Journal of Plastic, Reconstructive & Aesthetic Surgery (2009) 62, e633ee634

CORRESPONDENCE AND COMMUNICATION

Adipofascial versusfasciocutaneous anterolateral thighflap in oral cavity reconstruction.Focus on the vascular supply

Figure 1 The eccentric proximal perforator providesa longer vascular pedicle in a leaf ‘shape configuration’. Theskin is excised and haemostasis performed. The flap is thinnedto fill the defect with care to harvest 2 cm of fascia around thepedicle to preserve the vascularization.

The first goal is a radical excision of the tumor followed byan immediate reconstruction which should aim to restorefunction and cosmesis at both donor and recipient sites.The success of the radial forearm flap resides in thereplacement of the thin oral lining with a thin and pliabletissue. Since 1984 several methods to thin the anterolateralthigh flap (ALT) are described in literature for the lower andupper limbs, neck and oral cavity reconstruction.

The different constitution of the Orientals explains thewidespread use of the ALT flap by the Asiatic colleagues;indeed the high incidence of obesity limited the diffusion inour countries and as a consequence an extensive thinning isnecessary to obtain the desired thickness.

Alkureishi and co-workers demonstrated the inadequatearterial supply in the subdermal plexus of the skin distal tothe perforator in thinned ALT flaps (surrounded by a fascialcuff of 2 cm as recommended by the Asiatic colleagues).Moreover they proved a fascial cuff of 1 cm around theperforator resulted in greater damages to the vasculararchitecture. After the preliminary results on cadaverdissections the applications in oral cavity reconstructionconfirmed the partial or total necrosis of the skin.1,2

Evidently the main problem with the thinned cutaneousanterolateral flap is the possibility of marginal and totalskin necrosis due to an excessive damage to the subcuta-neous vascular network. For these reasons Ross et al.hypothesized the distal skin from the perforator receivesblood from the subdermal plexus of the adjacent tissue(similar to a graft) and saliva could interfere with thisneovascularisation.3

In our experience the adipofascial configuration of theALT flap proved a safety method for oral cavity recon-struction since the thinning procedures were uneventfulwithout partial or marginal necrosis.4,5

The adipofascial ‘leaf shaped’ ALT flap is raised withparticular care to leave a 2 cm fascial cuff around the

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perforator (Figure 1); the ‘branch of the leaf’ fills thetunnel between the oral cavity and the neck allowing goodprotection of the pedicle from saliva and preventing orocutaneous fistulas above all when a small cuff of muscle isharvested. The ‘body of the leaf’ is fixed in the defect ina reverse fashion. A hairless functioning tissue is provided45 days later with superior aesthetic and functional results(Figure 2). An excessive thinning must be avoided predict-ing a further decrease in size because of the postoperativeradiotherapy.

The evolved technique represents a safe and securemethod of thinning since the fascial plexus is kept intact;indeed the main bloody supply to the skin arises from theouter fascial layer, passing as fasciocutaneous or muscolo-cutaneous perforators with branches perpendicularoriented or radiated in all directions. A stable anchoring ofthe flap is obtained using the resistant deep fascia whichacts as a support to remucosalisation as well. This tech-nique represents a valid alternative to the traditional fas-ciocutaneous flaps and provides a functional hairless wettissue in the oral cavity respecting the principle of ‘replacetissue with like tissue’.

tiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.

Figure 2 Postoperative result at 40 days after the resectionof a T3 squamous cell carcinoma of the right tongue. Note thegranulation tissue of the neomucosa. The 22 year old patientunderwent hemiglossectomy, right neck dissection level 1 to 5and left neck dissection level 1e3. Postoperative radiotherapyfollowed in fractioned doses ranging from 5000 to 8000 cGy.

e634 Correspondence and communication

References

1. Alkureishi LW, Shaw-Dunn J, Ross GL. Effects of thinning theanterolateral thigh flap on the blood supply to the skin. Br JPlast Surg 2003 Jun;56:401e8.

2. Alkureishi LW, Ross GL. Thinning of the anterolateral thigh flap:unpredictable results. Plast Reconstr Surg 2006 Aug;118:569e70.

3. Ross GL, Dunn R, Kirkpatrick J, et al. To thin or not to thin: theuse of the anterolateral thigh flap in the reconstruction ofintraoral defects. Br J Plast Surg 2003 Jun;56:409e13.

4. Agostini V, Dini M, Mori A, et al. Adipofascial anterolateral thighfree flap for tongue repair. Br J Plast Surg 2003 Sep;56:614e8.

5. Agostini T, Agostini V. Further experience with adipofascial ALTflap for oral cavity reconstruction. J Plast Reconstr Aesthet Surg2008 Oct;61:1164e9.

Tommaso AgostiniVittorugo Agostini

Department of Plastic and Reconstructive Surgery, Schoolof Specialization in Plastic, Reconstructive and Aesthetic

Surgery, CTO-AOUC Largo Palagi 1-50100 Florence,University of Florence, Italy

E-mail addresses: tommasoagostini@ymail.com,agostinivitt@virgilio.it