” reconstruction. Ann Plast Surg 66: 530e533, 2011 Park CW, Miles BA: The expanding role of the anterolateral thigh free flap in head and neck reconstruction. Curr Opin Otolaryngol Head Neck Surg 19: 263e268, 2011 Riva FM, Tan NC, Liu KW, Hsieh CH, Jeng SF: Anteromedial thigh perforator free flap: report of 41 consecutive flaps and donor-site morbidity evaluation. J Plast Reconstr Aesthet Surg 66: 1405e1414, 2013 Savant DN, Patel SG, Deshmukh SP, Gujarati R, Bhathena HM, Kavarana NM: Folded free radial forearm flap for reconstruction of full-thickness defects of the cheek. Head Neck 17: 293e296, 1995 Song YG, Chen GZ, Song YL: The free thigh flap: a new free flap concept based on the septocutaneous artery. Br J Plast Surg 37: 149e159, 1984 Sun G, Lu M, Hu Q, Tang E: Reconstruction of extensive through-and-through cheek defects with free anterolateral thigh flap. J Craniofac Surg 25: 31e38, 2014 Sun J, Shen Y, Weng Y-Q, Li J, Zhang Z-Y: Lateral lip-splitting approach for total and subtotal maxillectomy. J Oral Maxillofac Surg 67: 1197e1205, 2009 Usami S, Okazaki M, Tanaka K, Homma T, Yano T: Lengthening the pedicle of a scapular osseous free flap by angular branch reconnection within the subscapular artery system. Microsurgery 34: 662e665, 2014 Valentini V, Saltarel A, Cassoni A, Battisti A, Egidi S: One-stage reconstruction of a defect of the oral commissure and of the cheek with a radial forearm free flap. J Craniofac Surg 19: 1508e1511, 2008 Xu ZF, Sun CF, Duan WY, Zhang EJ, Dai W, Zheng XJ, et al: Clinical anatomical study and evaluation of the use of the free anteromedial thigh perforator flaps in reconstructions of the head and neck. Br J Oral Maxillofac Surg 51: 725e730, 2013
Contents lists available at ScienceDirect
Journal of Cranio-Maxillo-Facial Surgery journal homepage: www.jcmfs.com
Double anterior (anterolateral and anteromedial) thigh flap for oral perforated defect reconstruction W.H. Wang a, *, J.Y. Deng b, B. Xu a, J. Zhu a, B. Xia a, B.J. Zhang a a b
Department of Oral and Maxillofacial Surgery, Affiliated Stomatology Hospital of Kunming Medical University, Kunming 650031, China Department of Computer Tomography, Second Affiliated Hospital of Kunming Medical University, Kunming 650101, China
a r t i c l e i n f o
a b s t r a c t
Article history: Paper received 14 July 2014 Accepted 25 September 2014 Available online 5 October 2014
Objective: The purpose of this study was to assess the therapeutic efficacy of oral perforated defect reconstruction with a double anterior (anterolateral and anteromedial) thigh flap through the modified lateral lip-submandibular approach. Materials and methods: From July 2010 to August 2013, eight patients with oral perforated defects secondary to oral cancer ablation involving the superior partial mandible or the posterior partial maxilla, with immediate reconstruction by double anterior (anterolateral and anteromedial) thigh flaps, were retrospectively enrolled into this study. Results: All double anterior flaps were musculocutaneous flaps. Seven double flaps resulted in good functional and aesthetic outcomes with complete flap survival. One patient required operative exploration in the postoperative period due to thrombosis in the external jugular vein. After the salvage, one of the double flaps in the intraoral region resulted in partial failure of the superficial skin of the flap. No functional impairment at the donor sites occurred in any of the cases. Conclusion: The double anterior (anterolateral and anteromedial) thigh flap is a feasible and acceptable technique for reconstruction of an oral perforated defect involving the mandible or the maxilla through the modified lateral lip-submandibular approach. It presents a very acceptable aesthetic and functional result with the additional advantage of low morbidity at the donor site. © 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
Keywords: Double anterior (anterolateral and anteromedial) thigh flap Oral perforated defect Reconstruction Modified lateral lip-submandibular approach
1. Introduction An oral perforated defect always results in substantial aesthetic and functional sequelae such as malformation of the facial contour, impairment of speech, and difficulty swallowing, which in turn impacts on the quality of life of the affected patients if reconstruction is not carried out immediately. It is widely accepted that simultaneous restoration of the oral perforated defect is now the standard protocol. For the primary repair of a full-thickness oral perforated defect, several techniques have been demonstrated in previous studies, for instance, double-skin paddled superficial temporofascial flap (Kilinc et al., 2013) and folded radial forearm flap (Kang et al., 2009; Katou et al., 1996; Savant et al., 1995; Valentini et al., 2008). Although these techniques can result in functionally satisfactory outcomes, several disadvantages, such as * Corresponding author. Department of Oral and Maxillofacial Surgery, Affiliated Stomatology Hospital of Kunming Medical University, China. Tel.: þ86 0871 65330099; fax: þ86 0871 65330116. E-mail address: [email protected] (W.H. Wang).
hyperpigmentation and temporal alopecia at the temporal site (Kilinc et al., 2013); numbness and poor aesthetic outcome of the forearm; and sacrificing the radial artery, which may have an association with the depression of pinch and grip strength, could not be overcome (Kang et al., 2009; Katou et al., 1996; Savant et al., 1995; Valentini et al., 2008). Moreover, these procedures frequently fail to provide enough tissue, especially for large, fullthickness oral perforated defects involving the mandible or maxilla. The bipaddle pectoralis major myocutaneous flap can offer an alternative method for the reconstruction of large and fullthickness cheek defects (Ahmad et al., 2006). However, the drawbacks of this method include loss of the nipple and limitation of applicability in females or in patients who do not need a radical neck dissection. In this study, we have developed a double anterior (anterolateral and anteromedial) thigh flap to restore oral perforated defects involving the superior mandible or the posterior maxilla. The method achieved a satisfactory appearance and functional speech in all patients, and resulted in only slight complications.
http://dx.doi.org/10.1016/j.jcms.2014.09.011 1010-5182/© 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
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W.H. Wang et al. / Journal of Cranio-Maxillo-Facial Surgery 42 (2014) 2041e2044
2. Materials and methods Between July 2010 and August 2013, eight male patients with oral perforated defects secondary to oral squamous cell carcinoma ablation, with immediate reconstruction by double anterior (anterolateral and anteromedial) thigh flaps (ALT flap and AMT flap) at the Department of Oral and Maxillofacial Surgery, Affiliated Stomatology Hospital of Kunming Medical University, were retrospectively enrolled into this study. No approval was needed from The Human Subjects Committee at Kunming University of Medical Science. All patients had advanced stage IV squamous cell carcinoma in the buccal mucosa which also involved part of the mandible or maxilla. Five patients presented with restricted mouth opening. The mean age of the patients was 50.4 years (range 42e61). Only one patient had a history of previous surgery, which involved an upper lip defect repaired by a nasolabial flap secondary to upper lip squamous cell carcinoma ablation. Prior to the reconstructive surgery, all patients received a spiral CT scan in which the data of the upper legs were acquired during a single arterial phase with the following scan parameters: 0.625 mm collimation; 1.0 mm slice thickness; and a slice reconstruction interval of 0.625 mm, and then imported into the commercial software program SimPlant Pro (version 11.04, Materialise NV, Leuven, Belgium). The lateral circumflex femoral artery (LCFA) was visually reconstructed on a computer and the points at which the lateral and medial branches arise from the LCFA and its perforator vessels were located in the horizontal and vertical plane (Fig. 1). Under general anaesthesia using nasoendotracheal intubation, all patients were operated on simultaneously by two teams. Using the modified lateral lip-submandibular approach, the initial incision began from the lower lip vermilion approximately 0.5 cm from the ipsilateral cheilion and then descending downward and backward along the nasolabial sulcus to about 1.5 cm beneath the inferior edge
Fig. 1. The lateral and medial branch of the LCFA was visually reconstructed.
of the mandible (Fig. 2). The cheek flap was raised along the surface of the marginal mandibular branch of the facial nerve, the lesion was exposed, and then the posterior partial maxillectomy and/or the superior partial mandibulectomy were performed along with the total excision of the lesion. In cases with involvement of the adjoining infratemporal fossa, the mandibular coronoid process and temporal muscle were included in the resection. The location of the perforator and the course of the artery were delineated onto the patient's thigh based on the preoperative reconstruction of the LCFA and the incision was made along the lateral branch of the LCFA (Fig. 3). After the ALT flap was harvested, the vascular pedicle of the ALT flap was dissected upward to its point of emergence from the branch of the descending LCFA, in which the medial branch of the descending LCFA was dissected downward to its perforator, and then the AMT flap including the partial rectus femoris muscle component was harvested on the basis of the lines drawn (Figs. 3 and 4). After the double anterior thigh flap was harvested for microscopic anastomoses, the donor wound was closed by primary intention in all cases. A functional neck dissection was performed in all patients. Finally, a suction drain was placed routinely for five days after the operation. Adjuvant radiotherapy was given postoperatively at a mean dose of 50.0 Gy. 3. Results All patients had combined bone and extensive soft-tissue defects. The area of the double anterior thigh flap with skin cover ranged from 4 7 cm to 8 12 cm. The musculocutaneous flaps were used to reconstruct the oral perforated defects as well as the partial mandible and the partial maxilla. Seven double flaps resulted in good functional and aesthetic outcomes with complete flap survival. One patient required operative exploration in the postoperative period due to thrombosis of the external jugular vein. After the salvage, one of the double flaps in the intraoral region suffered partial loss of the superficial skin. No functional impairment at the donor sites occurred in any patient. The patients were followed up for 8e30 months without evidence of local recurrence or postoperative trismus (Fig. 5).
Fig. 2. The modified lateral lip-submandibular approach.
W.H. Wang et al. / Journal of Cranio-Maxillo-Facial Surgery 42 (2014) 2041e2044
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Fig. 3. The design of the double anterior thigh flap.
4. Discussion The anterolateral thigh flap has gained in popularity in head and neck reconstructive surgery over other commonly used flaps, such as the radial forearm flap, scapular flap, parascapular flap, latissimus dorsi flap and abdominal perforator flap, because of its longer pedicle length, large surface area and the ability to tailor variable amounts of skin, muscle, fat, or fascia, as well as an associated low morbidity at the donor site (Agostini et al., 2013; Nasajpour and Steele, 2011; Park and Miles, 2011). Moreover, its versatility allows for the harvest of two independent flaps based on two individual musculocutaneous perforators or septocutaneous vessels from one donor site. This means the ALT flap can be folded for the reconstruction of both the inner and outer lining of through-andthrough cheek defects (Liu et al., 2013; Sun et al., 2014) and harvested with two small flaps for bilateral buccal mucosa reconstruction (Huang et al., 2010). However, in this situation with a large, full-thickness oral perforated defect involving partial mandibulectomy or partial maxillectomy, the free flaps should firstly contain the correct components and amount of tissue required to restore the intraoral and external defects and fulfil the functional and cosmetic requirements of the recipient defect. Secondly, two independent flaps with longer vessel pedicles should be considered as this allows for greater adjustment and for the flaps to be positioned smoothly.
Fig. 4. The harvested double anterior thigh flap.
Fig. 5. The frontal view four months after the operation.
The anteromedial thigh flap was first described by Song et al. in 1984. Over the last few decades, the AMT flap has been well described (Gong et al., 2014; Koshima et al., 1988; Xu et al., 2013). The AMT flap mostly shares the same grand vessel pedicle with the ALT flap, the former based on the medial branch of the descending LCFA which supplies the rectus femoris, and the latter based on the lateral branch of the descending LCFA which supplies the vastus lateralis, each with an isolated long vessel pedicle. Both own the common vessel, namely the LCFA, which arises from the branches of the profunda femoris artery. The branch of the descending LCFA runs inferolaterally behind the rectus femoris and then through the intermuscular space between the rectus femoris and vastus lateralis. According to different studies, the AMT flap can sometimes originate from the femoral artery or from the deep femoral artery (Ao et al., 1999; Cigna et al., 2014; Comert et al., 2011; Riva et al., 2013). Therefore, in this study all cases received a preoperative spiral CT scan, and the points at which the lateral and medial branches of the LCFA arise were visually located. Although the AMT flap presents some variation in vascular anatomy, it is a very good, reliable option for head and neck reconstruction when the ALT flap has already been used or in case of intraoperative failure or no sizable perforator (Liang et al., 2013). The AMT flap may even be used as a primary flap rather than as an alternative to the ALT flap or a component of a chimeric flap (Xu et al., 2013). A study by Ao et al. (1999) showed that deepithelialized anterior (anterolateral and anteromedial) thigh flaps could be used to fill space and for contour correction in head and neck surgery. Based on these studies, we have developed the technique of harvesting both the ALT and the AMT flaps with two independent long vessel pedicles from one donor site in the thigh region at the same time, which therefore can contribute to reducing the total operation time. Additionally, as demonstrated in our study, two
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W.H. Wang et al. / Journal of Cranio-Maxillo-Facial Surgery 42 (2014) 2041e2044
independent flaps can be used to reconstruct two soft-tissue defects, especially those involving partial mandibulectomy or partial maxillectomy and the temporal fossa. With the use of double anterior thigh flaps for defect reconstruction, all patients had good functional and aesthetic outcomes and only one patient had partial skin loss from one of the flaps in the intraoral region. Moreover, the five patients with advanced buccal carcinomas who preoperatively had restricted mouth opening regained satisfactory mouth opening after the coronoidectomy was performed. In addition, no trismus occurred in this series even after postoperative radiation. This may be attributed to the removal of the temporal muscle along with the complete obliteration of the resultant dead space and using adequate soft tissue thereby reducing fibrosis (Kekatpure et al., 2013). Furthermore, the incision at the donor site can be closed primarily, and the obvious scar can be concealed by clothing more easily than the other two donor sites (Huang et al., 2010). The split-lip incision and its modified incision have previously been used to perform a mandibulectomy in head and neck cancer patients (Nair et al., 2011; Sun et al., 2009). The satisfactory outcomes in our study supported the modified lateral lipsubmandibular approach. The symmetrical lower lip and the normal sensation of the lower lip contribute to the preservation of the marginal mandibular branch of the facial nerve and the mental nerve. The incision, which starts at about 0.5 cm from the ipsilateral cheilion, rather than the cheilion, can lead to normal mouth opening shortly after the operation. In addition, the modified incision has the advantages of wide exposure, low morbidity, and the recipient and supplying vessels can easily be adjusted and anastomosed in the same buccal region. 5. Conclusions In conclusion, this study suggests that the double anterior (anterolateral and anteromedial) thigh flap is a feasible and acceptable technique for the reconstruction of an oral perforated defect involving the mandible or maxilla through the modified lateral lip-submandibular approach. However, this technique has some disadvantages including texture mismatch with facial skin, bulkiness, and limitation of applicability in obese and female patients. Moreover, if a major full-thickness cheek defect is involved following extensive surgical resection, then an extensive pedicled supraclavicular fasciocutaneous island flap combined with an extended vertical lower trapezius island myocutaneous flap is the preferred technique (Chen et al., 2012). Also, if the defect involves a segmental mandibular defect or total maxillary defect, other techniques including osseocutaneous free tissue should be considered such as the fibula osteomyocutaneous flap flowthrough from radial forearm (He et al., 2009) or the scapular osseous free flap (Usami et al., 2014). Ethical approval Not required. Funding This work was supported by research grant D-201233 from the Health Department of Yunnan province. Conflict of interest All authors declare no conflict of interest. Acknowledgement This work was supported by the Department of Health, Yunnan Province under research grants D-201233.
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