I agree with and appreciate most of the comments made by Agostini et al. about the article.1 Nevertheless, certain points have to be clarified. The authors mention that only a very few patients with intraoral defects need reconstruction by means of a flap with limited thickness. However, it is not compatible in the scenario of my clinical practice. The oral cavity can be divided into several subunits. Reconstruction of each subunit requires special consideration of both the extent of the defect and the donor flap characteristics based on the principle of restoring the integrity and the function and form. For example, a thin and pliable flap such as a radial forearm flap is mostly indicated for reconstruction of the hemiglossectomy defect to preserve the mobility of the residual tongue. The idea is totally different for the subtotal and total glossectomy defect, which requires reconstruction using a flap with adequate bulkiness to maintain palatoglossal contact for speech and swallowing. An anterolateral thigh flap with inclusion of the vastus lateralis muscle is the preferred method in our institute.2 For buccal mucosa, retromolar trigone, hard palate, and oropharynx defects, a bulky flap may be frequently bitten by teeth and also result in unintelligible speech, difficulty swallowing, and chronic aspiration. That is why several primary thinning techniques have been developed for the anterolateral thigh flap, including the suprafascial harvest method.1,3–5 As for the outcome, whether anchoring of the deep fascia from the anterolateral thigh flap to the recipient tissue can prevent flap sagging is not yet known. We all understand that the human face is supported by multiple ligamentous structure but still cannot escape the fate of sagging over time. Although some articles have reported good results in the short term, the long-term outcome remains in question.6,7 Regarding the donor site, it is true that the suprafascial anterolateral thigh flap harvest method cannot avoid skin graft; however, preservation of the deep fascia can prevent functional impairment resulting from adhesion between skin graft and the muscle junction by maintaining the smooth gliding surface. Preservation of the deep fascia can also eliminate the concern that deep fascia harvest may result in persistent lower leg weakness.8 However, closure of the fascia may not prevent but would potentially cause compartment syndrome. Although we did not experience compartment syndrome in our suprafascial anterolateral thigh flap case series, this devastating condition should be kept in mind. In conclusion, the anterolateral thigh flap is versatile, with numerous modifications.9 The suprafascial harvest method provides a thinner flap with minimized donor-site morbidity.1 The decision regarding which harvest method is to be used should be determined by the extent of defects, the patient’s comorbidity, adjuvant radiotherapy, and the surgeon’s experience. Not only is the principle of “replacing like tissue with like” followed, but also “harvesting only the tissues needed for reconstruction” is considered.
The author has no financial conflicts or commercial associations to disclose.
Yen-Chou Chen, M.D.
Department of Plastic and Reconstructive Surgery
Body Science & Metabolic Disorders International Medical Center
China Medical University Hospital
No. 2, Yude Road
Taichung City 404, Taiwan
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. Engel H, Huang JJ, Lin CY, et alA strategic approach for tongue reconstruction to achieve predictable and improved functional and aesthetic outcomes.Plast Reconstr Surg20101261967–1977
3. Agostini T, Lazzeri D, Spinelli GAnterolateral thigh flap thinning: Techniques and complications.Ann Plast Surg201472246–252
4. Rajacic N, Gang RK, Krishnan J, Lal Bang RThin anterolateral thigh free flap.Ann Plast Surg200248252–257
5. Yang WG, Chiang YC, Wei FC, Feng GM, Chen KTThin anterolateral thigh perforator flap using a modified perforator microdissection technique and its clinical application for foot resurfacing.Plast Reconstr Surg20061171004–1008
6. Kuo YR, Jeng SF, Wei FC, Su CY, Chien CYFunctional reconstruction of complex lip and cheek defect with free composite anterolateral thigh flap and vascularized fascia.Head Neck2008301001–1006
7. Kuo YR, Yeh MC, Shih HS, et alVersatility of the anterolateral thigh flap with vascularized fascia lata for reconstruction of complex soft-tissue defects: Clinical experience and functional assessment of the donor site.Plast Reconstr Surg2009124171–180
8. Lipa JE, Novak CB, Binhammer PAPatient-reported donor-site morbidity following anterolateral thigh free flaps.J Reconstr Microsurg200521365–370
9. Ali RS, Bluebond-Langner R, Rodriguez ED, Cheng MHThe versatility of the anterolateral thigh flap.Plast Reconstr Surg2009124e395–e407
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