ANTEROLATERAL THIGH FLAP PEDICLE FOR INTERPOSITIONARTERY AND VEIN GRAFTS IN HEAD AND NECKRECONSTRUCTION: A CASE REPORT

BERNARDO BIANCHI, M.D., CHIARA COPELLI, M.D.,* SILVANO FERRARI, M.D., ANDREA FERRI, M.D., and ENRICO SESENNA, M.D.

The selection of receiving vessels is one of the most critical steps in ensuring a successful outcome in microvascular surgery. The use ofinterposition grafts in microsurgery offers the surgeon valuable options when the free flaps vascular pedicles are too short to be anasto-mosed directly to the recipient vessels. Here, we present a case in which artery and vein grafts were used in microsurgical reconstructionof an anterior maxillary defect with an iliac free flap. As donor vessels, we used the descending branch of the lateral circumflex femoral ar-tery and one of the two venae commitantes. The flap survived without major or minor complications. The anterolateral thigh flap pedicleallowed us to harvest safe, reliable grafts easily, with a suitable vessel length and diameter. VVC 2008 Wiley-Liss, Inc. Microsurgery 29:136–137, 2009.

With advances in microvascular surgery, free tissue

transfer is becoming the reconstructive option of choice

for many head and neck defects. One of the most critical

steps in ensuring a successful outcome is the selection of

safe, accessible vascular inflow and outflow sources capa-

ble of sustaining microvascular composite tissue-transfer

viability. Factors that may limit the surgeon’s options are

prior ipsilateral radical neck dissection, regional metasta-

sis, or atherosclerosis due to advanced age or preopera-

tive radiation therapy. Sometimes, the particular flap that

is selected has intrinsic restrictions in terms of the caliber

and length of the donor vessels. If the free flap vascular

pedicle is too short to be anastomosed to the recipient

vessels directly, a segmental graft is needed to bridge

this gap. Here, we present a case involving the use of a

simultaneous artery and vein graft performed in the

microsurgical reconstruction of an anterior maxillary

defect with an iliac free flap.

SURGICAL TECHNIQUE

A 65-year-old woman was admitted to our department

with an infiltrative T4 high-grade squamous cell carci-

noma of the anterior maxilla extending to the right nasal-

cheek skin.

The patient underwent combined surgery that con-

sisted of wide excision of the tumor mass and immediate

flap reconstruction. The surgical defect was reconstructed

through an iliac free flap. Because of the short pedicle,

the flap was anastomosed to the left facial vessels via a

vein and artery graft. As donor vessels, we used the de-

scending branch of the lateral circumflex femoral artery,

which arises from the deep femoral trunk, and one of the

two venae commitantes. The graft was harvested through

a 7-cm incision made on the proximal half of a line

drawn between the anterior superior iliac spine and the

superolateral border of the patella (see Fig. 1). Follow-

ing the technique used to identify the anterolateral thigh

flap pedicle, the rectus femoris muscle was identified

along with the intermuscular septum. Coursing obliquely

over the vastus lateralis muscle, the vascular pedicle

was seen and isolated (Fig. 2). An artery and vein seg-

ment 8 cm in length was harvested and anastomosed in

an end-to-end manner proximal to the flap artery and

vein, respectively, and distally to the facial artery and

vein in the left neck. The thigh incision was closed

directly.

The iliac crest flap survived well, without major or

minor postoperative complications at either the donor or

recipient site.

DISCUSSION

Despite recent advances, recipient vessel selection

remains one of the more critical steps in ensuring a suc-

cessful outcome in microvascular surgery. A short free

flap pedicle or a vessel-depleted neck may limit the

reconstructive options of head and neck defects.

The use of interposition grafts in microsurgery has

been reported in the presence of free flap vascular pedi-

cles too short to be anastomosed to the recipient vessels

directly.1–3 To achieve a tension-free vascular pedicle

that will accommodate the full range of motion of the

head and neck, vein grafts from the saphenous or ce-

phalic system are commonly considered the most versa-

tile and readily available.1–3 Nevertheless, they have

larger diameters than the iliac flap pedicle and the recipi-

ent vessels, which sometimes makes microanastomosis

Unita Operativa di Chirurgia Maxillo-Facciale, Dipartimento Testa-Collo,Ospedale Maggiore, Via Gramsci, 14-43100 Parma (Pr), Italy

*Correspondence to: Chiara Copelli, M.D., Unita Operativa di Chirurgia Max-illo-Facciale, Dipartimento Testa-Collo, Ospedale Maggiore, Via Gramsci,14-43100 Parma (Pr), Italy. E-mail: copkids@tin.it

Received 27 June 2008; Accepted 9 August 2008

Published online 22 October 2008 in Wiley InterScience (www.interscience.wiley.com). DOI 10.1002/micr.20566

VVC 2008 Wiley-Liss, Inc.

more difficult to perform. In the case described here, we

decided to use the descending branch of the lateral cir-

cumflex femoral artery and its two venae commitantes to

bridge the gap between the pedicle of an iliac crest free

flap and the neck vessels in reconstruction of an anterior

maxillary defect. Based on the cardiac literature, the pat-

ency rates of arterial conduits are far superior to those of

vein grafts.4,5 Moreover, some authors have reported that

high-flow vein grafts, such as the cephalic and saphenous,

have higher risks of acute thrombosis and hemorrhagic

complications due to hyperperfusion.6

The descending branch of the lateral circumflex femo-

ral artery has already been applied to vascular bypass

grafting by neuro- and cardiac surgeons.4,7 Its use for

coronary bypass has been associated with high rates of

patency and a low incidence of spasm.4

Following the technique used to identify the anterolat-

eral thigh flap pedicle, we harvested grafts with lengths

from 8 to 16 cm.8–10 The diameter of the artery can vary

from 1 to 2 mm and the two venae commitantes have

diameters slightly larger than the artery.8–10 The use of the

grafts allowed the full length and greatest caliber of the do-

nor artery to be used. We could take it closer to the source,

resulting in a larger lumen. The artery diameter was similar

to those of both the flap and facial artery. The presence of

two venae commitantes allowed the choice of the one with

the better diameter to reduce discrepancies between the do-

nor and recipient vessels. Furthermore, this allowed the

possibility of a second venous anastomosis, increasing the

venous outflow and reducing the risk of thrombosis.

The anterolateral thigh flap pedicle allowed us to eas-

ily harvest safe and reliable arterial and venous grafts of

suitable vessel length and diameter. In this way, we

obtained safe vascular inflow and outflow sources without

morbidity at either the donor or receiving site. In our

reconstruction of a maxillary defect with an iliac free

flap, the descending branch of the lateral circumflex fem-

oral artery and its two venae commitantes had good

matches with both the small vessels of the flap pedicle

and the larger recipient vessels of the neck.

Moreover, in comparison with grafts from the saphe-

nous or cephalic system, the method described here

resulted in only minor vessel mismatch and a reduction

of the risk of complications due to the surgical technique.

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Figure 1. A 7-cm incision made on the proximal half of a line drawn

between the anterior superior iliac spine and the superolateral bor-

der of the patella.

Figure 2. Identification of the lateral circumflex femoral artery (a)

and of the two venae commitantes (b) coursing obliquely over the

vastus lateralis muscle.

Use of Anterolateral Thigh Flap Pedicle 137

Microsurgery DOI 10.1002/micr