Journal of Plastic, Reconstructive & Aesthetic Surgery (2009) 62, e85ee86

CORRESPONDENCE AND COMMUNICATION

Chimeric anterolateral thigh freeflap for head and neckreconstruction

Case 1

A 57-year-old male patient presented with advancedtongue cancer and an ipsilateral huge fixed hard neck masswith left carotid artery adhesion. Having performed thecancer resection, we harvested a Chimeric ALT with VL toreconstruct the resultant two widely separated defects:the first was the tongue-oral cavity (Figure 1a) and the

Figure 1 a) Near total glossectomy following resection of advanceleft side of the neck with exposure of the left carotid artery. c) Rchimeric flap. d) Coverage of the defect at the left side of the ne

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second the extensive skin and soft tissue defect at the leftneck measuring approximately 15� 10 cm (Figure 1b).

Operative technique

Designing the flap, a line was drawn from the anteriorsuperior iliac spine to the superolateral border of thepatella.1,2 Preoperative identification of at least two widelyseparated perforators with loud signals was performed withhand-held Doppler. A medial skin incision was made and theflap was dissected in a subfascial plane towards the inter-muscular septum. We found two sizable widely separatedmusculocutaneous perforators, approximately 5 cm apart.Full intramuscular dissection of the perforators was not

d tongue cancer. b) Extensive skin and soft tissue defect at theeconstruction of the tongue using the distal skin island of theck using the proximal skin island of the chimeric flap.

tiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.

Figure 2 The skin paddle is splitted in two skin islands based on two widely separated perforators of the Descending ranch of theLCFA.

e86 Correspondence and communication

performed as we harvested a major part of VL muscle. Thelateral incision of the skin paddle was made and a 25� 10 cmskin paddle of ALT flap and 25� 10� 3 cm VL muscle wereharvested. The skin paddle was splitted in two skin islandsduring flap inset. The distal skin island (15� 10 cm) based onthe distal perforator was used to reconstruct the tongue(Figure 1c) and the proximal one (10� 8 cm) based on theproximal perforator to cover the neck defect (Figure 1d). TheVL muscle was placed at the left side of the neck to fill thedead space and to avoid postoperative infection, especiallyat the left carotid area. Microvascular anastomosis wasperformed using the transverse cervical vessels as recipientvessels. The donor site was closed primarily.

Discussion

The ALT free flap has been the flap of choice for Head andNeck Reconstruction following cancer resection in Asia.1

The versatility of this flap offers many advantages but thevariability of the pedicle anatomy and the difficult dissec-tion may be a challenge for the surgeon.1,3,4

We would like to emphasize some technical points toensure successful flapelevation, inset and survival (Figure2):

� Two team approach whenever possible.1,2

� Large skin paddle design; flap width that allows forprimary closure is 8 cm.1,2

� Preoperative identification of at least two widely(>5 cm) loud Doppler signals.� Perforator detection as usual but intramuscular dissec-

tion is not required, unless a limited muscle is harvested;then ‘deroofing’ of the perforator is performed toidentify its course, so that can be safely included duringharvest. Alternatively the flap can be harvested usingthe three-dimensional flap harvest technique.2

� Pedicle length as long as possible.� Meticulous haemostasis after muscle harvest to avoid

postoperative haematoma at the recipient and donorarea.� Design and inset two or more skin islands, depending on

the number of perforators and the recipient siterequirements.1,2,4

The Chimeric ALT flap with VL allows immediatedynamic three dimensional one stage reconstruction of twoor more separated defects by harvesting only one flap.1,3,4

The chimeric flap also solves the problem of deficiency ofthe recipient vessels which is often encountered due towide cancer resection and radiotherapy, as it requires onlyone pair of recipient vessels, thus saving time duringharvest and microsurgical anastomosis.1,4 Careful perfo-rator selection, correct design and surgical technique areessential for success. The flap is reliable and the donor sitemorbidity is less.1,2,4

Conflict of interest

None.

Funding

None.

References

1. Chen HC, Tang YB. Anterolateral thigh flap: an ideal soft tissueflap. Clin Plast Surg 2003;30:383e401.

2. Tsai FC, Yang JY, Mardini S, et al. Free split-cutaneous perfo-rator flaps procured using a three-dimensional harvest tech-nique for the reconstruction of postburn contracture defects.Plast Reconstr Surg 2004;113:185e93.

3. Kimata Y, Uchiyama K, Ebihara S, et al. Anatomic variations andtechnical problems of the anterolateral thigh flap: a report of 74cases. Plast Reconstr Surg 1998;102:1517e23.

4. Huang WC, Chen HC, Wei FC, et al. Chimeric flap in clinical use.Clin Plast Surg 2003;30:457e67.

Athanasios KaronidisSheng Fa Yao

Department of Plastic Surgery,E-Da Hospital/I-Shou University,

Yan-Chau Shiang, Kaohsiung County,Taiwan, ROC

E-mail address: thanasiskaronidis@hotmail.com