It was with extreme pleasure that we read the article titled “Suprafascial Anterolateral Thigh Flap Harvest: A Better Way to Minimize Donor-Site Morbidity in Head and Neck Reconstruction,” published in the September issue of Plastic and Reconstructive Surgery, where Chen et al. report their experience with anterolateral thigh flaps harvested with preservation of the deep fascia and applied to head and neck reconstruction.1 We would like to take the opportunity to further discuss this topic of interest to reconstructive plastic surgeons. Our point of discussion is pertinent both to the donor site and to the recipient site. Indeed, in a particular area such as the head and neck and specifically the oral cavity, the need for a thin flap can limit the long-term results of reconstruction. Flap sagging and atrophy are the main factors responsible of soft-tissue deviation toward the reconstructed side and bolus stagnation. Advantages of anterolateral thigh flaps of proper thickness include volume preservation over time, thus maintaining the palatal contact and the propulsive properties of a neotongue, enhancing the residual mobility and recreation of the hyoid mandibular tension arch with improved stability of the larynx/hyoid bone complex.2–4 Furthermore, more patients who undergo oral cavity reconstruction over time may develop gradual worsening of dysarthria, dysphagia, and swallowing secondary to flap sagging, physiologic atrophy, and adjuvant radiotherapy.2,3 These issues can be indications for a further onlay free flap with improved results in other centers, and for the same reasons, the anterolateral thigh flap has overcome the radial forearm flap in oral cavity reconstruction.3 Certainly, one of the advantages of the anterolateral thigh flap remains the possibility of choice of thickness at a certain body mass index. The second point of discussion is inherent in the recipient site: (1) preservation of the deep fascia is questionable because it can be a key point of the successful long-lasting reconstruction because of a stable anchoring (lower lip, floor of the mouth, oropharynx, through-and-through defects)4–6; (2) suprafascial dissection of the anterolateral thigh flap does not avoid skin graft on the donor site, which is responsible for increased thigh morbidity7 (in this regard, a users’ guide to anterolateral thigh flap donor-site closure has been published6); and (3) lower limb weakness following anterolateral thigh flap harvest is not influenced by the suprafascial dissection, although muscle damage occurs deriving from intramuscular dissection of the vascular pedicle.7 Because several studies suggest that musculocutaneous perforators are present in up to 80 percent of cases, intramuscular dissection can damage the vastus lateralis muscle to a certain degree, and in cases where two or more consecutive perforators are included in the flap, the muscle damage can be extensive.8
It is our opinion that the flap should be harvested to better replace the defect and not to minimize donor-site morbidity, with consequent indication for harvest of a suprafascial anterolateral thigh flap (1) to restore lower and upper limbs where the necessary thickness is usually limited; (2) to reconstruct defects in patients with increased body mass index; (3) to reconstruct very few cases into the oral cavity requiring limited thickness; and (4) in nononcologic patients in general, where the defect is obviously limited and is not further influenced by fresh frozen margin analysis, which would require surgical widening. Thus, to conclude, the true advantages of a suprafascial dissection of the anterolateral thigh flap rely on the prevention of compartment syndrome, muscle herniation, or muscle bulging and improved abnormal sensation of the skin of the thigh, in terms of dysesthesia, paresthesia, numbness, and itching as Chen et al. emphasize.1,7 Thus, the true question emerging from this interesting article is whether to preserve the thigh sensation by a suprafascial dissection or to enhance the reconstructive outcome of the head and neck. If the answer can be easily addressed in nononcologic patients then, regarding major head and neck reconstruction following tumor resection, the question will find a proper answer in each case based on tumor stage and estimated defect to be reconstructed, the patient’s comorbidities, and adjuvant therapy with the aim of replacing tissue with like tissue not only histologically but, and above all, in terms of bulkiness and long-lasting reconstructive outcome.
The authors have no financial interest to declare in relation to the content of this communication.
Tommaso Agostini, M.D.
Department of Maxillofacial Surgery
Azienda Ospedaliero Universitaria Careggi
Raffaella Perello, M.D.
Department of Plastic and Reconstructive Surgery
Centro Chirurgico San Paolo
Giuseppe Spinelli, M.D.
Department of Maxillofacial Surgery
Azienda Ospedaliero Universitaria Careggi
1. Chen YC, Scaglioni MF, Carrillo Jimenez LE, Yang JC, Huang EY, Lin TSSuprafascial anterolateral thigh flap harvest: A better way to minimize donor-site morbidity in head and neck reconstruction.Plast Reconstr Surg2016138689–698
2. Agostini T, Agostini V, Lazzeri DCurrent roles of adipofascial anterolateral thigh flap in head and neck reconstructions.Head Neck201133595–596; author reply 596
3. Rihani J, Lee T, Ducic YSecondary onlay free flap reconstruction of glossectomy defects following initial successful flap restoration.Otolaryngol Head Neck Surg2013149232–234
4. Agostini TAnterolateral thigh flap morbidity: Considerations and reflections on donor-site closure.Plast Reconstr Surg20091231133–1134; author reply 1134
5. Agostini T, Agostini VThe key roles of the deep fascia of the anterolateral thigh flap.Plast Reconstr Surg2010125757–758
6. Agostini T, Lazzeri DSurgical techniques to achieve direct anterolateral thigh flap donor-site closure.Plast Reconstr Surg2012129595e–597e
7. Agostini T, Lazzeri D, Spinelli GAnterolateral thigh flap: Systematic literature review of specific donor-site complications and their management.J Craniomaxillofac Surg20134115–21
8. Rozen WM, le Roux CM, Ashton MW, Grinsell DThe unfavorable anatomy of vastus lateralis motor nerves: A cause of donor-site morbidity after anterolateral thigh flap harvest.Plast Reconstr Surg20091231505–1509
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