Triple skin island fibula free flap: a good choice for combined mandible and tongue defect reconstruction

Resections of malignant tumors involving the mandible and anterior tongue result in complex defects that are still real challenges for reconstructive surgeons. Whereas there are preferred methods for mandible reconstruction involving isolated or limited loss of soft tissues, there are no standards for extended bone-soft tissue intraoral defects. This article documents the modification of the fibula free flap where triple skin islands are used for reconstruction of anterior tongue and floor of the mouth. The technique also includes filing the submandibular space with an isolated part of the flexor hallucis longus muscle, based on individual perforator. The details of flap designing, harvesting, and insetting are also presented. Eight such reconstructions have been performed on patients who underwent complex resection of the anterior mandible together with the mobile part of the tongue. Flap survival rate was 100%. In all eight cases, understandable speech and return to unrestricted diet mastication and swallowing were achieved. Analysis of aesthetic effects showed generally very good results. The presented modification of fibula free flap can be an alternative to double flaps in complex reconstruction of the mandible and mobile tongue.     

The buccinator musculomucosal island flap for partial tongue reconstruction

BACKGROUND: Ideal tongue reconstruction after partial or total glossectomy should be accomplished with like tissue. The buccinator musculomucosal island flap is similar to lingual tissue, consisting of thin, pliable mucosa of mucus production, with high cell renewal rate and minimal scar formation, excellent color, contour, texture match, and buccinator muscle fibers over the flap's entire length, providing tongual muscle reconstruction without a conspicuous donor site. STUDY DESIGN: The buccinator musculomucosal island flap, based on the facial artery and vein, is designed in a shuttle or in a fish-mouth fashion, encompassing the oral commissure anteriorly. If the flap design is made in a three-leaf shape, a larger flap will be obtained without an oral corner deformity or mouth opening difficulty. The flap is safe and simple to raise. The pedicle of the flap is longer and quite reliable and has a wide range of applicability. The flap may be used for reconstruction of the partial glossectomy defect (tongual defect was not more than half a tongue). The surgeon must know about possible anatomic variations, especially in the venous system, and plan to raise a contralateral buccinator musculomucosal island flap if homolateral facial vascular variation jeopardizes the flap's survival. RESULTS: The flap was successfully used for partial tongue reconstruction in 16 patients, and all flaps have survived without complications. Satisfactory results (including configuration and function of the neotongue) were achieved. Electromyographic studies performed on one patient with half glossectomy revealed reinnervation of the muscle in the flap with active motion of the reconstructed tongue. CONCLUSION: The buccal musculomucosal island flap based on the facial artery and vein is a better reconstruction option with the same or similar kind of tissue as the tongue and, with the addition of the reinnervated flap, offers the potential for improved physiologic motion.     

Head and neck reconstruction using lateral thigh free flap: flap design

Eleven lateral thigh free flaps were used in head and neck reconstruction, transferred on the basis of the second perforator as well as the third perforator of the profunda femoris artery. The lateral thigh free flap was useful and reliable in head and neck reconstruction and was versatile in flap design. Due to the wide cutaneous territory of the lateral thigh flap, the skin island could be designed freely in the lateral thigh region. Careful patient selection is mandatory for good results. The pinch test and an understanding of the variety of subcutaneous thicknesses in the lateral thigh region are helpful in designing a skin island of adequate thickness. Other considerations in flap design are discussed.     

Aesthetic and functional advantages of the anterolateral thigh flap in reconstruction of tumor-related scalp defects

Eleven patients underwent free-flap reconstruction of tumor-related defects of the scalp, forehead, and temporal region. Flap selection aimed at achieving acceptable functional and aesthetic results combined with negligible donor-site morbidity. Ten males and one female, aged 61.3 +/- 14.3 years, were included in this study. Eight patients presented with tumor recurrences after previous surgery, irradiation, and/or chemotherapy. The average extension of defects was 169.5 (range, 30-600) qcm. Free flaps employed for reconstruction included antero-lateral thigh flaps (8), suprafascial radial forearm flap (1), lateral arm flap (1), latissimus dorsi muscle flap (1), and myocutaneous vertical rectus abdominis flap (1). Other procedures included nerve grafts to the facial nerve (2), ectropion correction (2), and fascia lata slings for static procedure in facial palsy (2). There was no pedicle revision and no flap failure. Donor-site morbidity was negligible. Hospitalization averaged 9.2 +/- 1.7 days. The anterolateral thigh perforator flap offers excellent coverage of tumor-related defects of the scalp, which require a thin flap for adequate contouring. The customized harvested myocutaneous anterolateral thigh flap is regarded as an elegant option for covering defects which consist of both deep and superficial areas. Fascia lata and nerve grafts are available at the same donor site. This easily allows additional procedures for cosmetic and functional improvement that are of high benefit for patients.     

Transoral reconstruction of the mobile tongue,using radial forearm free flap

Tongue resection has significant influence on the patient's quality of life, because it interferes with masticatory and speech functions and affects facial aesthetics. To avoid the disadvantages of the traditional lip-splitting used to approach partial tongue reconstruction for resection (40% of the tongue or more), we recommend a completely transoral approach, with the radial forearm free flap as a donor flap. Between 1999-2001, the suggested technique was applied in 11 patients with squamous-cell carcinoma of the mobile tongue. A follow-up of 6-30 months showed good to excellent oral function, with preservation of tongue volume, motion, and facial aesthetics. This approach seems to be preferable over the lip-split approach for the reconstruction of mobile tongue defects.     

游离股前外侧组织瓣修复全舌或近全舌切除术后组织缺损

目的探讨游离股前外侧组织瓣在全舌或近全舌切除术后组织缺损修复的治疗效果。方法2015年3月-2018年5月,收治15例舌癌(全舌或近全舌切除)患者,肿瘤根治术后应用股前外侧组织瓣同期修复,皮瓣大小为6 cm×10 cm^8 cm×15 cm,对其临床资料进行回顾性分析,术后要求患者定期到门诊复查。结果15例皮瓣均成活,术后发生血管危象1例,经探查及相应处理后完全成活。术后于门诊随访12~48个月,平均30个月,舌部受区皮瓣成活良好,术后6个月患者张口度、咀嚼功能恢复良好,但是吞咽及语音功能欠佳;大腿供区运动功能良好,无麻木、疼痛不适。结论全舌或近全舌切根治术后遗留的组织缺损,以游离股前外侧组织瓣进行修复重建,可以较好的恢复舌的部分功能及外形。     

股薄肌皮瓣在修复舌癌术后缺损中的应用

目的:评价股薄肌皮瓣在舌癌术后缺损修复重建中的临床应用价值。方法:对7例舌癌患者在原发灶切除后利用股薄肌皮瓣行动力性舌再造,术后随访评价舌功能恢复情况。结果:7例股薄肌皮瓣均获得成功,再造舌外形丰满,运动良好,术后6个月均检测出不同程度的肌电信号,患者的言语、咀嚼、吞咽功能恢复满意。结论:股薄肌皮瓣位置表浅,供区隐蔽,血供稳定,容易塑形,可实现动力性舌再造,是修复舌癌术后缺损的一种较好选择。     

游离股前外侧肌皮瓣在舌癌术后缺损修复与舌再造中的应用

目的 探讨游离股前外侧肌皮瓣在舌癌术后缺损修复与舌再造中的应用.方法 2006年6月至2009年4月应用游离股前外侧肌皮瓣,对14例舌癌患者舌颌颈联合根治术后同期行舌口底缺损修复与舌再造,其中舌缘癌9例,舌腹癌3例,口底癌累及舌2例.肌皮瓣面积最大7 cm×9 cm,最小5 cm×7 cm.结果 14例肌皮瓣全部存活,供、受区伤口均一期愈合,无下肢运动感觉功能障碍.术后2周肌皮瓣略显臃肿,1个月后臃肿消退.随访12～26个月,再造舌形态良好,吞咽语言功能满意,肿瘤局部无复发,其中1例(T4N1M0)术后14个月死于远处转移.结论 股前外侧肌皮瓣组织量丰富,携带肌瓣可充填舌口底肌肉切除后缺损,再造舌外形及功能良好,供区隐蔽且对功能影响小,是舌癌术后舌、口底缺损修复与舌再造的理想选择.

Abstract：

Objective To investigate the application of free anterolateral thigh myocutaneous flap in the reconstruction of tongue and mouth floor defect after radical resection of tongue carcinoma. Methods From June 2006 to April 2009, 14 cases with tongue carcinoma underwent radical resection, leaving tongue and mouth floor defects which were reconstructed by anterolateral thigh myocutaneous flaps at the same stage. These 14 cases included tongue carcinoma at lingual margin( n = 9 ), at ventral tongue( n = 3 ) and at mouth floor( n = 2). The flap size ranged from 7 cm × 9 cm to 5 cm× 7 cm. Results All the 14 flaps survived completely with primary healing. There was no functional morbidity in the lower extremities. The patients were followed up for 12-26 months with satisfied esthetic and functional results in reconstructed tongue. Only one case (T4N1M0 )died of metastasis carcinoma 14 months after operation. No local recurrence happened. Conclusions The anterolateral thigh myocutaneous flap has abundant tissue volume to reconstruct the tongue and mouth floor defect, while leaving less morbidity at donor site. Both satisfied esthetic and functional results can be achieved.     

Double-free, flow-through flap reconstruction for complex scalp defects: a case report

This case report describes the use of a double-free, flow-through flap as a valuable tool in reconstruction following oncological resection of a large, fungating, squamous cell carcinoma extending through the scalp, forehead, skull, and dura. An anterolateral thigh flap was utilized to supply: soft tissue for the forehead reconstruction, vascularized fascia lata for the dural repair, and to act vascular conduit to supply a distally placed latissmus dorsi flap for total scalp reconstruction. We believe this is the first time this combination of double-free, flow-through flap design has been published for the reconstruction of complex, composite scalp and calvarial defects.     

Pharyngoesophageal reconstruction with lateral thigh free flap

BACKGROUND: We evaluated the use of a lateral thigh free flap in pharyngoesophageal reconstruction, which is often overlooked and less widely used despite its distinct advantages. METHODS: This study reviewed the patient's medical records, including the patient's age, gender, histopathologic diagnosis, surgical defects, flap size, flap survival, donor and recipient site complications, and swallowing function and voice rehabilitation. RESULTS: Twelve lateral thigh free flaps were used to primarily reconstruct the pharyngoesophagus in 11 patients after tumor resection from July 1997 to May 1999. Eleven of the 12 flaps (91.7%) were transferred successfully. In one patient, the flap failure occurred as a result of venous thrombosis, and therefore another lateral thigh free flap from the opposite thigh was used 3 days later. The swallowing function was restored in all patients. Prosthetic voice rehabilitation was successfully achieved in all five patients, who primarily underwent tracheoesophageal punctures. No frank fistula or stricture developed. Significant donor site morbidity was not noted. CONCLUSIONS: The lateral thigh free flap is useful and reliable in selected cases of pharyngoesophageal reconstruction and versatile in flap design with favorable functional outcomes of swallowing and voice rehabilitation with minimal donor site morbidity.     

Anterolateral thigh flap: ideal free flap choice for lower extremity soft-tissue reconstruction

This article presents the authors' experience with the anterolateral thigh free flap for lower extremity reconstruction. Twenty-one consecutive anterolateral thigh flaps were transferred for reconstruction of soft-tissue defects of the lower extremity from March 2000 to May 2002. Total flap survival was 90.5 percent, with two partial failures. Venous congestion was observed in one flap (4.7 percent) and the venous anastomosis was revised immediately in the postoperative second hour. The mean follow-up time was 13.4 months (range: 5 to 26 months). The cutaneous perforators were consistently found and presented as musculocutaneous in 19 patients (90.5 percent) or septocutaneous in two other patients (9.5 percent). A thinned anterolateral thigh flap was used in 11 patients. Sensate flaps were used in four patients (19.05 percent) for the reconstruction of amputation stumps. Five flaps (23.8 percent) were used also as flow-through flaps. All patients were satisfied with the cosmetic and functional results. The anterolateral thigh flap has many advantages over other free flap donors in lower extremity reconstruction. These include a long and large caliber vascular pedicle, large and pliable skin paddle, good color and texture matching, and minimal donor-site morbidity. Moreover, the flap can be used successfully and safely as a sensate, thin, or flow-through flap. The anterolateral thigh flap can be accepted as an ideal free flap choice for lower extremity reconstruction because it has maximal reconstructive capacity and produces minimal donor-site morbidity.     

A massive arterial thrombosis of a free anterolateral thigh flap in a patient with antiphospholipid syndrome

The antiphospholipid syndrome is a pathological condition characterized by recurrent thrombotic manifestations in venous and/or arterial vascular systems and by peculiar laboratory findings as anticardiolipin antibodies and/or positive lupus anticoagulant. We present a case of massive pedicle thrombosis of a free anterolateral thigh perforator flap used for tongue reconstruction following hemiglossectomy in a patient with antiphospholipid syndrome, which compelled us to an immediate second reconstruction choice with a radial forearm free flap. This case is an example of how this syndrome, especially if unknown before surgery, can influence the outcome of microsurgical transfer of flaps.     

股前外侧皮瓣修复中晚期舌癌术后缺损

目的 报道应用股前外侧皮瓣移植修复中晚期舌癌术后缺损的临床效果.方法 对9例中晚期舌癌患者接受舌癌联合根治术同期应用吻合血管的股前外侧皮瓣移植修复术后缺损.皮瓣切取面积最大10 cm×12 cm,最小7 cm×10 cm,修复舌及口底缺损.术后随访评价再造舌形态、活动度、吞咽功能及语音功能.结果 9例患者供区均直接拉拢缝合,术后供受区伤口一期愈合,股前外侧皮瓣成活.术后平均随访18个月,肿瘤无复发,无严重并发症,再造舌外形较丰满,有一定的活动度,吞咽、语音功能恢复良好,供区瘢痕隐蔽,临床疗效满意.结论 股前外侧皮瓣移植修复中晚期舌癌术后缺损的临床效果满意,值得推广应用.     

Modification of the anterolateral thigh free flap design for reconstruction after laryngo-pharyngoesophagectomy

The anterolateral thigh free flap (ALTFF) has become the favourable fasciocutaneous flap for reconstruction of laryngo-pharyngoesophagectomy (LPO) defects. Reconstruction of these defects can be challenging. We report our experience with a new flap design based on the traditional ALTFF template for single-stage reconstruction of circumferential LPO defects with anterior neck skin deficits in previously irradiated patients. The design uses the traditional tubed skin island to create the neopharynx and also utilises the natural dog-ears from the thigh as a second vascularised skin island that can be used to fill dead space or externalised to resurface the neck. This addresses the issues of monitoring the internal skin paddle and also of replacing anterior neck skin deficits with a single flap.Level of Evidence: Level V, therapeutic study.     

Tongue reconstruction with the gracilis myocutaneous free flap

We describe our experience in tongue reconstruction using the transverse gracilis myocutaneous (TMG) free flap after major demolitive surgery for advanced cancer. This technique was used in 10 patients: seven underwent total glossectomy and three partial glossectomy. In eight patients we performed motor reinnervation attempting to maintain muscular trophism and gain long-term volumetric stability. The follow-up period ranged from 6 to 28 months. The overall flap survival was 100%. Nine out of 10 patients resumed oral intake. Our preliminary experience shows that this flap is a good reconstructive option for total glossectomy patients, whereas it is less suited for reconstruction of hemiglossectomy defects. Functional and objective evaluation of the tongue reconstructed with TMG free flap requires further and standardized evaluation.     

320排螺旋CT血管造影和三维重建在阴股沟穿支皮瓣临床设计中的应用

目的：以320排螺旋CT血管造影和三维重建为基础,尝试在临床为阴股沟穿支皮瓣血管蒂的术前设计提供体表定位方法.方法：对18名需运用阴股沟穿支皮瓣行会阴部再造的实验组患者,术前进行320排螺旋CT血管造影和三维重建,并通过影像学资料为阴股沟穿支皮瓣血管蒂提供体表定位,从而进一步指导手术.同时设置对照组,包括20名运用阴股沟穿支皮瓣行会阴部再造患者,未使用CT血管造影技术.结果：两组共38名患者皮瓣完全存活,实验组手术时间较对照组明显缩短（P＜0.0001）,术后并发症实验组明显减少（P＜0.05）.皮瓣外观形态满意,生理功能接近正常.结论：320排螺旋CT血管造影及三维重建为阴股沟穿支皮瓣血管蒂的术前体表定位提供了一种可靠、有效的方法.     

应用腹直肌-后鞘-腹膜复合瓣游离移植再造半舌的初步报告

目的　探讨应用腹直肌 后鞘 腹膜复合瓣修复舌癌术后半舌缺损的可行性。方法　采用带腹壁下动、静脉、胸神经的腹直肌 后鞘 腹膜复合瓣转移修复半舌缺损 ,将腹直肌与舌内肌缝合 ,后鞘 腹膜与舌黏膜缝合 ,腹壁下动、静脉与颈部血管吻合 ,胸神经与舌下神经吻合。结果　临床应用于 2例因舌癌行半舌切除的患者 ,转移之复合组织瓣均成活 ,再造外形良好。供瓣区愈合 ,瘢痕小。结论　该复合组织瓣用于舌再造 ,具有损伤小 ,外形好 ,有可能恢复神经支配的优点     

游离股前外侧皮瓣修复口腔软组织缺损

目的 探讨分析3种游离股前外侧皮瓣在口腔软组织缺损修复中的临床特点与治疗效果。方法 2008年12月至2010年12月收治67例口腔肿瘤患者,切除肿瘤的同时,应用游离股前外侧皮瓣修复缺损处,包括舌、颊、牙龈、口底,通常将皮瓣的旋股外侧动脉降支与受区的颌外动脉或甲状腺上动脉吻合,伴行静脉与受区的面总静脉或颈外静脉吻合。根据游离股前外侧皮瓣的厚度将其分成3种类型：股前外侧肌皮瓣、股前外侧脂肪筋膜皮瓣和薄型股前外侧皮瓣。结果 67例中股前外侧肌皮瓣为35例,股前外侧脂肪筋膜皮瓣17例,薄型股前外侧皮瓣15例。66例皮瓣存活,成功率为98.5％,其中1例糖尿病患者皮瓣发生小部分坏死,经清创换药后痊愈;1例皮瓣完全坏死。67例皮瓣中41例吻合2条静脉,26例吻合1条静脉。8例出现血管危象：6例为静脉血栓（5例抢救成功、1例皮瓣完全坏死）,1例为术区血肿,1例为穿支血管扭转,经过相应处理,血管危象均得到缓解。术后随访2～ 24个月,平均8.7个月,受区组织缺损修复效果满意,供区创面愈合良好。结论 游离股前外侧皮瓣的受区功能良好,供区并发症少,是一种修复口腔软组织缺损的较为理想的方法。     

应用胸大肌岛状肌皮瓣重建全舌体、口底的初步报告

目的 探讨累及双侧的舌癌根治术后全舌体、口底重建的有效方法及临床评价。方法 对2000年10月至2002年12月问我科收治的7例累及双侧的舌癌患者实施根治性手术，造成全舌体、口底的大面积缺损，采用一侧胸大肌岛状肌皮瓣转移即时重建全舌体和双侧口底。结果 6例转移肌皮瓣完全成活，口腔和颈、胸部创面均一期愈合。1例肌皮瓣远端部分皮肤坏死，但无口底颌下瘘和感染等并发症发生。术后随访2～16个月，重建舌体、口底形态基本满意，语言功能大部分恢复，吞咽功能恢复良好。1例在术后9个月死于肿瘤肺转移，其余6例目前均继在。结论 胸大肌岛状肌皮瓣组织量大，血供丰富，是全舌体、口底重建的理想选择。     

Use of fascia component of the anterolateral thigh flap for different reconstructive purposes

The anterolateral thigh flap is commonly used for reconstruction of soft-tissue defects located at various sites of the body. This versatile flap offers many advantages to the reconstructive microsurgeons for the treatment of difficult defects. From 2000 to 2005, 70 anterolateral thigh flaps were transferred to reconstruct soft-tissue defects. We retrospectively reviewed these patients and found that the fascia lata component of the flap was used for different purposes in 19 patients. The fascia lata component of the flap was used for suspension of the flap in lip reconstruction in 12 patients, for reconstruction of dural defect in the scalp in 2 patients, for reconstruction of tendon defects in the forearm in 3 patients, and for reconstruction of fascia defect in the abdominal wall in the remaining 2. Complete loss of the flap was seen in an anterolateral thigh flap (5.2%) that was used for lower lip reconstruction. One flap necrosed partially (5.2%), and it was treated with surgical debridement and transposition of latissimus dorsi musculocutaneous flap. The objective of this study is to focus on the reliability of the fascial component of the anterolateral thigh flap. Although many authors have described other advantages of the anterolateral thigh flap extensively, this peculiarity has not been stressed adequately. Anterolateral thigh flap offers a thick and vascular fascial component with large amounts that can be used for different reconstructive purposes, and it should be taken into consideration as an important advantage of the flap, together with other well-known advantages.