Repair of buccal defects with anterolateral thigh flaps

REPAIR OF BUCCAL DEFECTS WITH ANTEROLATERALTHIGH FLAPS

OMER OZKAN, M.D., SAMIR MARDINI, M.D., HUNG-CHI CHEN, M.D.,* EMANUELE CIGNA, M.D., WEN-RUAY TANG, M.D.,

and YI-TIEN LIU, M.D.

The ideal reconstructive method for the buccal mucosa should provide durable, stable coverage and a natural contour, while simultane-ously minimizing morbidity of both the defect and donor sites. Since the first report of the anterolateral thigh flap in 1984, it has becomeone of the most commonly used flaps for the reconstruction of various soft-tissue defects. From March 2004–April 2005, 24 free anterolat-eral thigh flaps were used to reconstruct buccal defects, including the retromolar trigone and as far as the oral commissure, and in somecases with extension to the neighboring palatal region and tongue. The study comprised 1 female and 23 male patients, with ages rangingfrom 26–63 years (mean age, 45.8 years). Two flaps required reoperation due to vascular compromise, and both were salvaged with arte-rial and venous anastomosis revisions, giving an overall success rate of 100%. Primary thinning of the flap was performed in 10 cases. In2 cases, additional vastus lateralis muscle was included in the flap to fill the large defect. In 2 cases, marginal necrosis with dehiscence ofthe flap was observed, one of these patients having a history of atherosclerosis and diabetes mellitus (marginal skin necrosis and infectionof the donor area were also observed in this patient). In 2 patients, seroma collection was observed in the neck at the dissection site.Chart reviews showed that most patients had a history of betel-nut chewing (95.8%) or a combination of smoking and betel-nut chewing(79.2%). During the follow-up period of 4–12 months, a sufficient level of mouth-opening with interincisal distances of 34 mm, 44 mm, and48 mm was achieved in all 3 cases reconstructed after release of the trismus. Although it has some variations in the vascular pedicle,irregularity in derivation from the main vessels, and minimal morbidity of the donor site, the anterolateral thigh flap, with its evident func-tional, structural, and cosmetic advantages, can be considered an excellent and ideal flap option, and a first choice for most buccaldefects. VVC 2006 Wiley-Liss, Inc. Microsurgery 26:182–189, 2006.

The buccal mucosa is commonly directly exposed to many

kinds of trauma, and most importantly to various kinds of

mutagenic agents that may cause many types of distinct or

occult damage. In Taiwan, the betel quid-chewing habit is an

important risk factor for developing oral mucosal changes.1–5

Betel quid contains approximately 5.5% arecoline, which was

shown to be a mutagen and to stimulate the proliferation of

fibroblasts and collagen synthesis.1–5 The risk of developing

oral-mucosa carcinoma is therefore evidently higher in betel

nut chewers than in nonusers. It was shown that the most com-

mon region affected by the betel nut is the buccal mucosa.

Even without obvious carcinoma, oral submucous fibrosis is a

chronic disease caused by betel nut, and is characterized by

the deposition of fibrous tissue in the submucosal layer. It par-

ticularly causes functional deficits, including difficulties in

chewing, swallowing, articulation, and oral hygiene. Although

some medical modalities have been suggested, aiming to

reduce the collagen content in submucosal fibrosis, it is

obvious that surgical intervention in the affected region is a

current and reliable method for the treatment of both submu-

cosal fibrosis and buccal cancer, supported by adjuvant thera-

pies in advanced cancer cases.4,5

The objectives in the reconstruction of buccal defects

after surgical resection include restoration of function and

structural cosmesis, as in almost all tissue defects of the

body. Since it has thin and pliable mucosa, defects of

the buccal mucosa can present a significant challenge to the

reconstructive surgeon. Although a number of reconstruc-

tive options (including skin-grafting and local and regional

flaps) are available for the reconstruction of buccal defects,

the advent of free-tissue transfers has provided multiple

options for difficult defects of the oral cavity, including the

buccal mucosa, that allow the preservation and maintain the

functional and aesthetic status of this region.

The radial forearm flap is one of the most commonly

used tissues for reconstruction of buccal defects.4,5 How-

ever, it has a number of well-known disadvantages, particu-

larly related to donor-area complications.6–8 Since the first

report of the anterolateral thigh flap by Song et al. in 1984,9

because of its large cutaneous area and long vascular pedi-

cle with a suitable vessel diameter with acceptable donor-

site morbidity, and because it offers a number of evident

advantages, it has become one of the most commonly

used flaps for the reconstruction of various soft-tissue

defects.10–25 Here, we review our experiences with free an-

terolateral thigh flaps on buccal defects in a series of 24

patients. The functional and structural advantages of the an-

terolateral thigh flap, including its versatility and useful-

ness, are presented and discussed.

MATERIALS AND METHODS

From March 2004–April 2005, 24 free anterolateral

thigh flaps were used to reconstruct defects of the buccal

region, including the retromolar trigone and as far as the

oral commissure, and in some cases with extension to the

Department of Plastic and Reconstructive Surgery, E-Da Hospital/I-Shou Uni-versity, Kaohsiung County, Taiwan, Republic of China

*Correspondence to: Hung-Chi Chen, Superintendent and Professor ofDepartment of Plastic Surgery, E-Da Hospital/I-Shou University, 1 E-DaRoad, Jiau-shu Tsuen, Yan-chau Shiang, Kaohsiung County, Taiwan 824,Republic of China. E-mail: [email protected]

Received 11 July 2005; Accepted 2 November 2005

Published online 21 February 2006 in Wiley InterScience (www.interscience.wiley.com). DOI 10.1002/micr.20223

VVC 2006 Wiley-Liss, Inc.

neighboring palatal region and tongue. The cases included

in this study were limited to defects arising after surgery for

buccal cancer or submucosal fibrosis in this region causing

severe trismus. While in 9 patients defects were localized

to the buccal region only, in the remaining patients they

extended to the neighboring palate, mandible, and tongue.

Defects requiring reconstruction because of their being pri-

marily raised from the tongue, palate, mouth floor, or man-

dible were excluded from this study. The study group con-

sisted of 1 female and 23 male patients, with ages ranging

from 26–63 years (mean age, 45.8 years) (Table 1). While

17 patients had defects due to primary buccal carcinoma

resection, 4 had defects due to recurrent cancer, and the

remaining 3 patients were operated on after release of the

trismus due to submucosal fibrosis. In 5 cases there were

through-and-through cheek defects requiring reconstruction

of both intraoral and cheek skin defects. In 17 patients, neck

dissection was performed simultaneously with tumor exci-

sions of varying types, from selective node dissection to

radical lymph node dissection. The size of flaps ranged

from 6–26 cm in length, and 5–12 cm in width. The facial

artery was used as the recipient artery in 16 patients, the

superior thyroid artery in 7 patients, and the superficial tem-

poral artery in the remaining patient. Concomitant veins of

these arteries, the external jugular vein, and branches of the

internal jugular vein were the recipient vein sources used in

different cases, based on the recipient artery employed and

the number of veins available in the flap. All anastomoses

were performed without the use of any interpositional vein

graft. While all arterial anastomoses were performed in an

end-to-end manner, in 3 cases, end-to-side anastomosis was

performed between the internal jugular vein and the second

vein of the flap. In all cases, simultaneous flap elevation

and recipient-site surgery were performed to shorten the

total operation time.

The anatomy of the flap and the operative technique

were thoroughly described in previous studies.10–28 Some

modifications in flap elevation were proposed in almost

all clinical studies. A line is drawn from the anterior supe-

rior iliac spine to the superolateral border of the patella.

The dominant perforators supplying the flap are located

within a circle 3 cm in radius at the midpoint of this line.

However, the perforators may sometimes be located out-

side these borders. Although in some cases in our series

we used Doppler imaging to determine the location of the

most suitable perforator for the flap, in most cases this

was not necessary. In thin and loose skin structures in par-

ticular, the location of the perforator identified by Dopp-

Table 1. Patient Summary*

Case no. Age (years) Sex Cause Flap size (cm)

Donor area

closure

Follow-up

(months) Complications

1 40 M Buccal Ca 8 3 14 P 4 Marginal necrosis of flap,

marginal skin necrosis,

and infection of donor area

2 57 M Buccal Ca 10 3 18 G 7 Nil

3a 34 M Buccal Ca 9 3 14 P 11 Nil

4 33 M Buccal Ca 5 3 6 P 6 Nil

5 55 M Recurrent buccal Ca 10 3 14 G 5 Nil


7 26 F Buccal Ca 6 3 9 P 8 Nil

8 54 M Buccal Ca 10 3 12 G 6 Nil

9 38 M Recurrent buccal Ca 12 3 26 G 8 Nil


11 45 M Buccal Ca 9 3 18 G 8 Seroma collection in neck



14 56 M Recurrent buccal Ca 12 3 18 G 9 Marginal necrosis of flap

15 45 M Recurrent buccal Ca 5 3 8 P 11 Seroma collection in neck

16 40 M Submucosal fibrosis 7 3 10 P 4 Nil


18 63 M Buccal Ca 7 3 8 P 8 Anastomotic revisions due to

vascular compromise





23 35 M Buccal Ca 6 3 16 P 10 Anastomotic revisions due to

vascular compromise

24 52 M Buccal Ca 10 3 18 G 8 Nil

*M, male; F, female; P, primary closure; G, skin graft; Ca, cancer.aPresent cases.

Anterolateral Thigh Flaps for Buccal Defects 183

Microsurgery DOI 10.1002/micr

ler imaging may mislead the surgeon during the proce-

dure. If Doppler ultrasonography is employed, it is better

to do so just before the procedure, when the patient is

supine and in the position in which the flap elevation is to

be performed. We suggest starting the dissection medi-

ally, making an incision in the subfascial plane to isolate

and make sure of the location of the perforators. All the

noteworthy perforators suggested as coming from the

main vascular pedicle are preserved, and while at least

one of the largest of the perforators is identified, others

can be divided. If possible, in order to increase reliability

for the primary thinning procedure, as well as for three-

dimensional reconstruction, the inclusion of more than

one perforator based on the main pedicle will enhance the

safety of the procedure (Fig. 1A). If during elevation

more than one pedicle is identified in separate locations,

based on different vascular systems, one is chosen as the

flap pedicle, bearing in mind its position vis-a-vis entry to

the flap and the locations of the defect and recipient ves-

sels, and the others are divided and preserved for use in

case of need or in possible vascular revisional procedures,

as a fresh alternative pedicle when vascular compromise

is identified. If the perforator vessel is musculocutaneous

(since in cases of buccal defect a thin flap is usually

required and bulkiness should usually be avoided), we

usually follow the course of the pedicle by intramuscular

dissection, without the inclusion of any muscle part. Per-

forator dissection is continued until the main vascular

pedicle, which is either the descending branch or trans-

verse branch of the lateral circumflex femoral artery, is

identified. Dissection proceeds until the desired length of

the pedicle and optimal size of the vessel suitable for a

safe and reliable anastomosis are obtained. When a thin

flap is needed, as is usually preferred for buccal region

defects, the greater part of the thinning is performed

before transecting the pedicle. During the inset and adap-

tation of the flap to the defect, some minor degree of fat

removal may still be possible (Fig. 1B). The donor-site

defect can be closed primarily if its width is less than

8 cm, or even up to 10 cm in elderly patients. If skin ten-

sion is identified during primary closure, a skin graft is

recommended in order to prevent potential wound-healing

problems, underlying muscle necrosis, and potential vas-

cular problems in the donor limb.

PATIENT REPORTS

Patient 1

A 34-year-old man sustained left buccal cancer, with a

verrucous carcinoma extending from the left buccal region

and palate to the lower lip. Wide resection of the tumor and

selective neck lymph node dissection were performed. A

93 14 cm defect was formed after resection, and was recon-

structed with a free anterolateral thigh flap. The pedicle of

the flap was anastomosed to the facial artery and accom-

panying vein. The donor area was closed primarily. Post-

operative recovery was uneventful, and the flap survived

completely (Fig. 2).

Patient 2

A 53-year-old man suffered from right buccal cancer,

with a histology of moderately differentiated squamous-cell

carcinoma. The tumor extended to the right hard palate.

Wide excision of the defect, including the anterior wall of

the maxilla and hard palate, was performed simultaneously

with selective neck node dissection. After resection, the

Figure 1. A: To increase reliability for primary thinning procedure, as well as for three-dimensional reconstruction, inclusion of more than

one perforator based on main pedicle will enhance safety of procedure. B: Pliable nature of flap (either originally or after thinning) can pro-

vide easy adaptation of flap to defect, allowing structurally acceptable contour of buccal region.

184 Ozkan et al.


defect was covered with an anterolateral thigh flap mea-

suring 7 3 12 cm. Half of the flap was deepithelized to fill

the maxillary defect. Anastomoses were performed between

the vascular pedicle of the flap and the facial artery, and the

external jugular vein. The donor-area defect was closed pri-

marily. Postoperative recovery was uneventful (Fig. 3).

Patient 3

A 38-year-old patient suffered from right buccal cancer,

with a moderately differentiated buccal carcinoma. The tu-

mor was determined to extend to the retromolar trigone.

Resection with selective neck node dissection was per-

formed. A thin anterolateral thigh flap measuring 8 3 14 cm

was harvested and transferred to the defect. While the artery

of the flap was anastomosed to the facial artery, the veins

were anastomosed to the external jugular vein and a branch

of the internal jugular vein. The donor area was closed

primarily, and postoperative recovery was uneventful, with

satisfactory results (Fig. 4).

RESULTS

Two flaps required reoperation due to vascular compro-

mise. Both flaps were salvaged with arterial and venous

anastomosis revisions. Thus, the overall flap success rate

was 100%. Primary thinning of the flap was performed in

10 cases. In 2 cases, additional vastus lateralis muscle was

included in the flap to fill large defects. While we deter-

mined a musculocutaneous perforator in 19 cases, in 5 cases

the flaps were based on the septocutaneous vascular pedi-

cle. While donor sites were closed directly in 17 cases, the

remaining cases underwent split-thickness skin grafting of

Figure 2. A 34-year-old man with left buccal cancer, shown to be verrucous carcinoma, extending from left buccal region and hard palate

to lower lip. A: Preoperative view. B: Postoperative view at 11 months. C: Postoperative view of donor site at 11 months.



the donor site. In 2 cases, marginal necrosis with dehis-

cence of the flap was observed, one of these patients having

a history of atherosclerosis and diabetes mellitus. The mar-

gins of both flaps were debrided, repaired, and resutured

10 days postoperatively in one case, and 15 days postopera-

tively in the other. In 2 patients, seroma collection was

observed in the neck at the dissection site; this was treated

with bedside drainage, and resolved in approximately

1 week in both cases. Marginal skin necrosis and infection

of the donor area that closed primarily after flap harvesting

were again observed in the patient who had atherosclerosis

and diabetes mellitus. The necrosed part was excised, fol-

lowed secondarily, and closed using a split-thickness skin

graft 2 weeks postoperatively. During the follow-up period

of 4–12 months, a sufficient level of mouth-opening with

interincisal distances of 34 mm, 44 mm, and 48 mm was

achieved in all 3 cases reconstructed after release of the tris-

mus. No secondary corrections, including debulking proce-

dures or scar revision, were necessary.

A review of the relationship between betel nut chewing

and tumor or submucosal fibrosis formation requiring

reconstruction showed that this represents a significant risk

factor. Chart evaluations revealed that most patients had

a history of betel nut chewing (95.8%). A combination of

smoking and betel nut chewing was determined in 19

patients (79.2%).

Figure 3. A 53-year-old patient had right buccal cancer extending to right hard palate. A: Immediate view after wide excision. B: Postoper-

ative view at 4 months.

Figure 4. A 38-year-old patient suffered from right buccal cancer, extending to retromolar trigone. A: Intraoperative view after wide resec-

tion. B: Postoperative view of flap inset.

186 Ozkan et al.


DISCUSSION

Betel quid-chewing is the major cause of oral submuco-

sal fibrosis and buccal cancer in Taiwan.1–5 It was demon-

strated that betel quid-chewing constitutes a high risk factor

for oral cancer, especially when combined with smoking

and alcohol consumption.1–3 At a recent workshop in Kuala

Lumpur,29 a variety of betel/areca nut/tobacco habits were

categorized because of their possible causal association

with oral cancer and various oral precancerous lesions and

conditions, and on account of their widespread occurrence

in different parts of the world. It was recommended that

‘‘quid’’ be defined as ‘‘a substance, or mixture of substan-

ces, placed in the mouth or chewed and remaining in con-

tact with the mucosa, usually containing one or both of the

two basic ingredients, tobacco and/or areca nut, in raw or

any manufactured or processed form.’’ In Taiwan, areca nut

is a common component of betel quid. This is a mutagen and

stimulates the proliferation of fibroblast and collagen synthe-

sis, causing fibrosis of the oral mucous membrane and pro-

moting oral precancer formation. It was shown that the prod-

ucts of areca nut are powerful carcinogens in rats.1 The high

incidence of precancerous lesions and malignant transforma-

tions in oral mucosa requires that special attention be paid to

surgical intervention and reconstruction of defects. Although

the most common sites of oral squamous-cell carcinoma

may differ among patients without any oral habits, the buc-

cal mucosa is the most common site in both this group and

in patients who chew betel quid alone or in combination with

cigarette smoking and alcohol consumption.2

A number of methods were suggested to reconstruct

defects of the buccal mucosa.4,5 In cases of buccal defect,

the reconstructive surgeon must consider several factors

when selecting the appropriate method of reconstruction.

These include the extension and depth of the defect with si-

multaneous evaluation of accompanying problems, and the

medical status of the patient. Before the advent of free-tis-

sue transfers, resurfacing of buccal defects was insufficient

to meet both structural and functional needs.

When reconstruction is required, the functional as well

as structural aspects of reconstruction should be consid-

ered.4,5 At the end of reconstruction, sufficient mouth-open-

ing, which is important in chewing, swallowing, articula-

tion, and maintaining oral hygiene, should be provided and

maintained. Skin grafting yields disappointing results, even

in relatively small defects, because of scar contracture.

However, it is the only temporary solution for wound-clo-

sure in patients having medical problems and a high risk for

prolonged anesthesia. A number of local and regional flaps

are available. However, most of these are not ideal and have

several limitations. Local flaps from the surrounding buccal

mucosa, tongue, and palate for small defects have the risk

of submucosal fibrosis, thus limiting their use. Additionally,

tongue flaps are to be avoided as far as possible, because

adequate shape, volume, sensation, and motion are particu-

larly important for swallowing, taste, and lingual function.

Most defects after cancer surgery are too large to be cov-

ered by these flaps. In the use of local flaps, healing prob-

lems in the donor area may increase wound complications,

especially in patients who require radiation therapy. Most

pedicled flaps (including pectoralis major and deltopectoral

flaps) are limited by pedicle length from reaching the de-

fect, and by contracture, and generally require secondary

pedicle division and cause obvious scars.

The ideal reconstructive method for the buccal mucosa

should provide durable, stable coverage and a natural con-

tour, with a nonhair-bearing epithelial layer in a single

stage, simultaneously minimizing morbidity of both the

defect and donor sites. Advances in microsurgical techni-

ques permit reliable wound-closure and a substantial

decrease in patient morbidity with low complication rates,

while allowing a variety of reconstructive flap options in a

single stage. Microsurgical tissue transfers provide for the

single-procedure closure of large defects, and improved

wound-healing with well-vascularized tissue in a radiation

or infection setting. As in most oral cavity defects, because

of the thinness and pliability that make them easily adapta-

ble to the shape of the defect, fasciocutaneous flaps have

almost always been preferred over any other kind of flap

for buccal defects. The free radial forearm flap constitutes a

good option for this reconstructive task, with its reliable

and consistent vascular pedicle and pliable skin permitting

shaping and flexibility in design.4,5 However, the sacrifice

of a major artery of the hand and the skin graft to the fore-

arm with its potential risk of complications are the main

disadvantages of this flap.6–8

Since its description based on the descending branch of

the lateral circumflex femoral artery in 1984 by Song

et al.,9 the anterolateral thigh flap has gained increasing

popularity in reconstructive surgery for most tissue defects.

Its use gained greater currency following the extensive clin-

ical application of the technique by Koshima et al. in

1993.11 Wei et al. demonstrated this particular flap’s versa-

tility in various reconstructive needs in their large series.16

They suggested that the anterolateral thigh flap is adaptable

to many clinical situations and can substitute for most of

the commonly used conventional soft-tissue flaps. It can be

as thin as a radial forearm flap, with the additional advan-

tage of reduced donor-site morbidity.

Despite its common use for soft-tissue defects in clini-

cal series,10–25 no specific reports have focused on present-

ing the reliability of the anterolateral thigh flap in buccal

defects. This flap has a number of advantages, including a

long vascular pedicle with a suitable diameter for microsur-

gical anastomosis, and a large cutaneous area with accepta-

ble donor-site morbidity. The flap can thus be harvested as

a thinned skin, fasciocutaneous, or musculocutaneous flap.

Therefore, by adapting the depth of the defect,30–33 the pli-



able property of the skin can provide reconstruction of the

buccal region with a structurally acceptable thin natural

contour that meets the aesthetic requirements of this region

(Fig. 1B).

The variations in vascular anatomy of the flap were

classified and schematized by various authors, based on the

branching pattern of the perforators.26–28 Although the per-

forator vessel of the flap is musculocutaneous in most

cases10–25 (in 60–90% of cases, depending on the series), it

can also be isolated as septocutaneous. Flap elevation is sli-

ghtly more difficult when the pedicle is musculocutaneous.

Ross et al. used the anterolateral thigh flap to recon-

struct the oral lining in various regions of the oral cavity in

18 patients.34 They mostly used the flap in a standard man-

ner without employing any thinning procedure, while they

performed primary thinning in 4 cases. Of these 4 thinned

anterolateral thigh flaps, one failed completely, and 2 expe-

rienced partial necrosis. They suggested that thinning of the

flap is best performed as a secondary procedure, should it

be required for oral lining. However, as we experienced in

most cases in our series, and as suggested in other clinical

reports,30–33 when the thinning procedure is properly

applied, it can be performed safely. A safe technique for

flap-thinning was described as always determining an island

flap before transecting the pedicle vessel, with detection of

bleeding to preserve the blood circulation of the whole

flap.31,32 In most buccal region defects, a thin and pliable

flap is to be preferred. Our preference with regard to thin-

ning is performing the greater part of the procedure before

transecting the pedicle. However, we think that during the

inset and adaptation of the flap to the defect, some minor

degree of fat removal may still be possible. The most im-

portant element in this step is familiarity with the flap anat-

omy and the course of the pedicle that can be macroscopi-

cally observed. If the flap harvested based on more than one

separate perforator is eventually based on the main vascular

pedicle, it can be more easily and more safely thinned (Fig.

1A). The length-to-breadth ratio should be considered as

important during the thinning procedure as the precise non-

touchable circle area around the pedicle. Additionally, it

should kept in mind that if the patient has a history of

smoking and atherosclerosis, the area of the thin flap will

decrease, as suggested by Koshima,31,32 and in these cases,

the thinning procedure should be kept minimal or deferred

for secondary surgery. Considering these drawbacks, even

massive thinning of an anterolateral thigh flap up to 3–

4 mm in thickness can be safely performed in most cases.

In this way, the need for additional secondary surgery for

defatting can be prevented. Primary defatting of the flap

provides a more acceptable cosmetic appearance and func-

tional reconstruction even in the early period of the surgery,

and will facilitate easy inset of the flap (Fig. 1B), especially

when neighboring tissue defects are accompanied by buccal

defects. Psychological advantages of the results of single-

stage reconstruction, with a more acceptable structural and

functional appearance, are also evident in thinned flaps.

While defects localized solely to the buccal region can

be easily reconstructed, the particular features of the antero-

lateral thigh flap provide an anatomical three-dimensional

reconstruction in cases of extension to neighboring struc-

tures. As reported in many studies,10–28 variations in the

vascular pedicle have no considerable effect on the success

rate of the flap. With increased experience with the flap and

anatomical variations of the pedicle, elevation can be car-

ried out more easily and operation time can be reduced dra-

matically, especially compared with the most commonly

used conventional free flaps.

In conclusion, although it has some variations in the

vascular pedicle, irregularity in derivation from the main

vessels, and minimal morbidity of the donor site, the an-

terolateral thigh flap offers a series of advantages and modi-

fications for buccal defects: harvesting of the flap is easy

and rapid, especially after experience has been acquired

with it; it has a long and large vascular pedicle; it has a

large and reliable cutaneous skin paddle; massive defatting

can be performed safely with some basic requirements

when needed; and it does not require positional changes

while allowing simultaneous recipient-site preparation and

flap harvesting. As in the case of most other soft-tissue

defects that were recently reported in the literature, with its

evident functional and structural advantages, the anterolat-

eral thigh flap transfer can be considered an excellent and

ideal alternative to the most commonly used procedures for

most buccal region defects. It can be therefore considered a

first choice in most cases of buccal defects.

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Documents

Repair of buccal defects with anterolateral thigh flaps