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How I Do It

Anterolateral Thigh Flap Fascia Lata Suspension in OralFloor Reconstruction

Wan Jing Zhang, MBBS, BMedSci; Ardalan Ebrahimi, MBBS, FRACS;

Michael D. Kernohan, MBBS, BDS, MRCS, FDSRCS; Jonathan R. Clark, MBBS, BSc, FRACS

INTRODUCTIONLocally advanced oral cavity malignancies involving

the tongue or floor of mouth often require detachmentfrom the mandible and en bloc resection of the floor ofmouth musculature. In subtotal glossectomy and floor ofmouth defects, the reconstructive surgeon must balancethe volume of soft-tissue replacement against residualtongue mobility to optimize restoration of speech andswallowing and ensure reliable separation of the oralcavity from the neck to prevent postoperative salivaryfistulas.

The mylohyoid, digastric, and geniohyoid musclesprovide dynamic structural support for the tongue tocombat the combined forces of gravity, mastication, artic-ulation, and swallowing. When the floor of mouth‘‘diaphragm’’ is resected or detached, the reconstructionmay leave patients with a poorly positioned neotonguethat provides inadequate flap-palatal valving for speechand swallowing.1,2 Furthermore, without adequate sup-port, prolapse of the oral floor can lead to pooling of foodand saliva.3

Traditional methods of subtotal and total glossec-tomy reconstruction using muscle flaps such as therectus abdominus muscle (VRAM) are far from idealbecause the surgeon needs to guess the appropriate vol-ume of tissue to compensate for muscle atrophy. Thisprovides a situation where the initial volume is overcom-pensated, interfering with oral function; the laryngealapparatus cannot be resuspended, promoting aspiration;and the final volume is frequently insufficient.

Since its introduction by Song et al. in 1984,4 theanterolateral thigh (ALT) flap has gained widespreaduse in reconstruction of soft-tissue defects in the headand neck after ablative surgery. It is considered a highly

versatile and reliable flap that allows a two-teamapproach and is associated with minimal donor site mor-bidity. The fasciocutaneous ALT flap is particularlysuitable for oral cavity reconstruction because it pro-vides a large surface area and volume of soft tissue thatis pliable.5,6 Furthermore, the volume is more predict-able when compared with muscle flaps, which tend toatrophy significantly over time. Here, we describe atechnique using the fascia lata component of the fascio-cutaneous ALT flap to re-create the mylohyoid sling andprovide structural support designed to improve postoper-ative speech and swallowing function.

SURGICAL TECHNIQUEThe flap is based on either the septocutaneous or

musculocutaneous perforators of the descending branchof the lateral circumflex femoral artery.4–6 A standardfasciocutaneous ALT flap is harvested using the techni-ques of flap planning and dissection previously welldescribed in the literature.4,6–8 The flap easily providesadequate soft tissue to close the mucosal defect in theoral cavity as well as sufficient fascia lata to re-createthe floor of mouth diaphragm. In thin patients, it maybe necessary to harvest the subcutaneous tissue and fas-cia lata beyond the margins of skin to provide adequatesoft-tissue bulk for the reconstruction.9

The mandible is prepared prior to final harvest of theflap to reduce ischaemic time. A 2-mm drill is used to createholes through the inferior cortical border of the mandible,below the level of the inferior alveolar nerve, every 2 cmwhere the mylohyoid muscle has been removed. The ALTflap is usually inset via a pull-through (lingual release)approach, which is also utilized for the resection. For largesubtotal glossectomy defects, the skin and soft tissue isformed into a dome shape to prevent anterior pooling, allowcontact with the palate, and improve vocal resonance.

The fascia lata is then organized horizontally acrossthe base of the mandible to re-create the floor of mouthas shown in Figs. 1 and 2. Monofilament sutures arepassed through the mandibular tunnels to attach thefascia lata to the lower border of the mandible with thesuspension extending posteriorly to the mandibularangle if required. The repair must have adequate

From the Medical Training Unit (W.J.Z.), Sydney Head and NeckCancer Institute (A.E., M.D.K., J.R.C.), Royal Prince Alfred Hospital,Camperdown, New South Wales, Australia, and Liverpool Hospital(J.R.C.), Liverpool, New South Wales, Australia.

Editor’s Note: This Manuscript was accepted for publicationAugust 11, 2010.

Send correspondence to Dr. Wan Jing Zhang, Royal Prince AlfredHospital, Missenden Road, Camperdown, NSW, 2048, Australia.E-mail: w.z@live.com.au

DOI: 10.1002/lary.21336

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tension to prevent ptosis of oral contents, and as shownin Fig. 3, the technique facilitates excellent long-termmaintenance of intraoral volume.

While the fascia lata trampoline provides staticreconstruction of the floor of mouth, detachment of thehyoid bone causes laryngeal sagging and increases aspira-tion risk. As such, we routinely perform a mandibulohyoidsuspension that reattaches the hyolaryngeal complex tothe mandible, providing anterior traction and elevation to

‘‘tuck’’ the epiglottis under the tongue base to reduce aspi-ration risk (Fig. 4).10–12

DISCUSSIONIn patients requiring extensive resection of the floor

of mouth musculature or subtotal glossectomy, the tech-nique described can reconstitute the mylohyoid slingusing the fascial component of a fasciocutaneous ALTflap. Fixation of the fascia lata to the mandible creates aplatform to support soft-tissue convexity where required.

Fig. 1. Anterolateral thigh flap construction after partial glossec-tomy and resection of floor of mouth musculature. The fascia latacomponent has been used to re-create the mylohyoid sling, pro-viding structural support for the neotongue.

Fig. 2. Intraoperative photograph showing the fascia lata suspen-sion from below the inferior border of the mandible.

Fig. 3. Long-term maintenance of intraoral volume can beachieved after subtotal glossectomy and resection of floor tomouth musculature by incorporating the fascia lata suspension inthe reconstruction. This patient had intelligible speech and wasable to maintain total oral nutrition despite an extensive resection.The photo was taken at 8 months post-op, and the patient is now2.5 years post-op. At the most recent follow-up, the intraoral flapvolume has remained stable.

Fig. 4. Mandibulohyoid suspension reattaches the hyolaryngealcomplex to the mandible. By providing anterior traction and eleva-tion, the epiglottis is ‘‘tucked’’ under the tongue base to reduceaspiration risk.

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This static reconstruction maintains predictable intra-oral volume and improves flap-palatal contact with theaim of improving functional outcomes.

It is important to maintain tongue base volumeto act as a hood over the laryngeal inlet, reducing aspi-ration during swallowing. This is achieved by twovectors: anterior tongue volume to push the tongue baseposteriorly and mandibulohyoid suspension pulling thelarynx forward, as demonstrated in Fig. 4. Significantvolume loss predisposes to aspiration by opening the epi-glottis, funneling food and saliva into the airway. Thiscontrasts with total glossectomy reconstruction combinedwith total laryngectomy, where it may be better to havea funneling effect.

As there is no muscle component to the flap and itis suspended to fixed structures, the volume of recon-struction is constant and predictable. Although we havenot carried out formal functional studies to date, our ex-perience with the technique has been encouraging withregard to postoperative speech and swallowing function.This is particularly pleasing given these patients havelocally advanced tumors with large volume resectionswhere poor functional outcomes and long-term gastros-tomy feeding are often anticipated.13–16

Based on a similar concept, Arden et al.1 describeda case of static floor of mouth reconstruction using amarlex mesh suspension, but the potential disadvan-tages of foreign body reaction and mesh infection are asignificant concern. Attempts at dynamic reconstructionhave also been described using rectus abdominis muscu-locutaneous flaps with an intercostal nerve graft.17 Therectus sheath can be fixed to the mandible in a similarfashion to the fascia lata, and muscle atrophy is reducedby performing a neural anastomosis.

Another benefit of the fascia lata suspension tech-nique is the potential to reduce salivary fistula rates byintroducing vascularized fascia lata as an additionalphysical barrier between the oral cavity and neck andremoving tension from the mucosal closure. Whereneeded, vastus lateralis muscle can be used to fill anypotential space adjacent to the vascular pedicle to preventcollections and fistula as described by Rodrı́guez-Vegaset al.18 The procedure carries no additional donor sitemorbidity and adds little to the overall operative time.

In our experience, this simple adaptation of the fas-ciocutaneous ALT flap leads to total oral nutrition in

patients where long-term gastrostomy feeding had beenanticipated and achieves intelligible speech. This reinfor-ces the notion that the consequences of even morbiddefects after ablative head and neck surgery can bereduced with thoughtful reconstruction.

BIBLIOGRAPHY

1. Arden RL, Dworkin JP, Garfield I. Marlex mesh suspension of the floor ofmouth in the glossectomee. Oper Tech Otolaryngol Head Neck Surg1998;9:119–122.

2. Salibian AH, Allison GR, Rappaport I, Krugman ME, McMicken BL, Etch-epare TL. Total and subtotal glossectomy: function after microvascularreconstruction. Plast Reconstr Surg 1990;85:513–524.

3. Koshima I, Hosoda M, Moriguchi T, Kawada S. New multilobe ‘‘accordion’’flaps for three-dimensional reconstruction of wide, full-thickness defectsin the oral floor. Ann Plast Surg 2000;45:187–192.

4. Song YG, Chen GZ, Song YL. The free thigh flap: a new free flap conceptbased on the septocutaneous artery. Br J Plast Surg 1984;37:149–159.

5. Lin DT, Coppit GL, Burkey BB. Use of the anterolateral thigh flap forreconstruction of the head and neck. Curr Opin Otolaryngol Head NeckSurg 2004;12:300–304.

6. Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin CH. Have we foundan ideal soft-tissue flap? An experience with 672 anterolateral thighflaps. Plast Reconstr Surg 2002;109:2219–2226, discussion 2227–2230.

7. Koshima I, Fukuda H, Utunomiya R, Soeda S. Free anterolateral thighflaps for reconstruction of head and neck defects. Plast Reconstr Surg1993;92:421–430.

8. Yu P. Characteristics of the anterolateral thigh flap in a Western popula-tion and its application in head and neck reconstruction. Head Neck2004;26:759–769.

9. Kuo YR, Kuo MH, Chou WC, Liu YT, Lutz BS, Jeng SF. One-stage recon-struction of soft tissue and Achilles tendon defects using a compositefree anterolateral thigh flap with vascularized fascia lata: clinical expe-rience and functional assessment. Ann Plast Surg 2003;50:149–155.

10. Goode RL. Laryngeal suspension in head and neck surgery. Laryngoscope1976;86:349–355.

11. Jabaley M, Hoopes JE. A simple technique for laryngeal suspension afterpartial or complete resection of the hyomandibular complex. Am J Surg1969;118:685–690.

12. Weber RS, Ohlms L, Bowman J, Jacob R, Goepfert H. Functional resultsafter total or near total glossectomy with laryngeal preservation. ArchOtolaryngol Head Neck Surg 1991;117:512–515.

13. Borggreven PA, Verdonck-de Leeuw I, Langendijk JA, et al. Speech out-come after surgical treatment for oral and oropharyngeal cancer: a lon-gitudinal assessment of patients reconstructed by a microvascular flap.Head Neck 2005;27:785–793.

14. Borggreven PA, Verdonck-de Leeuw I, Rinkel RN, et al. Swallowing aftermajor surgery of the oral cavity or oropharynx: a prospective and longi-tudinal assessment of patients treated by microvascular soft tissuereconstruction. Head Neck 2007;29:638–647.

15. Nicoletti G, Soutar DS, Jackson MS, Wrench AA, Robertson G. Chewingand swallowing after surgical treatment for oral cancer: functional eval-uation in 196 selected cases. Plast Reconstr Surg 2004;114:329–338.

16. Pauloski BR, Rademaker AW, Logemann JA, et al. Surgical variablesaffecting swallowing in patients treated for oral/oropharyngeal cancer.Head Neck 2004;26:625–636.

17. Yokoo S, Komori T, Umeda M, et al. Functional reconstruction of mobiletongue and suprahyoid muscles after resection of cancer of the tongue.Br J Oral Maxillofac Surg 2001;39:252–255.

18. Rodriguez-Vegas JM, Trillo Bohajar E, Ruiz Alonso E, Casado Perez C.Refining the anterolateral thigh free flap to prevent orocervical fistulain head and neck reconstruction. Plast Reconstr Surg 2004;114:174–177.

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