ORIGINAL ARTICLE
Refinement of the myocutaneous anterolateral thigh flap for reconstruction of frontonasal fistula defects Chih-Wei Wu, MD,1,2 Ian L. Valerio, MD, MS, MBA,3,4 Jung-Ju Huang, MD,1,2 Kai-Ping Chang, MD, PhD,5 Ming-Huei Cheng, MD, MBA1,2* 1
Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University Medical College, Taoyuan, Taiwan, 2Center for Tissue Engineering, Chang Gung Memorial Hospital, Taoyuan, Taiwan, 3Department of Plastic Surgery, Division of Burn, Wound, and Trauma, Wexner Medical Center at the Ohio State University, Columbus, Ohio, 4Department of Plastic and Reconstructive Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, 5 Department of Otolaryngology–Head and Neck Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan.
Accepted 6 March 2015 Published online 15 July 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/hed.24038
ABSTRACT: Background. Frontonasal fistulas can lead to lifethreatening intracranial infections. Our refinement of the myocutaneous anterolateral thigh (ALT) flap for treating these fistulas is described. Methods. A retrospective review of the microsurgical treatment of frontonasal fistulas is presented. Demographics, etiologies, outcomes, and complications were evaluated. Results. Ten myocutaneous ALT flaps were used to reconstruct frontonasal fistula. The mean follow-up was 35 6 2.5 months. Nine fistulas were secondary to oncologic resections, and one was due to a traumatic origin. Complications included a recurrent abscess in 1 case (10%); there were no cases of cerebrospinal fluid (CSF) leak or flap loss. Preoperative intracranial infections were present in 7 cases, with 6 success-
INTRODUCTION Frontonasal fistulas are potentially life-threatening situations that pose serious clinical problems for the neurosurgeon and reconstructive surgeon. These fistulas can lead to refractory leakage of cerebrospinal fluid (CSF), exposing the intracranial space to the external environment by way of the nasal cavity. This situation greatly increases the risk of potential ascending infections, with an associated 10% risk of developing overt meningitis annually.1–3 Additionally, meningoencephalitis, pneumoencephalon, and cerebral hernias are other serious clinical entities that can result from these fistulas.4 The most common causes of CSF leaks and frontonasal fistulas involve posttraumatic injuries, subcategorized into either accidental or iatrogenic, and nontraumatic injuries, such as oncologic resections and extirpation procedures.1 Oncologic cases deserve special consideration, as preoperative and/or postoperative radiation therapy, chemotherapy, and history of multiple reoperations significantly
*Corresponding author: M.-H. Cheng, Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan, 5, Fu-Hsing Street, Kweishan, Taoyuan 333, Taiwan. E-mail: [email protected] Chih-Wei Wu and Ian L. Valerio contributed equally to this work.
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fully resolving their infection after surgical intervention and flap obliteration of their fistulas. Conclusion. Refinements in the myocutaneous ALT flap design have been illustrated to provide robust dead-space obliteration with vascularized muscle and reliable simultaneous scalp coverage in the treatment C 2015 Wiley Periodicals, Inc. Head Neck 38: of frontonasal fistulas. V E552–E558, 2016
KEY WORDS: anterolateral thigh (ALT) flap, myocutaneous ALT flap, vascularized free tissue transfer, head and neck reconstruction, frontonasal fistulas, cerebrospinal fluid (CSF) leakage
increases the incidence of CSF leaks, fistulas, and other complications; thus, vascularized tissue procedures are most often indicated to successfully salvage these complex cases.5,6 Other less common nontraumatic causes worth mentioning include complex congenital skull malformations, meningoceles, meningoencephaloceles, as well as other inflammatory conditions.5,6 The most common surgical procedures that can lead to frontonasal fistulas consist of functional endoscopic sinus surgeries and complex neurosurgical cases.6 Often, these fistulas can be encountered in large oncologic operations because the extirpation of the tumor can lead to large composite defects involving varying amounts of soft tissue, bone, and dura.7 These larger, composite tissue defects typically require substantial amounts of replacement vascularized tissue to repair and completely obliterate the connections between the extracranial and intracranial environments. The first reported case of frontonasal fistula treatment was by Dandy, who described a frontal craniotomy approach in 1926. In 1948, Dohlman described the first extracranial approach, and, in 1981, Wigand is credited with performing the first endoscopic repair.6 Although the endoscopic repair has mostly replaced the need for open craniotomy procedures for simple or minor types of frontonasal fistulas, large or more complex composite defect cases still require open procedures to address the
ANTEROLATERAL
significant tissue loss. Furthermore, certain refractory cases that are not amenable to endoscopic repair or that have previously failed more conservative fistula repair attempts may also necessitate an open repair. Thus, for these aforementioned cases, the treatment methods can be categorized into 2 main categories. The first is avascular tissue options, and the second involves the use of vascularized tissue. Although avascular options exist, many authors have reported better results with vascularized tissues over time.8 Free tissue transfer provides a better environment for wound healing, a source of vascularized tissue, and important growth factors, as well as decreased complication rates when used to treat frontonasal fistulas.7 This situation is especially critical in those patients who have undergone several prior surgical attempts to close frontonasal fistulas and who lack locoregional flaps. Often, local flaps are unavailable because of the significant scarring, prior radiation therapy injuries, losses from failed use of prior locoregional flaps, and/or insufficient tissue provided from these flaps.8 In taking into account the aforementioned issues, many patients with frontonasal fistulas may be ideal candidates for free tissue transfers. Many different types of flaps (eg, rectus abdominis, latissimus dorsi, radial forearm, scapula, omentum, and fascia lata) have been described in the treatment of frontonasal fistulas.9 The purpose of this study was to report our experience and modifications of the myocutaneous anterolateral thigh (ALT) flap specifically for the treatment of frontonasal fistulas.
PATIENTS AND METHODS A retrospective review of all frontonasal fistulas reconstructed with vascularized free tissue transfer from 2001 until 2009 at Chang Gung Memorial Hospital by the senior surgeon (M.H.C.) was performed. The medical records of each patient were reviewed to identify patient demographics, such as patient age and sex. The other data reviewed included the etiology of the patients’ frontonasal fistulas, the type of free tissue transfers utilized for their reconstructions, and the CT scans of these patients. The evaluated clinical outcomes included the rates of infectious complications, both preoperatively and postoperatively, resolution of preoperative infections by way of vascularized flap transfer and antibiotic therapy, postoperative CSF leakage rates, and the survival rates after flap transfer procedures. During the course of treating frontonasal fistulas, the senior surgeon transitioned from using buried microsurgical muscle flaps to a myocutaneous ALT flap because of the following benefits: (1) an externalized skin paddle to detect possible flap failure or problems early, (2) a source of additional skin to aid in releasing the scalp contractures or scars that resulted from their injuries and assisted in tension free closure, and (3) a buried muscle component to obliterate dead space and separate the intracranial space from the external environment/nasal cavity. Additionally, in cases in which a significant dural defect was encountered, a portion of conjoined tensor fascia lata (TFL) could also be harvested and used as neo-dura, if the dura required repair. The refinement in the design of
THIGH FLAP FOR FRONTONASAL FISTULA
the myocutaneous ALT flap for the application to treating frontonasal fistulas is outlined in Figure 1.
Surgical technique As described but modified from a report by Ali et al,10 Bernier et al,11 and Huang et al,12 the flap modifications of the myocutaneous ALT flap for frontonasal fistulas reconstruction are as follows. The myocutaneous ALT flap is marked with the patient lying in a supine position. The majority of myocutaneous perforators that nourish the skin paddle are located within a circle with a 3-cm radius around the midpoint of the longitudinal axis, extending between the anterior superior iliac spine and the superolateral patella. These perforators can be mapped with a handheld Doppler probe. The skin paddle is typically designed in an ellipse pattern centered on the selected previously Doppler identified perforator(s), with the skin island positioned more proximal to the underlying VL muscle that is to be included (see Figure 1). The proximal location of the skin island is critical, as this portion of the flap will be used to provide external coverage of the existing scalp defect and/or be used to replace any unwanted or unstable scars. Furthermore, the myocutaneous ALT flap vascular pedicle also typically exits from the proximal aspect, which allows for favorable positioning during anastomosis to the superficial temporal artery and veins. The vastus lateralis (VL) muscle portion of the flap is based on a separate myocutaneous perforator(s), which provides a well-vascularized distal-based muscle to obliterate and seal the frontonasal fistula defect (see Figure 2). Beginning with an incision along the medial border of the previously described flap markings, soft tissue dissection through the subcutaneous tissue and then through the rectus femoris muscle fascia is performed. As one proceeds laterally through a subfascial dissection plane, the intermuscular septum can soon be visualized. At this point, the rectus femoris muscle is then retracted medially, which exposes the descending branch of the lateral circumflex femoral artery (LCFA) and its accompanying veins can be identified. Continuing in a proximal and lateral direction, the myocutaneous perforators supplying the skin paddle are identified and preserved. Retrograde intramuscular dissection of the selected myocutaneous perforator(s) is performed to preserve their continuity to their parent or main pedicle (LCFA). Care is taken to dissect and preserve as much of the main pedicle as possible, as adequate pedicle length will be required to permit eventual anastomosis to the superficial temporal vessels. Occasionally, if the source vessel is the transverse branch of the LCFA, a longer and more careful intramuscular dissection is often required to gain necessary pedicle length. The septocutaneous perforators of the skin island portion of the flap, when present, are usually located in the most proximal aspect of the flap design, and these perforators follow a relatively shorter pathway to the parent or main vessel (LCFA). The distal VL muscle component typically measures approximately 6 3 15 cm in our experience, but the muscle portion of the flap can be customized to the size of the defect to be covered. Care is taken during dissection to ensure the inclusion of at least 1 muscle perforator HEAD & NECK—DOI 10.1002/HED
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FIGURE 1. (A) Frontonasal defect before flap placement. (B) Frontonasal defect obliterated with a myocutaneous anterolateral thigh (ALT) flap.
and/or any muscular branch from the main pedicle. Furthermore, during the dissection of the VL muscle flap, care is taken to spare the motor nerve for preservation of motor innervation to the remaining quadriceps musculature. Most commonly, the motor nerve tends to run in a superolateral direction and accompanies the main pedicle to the myocutaneous ALT flap. In some cases, the motor nerve will cross over the main myocutaneous ALT vascular pedicle, and, in such cases, it may be transected with immediate coaptation and repair after dissection and transfer of the myocutaneous ALT flap from its donor site. The ALT skin paddle and VL muscle can either be commonly harvested together as a true musculocutaneous flap (9 cases); however, in certain select cases, each component many be dissected separately and used as a more versatile chimeric flap option (1 case). Finally, one may also include a portion of the TFL during harvest in order to provide a vascularized fascial component for aiding in the repair of dura defects, when indicated. Once neurosurgical debridement and recipient site preparation of the frontonasal fistula is complete, a single burr hole of 1 3 2 cm is placed on the side of the temporal bone in which the flap vascular pedicle is to exit the skull. Often, a small portion of the superficial temporalis muscle was removed or partially divided as well to avoid
kinking and/or compression of the flap pedicle. Attention can then be turned to transferring the myocutaneous ALT flap to the resulting frontonasal, skull, and external craniofacial/scalp skin defect (see Figure 1). The main pedicle to the flap can then be divided, with the myocutaneous ALT flap transferred for inset into the frontonasal defect. The neurosurgical team prepares and tents the dura to integrate it with the VL muscle or TFL portion of the flap. The distal VL muscle is carefully inset into the frontonasal fistula to ensure complete obliteration of the fistula. First, the muscle flap is secured distally through pilot drill holes placed within the bony skeleton of the skull. Second, the muscle flap is secured proximally with sutures to the previously prepared dura (see Figure 3). After ensuing adequate and sufficient obliteration of the fistula defect with the muscle component of the flap, the myocutaneous ALT skin paddle is inset into the scalp defect in a manner to aid in wound closure while also providing additional skin/soft tissue coverage to protect the pedicle. In our experience, the pedicle length required to sufficiently reach the ipsilateral superficial temporal recipient vessels is approximately 12 to 15 cm (Figure 3).13 The microsurgical anastomoses proceed, usually with the arterial anastomosis performed first, which is followed by the venous anastomosis after adequate backflow from the vein is visualized and
FIGURE 2. Myocutaneous anterolateral thigh (ALT) flap design.
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THIGH FLAP FOR FRONTONASAL FISTULA
FIGURE 3. Schematic drawings for the inset of the myocutaneous anterolateral thigh (ALT) flap, the distal vastus lateralis (VL) muscle part was wrapping around and pulled by 2-0 silk to reach the frontonasal fistula. The pedicle, which was 12 to 15 in length) was passed through a widened burr hole to anastomose to the ipsilateral superficial temporal vessels. (A) Anterior-posterior view, (B) lateral view.
confirmed. In cases with inadequate backflow of the superficial temporal vein, the vein grafting to the facial vein or to a recipient vein within the neck region should then be performed. The skull bone, if not compromised by infection, is then returned to its proper place and fixed with miniplates. In cases in which the skull plate is compromised by infection, delayed definitive skull reconstruction can be performed with alloplastic or autologous bone grafting after approximately 6 months once the infection has cleared. The remaining scalp and surrounding skin is then used to cover any exposed VL muscle as well as inset to the skin island of the flap (see Figure 4). One hemovac drainage system is placed underneath the flap to aid in drainage and to prevent fluid accumulation and/or hematoma collection.
RESULTS A total of 10 cases of frontonasal fistulas were reconstructed with a vascularized anterolateral thigh or its modification transfer. Of the 10 cases, 8 patients were men and 2 were women. The mean age of the patients was 53.9 6 12.8 years (range, 29–67 years). The average postoperative follow-up was 35.2 6 22.5 months (range, 2.5– 66.8 months). The types of flaps used for these reconstructions consisted of 8 myocutaneous ALTs, 1 VL, and 1 chimeric ALT flap (Table 1). Fortunately, for these patients, there were no cases of either total and/or partial failures in this particular series of myocutaneous ALT vascularized free tissue transfers. When closely examining the patients who underwent treatment of their frontonasal fistulas, 9 cases (90%) resulted from oncologic extirpation surgeries, and the remaining single case (10%) was secondary to trauma (Table 1). Infections associated with fistula were present
in 7 of the 10 cases before their myocutaneous ALT flap reconstruction salvage surgeries. These preoperative infections consisted of 6 cases of frontal epidural abscesses and 1 case of a subdural abscess. All of these infections were cleared after appropriate debridement, successful vascularized tissue transfer, and completion of their antibiotic therapies. There was one exception to the complete resolution for the cases having infection, with 1 patient (10%) experiencing a recurrence of infection and abscess 173 days after his salvage flap reconstructive procedure. There were no cases of continued CSF leakage after flap reconstruction, and the overall survival rate was 100% in this series of reviewed cases.
DISCUSSION The surgical correction of frontonasal fistulas and resulting CSF leaks can be traced back to the early 20th century.6 Although a majority of these fistulas and CSF leaks will typically close spontaneously within a period of 7 to 10 days, a certain number will be refractory and require further intervention.6 Additionally, certain tumor extirpative defects, especially those associated with preoperative or postoperative radiotherapy, often can have more significant dural injuries and/or involvement that will warrant dural repair and coverage as well as unstable scarring and scalp issues where vascularized tissue is preferable.5,6 For many frontonasal fistulas that are a components of more complex composite tissue defects, endosurgical procedures usually cannot provide adequate soft tissue rearrangement for definitive reconstruction. Therefore, pedicled flap or microsurgical flap coverage is often required to address these fistulas.5,6 Many microvascular tissue transfer options have been previously described in the literature for the treatment of HEAD & NECK—DOI 10.1002/HED
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FIGURE 4. (A) Example of a preoperative frontonasal fistula case. (B) Postoperative result after flap inset. (C) Preoperative CT scan demonstrating the frontonasal fistula. (D) Postoperative CT scan revealing obliteration of the frontonasal fistula with a myocutaneous anterolateral thigh (ALT) flap.
frontonasal fistula. Examples of free flaps that have been reported for surgically treating these fistulas include the radial forearm, latissimus dorsi, serratus anterior, gracilis, rectus abdominis, flaps.7–9 The radial forearm and ulnar forearm flap are reliable, thin, pliable, and wellvascularized flap options, yet these flaps typically cannot provide sufficient bulky tissue to obliterate larger composite defects.14–16 Furthermore, the fasciocutaneous skin islands of these flaps may provide either good internal coverage or external coverage, but they cannot always reliably provide both because of their anatomic and vascular pedicle/perforator restraints. The latissimus dorsi muscle and its perforator derivatives, such as the thoracodorsal artery perforator flap, can also be used to treat frontonasal fistulas.9,17 These flap options provide both substantial healthy skin and muscle, if desired; however, these flaps have 3 important disadvantages. The first issue lies in the patient positioning changes that are usually necessary to harvest the flap.9 Therefore, access to both the defect and donor sites is not ideal. Second, the latissimus dorsi donor site tends to have higher morbidity, including higher rates of seroma, hematoma, contour irregularity, scar tethering, and scar hypertrophy as compared to other flap donor sites.18,19 The serratus anterior, with its relatively narrow and long muscle structure, is a good option to obliterate a frontonasal fistula. It can be harvested in a supine position and combined with the latissimus dorsi myocutaneous flap or the thoracodorsal artery perforator flap, allowing a chimeric flap design to reconstruct a complex craniofacial defect.20 However, a 2-team approach is E556
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difficult and winged scapula can happen if the long thoracic nerve is injured. Although the rectus abdominis and its perforator flap derivatives have also been described for skull reconstruction cases, the inability to utilize its perforator system for performing chimeric options, coupled with the inherent difficulty of molding the muscle component independent of its overlying skin island, is disadvantageous.21,22 Finally, the possibility of abdominal weakness or hernias after harvesting this flap, especially in cases in which the entire muscle is taken, makes the important donor site morbidities concerning, particularly in male patients.9 With respect to the ALT flap and its myocutaneous derivative, these flaps have many intrinsic advantages. First, the myocutaneous ALT can be harvested with a dimension of up to 8 3 22 cm, providing ample fasciocutaneous or skin island components as well as muscle for both scalp coverage and/or obliteration of larger defects, respectively.10–12,23 Even with a myocutaneous ALT harvested in these dimensions, the donor site can easily be closed first without any significant complication risks as well as with acceptable aesthetic results. Moreover, during the harvest of the VL muscle component, care to preserve the motor nerve branch to the remaining vastus and quadriceps musculature can greatly lessen the morbidity to knee extension and lower extremity strength.24 Another important advantage of this flap is that the externalized portion of the skin paddle can easily be used for monitoring. The ability to detect early flap failure or problems is crucial in the setting of using flaps for treating frontonasal fistulas and other intracranial defects.
ANTEROLATERAL
THIGH FLAP FOR FRONTONASAL FISTULA
TABLE 1. Demographics, Diagnoses, Types of Flaps and Outcomes of 11 Patients Who Underwent Reconstruction of Frontonasal Fistula Defects.
No. of patients Sex Age, y
1
M
55
2
M
29
3
M
68
4
M
53
5
M
67
6
M
56
7
M
33
8
F
60
9 10
F M
63 61
11
M
62
Diagnosis with frontonasal fistulas
Brain tumor, frontal epidural abscess* Traumatic ICH s/p, frontotemporal subdural abscess* Supra-orbital ridge osteoradionecrosis, frontal epidural abscess* Olfactory neuroblastoma, frontal bone necrosis and abscess* Frontal base epidural abscess* Malignant neoplasm of cerebrum, frontal lobe defect Sinonasal undifferentiated cancer s/p concomitant chemoradiation therapy with recurrent cancer Epidural abscess, osteoradionecrosis, frontal skin defect Nasal carcinoma Nasal carcinoma, frontal epidural abscess* Right parotid cancer s/p, osteoradionecrosis
Flap
Meningitis Postoperative symptom antibiotic duration, d used, d Complication
Follow-up, mo
Note
Myocutaneous ALT
60
173†
Abscess
65.1
Chimeric ALT flap
30
16
-
66.8
Tensor fascia lata for dura repair
Gracilis
NA
39
-
10.6
Died (recurrent cancer)
Myocutaneous ALT
-
15
-
49.9
Myocutaneous ALT
30
11
-
47.8
Myocutaneous ALT
-
67
-
2.5
Myocutaneous ALT
30
19
-
36.6
Myocutaneous ALT
30
21
-
10.3
VL flap Myocutaneous ALT
7
16 68
-
19.5 37.2
Myocutaneous ALT
-
10
-
16.9
Mean
17 6 48.5 41.4 6 48.5 (7–60) (10–173)
33 6 22.6 (2.5–66.8)
Abbreviations: ALT, anterolateral thigh; ICH, intracranial hemorrhage; s/p, status post; NA, not applicable; VL, vastus lateralis. * Frontal abscess, epidural, or subdural. † Recurrence of abscess day 173 requiring restarting of antibiotic regimen.
Impending flap failure and the associated infectious complications secondary to a delayed detection of and/or a necrotic flap can be devastating, and ultimately result in severe meningitis and patient death. Finally, although not a particular focus of this article, other benefits of utilizing the myocutaneous ALT flap include the ability to provide sensation to the skin portion of the flap by incorporating the sensory branch of the lateral femoral cutaneous nerve, the versatility in the many chimeric options it possesses, and its ability to provide a reliable flow-through flap for defects requiring additional vascular flow and/or second flap anastomotic options.10–12,23–29 For cases in which patients have undergone multiple prior neurological surgeries or have a history of chemotherapy and/or radiotherapy, important considerations must be had for the inherent unstable scars, relatively avascular resulting wound bed, and decreased vascularity of the surrounding locoregional tissue, as well as for the overall poor quality of the remaining tissues and depletion of local stem cell populations, all contribute to increased morbidity seen in secondary, tertiary and beyond, as well as in salvage procedures. Particularly, in patients who have had radiotherapy, the radiation resulted in injuries to the cellular DNA, dermal tissues, myofibroblasts, fibroblasts, and locoregional stem cell populations can lead to
visible and nonvisible damage to the wound bed and/or defect areas.30–32 Such damaged local tissues, coupled with deficiencies in cellular delivery systems and the development of atherosclerosis, contribute to a hypoxic and poor-healing wound environment.30–32 When considering these aforementioned issues, many local flap options may not be warranted or even available to adequately address complex frontonasal fistulas cases because of a compilation of the previously discussed areas.33 In these situations, free vascularized tissue transfer still remains the best choice in re-creating a healthy, independently vascularized environment for improved wound-healing potential, especially in the face of infectious frontonasal wounds. Furthermore, for those oncologic patients who require future radiotherapy, providing adequate coverage of the extirpative defects with vascularized free tissue transfer is crucial to lessening morbidity as well as achieving the highest potential successful definitive salvage operation.
CONCLUSIONS The refinement of the myocutaneous ALT flap is a valuable tool in the reconstructive surgeons’ armamentarium that can be used to obliterate and treat a variety of HEAD & NECK—DOI 10.1002/HED
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reconstructive defects, including complicated craniofacial cases, such as frontonasal fistulas. The modification of this flap described herein aids in readily obliterating the frontonasal fistula dead space with healthy vascularized muscle while also providing viable skin for definitive cranial and scalp coverage.
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16. Wax MK, Rosenthal EL, Winslow CP, Bascom DA, Andersen PE. The ulnar fasciocutaneous free flap in head and neck reconstruction. Laryngoscope 2002;112:2155–2160. 17. Hierner R, van Loon J, Goffin J, van Calenbergh F. Free latissimus dorsi flap transfer for subtotal scalp and cranium defect reconstruction: report of 7 cases. Microsurgery 2007;27:425–428. 18. Adams WP Jr, Lipschitz AH, Ansari M, Kenkel JM, Rohrich RJ. Functional donor site morbidity following latissimus dorsi muscle flap transfer. Ann Plast Surg 2004;53:6–11. 19. Schwabegger A, Ninkovic´ M, Brenner E, Anderl H. Seroma as a common donor site morbidity after harvesting the latissimus dorsi flap: observations on cause and prevention. Ann Plast Surg 1997;38:594–597. 20. Arai H, Yanai A, Nishida M, Yoshikata R, Nakanishi H, Sato K. Reconstruction of scalp and cranium defect utilizing latissimus dorsi musculocutaneous and serratus anterior muscle free flaps with interpositional anastomosis of T-shaped flap artery: case report. Skull Base Surg 1995;5: 117–121. 21. Senyuva C, Y€ ucel A, Okur I, Cansiz H, Sanus Z. Free rectus abdominis muscle flap for the treatment of complications after neurosurgical procedures. J Craniofac Surg 1996;7:317–321. 22. West CA, Towns G, Bachelor AG, Liddington MI. Reconstruction of skull base and dura using rectus abdominis muscle combined with a vascularised fascial perforator flap. J Plast Reconstr Aesthet Surg 2006;59:631–635. 23. Lutz BS, Wei FC. Microsurgical workhorse flaps in head and neck reconstruction. Clin Plast Surg 2005;32:421–430. 24. Kuo YR, Kuo MH, Lutz BS, et al. One-stage reconstruction of large midline abdominal wall defects using a composite free anterolateral thigh flap with vascularized fascia lata. Ann Surg 2004;239:352–358. 25. Ao M, Nagase Y, Mae O, Namba Y. Reconstruction of posttraumatic defects of the foot by flow-through anterolateral or anteromedial thigh flaps with preservation of posterior tibial vessels. Ann Plast Surg 1997;38:598– 603. 26. Kimata Y, Uchiyama K, Ebihara S, et al. Comparison of innervated and noninnervated free flaps in oral reconstruction. Plast Reconstr Surg 1999; 104:1307–1313. 27. Kimata Y, Uchiyama K, Ebihara S, et al. Versatility of the free anterolateral thigh flap for reconstruction of head and neck defects. Arch Otolaryngol Head Neck Surg 1997;123:1325–1331. 28. Koshima I, Fukuda H, Soeda S. Free combined anterolateral thigh flap and vascularized iliac bone graft with double vascular pedicle. J Reconstr Microsurg 1989;5:55–61. 29. Koshima I, Fukuda H, Yamamoto H, Moriguchi T, Soeda S, Ohta S. Free anterolateral thigh flaps for reconstruction of head and neck defects. Plast Reconstr Surg 1993;92:421–428; discussion 429–430. 30. Aitasalo K, Aro H. Irradiation-induced hypoxia in bones and soft tissues: an experimental study. Plast Reconstr Surg 1986;77:256–267. 31. Barwick WJ, Goldberg JA, Scully SP, Harrelson JM. Vascularized tissue transfer for closure of irradiated wounds after soft tissue sarcoma resection. Ann Surg 1992;216:591–595. 32. Robinson DW. Surgical problems in the excision and repair of radiated tissue. Plast Reconstr Surg 1975;55:41–49. 33. Chepeha DB, Wang SJ, Marentette LJ, Thompson BG, Prince ME, Teknos TN. Radial forearm free tissue transfer reduces complications in salvage skull base surgery. Otolaryngol Head Neck Surg 2004;131:958–963.
Refinement of the myocutaneous anterolateral thigh flap for reconstruction of frontonasal fistula defects Chih-Wei Wu, MD,1,2 Ian L. Valerio, MD, MS, MBA,3,4 Jung-Ju Huang, MD,1,2 Kai-Ping Chang, MD, PhD,5 Ming-Huei Cheng, MD, MBA1,2* 1
Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University Medical College, Taoyuan, Taiwan, 2Center for Tissue Engineering, Chang Gung Memorial Hospital, Taoyuan, Taiwan, 3Department of Plastic Surgery, Division of Burn, Wound, and Trauma, Wexner Medical Center at the Ohio State University, Columbus, Ohio, 4Department of Plastic and Reconstructive Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, 5 Department of Otolaryngology–Head and Neck Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan.
Accepted 6 March 2015 Published online 15 July 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/hed.24038
ABSTRACT: Background. Frontonasal fistulas can lead to lifethreatening intracranial infections. Our refinement of the myocutaneous anterolateral thigh (ALT) flap for treating these fistulas is described. Methods. A retrospective review of the microsurgical treatment of frontonasal fistulas is presented. Demographics, etiologies, outcomes, and complications were evaluated. Results. Ten myocutaneous ALT flaps were used to reconstruct frontonasal fistula. The mean follow-up was 35 6 2.5 months. Nine fistulas were secondary to oncologic resections, and one was due to a traumatic origin. Complications included a recurrent abscess in 1 case (10%); there were no cases of cerebrospinal fluid (CSF) leak or flap loss. Preoperative intracranial infections were present in 7 cases, with 6 success-
INTRODUCTION Frontonasal fistulas are potentially life-threatening situations that pose serious clinical problems for the neurosurgeon and reconstructive surgeon. These fistulas can lead to refractory leakage of cerebrospinal fluid (CSF), exposing the intracranial space to the external environment by way of the nasal cavity. This situation greatly increases the risk of potential ascending infections, with an associated 10% risk of developing overt meningitis annually.1–3 Additionally, meningoencephalitis, pneumoencephalon, and cerebral hernias are other serious clinical entities that can result from these fistulas.4 The most common causes of CSF leaks and frontonasal fistulas involve posttraumatic injuries, subcategorized into either accidental or iatrogenic, and nontraumatic injuries, such as oncologic resections and extirpation procedures.1 Oncologic cases deserve special consideration, as preoperative and/or postoperative radiation therapy, chemotherapy, and history of multiple reoperations significantly
*Corresponding author: M.-H. Cheng, Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan, 5, Fu-Hsing Street, Kweishan, Taoyuan 333, Taiwan. E-mail: [email protected] Chih-Wei Wu and Ian L. Valerio contributed equally to this work.
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fully resolving their infection after surgical intervention and flap obliteration of their fistulas. Conclusion. Refinements in the myocutaneous ALT flap design have been illustrated to provide robust dead-space obliteration with vascularized muscle and reliable simultaneous scalp coverage in the treatment C 2015 Wiley Periodicals, Inc. Head Neck 38: of frontonasal fistulas. V E552–E558, 2016
KEY WORDS: anterolateral thigh (ALT) flap, myocutaneous ALT flap, vascularized free tissue transfer, head and neck reconstruction, frontonasal fistulas, cerebrospinal fluid (CSF) leakage
increases the incidence of CSF leaks, fistulas, and other complications; thus, vascularized tissue procedures are most often indicated to successfully salvage these complex cases.5,6 Other less common nontraumatic causes worth mentioning include complex congenital skull malformations, meningoceles, meningoencephaloceles, as well as other inflammatory conditions.5,6 The most common surgical procedures that can lead to frontonasal fistulas consist of functional endoscopic sinus surgeries and complex neurosurgical cases.6 Often, these fistulas can be encountered in large oncologic operations because the extirpation of the tumor can lead to large composite defects involving varying amounts of soft tissue, bone, and dura.7 These larger, composite tissue defects typically require substantial amounts of replacement vascularized tissue to repair and completely obliterate the connections between the extracranial and intracranial environments. The first reported case of frontonasal fistula treatment was by Dandy, who described a frontal craniotomy approach in 1926. In 1948, Dohlman described the first extracranial approach, and, in 1981, Wigand is credited with performing the first endoscopic repair.6 Although the endoscopic repair has mostly replaced the need for open craniotomy procedures for simple or minor types of frontonasal fistulas, large or more complex composite defect cases still require open procedures to address the
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significant tissue loss. Furthermore, certain refractory cases that are not amenable to endoscopic repair or that have previously failed more conservative fistula repair attempts may also necessitate an open repair. Thus, for these aforementioned cases, the treatment methods can be categorized into 2 main categories. The first is avascular tissue options, and the second involves the use of vascularized tissue. Although avascular options exist, many authors have reported better results with vascularized tissues over time.8 Free tissue transfer provides a better environment for wound healing, a source of vascularized tissue, and important growth factors, as well as decreased complication rates when used to treat frontonasal fistulas.7 This situation is especially critical in those patients who have undergone several prior surgical attempts to close frontonasal fistulas and who lack locoregional flaps. Often, local flaps are unavailable because of the significant scarring, prior radiation therapy injuries, losses from failed use of prior locoregional flaps, and/or insufficient tissue provided from these flaps.8 In taking into account the aforementioned issues, many patients with frontonasal fistulas may be ideal candidates for free tissue transfers. Many different types of flaps (eg, rectus abdominis, latissimus dorsi, radial forearm, scapula, omentum, and fascia lata) have been described in the treatment of frontonasal fistulas.9 The purpose of this study was to report our experience and modifications of the myocutaneous anterolateral thigh (ALT) flap specifically for the treatment of frontonasal fistulas.
PATIENTS AND METHODS A retrospective review of all frontonasal fistulas reconstructed with vascularized free tissue transfer from 2001 until 2009 at Chang Gung Memorial Hospital by the senior surgeon (M.H.C.) was performed. The medical records of each patient were reviewed to identify patient demographics, such as patient age and sex. The other data reviewed included the etiology of the patients’ frontonasal fistulas, the type of free tissue transfers utilized for their reconstructions, and the CT scans of these patients. The evaluated clinical outcomes included the rates of infectious complications, both preoperatively and postoperatively, resolution of preoperative infections by way of vascularized flap transfer and antibiotic therapy, postoperative CSF leakage rates, and the survival rates after flap transfer procedures. During the course of treating frontonasal fistulas, the senior surgeon transitioned from using buried microsurgical muscle flaps to a myocutaneous ALT flap because of the following benefits: (1) an externalized skin paddle to detect possible flap failure or problems early, (2) a source of additional skin to aid in releasing the scalp contractures or scars that resulted from their injuries and assisted in tension free closure, and (3) a buried muscle component to obliterate dead space and separate the intracranial space from the external environment/nasal cavity. Additionally, in cases in which a significant dural defect was encountered, a portion of conjoined tensor fascia lata (TFL) could also be harvested and used as neo-dura, if the dura required repair. The refinement in the design of
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the myocutaneous ALT flap for the application to treating frontonasal fistulas is outlined in Figure 1.
Surgical technique As described but modified from a report by Ali et al,10 Bernier et al,11 and Huang et al,12 the flap modifications of the myocutaneous ALT flap for frontonasal fistulas reconstruction are as follows. The myocutaneous ALT flap is marked with the patient lying in a supine position. The majority of myocutaneous perforators that nourish the skin paddle are located within a circle with a 3-cm radius around the midpoint of the longitudinal axis, extending between the anterior superior iliac spine and the superolateral patella. These perforators can be mapped with a handheld Doppler probe. The skin paddle is typically designed in an ellipse pattern centered on the selected previously Doppler identified perforator(s), with the skin island positioned more proximal to the underlying VL muscle that is to be included (see Figure 1). The proximal location of the skin island is critical, as this portion of the flap will be used to provide external coverage of the existing scalp defect and/or be used to replace any unwanted or unstable scars. Furthermore, the myocutaneous ALT flap vascular pedicle also typically exits from the proximal aspect, which allows for favorable positioning during anastomosis to the superficial temporal artery and veins. The vastus lateralis (VL) muscle portion of the flap is based on a separate myocutaneous perforator(s), which provides a well-vascularized distal-based muscle to obliterate and seal the frontonasal fistula defect (see Figure 2). Beginning with an incision along the medial border of the previously described flap markings, soft tissue dissection through the subcutaneous tissue and then through the rectus femoris muscle fascia is performed. As one proceeds laterally through a subfascial dissection plane, the intermuscular septum can soon be visualized. At this point, the rectus femoris muscle is then retracted medially, which exposes the descending branch of the lateral circumflex femoral artery (LCFA) and its accompanying veins can be identified. Continuing in a proximal and lateral direction, the myocutaneous perforators supplying the skin paddle are identified and preserved. Retrograde intramuscular dissection of the selected myocutaneous perforator(s) is performed to preserve their continuity to their parent or main pedicle (LCFA). Care is taken to dissect and preserve as much of the main pedicle as possible, as adequate pedicle length will be required to permit eventual anastomosis to the superficial temporal vessels. Occasionally, if the source vessel is the transverse branch of the LCFA, a longer and more careful intramuscular dissection is often required to gain necessary pedicle length. The septocutaneous perforators of the skin island portion of the flap, when present, are usually located in the most proximal aspect of the flap design, and these perforators follow a relatively shorter pathway to the parent or main vessel (LCFA). The distal VL muscle component typically measures approximately 6 3 15 cm in our experience, but the muscle portion of the flap can be customized to the size of the defect to be covered. Care is taken during dissection to ensure the inclusion of at least 1 muscle perforator HEAD & NECK—DOI 10.1002/HED
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FIGURE 1. (A) Frontonasal defect before flap placement. (B) Frontonasal defect obliterated with a myocutaneous anterolateral thigh (ALT) flap.
and/or any muscular branch from the main pedicle. Furthermore, during the dissection of the VL muscle flap, care is taken to spare the motor nerve for preservation of motor innervation to the remaining quadriceps musculature. Most commonly, the motor nerve tends to run in a superolateral direction and accompanies the main pedicle to the myocutaneous ALT flap. In some cases, the motor nerve will cross over the main myocutaneous ALT vascular pedicle, and, in such cases, it may be transected with immediate coaptation and repair after dissection and transfer of the myocutaneous ALT flap from its donor site. The ALT skin paddle and VL muscle can either be commonly harvested together as a true musculocutaneous flap (9 cases); however, in certain select cases, each component many be dissected separately and used as a more versatile chimeric flap option (1 case). Finally, one may also include a portion of the TFL during harvest in order to provide a vascularized fascial component for aiding in the repair of dura defects, when indicated. Once neurosurgical debridement and recipient site preparation of the frontonasal fistula is complete, a single burr hole of 1 3 2 cm is placed on the side of the temporal bone in which the flap vascular pedicle is to exit the skull. Often, a small portion of the superficial temporalis muscle was removed or partially divided as well to avoid
kinking and/or compression of the flap pedicle. Attention can then be turned to transferring the myocutaneous ALT flap to the resulting frontonasal, skull, and external craniofacial/scalp skin defect (see Figure 1). The main pedicle to the flap can then be divided, with the myocutaneous ALT flap transferred for inset into the frontonasal defect. The neurosurgical team prepares and tents the dura to integrate it with the VL muscle or TFL portion of the flap. The distal VL muscle is carefully inset into the frontonasal fistula to ensure complete obliteration of the fistula. First, the muscle flap is secured distally through pilot drill holes placed within the bony skeleton of the skull. Second, the muscle flap is secured proximally with sutures to the previously prepared dura (see Figure 3). After ensuing adequate and sufficient obliteration of the fistula defect with the muscle component of the flap, the myocutaneous ALT skin paddle is inset into the scalp defect in a manner to aid in wound closure while also providing additional skin/soft tissue coverage to protect the pedicle. In our experience, the pedicle length required to sufficiently reach the ipsilateral superficial temporal recipient vessels is approximately 12 to 15 cm (Figure 3).13 The microsurgical anastomoses proceed, usually with the arterial anastomosis performed first, which is followed by the venous anastomosis after adequate backflow from the vein is visualized and
FIGURE 2. Myocutaneous anterolateral thigh (ALT) flap design.
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FIGURE 3. Schematic drawings for the inset of the myocutaneous anterolateral thigh (ALT) flap, the distal vastus lateralis (VL) muscle part was wrapping around and pulled by 2-0 silk to reach the frontonasal fistula. The pedicle, which was 12 to 15 in length) was passed through a widened burr hole to anastomose to the ipsilateral superficial temporal vessels. (A) Anterior-posterior view, (B) lateral view.
confirmed. In cases with inadequate backflow of the superficial temporal vein, the vein grafting to the facial vein or to a recipient vein within the neck region should then be performed. The skull bone, if not compromised by infection, is then returned to its proper place and fixed with miniplates. In cases in which the skull plate is compromised by infection, delayed definitive skull reconstruction can be performed with alloplastic or autologous bone grafting after approximately 6 months once the infection has cleared. The remaining scalp and surrounding skin is then used to cover any exposed VL muscle as well as inset to the skin island of the flap (see Figure 4). One hemovac drainage system is placed underneath the flap to aid in drainage and to prevent fluid accumulation and/or hematoma collection.
RESULTS A total of 10 cases of frontonasal fistulas were reconstructed with a vascularized anterolateral thigh or its modification transfer. Of the 10 cases, 8 patients were men and 2 were women. The mean age of the patients was 53.9 6 12.8 years (range, 29–67 years). The average postoperative follow-up was 35.2 6 22.5 months (range, 2.5– 66.8 months). The types of flaps used for these reconstructions consisted of 8 myocutaneous ALTs, 1 VL, and 1 chimeric ALT flap (Table 1). Fortunately, for these patients, there were no cases of either total and/or partial failures in this particular series of myocutaneous ALT vascularized free tissue transfers. When closely examining the patients who underwent treatment of their frontonasal fistulas, 9 cases (90%) resulted from oncologic extirpation surgeries, and the remaining single case (10%) was secondary to trauma (Table 1). Infections associated with fistula were present
in 7 of the 10 cases before their myocutaneous ALT flap reconstruction salvage surgeries. These preoperative infections consisted of 6 cases of frontal epidural abscesses and 1 case of a subdural abscess. All of these infections were cleared after appropriate debridement, successful vascularized tissue transfer, and completion of their antibiotic therapies. There was one exception to the complete resolution for the cases having infection, with 1 patient (10%) experiencing a recurrence of infection and abscess 173 days after his salvage flap reconstructive procedure. There were no cases of continued CSF leakage after flap reconstruction, and the overall survival rate was 100% in this series of reviewed cases.
DISCUSSION The surgical correction of frontonasal fistulas and resulting CSF leaks can be traced back to the early 20th century.6 Although a majority of these fistulas and CSF leaks will typically close spontaneously within a period of 7 to 10 days, a certain number will be refractory and require further intervention.6 Additionally, certain tumor extirpative defects, especially those associated with preoperative or postoperative radiotherapy, often can have more significant dural injuries and/or involvement that will warrant dural repair and coverage as well as unstable scarring and scalp issues where vascularized tissue is preferable.5,6 For many frontonasal fistulas that are a components of more complex composite tissue defects, endosurgical procedures usually cannot provide adequate soft tissue rearrangement for definitive reconstruction. Therefore, pedicled flap or microsurgical flap coverage is often required to address these fistulas.5,6 Many microvascular tissue transfer options have been previously described in the literature for the treatment of HEAD & NECK—DOI 10.1002/HED
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FIGURE 4. (A) Example of a preoperative frontonasal fistula case. (B) Postoperative result after flap inset. (C) Preoperative CT scan demonstrating the frontonasal fistula. (D) Postoperative CT scan revealing obliteration of the frontonasal fistula with a myocutaneous anterolateral thigh (ALT) flap.
frontonasal fistula. Examples of free flaps that have been reported for surgically treating these fistulas include the radial forearm, latissimus dorsi, serratus anterior, gracilis, rectus abdominis, flaps.7–9 The radial forearm and ulnar forearm flap are reliable, thin, pliable, and wellvascularized flap options, yet these flaps typically cannot provide sufficient bulky tissue to obliterate larger composite defects.14–16 Furthermore, the fasciocutaneous skin islands of these flaps may provide either good internal coverage or external coverage, but they cannot always reliably provide both because of their anatomic and vascular pedicle/perforator restraints. The latissimus dorsi muscle and its perforator derivatives, such as the thoracodorsal artery perforator flap, can also be used to treat frontonasal fistulas.9,17 These flap options provide both substantial healthy skin and muscle, if desired; however, these flaps have 3 important disadvantages. The first issue lies in the patient positioning changes that are usually necessary to harvest the flap.9 Therefore, access to both the defect and donor sites is not ideal. Second, the latissimus dorsi donor site tends to have higher morbidity, including higher rates of seroma, hematoma, contour irregularity, scar tethering, and scar hypertrophy as compared to other flap donor sites.18,19 The serratus anterior, with its relatively narrow and long muscle structure, is a good option to obliterate a frontonasal fistula. It can be harvested in a supine position and combined with the latissimus dorsi myocutaneous flap or the thoracodorsal artery perforator flap, allowing a chimeric flap design to reconstruct a complex craniofacial defect.20 However, a 2-team approach is E556
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difficult and winged scapula can happen if the long thoracic nerve is injured. Although the rectus abdominis and its perforator flap derivatives have also been described for skull reconstruction cases, the inability to utilize its perforator system for performing chimeric options, coupled with the inherent difficulty of molding the muscle component independent of its overlying skin island, is disadvantageous.21,22 Finally, the possibility of abdominal weakness or hernias after harvesting this flap, especially in cases in which the entire muscle is taken, makes the important donor site morbidities concerning, particularly in male patients.9 With respect to the ALT flap and its myocutaneous derivative, these flaps have many intrinsic advantages. First, the myocutaneous ALT can be harvested with a dimension of up to 8 3 22 cm, providing ample fasciocutaneous or skin island components as well as muscle for both scalp coverage and/or obliteration of larger defects, respectively.10–12,23 Even with a myocutaneous ALT harvested in these dimensions, the donor site can easily be closed first without any significant complication risks as well as with acceptable aesthetic results. Moreover, during the harvest of the VL muscle component, care to preserve the motor nerve branch to the remaining vastus and quadriceps musculature can greatly lessen the morbidity to knee extension and lower extremity strength.24 Another important advantage of this flap is that the externalized portion of the skin paddle can easily be used for monitoring. The ability to detect early flap failure or problems is crucial in the setting of using flaps for treating frontonasal fistulas and other intracranial defects.
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TABLE 1. Demographics, Diagnoses, Types of Flaps and Outcomes of 11 Patients Who Underwent Reconstruction of Frontonasal Fistula Defects.
No. of patients Sex Age, y
1
M
55
2
M
29
3
M
68
4
M
53
5
M
67
6
M
56
7
M
33
8
F
60
9 10
F M
63 61
11
M
62
Diagnosis with frontonasal fistulas
Brain tumor, frontal epidural abscess* Traumatic ICH s/p, frontotemporal subdural abscess* Supra-orbital ridge osteoradionecrosis, frontal epidural abscess* Olfactory neuroblastoma, frontal bone necrosis and abscess* Frontal base epidural abscess* Malignant neoplasm of cerebrum, frontal lobe defect Sinonasal undifferentiated cancer s/p concomitant chemoradiation therapy with recurrent cancer Epidural abscess, osteoradionecrosis, frontal skin defect Nasal carcinoma Nasal carcinoma, frontal epidural abscess* Right parotid cancer s/p, osteoradionecrosis
Flap
Meningitis Postoperative symptom antibiotic duration, d used, d Complication
Follow-up, mo
Note
Myocutaneous ALT
60
173†
Abscess
65.1
Chimeric ALT flap
30
16
-
66.8
Tensor fascia lata for dura repair
Gracilis
NA
39
-
10.6
Died (recurrent cancer)
Myocutaneous ALT
-
15
-
49.9
Myocutaneous ALT
30
11
-
47.8
Myocutaneous ALT
-
67
-
2.5
Myocutaneous ALT
30
19
-
36.6
Myocutaneous ALT
30
21
-
10.3
VL flap Myocutaneous ALT
7
16 68
-
19.5 37.2
Myocutaneous ALT
-
10
-
16.9
Mean
17 6 48.5 41.4 6 48.5 (7–60) (10–173)
33 6 22.6 (2.5–66.8)
Abbreviations: ALT, anterolateral thigh; ICH, intracranial hemorrhage; s/p, status post; NA, not applicable; VL, vastus lateralis. * Frontal abscess, epidural, or subdural. † Recurrence of abscess day 173 requiring restarting of antibiotic regimen.
Impending flap failure and the associated infectious complications secondary to a delayed detection of and/or a necrotic flap can be devastating, and ultimately result in severe meningitis and patient death. Finally, although not a particular focus of this article, other benefits of utilizing the myocutaneous ALT flap include the ability to provide sensation to the skin portion of the flap by incorporating the sensory branch of the lateral femoral cutaneous nerve, the versatility in the many chimeric options it possesses, and its ability to provide a reliable flow-through flap for defects requiring additional vascular flow and/or second flap anastomotic options.10–12,23–29 For cases in which patients have undergone multiple prior neurological surgeries or have a history of chemotherapy and/or radiotherapy, important considerations must be had for the inherent unstable scars, relatively avascular resulting wound bed, and decreased vascularity of the surrounding locoregional tissue, as well as for the overall poor quality of the remaining tissues and depletion of local stem cell populations, all contribute to increased morbidity seen in secondary, tertiary and beyond, as well as in salvage procedures. Particularly, in patients who have had radiotherapy, the radiation resulted in injuries to the cellular DNA, dermal tissues, myofibroblasts, fibroblasts, and locoregional stem cell populations can lead to
visible and nonvisible damage to the wound bed and/or defect areas.30–32 Such damaged local tissues, coupled with deficiencies in cellular delivery systems and the development of atherosclerosis, contribute to a hypoxic and poor-healing wound environment.30–32 When considering these aforementioned issues, many local flap options may not be warranted or even available to adequately address complex frontonasal fistulas cases because of a compilation of the previously discussed areas.33 In these situations, free vascularized tissue transfer still remains the best choice in re-creating a healthy, independently vascularized environment for improved wound-healing potential, especially in the face of infectious frontonasal wounds. Furthermore, for those oncologic patients who require future radiotherapy, providing adequate coverage of the extirpative defects with vascularized free tissue transfer is crucial to lessening morbidity as well as achieving the highest potential successful definitive salvage operation.
CONCLUSIONS The refinement of the myocutaneous ALT flap is a valuable tool in the reconstructive surgeons’ armamentarium that can be used to obliterate and treat a variety of HEAD & NECK—DOI 10.1002/HED
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reconstructive defects, including complicated craniofacial cases, such as frontonasal fistulas. The modification of this flap described herein aids in readily obliterating the frontonasal fistula dead space with healthy vascularized muscle while also providing viable skin for definitive cranial and scalp coverage.
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16. Wax MK, Rosenthal EL, Winslow CP, Bascom DA, Andersen PE. The ulnar fasciocutaneous free flap in head and neck reconstruction. Laryngoscope 2002;112:2155–2160. 17. Hierner R, van Loon J, Goffin J, van Calenbergh F. Free latissimus dorsi flap transfer for subtotal scalp and cranium defect reconstruction: report of 7 cases. Microsurgery 2007;27:425–428. 18. Adams WP Jr, Lipschitz AH, Ansari M, Kenkel JM, Rohrich RJ. Functional donor site morbidity following latissimus dorsi muscle flap transfer. Ann Plast Surg 2004;53:6–11. 19. Schwabegger A, Ninkovic´ M, Brenner E, Anderl H. Seroma as a common donor site morbidity after harvesting the latissimus dorsi flap: observations on cause and prevention. Ann Plast Surg 1997;38:594–597. 20. Arai H, Yanai A, Nishida M, Yoshikata R, Nakanishi H, Sato K. Reconstruction of scalp and cranium defect utilizing latissimus dorsi musculocutaneous and serratus anterior muscle free flaps with interpositional anastomosis of T-shaped flap artery: case report. Skull Base Surg 1995;5: 117–121. 21. Senyuva C, Y€ ucel A, Okur I, Cansiz H, Sanus Z. Free rectus abdominis muscle flap for the treatment of complications after neurosurgical procedures. J Craniofac Surg 1996;7:317–321. 22. West CA, Towns G, Bachelor AG, Liddington MI. Reconstruction of skull base and dura using rectus abdominis muscle combined with a vascularised fascial perforator flap. J Plast Reconstr Aesthet Surg 2006;59:631–635. 23. Lutz BS, Wei FC. Microsurgical workhorse flaps in head and neck reconstruction. Clin Plast Surg 2005;32:421–430. 24. Kuo YR, Kuo MH, Lutz BS, et al. One-stage reconstruction of large midline abdominal wall defects using a composite free anterolateral thigh flap with vascularized fascia lata. Ann Surg 2004;239:352–358. 25. Ao M, Nagase Y, Mae O, Namba Y. Reconstruction of posttraumatic defects of the foot by flow-through anterolateral or anteromedial thigh flaps with preservation of posterior tibial vessels. Ann Plast Surg 1997;38:598– 603. 26. Kimata Y, Uchiyama K, Ebihara S, et al. Comparison of innervated and noninnervated free flaps in oral reconstruction. Plast Reconstr Surg 1999; 104:1307–1313. 27. Kimata Y, Uchiyama K, Ebihara S, et al. Versatility of the free anterolateral thigh flap for reconstruction of head and neck defects. Arch Otolaryngol Head Neck Surg 1997;123:1325–1331. 28. Koshima I, Fukuda H, Soeda S. Free combined anterolateral thigh flap and vascularized iliac bone graft with double vascular pedicle. J Reconstr Microsurg 1989;5:55–61. 29. Koshima I, Fukuda H, Yamamoto H, Moriguchi T, Soeda S, Ohta S. Free anterolateral thigh flaps for reconstruction of head and neck defects. Plast Reconstr Surg 1993;92:421–428; discussion 429–430. 30. Aitasalo K, Aro H. Irradiation-induced hypoxia in bones and soft tissues: an experimental study. Plast Reconstr Surg 1986;77:256–267. 31. Barwick WJ, Goldberg JA, Scully SP, Harrelson JM. Vascularized tissue transfer for closure of irradiated wounds after soft tissue sarcoma resection. Ann Surg 1992;216:591–595. 32. Robinson DW. Surgical problems in the excision and repair of radiated tissue. Plast Reconstr Surg 1975;55:41–49. 33. Chepeha DB, Wang SJ, Marentette LJ, Thompson BG, Prince ME, Teknos TN. Radial forearm free tissue transfer reduces complications in salvage skull base surgery. Otolaryngol Head Neck Surg 2004;131:958–963.
