Reconstructive Indications of Anterolateral Thigh Free Flaps in Head and Neck Reconstruction

Profunda Artery Perforator Flaps in Head and Neck Reconstruction: Anatomy, Surgical Techniques, and Evolving Applications

Reconstructive surgeons navigate a plethora of options when choosing a soft-tissue flap donor site for head and neck reconstruction, each with its distinct pros and cons. This review delves into the profunda artery perforator flap and provides expert recommendations for its use in head and neck reconstruction.

Clinical applications of vascularized fascia lata in head and neck reconstruction: A systematic review

BACKGROUND

Given limitations in the current literature, the precise indications, techniques, and outcomes relevant to vascularized fascia lata free flap reconstruction remain uncertain. The objective of this study was to perform a systematic review of published literature to evaluate indications, methods, and complications for vascularized fascia lata free flap reconstruction.

METHODS

A systematic review of the literature was performed using a set of search criteria to identify patients who underwent free flap reconstruction of the head and neck region using vascularized fascia lata. Articles were reviewed based on relevance, with the primary outcome being surgical complications and surgical indications.

RESULTS

A comprehensive search revealed 783 articles and 5 articles were ultimately found to be appropriate to this review- 55 patients undergoing free flap reconstruction were identified. Overall complication rates were 10.9 % for major complications and 18.1 % for minor complications. Follow-up spanned 1 to 95 months with a median of 48 months.

CONCLUSIONS

Microvascular reconstruction of the head and neck with vascularized fascia lata is achievable with high adaptability and reliability reported in the literature.

Reconstructive techniques for radiation-induced hemifacial sequelae: A hemangioma case study

INTRODUCTION AND IMPORTANCE

The use of radiation therapy for infantile hemangiomas 30 years ago has led to severe consequences in adulthood.

CASE PRESENTATION

This article shares the experience of using multiple reconstructive procedures to treat radiation-induced hemifacial sequelae for capillary malformations. Based on the damaged anatomical surgical units, appropriate reconstructive materials are used for the surgery. Thin antero-lateral thigh (ALT) flaps cover lesions on the forehead and cheeks, while a skin expander covers the temporal scalp lesion. Autologous grafting covers damage in both eyelids.

CLINICAL DISCUSSION

Choosing a suitable reconstructive material will provide aesthetic outcomes such as facial symmetry, skin color compatibility, and textural similarity in the constructive areas for the patient. The patients were highly satisfied with the surgical results.

CONCLUSION

Using appropriate surgical techniques and materials, along with meticulous attention to facial integrity, can achieve optimal aesthetic and functional outcomes in patients with severe facial disfigurement from radiation therapy. A thorough understanding of pathophysiology and anatomy, along with skillful execution, can result in a successful outcome and improved quality of life.

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.

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.

Indication for management of oropharyngocutaneous fistulas after head and neck reconstruction using a "stick-shaped platysma flap" technique

The main strength of the stick-shaped platysma flap technique is it provides adequate tissue volume, while being comparatively simple to perform. It is a highly efficient and straightforward method to close intractable fistulas with minimal morbidity.

Free Flap Transfer, a Safe and Efficient Method for Reconstruction of Composite Skull Base Defects After Salvage Resection of Advanced Intracranial and Extracranial Communicating Tumors

OBJECTIVE

Surgical treatment of advanced intracranial and extracranial communicating skull base tumors is challenging, especially for the reconstruction of the large composite defect left by tumor resection. The aim of the study is to evaluate the utility of the free flap reconstruction of the defects resulting from radical resection of these tumors in a single institution.

METHODS

The clinical data of 17 consecutive patients who underwent free flap reconstruction for defect left by salvage resection of advanced intracranial and extracranial communicating tumors from 2013 to 2019 were retrospectively collected and analyzed.

RESULTS

There were 5 squamous cell carcinomas, 4 adenoid cystic carcinomas, 2 basal cell carcinomas, 2 meningiomas, 1 anaplastic hemangiopericytoma, 1 pleomorphic adenoma, 1 osteosarcoma, and 1 chondrosarcoma. All patients had recurrent neoplasms, 2 of whom had pulmonary metastasis. A modified radical cervical dissection was performed in 6 patients. The anterolateral thigh myocutaneous flap and rectus abdominis myocutaneous flap were used in 15 patients (88.2%) and 2 patients (11.8%), respectively. Complications were seen in 3 of 17 patients (17.6%) with 1 total flap loss. The median progression-free survival duration was 31 months. The 3- and 5-year progression-free survival rates were 0.47 and 0.24, respectively. The mean overall survival duration was 66 months. The 3- and 5-year overall survival rates were 0.85 and 0.68, respectively.

CONCLUSIONS

Free flap transfer is a safe and effective method with acceptable complications, useful for reconstruction of large composite skull base defects after salvage resection of advanced intracranial and extracranial communicating tumors. The functional and cosmetic results are satisfying.

Perforator Mapping of the Profunda Artery Perforator Flap: Anatomy and Clinical Experience

BACKGROUND

Discovering alternatives to workhorse flaps that have more consistent anatomy and lower donor-site morbidity has become a focus of reconstructive surgery research. This study provides a simplified approach to profunda artery perforator flap design and harvest based on reliable anatomical landmarks.

METHODS

A retrospective review was conducted of 70 patients who underwent 83 profunda artery perforator flap reconstructions for postoncologic defects from 2016 to 2018. The authors recorded and analyzed the profunda artery perforator flap sizes and clinical applications, the numbers and locations of the perforators, and the patient outcomes.

RESULTS

Most of the profunda artery perforator flaps were for head and neck [46 patients (65.7 percent)] and breast [21 patients (30 percent)] reconstructions. Flaps were most commonly based on perforator A (33.7 percent) and perforator B (33.7 percent), followed by perforators B and C combined (18.1 percent). Perforators were located a mean of 7.5 cm (perforator A), 12.7 cm (B), and 17.6 cm (C) distal to the pubic tubercle parallel to the axis between the pubic tubercle and the medial femoral condyle and 7.9 cm (A), 7.3 cm (B), and 6.1 cm (C) posterior from the axis. There was no flap loss. One patient underwent successful salvage surgery after arterial flap thrombosis. Eight patients (9.6 percent) developed superficial wound dehiscence that was managed conservatively.

CONCLUSIONS

Perforator mapping demonstrated consistent anatomical locations of sizeable profunda artery perforators in the inner thigh. Along with its consistent and robust vascular anatomy and minimal donor-site morbidity, the profunda artery perforator flap's volume and pliability make it a reliable option for soft-tissue reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Comparison of the outcomes between free anteromedial thigh flap and anterolateral thigh flap in head and neck cancer reconstruction: Analysis of propensity-score-matched patient cohorts

BACKGROUND

The anterolateral thigh (ALT) flap is a workhorse flap in head and neck cancer reconstruction. The anteromedial thigh (AMT) flap was developed as a rescue or alternative flap whenever the ALT flap is not available; however, the harvest of AMT flap seems to be more challenging in the sense that perforators have multiple variations. This study was designed to compare the outcome of the AMT and ALT flaps in head and neck cancer reconstruction.

METHODS

A total of 1,547 ALT and 57 AMT flaps were used for head and neck cancer reconstruction between March 1, 2008 and February 28, 2017. Differences in patient and operative characteristics were compared between the patients undergoing AMT and ALT flap reconstruction. The primary outcome of the free flap was its survival or failure, while the second outcome was the associated complications.

RESULTS

Compared to those who had ALT flap reconstruction, the patients who underwent AMT flap reconstruction had a higher rate of conditions that required reconstruction after previous cancer ablation and recurrence but a lower rate of primary cancer and deeply located cancer. Analysis of the 40 well-balanced pairs of propensity-score-matched patient cohorts revealed that the AMT flaps were associated with a significantly higher failure rate than the ALT flaps (15.0 vs. 0.0%, respectively; p = .026).

CONCLUSION

This study revealed that AMT flaps were associated with a significantly higher failure rate than ALT flaps in head and neck cancer reconstruction in the cohort of total patients and the propensity-score-matched cohorts.

Anterolateral thigh free flap in reconstruction of lateral skull base defects after oncological resection

Purpose

Evaluation of the utility of the free anterolateral thigh flap reconstruction of the defects resulting from radical temporal bone resection in the management of lateral skull base malignancies in a single institution.

Methods

An analysis of 17 en bloc subtotal petrosectomies for removal of malignant tumours was performed. There were 12 squamous cell carcinomas, 4 basal cell carcinomas and 1 adenoid cystic carcinoma. The tumours were staged with the University of Pittsburgh TNM system. In all patients, the lateral temporal bone with the preservation of the petrous apex and carotid artery was performed. All patients had parotid gland resection. The post-resection defect was reconstructed with an ALT free flap.

Results

Tumour radical resection and defect reconstruction with an ALT flap was achieved in all patients without intraoperative complications. The transplants were harvested as fasciocutaneous flaps, 11 perfused by musculocutaneous and 6 by septocutaneous perforators. The ALT flaps had a mean pedicle length of 8 cm (6–12 cm), and the flap size ranged between 6 × 15 cm and 15 × 30 cm. The flaps were supplied by nine facial, five occipital and three maxillary arteries. Recipient-site veins included eight internal jugular, seven facial, one retromandibular and one external jugular vein. All arterial pedicles were anastomosed in an end-to-end manner. The veins were anastomosed with interrupted sutures and in 11 cases with Synovis-Coupler® devices. All the flap transfers were performed successfully. Three patients experienced postoperative complications.

Conclusions

The ALT flap proved to be effective for covering large temporal skull base defects resulting from the radical removal of temporal bone malignancies. The functional and cosmetic results were acceptable with a low complication rate.

Application of a new classification of chimeric anterolateral thigh free flaps

BACKGROUND

The anterolateral thigh free flap is one of the most commonly used flaps in reconstructive procedures. The purpose of this study was to assess this new classification of chimeric anterolateral thigh free flaps.

METHODS

Sixty-five patients underwent free anterolateral thigh chimeric free flap reconstruction of defects in the head and neck region. We summarized the anatomic features of perforators, including the number and origin of the perforators.

RESULTS

Sixty-five cases of femoral anterolateral double island flaps were divided into 3 types: trunk type (type I), 11 cases (16.9%), in which the perforators of two flaps originated in the descending branch and the transverse branch of the lateral femoral circumflex artery; branch type (type II), 45 cases (69.3%), in which both the perforators originated in the descending branch or the transverse branch of the lateral femoral circumflex artery; and bifurcation type (type III), 9 cases (13.8%), in which two perforators originated in the bifurcation of one perforator that originated in the descending branch or the transverse branch of the lateral femoral circumflex artery. All 65 flaps survived and none showed partial necrosis.

CONCLUSIONS

The anterolateral thigh chimeric flap can be divided into 3 types: trunk type (I type), branch type (II type) and bifurcation type (III type).

Complex Intraoral Reconstruction Using a Single Free Anterolateral Thigh Flap and Supermicrosurgery After Corrosive Ingestion in a 14-Month-Old Child

Oral chemical burn injuries induce more damage to the underlying tissues with extensive scarring. It is very well known that alkali causes severe liquefaction necrosis and injury to the deeper tissues. Pediatric facial burns must be managed thoroughly and always require complex reconstruction, which is a challenging process. So, any reconstructive surgeon must be aware of all the deformities that may have significant functional and aesthetic impact on the burn survivors especially children. Few medical studies addressed pediatric microsurgical reconstruction for oral burn injuries induced by chemical materials. Anterolateral thigh (ALT) free flap is a common flap with a multitude of indications. The purpose of this article is to present the youngest case in the medical literature of caustic intraoral scarring managed with a very thin free anterolateral thigh flap in a 14-month-old child who underwent reconstruction of his inner cheek, the angle of the mouth and tongue using supermicrosurgery techniques. Further development of the surgical techniques is required to establish early and safe intraoral pediatric microsurgery with a long-term follow-up.