Current roles of adipofascial anterolateral thigh flap in head and neck reconstructions

To the Editor: It is with interest that we read the article published by Wong and Wei, titled ‘‘Anterolateral Thigh Flap,’’ in the May issue of Head and Neck. The report is focused on technical aspects regarding vascular and surgical anatomy and pitfalls of harvesting, giving an almost unique guide to flap rising. The anterolateral thigh (ALT) flap can be classified in different clinical configurations equipped with well-defined indications based on the receiving site: fasciocutaneous, myocutaneous, and cutaneous. The cutaneous variant of this flap is harvested as thinned or ultrathinned, depending on the defatting procedures, and its main advantage relies on the preservation of the deep fascia, reducing the risk for muscle herniation. Because of the thinning procedures and the possibility of harvesting a sensate flap (the lateral cutaneous femoral nerve), the flap is ideal for reconstructing oral cavity defects. This flap can be harvested as a flow-through type 1 and type 2, making it feasible to reconstruct through-and-through defects of the mandible. In 2003 V. Agostini and colleagues pioneered the concept of adipofascial anterolateral thigh (AALT) flap in oral cavity reconstruction: the first report describes a hemiglossectomy defect reconstructed with an adipofascial ALT flap. The A-ALT flap is harvested as a fasciocutaneous ‘‘leaf shape’’ flap with 1to 2-cm fascia around the pedicle to preserve the fascial plexus because the main blood supply to the skin arises from the outer fascial layer, passing as fasciocutaneous or muscolocutaneous perforators with branches perpendicularly oriented or radiated. The flap is thinned to fit the defect resulting from tumor excision (extreme thinning should be avoided in anticipation of postoperative radiotherapy), and meticulous hemostasis is achieved before pedicle section. The main portion of the flap is reversesutured in the oral cavity at the level of the lamina propria of the native mucosa to obtain obstacle-free advancement of the neomucosa over the deep fascia. The vascular pedicle is tunneled into the neck well protected from saliva. The A-ALT flap represents a valid alternative to oral cavity reconstruction, supplying a functional, hairless tissue 45 days later, observing the principle of ‘‘replace tissue with like tissue’’ and avoiding the ‘‘patch effect’’ of fasciocutaneous flaps. The idea of reconstructing oral cavity defects using fascial flaps has been previously tested by others who studied the remucosalization of the myofascial pectoralis major flap. The histologic results proved the flap was covered with a thin layer of squamous mucosa 1 month after surgery not influenced by postoperative radiotherapy. Flap thinning has had a major impact in the Western countries compared with Eastern countries because of the higher incidence of obesity in the West. Alkureishi and colleagues experienced partial or total necrosis of the distal skin from the perforator of thinned fasciocutaneous ALT flaps to oral cavity reconstructions, probably attributable to saliva interference with the subdermal plexus. A-ALT advantages include volume preservation over time, thus maintaining the palatal contact and the propulsive proprieties of a neo-tongue enhancing the residual mobility and re-creation of the hyoid mandibular tension arch with improved stability of the larynx–hyoid bone complex. Because neomucosa is a functional tissue, the lateral cutaneous femoral nerve dissection can be avoided. It does not preclude muscle harvesting (vastus lateralis/rectus medialis) in the mioadipofascial configuration for more demanding reconstructions. Moreover, the A-ALT flap avoids prelamination with unjustified delayed tumor resection and double-paddle flaps to throughand-through defects of the cheek and the floor of the mouth. Twelve patients underwent reconstruction with the A-ALT flap after squamous cell carcinoma resection of the oral cavity between December 2005 and August 2010 (Table 1). All patients underwent postoperative radiotherapy with flap volume and function maintenance. To limit wound contraction and impaired function, we always dissected more fascia compared with soft tissue. Thinning was uneventful, without partial or marginal necrosis, and we did not experience fascial slough that required debridement. One patient presented a scarring bridle without functional loss after reconstruction of the entire mobile tongue, which did not require surgery, and patient 4 had an orocutaneous fistula with spontaneous healing. One flap failed as the result of venous thrombosis, despite re-exploration. All underwent comparative biopsies (colored with hematoxylin and eosin stain) between the neomucosa and the native mucosa, showing a squamous epithelial lining and a mild inflammatory infiltrate charged to the lamina propria. Our results show the hot, cold, and touch sensitivities of Head & Neck 33: 595–597, 2011 Published online 7 March 2011 in Wiley Online Library (wileyonlinelibrary.com) DOI 10.1002/hed.21710 VC 2011 Wiley Periodicals, Inc.