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A review of the advantages of the anterolateral thigh flap in head and neck reconstruction Jagdeep S. Chana, Fu-chan Wei* Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, 199 Tung Hwa North Road, Taipei 10591, Taiwan, ROC and Mt Vernon Hospital, Northwood, Middlesex HA6 2RN, UK Received 3 July 2003; accepted 27 May 2004 The anterolateral thigh flap was originally described by Song in 1984 as a septocutaneous flap based on the descending branch of the lateral circumflex artery. 1 It was later determined that in the majority of cases the flap was supplied only by musculocutaneous perforators and septocutaneous supply only occurred in a small percentage of case. 2–5 In the past, the variable anatomy and the necessity for intramuscular dissection of perfora- tors has given this flap the reputation of requiring a relatively difficult dissection. In recent years, advances in perforator flaps have provided famili- arity of the technique required for safe dissection and in turn this has popularised the use of this flap for a wide variety of indications. Koshima et al. 6,7 and Kimata et al. 8 first described the use of this flap for the reconstruction of head and neck defects. Further reports have outlined the utility of this flap in head and neck reconstruction since it may be adapted to cover most defects of the face, neck or intraoral regions. 5,9 – 12 The flap may be thinned for pure intraoral defects. It also has good pliability and may be folded for the reconstruction of both the inner and outer lining of through and through defects. The vascular pattern also allows the use of a more versatile design with double skin paddles based on multiple perforators. In addition, the flap may be used in combination with vastus lateralis muscle as a myocutaneous flap or combined with adjacent flaps according to the chimaeric flap principle to reconstruct large or complex 3-dimensional defects. It is the aim of this article to describe the advantages of the use of this flap for recon- struction of a wide variety of head and neck defects. Flap anatomy The anterolateral thigh flap is supplied by the descending branch of the lateral circumflex femoral artery, which is the largest branch of the profunda femoris system. The pedicle lies in the groove between the rectus femoris and vastus lateralis muscles along with the motor nerve to the vastus lateralis. The anterior branch of the lateral cutaneous nerve of the thigh can be included to create a sensory flap. The pedicle length ranges between 8 and 16 cm with a vessel diameter larger than 2 mm. The pedicle supplies perforating branches to the surrounding rectus femoris and vastus lateralis muscles and septocutaneous vessels to the anterolateral thigh skin. Some of the perforators to the vastus lateralis muscle pierce the deep fascia and terminate in the anterolateral thigh skin after giving off numerous side branches to the muscle. These musculocutaneous perforators are dissected for harvest of a cutaneous or fasciocutancous flap. S0007-1226/$ - see front matter Q 2004 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2004.05.032 The British Association of Plastic Surgeons (2004) 57, 603–609 * Corresponding author. E-mail address: [email protected]

A review of the advantages of the anterolateral thigh flap in head and neck reconstruction

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A review of the advantages of the anterolateralthigh flap in head and neck reconstruction

Jagdeep S. Chana, Fu-chan Wei*

Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, 199 Tung Hwa NorthRoad, Taipei 10591, Taiwan, ROC and Mt Vernon Hospital, Northwood, Middlesex HA6 2RN, UK

Received 3 July 2003; accepted 27 May 2004

The anterolateral thigh flap was originallydescribed by Song in 1984 as a septocutaneousflap based on the descending branch of the lateralcircumflex artery.1 It was later determined that inthe majority of cases the flap was supplied only bymusculocutaneous perforators and septocutaneoussupply only occurred in a small percentage ofcase.2–5 In the past, the variable anatomy and thenecessity for intramuscular dissection of perfora-tors has given this flap the reputation of requiring arelatively difficult dissection. In recent years,advances in perforator flaps have provided famili-arity of the technique required for safe dissectionand in turn this has popularised the use of this flapfor a wide variety of indications.

Koshima et al.6,7 and Kimata et al.8 firstdescribed the use of this flap for the reconstructionof head and neck defects. Further reports haveoutlined the utility of this flap in head and neckreconstruction since it may be adapted to covermost defects of the face, neck or intraoralregions.5,9 –12 The flap may be thinned for pureintraoral defects. It also has good pliability and maybe folded for the reconstruction of both the innerand outer lining of through and through defects.The vascular pattern also allows the use of a moreversatile design with double skin paddles based onmultiple perforators. In addition, the flap may beused in combination with vastus lateralis muscle as

a myocutaneous flap or combined with adjacentflaps according to the chimaeric flap principle toreconstruct large or complex 3-dimensionaldefects. It is the aim of this article to describethe advantages of the use of this flap for recon-struction of a wide variety of head and neckdefects.

Flap anatomy

The anterolateral thigh flap is supplied by thedescending branch of the lateral circumflex femoralartery, which is the largest branch of the profundafemoris system. The pedicle lies in the groovebetween the rectus femoris and vastus lateralismuscles along with the motor nerve to the vastuslateralis. The anterior branch of the lateralcutaneous nerve of the thigh can be included tocreate a sensory flap. The pedicle length rangesbetween 8 and 16 cm with a vessel diameter largerthan 2 mm. The pedicle supplies perforatingbranches to the surrounding rectus femoris andvastus lateralis muscles and septocutaneous vesselsto the anterolateral thigh skin. Some of theperforators to the vastus lateralis muscle piercethe deep fascia and terminate in the anterolateralthigh skin after giving off numerous side branches tothe muscle. These musculocutaneous perforatorsare dissected for harvest of a cutaneous orfasciocutancous flap.

S0007-1226/$ - see front matter Q 2004 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved.doi:10.1016/j.bjps.2004.05.032

The British Association of Plastic Surgeons (2004) 57, 603–609

*Corresponding author.E-mail address: [email protected]

Flap dissection

With the patient in a supine position, a line is drawnbetween the anterior superior iliac spine to thesuperolateral border of the patella. This linerepresents the muscular septum between therectus femoris and the vastus lateralis muscles.The cutaneous vessels are mapped by portablehandheld pencil Doppler probe centred over themidpoint of this line.3,5,13 The majority of skinperforators are located within a circle of 3 cmradius centred at this midpoint (Fig. 1). Xu et al.located at least one perforator in the inferolateralquadrant of this circle in 80% of cases.2 The flap iscentred over the location of these vessels, and itslong axis is designed parallel to that of the thigh.

Dissection begins at the medial border of theflap, which should be located over the rectusfemoris muscle. An incision is made through thedeep fascia and the flap is raised laterally for ashort distance until the intermuscular septumbetween the rectus femoris and vastus lateralis isreached. At this stage, the descending branch ofthe lateral femoral circumflex artery is identified inthe groove between the rectus femoris and vastuslateralis, and a septocutaneous vessel may beidentified which facilitates further dissection.However, in the largest series to date septocuta-neous vessels were encountered in only 12.9% ofcases.5 Therefore, in the majority of cases flapharvest requires a careful dissection of a suitableintramuscular perforator.

The musculocutaneous perforator gives off manysmall branches to the vastus lateralis muscle fromthe lateral and posterior sides of the vessel, butfewer from the anterior side. The course of theperforator can, therefore, easily be traced byincising the muscle over the perforator, and ligatingthe branches to the muscle from the lateral and

posterior sides (Fig. 2). The perforator is tracedback to the main descending branch of the lateralcircumflex femoral artery, which is divided accord-ing to pedicle length requirements.

In the majority of cases, the flap is harvested as afasciocutaneous flap. When a thin pliable flap isrequired for intraoral defects a cutaneous flap maybe raised using a suprafascial dissection. Once asuitable skin perforator is identified the flap israised suprafascially and a small cuff of fascia ismaintained around the perforator (Fig. 3(A) and(B)). The cutaneous flap can be further thinned to5 mm but excessive thinning should be avoided toprevent marginal necrosis. Indications for thinanterolateral thigh flaps include reconstructionfor hemitongue, buccal mucosa, palate and phar-yngeal wall.

When soft tissue bulk is required for thereconstruction the flap may be raised as a muscu-locutaneous flap. If a septocutaneous vessel isfound, the skin and muscle components can beraised on different branches of the same vascularpedicle as a bipaddled composite flap. In themajority of cases, an intramuscular dissection ofthe perforator is not required. However, it isprudent to determine the course of the perforatorto the source vessel by deroofing the muscle fibresover the chosen perforator. The perforator mayhave a variable and tortuous intramuscular course;this manoeuvre avoids inadvertent injury to theperforator during incision of the muscle, and alsoestablishes that the perforator supplies the skinpaddle of the musculocutaneous flap. Determiningthe course of the perforator to the source vessel isimportant since in 10% of cases the perforator mayarise from the transverse branch of the lateralcircumflex artery, and enters the muscle superiorlywith a vertical course and is liable to damage duringmuscle incision at the upper border of the flap.9

Figure 1 Surface markings of the anterolateral thighflap.

Figure 2 Perforator being dissected back to descendingbranch of the circumflex femoral vessels.

J.S. Chana, F.-c. Wei604

Large defects of the head and neck arechallenging to reconstruct since there may bea 3-dimensional requirement of both volume andmultiple surfaces of oral lining and externalskin. In these situations, the chimaeric ante-rolateral thigh flap is particularly versatile.Since the lateral circumflex femoral arterygives off lateral, medial and descendingbranches, multiple components can be harvestedbased on the main pedicle. There are manycombinations of chimaeric anterolateral thighflaps, the majority of which are combined withthe rectus femoris muscle, tensor fasciae latae,anteromedial thigh skin and vastus lateralismuscle.14,15 Double skin paddle flaps may alsobe used with each paddle based on separateperforators.16 Musculocutaneous flaps may alsobe raised with muscle and skin paddles based onseparate perforators. This versatility facilitatesinsetting of the flap to complex 3-dimensionaldefects.

Advantages in head and neckreconstruction

The anterolateral thigh flap can be harvested asthin as the radial forearm flap, with the advantageof reduced donor site morbidity. In most situations,the donor site can be closed directly when the widthof the flap is 7–8 cm or less. It can, therefore,replace most intraoral reconstructions where pre-viously the radial forearm flap has been thepreferred option. This flap also allows a two teamapproach with flap harvest allowed to proceedsimultaneously with the head and neck resection,and therefore has advantages over scapular, para-scapular and latissimus dorsi flaps. The anterolat-eral thigh flap can be harvested with a skin paddleas large as that of abdominal perforator flaps andprovides a longer pedicle length. It also avoids theissue of abdominal donor site complications whenmyocutaneous flaps are required. The anterolateralthigh flap, therefore, provides all the advantages ofother commonly used flaps in head and neckreconstruction.

Reconstruction of buccal defects

Buccal defects requiring reconstruction of orallining alone are relatively straightforward forwhich thin anterolateral thigh flaps may be used.Larger defects may involve external cheek skinresulting in through and through defects. In thissituation, a folded anterolateral thigh flap can beused with the intervening folded portion being de-epithelialised. These defects have a significantvolume deficit, which often results in a long-termsunken appearance of the cheek. In our experience,this can be improved by incorporating muscle withthe anterolateral thigh skin to provide extra bulk,which augments the cheek and improves cosmesis(Fig. 4). If two suitable perforators are present theskin paddle can be split as a chimaeric flap whichallows for a more elegant reconstruction.16 If theoral commisure is involved in the defect the fascialata can be split and sutured into the upper andlower obicularis oris muscle as a static sling.16

Anterolateral thigh flap in extensivecomposite defects of the mandible

More extensive composite defects involving seg-mental resection of the mandible often result inextensive soft tissue loss of the cheek. The skinislands of the osteoseptocutaneous flap may be

Figure 3 A thin suprafascial anterolateral thigh flap. (A)Note the perforator emerging from the fascia andpreserved sensory nerve. (B) Elevated cutaneous flapwith a small fascia cuff around the perforator.

A review of the advantages of the anterolateral thigh flap in head and neck reconstruction 605

adequate for coverage of both inner and outerlining but inadequate to replace soft tissue loss.Soft tissue reconstruction in these situations has atleast as great a significance for the functional resultas does the bony reconstruction.17,18 The deadspace left by extirpation of the masseter muscles,buccal fat and the parotid gland must be obliter-ated to prevent fluid accumulation and secondaryinfection and to prevent further soft-tissue con-traction. A two flap procedure in these situations

provides adequate volume to prevent these com-plications and also avoids a sunken appearance ofthe cheek which may occur after radiotherapy.18 Inour previous experience, a free osteoseptocuta-neous fibula flap may be used for mandibularreconstruction and inner lining together with afree radial forearm flap or rectus abdominis flap forthe cheek.19 The radial forearm flap is usually toothin to cover the fibula and reconstruction plate andhas an inferior donor site when compared to an

Figure 4 ALT flap for tongue reconstruction and submental augmentation after hemiglossectomy and radical neckdissection. (A) Inset of flap for tongue reconstruction and neck augmentation. (B) Appearance of reconstructed tonguetwo years postoperation. (C) and (D) Face and neck appearance 2 years postoperation.

J.S. Chana, F.-c. Wei606

anterolateral thigh flap. The rectus abdominis flapmay be too bulky and has disadvantages with regardto the abdominal donor site. The anterolateralthigh flap is more suitable in these situations.16,18 Ithas a large cutaneous area10 and the volume iseasily adjustable by incorporating part of the vastuslateralis muscle18 (Fig. 5).

Tongue reconstruction

The anterolateral thigh flap has largely replaced theradial forearm flap in reconstruction of tonguedefects in our centres.5 This flap is pliable, adaptswell to 3-dimensional defects in the oral cavity,12

and the donor site is superior to that of the radialforearm flap since primary closure is achieved.Hemitongue defects are reconstructed using a thinsensate anterolateral thigh flap incorporating thelateral cutaneous nerve of the thigh (Fig. 5). Partialtongue defects involving more of the floor of themouth can be reconstructed with a larger flap partof which may be de-epithelialised and used to fillthe dead space and augment the defect in thesubmandibular region. Total glossectomy defectsrequire significant bulk to restore height andvolume to the reconstructed tongue and a myocu-taneous flap is therefore required. The musclecomponent can also be used to fill dead space in theneck from an associated neck dissection. Theanterolateral thigh flap can provide as much volumeas a rectus abdominis myocutaneous flap whichpreviously has been the most commonly used flapfor total glossectomy reconstruction and has theadded advantage of avoiding abdominal wallcomplications.

Midfacial reconstruction

These defects are complex because they generallyinvolve more than one midfacial component andoften require skin cover, mucosal lining and bonysupport. Although various free flaps have been usedfor midface reconstruction the commonly usedflaps include the radial forearm flap for smalldefects and the rectus abdominis or latissimusdorsi myocutaneous flaps for larger defects com-bined with bone grafts for orbital support ifindicated.20,21 Small defects involving palatealone or midfacial skin alone may be reconstructedwith a cutaneous or fasciocutaneous anterolateralthigh flap. Larger defects following maxillectomyrequire muscle to obliterate the dead space and amyocutaneous anterolateral thigh flap provides

sufficient volume. An important consideration inmidface reconstruction using free tissue transfer isthe use of recipient vessels. The pedicle has to belong enough to reach donor vessels in the neck. Theanterolateral thigh flap is ideal under these

Figure 5 Extensive composite mandibular defect recon-struction with a fibula osteoseptocutaneous flap forintraoral lining and the mandible defect and an ante-rolateraled thigh flap for external face defect (A)Extensive composite left mandibular defect. (B) Afterdouble flap reconstruction. (C) Appearance one and halfyear after surgery.

A review of the advantages of the anterolateral thigh flap in head and neck reconstruction 607

circumstances since a 10–15 cm pedicle is easilyprovided. Flaps harvested according to volumerequirement from this single donor site can, there-fore, replace the radial forearm, rectus abdominisor latissimus dorsi flaps which have been commonlyused for midface reconstruction.

Scalp reconstruction

The anterolateral thigh flap provides an extremelylarge surface area of skin10 and lends itself toresurfacing extensive defects of the scalp with boneexposure.22 An excellent contour of the scalp isachieved without excessive bulkiness that canresult from the use of other flaps with wide skinterritory such as the rectus abdominis and latissi-mus dorsi flaps.

Donor site morbidity

One of the primary advantages of the anterolateralthigh flap is the reduced donor site morbidity. Fewother donor sites in the body offer such an ampleamount of sensate skin and muscle for thereconstruction of through and through tumourdefects in the head and neck. To preserve maximalquadriceps function, a careful dissection andpreservation of the nerve to the vastus lateralisshould be performed. Kimata et al. observed thatweakness of the limb were related to the degree ofmuscle dissection and if a skin graft had beenused.23 The use of a V–Y perforator based localadvancement flap has been described to avoid theuse of a skin graft. Other authors have not found thedonor site to be problematic. Even when the vastuslateralis is transferred as a free muscle flap Wolffand Grundman found that there was no motordysfunction in their series confirmed by clinicalcomparison of the load capacity of both legs.13 In afurther recent report Kuo et al. have shownobjectively, using a kinetic communicator machine,that patients who underwent a myocutaneousanterolateral thigh flap showed minimal weaknessof the donor thigh at long term follow-up.24

The most important aspect of the anterolateralthigh flap in reconstruction of head and neckdefects lies in its versatility in design and compo-sition and low donor site morbidity. While a verythin pliable innervated flap may be harvested forintraoral reconstruction in one patient, the wholevastus lateralis may be incorporated in the flap toreconstruct a massive perioral defect in anotherpatient. Thus, the anterolateral thigh flap may be

used to reconstruct most soft tissue defects in thehead and neck region including intraoral, tongue,buccal, midface and scalp. With the diversity thatthis flap provides the anterolateral thigh flap cancover most of the indications of two commonly usedsoft tissue free flaps in head and neck reconstruc-tion, namely the radial forearm flap and the rectusabdominis flap. As Ao et al.4 have indicated themorbidity resulting from these two donor sitesshould not be overlooked when a versatile alterna-tive such as the anterolateral thigh flap is available.

References

1. Song YG, Chen GZ, Song YL. The free thigh flap: a new freeflap concept based on the septocutaneous artery. Br J PlastSurg 1984;37(2):149—59.

2. Xu DC, Zhong SZ, Kong JM, et al. Applied anatomy of theanterolateral femoral flap. Plast Reconstr Surg 1988;82(2):305—10.

3. Kimata Y, Uchiyama K, Ebihara S, et al. Anatomic variationsand technical problems of the anterolateral thigh flap: areport of 74 cases. Plast Reconstr Surg 1998;102(5):1517—23.

4. Ao M, Uno K, Maeta M, et al. De-epithelialised anterior(anterolateral and anteromedial) thigh flaps for dead spacefilling and contour correction in head and neck reconstruc-tion. Br J Plast Surg 1999;52(4):261—7.

5. Wei FC, Jain V, Celik N, et al. Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps.Plast Reconstr Surg 2002;109(7):2219—26. discussion 2227—30.

6. Koshima I, Hosoda S, Inagawa K, et al. Free combinedanterolateral thigh flap and vascularized fibula for wide,through-and-through oromandibular defects. J ReconstrMicrosurg 1998;14(8):529—34.

7. Koshima I. Free anterolateral thigh flap for reconstruction ofhead and neck defects following cancer ablation. PlastReconstr Surg 2000;105(7):2358—60.

8. Kimata Y, Uchiyama K, Ebihara S, et al. Versatility of the freeanterolateral thigh flap for reconstruction of head and neckdefects. Arch Otolaryngol Head Neck Surg 1997;123(12):1325—31.

9. Demirkan F, Chen HC, Wei FC, et al. The versatileanterolateral thigh flap: a musculocutaneous flap in disguisein head and neck reconstruction. Br J Plast Surg 2000;53(1):30—6.

10. Shieh SJ, Chiu HY, Yu JC, et al. Free anterolateral thigh flapfor reconstruction of head and neck defects following cancerablation. Plast Reconstr Surg 2000;105(7):2349—57. discus-sion 2358—2360.

11. Nakayama B, Hyodo I, Hasegawa Y, et al. Role of theanterolateral thigh flap in head and neck reconstruction:advantages of moderate skin and subcutaneous thickness.J Reconstr Microsurg 2002;18(3):141—6.

12. Cipriani R, Contedini F, Caliceti U, Cavina C. Three-dimensional reconstruction of the oral cavity using thefree anterolateral thigh flap. Plast Reconstr Surg 2002;109:53—7.

13. Wolff KD, Grundmann A. The free vastus lateralis flap: ananatomic study with case reports. Plast Reconstr Surg 1992;89(3):469—75. discussion 476—7.

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14. Koshima I, Fukuda H, Soeda S. Free combined anterolateralthigh flap and vascularized iliac bone graft with doublevascular pedicle. J Reconstr Microsurg 1989;5:55—61.

15. Koshima I, Hosoda M, Moriguchi T, et al. A combinedanterolateral thigh flap, anteromedial thigh flap, andvascularized iliac bone graft for a full-thickness defect ofthe mental region. Ann Plast Surg 1993;31(2):175—80.

16. Huang WC, Chen HC, Jain V, et al. Reconstruction ofthrough-and-through cheek defects involving the oral com-missure, using chimeric flaps from the thigh lateral femoralcircumflex system. Plast Reconstr Surg 2002;109(2):433—41. discussion 442—3.

17. Urken ML, Weinberg H, Vickery C, et al. Oromandibularreconstruction using microvascular composite free flaps.Report of 71 casts and a new classification scheme for bony,soft-tissue, and neurologic-defects. Arch Otolaryngol HeadNeck Surg 1991;117(7):733—44.

18. Wei FC, Celik N, Chen HC, et al. Combined anterolateralthigh flap and vascularized fibula osteoseptocutancous flapin reconstruction of extensive composite mandibulardefects. Plast Reconstr Surg 2002;109(1):45—52.

19. Wei FC, Demirkan F, Chen HC, Chen IH. Double free flaps inreconstruction of extensive composite mandibular defects inhead and neck cancer. Plast Reconstr Surg 1999;103(1):39—47.

20. Cordeiro PG, Santamaria E. A classification system andalgorithm for reconstruction of maxillectomy and midfacialdefects. Plast Reconstr Surg 2000;105(7):2331—46. discus-sion 2347—8.

21. Cordeiro PG, Disa JJ. Challenges in midface reconstruction.Semin Surg Oncol 2000;19(3):218—25.

22. Lutz BS. Aesthetic and functional advantages of theanterolateral thigh flap in reconstruction of tumor-relatedscalp defects. Microsurgery 2002;22(6):258—64.

23. Kimata Y, Uchiyama K, Ebihara S, et al. Anterolateral thighflap donor-site complications and morbidity. Plast ReconstrSurg 2000;106(3):584—9.

24. Kuo YR, Jeng SF, Kuo MH, et al. Free anterolateral thigh flapfor extremity reconstruction: clinical experience and func-tional assessment of donor site. Plast Reconstr Surg 2001;107(7):1766—71.

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