Clinical application of free anterolateral thigh flap in thereconstruction of intraoral defectsGuowen Sun, DDS, MD, PhD, Mingxing Lu, BDS, Enyi Tang, MDS, Xudong Yang, MDS,Jianmin Wen, BDS, and Zhiyong Wang, DDS, MD, PhD, Nanjing, China,DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY, SCHOOL OF STOMATOLOGY, NANJINGUNIVERSITY MEDICAL CENTER, NANJING UNIVERSITY, STOMATOLOGIC HOSPITAL OF NANJING

Objective. The purpose of this study was to assess the clinical features and therapeutic efficacy of the intraoral defectsreconstruction with 3 types of anterolateral thigh flaps.Study design. The clinicopathologic data of 39 cases with oral tumors were obtained from the School of Stomatology,Nanjing University Medical Center, from December 2008 to June 2010. These patients underwent the simultaneoustumor resection and intraoral defects reconstruction with free anterolateral thigh flaps.Results. There were 22 male and 17 female patients; the ratio of male to female was 1.3:1; the mean age was 56.1years. Twenty-two of the anterolateral thigh flaps were musculocutaneous flaps (56.4%), 8 were fasciocutaneous flaps(20.5%), and 9 were ultrathin flaps (23.1%). Five patients required operative exploration in the perioperative period.Three flaps were thrombotic events, 1 flap was hematoma, and 1 flap was twisting of perforator. After the salvages, 1flap was partial failure, 1 flap was total failure, and the other 3 flaps were complete survival.Conclusions. The free anterolateral thigh flap was the ideal soft tissue flap in the intraoral defects reconstruction. This flappresents good functional results at the receiving site with the additional advantages of minimal donor-site morbidity and a

high level of patient satisfaction. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;112:34-41)

Intraoral defects reconstruction after tumor resectionhas always been a challenging problem. The freeradial forearm flap and pectoralis major myocutane-ous flap are the most commonly used soft tissues forreconstruction of intraoral defects.1 However, theyhave a number of well-known disadvantages, partic-ularly related to donor-area complications.2-4 Sincethe first report of free anterolateral thigh (ALT) flapby Song et al.5 in 1984, the anterolateral thigh areahas become one of the preferred donor sites for softtissue reconstruction. Wei et al.6 reported that thefailure rate of free ALT flap was �2%, and heconcluded that the free ALT flap could replace mostother flaps for soft tissue reconstruction, because ofits versatility in design, long pedicle with a suitablevessel diameter, and low donor site morbidity. De-spite these advantages, this flap has not becomeparticularly popular, probably because of the vari-ability of vascular anatomy and need to dissect theperforator. In the present paper, we present our pre-liminary experience with this flap, which was exclu-sively used for defects in the oral cavity.

The first two authors contributed equally to this work.Received for publication Jul. 24, 2010; returned for revision Sep. 5,2010; accepted for publication Sep. 22, 2010.1079-2104/$ - see front matter© 2011 Mosby, Inc. All rights reserved.

doi:10.1016/j.tripleo.2010.09.062

34

PATIENTS AND METHODSThe study included 39 patients with oral cavity de-

fects due to tumor resection from December 2008 toJune 2010 in the School of Stomatology, Nanjing Uni-versity Medical Center. These patients underwent thesimultaneous reconstruction of intraoral defects withfree ALT flap. There were 22 male and 17 femalepatients (ratio 1.3:1), ranging in age from 37 to 72 years(mean 56.1 years).

Because the thickness of the flap is adjustable, thefree ALT flap is divided into 3 types according to theclinical need. They are musculocutaneous ALT flap,fasciocutaneous ALT flap, and ultrathin ALT flap.Musculocutaneous ALT flaps included part or whole ofthe vastus lateralis muscle and no need to dissect theperforator in the muscle. The fasciocutaneous ALT flapis undermined and dissected under the deep fascia untilthe perforator passing through the deep fascia into theskin flap are identified. It requires dissect the perforatorin the muscle. The ultrathin ALT flap requires trimmingthe subdermal fat to within 3-5 mm of the subdermalplexus, and a cuff of fascia 1.5 cm from the mainperforator is preserved.

Surgical techniqueTumor radical resections and intraoral defects recon-

struction with ALT flaps were performed simultane-ously on each of the patients.

First, the anterior superior iliac spine and the su-

perolateral border of the patella were identified and

OOOOEVolume 112, Number 1 Sun et al. 35

marked. A line was drawn between the 2 points, themidpoint of this line was determined, and a skinpaddle was drawn using this as a center point. Then,an incision was made at the medial margin of the flapdown to the fascia. Once the perforator was identi-fied subfascially, the skin paddle position could beadjusted appropriately, then the descending branchand/or oblique branch were exposed between therectus femoris muscle and vastus lateralis muscle.Depending on the design of the flap needed, thethickness and volume of ALT flap could be adjustedfor the individual extent of the defect.

If the extent of the defect required the musculocuta-neous ALT flap (Fig. 1), there was no need to dissectthe intramuscular perforator. The medial incision of theflap was made down to fascia above the rectus femoris

Fig. 1. A, Preoperative clinical appearance of squamous celtaneous ALT flap; the part of vastus lateralis muscle, the skitaneous flap, including part of vastus lateralis muscle. D, Appover anterolateral thigh donor site at 2 months.

muscle. The subfascial dissection was continued later-

ally until the septocutaneous or the musculocutaneousperforator passing through the deep fascia into the skinflap was identified. Then, the part or whole of vastuslateralis muscle, the skin perforator, and the skin paddlewere cut together, because of the vastus lateralis musclecontaining the skin perforator.

If the extent of the defect required the fasciocutane-ous ALT flap (Fig. 2), it required dissecting the septo-cutaneous perforator or musculocutaneous perforatorcarefully in the vastus lateralis muscle. First, the sep-tocutaneous or the musculocutaneous perforator wasidentified under the deep fascia, then followed theperforators via intramuscular dissection, and a 0.5 cmmuscle cuff around the vessel was preserved for pro-tection of the perforator.

If the extent of the defect required the ultrathin ALT

oma on the floor of mouth. B, Elevation of the musculocu-rator, and the skin paddle were cut together. C, Musculocu-

e of the ALT flap 2 weeks after reconstruction. E, Linear scar

l carcinn perfoearanc

flap (Fig. 3), it required trimming the subdermal fat.

ar ove

OOOOE36 Sun et al. July 2011

First, the ALT flap was made into the fasciocutaneousALT flap. Then, the fasciocutaneous ALT flap wasthinned in the deep adipofascial layer before transplan-tation. The ultrathin ALT flap can be safely thinned to3-5 mm, and a cuff of fascia 1.5 cm from the mainperforator was preserved.

All flaps were anastomosed to neck vessels. Thedonor defects were closed directly.

RESULTSTable I summarizes the clinical details for all pa-

tients, including tumor stages, flap size, type of flap,complications, result, and so on. All 39 patientssuffered from oral malignant tumors. The clinic stag-ing was according to the International Union AgainstCancer TNM classification of malignant tumors.7

They each underwent simultaneous reconstructionwith ALT flaps. In these free 39 flaps, 22 weremusculocutaneous flaps (56.4%), 8 were fasciocuta-

Fig. 2. A, Preoperative clinical appearance of squamous cellALT flap; note the fasciocutaneous flap including the fasciaview at 2 weeks after the defect reconstruction. D, Linear sc

neous flaps (20.5%), and 9 were ultrathin flaps

(23.1%). Two cases failed: One was complete failurebecause of arterial and venous thrombosis, and theother was partial necrosis because of venous throm-bosis and diabetes. In our series, 33 flaps had 1perforator and 6 flaps had 2 perforators. Thirty-fourcases were musculocutaneous perforators and 5 caseswere septocutaneous perforators. Although this anat-omy of septocutaneous perforator occurs in only 5cases (12.8%), this is a very favorable situation,making flap harvest quick and easy. Twenty-fourflaps used double venous anastomoses (61.5%). Theflap sizes ranging from 10 � 7 cm to 4.5 � 4 cm. Thedonor sites were closed directly in all patients, andthe wounds healed uneventfully.

DISCUSSIONThe radial forearm flap and pectoralis major myo-

cutaneous flap are commonly used for reconstructionof intraoral defects after tumor resection. These flaps

oma on the left tongue. B, Elevation of the fasciocutaneoust including the vastus lateralis muscle. C, Postoperative oralr anterolateral thigh donor site at 2 weeks.

carcinbut no

are easy to harvest and are reliable. However, they

OOOOEVolume 112, Number 1 Sun et al. 37

Fig. 3. A, Preoperative clinical appearance of squamous cell carcinoma on the right tongue. B, The lesion was completely excised. C, Thetumor was wholly removed. D, The thinning of ALT flap was completed (4 mm thick). E, Intraoperative photograph showed the reconstructed

tongue. F, Appearance of the ALT flap 3 months after reconstruction. G, Linear scar over anterolateral thigh donor site at 3 months.

OOOOE38 Sun et al. July 2011

Table I. Patient and anterolateral thigh flap characteristics

Caseno.

Age/gender

Tumorsites Diagnosis

TNMstage

Flap size(cm)

Type offlap

No. ofanastomosed

venous

No. andtype of

perforators ComplicationsSalvage

procedure Result

1 53/M Tongue SCC T3N0M0 9 � 6 MF 1 1, MP None — CS2 43/F Mandible leiomyosarcoma T1bN0M0 8 � 7 MF 1 1, MP None — CS3 68/F Buccal

mucosaSCC T2N0M0 7 � 5 UTF 1 1, MP None — CS

4 69/M Retromolartrigone

SCC T3N0M0 6 � 5 MF 1 1, MP None — CS

5 62/M Tongue SCC T3N2bM0 6.5 � 5 FF 1 1, MP None — CS6 54/F Buccal

mucosaSCC T4aN0M0 11 � 5 MF 2 2, MP None — CS

7 54/M Lowergingiva

SCC T3N2bM0 6 � 4 FF 2 1, SP None — CS

8 53/F Mandible SCC T3N1M0 11 � 6 MF 1 1, MP Arterial andvenousthrombosis

Flap removed TF

9 65/M Lowergingiva

SCC T3N1M0 7 � 5 MF 2 1, MP None — CS

10 56/F Retromolartrigone

SCC T3N0M0 6.5 � 5.5 UTF 2 1, SP None — CS

11 64/F Tongue SCC T3N0M0 6 � 4 MF 2 1, MP None — CS12 57/F Tongue SCC T3N1M0 8 � 6 MF 2 2, MP None — CS13 66/F Tongue SCC T2N0M0 6 � 5 UTF 2 1, MP Twisting of

perforatorCorrect

positionCS

14 56/M Lowergingiva

SCC T2N1M0 6 � 4 FF 1 1, MP Hematoma,from thebranch ofpedicle

Ligation ofbranch

CS

15 48/M Floor ofmouth

SCC T4aN2bM0 7 � 5 MF 1 1, MP None — CS

16 63/M Mandible OS T1N1M0 10 � 7 MF 1 2, MP None — CS17 60/F Tongue SCC T4aN2bM0 7 � 5 MF 2 1, MP None — CS18 63/F Sublingual

GlandACC T4aN0M0 9 � 6 MF 1 1, MP None — CS

19 62/M Lowergingiva

Malignantmelanoma

T4aN1M0 9 � 4.5 MF 2 1, MP None — CS

20 54/M Tongue SCC T2N0M0 7.5 � 5 FF 2 2, MP None — CS21 64/M Floor of

mouthSCC T3N0M0 6 � 5 MF 1 1, MP None — CS

22 65/M Floor ofmouth

SCC T3N2bM0 7 � 4.5 MF 2 1, MP None — CS

23 42/M Tongue SCC T3N0M0 6 � 5 FF 2 1, MP None — CS24 47/F Tongue SCC T2N0M0 7 � 5 UTF 1 1, MP None — CS25 63/M Retromolar

trigoneSCC T3N0M0 8 � 7 MF 1 1, MP None — CS

26 40/F Buccalmucosa

SCC T2N0M0 7 � 6 MF 1 1, MP Venousthrombosis

Revise venousanastomosis

PF

27 54/F Lowergingiva

SCC T2N1M0 7.5 � 4 FF 2 1, SP None — CS

28 63/M Buccalmucosa

SCC T3N0M0 9.5 � 7 MF 2 2, MP None — CS

29 41/M Tongue ACC T3N2bM0 9 � 8 MF 2 2, MP None — CS30 61/M Tongue SCC T2N0M0 6 � 4 UTF 2 1, SP None — CS31 52/M Floor of

mouthSCC T3N0M0 6 � 5 MF 2 1, MP None — CS

32 45/M Floor ofmouth

SCC T2N0M0 4.5 � 4 UTF 2 1, MP None — CS

33 37/M Sublingualgland

ACC T3N0M0 6 � 4 UTF 2 1, MP None — CS

34 46/M Tongue SCC T2N0M0 5.5 � 4.5 FF 2 1, SP None — CS

35 61/F Tongue SCC T2N0M0 6.5 � 4.5 MF 1 1, MP None — CS

OOOOEVolume 112, Number 1 Sun et al. 39

have some obvious disadvantages. The radial fore-arm flap leaves behind a conspicuous esthetic defor-mity in the forearm and requires the sacrifice of themajor artery of the forearm, the radial artery, whichmay have some potential dysfunction: hand stiffness,pain, anesthesia, and so on. The pectoralis majormyocutaneous flap causes loss of pectoralis majormuscle function in arm adduction and/or rotation. Inwomen, the flap might include breast tissue, whichmay lead to breast asymmetry. This flap is too bulkyin the overweight patient.2-4

In recent years, the free ALT flap has becomemore and more popular in the body soft tissue defectreconstruction. It is also an ideal flap for intraoraldefect reconstruction.8 The free ALT flap is reliableand versatile. It can transfer multiple soft tissueswith large amounts of skin. Chen and Tang9 reportedthat the maximum dimension of the ALT flap was 40� 20 cm. It also can be trimmed to the subdermal fatas thin as 3-5 mm9,10 (Fig. 4). The body habitus hasno obvious impact on the choice of ALT flap, al-though the incidence of obesity is higher in theWestern population. The ALT flap can be thinned inthe deep adipofascial layer before transplantation,unlike the pectoralis major myocutaneous flap whichcannot be thinned. Thinning of the ALT flap can besafely performed when a cuff of fascia 1.5 cm from themain perforator is preserved before dividing the pedi-cle. Some difficulties may be increased in the flapharvest for patients with a larger thigh, but the ALT flapis practicable via thinning it.

In the present study, the free ALT flaps weredivided into 3 groups: the musculocutaneous ALTflap, the fasciocutaneous ALT flap, and the ultrathinALT flap. The musculocutaneous ALT flap is a goodchoice to fill large dead space because it can becombined with the vastus lateralis muscle, rectusfemoris muscle, and tensor fasciae latae. This mus-culocutaneous ALT flap is particularly suitable for

Table I. Continued

Caseno.

Age/gender

Tumorsites Diagnosis

TNMstage

Flap size(cm)

36 47/F Tongue SCC T1N0M0 5.5 � 4.537 62/F Tongue SCC T1N0M0 6 � 4.538 55/M Tongue SCC T3N0M0 6 � 4.539 72/F Tongue SCC T2N0M0 8 � 5

ACC, adenoid cystic carcinoma; CS, complete survival; FF, fasciomalignant melanoma; MP, musculocutaneous perforator; OS, osteosneous perforator; TF, total failure; UTF, ultrathin flap.

advanced oral cancer. However, it is usually too

thick for early-stage squamous cell carcinoma oftongue or cheek. Although secondary debulking pro-cedures can be performed,11 they impose additionalburdens on patients. Because early-stage oral cancerrepair requires a relatively thin skin flap, the ultrathinALT flap and the fasciocutaneous ALT flap canprovide a better size match than other fasciocutane-ous flaps for the reconstruction of intraoral defects,thus leading to better functional results. For thereconstruction of intraoral defects, the ultrathin ALTflap and the fasciocutaneous ALT flap or the freeforearm flap could provide similar soft-tissue cover-age, but they result in different donor-site appear-ance. The donor site is closed primarily for ALT flap,leaving only a linear scar that is inconspicuous withnormal clothing, and no functional deficit is leftbehind in the thigh.

In the present group, double venous anastomosis wasperformed in 24 flaps (61.5%; Fig. 5). Ichinose et al.12

Fig. 4. The ALT flap was 4 mm thick after thinningprocedure.

No. ofanastomosed

venous

No. andtype of

perforators ComplicationsSalvage

procedure Result

2 1, MP None — CS2 1, MP None — CS2 1, MP None — CS2 1, MP Venous

thrombosisRevise venous

anastomosisCS

us flap; LMS, leiomyosarcoma; MF, musculocutaneous flap; MM,; PF, partial failure; SCC, squamous cell carcinoma; SP, septocuta-

Type offlap

UTFUTFMFFF

cutaneoarcoma

concluded that that dual venous anastomosis can reduce

OOOOE40 Sun et al. July 2011

the risk of flap failure—the rationale being that the flapis still likely to survive if one vein becomes throm-bosed. So in this study, the majority of the flaps were2-vein anastomoses.

In these 39 patients, 5 patients (12.8%) requiredoperative exploration in the perioperative period.Thrombotic events occurred in 3 patients: 1 flap wassuccessfully salvaged by surgical revision at the ve-nous anastomosis, 1 flap was partial failure, and 1flap was total failure. Partial loss of flap was due tothe venous thrombosis and the diabetes, and thewound showed mild infection in a later stage. Totalloss of flap was because of the arterial and venousthrombosis. Hematoma from the branch of pedicleoccurred in 1 patient, and the twisting of perforatoroccurred in another patient, both of them success-fully salvaged (Table I).

In brief, the free ALT flap is relatively safe andeasy to raise, with a long vascular pedicle, at least 8cm in all cases. All flaps were anastomosed to neckvessels without tension and without the need for veingrafts. The operations for tumor resection and flapharvest can be simultaneously performed by a 2-teamapproach, unlike scapular, parascapular, and latissi-mus dorsi flaps, shortening the operative time.13

There have been no problems with donor-site mor-bidity in this group after the donor site was closeddirectly. The major problems with the ALT flap arethe variations in the anatomy of the vascular pedicle,the difficult dissection technique, and the high inci-dence of hairy skin, especially in male. These ledinitially to a lack of popularity of this flap.14 Despitethese disadvantages, the application of this skin flap

Fig. 5. Double venous anastomosis was performed(arrows).

has become increasingly widespread.15,16

CONCLUSIONSThe versatile anterolateral thigh perforator flap is

an ideal flap for soft tissue reconstruction of intraoraldefects owing to its thickness and volume which canbe adjusted according to the individual extent of thedefect, and it can be reliably harvested without in-curring serious donor morbidity. The free ALT flap isnow considered to be a workhorse for head and neckreconstruction in our center with the development ofmicrosurgical techniques. When a forearm flap willlikely be too thin or too morbid, the ALT flap can beconsidered as its “big brother.”17 In our experience,we recommend the ALT flap should be considered asa first choice for soft tissue defects in the oral cavity.

REFERENCES1. Kroll SS, Evans GR, Goldberg D, Wang BG, Reece GP, Miller

MJ, et al. A comparison of resource costs for head and neckreconstruction with free and pectoralis major flaps. Plast Recon-str Surg 1997;99:1282-6 [PubMed].

2. Timmons MJ, Missotten FE, Poole MD, Davies DM. Complica-tions of radial forearm flap donor sites. Br J Plast Surg 1986;39:176-8 [PubMed].

3. Carlson ER. Pectoralis major myocutaneous flap. Oral Maxillo-fac Surg Clin North Am 2003;15:565-75 [PubMed].

4. Hallock GG. Complications of the free-flap donor site from acommunity hospital perspective. J Reconstr Microsurg 1991;7:331-4 [PubMed].

5. Song YG, Chen GZ, Song YL. The free thigh flap: a new freeflap concept based on the septocutaneous artery. Br J Plast Surg1984;37:149-59 [PubMed].

6. Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin CH. Have wefound an ideal soft-tissue flap? An experience with 672 anterolateralthigh flaps. Plast Reconstr Surg 2002;109:2219-26 [PubMed].

7. Sobin LH, Wittekind CH, editors. UICC TNM classification ofmalignant tumors. 6th ed. New York: Wiley; 2002. p. 17-50.

8. Wolff KD, Kesting M, Thurmüller P, Böckmann R, Hölzle F.The anterolateral thigh as a universal donor site for soft tissuereconstruction in maxillofacial surgery. J Craniomaxillofac Surg2006;34:323-31 [PubMed].

9. Chen HC, Tang YB. Anterolateral thigh flap: an ideal soft tissueflap. Clin Plast Surg 2003;30:383-401 [PubMed].

10. Kimura N, Satoh K. Consideration of a thin flap as an entity andclinical applications of the thin anterolateral thigh flap. PlastReconstr Surg 1996;97:985-92 [PubMed].

11. Huang SH, Wu SH, Chang KP, Wang WH, Lai CH, Sun IF, et al.Contour refinements of free flaps for optimal outcome in oralreconstruction: combination of modified liposuction techniqueand w-plasty in one-stage procedure. J Craniomaxillofac Surg2009;37:201-5 [PubMed].

12. Ichinose A, Terashi H, Nakahara M, Sugimoto I, Hashikawa K,Nomura T, et al. Do multiple venous anastomoses reduce risk ofthrombosis in free-flap transfer? Efficacy of dual anastomoses ofseparate venous systems. Ann Plast Surg 2004;52:61-3 [PubMed].

13. Valentini V, Cassoni A, Marianetti TM, Battisti A, Terenzi V,Iannetti G. Anterolateral thigh flap for the reconstruction of headand neck defects: alternative or replacement of the radial forearmflap? J Craniofac Surg 2008;19:1148-53 [PubMed].

14. Kimata Y, Uchiyama K, Ebihara S, Nakatsuka T, Harii K.Anatomic variations and technical problems of the anterolateralthigh flap: a report of 74 cases. Plast Reconstr Surg 1998;102:

1517-23 [PubMed].

OOOOEVolume 112, Number 1 Sun et al. 41

15. Kuo YR, Yeh MC, Shih HS, Chen CC, Lin PY, Chiang YC, etal. Versatility of the anterolateral thigh flap with vascularizedfascia lata for reconstruction of complex soft-tissue defects:clinical experience and functional assessment of the donor site.Plast Reconstr Surg 2009;124:171-80 [PubMed].

16. Chen HH, Lin MS, Chou EK, Chang SC, Chen HC, Xu E, et al.Anterolateral thigh perforator flap: varying perforator anatomy.Ann Plast Surg 2009;63:153-5 [PubMed].

17. Lueg EA. The anterolateral thigh flap: radial forearm’s “bigbrother” for extensive soft tissue head and neck defects. Arch

Otolaryngol Head Neck Surg 2004;130:813-8 [PubMed].

Reprint requests:

Guowen Sun, DDS, MD, PhDDepartment of Oral and Maxillofacial SurgerySchool of StomatologyNanjing University Medical CenterNanjing UniversityStomatological Hospital of Nanjing30 Zhongyang RoadNanjing 210008, PR China

e-mail: guowensun@yahoo.com