Anterolateral thigh myocutaneous flaps as the preferred flaps for reconstruction of oral and maxillofacial defects

Accepted Manuscript

Anterolateral thigh myocutaneous flaps as the preferred flaps for reconstruction oforal and maxillofacial defects

Zhen-Hu Ren , MCS, oral and maxillofacial surgery Han-Jiang Wu , DDS oral andmaxillofacial surgery Kai Wang , DDS, PHD oral and maxillofacial surgery ShengZhang , DDS, PHD oral and maxillofacial surgery Hong Yu Tan , MCS, oral andmaxillofacial surgery Zhao Jian Gong , DDS, PHD oral and maxillofacial surgery

PII: S1010-5182(14)00135-8

DOI: 10.1016/j.jcms.2014.04.012

Reference: YJCMS 1788

To appear in: Journal of Cranio-Maxillo-Facial Surgery

Received Date: 2 February 2014

Revised Date: 28 February 2014

Accepted Date: 22 April 2014

Please cite this article as: Ren Z-H, Wu H-J, Wang K, Zhang S, Tan HY, Gong ZJ, Anterolateral thighmyocutaneous flaps as the preferred flaps for reconstruction of oral and maxillofacial defects, Journal ofCranio-Maxillo-Facial Surgery (2014), doi: 10.1016/j.jcms.2014.04.012.

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http://dx.doi.org/10.1016/j.jcms.2014.04.012

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TITLE: Anterolateral thigh myocutaneous flaps as the preferred flaps

for reconstruction of oral and maxillofacial defects

First author: Zhen----Hu Ren

Degree: MCS, oral and maxillofacial surgery

Affiliations: Department of Oral and Maxillofacial surgery,

The second Xiangya hospital of Central South University

Mailing address: : Department of Oral and Maxillofacial surgery, The second Xiangya hospital of Central South University,Renmin road, no 139, Changsha, Hunan ,410011,CHINA

Email: [email protected]

Corresponding author: Han-Jiang WU

Degree: DDS oral and maxillofacial surgery




Email address: [email protected]

Telephone no: +86-18670369614

Third author: Kai Wang

Degree: DDS, PHD oral and maxillofacial surgery




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Sheng Zhang





Hong Yu Tan

Degree: MCS, oral and maxillofacial surgery




Zhao Jian Gong






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Anterolateral thigh myocutaneous flaps as the preferred flaps for reconstruction of oral and

maxillofacial defects

Background: The anterolateral thigh myocutaneous flap is one of the most commonly used flaps in

reconstructive procedures, but its application in oral and maxillofacial defects has not been fully

determined. Herein, we summarize the application of 1212 anterolateral thigh myocutaneous flaps in

the repair of oral and maxillofacial defects and examine their benefits in maxillofacial reconstruction

of these defects.

Methods: Patients were recruited from February 2002 to June 2013 in the Department of Oral and

Maxillofacial Surgery of Central South University. All patients underwent reconstructive surgery

employing anterolateral thigh myocutaneous flaps. Patient ages ranged from 6 to 82 years with a

mean age of 51.2 years. There are 1015 flaps showing single lobe and 197 flaps showing a multi-island

pedicle and one of which carries the iliac bone. The largest area among the single flaps was 28 × 12

cm2, and the smallest was 3 × 2 cm

2.

Results: Among the 1212 transferred flaps, 1176 survived and 36 showed necrosis, a survival rate of

about 97.0%. The common complications at flap donor site were poor wound healing (10.1%),

localized paraesthesia (50.1%), and altered quadriceps force (11.0%). No cases presented with local

serious complications, and 90% of patients achieved good functional recovery and aesthetically

acceptable results after reconstruction of oral and maxillofacial defects at various locations using

anterolateral thigh myocutaneous flaps. The time (23–121 min; average 51 min) for anastomosis of

one vein and one artery was significantly less than that for two veins and one artery (45–153 min,

average 83 min; p = 0.0003), which indicates one vein anastomosis can significantly reduce the

operating time.

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Conclusion: The anterolateral thigh myocutaneous flaps can be easily obtained and can provide a

good amount of muscle for filling dead space and fascia lata. These flaps can be prepared into a

separate fat flap, multi-island fascia with iliac bone, and other composite pedicle flaps to meet the

various requirements of oral and maxillofacial defects. The subcutaneous fat thickness of the

anterolateral area can vary considerably and thus can be used to repair defects requiring different flap

thickness. Therefore, the anterolateral thigh myocutaneous free flaps are more suitable for oral and

maxillofacial defects than other flaps.

Key word: Anterolateral thigh myocutaneous flap; oral and maxillofacial defects; oral cancer;

Reconstruction

Introduction

The oral and maxillofacial areas are extremely important regions for both aesthetic and

functional reasons. If defects at these regions are not promptly repaired, the adverse effects can

include not only bad speech and chewing and swallowing disorders but also psychological problems

caused by disfigurement.

With the development of free flaps and microsurgical techniques, a variety of free flaps have

become the most commonly used tissue source for repair of maxillofacial defects (Crow and Crow,

1976; Bianchi B et al., 2008). More than a dozen free flaps can be considered, and knowing how to

choose the right flap for reconstruction is an important key step for successful repair (Futran and

Mendez, 2006). The ideal free flaps for oral and maxillofacial defects should have the following

features: simple preparation, constant vascular anatomy, a sufficient amount of diverse tissues, few

donor site complications, and vascular diameter similar to that of neck and maxillofacial vessels.

Investigators around the world have made great efforts to find the best free flaps for the repair of

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maxillofacial defects (Gedebou, 2002).

The application of an anterolateral thigh flap was first reported by Song et al(Song, 1984),

Anterolateral thigh flaps offer many features and can be prepared as perforating flaps, fat flaps, fascia

flaps, muscle flaps, various chimeric flaps, and others(Koshima, 2000; Demirkan et al., 2000; Koshima

et al., 1993; Fang et al., 2013). Therefore, these flaps have become one of the most commonly used

flaps for the repair of defects in the head and neck, limbs, torso, and other body parts. However, the

clinical value of anterolateral thigh myocutaneous flaps in oral and maxillofacial surgery has not been

widely recognized, and a large cohort-based report of the application of anterolateral thigh

myocutaneous flap in oral and maxillofacial defects has not been reported. Here, we collected and

summarized data of 1185 patients who underwent reconstruction of oral and maxillofacial defects

using anterolateral thigh myocutaneous flaps from February 2002 to June 2013. Our results clearly

demonstrate that anterolateral thigh myocutaneous flaps are the preferred flaps for oral and

maxillofacial defects.

Methods

Patients

Patients were treated from February 2002 to June 2013 in the Department of Oral and

Maxillofacial Surgery of Second Xiangya Hospital. All 1185 patients (1212 flaps) underwent

reconstruction of defects caused by tumour resection or trauma using anterolateral thigh

myocutaneous flaps. 904 cases were male and 281 cases were female. The youngest was 6 years old,

and the oldest was 82 years. The mean age was 51.2 years. Among all of the transferred flaps, 1015

were single lobe, and 197 were multi-island pedicle flaps, of which one carried the iliac bone. The

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largest area among the single flaps was 28 × 12 cm2, and the smallest was 3 × 2 cm

2. Postoperative

follow-up was performed for 1092 patients. Follow-up time varied from 5–84 months, and the mean

follow-up time was 32.6 months. Basic information for all patients including defect side, flap size and

type, recipient vessel processing method, donor complications, and postoperative quality of life were

recorded and statistically analysed

Surgical technique

The incision line is parallel to the iliac patellar connection line at 2 cm to the inside of the iliac

patellar connection line (Figure 1). The position and distance of the incision line are adjusted

according to the width of the prepared flap. If the flap is wide, the incision line is moved to the inside;

if the flap is narrow, the incision line is moved outward. Retrograde anatomy is performed to obtain

appropriate vessel and vascular pedicle as well as its concomitant vastus lateralis and motor nerves,

and all the tissues are appropriately restored. Different amounts of vascular pedicle muscle tissue are

used to fill the dead space. When repairing complicated defects, we can also take advantage of the

lateral femoral circumflex artery, which is characterized by multiple perforating branches, to prepare

separate fat flaps, fascia, muscle flaps, or iliac pedicles of a multi-island composite flap (Case 1).

The donor wound is closed by direct suture after preparation of complete flaps. When the cut

flap is too wide or under too much tension, the flap can be prepared in a region above or below the

anterolateral area by cutting full-thickness skin without expanding the donor site. We also can use the

lateral femoral circumflex artery to prepare the anterolateral thigh flap pedicle or tensor fascia lata

flap and close the wound by local pedicle flap repair.

Statistical Analysis

Data were analysed using SPSS 16.0 software (SPSS, Inc., Chicago, IL, USA). χ2 test or Fisher's

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exact test were used to analyse the data. A p value < 0.05 was considered to indicate a statistically

significant difference.

Results

Among all 1212 anterolateral thigh myocutaneous flaps transferred, 1176 survived and 55

showed postoperative vascular crisis. Among those 55, 19 survived completely after treatment,

whereas 36 showed necrosis. The overall survival rate was 97.0% (1176/1212; Table 1).

We compared the ratio of vascular crisis between the cases of two vein anastomosis and cases of

one vein anastomosis. Two vein anastomosis was performed with 1091 flaps, and 39 cases showed

venous crisis, 26 of which showed necrosis. Eleven cases showed crisis within 12 hours after surgery,

and 28 cases showed crisis beyond 12 hours after surgery. The incidence of venous crisis was 3.6%

(39/1091), and the survival rate after treatment was 33.3% (13/39). Necrosis occurred in 2 of 121

cases (1.7%). The survival rate after treatment was slightly higher in the one vein anastomosis group

compared to that in the two vein anastomosis group. However, the incidence of venous crisis, the

survival rate after treatment, and the rate of venous crisis resulting in flap necrosis were comparable

between the groups (p > 0.05; Table 2). The average micromanipulator processing time for two vein

anastomosis was 83 min (range, 45–153 min). The average micromanipulator processing time for one

vein anastomosis was 51 min (23–121 min), which was significantly shorter than that for two vein

anastomosis (p = 0.0003).

No case showed limited knee movement, compartment syndrome, or other serious

complications (Table 3).

Postoperative follow-up was performed in 1092 patients (1092/1185 = 92.2%). Follow-up time

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ranged from 5–84 months, and mean follow-up time was 32.6 months. Questionnaires, oral

evaluation, or other methods were used to assess patients’ quality of life and obtain information

about their speech, swallowing, chewing, and appearance. In addition, 150 patients with tongue, 50

cases with buccal carcinoma, 20 cases with oropharyngeal cancer, and 20 cases with mouth cancer

were randomly selected and further analysed 1 year after surgery. Patients were grouped according to

chewing function as normal, only soft food, and non-masticatory function by considering foods that

could be chewed by patients. Patients were also grouped according to normal verbal communication,

barely able to verbally communicate and unable to communicate verbally according to the clarity of

pronunciation and their ability to be understood. Patients were also grouped according to the patients’

opinions of their change in appearance as good and beautiful, acceptable, and unacceptable. Because

the degree of mouth opening in patients with buccal cancer is an important indicator of the quality of

life, we measured the buccal opening degree and divided cases into ≥3 cm, 1–3 cm, and <1 cm. The

results showed that chewing, swallowing, speech, appearance, and other oral maxillofacial functions

were perfectly recovered in 90% of patients with tongue, cheek, floor of the mouth, and other oral

and oropharyngeal cancers through anterolateral thigh myocutaneous flap reconstruction (Table 4).

Discussion

Although the advantages and application of anterolateral thigh flaps have been widely reported,

many investigators believe that the thickness of fat in the anterolateral thigh flap is unsuitable for

repair of oral and maxillofacial defects. Our results obtained for a large cohort clearly demonstrate

that thicker flaps are suitable in the reconstruction of defects in oropharynx, cheek, and other areas

and for the recovery of related functions. We also found that fat thickness is significantly different in

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the upper and lower regions of the anterolateral area, and thus we can prepare the flaps according to

varying requirements of the defects to be repaired. In addition, thick flaps can be processed into thin

flaps (Case 2). Some investigators considered that the preparation of an anterolateral thigh flap may

fail due to variation of perforating branches (Wei et al, 2002). Our data show that none of the 1212

anterolateral thigh myocutaneous flaps failed due to variation of perforating branches. When

preparing the anterolateral thigh myocutaneous flaps, we retained a certain amount of muscle sleeves

around the perforating branches to ensure that the perforating branches were not damaged, because

even smaller perforating branches can provide the blood supply to the flap. In addition, the

perforating branches surrounding muscle tissue can fill the dead space and serve to prevent effusion

and infection.

Wong et al.( Wong et al., 2010) and Kimata et al.( Kimata et al., 1997) reported that the

anterolateral thigh flap has advantages in head and neck applications. In 2000, Demirkan et

al.( Demirkan et al., 2000) were the first to report that anterolateral thigh myocutaneous flaps not

only have reduced potential for damage to branches but also that surrounding muscle can be used to

fill dead space. Subsequent studies also show that anterolateral thigh myocutaneous flaps have

advantages in the preparation process and that it is necessary to include muscle tissue when repairing

large defects (Kuo et al, 2002; Wong et al, 2009; Liu et al., 2010). However, the numbers of cases

included in previous reports are relatively small, and the application of anterolateral flaps in oral and

maxillofacial defects was not examined. The present study summarizes the outcomes of the

application of 1212 anterolateral flaps in oral and maxillofacial defects and their preparation process

and provides useful information regarding the application of anterolateral flaps in oral and

maxillofacial defects.

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The organizational structure in the oral and maxillofacial area is very complicated, and the

thickness and volume of tissue required for reconstruction varies greatly. In addition, the presence of

the mandible, zygomatic, zygomatic arch, and other bone tissues in these area are conducive to the

formation of void spaces in the skull base, zygomatic, lateral pharyngeal, and submandibular areas.

The thickness of the subcutaneous fat in the upper and lower portions of the anterolateral area differs

considerably, and this area contains skin, muscle, and other tissues, which can satisfy the

requirements for repairing oral and maxillofacial defects(Gong and WU, 2013). Although the free

forearm flap is the preferred flap for buccal and oropharyngeal defects, the insufficient amount of

forearm flap tissue increases the likelihood of collapse at the repaired site. Thus, the use of a forearm

flap is not an ideal method in terms of both appearance and functional considerations (Fang et al.,

2013; Seikaly et al., 2003). In the present study, we prepared flaps from the upper anterolateral area

regularly for oropharyngeal or cheek defects.

Immediately after surgery, the transferred flaps appeared slightly bloated, but vocal activity,

swallowing movement, and tongue pressure can re-shape the form of the flaps. The reconstruction of

the cheek or the oropharynx was able to achieve good shape and restoration of function within 3–6

months after surgery (Case 3 and 4). Repairing the tongue or floor of the mouth after cancer

treatment often requires a thin subcutaneous fat flap, which can be obtained under the anterolateral

area (Case 5).

Careful control of the length of a vascular pedicle is needed, because a vascular pedicle that is

too long or too short will cause postoperative venous crisis (Yu et al., 2009). According to our results

from using 1212 flaps in the repair of oral and maxillofacial defects, when there is no obvious damage

in the ipsilateral neck vein, a vascular pedicle length of 8 cm is appropriate. When reconstructing a

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defect in the floor of the mouth, the vascular pedicle length can be shortened as needed. For the

repair of a cheek defect, a vascular pedicle length of 10 cm is appropriate. When reconstructing a

defect in the oropharynx or upper jaw, a vascular pedicle length of 12 cm is appropriate. We used

upper and lower extremity superficial veins (saphenous vein, cephalic vein, small saphenous vein or

external jugular vein anastomosis) for bridging via arterial and (or) venous anastomosis, if the vascular

pedicle flap length was insufficient and achieved good results. Bridging anastomosis was performed in

25 cases in this study, and all flaps survived without vascular crisis.

Gedebou et al.( Gedebou et al., 2002) reported the application of 1284 free anterolateral flaps at

various body sites and showed that the main drawback of the anterolateral thigh flap is the inability to

carry bone tissue. In our study, one double island flap carried one iliac; the flap area was 7 × 12 cm

and the bone portion was approximately 6 × 2 × 2 cm in size. The flap was used to repair a defect in an

advanced mandibular buccal cancer patient. Survival of the flap was good, and satisfactory recovery

was achieved. However, the transferred bone tissue should be less than 10 cm in length. We also used

a separate fat-containing flap or fascia of a multi-island pedicle anterolateral thigh myocutaneous flap

for mandibular reconstruction in oral cancer patients, and a flap of fat or with fascia covering the

titanium surface effectively prevented postoperative titanium plate exposure and increased the

fullness of the cheeks.

The anterolateral (musculocutaneous) pedicle flap usually contains one artery and two veins.

Anastomosis was performed in all arteries and veins at the beginning of this study. By contrast, from

February 2013 to June 2013, anastomosis was performed in one artery and one vein in a total of 121

cases (Ren et al., 2013). We believe that one vein anastomosis has many advantages, and the two

most prominent advantages are: (1) this creates an "early warning" before crisis and improves the skin

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flap survival rate after crisis (“early warning” means venous crisis can be discovered earlier), (2)

significantly shorter flap anastomosis time.

In this study, the most common donor site complications included poor wound healing,

localized paraesthesia’s, and decreased quadricep strength, among others. The main causes of the

above complications are known to be eccessive suture tension and intraoperative injury of the

anterolateral thigh muscle motor nerve and cutaneous nerve (Lin et al., 2006; Choi et al., 2007; Wong

et al., 2009). Therefore, during flap preparation, we should protect the anterolateral cutaneous nerve

and vastus lateralis motor nerve as much as possible and avoid large suture tension to further reduce

donor site complications.

Conclusion

Anterolateral thigh myocutaneous flaps can be easily obtained and can provide a good amount of

muscle for filling dead space and fascia lata. These flaps can be prepared into a separate fat flap,

multi-island fascia with iliac bone, and other composite pedicle flaps to meet the various

requirements of oral and maxillofacial defects. The subcutaneous fat thickness of the anterolateral

area can vary considerably and thus can be used to repair defects requiring different flap thickness.

Therefore, the anterolateral thigh myocutaneous free flaps are more suitable for oral and maxillofacial

defects than other flaps. In addition, compared to two vein anastomosis, one vein anastomosis is

associated with a similar flap survival rate but significantly shorter vascular anastomosis time.

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References

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Koshima I: Free Anterolateral Thigh Flap for Reconstruction of Head and Neck Defects following

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Kuo YR, Seng-Feng J, Kuo FM, Liu YT, Lai PW: Versatility of the free anterolateral thigh flap for

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Table 1. Causes of of venous crisis and flap survival rate after treatment.

Crisis, n Survival rate after treatment, n (%)

Necrosis, n

Arterial factors 9 1（11.1%） 8

Venous factors 46 18（39.1%） 28

Total 55 19（34.5%） 36

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Table 2. Venous crisis rate, survival rate, and necrosis rate in one and two vein anastomosis groups Group N Venous

crisis, n (%)

P Survival rate after treatment,

n (%)

P Necrosis, n (%)

P

A (one vein) 1091 39 (3.6%)

0.227

13 (33.3%)

0.057

26 (2.4%)

0.611

B (two veins) 121 7 (5.8%) 5 (71.4%) 2 (1.7%)

Total 1212 46 (3.8%) 18 (39.1%) 28 (2.3%)

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Table 3. Complications at flap donor site Complications n % Poor wound healing 122 10.1 Skin graft necrosis 4 0.3 Muscle necrosis 3 0.2 Hematoma 17 1.4 Local discomfort 607 50.1 Mildly impaired muscle function

133 11.0

Delayed wound healing 35 2.9 Severe scarring 57 4.7 Restricted knee function 0 0 Osteofascial syndrome 0 0

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Table 4. Functional and aesthetic results after reconstruction for patients with oral cancer

Site of repaired

defect

Number of

cases Chew function, n (%)

Swallowing

function, n (%)

Voice, n (%)

Appearance, n (%)

Mouth opening,

n (%)

Tongue

150 Normal: 68 (45.3%) Only soft food: 77

(51.3%)

Unable to chew: 5

(3.3%)

Normal: 118

(78.7%) Liquids: 29 (19.3%)

Solids: 3 (2.0%)

Normal: 97 (64.7%) Barely able to

communicate: 41 (27.3%)

Unable to communicate:12

(8.0%)

Good: 37

(24.7%) Acceptable: 104

(69.3%)

Unacceptable: 9

(6.0%)

Cheek


(16.0%)

Unable to chew: 1

(2.0%)

Normal: 48 (96.0%) Liquids: 1 (2.0%)

Solids: 1 (2.0%)



Unable to communicate: 0 (0%)

Good: 11


(64.0%)

Unacceptable: 7 (14.0%)

≥3 cm: 26

(52.0%) 1–3 cm: 21

(42.0%)

<1 cm: 3 (6.0%)

Oropharynx


(35.0%)

Unable to chew: 2

(10.0%)

Normal: 7 (35.0%) Liquids: 11 (55.0%)

Solids: 2 (10.0%)



Unable to communicate: 3 (15.0%)

Good: 6 (30.0%) Acceptable: 12

(60.0%)

Unacceptable: 2

(10.0%)

Floor of the

mouth


(50.0%)

Unable to chew: 3

Normal: 15 (75.0%) Liquids: 5 (25.0%)

Solids: 0 (0%)



Unable to communicate:

Good: 8 (40.0%) Acceptable: 8

(40.0%)

Unacceptable: 4

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(15.0%) 1 (5.0%)

(20.0%)

Totals 240 Normal: 127 (52.9%) Only soft food: 102

(42.5%)

Unable to chew: 11

(4.6%)

Normal: 188

(78.3%) Liquids: 46 (19.2%)

Solids: 6 (2.5%)



Unable to communicate: 16 (6.7%)

Good: 62


(65.0%)

Unacceptable:

22 (9.2%)

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Schematic diagram

A:：： Anterior：superior：iliac：crest：

B:：： Lateral：margin：of：the：patella：

AB:：Iliac：patellar：Connection：

C:：： Upper：border：

D:：： Lower：border：

O:：： Inside：incision：line：

a c e： Up,：middle：and：lower：regions：

of：anterolateral：area：：

b d f： Up,：middle：and：lower：regions：

of：share：anteromedial：region

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Preoperative opening image showed the cancer was located on the front cheek

One year after surgery, the patient showed almost symmetry maxillofacial, no obvious bloated at

inside and outside the mouth flap and without significant distortion when smile.

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Primary tumor was located in the right retromolar pad area and invade the gums, tongue and

so on.

Vascularized iliac anterolateral thigh flap

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

After two and half years of surgery, the patient showed a good degree of opening and CT shows

well healing vascularized iliac bone.

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

Before thinning

Cut off the fat

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

After thinning

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

One year after surgery, the flap shape further modified and ipsilateral soft palate forms showed

smimilar structure with the contralateral side.

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

Preoperative image of the patient with tongue cancer

After 1 month of surgery, flap slightly bloated.

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

After 5 months of surgery, the morphology becomes better and showing good shape.

Documents

Anterolateral thigh myocutaneous flaps as the preferred flaps for reconstruction of oral and maxillofacial defects