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Unformatted text preview: Anterolateral Thigh Anterolateral Thigh Free Flap Garrett Hauptman M.D. Vicente A. Resto, M.D., Ph.D. University of Texas Medical Branch Department of Otolaryngology Grand Rounds Presentation April 2, 2008 Head & Neck Reconstruction Goals Head & Neck Reconstruction Goals #1 = Wound healing #2 = Function #3 = Cosmesis Reconstructive Ladder Reconstructive Ladder Secondary intention Primary closure Skin grafting Local flaps Distant pedicled flaps Free tissue transfer Overview Overview Anatomy Flap Design Literature Review Comparisons Complications Applications Anatomy of the Leg Anatomy of the Leg Muscular Anatomy Muscular Anatomy Vascular Anatomy Vascular Anatomy Sensory Innervation Sensory Innervation History and History and Emergence Nomenclature Clarification Nomenclature Clarification ALT 1984 ­ Song Lateral Thigh 1983 ­ Baek Anterolateral thigh skin Posterolateral thigh skin Lateral circumflex femoral → Descending branch Profunda femoris → 3rd cutaneous perforator No repositioning Repositioning or flexed internally rotated hip with flexed knee Emergence of the ALT Emergence of the ALT Very popular reconstructive flap in Asia Limited reports of use in Western countries, particularly United States Possible reasons Vascular anatomy variations Difficult dissection Thick thigh fat Creatures of Habitus Creatures of Habitus Workhorse Attributes Workhorse Attributes No repositioning Remote from defect Long pedicle Flap Design Flap Design Tale of the Tape Tale of the Tape Maximum size From horizontal line at greater trochanter to horizontal line 3cm above patella 25cm X 40cm Vascular pedicle Length = 16cm Diameter Artery = 2.1mm Vein = 2.6mm Donor site defect can be closed primarily if width < 8cm Vascular Pedicle Vascular Pedicle Lateral circumflex femoral a. → Descending branch → Perforators Descending branch Perforators: 2 types Runs superior to inferior in intramuscular space between rectus femoris and vastus lateralis Terminates in vastus lateralis just above knee Septocutaneous: run between rectus femoris and vastus lateralis and traverse the fascia lata to skin Musculocutaneous: traverse vastus lateralis and deep fascia to skin Details 8 – 16cm 2 venae commitantes Landmarks Landmarks Line drawn between anterior superior iliac spine (ASIS) and lateral border of patella Approximates septum between rectus femoris and vastus lateralis Skin perforators mapped by Doppler Accuracy decreases as BMI increases Yu P. Plast Reconstr Surg 2006 Perforator Mapping Perforator Mapping 70 pts. Kimata Y. Plast Reconstr Surg 1998 Perforator Mapping Perforator Mapping 72 pts. Yu P. Head Neck 2004 Perforator Mapping Perforator Mapping Most consistently present perforator midway between ASIS and superolateral patella Another perforator may be found more distally and more proximally All within 5cm apart from each other Perforators labeled A, B, and C A = most proximal C = most distal Perforators range between 0 and 3 per patient with 2.04 being the mean per patient 0 = 2% 1 = 22% 2 = 54% 3 = 22% Yu P. Head Neck 2004 Cutaneous Perforator Origin Cutaneous Perforator Origin 3 Different Origins Type I: descending branch of lateral circumflex femoris artery (90%) Type II: single cutaneous perforator originates from the transverse branch of lateral circumflex femoris artery and travels longitudinally in vastus lateralis (4%) Type III: single perforator from profundus femoris artery pierces through rectus femoris (4%) Yu P. Head Neck 2004 Cutaneous Perforator Origin Yu P. Head Neck 2004 Type I Type I Right Thigh Yu P. Head Neck 2004 Type II Type II Left Thigh Yu P. Head Neck 2004 Type III Type III Right Thigh Yu P. Head Neck 2004 Perforator Classification Perforator Classification Type 1 (50%): extends perpendicularly to subdermal plexus Type 2 (35%): branch in adipose and extends to subdermal plexus Type 3 (15%): extend along deep fascia and gradually into adipose Kimura N et al. Plast Reconstr Surg 2001 Flap Harvesting Flap Harvesting Initial skin incision on medial flap aspect Lateral dissection Suprafascial technique for thin flap carried laterally until perforators identified Fasciocutaneous flap (subfascial) involves incision through deep fascia with lateral dissection until perforators identified Flap Harvesting Flap Harvesting Flap Harvesting Flap Harvesting Flap Harvesting Flap Harvesting Skin incisions completed upon perforator identification Retrograde dissection of pedicle to descending branch May involve dissection of vastus lateralis­ cuff of muscle may be left to protect perforating branches Lateral femoral cutaneous nerve of thigh may be used for sensation Thinning performed in deep fat layer to avoid pedicle injury Sensory Innervation Sensory Innervation Lateral femoral cutaneous nerve Direct branch of lumbar plexus (L2­L3) Enters thigh deep to lateral aspect of inguinal ligament near anterior superior iliac spine Follows path of deep circumflex iliac artery and vein Lies along line connecting ASIS to lateral patella Travels in deep subcutaneous layer immediately superficial to deep fascia Sensory Innervation Sensory Innervation Yu P. Head Neck 2004 Flap Composition Flap Composition Subcutaneous Fasciocutaneous Myocutaneous Adipofascial Modifications Modifications Two Independent Flaps Two Independent Flaps Chou EK. Plast Recostr Surg Use of Tissue Expander to Allow Use of Tissue Expander to Allow Primary Closure Hallock G. Ann Plast Surg The Survey Says The Survey Says RF’s “Big Brother” RF’s “Big Brother” 34 consecutive cases 2 flaps with partial necrosis No flap failures No significant donor morbidity Skin Large – 40cm X 25cm Moderately thick Uniform Sensate potential Multipaddle skin potential Lueg E. Arch Otolaryngol Head Neck Surg 2004 Largest Case Series Largest Case Series 672 ALTs in 660 pts. 87% musculocutaneous perforators & 13% septocutaneous perforators 439 flaps cutaneous/fasciocutaneous based on musculocutaneous perforators Flap failure (15) Total = 1.8% Partial = 2.5% Wei F. Plast Reconstr Surg 2002 Septocutaneous –vs­ Septocutaneous –vs­ Musculocutaneous Amount & Type Song 1984 Xu 1988 9 flaps Septocutaneous (%) 100 Musculocutaneous (%) 0 42 cadavers 40 60 Koshima 1989 13 flaps 61.5 38.5 Zhou 1991 32 flaps 37 63 Wolff 1992 100 cadavers 10 90 Pribaz 1995 44 flaps 36 64 Shimizu 1997 41 cadavers 49 51 Kimata 1997 38 flaps 26.3 73.7 Sheih 1998 37 flaps 16.2 83.8 Kimata 1998 70 flaps 18 82 Luo 1999 152 flaps 18 82 Demirkan 2000 59 flaps 12 88 Wei 2002 672 flaps 13 87 Septocutaneous –vs­ Septocutaneous –vs­ Musculocutaneous Amount & Type Song 1984 Xu 1988 9 flaps Septocutaneous (%) 100 Musculocutaneous (%) 0 42 cadavers 40 60 Koshima 1989 13 flaps 61.5 38.5 Zhou 1991 32flaps 37 63 Wolff 1992 100 cadavers 10 90 Pribaz 1995 44 flaps 36 64 Shimizu 1997 41 cadavers 49 51 Kimata 1997 38 flaps 26.3 73.7 Sheih 1998 37 flaps 16.2 83.8 Kimata 1998 70 flaps 18 82 Luo 1999 152 flaps 18 82 Demirkan 2000 59 flaps 12 88 Wei 2002 672 flaps 13 87 ALT Versus ALT Versus ALT –vs­ RF for Intraoral ALT –vs­ RF for Intraoral Defects No functional difference with speech or swallow in 20 pts. – 10 ALT, 10 RF ALT Increased learning curve Primary closure Morbidity related to vastus lateralis damage Potential dysfunction Quadriceps Pain Disto­lateral thigh anesthesia/parasthesia RF Potential tendon exposure Sacrifice dominant distal forearm blood supply Usually close with STSG Potential dysfunction Hand stiffness Pain Anesthesia/parasthesia Farace F. J Plast Reconstr Aesth Surg 2007 Advanced Tongue Cancer Advanced Tongue Cancer Reconstruction: Functional Outcome Chien C. J Cancer Surg Advanced Tongue Cancer Advanced Tongue Cancer Reconstruction: Functional Outcome Chien C. J Cancer Surg 2006 Reconstruction Trends: Reconstruction Trends: Pharyngectomy 153 pharyngectomy pts. 85 partial 68 circumferential Clark J. Laryngoscope Reconstruction Trends: Reconstruction Trends: Pharyngectomy Clark J. Laryngoscope Pharyngoesophageal Pharyngoesophageal Reconstruction: ALT –vs­ Jejunal Flaps 57 circumferential reconstructions 26 ALT & 31 FJT Results Better function Quicker recovery More cost­effective Similar complication rates Yu P. Plast Reconstr Surg 2006 Complications: ALT –vs­ FJT Complications: ALT –vs­ FJT Yu P. Plast Reconstr Surg 2006 TEP Speech: ALT –vs­ FJT TEP Speech: ALT –vs­ FJT ALT = 89% FJT = 22% Yu P. Plast Reconstr Surg 2006 Swallowing: ALT –vs­ FJT Swallowing: ALT –vs­ FJT Yu P. Plast Reconstr Surg 2006 Hospital Course: ALT –vs­ FJT Hospital Course: ALT –vs­ FJT Yu P. Plast Reconstr Surg 2006 New Sensation New Sensation Implications of Sensory Innervation Implications of Sensory Innervation Yu P. Head Neck 2004 Implications of Sensory Innervation Implications of Sensory Innervation Superior sensory recovery in all testing modalities 2 point discrimination Monofilament testing Pain Temperature Improves swallow function Improves patient satisfaction Post­op XRT may delay sensory recovery Yu P. Head Neck 2004 Complications Complications ALT Failure Etiology ALT Failure Etiology Inadvertent perforator division at fascial plane Inadvertent perforator injury during intramuscular dissection Pedicle twisting during inset Vessel size mismatch Celik N. Plast Reconstr Surg 2002 ALT Failure Rates ALT Failure Rates Failure (%) Sheih 2000 2.7 Demirkan 2000 3.3 Wei 2002 2.2 Makitie 2003 2.6 Donor­Site Morbidity Donor­Site Morbidity 37 pts. with free or pedicled ALT 32 primary closure & 5 STSG closure Results Primary closure STSG All normal ADLs 87.5% appearance satisfaction 1 pt. with ↓ ROM 3/5 with ↓ ROM Less appearance satisfaction Sensation deficit in 87.5% of entire group Kimata Y. Plast Reconstr Surg 2000 Donor­Site Morbidity: Donor­Site Morbidity: ALT –vs­ RF 37 pts. : 18 ALT, 19 RF Telephone questionnaire Results Bothered by cold RF: 26% ­vs­ ALT: 0% Shape difference bothersome RF: 32% ­vs­ ALT: 11% Novak C. Microsurgery 2007 Complications Complications Necrosis of lower limb­ case report Obstructed superficial femoral artery by angiography Lateral circumflex femoral artery supplied critical collaterals Importance of checking popliteal pulsations Absence necessitates angiography Hage J. Ann Plast Surg 2004 Post­Operative Complications Post­Operative Complications 23 patients Mureau M. Plast Reconstr Surg Objective Functional and Aesthetic Objective Functional and Aesthetic Follow­up: Recipient Site 14 patients Mureau M. Plast Reconstr Surg 2005 Objective Functional and Aesthetic Objective Functional and Aesthetic Follow­up: Donor Site 14 patients Mureau M. Plast Reconstr Surg 2005 Post­Op Scar Post­Op Scar Flap Smorgasbord Flap Smorgasbord AVM AVM Pre­operative selective embolization Resection & ALT reconstruction 6 months post­embolization Koshima I. Ann Plast Surg 2003 Buccal Mucosa Defects Buccal Mucosa Defects Mouth opening and oral intake preserved Chuang HC. Otolaryngol Head neck Surg Buccal Through­and­Through Buccal Through­and­Through Lower Lip Lower Lip Yildirim S. Plast Reconstr Surg 2006 Pharyngoesophageal Reconstruction Pharyngoesophageal Reconstruction Genden E. Arch Otolaryngol Head Neck Surg 2005 Lateral Skull Base Defects Lateral Skull Base Defects Malata C. Ann Plast Surg 2006 Tongue and FOM Tongue and FOM Agostini V. Brit J Plast Surg Anterior Skull Base Anterior Skull Base Scalp Scalp Calikapan G. Microsurgery Scalp Scalp Combined with Fibula Free Flap Combined with Fibula Free Flap How About Us? How About Us? “We’re Doing ’em” Anterior Skull Base Anterior Skull Base Total Glossectomy­Total Total Glossectomy­Total Laryngectomy Total Glossectomy – Total Total Glossectomy – Total Laryngopharyngectomy Questions Questions Bibliography Bibliography Hallock GG. The preexpanded anterolateral thigh free flap. Ann Plast Surg. 2004 Aug;53(2):170­3. Lueg EA. The anterolateral thigh flap: radial forearm's "big brother" for extensive soft tissue head and neck defects. Arch Otolaryngol Head Neck Surg. 2004 Jul;130(7):813­8. Lin DT, Coppit GL, Burkey BB. Use of the anterolateral thigh flap for reconstruction of the head and neck. Curr Opin Otolaryngol Head Neck Surg. 2004 Aug;12(4):300­4. Review. Rodríguez­Vegas JM, Trillo Bohajar E, Ruiz Alonso E, Casado P érez C. Refining the anterolateral thigh free flap to prevent orocervical fistula in head and neck reconstruction. Plast Reconstr Surg. 2004 Jul;114(1):174­7. No abstract available. Hage JJ, Woerdeman LA. Lower limb necrosis after use of the anterolateral thigh free flap: is preoperative angiography indicated? Ann Plast Surg. 2004 Mar;52(3):315­8. Yu P. Reinnervated anterolateral thigh flap for tongue reconstruction. Head Neck. 2004 Dec;26(12):1038­44. Yu P. Characteristics of the anterolateral thigh flap in a Western population and its application in head and neck reconstruction. Head Neck. 2004 Sep;26(9):759­69. Mäkitie AA, Beasley NJ, Neligan PC, Lipa J, Gullane PJ, Gilbert RW. Head and neck reconstruction with anterolateral thigh flap. Otolaryngol Head Neck Surg. 2003 Nov;129(5):547­55. Hsieh CH, Yang CC, Kuo YR, Tsai HH, Jeng SF. Free anterolateral thigh adipofascial perforator flap. Plast Reconstr Surg. 2003 Sep 15;112(4):976­82. Agostini V, Dini M, Mori A, Franchi A, Agostini T. Adipofascial anterolateral thigh free flap for tongue repair. Br J Plast Surg. 2003 Sep;56(6):614­8. Koshima I, Nanba Y, Tsutsui T, Takahashi Y, Watanabe A, Ishii R. Free perforator flap forthe treatment of defects after resection of huge arteriovenous malformations in the head and neck regions. Ann Plast Surg. 2003 Aug;51(2):194­9. Ross GL, Dunn R, Kirkpatrick J, Koshy CE, Alkureishi LW, Bennett N, Soutar DS, Camilleri IG. To thin or not to thin: the use of the anterolateral thigh flap in the reconstruction of intraoral defects. Br J Plast Surg. 2003 Jun;56(4):409­13. Baek CH, Kim BS, Son YI, Ha B. Pharyngoesophageal reconstruction with lateral thigh free flap. Head Neck. 2002 Nov;24(11):975­81. Lutz BS. Aesthetic and functional advantages of the anterolateral thigh flap in reconstruction of tumor­related scalp defects. Microsurgery. 2002;22(6):258­64. Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin CH. Have we found an ideal soft­tissue flap? An experience with 672 anterolateral thigh flaps. Plast Reconstr Surg. 2002 Jun;109(7):2219­26; discussion 2227­30. Celik N, Wei FC, Lin CH, Cheng MH, Chen HC, Jeng SF, Kuo YR. Technique and strategy in anterolateral thigh perforator flap surgery, based on an analysis of 15 complete and partial failures in 439 cases. Plast Reconstr Surg. 2002 Jun;109(7):2211­6; discussion 2217­8. Rajacic N, Gang RK, Krishnan J, Lal Bang R. Thin anterolateral thigh free flap. Ann Plast Surg. 2002 Mar;48(3):252­7. Cipriani R, Contedini F, Caliceti U, Cavina C. Three­dimensional reconstruction of the oral cavity using the free anterolateral thigh flap. Plast Reconstr Surg. 2002 Jan;109(1):53­7. Kimura N, Satoh K, Hasumi T, Ostuka T. Clinical application of the free thin anterolateral thigh flap in 31 consecutive patients. Plast Reconstr Surg. 2001 Oct;108(5):1197­208; discussion 1209­10. Kim HG, Ha B, Baek CH, Park YJ, Hyon WS, Kim JJ, Shin MS. The short head of the biceps femoris as a monitor for the free lateral thigh flap in pharyngoesophageal reconstruction. Br J Plast Surg. 2001 Jan;54(1):62­6. Kimata Y, Uchiyama K, Ebihara S, Sakuraba M, Iida H, Nakatsuka T, Harii K. Anterolateral thigh flap donor­site complications and morbidity. Plast Reconstr Surg. 2000 Sep;106(3):584­9. Shieh SJ, Chiu HY, Yu JC, Pan SC, Tsai ST, Shen CL. Free anterolateral thigh flap for reconstruction of head and neck defects following cancer ablation. Plast Reconstr Surg. 2000 Jun;105(7):2349­57; discussion 2358­60. Demirkan F, Chen HC, Wei FC, Chen HH, Jung SG, Hau SP, Liao CT. The versatile anterolateral thigh flap: a musculocutaneous flap in disguise in head and neck reconstruction. Br J Plast Surg. 2000 Jan;53(1):30­6. Ao M, Uno K, Maeta M, Nakagawa F, Saito R, Nagase Y. De­epithelialised anterior (anterolateral and anteromedial) thigh flaps for dead space filling and contour correction in head and neck reconstruction. Br J Plast Surg. 1999 Jun;52(4):261­7. Hayden RE, Deschler DG. Lateral thigh free flap for head and neck reconstruction. Laryngoscope. 1999 Sep;109(9):1490­4. Luo S, Raffoul W, Luo J, Luo L, Gao J, Chen L, Egloff DV. Anterolateral thigh flap: A review of 168 cases. Microsurgery. 1999;19(5):232­8. Ha B, Baek CH. Head and neck reconstruction using lateral thigh free flap: flap design. Microsurgery. 1999;19(3):157­65. Kimata Y, Uchiyama K, Ebihara S, Nakatsuka T, Harii K. Anatomic variations and technical problems of the anterolateral thigh flap: a report of 74 cases. Plast Reconstr Surg. 1998 Oct;102(5):1517­23. Truelson JM, Leach JL. Lateral thigh flap reconstruction in the head and neck. Otolaryngol Head Neck Surg. 1998 Feb;118(2):203­10. Bibliography Bibliography Novak CB, Lipa JE, Noria S, Allison K, Neligan PC, Gilbert RW. Comparison of anterolateral thigh and radial forearm free flap donor site morbidity. Microsurgery. 2007;27(8):651­4. Chuang HC, Su CY, Jeng SF, Chien CY. Anterior lateral thigh flap for buccal mucosal defect after resection of buccal cancer. Otolaryngol Head Neck Surg. 2007 Oct;137(4):632­5. Posch NA, Mureau MA, Dumans AG, Hofer SO. Functional and aesthetic outcome and survival after double free flap reconstruction in advanced head and neck cancer patients. Plast Reconstr Surg. 2007 Jul;120(1):124­9. Farace F, Fois VE, Manconi A, Puddu A, Stomeo F, Tullio A, Meloni F, Pisanu G, Rubino C. Free anterolateral thigh flap versus free forearm flap: Functional results in oral reconstruction. J Plast Reconstr Aesthet Surg. 2007;60(6):583­7. Epub 2007 Jan 24. Hurvitz KA, Kobayashi M, Evans GR. Current options in head and neck reconstruction. Plast Reconstr Surg. 2006 Oct;118(5):122e­133e. Review. Yu P, Youssef A. Efficacy of the handheld Doppler in preoperative identification of the cutaneous perforators in the anterolateral thigh flap. Plast Reconstr Surg. 2006 Sep 15;118(4):928­33; discussion 934­5. Malata CM, Tehrani H, Kumiponjera D, Hardy DG, Moffat DA. Use of anterolateral thigh and lateral arm fasciocutaneous free flaps in lateral skull base reconstruction. Ann Plast Surg. 2006 Aug;57(2):169­75; discussion 176. Calderón W, Borel C, Roco H, Piñeros JL, Olguin F. Primary closure of donor site in anterolateral cutaneous thigh free flap. Plast Reconstr Surg. 2006 Jun;117(7):2528­9. No abstract available. Chou EK, Ulusal B, Ulusal A, Wei FC, Lin CH, Tsao CK. Using the descending branch of the lateral femoral circumflex vessel as a source of two independent flaps. Plast Reconstr Surg. 2006 May;117(6):2059­63. Yildirim S, Gideroğlu K, Aydogdu E, Avci G, Akan M, Aköz T. Composite anterolateral thigh­fascia lata flap: a good alternative to radial forearm­palmaris longus flap for total lower lip reconstruction. Plast Reconstr Surg. 2006 May;117(6):2033­41. Spyriounis PK. The extended approach to the vascular pedicle of the anterolateral thigh perforator flap: anatomical and clinical study. Plast Reconstr Surg. 2006 Mar;117(3):997­1001; discussion 1002­3. Yu P, Lewin JS, Reece GP, Robb GL. Comparison of clinical and functional outcomes and hospital costs following pharyngoesophageal reconstruction with the anterolateral thigh free flap versus the jejunal flap. Plast Reconstr Surg. 2006 Mar;117(3):968­74. Calikapan GT, Yildirim S, Aköz T. One­stage reconstruction of large scalp defects: anterolateral thigh flap. Microsurgery. 2006;26(3):155­9. Ozkan O, Mardini S, Chen HC, Cigna E, Tang WR, Liu YT. Repair of buccal defects with anterolateral thigh flaps. Microsurgery. 2006;26(3):182­9. Clark JR, Gilbert R, Irish J, Brown D, Neligan P, Gullane PJ. Morbidity after flap reconstruction of hypopharyngeal defects. Laryngoscope. 2006 Feb;116(2):173­81. Chien CY, Su CY, Hwang CF, Chuang HC, Jeng SF, Chen YC. Ablation of advanced tongue or base of tongue cancer and reconstruction with free flap: functional outcomes. Eur J Surg Oncol. 2006 Apr;32(3):353­7. Epub 2006 Feb 7. Lyons AJ. Perforator flaps in head and neck surgery. Int J Oral Maxillofac Surg. 2006 Mar;35(3):199­207. Epub 2005 Nov 15. Review. Genden EM, Jacobson AS. The role of the anterolateral thigh flap for pharyngoesophageal reconstruction. Arch Otolaryngol Head Neck Surg. 2005 Sep;131(9):796­9. Posch NA, Mureau MA, Flood SJ, Hofer SO. The combined free partial vastus lateralis with anterolateral thigh perforator flap reconstruction of extensive composite defects. Br J Plast Surg. 2005 Dec;58(8):1095­103. Epub 2005 Jul 25. Chen CM, Chen CH, Lai CS, Lin SD, Huang IY, Shieh TY. Anterolateral thigh flaps for reconstruction of head and neck defects. J Oral Maxillofac Surg. 2005 Jul;63(7):948­52. Sekido M, Yamamoto Y, Sugihara T. Arterial blood flow changes after free tissue transfer in head and neck reconstruction. Plast Reconstr Surg. 2005 May;115(6):1547­52. Mureau MA, Posch NA, Meeuwis CA, Hofer SO. Anterolateral thigh flap reconstruction of large external facial skin defects: a follow­up study on functional and aesthetic recipient­ and donor­site outcome. Plast Reconstr Surg. 2005 Apr;115(4):1077­86. ...
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