Application of Anteromedial Thigh Flap for the Reconstruction of Oral and Maxillofacial Defects

Reconstruction of Complex Oral and Maxillofacial Defects After Oral Cancer Resection With Individualized Anterolateral Thigh Multiple Paddle Flaps

PURPOSE

This study aimed to use reconstructive methods for complex oral and maxillofacial defects, explore their feasibility, and evaluate the efficacy of defect reconstruction using anterolateral thigh (ALT) multiple paddle flaps.

PATIENTS AND METHODS

The authors performed a retrospective case series of 33 patients who underwent oral and maxillofacial defect reconstruction using the ALT multiple paddle flaps. The design and harvest of the flaps, methods for defects reconstruction, and reconstructive efficacy are described.

RESULTS

All 33 patients were men, with a mean age of 49.5 years. Of the flaps, triple skin paddles plus muscle paddles were included in 3 cases, triple skin paddles were included in 1 case, 2 skin paddles plus muscle paddles were included in 29 cases. The skin paddles measured 3×5 cm to 10×16 cm. Postoperatively, all flaps survived completely. Parotid salivary fistula and orocutaneous fistula occurred in 1 patient of each, thigh wound infection and effusion occurred in 1 and 2 patients, respectively. All patients were followed up for ~2 to 93 months; most patients' oral functions and appearance were acceptable, and thigh motor dysfunction was not observed.

CONCLUSIONS

With separate skin paddles for defects of different positions, individualized muscle flap for dead spaces, combination of different skin paddles for larger defects, effective reduction or avoidance of wound complications, and acceptable donor site morbidity, the ALT multiple paddle flaps are an ideal candidate for complex oral and maxillofacial defects reconstruction.

Comprehensive analysis of risk factors for flap necrosis in free flap reconstruction of postoperative tissue defects in oral and maxillofacial tumors

Free flap reconstruction for postoperative tissue defects in oral and maxillofacial tumors is a critical component of reconstructive surgery. Identifying risk factors for flap necrosis is essential for improving surgical outcomes and patient quality of life. A retrospective study was conducted on patients who underwent free flap reconstruction between January 2020 and December 2023. Patients were included if they had comprehensive medical records and at least a six-month follow-up. We excluded those with a history of flap necrosis, uncontrolled systemic diseases, non-adherence to postoperative care, or concurrent malignancy treatments. Data on demographics, comorbidities, flap characteristics, and operative details were collected and analyzed using univariate analysis and logistic regression tests. Univariate analysis did not find a significant correlation between flap necrosis and factors such as hyperlipidemia, lymph node metastasis, or flap type. However, diabetes mellitus, oral infections, and albumin levels below 35 g/L were significantly associated with flap necrosis. Multivariate logistic regression showed diabetes mellitus increased the odds of flap necrosis by approximately ninefold, and oral infection increased it by over tenfold. Diabetes mellitus, oral infection, and low albumin levels are significant risk factors for flap necrosis in free flap reconstruction after oral and maxillofacial surgery. Prompt identification and management of these factors are crucial to mitigate the risk of flap necrosis.

Comparison of The Thickness of Free Anterolateral Thigh Flap in Different Fascial Planes: Clinical Results of Subfascial and Superficial Fat Flap

Background  The anterolateral thigh (ALT) flap is a preferred option in the reconstruction of a wide variety of defects, enabling multiple tissue components and thicknesses. Methods  This study was conducted to investigate the correlation of the thickness of the traditional subfascial ALT flap and superficial fat flap with age, gender, and body mass index (BMI). A total of 42 patients (28 males and 14 females) were included in the study. Results  Mean age was 50.2 (range, 16-75) years and mean BMI was 24.68 ± 4.02 (range, 16.5-34.7) kg/m 2 . The subfascial flap thickness was significantly thinner in male patients (16.07 ± 2.77 mm) than in female patients (24.07 ± 3.93 mm; p  < 0.05), whereas no significant difference was found between male (4.28 ± 1.15 mm) and female patients (4.85 ± 1.09 mm) regarding superficial fat flap thickness ( p  = 0.13). The thickness of both flaps had a positive correlation with BMI, and the strongest correlation was found for subfascial ALT thickness in female patients ( r  = 0.81). Age had no effect on both flap thickness measurements. The anterior thigh is thicker in women than in men, although it varies according to BMI. This shows that flap elevation is important in the superthin plane, especially if a thin flap is desired in female patients in defect reconstruction with the ALT flap. Thus, a single-stage reconstruction is achieved without the need for a defatting procedure after subfascial dissection or a second defatting procedure 3 to 6 months later. Conclusion  The appropriate ALT flap plane should be selected considering the gender and BMI of the patient.

One stage reconstruction of mid-face fistulous defects after maxillary sinus carcinoma resection with chimeric perforator free flaps

BACKGROUND

The reconstruction of large fistulous defects following the radical ablation of maxillary sinus carcinoma remains challenging. The procedure requires not only the coverage of both intra-nasal lining and cheek skin but also sufficient obliteration of dead space between the two surfaces. In this report, we present our experience on the reconstruction of through-and-through defects in the mid-face with poly-foliated chimeric perforator flaps.

METHODS

Nine patients (five males and four females) who received a two-skin paddled and one muscle segment chimeric perforator flap reconstruction after maxillary sinus carcinoma ablation between March 2015 and December 2019 were retrospectively reviewed in authors' hospital. The mean age of the patients was 59.11. Six patients were diagnosed as squamous cell carcinoma, two as adenoid cystic carcinoma, and one as adenocarcinoma. Brown class IIIa defects were found in eight patients, and one patient had a Brown class IVa defect. The mean size of intra-nasal defect was 5.67 × 4.06 cm² , and the mean size of facial skin defect was 8.94 × 6.56 cm² . ALT flaps were used in five patients, LD flaps in four patients. The minor skin paddle was firstly inset to the mucosal defect site as the lining. Then, the muscle segment was inset to eliminate the dead cavity. Finally, the major skin paddle was inset to recover the cutaneous defect.

RESULTS

In ALT group, the mean size of the minor skin paddle was 5.7 × 4.7 cm² , and the mean size of the major skin paddle was 8.7 × 6.6 cm² . In LD group, the mean size of the minor skin paddle was 6.88 × 4.38 cm² , and the mean size of the major skin paddle was 11 × 7.75 cm² .All donor sites were closed primarily. All flaps survived and no partial flap loss was encountered. The mean follow-up time was 14.67 months, and there were no major postoperative complications.

CONCLUSION

The use of poly-foliated chimeric perforator free flaps can provide functional and aesthetic coverage for extensive through-and-through mid-face defects without significant donor-site morbidities.

Reconstruction of Complex Lateral Skull Base Defects After Oral Cancer Resection With Individualized Anterolateral Thigh Flap

Objectives

Complex lateral skull base defects resulting from advanced or recurrent oral cancer resection are continuously challenging reconstructive surgeons. This study aimed to use reconstructive methods for lateral skull base defects, explore their feasibility, and evaluate the efficacy of defect reconstruction using anterolateral thigh (ALT) flaps.

Patients and Methods

We performed a retrospective case series of 37 patients who underwent lateral skull base defect reconstruction using the ALT/anteromedial thigh (AMT) flap between March 2016 and May 2021 at the Second Xiangya Hospital. The design and harvest of the flaps, methods for defect reconstruction, and reconstructive efficacy are described.

Results

Of the 37 patients, 3 were women and 34 were men, with a mean age of 51.7 years. Among the defects, 26 were through-and-through defects and were reconstructed using ALT chimeric flaps, double ALT flaps, folded ALT flap, combined ALT chimeric flaps and AMT flaps, or combined ALT chimeric flaps and pectoralis major flaps; the large lateral skull base dead spaces were filled with muscle tissues or fatty tissues. Postoperatively, 38 of the 39 ALT/AMT flaps survived completely, and the remaining flap experienced partial necrosis. Venous compromise occurred in one patient who was salvaged after operative exploration. Oral and maxillofacial wound infections occurred in two patients, salivary fistula in three patients, and thigh wound effusion in three patients. The wounds healed gradually in all patients after repeated dressing changes. Thirty-three patients were followed up for approximately 3–60 months; their oral functions and appearance were acceptable, and thigh motor dysfunction was not observed.

Conclusions

With the convenient flap design and muscle flap harvest, large and individualized tissue supply, feasible combination with other flaps, effective reduction or avoidance of wound complications, and acceptable donor site morbidity, the ALT flap is an appropriate choice for complex lateral skull base defect reconstruction.

Chimeric Anterolateral Thigh Flap in Skull Base Reconstruction: A Case-Based Update and Literature Review

Oncologic and traumatic neurosurgery may have to cope with the issue of skull base defects, which are associated with increased risk of meningitis, epidural abscess and cerebro-spinal fluid (CSF) leak. The aim of skull base reconstruction is to repair the dural exposure and to separate the intracranial contents from the nonsterile sino-nasal cavities and extracranial space. Currently, many different surgical techniques have been described, and one of the most performed is the use free flap. In the present paper we performed a case-based update and literature review of the use of chimeric anterolateral thigh free flap harvested from rectus femoris, reporting the case of a 68-year-old man with recurrent spheno-ethmoidalis plane meningioma.

Femoral artery-nourished anteromedial thigh flap: A new perspective in oral and maxillofacial defect reconstruction

OBJECTIVES

The aim of this study was to evaluate the feasibility and efficacy of the femoral artery (FA)-nourished anteromedial thigh (AMT) flap for reconstructing oral and maxillofacial defects.

PATIENTS AND METHODS

The authors analyzed a retrospective case series of 13 patients who underwent the reconstruction of oral and maxillofacial defects with the FA-nourished AMT flap. The flap design and the methods for defect reconstruction are described, and the reconstructive efficacy is reported.

RESULTS

Of the 13 patients, 12 were men, and 1 was woman, with an average age of 52.2 years. Of these FA-supplied AMT flaps, 7 were singly used, 5 were combined with the anterolateral thigh (ALT) flap or its chimeric flaps, and 1 was separately used with the ALT flap. Postoperatively, all flaps survived completely, without vascular compromise or major wound complications.

CONCLUSIONS

The FA-nourished AMT flap can also be used to reconstruct some common oral and maxillofacial defects, especially as a new alternative to the ALT flap. In addition, this flap can be combined with the ALT flap or its chimeric flaps or separately used with the ALT flap for the reconstruction of complex defects.

Double Thread Suspension: A Novel Technique to Facilitate End-to-Side Venous Anastomosis With a Microvascular Coupling Device in Head and Neck Reconstruction

PURPOSE

Microvascular free tissue transfer has become a mainstay for head and neck reconstruction, and vascular anastomosis is 1 of the most challenging aspects. This study aimed to explore a safe, convenient, and efficient technique for end-to-side venous anastomosis using the coupling device.

MATERIALS AND METHODS

We evaluated a novel surgical strategy, double thread suspension (DTS), by reviewing data collected in a consecutive series of 60 patients who underwent free tissue grafting after surgical resection of head and neck tumors. Patients who underwent end-to-side microvascular anastomosis using the microvascular coupler device were randomly divided into the DTS group (n = 30) and the traditional procedure group (TRA, n = 30), the demographic data, coupler size, anastomosis time, microvascular complications, and flap survival were determined.

RESULTS

The optional size range of coupler devices in the DTS group is better than that of the conventional group, ranging from 1.5 to 4.0 mm compared with 2.0 to 4.0 mm. The average anastomosis time was 4.68 ± 0.43 minutes in the DTS group which was significantly lower than the conventional group that was 9.24 ± 1.46 minutes (P < .0001) . There was no statistically significant difference between the 2 groups in coupler related complications or flap survival.

CONCLUSION

The novel DTS technique provides the advantages of lowering procedure complexity, reducing operative time, and preventing tearing of vessel wall, therefore making DTS-guided end-to-side anastomosis a safe, relatively straightforward, and reliable technique.

Characteristics and Management of Free Flap Compromise Following Internal Jugular Venous Thrombosis

PURPOSE

Free flap compromise after internal jugular venous thrombosis (IJVT) occurs fairly infrequently in oral and maxillofacial rehabilitation and reconstruction but could seriously affect the patient's postoperative recovery. The aim of this study was to analyze and discuss the characteristics and management of such flap compromise.

PATIENTS AND METHODS

The authors performed a retrospective case series of 13 patients who underwent reconstruction of oral and maxillofacial defects with anterolateral thigh flaps and developed flap compromise from IJVT from July 2014 through December 2016 at the Second Xiangya Hospital of Central South University (Changsha, China). The clinical features of flap compromise are described, and the precautions and improvement measures are reported.

RESULTS

All 13 patients were men with an average age of 50.3 years. Flap compromise caused by IJVT occurred on postoperative days 3 to 7, of which 2 flaps were salvaged (15.4%) and 11 flaps failed completely after immediate urgent re-exploration. Four patients presented with orocutaneous fistula after salvage surgery that healed well after a period of wound dressing.

CONCLUSIONS

Because of the late occurrence and low salvage rate of flap compromise caused by IJVT, intensive flap monitoring after reconstruction surgery is necessary for patients with free flap transfer.

Distally based anteromedial thigh flaps pedicled on the rectus femoris branch of the lateral circumflex femoral artery for reconstruction of soft-tissue defect of the knee

BACKGROUND

Anteromedial thigh flaps are far less clinically appealing than their anterolateral counterparts, and are occasionally considered as an alternative to the anterolateral thigh flap. Herein, we report the study of soft-tissue defects reconstruction in the knee using a distally based anteromedial thigh flap pedicled on the rectus femoris branch of the descending branch of the lateral circumflex femoral artery.

PATIENTS AND METHODS

Between July 2008 and September 2016, a distally based anteromedial thigh flap was used to reconstruct soft-tissue defects of the knee in 5 patients (3 males, 2 females; age range at surgery 4-55 years old). The perforating vessels supplying anteromedial thigh were derived from the rectus femoris branch of the lateral circumflex femoral artery. The rectus femoris branch shared a common trunk with the descending branches of the lateral circumflex femoral artery. Defect etiologies included malignant neoplasms in 2 cases and post-burn scar contracture in the remaining 3 cases.

RESULTS

The average flap size was 19.6 × 9.2 cm (range: 15-24 × 6-12 cm). There was no flap loss. Postoperative muscle weakness occurred in one case. The average follow-up time was 17.8 months (range: 5-36 months). No recurrence of tumor or scar contracture was noted.

CONCLUSIONS

Distally based anteromedial thigh flaps pedicled on the rectus femoris branch of the descending branch of the lateral circumflex femoral artery may serve as an alternative option to the distally based anterolateral thigh flap for soft-tissue defect reconstruction of the knee.

Medial Sural Artery Perforator Flap Aided by Ultrasonic Perforator Localization for Reconstruction After Oral Carcinoma Resection

PURPOSE

To evaluate the application of the medial sural artery perforator flap (MSAPF) aided by preoperative ultrasonic perforator localization for postsurgical reconstruction of oral carcinoma.

MATERIALS AND METHODS

From November 2013 to August 2014, 25 patients with oral carcinoma underwent postsurgical reconstruction after oral carcinoma resection using MSAPFs. To explore and locate the perforators, preoperative vascular ultrasound localization was used to find the MSAPs. The number and location of the perforators, length of the vascular pedicle, and thickness of the MSAPF were measured. Thirty-eight patients who underwent reconstruction with a radial forearm flap (RFF) and 21 patients who underwent reconstruction with an anterolateral thigh flap (ALTF) were selected for comparison.

RESULTS

The number of MSAPs ranged from 1 to 4, and 52 perforators were found accurately using preoperative ultrasonic localization (92.86%). The distance from the perforator to the popliteal crease ranged from 6.2 to 17.1 cm (10.70 ± 2.31 cm); the distance from the perforator to the midline of the back of the calf ranged from 0.1 to 3.5 cm (1.83 ± 0.81 cm); and the pedicle length ranged from 6.8 to 12.5 cm (10.14 ± 1.51 cm). Compared with the RFF, and ALTF, the thickness, postoperative oral sensation, and function of the MSAPF were similar to those of the RFF but better than those of the ALTF. In appearance and function of the donor site, the MSAPF was similar to the ALTF, but better than the RFF.

CONCLUSION

The MSAPF is a good alternative for postsurgical reconstruction of oral carcinoma because of its anatomic structural stability, suitable thickness, minimal donor-site scar, and ideal functional recovery after surgery. Preoperative vascular ultrasonic localization is a feasible and advantageous method for preoperative mapping of the MSAP because of its high accuracy.

Double anterior (anterolateral and anteromedial) thigh flap for oral perforated defect reconstruction

OBJECTIVE

The purpose of this study was to assess the therapeutic efficacy of oral perforated defect reconstruction with a double anterior (anterolateral and anteromedial) thigh flap through the modified lateral lip-submandibular approach.

MATERIALS AND METHODS

From July 2010 to August 2013, eight patients with oral perforated defects secondary to oral cancer ablation involving the superior partial mandible or the posterior partial maxilla, with immediate reconstruction by double anterior (anterolateral and anteromedial) thigh flaps, were retrospectively enrolled into this study.

RESULTS

All double anterior flaps were musculocutaneous flaps. Seven double flaps resulted in good functional and aesthetic outcomes with complete flap survival. One patient required operative exploration in the postoperative period due to thrombosis in the external jugular vein. After the salvage, one of the double flaps in the intraoral region resulted in partial failure of the superficial skin of the flap. No functional impairment at the donor sites occurred in any of the cases.

CONCLUSION

The double anterior (anterolateral and anteromedial) thigh flap is a feasible and acceptable technique for reconstruction of an oral perforated defect involving the mandible or the maxilla through the modified lateral lip-submandibular approach. It presents a very acceptable aesthetic and functional result with the additional advantage of low morbidity at the donor site.