CASE REPORT

Flow-through anterolateral thigh flap for a freeosteocutaneous fibula flap in secondary compositemandible reconstruction

P. Ceulemans, S.O.P. Hofer*

Department of Plastic, Reconstructive and Hand Surgery, Erasmus University Medical Center Rotterdam,P.O. Box 2040, 3000 CA Rotterdam, The Netherlands

Received 2 May 2003; accepted 17 February 2004

KEYWORDSFlow-through flap;

Anterolateral thigh flap;

Fibula flap; Mandibular

reconstruction;

Radiotherapy

Summary Head and neck reconstruction after tumour ablation and radiotherapy oftenrequires complex surgery. The need for free composite tissue transfer and the poorquality of the recipient site increase the level of difficulty substantially. We report acase in which the mandible, floor of the mouth and skin of the neck needed to bereconstructed in a heavily irradiated field. A single osteocutaneous fibula flap wasinsufficient to reconstruct the defect, and a free anterolateral thigh (ALT) flap was alsoused for external neck skin resurfacing. As the recipient vessels in the ipsilateral neckhad been heavily irradiated the free ALT flap was used as an interposition conduit forthe free osteocutaneous fibula flap enabling it to reach the healthy recipient vessels inthe contralateral neck without needing vein grafts.Q 2004 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rightsreserved.

The abundant vascular supply of the head and neckarea greatly facilitates the use of free flaps in thisarea. Even in those cases where recurrence and/orprevious radiotherapy have complicated surgery,recipient vessels are usually adequate, althoughpreviously used or resected vessels, or fibrosis ofthe internal jugular vein and/or carotid vessels maycomplicate reconstruction. In such cases the con-tralateral neck may offer recipient vessels whichcan be reached by selecting a flap with a longpedicle, rather than using vein grafts. In secondarycases where double free flaps are indicated

recipient vessels can be in short supply or vascularpedicle length can be insufficient for both flaps toreach the contralateral neck. In those cases seriallyanastomosed free flaps, using the flow throughprinciple, can facilitate reconstruction.

The flow-through flap principle in which thedistal end of the vascular pedicle of a free flap isanastomosed to provide blood flow in tissues distalto the flap has been suggested by Soutar et al.1 Theydescribed a free radial forearm flap, achievingexternal carotid artery flow continuity while cover-ing a defect. Different flow-through flaps have beendescribed that achieved revascularisation in extre-mities, as well as the head and neck area, whilecovering a defect.2 –7 Sanger et al. introduced theuse of sequential connections of free flaps in 1990,

The British Association of Plastic Surgeons (2004) 57, 358–361

S0007-1226/$ - see front matter Q 2004 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved.doi:10.1016/j.bjps.2004.02.013

*Corresponding author. Tel.: þ31-10-463-4638; fax: þ31-10-463-3731.

E-mail address: sophofer@hotmail.com

using a combined vascularised iliac bone graft orfibula bone graft and radial forearm flap.8 Differentcombinations of sequential flaps using vascularisedbone with free skin flaps in the reconstruction ofextensive composite mandibular defects have beendescribed.9

A patient requiring an extensive head and neckreconstruction after previous surgery and radio-therapy received a flow-through anterolateral thigh(ALT) flap and an osteocutaneous fibula flapoffering several advantages over other sequentialflaps as will be discussed.

Case

A 63-year-old man had undergone surgical resectionof an adenoid cystic carcinoma of the left parotidgland followed by radiation therapy (70 Gy) 7 yearsearlier. The patient had sustained a mandibularfracture 5 years later, which was plated. Hedeveloped an orocutaneous fistula after 10 monthsfor which plate removal and a left-sided hemi-mandibulectomy were performed. Four monthsafter his last operation the patient was referredto our service (Fig. 1(A)–(C)). At presentation thepatient complained about mandibular dissociationdue to his bony defect causing occlusion problemsand therefore problems with chewing. The patienthad no pain. Severe radiodermatitis of the left neckwas seen without evidence of an orocutaneousfistula. The skin at the left side of the neck wasextremely tight and would not allow mandibular

reconstruction without substantial skin and softtissue addition. The patient was scheduled for left-sided mandibular reconstruction and neck skinreplacement. Intraoperative exposure of the man-dibular stumps and excision of radiation damagedskin showed the definitive extent of the defect. Theinternal jugular and carotid vessels on the left sidewere completely fibrosed and calcified and not fitfor any type of vascular anastomoses. The rightfibula could be harvested over 19 cm to bridge a12 cm bony defect with a 6 £ 3 cm skin island.Harvest of the osteocutaneous fibula flap wasperformed from a lateral approach under tourni-quet control. The peroneal vessels were far tooshort to reach the contralateral neck. The skinreplacement of the left neck was established with a15 £ 8 cm fasciocutaneous ALT flap from the rightleg. The vascular pedicle of the ALT flap, measuring12 cm from the proximal of two skin perforators,was designed at the edge of the flap and reachedthe contralateral neck comfortably. The distal endof the vascular pedicle, distal to the distal skinperforator, was dissected over a distance of 6 cm toallow easy anastomosis of the peroneal vessels ofthe fibula flap. The ALT flap was anastomosed end-to-end to the superior thyroid artery and end-to-end to the internal jugular vein on the right side andthe peroneal vessels were anastomosed end-to-endto the distal runoff of the ALT flap. The donor site ofthe ALT flap was closed primarily and a small split-thickness skin graft was used for closure of thefibula flap donor site. An immobilizing plaster castwas used for 2 weeks. The post-operative course

Figure 1 (A) Anterior preoperative view with marked right-sided mandibular dissociation and heavily irradiated tightskin in the neck. (B) Oblique preoperative view. (C) Lateral preoperative view.

Flow-through ALT flap 359

was uneventful and the patient was dischargedafter 6 days. At 6 months follow-up the patientshowed good oral function, as well as a goodaesthetic result (Fig. 2(A)–(C)). Both aestheticallypleasing donor sites showed no functional limi-tations. Bony union of the fibula was achieved(Fig. 3).

Discussion

Different classifications for mandibular defectshave been described in which isolated bone, boneand oral lining or skin (compound), and bone, orallining and skin (composite) are distinguished.9,10

The defect in the present case was a lateralcomposite defect involving the left lateral mand-ible, oral lining and skin. The extensive involvementof the lateral neck soft tissue and skin due toradiodermatitis made a second free flap necessary.This is in keeping with previous reports of indi-cations for second free flaps where completereconstructions in one stage without an increasein complication rates were achieved.9,11 –13

For mandibular and intraoral reconstruction anosteocutaneous fibula flap was used.13,14 In thepresent case the vascular pedicle failed to reachthe contralateral neck, as the heavily irradiatedvessels in the ipsilateral neck had made anasto-moses impossible. For lateral neck soft tissue andskin reconstruction an ALT flap was used. The ALTflap has a number of advantages. The ALT flap has along vascular pedicle, which was, relative to the

flap, even further extended by designing thepedicle at one end of the flap. In this fashion veingrafting, which needs additional microvascularanastomoses and donor vessel dissection, was notnecessary. The main vascular pedicle can distally bedissected beyond the skin perforators providing theopportunity for a flow-through flap. The use of flow-through flaps as a means to hook up a second flaphave been described extensively, however, cautionwas advised since occlusion in the proximal flapwould automatically occlude the second flap.9,12,15

The large calibre of the vascular pedicle at bothends greatly facilitates microsurgical anastomoses.The ALT flap offers sufficient soft tissue to fill acontour defect as in the current case, but can alsobe thinned to provide a thinner skin cover. A largesize skin flap can be harvested as shown in this case(15 £ 8 cm), still permitting primary closure. Theabove advantages made the ALT flap an idealconduit to vascularise the mandible while at thesame time covering the extensive soft tissue andskin deficit. The major technical advantage of the

Figure 2 (A) Anterior early postoperative view at 2 months with good mandibular position. (B) Oblique postoperativeview. (C) Lateral postoperative view.

Figure 3 X-ray of mandibular reconstruction.

P. Ceulemans, S.O.P. Hofer360

ALT flap is the possibility to harvest it without anytrouble as a two team effort reducing operativetime.

Conclusion

In the current case the sequential linking of anosteocutaneous fibula flap to an ALT flap in a flow-through fashion provided an excellent reconstruc-tion of a lateral composite mandibular defect. Inour opinion this flap combination is the preferreddouble free flap combination in these complexcomposite mandibular defects.

References

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2. Lamberty B, Cormack G. The antecubital fascio-cutaneousflap. Br J Plast Surg 1983;36:428—33.

3. Foucher G, Van Genechten F, Merle N, Michon J. A compoundradial artery forearm flap in hand surgery: an originalmodification of the Chinese forearm flap. Br J Plast Surg1984;37:139—48.

4. Costa H, Guimaraes I, Cardoso A, Malta A, Amarante J,Guimaraes F. One-staged coverage and revascularisation oftraumatized limbs by a flow-through radial mid-forearm freeflap. Br J Plast Surg 1991;44:533—7.

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10. Daniel R. Mandibular reconstruction with vascularized iliaccrest: a 10-year experience (Discussion). Plast Reconstr Surg1988;82:802—3.

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12. Wells M, Luce E, Edwards AL, Vasconez HC, Sadove RC,Bouzaglou S. Sequentially linked free flaps in head and neckreconstruction. Clin Plast Surg 1994;21:59—67.

13. Wei FC, Seah C, Tsai Y, Liu SJ, Tsai MS. Fibula osteosepto-cutaneous flap for reconstruction of composite mandibulardefects. Plast Reconstr Surg 1994;93:294—304.

14. Hidalgo D. Fibula free flap: a new method of mandiblereconstruction. Plast Reconstr Surg 1989;84:71—9.

15. Urken ML, Weinberg H, Vickery C, et al. The combinedsensate radial forearm flap and iliac crest free flaps forreconstruction of significant glossectomy-mandibulectomydefects. Laryngoscope 1992;102:543—58.

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