Combined Anterolateral Thigh Flap and Vascularized Fibula Osteoseptocutaneous Flap in Reconstruction of Extensive Composite Mandibular Defects

Abstract

Extensive composite defects of the oromandibular area are usually created after the surgical treatment of T3 and T4 cancers, requiring complex reconstructive plastic surgical procedures. The preferred treatment method for this type of defect is reconstruction with two free flaps. The use of the vascularized fibula osteoseptocutaneous flap for the bone and inner lining defect is well known and accepted. Among the flaps that can be used for the outer lining and soft-tissue reconstruction, the two most commonly used have been the forearm flap and the rectus abdominis myocutaneous flap. However, these flaps have some disadvantages that restrict their use for this purpose. The forearm flap is usually too thin to cover the fibular bone and reconstruction plate, and the rectus abdominis myocutaneous flap can cause a subclinical reduction in abdominal strength. Both radial forearm and rectus abdominis myocutaneous flaps are difficult to harvest during tumor excision. Because of these drawbacks, over the past several years the authors have preferred to use the anterolateral thigh flap for outer face, neck, and submandibular region reconstructions. From October of 1998 to June of 2000, 22 extensive composite mandibular defect reconstructions using the free anterolateral thigh flap, combined with the vascularized free fibula osteoseptocutaneous flap, were performed at the Chang Gung Memorial Hospital. Complete flap survival was 90.9 percent (40 of 44 flaps). Complete loss was seen in an anterolateral thigh flap, which was then reconstructed with a pectoralis major myocutaneous pedicled flap (2.3 percent). There were five venous problems: three in osteoseptocutaneous free fibula flaps, the other two in anterolateral thigh flaps; all were revised immediately. However, the skin islands of two osteoseptocutaneous free fibula flaps and one anterolateral thigh flap developed partial necrosis (6.8 percent). The other complications were compartment syndrome in the leg in one patient, external carotid artery rupture in one patient, three donor-site infections in two patients, three neck wound infections, and one myocardial insufficiency; all were treated properly. Thirteen patients underwent revision procedures 6 months after the first operation. These procedures included debulking of the flap or revision of the mouth angle or both. Trismus or intraoral contraction was noted in none of these patients. In conclusion, the free anterolateral thigh flap combined with the vascularized fibula osteoseptocutaneous flap seems to be a good choice in the reconstruction of the extensive composite defects of the oromandibular region aesthetically and functionally.

A systematic review of anterolateral thigh flap donor site morbidity

“…Most authors quote a maximum width for a primary closure of the donor site of 8 cm to 10 cm (3,7,25,(35)(36)(37)39,42); however, wider defects have been closed, such as a reported 12 cm defect in a patient with a relatively large thigh circumference secondary to a high body mass index (3). A primarily closed donor site may result in a long scar, but it is usually more aesthetically pleasing than when closed with a skin graft, which is commonly done if a donor site defect is too wide to safely close without significant tension (32,39).…”

“…A primarily closed donor site may result in a long scar, but it is usually more aesthetically pleasing than when closed with a skin graft, which is commonly done if a donor site defect is too wide to safely close without significant tension (32,39). This aesthetic issue may preclude the use of this flap in the female population, and this issue must thoroughly be discussed during informed consent (16).…”

“…T he anterolateral thigh (ALT) flap, first described as a septocutaneous perforator-based flap by Song et al (1) in 1984, has recently gained popularity and has become an important option for reconstruction of multiple anatomical locations such as the head and neck (3)(4)(5)(6)(7)9,10,(12)(13)(14)16,(18)(19)(20)(21)(22)(23)(25)(26)(27)(28)(29)(30)32,34,36,38,39,(41)(42)(43), upper (15)(16)(17)(18)(19)26,32,35,37,38,42) and lower (8,(16)(17)(18)(19)22,24,…”

Multipaddled anterolateral thigh chimeric flap for reconstruction of complex defects in head and neck

“…Kimata et al [17] and Wei et al [18] considered that 2 to 3 cutaneous perforators can be found to run through the medial edge of vastus lateralis. From our experience and the work of others, at least 1 suitable cutaneous perforator could be always found [19]. The first perforator with the largest diameter can be always found to exit within a 5-cm-diameter circle centered at the midpoint of the line between the anterior superior iliac crest and the superolateral border of the patella.…”

Reconstrucción compleja de la cavidad oral mediante dos colgajos simultáneos de peroné y radial

“…Cada vez existen más aportaciones en la bibliografía donde se utilizan dos colgajos para solucionar el problema de las reconstrucciones oromandibulares complejas. 1,2,[5][6][7][8][9][10][11] La combinación de varios colgajos pretende suplir los defectos que puede tener una reconstrucción única en defectos complejos. Cada colgajo se selecciona independientemente por sus características que lo hacen ideal para cada tipo de defecto, óseo y de partes blandas con la finalidad de conseguir un resultado estético y funcional superior a la utilización de un solo colgajo.…”