SURGICAL ONCOLOGY AND RECONSTRUCTION

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Anterior Tibial Artery Perforator Flap forReconstruction of Intraoral Defects

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Rong-Lin Wang, MD,* Ning Li, DDS, MD,y Can-Hua Jiang, DDS, MD,zFeng Guo, DDS, MD,x and Tong Su, DDS, MDk

Purpose: The present clinical study assessed the feasibility of using an anterior tibial artery perforator

(ATAP) flap for the reconstruction of an intraoral defect after ablative surgery for oral cancer.

Patients and Methods: A cohort of consecutive patients with oral cancer requiring reconstruction of

an intraoral defect using an ATAP flap were enrolled after ablative surgery for oral cancer and ipsilateral

neck dissection.

Results: Twelve patients had primary oral squamous cell carcinoma (8 with tongue cancer and 4 with

buccal cancer). All patients received intraoral defect repair using an ATAP flap from the lower left leg.

The flapmeasured 7� 4 to 8� 6 cm2. Flap thickness was approximately 4.8 mm (3 to 6mm). Anastomosis

of all ATAP flaps was straightforward because of the long and high-caliber vessel pedicle. All flaps survivedand yielded excellent esthetic results for intraoral reconstruction. Nomajor complications occurred in any

patient.

Conclusion: The main advantages of the ATAP flap included the thin and pliable tissue characteristics

and a long and high-caliber pedicle. For small and medium-size intraoral defects, the ATAP flap is a reliable

alternative to the radial forearm free flap.

� 2014 American Association of Oral and Maxillofacial Surgeons

J Oral Maxillofac Surg 72:804-810, 2014

To optimally reconstruct an intraoral soft tissue defect

by a free flap, the flap should be relatively thin and

pliable to provide the best replacement for the soft

and mobile oral mucosa.1,2 Moreover, its vessel

pedicle should be long enough with adequate

caliber for vascular anastomosis, because commonlythe recipient vessels (the facial artery or superior

thyroid artery as the recipient artery and the

external jugular vein or branches of the internal

jugular vein as the recipient vein) in the head and

ing Physician, Jinan Stomatology Hospital, Jinan, China.

ing Physician, Department of Oral and Maxillofacial

iangya Hospital, Central South University, Changsha,

ate Professor, Department of Oral and Maxillofacial

iangya Hospital, Central South University, Changsha,

ate Professor, Department of Oral and Maxillofacial

iangya Hospital, Central South University, Changsha,

iate Professor, Department of Oral and Maxillofacial

iangya Hospital, Central South University, Changsha,

rk was supported by the National Natural Sciences Foun-

hina (grant 81000445), the Foundation of theDepartment

804

neck have a large diameter and are distant from

intraoral defects.

Although the radial forearm (RF) free flap has the

thin and pliable characteristics and a long and high-

caliber pedicle, its harvesting leaves an unsightly and

conspicuous scar at the donor site and results insome potential complications in the upper limb

because of scarification of an important vessel of the

forearm.3-5 The anterolateral thigh (ALT) free flap, as

a 4-season flap, is unsuitable for obese patients owing

of Science & Technology of Hunan Province in China (grant

2010TD2023), and the State Key Specialist Construction Projects

of China.

Conflict of Interest Disclosures: None of the authors reported any

disclosures.

Address correspondence and reprint requests to Dr Li: Depart-

ment of Oral and Maxillofacial Surgery, Xiangya Hospital, Central

South University, No 87, Xiangya Road, Changsha, 410008, People’s

Republic of China; e-mail: liningbeta@hotmail.com

Received June 27 2013

Accepted October 29 2013

� 2014 American Association of Oral and Maxillofacial Surgeons

0278-2391/13/01412-2$36.00/0

http://dx.doi.org/10.1016/j.joms.2013.10.025

WANG ET AL 805

to excessive subcutaneous fat in the thighs, which re-

quires a flap-thinning procedure to achieve good re-

sults.6-8 However, the thinning procedure requires a

high degree of technical skill and exact knowledge

of the vascular anatomy to avoid accidental

perforator injuries.9,10 Acceptance of a jejunal graft is

restricted by its vulnerable mucosa and possible

postoperative complications, including adhesion-induced ileus, abdominal wall dehiscence, peritonitis,

or hernias.11 Except for total tongue reconstruction,

the rectus abdominis musculocutaneous flap is not

preferred for intraoral reconstruction owing to its

bulky volume.12 The lateral upper arm free flap is al-

ways thin and pliable; however, the small vessel diam-

eter, short pedicle length, deep location of the pedicle,

and close relation to the radial nerve are major disad-vantages.13,14 Other free flaps proposed for intraoral

lining have their limitations. Therefore, there is no

FIGURE 1. Anatomy of the ATAP flap and its surroundin

Wang et al. Anterior Tibial Artery Perforator Flap. J Oral Maxillofac Sur

gold standard for the reconstruction of an intraoral

soft tissue defect by a free flap.

The choice of a free flap typemust bemade after tak-

ing into account the anatomic and functional charac-

teristics of the tissue removed, the recipient and

donor sites, the patient’s general condition, and the

experience of the surgeon. This report describes the

authors’ successful clinical application of a reliablefree flap, the anterior tibial artery perforator (ATAP)

free flap, with a long and high-caliber pedicle, for in-

traoral reconstruction. The ATAP flap results in an

inconspicuous scar and minimal functional conse-

quences to the donor site.

Patients and Methods

From July 2012 to March 2013, the free ATAP flapwas used to reconstruct intraoral soft tissue defects

g structures. ATAP, anterior tibial artery perforator.

g 2014.

806 ANTERIOR TIBIAL ARTERY PERFORATOR FLAP

in patients with oral cancer. Patients with varicosities

or restricted walking ability were excluded preopera-

tively. Then, anatomic variations of the 3 main arteries

in the lower legs of the remaining patients were

assessed further by computed tomographic angio-

graphic (CTA) examination. Patients with anterior

tibial artery (ATA) arteriosclerotic damage, a partly ste-

nosed ATA, or an entirely absent ATA were excluded.Color Doppler ultrasonography was used to predict

the location and pulse of a suitable perforator from

the ATA in the anterolateral lower leg in the remaining

patients. All patients had flaps raised in conjunction

with radical resection of the tumor, with safe margins

of at least 1.5 cm. This studywas approved by the Xian-

gya Hospital (Changsha, China) institutional review

board and all participants signed an informed consentagreement.

SURGICAL TECHNIQUE

Ablative resection of oral cancer and ipsilateral neck

dissection were completed under general anesthesia.

The size of the intraoral defect was assessed. The legfrom which the ATAP flap would be harvested was

bent at the knee joint. Themain septocutaneous perfo-

rators of the ATAP flap were identified near the

midpoint between the fibular head and the lateral mal-

leolus by preoperative Doppler. Then, a flap with the

required size was designed around the perforator

point and raised without a tourniquet to assess

the perforator. A dissection was initiated at the subfas-cial level from the posterior side of the designed

flap outline along the anterolateral direction and

continued to the perforator point. Then, the dissec-

tion was performed in the same way on the anterior

Table 1. DETAILS OF 12 PATIENTS TREATED WITH AN ANTER

Patient Age/Gender Lesion Flap Size (cm2)

1 34/male BC 8 � 5

2 47/male TC 8 � 5

3 45/male TC 7 � 5

4 39/female TC 7 � 5

5 58/male BC 8 � 6

6 49/male BC 7 � 4

7 50/male TC 8 � 4

8 33/male TC 8 � 4

9 36/male TC 9 � 5

10 54/female TC 8 � 5

11 32/male TC 8 � 4

12 61/male BC 7.5 � 4

Abbreviations: BC, buccal cancer; TC, tongue cancer.* Distance between fibular head and perforator.

Wang et al. Anterior Tibial Artery Perforator Flap. J Oral Maxillofac Sur

side. When reaching the septocutaneous perforator,

the dissection proceeded deeply along the anterior in-

termuscular septum between the extensor digitorum

longus and tibialis anterior or peroneus longus

(Fig 1). After confirming the perforator as a branch

of the ATA, the perforator vessel was dissected

back to the ATA, leaving a small piece of fascia encir-

cling the perforator. Before harvesting the ATAP flap,ligation and dissection of the distal ATA were per-

formed in front of the origin point of the identified

perforator. Next, the ATA vessel was traced proximally

until a sufficient length was obtained. The vessel

pedicle was divided and the ATAP flap was harvested.

Manipulation was performed carefully to avoid injury

to the deep peroneal nerve. All flaps were anasto-

mosed to ipsilateral cervical vessels. In all cases, asplit-thickness skin graft was required for the

donor site.

Results

Initially, 3 patients with varicosities of the lower leg

were excluded from the 19 oral cancer cases. CTAassessment in the remaining 16 patients led to the sec-

ondary exclusion of 4 cases (1 for bilateral ATA steno-

sis and 3 for arteriosclerotic damage). The remaining

12 patients received preoperative Doppler examina-

tion, and the main perforators of the ATA in the antero-

lateral lower leg were identified. Clinical details of the

12 enrolled patients (10 men and 2 women; mean age,

44.8 yr) are presented in Table 1. The mean flap sizewas 36.4 cm2 (7� 4 to 8� 6 cm2). Themean thickness

of the flapwas 4.8mm (3 to 6mm). Anastomosis of the

ATAP flap was straightforward because of the high

caliber (artery, 2 to 3 mm; veins, 2 to 4.5 mm; data

IOR TIBIAL ARTERY PERFORATOR FLAP

Position of

Perforator (cm)*

Length of Vessel

Pedicle (cm)

Flap Thickness

(mm)

10.5 5.7 4

13. 6 5

12.7 6 6

16 4 5

15.1 7.5 4.5

14 9 5.5

13.5 8 6

16.5 10 5

14.4 7.5 4.5

14.3 6 4

15 6 5

12.4 8.5 3

g 2014.

FIGURE 4. An anterior tibial artery perforator flap with a 2-cmsegment of anterior tibial artery.

Wang et al. Anterior Tibial Artery Perforator Flap. J Oral Maxillo-

fac Surg 2014.

FIGURE 2. A 45-year-old man with primary squamous cell carci-noma of the left tongue.

Wang et al. Anterior Tibial Artery Perforator Flap. J Oral Maxillo-

fac Surg 2014.

WANG ET AL 807

not shown) and suitable length (maximum, 10 cm;

mean, 7.5 cm) of the vessel pedicle. All flaps sur-

vived. Patients could swallow a soft diet and speak

intelligibly at 10 days after surgery. All flaps yielded

excellent esthetic and functional results. All grafted

full-thickness skin in the lower leg healed well

without any functional complications at the donor

site.

REPORT OF CASES

Case 1 (Patient 3)

A 45-year-old man presented with T2N0M0 squa-

mous cell carcinoma (SCC) of the left tongue (Fig 2).

The patient underwent a radical excision, includingthe left side of the tongue, and ipsilateral modified

neck dissection. A 7-� 5-cm2 ATAP flap was harvested

(Fig 3) with a 6-cm vessel pedicle (including 2 cm of

the ATA; Fig 4) for the soft tissue defect of the tongue.

FIGURE 3. A 7- � 5-cm2 anterior tibial artery perforator flap washarvested.

Wang et al. Anterior Tibial Artery Perforator Flap. J Oral Maxillo-

fac Surg 2014.

The artery of the ATAP flap was anastomosed to the su-

perior thyroid artery and the vein was anastomosed to

the external jugular vein. Full-thickness skin grafting

was performed at the donor site and healed well.

The reconstructed contour of the right tongue was

satisfactory at 10-month follow-up (Fig 5).

Case 2 (Patient 1)

The patient was a 34-year-old man with left buccal

mucosa SCC (Fig 6). After a radical excision, a 7- � 5-

cm2 soft tissue defect was left on the left buccal site.

An ATAP flap was harvested with a segment of the

ATA as its vessel pedicle (Fig 7). The artery of the

vessel pedicle was anastomosed to the superior thy-

roid artery and the vein was anastomosed to the inter-

nal jugular vein. Full-thickness skin grafting wasperformed at the donor site. After surgery, the flap

(Fig 8) and the donor site (Fig 9) healed well without

any major events.

FIGURE 5. The result of tongue reconstruction after 10 months.

Wang et al. Anterior Tibial Artery Perforator Flap. J Oral Maxillo-

fac Surg 2014.

FIGURE 8. Intraoral view after repair.

Wang et al. Anterior Tibial Artery Perforator Flap. J Oral Maxillo-

fac Surg 2014.

FIGURE 6. A 34-year-old man with left buccal mucosa squamouscell carcinoma.

Wang et al. Anterior Tibial Artery Perforator Flap. J Oral Maxillo-

fac Surg 2014.

808 ANTERIOR TIBIAL ARTERY PERFORATOR FLAP

Discussion

Septocutaneous perforator flaps using the lower leg

as a donor site have been developed and applied for

FIGURE 7. An anterior tibial artery perforator flap with a segmentof anterior tibial artery was harvested.

Wang et al. Anterior Tibial Artery Perforator Flap. J Oral Maxillo-

fac Surg 2014.

reconstructive surgery since the early 1980s.15 Perfo-

rators of lower leg flaps derive from 3 main vessels:

the ATA, the posterior tibial artery, and the peroneal ar-

tery.16 Carriquiry et al17 divided these septocutaneous

perforators of the lower leg into 3 groups: medial(from the posterior tibial vessels), anterolateral (from

the anterior tibial vessels), and posterolateral (from

FIGURE 9. The donor site healed well without any major events.

Wang et al. Anterior Tibial Artery Perforator Flap. J Oral Maxillo-

fac Surg 2014.

WANG ET AL 809

the peroneal vessels). Cormack and Lamberty18 found

that most ATA perforators course along the anterior

peroneal septum, between the extensor digitorum

longus and tibialis anterior or peroneus longus, in

the anterolateral area of lower leg. Based on anatomic

and color Doppler imaging data, Panagiotopoulos

et al19 considered that a series of ATA septocutaneous

perforators with large diameter were clustered in theproximal and intermediate segments of the lower leg

and penetrated the deep fascia to form an intercon-

necting network supplying the skin. However, there

was a relative lack of large perforators in the distal

segment of the lower leg. In the present study, the sep-

tocutaneous perforators in the intermediate segment

of the lower leg were chosen as the main perforators

of the ATAP flap, because the intermediate area ofthe anterolateral lower leg can provide a longer vessel

pedicle than the proximal area and ensure more perfo-

rators than the distal area.

Kim et al20 developed a free flap based on perfora-

tors originating from ATA branches to repair lower

leg defects. However, the short and low-caliber

(approximately 0.6 to 1.2 mm) vessel pedicle could

be unsuitable for vessel anastomosis in the head andneck. Although the ‘‘supermicrosurgery’’ technique

enables surgeons to successfully anastomose blood

vessels 0.5 to 0.8 mm in diameter, a sufficient learning

time and substantial skills are required for surgeons to

successfully anastomose such vessels.21 In the present

study, themethod ofKimet alwasmodified and a series

of ATAPflapswith a segment of ATAas its vessel pedicle

were harvested to reconstruct intraoral defects func-tionally and esthetically. Compared with other types

of free flap, the ATAP flap has distinct advantages,

including a thin and pliable skin paddle, a long and

high-caliber vessel pedicle, an inconspicuous and hid-

den scar at the donor site, a straightforward way for

flap raising, and the feasibility for 2-teamwork. Howev-

er, the donor site should be covered by a full-thickness

skin graft, which is more time consuming and causesscarring of the lower leg. Compared with the RF flap,

the donor-site scar of the ATAP flap is less conspicuous

because the lower leg scar can be covered by trousers.

However, the surgical procedure of harvesting anATAP

flap is not as straightforward as the harvesting of an RF

flap for a novice. Moreover, the sacrifice of ATA conti-

nuity remains a concern for surgeons and could result

in potential complications for the lower leg, such asvenous congestion, arterial insufficiency, and foot

drop.22 However, in the present cases, the authors

found the obvious repulse of the distal ATA residual

within 15 minutes after the segmental ATA had been

dissected. They considered that retrograde blood

flow from the posterior tibial artery might cause the

repulse of the distal ATA, which might decrease post-

operative complications of the lower limb. Moreover,

just like the ATAP flap, the peroneal artery perforator

flap has some similar advantages for intraoral repair;

however, exposure of the peroneal vessel is more diffi-

cult and demanding even when using the lateral

approach.23

In the present study, preoperative CTA was per-

formed to exclude patients with anatomic variations

of the 3 main vessels, especially the ATA. Althoughthe ATA is an important artery of the lower leg, it

can be too narrow, deficient to a greater or lesser

extent, or entirely wanting. Its function can be sup-

plied by perforating branches from the posterior tibial

or peroneal artery. In addition, Chiu et al24 considered

that preoperative CTA could be used to map the perfo-

rator accurately and evaluate the dominant vascularity

before transferring ALT flaps. However, the authors ofthe present study did not identify the exact course of

the perforator of the ATAP flap in the lower leg using

CTA. High-resolution CTA or magnetic resonance angi-

ography might help visualize the ATA perforators,

which needs further confirmation. Although preoper-

ative Doppler examination can help predict the loca-

tion and pulse of a septocutaneous perforator,

especially those with large diameter, operator depen-dence and false positive detection are its main disad-

vantages.25 Therefore, their intraoperative presence

is most important for proper selection.

In conclusion, the authors believe the ATAP flap can

be used to reconstruct intraoral soft tissue defects

functionally and esthetically and is a reliable alterna-

tive to the RF flap for small and medium-size defects

in the head and neck.

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810 ANTERIOR TIBIAL ARTERY PERFORATOR FLAP

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