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.