Nvessels for flap anastomosis.
Surgical technique of MATT
point. Using 2.5 loupe magnification, the fascial layerwas dissected from the underlying fatty layer, preserving
dissected from the fat layer (Figure 1d), using scissorsand gentle traction (Figure 1e), similar to lipoma
The findings of a larger on-going study will confirm overallefficacy.
sub-dermal plexuses, are easily identified and preserved.This is especially significant around the perforator, wherehalf are either type 2 (perforator side-branches into theadipose tissue) or type 3 patterns (perforator branchesrunning parallel and above the deep fascia).5
* Meetings presented at the: International Meeting on Aestheticand Reconstructive Facial Surgery, Mykonos, May 2009.
Journal of Plastic, Reconstructive & Aesthetic Surgery (2010) 63, e706ee708all supra-fascial vessels (Figure 1b and c). Initially,peripheral fatty lobules or multiple adipoctye units were
Primary ALT thinning is best performed in perfusedtissue. When combined with loupe magnification, finervessels in the supra-facial plexus, subcutaneous fat andWith the flap raised sub-fascially and pedicle still conected in the thigh, it was turned over, to expose iunderside. Flap thickness was measured (cm) at its miCORRESPONDENCE AND COMMUNICATIO
Thinning the antero-lateral thighflap using a MATT-finish*
The antero-lateral thigh flap (ALT) is commonly used inhead and neck reconstruction, but not always as firstchoice, perhaps due to its thickness (3 cm possible,1
Figure 1a). One stage thinning can overcome thisproblem, in so far as the ALT flap is then functionally asgood as the radial forearm flap,2 but practise is not routine.Concerns of flap necrosis have contributed to this lack ofuptake.3,4 We describe the Multiple Adipocyte ThinningTechnique (MATT), to primarily thin the ALT flap as a simpleprocedure and with good outcome.
Fifteen patients had MATT thinned ALT flaps, by onesurgeon (TS), from Jan. 2006-2007. The male to femaleratio was 2:1 and mean age 52-years (range: 23e74 years).Defects resulted from wide excisions (cT2eT4,) of oraltumours in 13 patients and 2 cheek skin squamous cellcarcinomas. Oral defects comprised the floor of mouth(FOM, 3), tongue (4), combined tongue and FOM (4), ret-romolar trigone (1) and alveolus (1). All patients underwentipsilateral selective neck dissection (I-IV), preservingexcision. Fine intra-flap vessels are preserved this way(Figure 1d). A 1 cm tissue cuff was left around theperforator, as previously described.1 Deeper fatty lobuleswere removed with the original, as a train, for timeefficiency. The entire periphery was thinned similarly.Using micro-instruments, the MATT was finally centralisedover the perforator vessel. Flap vascularity wasconfirmed, stepwise, by edge bleeding and capillaryreturn. Once completely thinned (Figure 1f), a midpointtissue measure was taken, again, the fascia redraped andsutured to prevent shear. The fascial layer providesanchorage during flap transfer and facilitates recipientsite suspension.
All flaps were raised on one intra-muscular perforatorand mean surface area of 6.0 cm 4.0 cm (maximumwidth 6.0 cm, maximum length 12 cm). The average timetaken to perform the MATT was 30 minutes (range:15e53 minutes). Capillary return and flap bleedingremained unaltered, no inset difficulties were encoun-tered and all micro-anatomoses (one artery and twoveins) were uneventful. Flap revascularisations weresuccessful and no immediate post-operative complicationsensued. At follow-up (mean: 6 months) speech function,deglutition, facial contour and appearance were allsatisfactory.
Thinned ALT flaps have achieved good outcome in thepost-burn neck, dorsal foot, auricular region, forearm,axilla, lower limb and hand (see Table 1). Other reportsdispute flap thinning from concerns regarding tissueviability.3,4 Furthermore, current literature lacks a stan-dard technique to thin ALT flaps (Table 1). The MATTpreserves finer vessels in the fat layer, thereby simulta-neously removing multiple adipocyte units and lesseningthe risk of tissue necrosis. Stepwise thinning also ensuresassessment of flap vascularity at each stage of the MATT.
Correspondence and communication e707A mean performance time of 30 minutes suggests theMATT is time-efficient. Thinning the periphery first, thenperforator using finer micro-instruments, avoids repeatedchange in instruments and provides a topographical map ofareas to thin.
Although weights of thinned flaps were not recorded,the expected weight reduction combined with adequateflap suspension, would negate gravitational effects onrecipient skin. Two patients with cheek/lower eyeliddefects achieved good aesthetic outcome and seemed toavoid subsequent ectropion, in this regard.
ALT flaps are safely thinned to 3e4 mm, for lengths of9 cm, based on a single perforator.5 Dimensions beyond thiscompromise flap survival, however if thinned to >4 mm,proportional size extensions are possible.5 This study hasshown thicker flaps (mean thickness of 7 mm, post-MATT),indeed, achieve greater lengths (12 cm).
The safety of the MATT in the ALT flap has shown benefitin head and neck reconstruction and may be a usefulalternative to the radial forearm flap.
Figure 1 a) The normal subcutaneous tissue thickness in the ALTthe underlying subcutanoeus fat layer in the ALT flap. c) Part separMATT thinning. d) An avascular plane developed to facilitate separae) MATT: A mutiple adipocyte unit with an inter-connected deeper l(compare to Figure 1a).Conflict of interest statement
The authors wish to state that we did not have any financialand personal relationships with other people or organisa-tions that could inappropriately influence (bias) the workpresented in this manuscript.
This study did not attract any funding.
The investigations performed in this study were carried outto a high ethical standard and met with local ethicalapproval.
flap. b) Separation of the deep fascia by sharp dissection fromation of the fascial layer to expose the subcutaneous layer fortion of the multiple adipocyte unit from the reamining fat layer.obule for removal as a train. f) The thinned ALT flap post-MATT
Table 1 Literature review of primary ALT flap thinning
Author Year Patientnumber
Stage atwhen to thin
Kimura N et ala 1996 5 Before pedicledivision
Not stated Neck, foot, axilla andwrist
Kimura N et al.a 2001 31 Before pedicledivision
Not stated Neck, foot, forearm,axilla, lower limb,hand, wrist
Yang J-Y et al.a 2002 7 Not stated Not stated Post cervicalcontracture release
Ross GL et al.b 2003 12 Before pedicleligation
Not statedc Oral cavity Thinning notrecommended at 1st
e708 Correspondence and communicationAlkureishi et al.b 2003 10 Before pedicleligation
Huang C-H et ala 2004 41 Before pedicleligation or followingrevascularisation
Adani R et al.a 2005 9 Before pedicledivision
Yang W-G et al.a 2006 18 Before pedicleligation
Kimura et ala 2009 59 Before pedicle ThReferences
1. Yang W-G, Chiang Y-C, Wei F-C, et al. Thin anterolateral thighperforator flap using a modified perforator microdissectiontechnique and its clinical application for foot resurfacing. Plast.Reconstr. Surg 2006;117:1004e8.
2. Huang C-H, Chen H-C, Huang Y-L, et al. Comparison of the radialforearm flap and thinned anterolateral thigh cutaneous flap forreconstruction of tongue defects: an evaluation of donor sitemorbidity. Plast. Reconstr. Surg 2004;114:1704e10.
3. Alkureishi LWT, Shaw-Dunn J, Ross GL. Effects of thinning theanterolateral thigh flap on the blood supply to the skin. Br. J.Plast. Surg 2003;56:401e8.
a Plast. Reconstr. Surg.b Br. J. Plast. Surg.c Personal communication: performed with scissor dissection.r dissection Cadaver study Thinning notrecommended at 1st
stager or knifetion to 2 mmdermal-plexus
ated Hand Thinningrecommended
ng intaor zone byscopiction
ng by Multiple areas Thinning4. Ross GL, Dunn R, Kirkpatrick J, et al. To thin or not to thin: theuse of the anterolateral thigh flap in the reconstruction ofintraoral defects. Brit. J. Plast. Surg 2003;56:409e13.
5. Kimura N, Satoh K, Hansumi T, et al. Clinical application of thefree thin anterolateral thigh flap in 31 consecutive patients.Plast. Reconstr. Surg 2001;108:1197e208.
A. MisraT. ShoaibD. Soutar
Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary,84Castle Road, Glasgow G4 0SF, UKE-mail address: firstname.lastname@example.org
Thinning the antero-lateral thigh flap using a MATT-finishSurgical technique of MATTConflict of interest statementFundingEthicsReferences