Association of the Anterolateral Thigh Osteomyocutaneous Flap With Femur Structural Integrity and Assessment of Prophylactic Fixation

Segmental mandibular reconstruction in patients with poor lower extremity perfusion, vessel-depleted necks and/or profound medical frailty

PURPOSE OF REVIEW

Options for segmental mandibular reconstruction in patients poorly suited to undergo fibula free flap (FFF).

RECENT FINDINGS

Although FFF is the current 'gold standard' for segmental mandibular reconstruction, other reconstructive options must be considered when FFF is contraindicated or disfavoured and/or patient frailty precludes a lengthy anaesthetic. In addition to various nonvascularized and soft tissue only reconstructions, excellent osseous free flap alternatives for functional segmental mandibular reconstruction may be employed. The subscapular system free flaps (SSSFF) may be ideal in frail and/or elderly patients, as SSSFF allows for early mobility and does not alter gait. In extensive and/or symphyseal defects, functional mandibular reconstruction in lieu of a free flap is extremely limited. Pedicled segmental mandibular reconstructions remain reasonable options, but limited contemporary literature highlights unpredictable bone graft perfusion and poor long-term functional outcomes.

SUMMARY

There are several excellent free flap alternatives to FFF in segmental mandibular reconstruction, assuming adequate cervical recipient vessels are present. On the basis of the current literature, the optimal mandibular reconstruction for the medically frail, elderly and/or patients with extreme vessel-depleted necks is limited and debatable. In qualifying (i.e. limited, lateral) defects, soft tissue only reconstructions should be strongly considered when osseous free flaps are unavailable.

Anterolateral thigh osteomyocutaneous flap in head and neck: Lessons learned

BACKGROUND

Concerns regarding iatrogenic femur fracture may deter adoption of the anterolateral thigh osteomyocutaneous (ALTO) flap as an alternative reconstructive technique for large composite defects of the head and neck. We describe the evolution of our experience with this flap and the lessons learned in femur management.

METHODS

Records from a prospective database (July 2009-January 2020) were reviewed to identify patients with composite osseous free tissue reconstructions. Venous thromboembolic events (VTE), femur fracture, estimated blood loss (EBL), procedure time, blood transfusions, and length of stay (days) were compared for ALTO flaps prior to and after the adoption of intramedullary fixation protocol.

RESULTS

ALTO represented 10.5% (n = 23) of total osseus (n = 219) flaps. For large composite reconstructions with either ALTO flap, double flap (n = 2), or subscapular mega flaps (n = 14), ALTO flaps were most frequently used (59%, n = 23/59). There were no differences in operative time prior to and after implementation of prophylactic fixation [median (range): 5.4 (1.7-19.2) vs. 5.8 (1.7-15.0), p = .574]. Additionally, there were no differences in VTE, femur fracture, EBL, blood transfusion, or length of stay (p > .05) with adoption of prophylactic intramedullary fixation.

CONCLUSIONS

The ALTO flap represents a useful tool to consider in the armamentarium of reconstructive options for large through and through defects of the head and neck. In our experience, the ALTO flap is a reasonable alternative to subscapular or double flap reconstructions and especially in the setting of unusable fibular flaps or when bone need exceeds that available from the scapula.

Anatomic study of the femur-vastus intermedius muscle-anterolateral thigh osteomyocutaneous free flap

INTRODUCTION

Resection of head and neck malignancy usually causes facial defects and esthetic deformities. Among the wide range of free flaps available for reconstruction, a novel chimeric free flap-the femur-vastus intermedius muscle-anterolateral thigh osteomyocutaneous free flap (FVATLO flap)-has been demonstrated for clinical use. In this study, we illustrate the anatomy and harvest of the FVATLO flap.

METHODS

Eighteen fresh cadavers without damage to either thigh were recruited for dissection. Blood supply to the vastus intermedius muscle and femur were traced and recorded. The diameter, circumference of the middle part of the femur, and thickness of the femoral cortex were measured.

RESULTS

The major blood supply to the vastus intermedius muscle showed two patterns of origin. The first arising from the descending branch of the lateral circumflex femoral artery (LCFA-db) accounts for 78% of the cases (28/36), and the second arising from the transverse branch of the lateral circumflex femoral artery (LCFA-tb) accounts for 22% (8/36). Blood supply to the femur consists of two major sources: one from branches penetrating through the nutrient foramen on the posteromedial surface of the femur to the medullary cavity, and the other from the periosteum branches spreading over on the femoral surface. No visible branch from the vastus intermedius muscle to the underlying periosteum was found. The mean diameter, femoral circumference, and mean cortical thickness were 26.30 mm, 85.58 mm, and 6.85 mm, respectively.

CONCLUSION

Considering that there is only one injured donor site, the FVALTO flap is an alternative chimeric flap for cases with a large amount of soft tissue loss together with small bony defects.