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Table of Contents   
CASE REPORT  
Year : 2012  |  Volume : 23  |  Issue : 2  |  Page : 275-278
Anterolateral thigh free flap for the reconstruction of through and through defect of cheek following cancer ablation


1 Department of Oral and Maxillofacial Surgery and Oral Implantology, M.A. Rangoonwala College of Dental Sciences and Research Center, Pune, MUHS, Nashik, Maharashtra, India
2 Department of Pedodontics and Preventive Dentistry, Barkatulla University, Bhopal, India
3 Department of Periodontics, Rishiraj College of Dental Sciences and Research Center, Barkatulla University, Bhopal, India
4 Department of Pedodontics and Preventive Dentistry, Shree Bankey Bihari Dental College and Research Center, Ghaziabad, India

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Date of Submission16-Apr-2010
Date of Decision01-Jun-2011
Date of Acceptance11-Sep-2011
Date of Web Publication3-Sep-2012
 

   Abstract 

The anterolateral thigh flap is a highly versatile and reliable flap for use in the reconstruction of various soft-tissue defects of the head and neck. This flap has gained great popularity due to its versatility, ability for a two-team approach, and minimal donor site morbidity. However, it has not met the same enthusiasm in the armamentarium of Maxillofacial Surgeons due to its relative difficulty in perforator dissection, reported variations of the vascular anatomy, and the presumed increased thickness of the anterolateral thigh tissue. These obstacles may be overcome by increased surgical experience and by the ability to create a thinner suprafacial flap or thinning the flap after it has been obtained. We have described the versatility of this flap for the reconstruction of the through and through defect of cheek following cancer ablation along with difficulties in raising flap.

Keywords: Anterolateral thigh flap, cancer, cheek reconstruction, free flap reconstruction

How to cite this article:
Rastogi S, Patwardhan B, Gulati A, Thayath MN. Anterolateral thigh free flap for the reconstruction of through and through defect of cheek following cancer ablation. Indian J Dent Res 2012;23:275-8

How to cite this URL:
Rastogi S, Patwardhan B, Gulati A, Thayath MN. Anterolateral thigh free flap for the reconstruction of through and through defect of cheek following cancer ablation. Indian J Dent Res [serial online] 2012 [cited 2021 Jul 26];23:275-8. Available from: https://www.ijdr.in/text.asp?2012/23/2/275/100440
The anterolateral thigh flap is one of the fasciocutaneous flaps in the thigh based on the septocutaneous or musculocutaneous perforators derived from the lateral circumflex femoral system. It is not popularly used because of the variable anatomy of the vascular pedicle and the relatively difficult dissection technique. [1],[2],[3],[4],[5],[6] The application of the anterolateral thigh flap as a favorable choice for head and neck reconstruction had been widely used until recent years. [7],[8],[9] The difficulty of perforator dissection and variations of vascular anatomy are major disadvantages that preclude the widespread use of this flap. Repairing full-thickness cheek defects involving the oral commissure in the head and neck regions after tumor resection is a challenge for reconstructive surgeons. First, they are usually relatively large defects. Second, the axes of the cheek and intraoral lining are different from each other. Third, the shape and volume of the defect and the oral sphincter should be considered individually. We present our recent experience with the use of this versatile flap in full-thickness defects of cheek.


   Case Report Top


A 60-year-old man sustained right buccal cancer, well-differentiated squamous-cell carcinoma, with cheek skin involvement (T4N2bM0). Wide resection of tumor with right side modified radical type II neck dissection was carried out and a 10 × 10-cm through and through defect was left [Figure 1]. The defect was reconstructed with ipsilateral side anterolateral thigh flap including two musculocutaneous perforators [Figure 2]. Immediate follow-up revealed good vascularity and viability of the flap [Figure 3]. After one year of follow-up, satisfactory results were obtained with adequate mouth opening [Figure 4].
Figure 1: Reveals through and through cheek defect on the right side along with modified radical type II neck dissection

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Figure 2: Shows immediate inset of ALT flap intraoperatively

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Figure 3: Shows excellent vascularity of the flap

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Figure 4: Follow-up after 1 year shows excellent functionality of the flap

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   Discussion Top


The anterolateral thigh flap was originally described as a septocutaneous artery flap by Song et al. in 1984, [1] the vascular variations of which were also reported by Koshima et al. in 1989. [2] The detailed anatomy of this flap was further presented from cadaver dissections or clinical experiences. It was found that the blood supply of the anterolateral thigh flap was based on the septocutaneous or musculocutaneous perforators, or both. [3]

The descending branch of the lateral circumflex femoral artery is usually of sufficient caliber that a flap may even be based distally. As such, this flap has the ability to cover a variety of large cutaneous or mucosal defects. In special circumstances, it can be combined with other flaps (such as the fibula or iliac crest), using the "mosaic or chimeric" principle to provide coverage of extremely large and challenging head and neck defects. In addition, the flap can easily be harvested using a two-team approach without patient repositioning. The donor site can easily be closed primarily without functional deficit or significant conspicuous deformity. About 40% of the time, the donor site requires a skin graft. In elective situations, the graft may be avoided by pre-expanding the flap site for several months prior to flap elevation. Despite skin graft concerns, donor site morbidity is limited.

The anterolateral thigh flap is useful for covering thin defects such as those in the face, neck, extremities, or intraoral region, or following burn-scar contracture release and trauma. [4] The application of the anterolateral thigh flap, which is specially focused on the reconstruction of the head and neck defects, was described by Koshima et al.[5] in 1993 and Kimata et al.[6] in 1998.

This flap has many advantages and disadvantages [Table 1] and [Table 2] when compared with other conventional free flaps. It is suitable for a two-team approach. In this manner, the duration of the operation can be reduced at least 1.5 to 2 hours. This flap provides a large skin territory.
Table 1: Anterolateral thigh free flap

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Table 2: Anterolateral thigh free flap

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Koshima et al.[10] reported their maximum dimension of the anterolateral thigh flap as 25 × 18 cm in their series. In our case, the dimensions of the flap were 15 × 10 cm. The donor site of the anterolateral thigh flap is suitable for various flap designs and it can be used as a combined flap to reconstruct composite defects. It can be thinned safely to 2 to 3 mm. In our case, a thinned anterolateral thigh flap was used successfully for intraoral lining. Our patient did not require a secondary debulking procedure. When obliteration of cavities with bulky flaps is needed, the anterolateral thigh flap can be used by planning the flap in the upper half of the leg, where the subcutaneous tissue is thicker. The dissection plane can interfere with the tensor fascia lata in this region, but changing the dissection plane can solve this problem. If a thin flap is required, the flap can be planned in the lower half of the leg. The length of the vascular pedicle was 10 to 16 cm (average, 12.5 cm). If a longer pedicle is needed, the upper one-third of the flap should be planned on the selected perforator. In this manner, extra pedicle length (approximately, 3-4 cm) can be obtained. In our case, it did not require any extremely long vascular pedicles. No vascularity problems were observed in this flap as it is based on excellent perforators maintaining the vascularity. The average diameter of the vascular pedicle was 2.1 mm for the artery and 2.6 mm for the vein in our patient. The large-caliber vascular pedicle facilitates microvascular anastomoses and provides a high anastomotic success rate. Vascular anastomoses can be performed successfully with loupe magnification except in children.

The flap can be used as a sensate flap by including the lateral femoral cutaneous nerve. [7] A donor site defect less than 8 cm in width could be closed primarily. [8] We used a skin graft to close the donor site if the width of the flap was more than 10 to 11 cm. The lateral and medial flaps of the donor site should be dissected approximately 8 to 9 cm in the suprafacial plane and, subsequently, primary closure should be tried. If the fascia lata is not harvested with the flap, there is no muscle herniation and primary closure can be attempted easily.

The variations in the vascular pedicle and the difficulty of the perforator dissection are the chief reasons that the anterolateral thigh flap has not become popular despite its advantages. In our case, an average of three perforators (range, two to five perforators) derived from the lateral circumflex femoral artery were identified. All perforators were determined to lie within a circle with a radius of 3 cm. The center of this circle was the midpoint of the line marked between the anterosuperior iliac spine, the intermuscular septum, and the superolateral border of the patella. We think that the anterolateral thigh flap can be elevated without locating the perforators preoperatively with a hand-held Doppler probe if the flap includes the entire circle or a medial incision is made at least 3 cm from the midpoint of this line [Figure 4].

Following the initial description of this flap as based on the septocutaneous perforators, [1] Xu and associates [3] reported only 40% of the perforators were septocutaneous and 60% were musculocutaneous. In our case, majorities of perforator were musculocutaneous perforators, only one or two were septocutaneous perforators. Although Shief et al.[9] reported that 27% of musculocutaneous perforators arise from the transverse branch of the lateral circumflex artery, we found that most of the musculocutaneous perforators are derived from the descending branch of the lateral circumflex femoral artery.

We think that the variations in the vascular pedicle are not important for successful flap elevation if the possible variations are known by the surgeon, because the elevation of the flap is based on the "find-the-perforator-and follow- it" principle in all circumstances. Retrograde dissection of the perforator to the main pedicle is accepted as a difficult and time-consuming procedure.

The presence of hair in the flap for men and an unacceptable scar in the donor area (especially for women) are other minor disadvantages of this flap. If needed, laser or other conventional techniques can be used successfully to remove these hairs. We also think that the large scar of the donor site is not a major concern because it can be hidden easily. We think these disadvantages are not important when compared with the advantages of this flap.

In conclusion, anterolateral thigh flaps may be combined with other free flaps using the chimeric or mosaic principle. This concept involves anastomosing the vessels of a second flap to a branch of the lateral circumflex femoral system. The technique is useful for large, complex wounds. The anterolateral thigh flap has been combined with fibula, radial forearm, iliac crest, groin, anteromedial thigh, and latissimus dorsi flaps. Because of its size, ease of harvest, vessel quality, and low donor site morbidity, the anterolateral thigh flap is aptly suited and has emerged the "workhorse" flap for soft tissue head and neck reconstruction.

 
   References Top

1.Song YG, Chen GZ, Song YL. The free thigh flap: A new free flap concept based on septocutaneous artery. Br J Plast Surg 1984;37:149-59.  Back to cited text no. 1
[PUBMED]    
2.Koshima I, Fukuda H, Utunomiya R, Soeda S. The anterolateral thigh flap: Variations in its vascular pedicle. Br J Plast Surg 1989;42:260-2.  Back to cited text no. 2
[PUBMED]    
3.Xu DC, Zhong SZ, Kong JM Wang JY, Liu MZ, Luo LS, Gao JH. Applied anatomy of the anterolateral thigh flap. Plast Reconstr Surg 1988;84:305-10.  Back to cited text no. 3
    
4.Zhou G, Qiao Q, Chen GY, Ling YC, Swift R. Clinical experience and surgical anatomy of 32 free anterolateral thigh flap transplantations. Br J Plast Surg 1991;44:91-6.  Back to cited text no. 4
[PUBMED]    
5.Koshima I, Fukuda H, Yamamato H, Moriguchi T, Soeda S, Ohta S. Free anterolateral thigh flaps for reconstruction of head and neck defects. Plast Reconstr Surg 1993; 92:421-8.  Back to cited text no. 5
    
6.Kimata Y, Uchiyama K, Ebihara S, Nakatsuka T, Harii K. Anatomic variations and technical problems of the anterolateral thigh flap. A report of 74 cases. Plast Reconstr Surg 1998;102:1517-23.  Back to cited text no. 6
[PUBMED]    
7.Luo S, Raffoul W, Luo J, Luo L, Gao J, Chen L, et al. Anterolateral thigh flap: A review of 168 cases. Microsurgery 1999;19:232-8.  Back to cited text no. 7
[PUBMED]    
8.Wei FC, Çelik N, Chen HC, Cheng MH, Huang WC. Combined anterolateral thigh flap and vascularized fibula osteoseptocutaneous flap in reconstruction of extensive composite mandibular defects. Plast Reconstr Surg 2002;109:45-52.  Back to cited text no. 8
    
9.Shief SS, Chiu HY, Yu JC, Pan SC, Tsai ST, Shen CL. Free anterolateral thigh flap for reconstruction of head and neck defects following cancer ablation. Plast Reconstr Surg 2000;105:2349-57.  Back to cited text no. 9
    
10.Koshima I, Yamamato H, Hosoda M, Moriguchi T, Orita Y, Nagayama H. Free combined composite flaps using the lateral circumflex femoral system for repair of massive defects of the head and neck regions: An introduction to the chimeric flap principle. Plast Reconstr Surg 1993;92:411-20.  Back to cited text no. 10
    

Top
Correspondence Address:
Sanjay Rastogi
Department of Oral and Maxillofacial Surgery and Oral Implantology, M.A. Rangoonwala College of Dental Sciences and Research Center, Pune, MUHS, Nashik, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.100440

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]

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2 Three-dimensional contrast-enhanced magnetic resonance angiography for anterolateral thigh flap outlining: A retrospective case series of 68 patients
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