Application of Anteromedial Thigh Flap for the Reconstruction of Oral and Maxillofacial Defects

SURGICAL ONCOLOGY AND RECONSTRUCTION

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Application of Anteromedial Thigh Flapfor the Reconstruction of Oral and

Maxillofacial Defects

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spital, C

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ence Fo

Zhao-Jian Gong, MD,* Sheng Zhang, MD,y Zhen-Hu Ren,z Zhao-Fu Zhu,xJin-Bin Liu, MD,k and Han-Jiang Wu, MD{

Purpose: To discuss the vascular anatomy of the anteromedial thigh (AMT) flap and to evaluate the feasi-

bility of the AMT flap for the reconstruction of oral and maxillofacial defects.

Patients and Methods: A retrospective review was performed of 18 patients who underwent recon-

struction of oral and maxillofacial defects with AMT flaps from January 2009 through December 2011

in the Second Xiangya Hospital. Eleven unifoliate AMT flaps were elevated to reconstruct defects of the

tongue, soft palate, and floor of the mouth and 7 chimeric anterolateral thigh (ALT) and AMT flaps wereharvested to reconstruct through-and-through cheek defects.

Results: The flapswere 4� 6 to 9� 11 cm2. All the AMT flapswere nourished by the descending branch(DB) of the lateral circumflex femoral artery. The cutaneous perforators were derived from the rectus fem-

oris branch of the DB in 15 cases and directly from the DB in the other 3 cases. Postoperatively, all flaps

survived completely, without major complications. Of the 18 donor sites, 14 were closed directly, leaving

only linear scars, and 4 were closed using full-thickness skin grafts owing to larger defects. All patients

were followed for approximately 6 to 30 months, and they were satisfied with the esthetic and functional

results of the donor and recipient sites after the reconstruction.

Conclusions: Because of easy perforator dissection, the AMT flap can be used as an alternative to the ALT

flap or harvested with the ALT flap as chimeric ALTand AMT flaps for the reconstruction of oral and maxil-

lofacial defects.

� 2014 American Association of Oral and Maxillofacial Surgeons

J Oral Maxillofac Surg 72:1212-1225, 2014

Large defects resulting fromoral andmaxillofacialmalig-

nant tumor resection seriously affect the appearance

and function of patients. How to achieve satisfactory

functional and esthetic results has always been a recon-

structive challenge. The anterolateral thigh (ALT) flap

was first reported by Song et al1 in 1984. It has gained

widespread popularity in recent years, especially for

the reconstruction of oral andmaxillofacial defects aftercancer ablation, because of the long pedicle, suitable

vessel caliber, large skin territory, and minimal donor-

from the Department of Stomatology, Second Xiangya

entral South University, Changsha, China.

nt.

ate Professor.

nt.

sor.

iate Professor.

sor.

rk was supported by the National Natural Science Foun-

hina (grant 81301757) and the Hunan Province Natural

undation of China (grant 12JJ5067).

1212

site morbidity.2,3 In contrast, the anteromedial thigh

(AMT) flap has seldom been used for the recon-

struction of oral and maxillofacial defects and is less

well known.4,5 The authors6 and other groups7-9 have

found that the cutaneous perforators derived from the

lateral circumflex femoral artery (LCFA) system also

are located in the AMT region in some patients. These

cutaneous perforators are supplied to elevate theAMT flap. Most cutaneous perforators of the AMT

flap are septocutaneous perforators (SCPs), and

Address correspondence and reprint requests to Dr Wu: Depart-

ment of Stomatology, Second Xiangya Hospital, Central South Uni-

versity, No.139 Middle Renmin Road, Changsha, Hunan 410011,

China; e-mail: [email protected]

Received September 26 2013

Accepted November 11 2013

� 2014 American Association of Oral and Maxillofacial Surgeons

0278-2391/13/01428-6$36.00/0

http://dx.doi.org/10.1016/j.joms.2013.11.017

Delta:1_given name

Delta:1_surname

Delta:1_given name

Delta:1_surname

Delta:1_given name

Delta:1_surname

mailto:[email protected]

http://dx.doi.org/10.1016/j.joms.2013.11.017

Table 1. PATIENT SUMMARIES

Patient

Number Gender

Age

(yr) Site of Primary Tumor Size of Defect (cm) Flap Complications

1 M 51 right tongue, T2N0M0 6 � 9 AMT flap none

2 M 69 right tongue, T1N0M0 5 � 7 AMT flap none

3 F 71 left tongue, T3N1M0 8 � 11 AMT flap none

4 M 43 left buccal mucosa

(recurrence)

9 � 11 (intraoral),

8 � 10 (extraoral)

chimeric ALT and

AMT flaps

none

5 F 35 left tongue, T2N1M0 6 � 8 AMT flap none

6 F 65 left soft palate,

T1N0M0

5 � 8 AMT flap none

7 M 44 left tongue, T1N0M0 4.5 � 8 AMT flap none

8 M 54 left buccal mucosa,

T2N0M0


6 � 8 (extraoral)

chimeric ALT and

AMT flaps

none

9 F 58 left buccal mucosa,

T2N0M0


6 � 8 (extraoral)

chimeric ALT and

AMT flaps

none

10 M 68 left tongue, T2N0M0 6 � 8 AMT flap floor-of-mouth fistula

11 M 60 right soft palate,

T2N1M0


12 M 55 floor of mouth,

T1N0M0



T3N2M0


7 � 9 (extraoral)

chimeric ALT and

AMT flaps

none

14 F 46 left tongue

(recurrence)


15 F 50 left buccal mucosa,

T3N1M0


7 � 9 (extraoral)

chimeric ALT and

AMT flaps

wound effusion from

salivary fistula


T2N0M0


6 � 9 (extraoral)

chimeric ALT and

AMT flaps

none

17 F 59 right tongue, T2N1M0 6 � 8 AMT flap none

18 M 52 right buccal mucosa,

T4N2M0


9 � 10 (extraoral)

chimeric ALT and

AMT flaps

none

Abbreviations: ALT, anterolateral thigh; AMT, anteromedial thigh; F, female; M, male.

Gong et al. Anteromedial Thigh Flap for Oral Defects. J Oral Maxillofac Surg 2014.

GONG ET AL 1213

musculocutaneous perforators (MCPs) are superficial in

themuscle. Therefore, elevationof theAMTflap is easy.6

When the cutaneous perforators of the ALT flap pene-

trate the muscle deeply and are difficult to dissect,

exploration of the AMT flap can proceed to shorten

the operation time and decrease local damage to pa-

tients.When failure ofALTflappreparationor transplan-

tation is encountered, the AMT flap may be a goodalternative for reconstruction. Furthermore, the AMT

flap can be combined with the ALT flap as chimeric

ALT and AMT flaps, sharing the same vascular pedicle,

for the reconstruction of complex oral andmaxillofacial

defects.6 The authors report their experience with 18

patients who underwent reconstruction of oral and

maxillofacial defects with an AMT flap from January

2009 through December 2011.

Patients and Methods

A retrospective case series was performed in patients

who underwent the reconstruction of oral and maxillo-

facial defects with an AMT flap from January 2009

throughDecember2011 in the SecondXiangyaHospital

ofCentral SouthUniversity (Changsha,China). Included

werepatientswhopresentedwithoral andmaxillofacial

malignant tumors and underwent AMT flap reconstruc-

tion for the defects after tumor ablation. Excluded were

patients with oral and maxillofacial defects resulting

from causes other than malignant tumor resection.This studywas approvedby the ethics committee of Sec-

ond Xiangya Hospital, Central South University and all

participants signed an informed consent agreement.

This study followed the guidelines set forth in theDecla-

ration of Helsinki.

Of the 18 patients, 11 were men and 7 were women,

with an average age of 55.3 years (range, 35 to 71 yr).

The flaps were harvested to repair defects of the tongue(8 cases), buccal area (7 cases), soft palate (2 cases),

and floor of the mouth (1 case). Clinical staging was per-

formed in the16 cases of newly diagnosedcancer accord-

ing to the 2002 International Union Against Cancer TNM

classification ofmalignant tumors. Of these, therewere 4

FIGURE 1. Esthetic and functional outcomes after reconstruction (arrows). A, B, Six months postoperatively. C, Two years postoperatively,reconstruction with chimeric anterolateral thigh and anteromedial thigh flaps plus vermilion flaps. (Fig 1 continued on next page.)


1214 ANTEROMEDIAL THIGH FLAP FOR ORAL DEFECTS

casesofT1N0M0,5casesofT2N0M0,3casesofT2N1M0,

2 cases of T3N1M0, 1 case of T3N2M0, and 1 case ofT4N2M0 (Table 1).

The elevation of flaps was performed simulta-

neously with neck dissection and tumor resection by

2 surgical teams. The incision for the AMT flap was de-

signed according to that of the classic ALT flap. A line

from the anterior superior iliac spine to the lateral

border of the patella was drawn, and the incision

was made 3 cm (depending on the width of the flaps)medial to this line, down to the plane immediately

below the fascia lata. The medial fascia lata was turned

open and the cutaneous perforators that originated

from the LCFA system were explored. Once sizable

cutaneous perforators arising from the LCFA or its

branches were found, the AMT flap could be raised

for the reconstruction. The cutaneous perforators

were dissected and traced until an adequate pediclelength and a satisfactory pedicle size for safe anasto-

mosis were achieved. Muscle tissue in various sizes,

such as the vastus medialis and rectus femoris, was

cut off accordingly to fill the dead spaces. Chimeric

ALT and AMT flaps based on the same vascular pedicle

were harvested for the reconstruction of through-and-

through cheek defects. One-stage thinning of the flapswas properly performed in cases in which the flaps

were excessively bulky and too thick to repair

the defects.

In the present series, 11 unifoliate AMT flaps were

raised to repair defects of the tongue, soft palate,

and floor of the mouth, and 7 chimeric ALT and AMT

flaps were elevated to reconstruct through-and-

through cheek defects (Table 1). In 9 patients, a rectusfemoris muscle flap was harvested to fill the dead

spaces. In all patients with buccal cancer, the flaps

that provided intraoral mucosal lining were sutured

while the mouth was open, and mouth-opening exer-

cises were practiced postoperatively.

Results

The flaps were 4 � 6 to 9 � 11 cm2, and all AMTflaps were harvested from a single dominant cuta-

neous perforator, except for 2 flaps in which 2 cuta-

neous perforators were included. In this series, all 18

AMT flaps were nourished by the descending branch

FIGURE 1 (cont’d). (Fig 1 continued on next page.)


GONG ET AL 1215

(DB) of the LCFA. The cutaneous perforators were

derived from the rectus femoris branch (RFB) of theDB in 15 cases and directly from the DB in the other

3 cases. Among these AMT flap perforators, 14 were

SCPs and 6 were MCPs. Arterial anastomosis of the

flaps was performed in 9 cases to the superior thyroid

artery, in 6 cases to the facial artery, in 2 cases to the

lingual artery, and in 1 case to the external carotid

artery. Venous anastomosis of the flaps was performed

to the internal jugular vein, internal jugular veinbranches, or the external jugular vein. Two venous

anastomoses were performed in 15 cases and 1 venous

anastomosis was performed in 3 cases.

All 18 flaps survived completely, without major com-

plications. Wound effusion caused by salivary fistula

occurred in 1 patient with buccal cancer, and a fistula

in the floor of the mouth occurred in another patient

with tongue cancer (Table 1). Gradual wound healingwas observed after daily wound dressings in these 2 pa-

tients. Of the 18 donor sites, 14 were closed directly,

leaving only linear scars, and 4 were closed using full-

thickness skin grafts owing to larger defects. In those

4 cases in which skin grafts were used, chimeric ALT

andAMTflapswere raised and thedefectswere too large

to be closed primarily. The skin grafts were harvestedfrom the upper part of the donor sites. All donor sites

healed well without significant morbidity. No remark-

able donor-site hematoma or seroma was observed.

All patients were followed for approximately 6 to

30 months, and they were satisfied with the esthetic

and functional outcomes after the reconstruction

(Fig 1). For 8 patients with tongue cancer, the recon-

structed tongues were satisfactory, and the linguisticand swallowing functions recovered well. The patients

had suitable hyomandibular furrow depth and good

tongue movements. No depression was observed in

the submandibular region. For 7 patients with buccal

cancer, the appearance was acceptable, and the degree

of mouth opening in these patients was larger than 2

fingers. For 2 patientswith soft palate cancer, the recon-

structed palates and pharynxes seemed to be perfect,nearly matching those in healthy people, and the lin-

guistic and swallowing functions were satisfactory. In

the present 18 cases, the scars of the donor sites were

not readily visible and thigh motor dysfunctions were

not observed.

FIGURE 1 (cont’d).



During the follow-up period, tumor recurrence and

cervical lymph node metastasis occurred in 5 patients.

Of these, 2 were local primary tumor recurrence,

2 were cervical lymph node recurrence, and 1 was

contralateral cervical lymph node metastasis. Three

patients underwent reoperation and radiotherapy, 1

received palliative radiotherapy, and 1 refused further

treatment. Of the 5 patients, 2 died within the follow-up period because of local tumor recurrence and cer-

vical lymph node recurrence.

Report of Case

A 44-year-old man presented with moderately differ-

entiated squamous cell carcinoma of the left tongue.

He underwent continuous en bloc excision of tumor,

floor of the mouth, and cervical lymph nodes, and the

defect was reconstructed with a 4.5- � 8-cm2 AMT

flap. The flap was supplied by an SCP derived from the

RFB of the DB. In addition to the AMT flap, a rectus fem-oris muscle flap was elevated to fill the floor of the

mouth and submandibular dead space to prevent the

occurrence of fistula in the floor of the mouth. Arterial

anastomosis of the flap was performed to the left supe-

rior thyroid artery in an end-to-endmanner. For 2 venae

comitans, 1 was anastomosed end to end to a branch of

the internal jugular vein and the other one was anasto-

mosed end to end to the external jugular vein. The

donor site was closed primarily, leaving only a linear

scar. Postoperatively, the flap survived completely. No

wound effusion, infection, oe donor and recipient sites

(Figs 2 to 7).

Discussion

With the advancement of microsurgery, free flapshave become the first choice for the reconstruction

of oral andmaxillofacial defects after cancer ablation.10

In particular, the ALT flap is suitable for the reconstruc-

tion of all kinds of oral and maxillofacial soft tissue de-

fects, because of its versatility in design, long pedicle

with a suitable vessel diameter, abundant cutaneous

perforators, large skin territory, adequate flap thick-

ness, ability for a 2-team approach, minimal donor-sitemorbidity, high success rate of flap transplantation,

and so on.6,11 In contrast, the AMTflap also supplied by

LCFA system has seldom been used. Moreover, the

vascular anatomy of the AMT flap has seldom been

FIGURE 2. Tongue carcinoma: preoperative appearance.


GONG ET AL 1217

described. Shimizu et al7 described that cutaneous per-

forators of the AMT flap derived from the LCFA systemwere observed in 46% (17 of 37) of cadaveric speci-

mens. Yu and Selber9 reported that the AMT flap cuta-

neous perforators that originated from the LCFA

system were present in 51% (51 of 100) of patients.

The authors also found this kind of cutaneous perfo-

rator in 57.6% (38 of 66) of cases during the harvesting

of ALT and AMT flaps.6 These cutaneous perforators

exit from the intermuscular septum among the sarto-rius, vastus medialis, and rectus femoris.6 Thus, the

AMT flap can be harvested through the same incision

as the ALT flap. The LCFA gives off 3 branches: the

ascending branch, the transverse branch, and the DB.

Among these branches, the DB is the largest and

longest branch.12 The classic ALT flap is pedicled

mainly with the DB. In the authors’ experience with

more than 1,000 anterior thigh flaps, the RFB of theDB is consistently present in the upper part of the

AMT region. The RFB usually travels along the medial

edge of the rectus femoris and enters this muscle on

the medial and deep surface. Most cutaneous perfora-

tors of the AMT flap arise from this RFB, and some cuta-

neous perforators also originate directly from theDBor

the LCFA.6 Most of these cutaneous perforators areSCPs and located in the middle or upper part of the

AMT region. The sizable vascular pedicle of the AMT

flap could be traced to about 5 to 10 cm in length. In

general, the cutaneous perforators arising directly

from the DB or the LCFA trunk are SCPs (Fig 8A).

Most cutaneous perforators originating from the RFB

are also SCPs, and they originate from the RFB before

it enters the rectus femoris (Fig 8B). The MCPs arisefrom the RFB after it enters the rectus femoris, and nor-

mally they are superficial in the rectus femoris (Fig 8C).

Similar to the ALT flap, the AMT flap has a high suc-

cess rate of vascular anastomosis. In the present series,

all vascular anastomoses were performed under a mi-

croscope. Two venous anastomoses were performed

in 15 cases and 1 venous anastomosis was performed

in 3 cases. All 18 flaps survived completely, withoutvascular crisis. Most cutaneous perforators of the

AMT flap are SCPs; furthermore, the MCPs are superfi-

cial in themuscle. Therefore, elevation of the AMT flap

is straightforward. When the cutaneous perforators of

the ALT flap penetrate the muscle deeply and are

FIGURE 3. Defect after tumor resection.


FIGURE 4. Design of the anteromedial thigh flap according to the defect.



FIGURE 5. Anteromedial thigh flap with a rectus femoris muscle flap.


GONG ET AL 1219

difficult to dissect, exploration of the AMT flap canproceed. In 6 patients of the present series, the AMT

flap was harvested instead of the ALT flap owing to

the difficult perforator dissection. The local damage

to the patients and the difficulty of cutaneous perfo-

rator dissection were obviously decreased.

Dead spaces of different sizes are often left after oral

and maxillofacial malignant tumor resection. The RFB,

which nourishes the rectus femoris, consistently arisesfrom the DB of the LCFA. Thus, in addition to the

FIGURE 6. Reconstruction of the defec

Gong et al. Anteromedial Thigh Flap for Oral Defects. J Oral Maxillofac

vastus medialis, the rectus femoris muscle tissue invarious sizes can be easily obtained with the raised

AMT flap to fill the large dead space. In 9 patients of

the present series, the rectus femoris muscle flaps

were harvested to fill the dead space of the floor of

the mouth, submandibular region, and subzygomatic

region. Of these, a whole rectus femoris (8 cm in

length) was cut off to fill the dead space of the floor

of the mouth in a patient with tongue cancer who un-derwent total glossectomy. With the filling of dead

t with an anteromedial thigh flap.

Surg 2014.

FIGURE 7. One year postoperatively.



FIGURE8. Cutaneous perforators of the anteromedial thigh flap (arrows).A,A septocutaneous perforator directly arising from the descendingbranch. B, A septocutaneous perforator originating from the rectus femoris branch before it enters the rectus femoris. (Fig 8 continued onnext page.)


GONG ET AL 1221

space by muscle tissue, the occurrence of wound

effusion, fistula in the floor of the mouth, and other

complications was effectively avoided. However,because of the anatomic variation of the cutaneous

perforators, the AMT flap cannot be elevated in

every case.13 Furthermore, the AMT flap is located

in the erogenous zone. Therefore, the AMT region

is not a primary donor site for the flaps. Clinically,

the AMT flap is used mainly as an alternative to

the ALT flap.14 In 2 cases of the present series,

exploration of the AMT flap proceeded becausethe ALT flap perforators were injured during flap

harvesting and there were no other sizable perfora-

tors identified. Then, the AMT flap was successfully

harvested instead of the ALT flap through the

same incision.

FIGURE 8 (cont’d). C, A musculocutaneous perforator deriving from the rectus femoris branch after it enters the rectus femoris.


FIGURE 9. Through-and-through cheek defect.



FIGURE 10. Design of the chimeric anterolateral thigh and anteromedial thigh flaps according to the defect.


FIGURE 11. Chimeric anterolateral thigh and anteromedial thigh flaps.


GONG ET AL 1223

FIGURE 12. Reconstruction of the defect with chimeric anterolateral thigh and anteromedial thigh flaps.



Apart from being an alternative to the ALT flap, the

AMT flap can be raised with the ALT flap as chimeric

ALT and AMT flaps through the same vascular pediclefor the reconstruction of through-and-through oral and

maxillofacial defects.15 As shown in the authors’ previ-

ous report,6 the ALTand AMT flaps can be harvested at

the same time through a single incision. The LCFA or

its main branches, such as the DB, could be taken as

a vascular pedicle to raise polyfoliate flaps. If the cuta-

neous perforators arising from the LCFA system are

found in the AMT region, the AMT flap and ALT flapcould be harvested by cutaneous perforators located

in the AMT and ALT regions, respectively, sharing the

same origin. Then, these 2 flaps could form chimeric

FIGURE 13. Donor site with primary closure.

Gong et al. Anteromedial Thigh Flap for Oral Defects. J Oral Max-

illofac Surg 2014.

ALT and AMT flaps using the same vascular pedicle.

With a large number of cutaneous perforators consis-

tently located in the upper and lower parts of the ALTregion, the ALT flap could be harvested in different

parts6,12,16,17; however, cutaneous perforators of the

AMT flap are usually located in the upper part of the

thigh region. Therefore, when raising chimeric ALT

and AMT flaps, the ALT flap should be elevated in the

lower part. Thus, the AMT flap and the ALT flap could

be staggered in the upper and lower parts of the

anterior thigh region to decrease the tension of thewound suture and avoid or decrease skin grafting. In

general, a donor-site defect of the AMT flap narrower

than 8 cm could be closed primarily. In 7 patients

with buccal cancer in the present series, chimeric

ALT and AMT flaps were harvested to reconstruct

through-and-through cheek defects (Figs 9 to 13). Of

these, the rectus femoris muscle flap was raised in 4

cases to fill the dead space. In the 7 patientswith buccalcancer, the wounds of the donor and recipient sites

healed uneventfully, except in 1 case in which wound

effusion caused by salivary fistula occurred; skin graft-

ing of the donor sites was performed in 4 cases because

of skin defects that were too large, and the skin grafts

were raised from the upper part of the donor sites.

The appearance and degree of mouth opening in all pa-

tients with buccal cancer were satisfactory after thereconstruction.

For obese or female patients who have thicker sub-

cutaneous fat in the thigh, the AMT flap is usually

excessively bulky and too thick to reconstruct tongue

or soft palate defects. In this situation, the flap could

GONG ET AL 1225

be appropriately thinned by removing excess subcu-

taneous fat, thus helping to repair the defects. In the

present series, thinned AMT flaps were used success-

fully for the reconstruction of tongue defects in 2 cases

and a soft palate defect in 1 case. Thinning of these 3

AMT flaps was performed before ligation of the

vascular pedicles. Postoperatively, the flaps survived

completely, without vascular crisis, and the patientswere satisfied with the esthetic and functional results.

The cutaneous perforators of the AMT flap are usu-

ally located in the upper part of the AMT region; thus,

its pedicle (about 5 to 10 cm in length) is often shorter

than that of the ALT flap. For contralateral defects or

defects above the oral fissure, whether the pedicle is

long enough for reconstruction should be taken into

account. Because the AMT flap perforators originatefrom the LCFA system (mainly from the DB), the DB

might be traced in the opposite direction to lengthen

the pedicle when it is not long enough.

Because of the variable vascular anatomy, the AMT

flap is not the first choice for the reconstruction of

oral and maxillofacial defects. The cutaneous perfora-

tors of the AMT flap can be easily dissected; thus,

elevation of the AMT flap is very simple. In addition,the vastus medialis and rectus femoris in various sizes

could be cut off along with the raised AMT flap to fill

the large dead space. In summary, the AMT flap can

be used as an alternative to the ALT flap or harvested

with the ALT flap as chimeric ALT and AMT flaps for

the reconstruction of oral and maxillofacial defects.

References

1. Song YG, Chen GZ, Song YL: The free thigh flap: A new free flapconcept based on the septocutaneous artery. Br J Plast Surg 37:149, 1984

2. Liu ZM, Wu D, Liu XK, et al: Reconstruction of through-and-through cheek defects with folded free anterolateral thigh flaps.J Oral Maxillofac Surg 71:960, 2013

3. Loreti A, Di Lella G, Vetrano S, et al: Thinned anterolateral thighcutaneous flap and radial fasciocutaneous forearm flap for recon-struction of oral defects: Comparison of donor site morbidity.J Oral Maxillofac Surg 66:1093, 2008

4. Leduey A, Leymarie N, Bidault F, et al: Cervicothoracic recon-struction with an anteromedial thigh flap: A novel flap concept.J Plast Reconstr Aesthet Surg 66:855, 2013

5. Katre C, Shaw R, Batstone M, et al: Rescue of anterolateral thighflap with absent perforators using anteromedial thigh flap. Br JOral Maxillofac Surg 46:334, 2008

6. Gong ZJ, Wu HJ: Measurement for subcutaneous fat and clinicalapplied anatomic studies on perforators in the anterior thigh re-gion. J Oral Maxillofac Surg 71:951, 2013

7. Shimizu T, Fisher DR, Carmichael SW, et al: An anatomic compar-ison of septocutaneous free flaps from the thigh region. AnnPlast Surg 38:604, 1997

8. Liang CC, Jeng SF, Yang JC, et al: Use of anteromedial thigh flaps asanalternative to anterolateral thighflaps for reconstructionofheadand neck defects in cancer patients. Ann Plast Surg 71:375, 2013

9. Yu P, Selber J: Perforator patterns of the anteromedial thigh flap.Plast Reconstr Surg 128:151e, 2011

10. Hurvitz KA, Kobayashi M, Evans GR: Current options in headand neck reconstruction. Plast Reconstr Surg 118:122e, 2006

11. Wei FC, Jain V, Celik N, et al: Have we found an ideal soft-tissueflap? An experience with 672 anterolateral thigh flaps. PlastReconstr Surg 109:2219, 2002

12. Tansatit T, Wanidchaphloi S, Sanguansit P: The anatomy of thelateral circumflex femoral artery in anterolateral thigh flap.J Med Assoc Thai 91:1404, 2008

13. Schoeller T, Huemer GM, Shafighi M, et al: Free anteromedialthigh flap: Clinical application and review of literature. Micro-surgery 24:43, 2004

14. Riva FM, TanNC, Liu KW, et al: Anteromedial thigh perforator freeflap: Report of 41 consecutive flaps and donor-sitemorbidity eval-uation. J Plast Reconstr Aesthet Surg 66:1405, 2013

15. Nakagawa F,MaetaM,UnoK, et al: [Double anterior (anterolateraland anteromedial) thigh flaps for reconstruction of head andneck defects]. Nihon Jibiinkoka Gakkai Kaiho 107:645, 2004(in Japanese)

16. Fathi M, Reza Fathi H, Hatamipour E, et al: Anatomical study oflateral circumflex femoral arterial system for the anterolateralthigh flap. Minerva Chir 63:283, 2008

17. Kawai K, Imanishi N, Nakajima H, et al: Vascular anatomy ofthe anterolateral thigh flap. Plast Reconstr Surg 114:1108,2004

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Application of Anteromedial Thigh Flap for the Reconstruction of Oral and Maxillofacial Defects