Free anterolateral thigh flap for reconstruction of head and neck defects following cancer ablation

Thirty-seven consecutive free anterolateral thigh flaps in 36 patients were transferred for reconstruction of head and neck defects following cancer ablation between January of 1997 and June of 1998. The success rate was 97 percent (36 of 37), with one flap lost due to a twisted perforator. The anatomic variations and length of the vascular pedicle were investigated to obtain better knowledge of anatomy and to avoid several surgical pitfalls when it is used for head and neck reconstruction. The cutaneous perforators were always found and presented as musculocutaneous or septocutaneous perforators in this series of 37 anterolateral thigh flaps. They were classified into four types according to the perforator derivation and the direction in which it traversed the vastus lateralis muscle. In type I, vertical musculocutaneous perforators from the descending branch of the lateral circumflex femoral artery were found in 56.8 percent of cases (21 of 37), and they were 4.83 +/- 2.04 cm in length. In type II, horizontal musculocutaneous perforators from the transverse branch of the lateral circumflex femoral artery were found in 27.0 percent of cases (10 of 37), and they were 6.77 +/- 3.48 cm in length. In type III, vertical septocutaneous perforators from the descending branch of the lateral circumflex femoral artery were found in 10.8 percent of cases (4 of 37), and they were 3.60 +/- 1.47 cm in length. In type IV, horizontal septocutaneous perforators from the transverse branch of the lateral circumflex femoral artery were found in 5.4 percent of cases (2 of 37). They were 7.75 +/- 1.06 cm in length. The average length of vascular pedicle was 12.01 +/- 1.50 cm, and the arterial diameter was around 2.0 to 2.5 mm; two accompanying veins varied from 1.8 to 3.0 mm and were suitable for anastomosis with the neck vessels. Reconstruction of one-layer defect, external skin or intraoral lining, was carried out in 18 cases, through-and-through defect in 17 cases, and composite mandibular defect in two cases. With increasing knowledge of anatomy and refinements of surgical technique, the anterolateral thigh flap can be harvested safely to reconstruct complicated defects of head and neck following cancer ablation with only minimal donor-site morbidity.     

Combined anterolateral thigh flap and vascularized fibula osteoseptocutaneous flap in reconstruction of extensive composite mandibular defects.

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.     

Free fibula osteoseptocutaneous-pedicled pectoralis major myocutaneous flap combination in reconstruction of extensive composite mandibular defects

Lateral composite mandibular defects resulting from excision of advanced oral carcinoma often require mandible, intra-oral lining, external face, and soft-tissue bulk reconstruction. Ignorance of importance soft-tissue deficit in those patients may cause significant morbidity and functional loss. Such defects, therefore, can be reconstructed best with a double free flap technique. However, this procedure may not be feasible for every patient or surgeon. An alternative procedure is a free fibula osteoseptocutaneous flap combined with a pedicled pectoralis major myocutaneous flap. This combination was used in reconstruction of extensive composite mandibular defects in 14 patients with T3/T4 oral squamous cell carcinoma. All patients were men, and the average age was 54.3 years. The septocutaneous paddle of the fibula flap was used for the mucosal lining of the defects while the bony part established the rigid mandibular continuity. The pectoralis major flap then covered the external skin defect in the face and cheek, and the dead spaces left by the extirpated masticator muscles, buccal fat, and parotid gland. One free fibula flap failed totally, and one pectoralis major flap developed marginal necrosis. At the time of final evaluation, nine patients (64.3 percent) were alive, surviving an average of 25.7 months. All patients eventually regained their oral continence and an acceptable cosmetic appearance. In conclusion, the fibula osteoseptocutaneous flap plus regional myocutaneous flap choice is a successful and technically less demanding alternative to the double free flap procedures in reconstruction of extensive lateral mandibular defects.     

Intraoral reconstruction with a microvascular peritoneal flap

The microvascular peritoneal flap offers a new reconstructive option for closure of intraoral defects. The flap is easy to raise, and donor-site morbidity is low. Unlike fascial flaps, in which the raw surface may take weeks to "mucosalize," the peritoneal surface heals primarily. Finally, the rectus muscle effectively covers all forms of mandibular reconstruction, and the reliable skin paddle makes possible the closure of substantial cutaneous defects.     

Fibula free flap: a new method of mandible reconstruction

The fibula was investigated as a donor site for free-flap mandible reconstruction. It has the advantages of consistent shape, ample length, distant location to allow a two-team approach, and low donor-site morbidity. It can be raised with a skin island for composite-tissue reconstruction. Twelve segmental mandibular defects (average 13.5 cm) were reconstructed following resection for tumor, most commonly epidermoid carcinoma. Five defects consisted of bone alone, and four others had only a small amount of associated intraoral soft-tissue loss. Eleven patients underwent primary reconstructions. At least two osteotomies were performed on each graft, and miniplates were used for fixation in 11 patients. Six patients received postoperative radiation, and two patients received postoperative chemotherapy. The flaps survived in all patients. All osteotomies healed primarily. The septocutaneous blood supply was generally not adequate to support a skin island for intraoral soft-tissue replacement. The aesthetic result of the reconstruction was excellent in most patients, particularly in "bone only" defects. There was no long-term donor-site morbidity.     

Primary reconstruction of complex midfacial defects with combined lip-switch procedures and free flaps.

Free flaps are generally the preferred method for reconstructing large defects of the midface, orbit, and maxilla that include the lip and oral commissure; commissuroplasty is traditionally performed at a second stage. Functional results of the oral sphincter using this reconstructive approach are, however, limited. This article presents a new approach to the reconstruction of massive defects of the lip and midface using a free flap in combination with a lip-switch flap. This was used in 10 patients. One-third to one-half of the upper lip was excised in seven patients, one-third of the lower lip was excised in one patient, and both the upper and lower lips were excised (one-third each) in two patients. All patients had maxillectomies, with or without mandibulectomies, in addition to full-thickness resections of the cheek. A switch flap from the opposite lip was used for reconstruction of the oral commissure and oral sphincter, and a rectus abdominis myocutaneous flap with two or three skin islands was used for reconstruction of the through-and-through defect in the midface. Free flap survival was 100 percent. All patients had good-to-excellent oral competence, and they were discharged without feeding tubes. A majority (80 percent) of the patients had an adequate oral stoma and could eat a soft diet. All patients have a satisfactory postoperative result. Immediate reconstruction of defects using a lip-switch procedure creates an oral sphincter that has excellent function, with good mobility and competence. This is a simple procedure that adds minimal operative time to the free-flap reconstruction and provides the patient with a functional stoma and acceptable appearance. The free flap can be used to reconstruct the soft tissue of the intraoral lining and external skin deficits, but it should not be used to reconstruct the lip.     

The descending branch of the superficial circumflex artery supplying anteromedial thigh skin

This report presents an extended groin flap design that consists of a conventional skin paddle in the groin region and a vertical extension in the anteromedial thigh region, based on the superficial iliac circumflex artery and an unnamed descending branch, respectively. The inferior branch of the superficial iliac circumflex artery that supplies the thigh extension of the flap, spanning approximately the upper half of the thigh region, was found to originate approximately 2 cm from the origin of the superficial iliac circumflex artery. A total of six free and four local flaps were used in 10 patients with ages ranging from 10 to 60 years (average, 45 years). There were six male and four female patients. The free flaps were required for total facial resurfacing, through-and-through cheek defect, and burn scar contractures and traumatic defects of the lower extremity. The local flaps were used for reconstruction of scrotum defect, trochanteric decubitus ulcer, and lower abdominal skin and fascia defects. All 10 flaps survived completely. The groin flap with anteromedial thigh extension offers the following advantages: (1) it is very easy and quick to elevate; (2) a significantly increased volume of tissue is available for reconstruction, based on one axial vessel and being completely reliable; (3) the flap offers two skin paddles that are independently mobile; (4) there is no need for positional change and a two-team approach is possible; and (5) it can be raised as a vertical skin island only. The authors conclude that the groin flap with anteromedial thigh extension is a useful modification for reconstruction of both distant and local defects.     

Mandibular reconstruction in the radiated patient: the role of osteocutaneous free tissue transfers

This paper discusses our experience with the second metatarsal and iliac crest osteocutaneous transfers for mandibular reconstruction. The prime indication for this type of reconstruction was for anterior mandibular defects when the patient had been previously resected. Midbody to midbody defects were reconstructed with the metatarsal and larger defects with the iliac crest. In most cases, an osteotomy was done to create a mental angle. The evaluation of speech, oral continence, and swallowing revealed good results in all patients unless lip or tongue resection compromised function. Facial contour was excellent in metatarsal reconstructions. The iliac crest cutaneous flap provided a generous supply of skin for both intraoral reconstruction and external skin coverage but tended to be bulky, particularly when used in the submental area. Thirty three of 36 flaps survived completely. Flap losses were due to anastomosis thrombosis (1), pedicle compression (1), and pedicle destruction during exploration for suspected carotid blowout (1). Ninety three percent of bone junctions developed a solid bony union despite the mandible having had a full therapeutic dose of preoperative radiation. Despite wound infections in 8 patients, and intraoral dehiscence with bone exposure in 12 patients, all but one of these transfers went on to good bony union without infection in the bone graft.     

Double-paddle peroneal tissue transfer for oromandibular reconstruction

The double-paddle peroneal tissue transfer is a useful technique for reconstructing the extensive and complex defect that results after ablative surgery for oral cancer. It can facilitate the design and inset of the skin paddle and avoid the need for a second free flap. The two skin paddles can be based on either two cutaneous perforators of the peroneal vessels or two branches of a single cutaneous perforator. The authors report their experience with double-paddle peroneal tissue flaps (10 fasciocutaneous and five osteocutaneous) in 15 patients. The largest double paddle used was (16 x 9) (15 x 6) cm, and the smallest one was (7 x 5.5) (4.5 x 4) cm. All flaps were used for both intraoral and extraoral defect reconstruction. There was one single skin paddle necrosis caused by erroneous manipulation of the flap 1 week after the operation; however, the skin paddle had survived completely before the manipulation. All other flaps survived completely, with a good to excellent appearance, and no patient had a significant gait disturbance after the operation.     

Neuromucosal prelaminated flaps for reconstruction of intraoral lining defects after radical tumor resection

To reconstruct intraoral lining defects after radical tumor resection by reinnervated vascularized mucosa, eight distal radial forearm flaps and two fibula flaps were prelaminated. Prelamination was performed by exposing the vascularized fascia, onto which the split distal end of a sural graft was fixed. The fascia and the sural nerve graft were covered by device-meshed mucosa or small full-thickness mucosa pieces. These structures again were covered by a Silastic sheet as large as the future flap, and the wound was closed by the elevated skin and subcutaneous tissue. Coverage by a Silastic sheet enabled mucosal spreading on the fascia, and the final flaps were thin, mucus-producing, and larger than the originally inserted mucosa. The 10 neuromucosal prelaminated flaps were harvested together with the inserted sural nerve graft after 8 to 10 weeks. During this time, the patient underwent radiotherapy and chemotherapy. Donor sites were closed directly by the preserved skin and subcutaneous tissue. Intraoral defects were reconstructed successfully by eight neuromucosal prelaminated distal radial forearm flaps and two neuromucosal prelaminated fibula flaps. The sural nerve grafts, inserted between the fascia and the mucosa, were coaptated eight times with the lingual nerve and two times with the inferior alveolar nerve. Intended reinnervation of the mucosa could already be proved clinically and histologically in the first two patients after 11 and 9 months. Preservation of skin and subcutaneous tissue considerably lowered donor-site morbidity. Neuromucosal prelamination enables reconstruction of intraoral lining defects by reinnervated mucus-producing tissue. Reconstruction of other mucosa-lined structures by this method seems feasible. Avoidance of skin islands for reconstruction lowers donor-site morbidity.     

Fibular osteoseptocutaneous flap: anatomic study and clinical application

The vascularized fibular graft has been expanded to an osteoseptocutaneous flap by including a cutaneous flap on the lateral aspect of the lower leg. The cutaneous flap can serve not only for postoperative monitoring of the grafted fibula, but also as extra skin coverage to replace substantial skin defects or prevent tight closure of the wound. From anatomic studies of 20 cadaver legs and 15 clinical cases, it has been possible to demonstrate adequate circulation to the skin of the lateral aspect of the lower leg from the septocutaneous branches of the peroneal artery alone. This finding has allowed the development of a new concept and technique to elevate the fibula as an osteoseptocutaneous flap for reconstruction which provides the following advantages: Elevation of the fibular osteoseptocutaneous unit is easy and fast. The cutaneous flap of the fibular osteoseptocutaneous unit can slide almost freely while attached to the paper-thin posterior crural septum without being tethered by a bulky muscle cuff, facilitating the setting of the fibular osteocutaneous flap when the bone and skin are widely separated. Intraoperatively, in a situation in which it is necessary to change from originally selected recipient vessels to ones more suitable, the thin posterior crural septum can be folded around the fibula allowing more flexibility in choice of recipient vessels. The fibular osteoseptocutaneous flap meets the criteria outlined for composite tissue reconstruction of defects of the extremities.(ABSTRACT TRUNCATED AT 250 WORDS)     

Reconstruction of concomitant lip and cheek through-and-through defects with combined free flap and an advancement flap from the remaining lip

Massive facial defects involving the oral sphincter are challenging to the reconstructive surgeon. This study presents the authors' approach to simultaneous reconstruction of complex defects with an advancement flap from the remaining lip and free flaps. From January of 1997 to December of 2001, 22 patients were studied following ablative oral cancer surgery. Their ages ranged from 32 to 66 years. Nineteen patients had buccal cancer, two patients had tongue cancer, and one patient had lip cancer. In all cases, the disease was advanced squamous cell carcinoma. Nine patients underwent composite resection of tumor with segmental mandibulectomy, and seven patients underwent marginal mandibulectomy. Cheek defects ranged from 15 x 12 cm to 4 x 3 cm, and intraoral defects ranged from 14 x 8 cm to 5 x 4 cm in size. One third of the lower lip was excised in nine patients, both the upper and lower lips were excised in 10 patients, and only commissure defects were excised in three patients. An advancement flap from the remaining upper lip was used for reconstruction of the oral commissure and oral sphincter. Then, the composite through-and-through defect of the cheek was reconstructed with radial forearm flaps in 13 patients, fibula osteocutaneous flaps in five patients, double flaps in three patients, and an anterolateral thigh flap in one patient. The free flap survival rate was 96 percent, and only one flap failed. With regard to complications, there were two patients with cheek hematoma, six patients with orocutaneous fistula or neck infection, and one patient with osteomyelitis of the mandible. All but one patient had adequate oral competence. All patients had an adequate oral stoma and could eat a regular or soft diet; two patients could eat only a liquid diet. For moderate lip defects, immediate reconstruction of complex defects took place using an advancement flap from the remaining lip to obtain a normal and functional oral sphincter; the free flap can be used to reconstruct through-and-through defects. This simple procedure can provide patients with a useful oral stoma and acceptable cosmesis.     

Reconstruction of through-and-through cheek defects involving the oral commissure, using chimeric flaps from the thigh lateral femoral circumflex system

Repairing full-thickness cheek defects involving the oral commissure in the head and neck regions after tumor resection is a challenge for reconstructive surgeons. First, they are usually relatively large defects. Second, the axes of the cheek and intraoral lining are different from each other. Third, the shape and volume of the defect and the oral sphincter should be considered individually. Lateral femoral circumflex perforator flaps with at least two independent cutaneous perforators are suitable for reconstruction of such a defect in one stage. In this study, between January and December of 1999, a total of nine patients underwent reconstruction with chimeric lateral femoral circumflex perforator flaps immediately after resection of their oral cancers. The average age of the patients was 61 years (range, 42 to 74 years). The oral lining defects were between 5 x 5 cm and 6 x 12 cm in size, whereas the cheek defects were between 5 x 6 and 8 x 12 cm. Fifteen flaps were supplied by one perforator, and three flaps were supplied by two perforators. There were nine single arterial anastomoses, eight single venous anastomoses, and one double venous anastomosis. There were no total flap failures. One case of postoperative venous congestion was successfully treated by a second venous anastomosis. The average duration of hospitalization was 31.8 days (range, 18 to 49 days). The median follow-up time was 8.6 months, and all patients were alive at the time of evaluation. Six of nine patients had satisfactory or good contours of the cheek. Five of nine patients had normal deglutition. Six of nine patients had adequate oral continence. Compared with other free flaps, use of the combined (chimeric) lateral femoral circumflex perforator flaps for the reconstruction of cheek through-and-through defects involving the oral commissure has several advantages: (1) easy three-dimensional insetting, (2) a unique character suitable for the requirements of the oral lining and cheek skin to achieve good aesthetic appearance, (3) functional preservation of the oral sphincter and the resistance of gravity by use of the tensor fasciae latae, (4) minimal donor-site morbidity, (5) economic design, and (6) no need for microsurgical fabrication, because major vascular branches such as the transverse branch, the ascending branch, and the feeding branch to the rectus femoris muscle are not sacrificed in the procedure. The disadvantages of these flaps include (1) the complicated anatomy of the perforators, (2) the learning-curve requirement for their use, and (3) the occasional need for secondary venous drainage and shifts to double flaps. Although there are some difficulties, it was concluded that use of the chimeric lateral femoral circumflex perforator flaps in the selected cases is one of the good options available for the reconstruction of cheek through-and-through defects involving the oral commissure.     

One-stage reconstruction of composite bone and soft-tissue defects in traumatic lower extremities

Management of bone loss that occurs after severe trauma of open lower extremity fractures continues to challenge reconstructive surgeons. Sixty-one patients who had 62 traumatic open lower extremity fractures and combined bone and composite soft-tissue defects were treated with the following protocol: extensive debridement of necrotic tissues, eradication of infection, and vascularization of osteocutaneous tissue for one-stage bone and soft-tissue coverage reconstruction. The mechanism of injury included 49 motorcycle accidents (80.3 percent), five falls (8.2 percent), three crush injuries (4.9 percent), two pedestrian-automobile accidents (3.3 percent), and two motor vehicle accidents (3.3 percent). The bone defects were located in the tibia in 49 patients (79 percent; one patient had bilateral open tibial fractures), in the femur in seven patients (11.3 percent), in the calcaneus bone in four patients (6.5 percent), and in the metatarsal bones in two patients (3.2 percent). The size of soft-tissue defects ranged from 5 x 9 cm to 30 x 17 cm. The average length of the preoperative bony defect was 11.7 cm. The average duration from injury to one-stage reconstruction was 27.1 days, and the average number of previous extensive debridement procedures was 3.4. Fifty patients had vascularized fibula osteoseptocutaneous flaps, six had vascularized iliac osteocutaneous flaps, and five patients had seven combined vascularized rib transfers with serratus anterior muscle and/or latissimus dorsi muscle transfers. One patient received a second combined rib flap because the first combined rib flap failed. The rate of complete flap survival was 88.9 percent (56 of 63 flaps). Two combined vascularized rib transfers with serratus anterior muscle and latissimus dorsi muscle flaps were lost totally (3.2 percent) because of arterial thrombosis and deep infection, respectively. Partial skin flap losses were encountered in the five fibula osteoseptocutaneous flaps (7.9 percent). Postoperative infection for this one-stage reconstruction was 7.9 percent. Excluding the failed flap and the infected/amputated limb, the primary bony union rate after successful free vascularized bone grafting was 88.5 percent (54 of 61 transfers). The average primary union time was 6.9 months. The overall union rate was 96.7 percent (59 of 61 transfers). The average time to overall union was 8.5 months after surgery. Seven transferred vascularized bones had stress fractures, for a rate of 11.5 percent. Donor-site problems were noted in six fibular flaps, in two iliac flaps, and in one rib flap. The fibular donor-site problems were foot drop in one patient, superficial peroneal nerve palsy in one patient, contracture of the flexor hallucis longus muscle in two patients, and skin necrosis after split-thickness skin grafting in two patients. The iliac flap donor-site problems were temporary flank pain in one patient and lateral thigh numbness in the other. One rib flap transfer patient had pleural fibrosis. Transfer of the appropriate combination of vascularized bone and soft-tissue flap with a one-stage procedure provides complex lower extremity defects with successful functional results that are almost equal to the previously reported microsurgical staged procedures and conventional techniques.     

Blood supply to osteocutaneous free fibula flap and peroneus longus muscle: prospective anatomic study and clinical applications.

From January of 1998 to December of 1999, a total of 24 fibula free flaps in 24 patients were evaluated in a prospective clinical study. Once the perforators were identified, they were dissected toward the parent vessel and labeled according to type. The soleus and flexor hallucis longus muscles of the fibula were dissected, and the proximal part of the pedicle was reached. Subsequently, the configuration of all muscular branches to the peroneus muscle was studied. The types of skin perforators of the peroneal artery were noted as septocutaneous, musculocutaneous, or septomusculocutaneous. A total of 86 perforators were identified in 24 legs. The average number of perforators per leg was 3.58 +/- 0.71. Among them, 22 were musculocutaneous, 31 were septomusculocutaneous, and were 33 septocutaneous. The septocutaneous branches were significantly more distal than the musculocutaneous and septomusculocutaneous perforators. Eight perforators were identified 25 cm distal from the fibular head and six were identified at 15 cm. Five perforators were then identified at each distance of 8, 12, 19, and 22 cm distal from the fibular head. The total number of muscular branches to the peroneus longus was 62, with an average of 2.58 +/- 0.45. Most muscular branches were found between 8 and 16 cm distal to the fibular head. Nine branches were identified at 13 cm distal to the fibular head, eight at 9 cm, and seven at 12 cm. The number of dominant branches with the largest diameter was seven at 13 cm distal from the fibular head, five at 12 cm, five at 16 cm, and two at 11 cm. In summary, when designing an osteocutaneous free fibula flap 10 to 20 cm from the fibular head, it is recommended that a soleus and flexor hallucis longus muscle cuff be included to incorporate these perforators. In contrast, when designing a flap 20 to 30 cm from the fibular head, it is possible to elevate the flap without incorporating the soleus or flexor hallucis muscles.     

Outcome comparison in traumatic lower-extremity reconstruction by using various composite vascularized bone transplantation

Lower-extremity injury may present as a composite soft-tissue and bone defect, resulting directly from trauma or subsequent debridements. These composite defects often require vascularized osteocutaneous flaps for an effective, staged reconstruction. Among various donor sites, the vascularized fibular flap is generally considered the best option because of its inherent advantages. However, when the fibular flap is not available, iliac and rib flaps become the alternative choices. The purpose of this retrospective study was to compare the functional results of the alternatively chosen bone flaps (iliac and rib flaps) with those of the fibular flaps.     

Orofacial and mandibular reconstruction with the iliac crest free flap: a review of 60 cases and a new method of classification

Sixty vascularized iliac crest free-tissue transfers were used for oromandibular reconstruction, 46 as osteocutaneous and 14 as osseous flaps. Forty-one patients had preoperative radiotherapy, and 8 had failed previous attempts at reconstruction. Forty-nine of the 60 reconstructions were carried out primarily, most commonly following ablative surgery for radiorecurrent squamous carcinoma. Ages ranged from 19 to 85 years, and follow-up ranged from 2 months to 5 years. Flap survival was 95 percent. Eight-six percent of patients returned to their previous activities. There were 2 perioperative deaths, and 31 patients were alive at follow-up. Horizontal defects from 5 to 16 cm were reconstructed, and in 22 patients, both oral lining and skin coverage were replaced. Radiographic evidence of bone union was noted in 96 percent of synostoses, and clinical union was seen in all but one patient. One patient required bilateral hemimandibular reconstructions for sequential primaries at different operative sittings. Functional and cosmetic results were generally satisfactory and were excellent in bone-only reconstructions. Several surgical principles evolved to minimize bulk and eliminate the need for intermaxillary fixation or external fixation postoperatively. To improve results in large or more lateral through-and-through defects, an accessory pectoralis musculocutaneous flap proved advantageous. Cosmetic and functional results depend largely on three factors: the extent of the surgery, the leanness of the patient, and his or her position on the surgical learning curve.     

Free anterolateral thigh adipofascial perforator flap

The anterolateral thigh adipofascial flap is a vascularized flap prepared from the adipofascial layer of the anterolateral thigh region. It is a perforator flap based on septocutaneous or musculocutaneous perforators of the lateral circumflex femoral system. With methods similar to those used for the free anterolateral thigh flap, only the deep fascia of the anterolateral thigh and a 2-mm-thick to 3-mm-thick layer of subcutaneous fatty tissue above the fascia were harvested. In 11 cases, this flap (length, 5 to 11 cm; width, 4 to 8 cm) was used for successful reconstruction of extremity defects. Split-thickness skin grafts were used to immediately resurface the adipofascial flaps for eight patients, and delayed skin grafting was performed for the other three patients. The advantage of the anterolateral thigh adipofascial flap is its ability to provide vascularized, thin, pliable, gliding coverage. In addition, the donor-site defect can be closed directly. Other advantages of this flap, such as safe elevation, a long wide vascular pedicle, a large flap territory, and flow-through properties that allow simultaneous reconstruction of major-vessel and soft-tissue defects, are the same as for the conventional anterolateral thigh flap. The main disadvantage of this procedure is the need for a skin graft, with the possible complications of subsequent skin graft loss or hyperpigmentation.     

Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps

The free anterolateral thigh flap is becoming one of the most preferred options for soft-tissue reconstruction. Between June of 1996 and August of 2000, 672 anterolateral thigh flaps were used in 660 patients at Chang Gung Memorial Hospital. Four hundred eighty-four anterolateral thigh flaps were used for head and neck region recontruction in 475 patients, 58 flaps were used for upper extremity reconstruction in 58 patients, 121 flaps were used for lower extremity reconstruction in 119 patients, and nine flaps were used for trunk reconstruction in nine patients. Of the 672 flaps used in total, a majority (439) were musculocutaneous perforator flaps. Sixty-five were septocutaneous vessel flaps. Of these 504 flaps, 350 were fasciocutaneous and 154 were cutaneous flaps. Of the remaining 168 flaps, 95 were musculocutaneous flaps, 63 were chimeric flaps, and the remaining ten were composite musculocutaneous perforator flaps with the tensor fasciae latae. Total flap failure occurred in 12 patients (1.79 percent of the flaps) and partial failure occurred in 17 patients (2.53 percent of the flaps). Of the 12 flaps that failed completely, five were reconstructed with second anterolateral thigh flaps, four with pedicled flaps, one with a free radial forearm flap, one with skin grafting, and one with primary closure. Of the 17 flaps that failed partially, three were reconstructed with anterolateral thigh flaps, one with a free radial forearm flap, five with pedicled flaps, and eight with primary suture, skin grafting, and conservative methods.In this large series, a consistent anatomy of the main pedicle of the anterolateral thigh flap was observed. In cutaneous and fasciocutaneous flaps, the skin vessels (musculocutaneous perforators or septocutaneous vessels) were found and followed until they reached the main pedicle, regardless of the anatomic position. There were only six cases in this series in which no skin vessels were identified during the harvesting of cutaneous or fasciocutaneous anterolateral thigh flaps. In 87.1 percent of the cutaneous or fasciocutaneous flaps, the skin vessels were found to be musculocutaneous perforators; in 12.9 percent, they were found as septocutaneous vessels. The anterolateral thigh flap is a reliable flap that supplies a large area of skin. This flap can be harvested irrespective of whether the skin vessels are septocutaneous or musculocutaneous. It is a versatile soft-tissue flap in which thickness and volume can be adjusted for the extent of the defect, and it can replace most soft-tissue free flaps in most clinical situations.     

Free split-cutaneous perforator flaps procured using a three-dimensional harvest technique for the reconstruction of postburn contracture defects

With recent advances in free-tissue transfer, microsurgical techniques have been used more frequently for the reconstruction of postburn contracture defects. Traditional methods, including full-thickness skin grafts and local flaps, often result in a good outcome; however, multiple operative procedures, long periods of splinting, and physical rehabilitation are often required. Free split-cutaneous perforator flaps, consisting of one large cutaneous paddle with two perforating vessels split into two separate skin regions, were used for two kinds of postburn contractures: rectangular and spatially separate defects. From September of 2000 to October of 2002, seven patients underwent this method of reconstruction at Chang Gung Memorial Hospital in Taiwan. A three-dimensional flap harvest method, in which the skin paddle is circumferentially elevated early in the harvest, was used. Postburn scar contractures had resulted from flame burns in six cases and an electric burn in one case. The reconstructive regions included the neck in two patients, the breast in one patient, and the hand in four patients. There were six male patients and one female patient, with a mean age of 34.8 years (range, 25 to 49 years). The size of the excised scar ranged from 120 cm2 to 308 cm2 (mean, 162.3 cm2). The size of the unsplit flaps ranged from 144 cm2 to 337.5 cm2 (mean, 192.1 cm2). The average time for flap harvest using this three-dimensional harvest technique was 39.1 minutes. The average total operative time was 4.3 hours. The average total hospital stay was 7.3 days (range, 6 to 11 days). All flaps survived without major complications. The donor site was closed primarily in all cases. At a mean follow-up time of 9 months, the functional and aesthetic outcomes showed significant improvement as compared with the preoperative condition. In this study, a new method of flap harvest using a three-dimensional technique is introduced, and its application in the reconstruction of postburn contractures is evaluated.