Thinned Anterolateral Thigh Cutaneous Flap and Radial Fasciocutaneous Forearm Flap for Reconstruction of Oral Defects: Comparison of Donor Site Morbidity

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J Oral Maxillofac Surg66:1093-1098, 2008

Thinned Anterolateral Thigh CutaneousFlap and Radial Fasciocutaneous ForearmFlap for Reconstruction of Oral Defects:

Comparison of Donor Site MorbidityAndrea Loreti, MD,* Giovanni Di Lella, MD,†

Stefano Vetrano, MD,‡ Massimiliano Tedaldi, MD,§

Aldo Dell’Osso, MD,� and Giuseppe Poladas, MD¶

Purpose: The thinned anterolateral thigh flap (tALT) has been utilized in clinical applications for soft tissuereconstruction. This flap has many advantages: no major artery is sacrificed; functional and esthetic results areoften good. The purpose of this study is to investigate the esthetic outcome of the donor site afterreconstruction of oral defects with tALT compared to the radial fasciocutaneous forearm flap (RFFF).

Patients and Methods: Between January 2003 and December 2005, 42 patients affected by oralsquamous cell carcinoma (27 males, 15 females; age range: 34-82 years, mean age, 61.4 years) receivedmicrosurgical reconstruction. We treated 17 patients with RFFF and 25 cases with tALT.

Results: The RFFF group showed a success rate of 94.2% with only 1 total flap loss due to not reversiblevenous trombosis. In the tALT group we accomplished a 100% flap survival. Functional results at donorsite in the RFFF group showed a persistent forearm movement impairment in about 30% of cases andsensitivity alterations in skin graft area in 75% of patients; in the tALT group we noticed only a transitorygait impairment in 1 patient; no clinical signs of circulatory disturbance were observed and no sensorydisturbance of the thigh was reported.

Conclusions: In our experience, we found the thinned ALT coutaneous flap the ideal soft tissue flap inoral reconstruction. This flap presents functional results at the receiving site with the additionaladvantage of minimal donor-site morbidity and a high level of patient satisfaction.© 2008 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 66:1093-1098, 2008
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econstructive procedures after oral cancer resectionre critical to restore functional and esthetic out-omes and allow complete resection of the tumor,reserving function by reconstructing the region withinimal recipient and donor site morbidity. Over the

eceived from the San Giovanni-Addolorata Hospital, Rome, Italy.

*Plastic Surgery Consultant, Breast, Plastic, and Reconstructive

urgery Unit.

†Ear, Nose, and Throat and Maxillofacial Surgery Consultant,

axillofacial Surgery Unit.

‡Maxillofacial Surgery Consultant, Maxillofacial Surgery Unit.

§Resident, Maxillofacial Surgery Unit.

�Head, Breast, Plastic, and Reconstructive Surgery Unit.

¶Head, Maxillofacial Surgery Unit.

Address correspondence and reprint requests to Dr Loreti: Via

apo D’Africa 23, 00184 Rome, Italy; e-mail: aloreti@hsangiovanni.

oma.it

2008 American Association of Oral and Maxillofacial Surgeons

278-2391/08/6606-0003$34.00/0

eoi:10.1016/j.joms.2007.09.021

1093

ast decade, clinical applications of the anterolateralhigh flap (ALT) in soft tissue reconstruction have in-reased, because this flap permits transfer of differentissues with large amounts of skin and of adjustablehickness, with a vascular pedicle of suitable length withelatively large-diameter vessels, and low donor site mor-idity. This flap has many advantages with respect tother fasciocutaneous free flaps at the donor site: noajor artery of the limb is sacrificed, and functional and

sthetic results are often very good, because the defects almost always closed primarily.1-4

This study investigated and compared the subjec-ive and objective functional and esthetic outcomes ofhe donor site after reconstruction of extensive oralefects with a thinned ALT (tALT) flap and a radialasciocutaneous forearm flap (RFFF).

lap Anatomy and Dissection

We performed the standard technique for surgical
levation of RFFF as described in the literature.5-7 The
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1094 DONOR SITE MORBIDITY IN FLAP RECONSTRUCTION OF ORAL DEFECTS

ALT is a fasciocutaneous flap based on the cutaneouserforators of the descending branch of the lateral

emoral circumflex vessels.8 The flap can vary inhickness in terms of the subdermal fat level for use as

thin or ultrathin flap,4 and can be adapted as aensate flap if necessary. The central axis of the flap isocated by a line drawn from the anterior superiorliac spine to the lateral edge of the patella and cen-ered over the perforators.

Dissection proceeds from medial to lateral in theubfascial plane to the perforators, either septocuta-eous or musculocutaneous. The septocutaneous per-orator always lies superficially on the vastus lateralisuscle and crosses into the intermuscular septum of

ectus femoris and vastus lateralis muscles proximally.he musculocutaneous perforators emerge from theastus lateralis muscle either 2 or 3 at a time.9 Usuallyhe most proximal perforator is dissected because ofts relatively greater diameter.

The branches are isolated with a 0.5-cm cuff ofastus lateralis muscle attached from distal to prox-mal and following the descending branch of theateral femoral circumflex vessels, the artery, and 2oncomitant veins. The vascular pedicle must behen carefully dissected from the motor branches tohe vastus lateralis and rectus femoralis muscle ofhe femoral nerve, which should be well preservedntil it emerges from the lateral circumflex femoralessels. The lateral femoral cutaneous nerve is alsoreserved whenever possible.At this point, the tALT flap is accurately delin-

ated and harvested to fill the damaged area to beeconstructed. Thinning of the ALT flap can be

Table 2. ANATOMIC LOCATIONS OF THE ORALLESION IN THE tALT AND RFFF GROUPS

Anatomic Location tALT Group RFFF Group

ongue 7 5ongue � oral floor 14 9onsil � soft palate 4 3otal 25 17

Table 1. POPULATION DATA

Group A (

ean age, years 59.3ender, males/females 1.8/1istology Squamous cell carctage T2N0M0-T4N2MOean flap size, cm2 52.6ean follow-up, months 20.6

oreti et al. Donor Site Morbidity in Flap Reconstruction of Oral

oreti et al. Donor Site Morbidity in Flap Reconstruction of Oralefects. J Oral Maxillofac Surg 2008.

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one before or after ligation of the vascular pedicle.o achieve more reliable hemostasis, thinning ei-

her before pedicle ligation or after revasculariza-ion is recommended. The flap is thinned usingcissors down to the level of the subdermal plexus.

e routinely leave a 5-mm cuff of subdermal fatround the perforator vessels, preserving 2 mm to 3m of superficial fat below the subdermal plexus

o prevent injury to the plexus.10-29

atients and Methods

Between January 2003 and December 2005, weerformed microsurgical reconstruction in 42 pa-ients (27 males, 15 females; age range, 34 to 82 years,ean age, 61.4 years) with oral squamous cell carci-oma (Table 1). Specifically, we treated 17 patientsith RFFFs and 25 patients with thinned tALTs (Ta-les 2 and 3). Preoperatively, color Doppler ultra-onography was used to study the forearm vascularupply coupled with the Allen test in the patientsndergoing an RFFF; the patients scheduled for tALTap surgery were examined preoperatively, usingolor Doppler ultrasonography, to map points wherehe perforators seemed to penetrate the fascia latan the region between the proximal and medial thirdf the anterolateral region of the thigh. All flaps wereissected simultaneously with tumor resections by 2urgical teams.

Table 3. SURGICAL PROCEDURES

Group A(RFFF),n (%)

Group B(tALT),n (%)

omposite resection withmandibulotomy

9/17 (52.9%) 11/25 (44%)

omposite resection withmarginal mandibulectomy

7/17 (41.3%) 12/25 (48%)

omposite resection withsegmental mandibulectomy

1/17 (5.8%) 2/25 (8%)

� .9 (�2 test).

Group B (tALT)

62.21.7/1

(17/17) Squamous cell carcinoma (25/25)T2N0MO-T4N2M0

67.516.2

s. J Oral Maxillofac Surg 2008.

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Loreti et al. Donor Site Morbidity in Flap Reconstruction of Oral Defect

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LORETI ET AL 1095

During tALT dissection, the lateral femoral cuta-eous nerve and the motor branches to the vastus

ateralis and rectus femoralis muscle of the femoralerve were respected in all cases. In RFFF dissec-ion, the superficial branch of the radial nerve wasreserved. All of the ALT flaps were trimmed to theubdermal fat level for use as a thin flap (10 to 12m thick).In all of the patients treated with RFFFs, the donor

ites were closed with skin grafts. In the patientsreated with tALT flaps, the donor sites were closed

r site necrosis. C, Surgical revision with skin graft. D, Donor site with


Table 5. DONOR SITE MORBIDITY: SUBJECTIVEESTHETIC AND FUNCTIONAL APPEARANCE

Group A (RFFF), n (%) Group B (tALT), n (%)

xcellent 0/17 (0%) 2/25 (8%)ood 3/17 (17.6%) 12/25 (48%)cceptable 4/17 (23.5%) 11/25 (44%)oor 10/17 (58.8%) 0/25 (0%)

IGURE 1. RFFF complications. A, Good outcome; donor site view. B, Donoendon exposition.

Table 4. DONOR SITE MORBIDITY: OBJECTIVEASSESSMENT

Group A(RFFF), n (%)

Group B(tALT),n (%)

ypertrophic scaring 6/17 (35.3%) 1/25 (4%)tching* 13/17 (76.4%) 7/25 (28%)igmentation 17/17 (100%) 0/25 (0%)umbness of skin-grafted area

15/17 (88.2%) 1/1 (100%)

areshesia of skin-grafted area

13/17 (76.4%) 1/1 (100%)

ecrosis/diastasis ofdonor site*

7/17 (41.2%) 1/25 (4%)

ocial stigma 5/17 (29.4%) 0/25 (0%)ransitory functionimpairment†

12/17 (70.6%) 1/25 (4%)

ermanent functionimpairment

6/17 (35.3%) 0/25 (0%)

*P � .01 (�2 test).†P � .001 (�2 test).


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rimarily in all but 1 case, which was repaired with akin graft. All flaps were fasciocutaneous flaps withkin island dimensions ranging from 8 cm to 13 cmide and 11 cm to 13 cm long.

esults

The RFFF group demonstrated a success rate of

IGURE 2. Reconstruction of tongue with a tALT flap. A, Preoperatiutcome.


4.2%, with only 1 total flap loss due to irreversible R

enous thrombosis. In 2 cases, revision of venous anas-omoses was necessary to save the flaps. In 1 case, aartial flap failure healed by second intention. In theALT group, flap survival was 100%. Only 1 case re-uired revision of anastomoses, with salvage of the flap.unctional results at the recipient sites were comparablen both groups.

Concerning major donor site complications, in the

. B, Donor site view, C, Intraoral postoperative view. D, Donor site


ve view

FFF group, tendon exposition necessitating surgical

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evision was seen in 4 patients, and partial necrosis ofkin grafts (healing by second intention) was seen inpatients (Fig 1). In the tALT group, partial diastasis

f the suture (managed with conservative treatment)as noted in 1 case.Objective assessment of the donor site was per-

ormed by the same external specialist surgeon.unctional results at the donor sites in the RFFFroup showed persistent forearm movement im-airment in about 30% of patients and sensitivitylterations in the skin graft area in 75% of patients.n the tALT group, transitory gait impairment wasoted in 1 patient; no clinical signs of circulatoryisturbance in the donor leg were observed, and noensory disturbance in the anterolateral aspect of

IGURE 3. Reconstruction of tongue and oral cavity with a tALT flap.ite outcome.


he thigh was reported (Table 4). a

The postoperative subjective appearance of the do-or site was self-evaluated by the patients. The out-ome assessment was rated as “excellent or good” by4 patients (56%) in the tALT group and by 3 patients17.6%) in the RFFF group, “acceptable” by 11 pa-ients (44%) in the tALT group and by 4 patients23.5%) in the RFFF group, and “poor” by 10 patients58.8%) of the RFFF group (Table 5).

iscussion

Free flaps have been used for nearly 3 decades andave become the gold standard in oral reconstruction.he reliability of this surgical technique has allowedicrosurgeons to focus more on the function and

or site view. B, Intraoperative view. C, Postoperative view. D, Donor


A, Don

Defect

ppearance of the recipient and donor sites.11

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Over the last decade, the ALT cutaneous flap hasained popularity. This flap is a reliable and versatileption in soft tissue reconstruction; it can transferultiple soft tissues with large amounts of skin, or

an be trimmed to the subdermal fat as thin as anFFF.29 The long vascular pedicle provides multipleecipient vessel choices in the neck region; forhrough-and-through defects of the cheek, it can besed either as a folded flap or as a double skin paddleap; as a sensate flap, it is useful for tongue recon-truction.11 In head and neck reconstruction afterblative surgery, the operations can be carried out byteams working simultaneously.11,15,16 Moreover, the

ALT flap has shown functional results at the receivingite comparable to those of the other fasciocutaneousaps used in oral reconstruction.The tALT flap has major advantages over the other

asciocutaneous flaps in terms of functional and es-hetic outcomes, coupled with minimal morbidity ofhe donor site, which rarely requires more than pri-ary closure (Figs 2, 3). Unlike the RFFF, its use

voids the sacrifice of important muscle or majorascular axis and the risk of exposing important struc-ures, such as tendons and nerves.29

In our experience, the tALT flap provides betteronor site outcomes than the RFFF in terms of mor-idity and functional and esthetic objective and sub-

ective evaluations. The advantages of the tALT flapver the RFFF are evident in the high level of patientatisfaction with esthetic and functional outcomes ofhe donor site only in the tALT group.30 In our esti-ation, the tALT cutaneous flap is the ideal soft tissue

ap for oral reconstruction. It provides functionalesults at the receiving site comparable to those of thether fasciocutaneous flaps, like RFFF, with the addi-ional advantage of minimal donor site morbidity andhigh level of patient satisfaction.11,29,31

eferences1. Kimata Y, Uchiyama K, Ebihara S, et al: Anterolaleral thigh flap

donor side complications and morbidity. Plast Reconstr Surg106:584, 2000

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

3. Cormack GC, Lamberty BGH: A classification of fascio-cutane-ous flaps according to their patterns of vascularisation. Br JPlast Surg 37:80, 1984

4. Kimura N, Satoh K: Consideration of a thin flap as an entity andclinical applications of the thin anterolateral thigh flap. PlastReconstr Surg 97:985, 1996

5. Soutar DS, McGregor IA: The radial forearm flap in intraoralreconstruction: The experience of 60 consecutive cases. PlastReconstr Surg 78:1, 1986

6. Meek MF, Vermey A, Robinson EH, et al. Radial forearm flap: 8years experience with oral and oropharyngeal reconstruction.Donor and acceptor site morbidity. Eur J Plast Surg 21:293, 1988

7. Lutz BS, Wei FC, Chang SC, et al: Donor site morbidity aftersuprafascial elevation of the radial forearm flap: A prospective
study in 95 consecutive cases. Plast Reconstr Surg 103:132, 1999
8. Chou EK, Ulusal BM, Ulusal A, et al: Using the descendingbranch of the lateral femoral circumflex vessel as a source oftwo independent flaps. Plast Reconstr Surg 117;2059, 2006

9. Wei FC, Jain V, Suominen S, et al: Confusion among perforator flaps:What is a true perforator flap? Plast Reconstr Surg 107:874, 2001

0. Kimata Y, Uchiyama K, Ebihara S, et al: Anatomic variations andtechnical problems of the anterolateral thigh flap: A report of74 cases. Plast Reconstr Surg 102:1517, 1998

1. Fu-Chan W, Vivek J, Naci C, et al: Have we found an ideal softtissue flap? An experience with 672 anterolateral thigh flaps.Plast Reconstr Surg 109:1, 2002

2. Ribuffo D, Cigna E, Gargano F, et al: The innervated anterolat-eral thigh flap: Anatomical study and clinical implications. PlastReconstr Surg 115:464, 2005

3. Pan SC, Yu JC, Shieh SJ, et al: Distally based anterolateral thigh flap:An anatomic and clinical study. Plast Reconstr Surg 114:1768, 2004

4. Alkureishi LW, Shaw-Dunn J, Ross GL: Effects of thinning theanterolateral thigh flap on the blood supply to the skin. Br JPlast Surg 56:401, 2003

5. Mureau MA, Posch NA, Meeuwis CA, et al: Anterolateral thighflap reconstruction of large external facial skin defects: A fol-low-up study on functional and aesthetic recipient and donorsite outcome. Plast Reconstr Surg 115:1077, 2005

6. Lewin JS, Barringer DA, May AH: Functional outcomes afterlaryngopharyngectomy with anterolateral thigh flap recon-struction. Head Neck 28:142, 2006

7. Koshima I, Hosoda S, Inagawa K, et al: Free combined anterolat-eral thigh flap and vascularized fibula for wide, through-and-through oromandibular defects. J Reconstr Microsurg 14:529,1998

8. Wei FC, Jain V, Suominem S, et al: Combined anterolateralthigh flap and vascularized fibula osteoseptocutaneous flap inreconstruction of extensive composite mandibular defects.Plast Reconstr Surg 109:45, 2002

9. Adani R, Tarallo L, Marcoccio I, et al: First web-space reconstruc-tion by the anterolateral thigh flap. J Hand Surg 31:640, 2006

0. Wang HT, Erdmann D, Fletcher JW, et al: Anterolateral thighflap technique in hand and upper extremity reconstruction.Tech Hand Up Extrem Surg 8:257, 2004

1. Ozkan O, Coskunfirat OK, Ozgentas HE: The use of free an-terolateral thigh flap for reconstructing soft tissue defects ofthe lower extremities. Ann Plast Surg 43:455, 2004

2. Ao M, Nagase Y, Mae O, et al: Reconstruction of post-traumaticdefects of the foot by flow-through anterolateral or anterome-dial thigh flaps with preservation of posterior tibial vessels.Ann Plast Surg 38:598, 1997

3. Sasaki K, Nozaki M, Nakazawa H: Reconstruction of a largeabdominal wall defect using combined free tensor fasciae lataemuscolocutaeous flap and anterolateral thigh flap. Plast Recon-str Surg 102:2244, 1999

4. Wei FC, Suominen S, Cheng MH: Anterolateral thigh flap forpostmastectomy breast reconstruction. Plast Reconstr Surg110:82, 2002

5. Kaplan JL, Allen RJ, Guerra A, et al: Anterolateral thigh flap forbreast reconstruction: Review of the literature and case re-ports. J Reconstr Microsurg 19:63, 2003

6. Davidge K, Pusic A, Disa JJ, et al: Use of the anterolateral thighflap as an alternative to the rectus flap in obese and overweightpatients. Ann Plast Surg 56:536, 2006

7. Rosenberg JJ, Chandawarkar R, Ross MI, et al: Bilateral antero-lateral thigh flaps for large-volume breast reconstruction. Mi-crosurgery 24:281, 2004

8. Yildirim S, Taylan G, Akoz T: Use of fascia component of theanterolateral thigh flap for different reconstructive purposes.Ann Plast Surg 55:479, 2005

9. Yang JY, Tsai FC, Chana JS: Use of free thin anterolateral thighflaps combined with cervicoplasty for reconstruction of postburnanterior cervical contractures. Plast Reconstr Surg 110:39, 2002

0. Hidalgo DA: Aesthetic improvements in free flap mandiblereconstruction. Plast Reconstr Surg 88:574, 1991

1. Huang CH, Chen HC, Huang YL, et al: Comparison of the radialforearm flap and the thinned anterolateral thigh cutaneous flapfor reconstruction of tongue defect: An evaluation of donor-site
morbidity. Plast Reconstr Surg 114:1704, 2004

Documents

Thinned Anterolateral Thigh Cutaneous Flap and Radial Fasciocutaneous Forearm Flap for Reconstruction of Oral Defects: Comparison of Donor Site Morbidity