Technique and clinical application of free lobed anteromedial thigh perforator flap_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

SONG Dajiang ¹ ,  LI Zan ¹ , ZHANG Yixin ²

1. Department of Oncology Plastic Surgery, Hunan Cancer Hospital, Changsha Hunan, 410008, P. R. China;
2. Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, P. R. China;

Corresponding?author：

LI Zan, Email: zzanli@163.com

Keywords：

Anterolateral thigh flap; anteromedial thigh perforator; free flap; oral and buccal cancer; penetrating defect

DOI：

10.7507/1002-1892.202212068

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Objective To introduce the technique and clinical application of free lobed anteromedial thigh perforator flap. Methods Between October 2017 and December 2021, 65 patients with buccal and oral cancer penetrating defects were planned to treat with free lobed anterolateral thigh flap transplantation, of which 15 cases were found that the sole anterolateral thigh perforator was actually a branch of the anteromedial thigh perforator, and then the free lobed anteromedial thigh perforator flap was harvested for repair. There were 12 males and 3 females with an average age of 34.6 years (range, 29-55 years). According to Union for International Cancer Control (UICC) TNM staging, there were 7 cases of T₄N₀M₀, 4 cases of T₄N₁M₀, 2 cases of T₃N₁M₀, and 2 cases of T₃N₂M₀. The disease duration was 1-10 months (mean, 6.3 months), and the area of secondary soft tissue defect left after radical resection of buccal and oral cancer was from 5 cm×4 cm to 10 cm×6 cm. The anterolateral thigh skin flap ranged from 5 cm×4 cm to 13 cm×6 cm, and the anteromedial thigh skin flap ranged from 5 cm×3 cm to 10 cm×6 cm. The free trilobed anteromedial thigh flap was prepared according to the actual branches of the main trunk of the anteromedial thigh perforator in 4 cases, and the vastus medialis muscle flap was used to fill the cavity defect of the floor of mouth in 7 cases. Among the 15 patients, the vessel pedicles of the anteromedial thigh perforators were derived from the main femoral artery and vein in 8 cases, from the main descending branch of the lateral femoral circumflex artery in 4 cases, and from the main lateral femoral circumflex artery in 3 cases. Results Hematoma occurred in 2 cases after operation, which was successfully saved after emergency exploration. No vascular crisis occurred, and partial necrosis of anterolateral femoral skin island occurred in 1 case, which was healed with debridement. The remaining flaps survived successfully, and the wounds and donor site incisions healed by first intention. All the patients were followed up 12-36 months (mean, 14.6 months). The appearance of the flap was satisfactory, and no obvious swelling was found; the mouth opening and language function were satisfactory; only linear scar was left in the donor area, and the thigh function was not significantly affected. Local recurrence occurred in 3 cases, and the defect after tumor resection was repaired with pedicled pectoralis major myocutaneous flap. Four patients with neck lymph node metastasis, including ipsilateral side in 3 patients and contralateral side in the other 1 patient, all underwent neck lymph node dissection again. The 3-year survival rate was 86.7% (13/15). Conclusion The anteromedial thigh perforator vessels distributed in the anterolateral region of the thigh can be used to prepare the anterolateral thigh split lobed flap to repair the buccal and oral cancer penetrating defects.

Citation： SONG Dajiang, LI Zan, ZHANG Yixin. Technique and clinical application of free lobed anteromedial thigh perforator flap. Chinese Journal of Reparative and Reconstructive Surgery, 2023, 37(3): 336-342. doi: 10.7507/1002-1892.202212068 Copy

1.	Koshima I, Fukuda H, Yamamoto H, et al. Free anterolateral thigh flaps for reconstruction of head and neck defects. Plast Reconstr Surg, 1993, 92(3): 421-430.
2.	Wei FC, Jain V, Celik N, et al. Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps. Plast Reconstr Surg, 2002, 109(7): 2219-2226.
3.	Wong CH, Wei FC. Anterolateral thigh flap. Head Neck, 2010, 32(4): 529-540.
4.	Ahmad QG, Navadgi S, Agarwal R, et al. Bipaddle pectoralis major myocutaneous flap in reconstructing full thickness defects of cheek: a review of 47 cases. J Plast Reconstr Aesthet Surg, 2006, 59(2): 166-173.
5.	Levis C, Hynes N, Archibald S. Through and through defects of the lower face. Clin Plast Surg, 2005, 32(3): 327-337.
6.	Lyons A. Current concepts in the management of oral cancer. Dent Update, 2006, 33(9): 538-539.
7.	Blackwell KE, Buchbinder D, Biller HF, et al. Reconstruction of massive defects in the head and neck: the role of simultaneous distant and regional flaps. Head Neck, 1997, 19(7): 620-628.
8.	Hsing CY, Wong YK, Wang CP, et al. Comparison between free flap and pectoralis major pedicled flap for reconstruction in oral cavity cancer patients-a quality of life analysis. Oral Oncol, 2011, 47(6): 522-527.
9.	宋達疆, 李贊, 周曉, 等. 游離分葉股前外側穿支皮瓣修復口腔頜面部惡性腫瘤術后頰部洞穿缺損. 中國修復重建外科雜志, 2018, 32(5): 607-611.
10.	宋達疆, 李贊, 周曉, 等. 分葉股前外側穿支皮瓣修復口腔復雜洞穿缺損. 中華整形外科雜志, 2019, 35(10): 978-985.
11.	Kang SH, Nam W, Cha IH, et al. Double continuous radial forearm flap for the reconstruction of full-thickness buccal cheek defect. J Plast Reconstr Aesthet Surg, 2009, 62(5): e95-e96.
12.	Song YG, Chen GZ, Song YL. The free thigh flap: a new free flap concept based on the septocutaneous artery. Br J Plast Surg, 1984, 37(2): 149-159.
13.	宋達疆, 李贊, 周曉, 等. 股前內側接力穿支皮瓣修復游離股前外側穿支皮瓣供區的臨床應用. 中國修復重建外科雜志, 2017, 31(1): 52-56.
14.	宋達疆, 李贊, 周曉, 等. 股前外側接力穿支皮瓣修復股前內側穿支皮瓣供區. 中國醫師雜志, 2018, 20(11): 1627-1631.
15.	Hupkens P, Van Loon B, Lauret GJ, et al. Anteromedial thigh flaps: an anatomical study to localize and classify anteromedial thigh perforators. Microsurgery, 2010, 30(1): 43-49.
16.	Chang CC, Wong CH, Wei FC. Free-style free flap. Injury, 2008, 39 Suppl 3: S57-S61.
17.	Schoeller T, Huemer GM, Shafighi M, et al. Free anteromedial thigh flap: clinical application and review of literature. Microsurgery, 2004, 24(1): 43-48.
18.	C?mert A, Altun S, Unlü RE, et al. Perforating arteries of the anteromedial aspect of the thigh: an anatomical study regarding anteromedial thigh flap. Surg Radiol Anat, 2011, 33(3): 241-247.
19.	宋達疆, 李贊, 周曉, 等. 游離股前內側穿支皮瓣修復口腔腫瘤根治術后缺損并用接力股前外側穿支皮瓣修復供區創面的效果. 中華燒傷雜志, 2017, 33(2): 72-76.
20.	宋達疆, 李贊, 周曉, 等. 游離股內側嵌合穿支肌皮瓣在舌癌術后缺損修復中的臨床應用. 中華耳鼻咽喉頭頸外科雜志, 2017, 52(4): 278-282.
21.	宋達疆, 李贊, 周曉, 等. 游離股前內側穿支皮瓣在舌癌術后缺損修復中的應用. 中華整形外科雜志, 2017, 33(2): 106-111.
22.	Yu P, Selber J. Perforator patterns of the anteromedial thigh flap. Plast Reconstr Surg, 2011, 128(3): 151e-157e.
23.	宋達疆, 李贊, 周曉, 等. 應用不同入路切取股前外側皮瓣行舌癌切除后缺損的修復重建. 中國耳鼻咽喉顱底外科雜志, 2016, 22(2): 129-133.
24.	沈永輝, 宋達疆, 周曉, 等. 內外側入路切取股前外側皮瓣比較. 中國醫師雜志, 2017, 19(5): 671-674.
25.	Liang CC, Jeng SF, Yang JC, et al. Use of anteromedial thigh flaps as an alternative to anterolateral thigh flaps for reconstruction of head and neck defects in cancer patients. Ann Plast Surg, 2013, 71(4): 375-379.
26.	Lu JC, Zelken J, Hsu CC, et al. Algorithmic approach to anterolateral thigh flaps lacking suitable perforators in lower extremity reconstruction. Plast Reconstr Surg, 2015, 135(5): 1476-1485.
27.	Riva FM, Tan NC, Liu KW, et al. Anteromedial thigh perforator free flap: report of 41 consecutive flaps and donor-site morbidity evaluation. J Plast Reconstr Aesthet Surg, 2013, 66(10): 1405-1414.
28.	Koshima I, Yamamoto H, Hosoda M, et al. Free combined composite flaps using the lateral circumflex femoral system for repair of massive defects of the head and neck regions: an introduction to the chimeric flap principle. Plast Reconstr Surg, 1993, 92(3): 411-420.
29.	Gong ZJ, Zhang S, Ren ZH, et al. Application of anteromedial thigh flap for the reconstruction of oral and maxillofacial defects. J Oral Maxillofac Surg, 2014, 72(6): 1212-1225.

1. Koshima I, Fukuda H, Yamamoto H, et al. Free anterolateral thigh flaps for reconstruction of head and neck defects. Plast Reconstr Surg, 1993, 92(3): 421-430.
2. Wei FC, Jain V, Celik N, et al. Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps. Plast Reconstr Surg, 2002, 109(7): 2219-2226.
3. Wong CH, Wei FC. Anterolateral thigh flap. Head Neck, 2010, 32(4): 529-540.
4. Ahmad QG, Navadgi S, Agarwal R, et al. Bipaddle pectoralis major myocutaneous flap in reconstructing full thickness defects of cheek: a review of 47 cases. J Plast Reconstr Aesthet Surg, 2006, 59(2): 166-173.
5. Levis C, Hynes N, Archibald S. Through and through defects of the lower face. Clin Plast Surg, 2005, 32(3): 327-337.
6. Lyons A. Current concepts in the management of oral cancer. Dent Update, 2006, 33(9): 538-539.
7. Blackwell KE, Buchbinder D, Biller HF, et al. Reconstruction of massive defects in the head and neck: the role of simultaneous distant and regional flaps. Head Neck, 1997, 19(7): 620-628.
8. Hsing CY, Wong YK, Wang CP, et al. Comparison between free flap and pectoralis major pedicled flap for reconstruction in oral cavity cancer patients-a quality of life analysis. Oral Oncol, 2011, 47(6): 522-527.
9. 宋達疆, 李贊, 周曉, 等. 游離分葉股前外側穿支皮瓣修復口腔頜面部惡性腫瘤術后頰部洞穿缺損. 中國修復重建外科雜志, 2018, 32(5): 607-611.
10. 宋達疆, 李贊, 周曉, 等. 分葉股前外側穿支皮瓣修復口腔復雜洞穿缺損. 中華整形外科雜志, 2019, 35(10): 978-985.
11. Kang SH, Nam W, Cha IH, et al. Double continuous radial forearm flap for the reconstruction of full-thickness buccal cheek defect. J Plast Reconstr Aesthet Surg, 2009, 62(5): e95-e96.
12. Song YG, Chen GZ, Song YL. The free thigh flap: a new free flap concept based on the septocutaneous artery. Br J Plast Surg, 1984, 37(2): 149-159.
13. 宋達疆, 李贊, 周曉, 等. 股前內側接力穿支皮瓣修復游離股前外側穿支皮瓣供區的臨床應用. 中國修復重建外科雜志, 2017, 31(1): 52-56.
14. 宋達疆, 李贊, 周曉, 等. 股前外側接力穿支皮瓣修復股前內側穿支皮瓣供區. 中國醫師雜志, 2018, 20(11): 1627-1631.
15. Hupkens P, Van Loon B, Lauret GJ, et al. Anteromedial thigh flaps: an anatomical study to localize and classify anteromedial thigh perforators. Microsurgery, 2010, 30(1): 43-49.
16. Chang CC, Wong CH, Wei FC. Free-style free flap. Injury, 2008, 39 Suppl 3: S57-S61.
17. Schoeller T, Huemer GM, Shafighi M, et al. Free anteromedial thigh flap: clinical application and review of literature. Microsurgery, 2004, 24(1): 43-48.
18. C?mert A, Altun S, Unlü RE, et al. Perforating arteries of the anteromedial aspect of the thigh: an anatomical study regarding anteromedial thigh flap. Surg Radiol Anat, 2011, 33(3): 241-247.
19. 宋達疆, 李贊, 周曉, 等. 游離股前內側穿支皮瓣修復口腔腫瘤根治術后缺損并用接力股前外側穿支皮瓣修復供區創面的效果. 中華燒傷雜志, 2017, 33(2): 72-76.
20. 宋達疆, 李贊, 周曉, 等. 游離股內側嵌合穿支肌皮瓣在舌癌術后缺損修復中的臨床應用. 中華耳鼻咽喉頭頸外科雜志, 2017, 52(4): 278-282.
21. 宋達疆, 李贊, 周曉, 等. 游離股前內側穿支皮瓣在舌癌術后缺損修復中的應用. 中華整形外科雜志, 2017, 33(2): 106-111.
22. Yu P, Selber J. Perforator patterns of the anteromedial thigh flap. Plast Reconstr Surg, 2011, 128(3): 151e-157e.
23. 宋達疆, 李贊, 周曉, 等. 應用不同入路切取股前外側皮瓣行舌癌切除后缺損的修復重建. 中國耳鼻咽喉顱底外科雜志, 2016, 22(2): 129-133.
24. 沈永輝, 宋達疆, 周曉, 等. 內外側入路切取股前外側皮瓣比較. 中國醫師雜志, 2017, 19(5): 671-674.
25. Liang CC, Jeng SF, Yang JC, et al. Use of anteromedial thigh flaps as an alternative to anterolateral thigh flaps for reconstruction of head and neck defects in cancer patients. Ann Plast Surg, 2013, 71(4): 375-379.
26. Lu JC, Zelken J, Hsu CC, et al. Algorithmic approach to anterolateral thigh flaps lacking suitable perforators in lower extremity reconstruction. Plast Reconstr Surg, 2015, 135(5): 1476-1485.
27. Riva FM, Tan NC, Liu KW, et al. Anteromedial thigh perforator free flap: report of 41 consecutive flaps and donor-site morbidity evaluation. J Plast Reconstr Aesthet Surg, 2013, 66(10): 1405-1414.
28. Koshima I, Yamamoto H, Hosoda M, et al. Free combined composite flaps using the lateral circumflex femoral system for repair of massive defects of the head and neck regions: an introduction to the chimeric flap principle. Plast Reconstr Surg, 1993, 92(3): 411-420.
29. Gong ZJ, Zhang S, Ren ZH, et al. Application of anteromedial thigh flap for the reconstruction of oral and maxillofacial defects. J Oral Maxillofac Surg, 2014, 72(6): 1212-1225.

Chinese Journal of Reparative and Reconstructive Surgery

Technique and clinical application of free lobed anteromedial thigh perforator flap

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