Anterolateral Thigh Free Flap

TITLE: Anterolateral Thigh Free Flap Transfer
SOURCE: Grand Rounds Presentation, UTMB, Dept. of Otolaryngology
DATE: April 2, 2008
RESIDENT PHYSICIAN: Garrett Hauptmann, M.D.
FACULTY PHYSICIAN: Vicente Resto, M.D., Ph.D.
SERIES EDITORS: Francis B. Quinn, Jr., M.D.

"This material was prepared by resident physicians in partial fulfillment of educational requirements established for the Postgraduate Training Program = of the UTMB Department of Otolaryngology/Head and Neck Surgery and was not intended for clinical use in its present form. It was prepared for the purp= ose of stimulating group discussion in a conference setting. No warranties, eit= her express or implied, are made with respect to its accuracy, completeness, or timeliness. The material does not necessarily reflect the current or past opinions of members of the UTMB faculty and should not be used for purposes= of diagnosis or treatment without consulting appropriate literature sources and informed professional opinion."

The goal of reconstruction in the head and neck involves three fundamental components: wound healing, function, and cosmesis. When deciding which reconstructive option is best suited for a particular patient, the reconstructive ladder must be taken into consideration. These options include healing by secondary intention, primary closure, skin grafting, local flaps, distant pedicled flaps, and free tissue transfer.

The anterolateral thigh free flap (ALT) has emer= ged as a popular option for reconstruction of head and neck defects. It has the attributes of a “workhouse” flap which include absence of patient repositioning, remote locat= ion from the potential defect, and a long pedicle. The ALT was first described by Son= g in 1984. It should be emphasized= that the skin associated with this flap is anterolateral thigh skin and that the pedicle is the descending branch of the lateral circumflex femoral artery.<= span style=3D'mso-spacerun:yes'> This differs from the lateral thig= h flap that was described by Baek in 1983 which involves posterolateral thigh skin= and a pedicle from the third cutaneous perforator off of the profunda femoris.<= span style=3D'mso-spacerun:yes'> After description of the ALT it ma= inly had reported use in Asia. Proposed reasons for this trend we= re vascular anatomy variations, difficult dissection, and thick thigh fat. However, in the last decade, the A= LT has become a popular reconstructive option in Western countries.

In designing an ALT, a line is drawn between the anterior superior iliac spine and the lateral border of the patella. This line approximates the septum between the rectus femoris and the vastus lateralis. Skin perforators are mapped with a Doppler. As mentioned before,= the pedicle is the descending branch of the lateral circumflex femoral artery.<= span style=3D'mso-spacerun:yes'> Perforators come off of the descen= ding branch and are labeled A, B, and C (A is the most proximal and C is the most distal). Perforators range be= tween 0 and 3 per patient with the mean being 2.= The perforators are classified as either septocutaneous or musculocutaneous. Septocutane= ous perforators run between the rectus femoris and vastus lateralis and traverse the fascia lata to the skin. Musculocutaneous perforators traverse the vastus lateralis and deep fascia to the skin. After map= ping the perforators with the Doppler, the skin paddle is planned and an incisio= n is made on the medial aspect. La= teral dissection is performed to locate the perforators. Once the perforators have been identified, the skin incision may be completed. Retrograde dissection of the perfo= rators to the pedicle is performed to the descending branch of the lateral circumf= lex femoral artery. Alterations in harvesting the flap based on the defect size are instituted. The flap may be harvested as a subcutaneous flap, a fasciocutaneous flap, a myocutaneous flap, or an adipofascial flap. Additional= ly, the flap has the ability to be sensate via the lateral femoral cutaneous nerve which comes from L2 and L3.

The largest case series of ALTs was published by Wei. It involved 660 patients= with 672 ALTs. A total of 484 flap= s were transplanted to the head and neck region.&= nbsp; A total of 1.8% had total failure and 2.5% had partial failure. This is consistent with the failur= e rate from other case reports which ranged from 2.2 to 3.3%.

Issues involving the recipient site with ALTs ca= n be divided into functional outcomes and aesthetic outcomes. From a functional perspective, pro= blems encountered include speech problems, oral incompetence, swallowing problems, facial pain, nasal obstruction, and flap contracture. From an aesthetic perspective, pro= blems encountered include flap sagging, color mismatch, hair growth, contour defe= ct, and flap bulkiness. Issues involving the donor site with ALTs can also be divided into functional outc= ome and aesthetic outcome. Functi= onal issues include gait alteration, sensory disturbance, and cold intolerance.<= span style=3D'mso-spacerun:yes'> Aesthetic issues include hypertrop= hic scarring, hypopigmentation/hyperpigmentation, keloid formation, and contour defect.

Comparisons have been made between ALTs and othe= r free flaps from a functional standpoint. Intraoral defects repaired with an ALT versus a radial forearm free = flap show no functional difference regarding swallowing, aspiration, and speech.= Repair of circumferential pharynge= al defects with ALTs compared to jejunal flaps showed better function, quicker recovery, less cost, and similar complication rates with regards to ALTs.

ALTs have recently taken an increased role in he= ad and neck reconstruction. It is a versatile flap with the necessary “workhorse” attributes. The large skin paddle that can be harvested in combination with the potential harvest of muscle allow for reconstruction of large defects. Additionally, it can be a sensate flap. Keeping these facts in mind, ALTs = will likely continue to be a quality reconstructive option for head and neck defects.

BIBLIOGRAPHY

Novak CB, Li= pa JE, Noria S, Allison K, Neligan PC, Gilbert RW. Comparison of anterolateral thigh and radial forearm free flap donor site morbidity. Micr= osurgery. 2007;27(8):651-4.

Chuang HC, Su CY, Jeng SF, Chien CY.= Anterior lateral thigh flap for buccal mucosal defect after resection of buccal canc= er. Otolaryngol Head Neck Surg. 2007 Oct;137(4):632-5.

Posch NA, Mu= reau MA, Dumans AG, Hofer SO. Functional and aesthetic outcome and survival after double free flap reconstruction in advanced head and neck ca= ncer patients. Plast Reconstr Surg. 2007 Jul;120(1):124-9.

Farace F, Fo= is 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):583-7. Epub 2007 Jan 24.=

Hurvitz KA, = Kobayashi M, Evans GR. Current options in head and neck reconstruction. Pl= ast Reconstr Surg. 2006 Oct;118(5):122e-133e. Review.

Yu P, Yousse= f 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):<= span class=3Dpages>928-33; discussion 934-5.

Malata CM, T= ehrani 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):169-75; discussion 176. =

Calder&oacut= e;n 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):2528-9. No abstract available.

Chou EK, Ulu= sal 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):2059-63.

Yildirim S, Gideroğlu K, Aydogdu E, Avci G, Akan M, Aköz T. Compos= ite anterolateral thigh-fascia lata flap: a good alternative to radial forearm-palmaris longus flap for total lower lip reconstruction. Plast Reco= nstr Surg. 2006 May;117(6= ):2033-41.

Spyriounis P= K. The extended approach to the vascular pedicle of the anterolateral thigh perforator flap: anatomical and clinical study. Plast Reconstr Surg. 2006 M= ar;117(3):997-1001; discussion 1002-3.

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):968-74.

Calikapan GT, Yildirim S, Aköz T. One-stage reconstruction of large scalp defects: anterolateral thigh flap. Microsurgery. 2006;= 26(3):155-9.

Ozkan O, Mar= dini S, Chen HC, Cigna E, Tang WR, Liu YT. Repair of buccal defects w= ith anterolateral thigh flaps. Microsurgery. 2006;26(3):182-9.

Clark JR, Gi= lbert R, Irish J, Brown D, Neligan P, Gullane PJ. Morbidity after flap reconstruction of hypopharyngeal defects. Laryngoscope. 2006 Feb;116(2):173-81.

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. Eu= r J Surg Oncol. 2006 Apr;32(3):353-7. Epub 2006 Feb 7.

Lyons AJ. Perforator flaps in head and neck surgery. Int J Oral Maxillofac Surg. 2006 Mar;35(3):199-207. 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 Se= p;131(9):796-9.

Posch NA, Mu= reau MA, Flood SJ, Hofer SO. The combined free partial vastus lateral= is with anterolateral thigh perforator flap reconstruction of extensive compos= ite defects. Br J Plast Surg. 2005 Dec;58(8):1095-103. Epub 2005 Jul = 25.

Chen CM, Che= n 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;<= span class=3Dvolume>63(7):= 948-52.

Sekido M, Ya= mamoto Y, Sugihara T. Arterial blood flow changes after free tissue transfer in head and neck reconstruction. Plast Reconstr Surg. 2005 May;115(6):1547-52.

Mureau MA, P= osch NA, Meeuwis CA, Hofer SO. Anterolateral thigh flap reconstructio= n of large external facial skin defects: a follow-up study on functional and aesthetic recipient- and donor-site outcome. Plast Reconstr Surg. 2005 Apr;= 115(4):1077-86.

Hallock GG.<= /span> The preexpanded anterolateral thigh free flap. Ann Plast Surg. 2004 Aug;53(2):= 170-3.

Lueg EA. The anterolateral thigh flap: radial forearm's "big brother" for extensive soft tissue head and neck defects. Arch Otolaryngol Head Neck Sur= g. 2004 Jul;130(7):813-8.

Lin DT, Copp= it GL, Burkey BB. Use of the anterolateral thigh flap for reconstructio= n of the head and neck. Curr Opin Otolaryngol Head Neck Surg. 2004 Aug;12(4):= 300-4. Review.

Rodrí= guez-Vegas JM, Trillo Bohajar E, Ruiz Alonso E, Casado Pérez C. Refi= ning the anterolateral thigh free flap to prevent orocervical fistula in head and neck reconstruction. Plast Reconstr Surg. 2004 Jul;114= (1):174-7. No abstract avail= able.

Hage JJ, Woe= rdeman LA. Lower limb necrosis after use of the anterolateral thigh free flap: is preoperative angiography indicated? Ann Plast Surg. 2004 Mar;52(3):= 315-8.

Yu P.= Reinnervated anterolateral thigh flap for tongue reconstruction. Head Neck. 2004 Dec;26(12):1038-44.

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):759-69.

Mäkitie= AA, Beasley NJ, Neligan PC, Lipa J, Gullane PJ, Gilbert RW. Head and neck reconstruction with anterolateral thigh flap. Otolaryngol Head Neck Su= rg. 2003 Nov;129(5):547-55.

Hsieh CH, Ya= ng CC, Kuo YR, Tsai HH, Jeng SF. Free anterolateral thigh adipofascial perforator flap. Plast Reconstr Surg. 2003 Sep 15;112<= /span>(4):976-82.

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):= 614-8.

Koshima I, N= anba Y, Tsutsui T, Takahashi Y, Watanabe A, Ishii R. Free perforator = flap for the treatment of defects after resection of huge arteriovenous malformations in the head and neck regions. Ann Plast Surg. 2003 Aug;51(2):= 194-9.

Ross GL, Dun= n 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):= 409-13.

Baek CH, Kim= BS, Son YI, Ha B. Pharyngoesophageal reconstruction with lateral thi= gh free flap. Head Neck. 2002 Nov;24(11):975-81.

Lutz BS. Aesthetic and functional advantages of the anterolateral thigh flap in reconstruction of tumor-related scalp defects. Microsurgery. 2002;22(6):= 258-64.

Wei FC, Jain= V, Celik N, Chen HC, Chuang DC, Lin CH. Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps. Plast Reconstr Surg. 2002 Jun;109(7):2219-26; discussion 2227-30.

Celik N, Wei= FC, Lin CH, Cheng MH, Chen HC, Jeng SF, Kuo YR. Technique and strate= gy in anterolateral thigh perforator flap surgery, based on an analysis of 15 complete and partial failures in 439 cases. Plast Reconstr Surg. 2002 Jun;<= span class=3Dvolume>109(7):2211-6; discussion 2217-8.

Rajacic N, G= ang RK, Krishnan J, Lal Bang R. Thin anterolateral thigh free flap. = Ann Plast Surg. 2002 Mar;48(3):252-7.

Cipriani R, Contedini F, Caliceti U, Cavina C. Three-dimensional reconstruct= ion of the oral cavity using the free anterolateral thigh flap. Plast Reconstr Surg. 2002 Jan;109(1= ):53-7.

Kimura N, Sa= toh K, Hasumi T, Ostuka T. Clinical application of the free thin anterolateral thigh flap in 31 consecutive patients. Plast Reconstr Surg. 2= 001 Oct;108(5):1197-208; discussion 1209-10.

Kim HG, Ha B= , Baek CH, Park YJ, Hyon WS, Kim JJ, Shin MS. The short head of the bic= eps femoris as a monitor for the free lateral thigh flap in pharyngoesophageal reconstruction. Br J Plast Surg. 2001 Jan;54(1):62-6. =

Kimata Y, Uc= hiyama K, Ebihara S, Sakuraba M, Iida H, Nakatsuka T, Harii K. Anterola= teral thigh flap donor-site complications and morbidity. Plast Reconstr Surg. 2000 Sep;106(3):584-9.

Shieh SJ, Ch= iu HY, Yu JC, Pan SC, Tsai ST, Shen CL. Free anterolateral thigh flap f= or reconstruction of head and neck defects following cancer ablation. Plast Reconstr Surg. 2000 Jun;105(7):2349-57; discussion 2358-60.

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 n= eck reconstruction. Br J Plast Surg. 2000 Jan;53(1):30-6. =

Ao M, Uno K,= Maeta M, Nakagawa F, Saito R, Nagase Y. De-epithelialised anterior (anterolateral and anteromedial) thigh flaps for dead space filling and con= tour correction in head and neck reconstruction. Br J Plast Surg. 1999 Jun;52(4):= 261-7.

Hayden RE, Deschler DG. Lateral thigh free flap for head and neck reconstruction. Laryngoscope. 1999 Sep;109(9):1490-4.

Luo S, Raffo= ul W, Luo J, Luo L, Gao J, Chen L, Egloff DV. Anterolateral thigh flap= : A review of 168 cases. Microsurgery. 1999;19(5):232-8.

Ha B, Baek C= H. Head and neck reconstruction using lateral thigh free flap: flap design. Mi= crosurgery. 1999;19(3):157-65.

Kimata Y, Uc= hiyama K, Ebihara S, Nakatsuka T, Harii K. Anatomic variations and technical problems of the anterolateral thigh flap: a report of 74 cases. P= last Reconstr Surg. 1998 Oct;102(5):1517-23.

Truelson JM,= Leach JL. Lateral thigh flap reconstruction in the head and neck. Otol= aryngol Head Neck Surg. 1998 Feb;118(2):203-10.