Anterolateral Thigh Adipofascial Flap in Mucosal Reconstruction

Abstract

arge mucosal defects can be challenging to the reconstructive surgeon. Throughout the oral and nasal cavities, the mucosa is a thin, compliant, and functional membrane providing properties necessary for mastication, food bolus control, speech, and nasal airway patency. The unique properties and limited supply of mucosa are fundamental difficulties in reconstruction of large defects. With larger mucosal defects, complicated closures, or irradiated fields, microvascular-free tissue transfer often is indicated to ensure vascularized coverage.The anterolateral thigh (ALT) flap has recently become a "workhorse" of head and neck reconstruction. Since its description as a musculocutaneous free flap by Song et al in 1984, 1 the ALT has been adopted for a number of indications. The flap is reliably vascularized by several perforators off of the descending or transverse branch of the lateral circumflex femoral artery. Although predominantly musculocutaneous, all of these perforators traverse the fascia overlying the vastus lateralis (fascia lata) as well as the subcutaneous fat before terminating in the subdermal plexus. 2 Consequently, the ALT flap can be harvested without skin and without inclusion of muscle surrounding the perforators, resulting in a thin, pliable, ALT adipofascial free flap (ALTAF).To date, there have been few case series and case reports 3-6 describing the use of ALTAF in the head and neck. We now have several years of experience with this flap for mucosal reconstruction and have used it for oral cavity reconstruction, including palate, gingival, tongue, and buccal mucosa reconstruction. We also have used the flap in nasal lining reconstruction. 7 In this article, we review the straightforward harvest of the ALTAF and highlight our experience with the versatile indications and some contraindications for use of this flap. MethodsAll patients undergoing free tissue transfer at the Cleveland Clinic, Cleveland, Ohio, between January 1, 2009, and June 30, 2013, were reviewed, and those undergoing ALTAF for muco-IMPORTANCE This study describes a reliable technique for mucosal reconstruction of large defects using components of a common free flap technique.OBJECTIVE To review the harvest technique and the varied scenarios in which the anterolateral thigh adipofascial flap (ALTAF) can be used for mucosal restoration in oral cavity and nasal reconstruction. DESIGN, SETTING, AND PARTICIPANTSA retrospective review of the medical records of 51 consecutive patients was conducted. The patients had undergone ALTAF head and neck reconstruction between January 2009 and June 2013. Each case was reviewed, and flap survival and goal-oriented results were evaluated.RESULTS Thirty patients met the inclusion criteria and were included in the analysis. The mean patient age was 60.6 years. Reconstruction sites included the tongue, palate, gingiva, floor of the mouth, and nasal mucosa. All mucosal reconstructions maintained function and form of replaced and preserved tissues. One patient (3%) experienced flap failure that was ...

Short‐stay hospital admission after free tissue transfer for head and neck reconstruction

“…Aggressive adaptation of the ALT flap has created an exponential increase in its use by far surpassing in frequency of use the more traditional donor sites that confer greater morbidity and more visible harvest site deformity (e.g., radial forearm, rectus abdominus, pectoralis major). This has been accomplished with aggressive perforator flap techniques and flap thinning, as well as novel uses of the ALT fascial or adipofascial flaps . Second, minimal access approaches to expose vessels for microvascular anastomosis have been developed, which avoid increased morbidity and surgical time and also confer the benefit of improved pedicle reach to palatal, nasal, and skull base defects .…”

“…This has been accomplished with aggressive perforator flap techniques and flap thinning, as well as novel uses of the ALT fascial or adipofascial flaps. 5 Second, minimal access approaches to expose vessels for microvascular anastomosis have been developed, which avoid increased morbidity and surgical time and also confer the benefit of improved pedicle reach to palatal, nasal, and skull base defects. 6,7 The greater breadth of defects addressed with free tissue transfer results in a much more diverse patient population, with fewer of the chronic medical issues plaguing the head and neck cancer population.…”

Reconstruction of nasal defects: contemporary approaches

“…All patients had satisfactory nasal contour and patent nasal airways with negligible donor site morbidity. In a subsequent study, they also described the use of anterolateral thigh adipofascial flaps for larger mucosal defects [18]. …”

51 Microvascular and Regional Flaps in Head and Neck Reconstruction

“…Fibers of the brachioradialis originate from the septum itself and must be separated to facilitate identification reconstruction, often being utilized for tongue, laryngopharyngeal, oropharyngeal, maxillary, nasal lining, and external soft tissue defects. 62,63,64 …”

“…70 The temporal the methods of harvest are similar to the conventional method outlined above, except that the adipofascial layer is elevated with a small amount of skin. 63 If the skin-paddle width measures less the 8 cm, the donor site can often be closed primarily.…”