Original Research—Head and Neck Surgery
Application of Proximal Lateral Leg Perforator Flaps for Head and Neck Reconstructions
Otolaryngology– Head and Neck Surgery 2014, Vol. 151(5) 791–796 Ó American Academy of Otolaryngology—Head and Neck Surgery Foundation 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0194599814549731 http://otojournal.org
Honda Hsu, MBChB1,2, Peir-Rong Chen, MD2,3, Sou-Hsin Chien, MD2,4, and Jiunn-Tat Lee, MD2,5
No sponsorships or competing interests have been disclosed for this article.
Abstract Objective. Analyze the reliability, complications, and donor site morbidity of the proximal lateral leg flap when applied to head and neck reconstruction. Study Design. Case series and chart review. Setting. Tertiary care teaching hospital. Subjects and Methods. Nineteen patients who underwent reconstruction of various head and neck defects with this flap were analyzed. The patient demographics, flap characteristics, method of donor site closure, scars of the donor area, complication rates, as well as functional results at the recipient site were assessed. Results. The flap size ranged from 4 3 4 cm to 11 3 8 cm. Vascular pedicle length ranged from 5 to 9 cm. The mean distance of the perforator from the fibula head was 9.2 cm. The mean thickness of this flap was 5.5 mm. All the donor wounds were closed primarily. The flap survival rate was 100%. Conclusion. This flap has the advantages of thinness, short harvesting time, minimal donor site morbidity, and primary closure at the donor site when the flap width is less than 6 cm. This flap may be useful for reconstruction in selected patients with small and thin heads and neck defects. Keywords
allowed the reconstructive surgeon to harvest flaps without sacrificing underlying muscle and major vasculature. Yajima et al introduced the proximal lateral leg flap in 1994.5 They found that there were usually 1 or 2 perforators located at the distal portion of the proximal third of the lower lateral leg along the posterior margin of the fibula. This flap was based on these perforator vessels, thus preserving the peroneal artery. If a thin and pliable flap is required in head and neck reconstruction, the proximal lateral leg flap will do as well as the radial forearm flap in selected cases but is associated with minimal donor site morbidity. In this study, we analyzed the reliability, complications, and donor site morbidity of the proximal lateral leg flap when applied to head and neck reconstruction.
Materials and Methods A retrospective study of medical records was performed at Hualien Tzu Chi General Hospital from September 2005 to June 2012. The institutional review board of Hualien Tzu Chi General Hospital approved the review of charts. Nineteen patients with various head and neck defects were reconstructed with a proximal lateral leg flap. Most patients had T1 or T2 intraoral malignancies. Indications for the usage of this flap were as follows: first, in patients with thin, small- to medium-sized defects with a width of less than 6 cm, which allowed direct closure of the donor site over the lateral leg; second, in those patients where donor site morbidity and cosmesis are important issues. We usually performed a pinch test to determine if the donor site
proximal lateral leg, perforator flap, head and neck 1
Received March 13, 2014; revised July 24, 2014; accepted August 12, 2014.
S
ince the 1980s, free tissue transfer has provided the reconstructive surgeon with an alternative treatment option for patients with head and neck cancer. If the defect to be reconstructed is small and thin, then the radial forearm free flap is a good and reliable choice. However, the main disadvantage of this flap is that the radial artery has to be sacrificed. It is also associated with a myriad of donor site morbidities.1-4 Nowadays, perforator flaps have
Division of Plastic Surgery, Buddhist Dalin Tzu Chi Hospital, Dalin, Taiwan School of Medicine, Tzu Chi University, Hualien, Taiwan 3 Department of Otolaryngology, Buddhist Tzu Chi General Hospital, Hualien, Taiwan 4 Division of Plastic Surgery, Buddhist Taichung Tzu Chi General Hospital, Taichung, Taiwan 5 Division of Plastic Surgery, Buddhist Tzu Chi General Hospital, Hualien, Taiwan 2
Corresponding Author: Jiunn-Tat Lee, MD, Division of Plastic Surgery, Buddhist Tzu Chi General Hospital, Hualien Tzu Chi University, No. 707, Sec. 3, Chung Yang Rd., Hualien 970, Taiwan, ROC Email: [email protected]
Downloaded from oto.sagepub.com at MICHIGAN STATE UNIV LIBRARIES on April 5, 2015
792
Otolaryngology–Head and Neck Surgery 151(5)
Figure 1. (A) The location of the perforators can be easily detected with a handheld Doppler flowmeter. One or two perforators are usually located near the distal portion of the proximal third of the lateral leg. (B) Cross-section anatomy showing that the flap can be based on a musculocutaneous or septocutaneous perforator.
could be closed primarily. A handheld Doppler flowmeter was used to localize the perforators preoperatively. The patient’s age, sex, etiology, tumor location, histology, stage, size of defect, flap size, flap dissection time, flap thickness, pedicle length, diameter of the vascular pedicle, as well as the distance of the pedicle from the fibula head were recorded. The method of donor site closure was also recorded. The complication rates and flap failure rates were noted. Functional results at the recipient site, including diet and speech, were evaluated at 1-year postsurgery. Clinical assessment of the motor function of the leg, the range of motion of the ankle joint, and cosmesis of the donor sites were evaluated too. All the linear scars of the donor area were assessed for width, height, vascularity, and pigmentation. The patients were asked to self-evaluate the cosmesis of the donor site subjectively.
Surgical Procedure Based on a 2-team approach, the proximal lateral leg flap was harvested simultaneously with oncologic resection. The patient was placed in the supine position with the hip and knee flexed. The outline of the fibula was marked out and divided into 3 equal parts. The location of perforator vessels was identified preoperatively with a handheld Doppler flowmeter. There were usually 1 or 2 points near the distal portion of the proximal third of the lateral leg along the posterior margin of the fibula,5 usually 7 to 15 cm from the fibula head, where a perforator could be located. The perforator could be located without difficulty and with accuracy because of the thinness of the skin at this area. The outline of the flap was then designed to include the marked-out points (Figure 1A). Tourniquet was not applied, as this would hinder us from visualizing the perforator, as well as its pulsatile strength, with clarity. The skin was incised anteriorly to the posterior septum and the flap elevated subfascially. After the presence of the perforator vessels was confirmed, the flap was elevated from the posterior border. The perforator vessel was dissected intramuscularly with ligation of the muscular branches if it
was found to be traversing the soleus muscle. If a septocutaneous perforator was found, then the dissection was straightforward (Figure 1B). When more than 1 perforator was present, the larger perforator or the septocutaneous perforator was chosen. The soleus muscle was then detached from the fibula, and the bifurcation of the perforator vessels from the main artery was located. The flap was elevated after the perforator vessels were ligated at their bifurcation. The peroneal nerve could at times be encountered during proximal dissection of the flap. This must be carefully protected to avoid potential injury to the peroneal nerve. The donor site was closed primarily in all our cases.
Results A total of 19 cases were included in the study. The flap was used for coverage of intraoral soft tissue defects in 16 patients; these included 12 primary malignancies (Figure 2) and 4 second primary malignancies, the face in 1 patient, the chin in 1 patient, and the scalp in 1 patient (Figure 3). There were 14 men and 5 women, with a mean age of 53 years old (range, 20 to 70 years). The final pathology for all 16 patients with oral cancer was squamous cell carcinoma. The patients’ data are shown in Table S1 (available at otojournal.org). The flap size ranged from 4 3 4 cm to 11 3 8 cm. The mean thickness of the flap was 5.5 mm (range, 3.5 to 7 mm). The mean distance of the perforator from the fibula head was 9.2 cm (range, 7 to 15 cm), and the mean length of the vascular pedicle was 7 cm (range, 5 to 9 cm). The mean time of flap harvesting was 48 minutes (range, 30 to 80 minutes). In 47% of the cases, a septocutaneous perforator was used, and in 53%, a musculocutaneous perforator was used. The mean diameter of the perforator artery was 1.4 mm (range, 0.8 to 2.0 mm). Five flaps had only a single vein; the other 14 flaps had 2 veins. The diameter of the vena comitans ranged from 1.2 to 2.8 mm (mean, 1.9 mm). No vein graft was used in all these cases. Venous thrombosis developed in a patient with primary oral cancer. This flap was successfully salvaged. The flap survival rate was 100%. The donor site was closed primarily
Downloaded from oto.sagepub.com at MICHIGAN STATE UNIV LIBRARIES on April 5, 2015
Hsu et al
793 intelligible, and comprehensible in all patients by their families and the hospital staff. Only 1 secondary debulking procedure was required, in an obese female patient with a relatively thick flap. As no significant amount of soleus muscle was damaged, even in the presence of a musculocutaneous perforator, the motor function of the donor leg was not affected, and the ankle’s range of motion was within normal limits. No peroneal nerve was injured, and no sensory deficits were seen in this series, as the common peroneal nerve was well protected when a more proximally located flap was harvested and the lateral sural nerve was not encountered during the dissection of this flap in our series. None of the patients complained of circulatory or cold intolerance problems. Three patients (16%) had hypertrophic or depressed scar, and 4 (21%) had hyperpigmentation of the scar of the donor leg. Subjectively, all the patients were satisfied with the cosmesis of the scar over the donor leg.
Discussion
Figure 2. (A) A 30-year-old man (case 9) with primary squamous cell carcinoma of the right tongue, post–wide excision, with resultant defect measuring 6 3 4 cm. (B) A flap based on a musculocutaneous perforator was elevated. (C) Six-month postoperative photograph showing a well-healed thin flap contouring the tongue well.
in all 19 cases. Two cases developed wound dehiscence, both of which healed with conservative treatment. The mean follow-up time was 15 months. The functional results at the intraoral recipient site were satisfactory. All patients returned to normal diet. Speech was deemed clear,
For head and neck reconstruction, the anterolateral thigh flap6 and the radial forearm flap have become the workhorse flaps in the past decade at our center. The former is especially useful when a larger and thicker flap is required, while the latter is still the favored flap for small and shallow defects. However, the long-term donor site morbidity1-3 of the radial forearm flap, including functional and aesthetic outcome, offsets many of the benefits of this flap. In the Asian population, where hyperpigmentation and hypertrophic scar commonly occur, cosmesis remains a major problem. We recently performed a comparison between proximal lateral leg flap and the radial forearm flap and found that 48% of patients complained of either functional deficit or poor cosmesis of the radial forearm donor site. In contrast, 83% of patients had excellent or good outcome in the proximal lateral leg donor site.4 The anterolateral thigh perforator flap is at times too bulky for certain intraoral defects, especially in female and obese patients. In the Caucasian population, it is bulky—with an average thickness of 13 mm in males and 20 mm in females. This may preclude its use for certain intraoral defects, such as those in the anterior mouth floor and the buccal mucosa.7 Some surgeons applied thinned anterolateral thigh flap for the reconstruction of oral defects.8 However, in our experience and that of others, primary thinning runs the risk of damaging the subdermal plexus and can result in flap ischemia and partial necrosis.9,10 A number of perforator flaps have been described, but thin perforator flaps are still uncommon. Yoshimura et al introduced the peroneal flap in 1984.11 This flap can be harvested with the fibular bone as an osteocutaneous flap or with the fibula bone and the soleus muscle as a osteomyocutaneous flap. The pedicle, which is the peroneal artery, is sacrificed in the harvesting of this flap. In 1994, Yajima et al described the proximal lateral leg flap.5 They based the flap on the cutaneous branches of the major nutrient vessel to the soleus muscle, thereby
Downloaded from oto.sagepub.com at MICHIGAN STATE UNIV LIBRARIES on April 5, 2015
794
Otolaryngology–Head and Neck Surgery 151(5)
Figure 3. (a) A 20-year-old woman (case 3) presented with scalp defect and exposure of prosthetic cranium (methylmethacrylate). The prosthesis was removed, and the wound was covered with a flap measuring 4 3 4 cm. (b) The flap survived well and resulted in stable wound coverage. (c) Two-year follow-up of the donor site: Only a good linear scar is visible.
sparing the peroneal artery. With the introduction of the concept of perforator flaps, Kawamura with Yajima and others in 2005 described in 2 separate reports the use of this flap and renamed it the ‘‘soleus perforator flap.’’12,13 According to our experiences in this series, 47% of the flap perforator used were septocutaneous. These perforator vessels do not necessarily have to penetrate the soleus muscle. We do not use the term ‘‘peroneal perforator flap’’ either, because (1) there is a potential to harvest multiple perforator flaps from this vessel from multiple areas of the lower leg and (2) at the proximal lateral leg, the perforator can originate from several different source arteries other than the peroneal artery. We therefore recommend the use of its original name: the proximal lateral leg flap.5 This is in accordance to the location of the flap. This flap was chosen for patients with T1 or T2 primary intraoral malignancies of the buccal mucosa, mouth floor, and tongue, as well as for small- to medium-sized superficial head and neck defects, usually with a width of less than 6 cm. Before the reconstruction, we always held discussions with the patients and their families to explain the advantages and disadvantages of both the radial forearm flap and the proximal lateral leg flap. In those patients where the functional and cosmetic morbidities of the radial forearm donor site were of immense concern, the proximal lateral leg flap could be used. The learning curve for elevating the proximal lateral leg perforator flap is short. The flap can be elevated within 30 minutes with experience. Due to the short pedicle of this flap, we chose the lingual artery and the facial artery as the recipient vessels in most cases. Numerous veins can be used in this area. The average size of the perforator arteries was 1.4 mm, although it may at times be less than 1.0 mm. The small diameter of the pedicle vessels was the main challenge for anastomosis, but it was not especially difficult in the hands of an experienced microsurgeon. Venous thrombosis was seen in 5 of 18 flaps (28%) in Kawamura’s series.12 These 5 flaps were successfully salvaged, and all 18 flaps
survived completely. In our series, 1 flap developed venous thrombosis, and this was successfully salvaged. We prefer to perform 2 venous anastomoses where possible, to reduce the possibility of venous thrombosis. Our flap survival rate was 100%, which is comparable to the use of the radial forearm flap or the anterolateral thigh flap. When compared to the ‘‘peroneal perforator flap’’ located at distal lower leg in Kawamura’s study,12 the proximal lateral leg flap has the advantage of being located in a region where the surrounding skin is looser. This permits a slightly larger flap to be harvested while still allowing for primary closure of the donor site. The proximal lateral leg flap also has a longer pedicle than the ‘‘peroneal perforator flap’’ described by Kawamura et al. Although we used the proximal lateral leg flap in 4 patients who had second primary malignancies, it is often more difficult to dissect out an adequate recipient vessel in patients who had undergone previous surgery or radiotherapy, owing to diffuse fibrosis. In secondary free flap transfer, the shorter and smaller pedicle of the proximal lateral leg flap increases the difficulty with anastomosis and ultimately may increase the risk of flap failure. We suggest that this flap be used as an alternative to the radial forearm flap for selected patients with primary head and neck malignancies where a small and thin flap is required. Some surgeons recommend the use of color duplex ultrasound,14 computed tomographic angiography,15 or magnetic resonance angiography16 for perforator flaps with variable anatomy, such as anterolateral thigh flap and deep inferior epigastric perforator flap. However, because the vascular anatomy of this flap is simple and the skin at the proximal lateral leg is thin, even if the perforator was a musculocutaneous type, the intramuscular course was short. We did not perform any of the aforementioned diagnostic tools in our series. In all our cases, 1 or 2 perforator vessels could easily be located by Doppler flowmeter preoperatively. We made the anterior incision first, which is an important modification
Downloaded from oto.sagepub.com at MICHIGAN STATE UNIV LIBRARIES on April 5, 2015
Hsu et al
795
Table 1. Comparison of Different Perforator Flaps for Head and Neck Reconstruction. Name of Flap Proximal lateral leg flap Medial sural artery perforator flap21,22 Anterolateral thigh flap6,7 Deep inferior epigastric perforator flap17,18 Thoracodorsal artery perforator flap17,19 Anteromedial thigh flap20
Pedicle Length, cm
Arterial Diameter, mm
Flap Thickness, mm
Perforator Type
7 9-16 15 8-12 15 7-13
1.4 1-2 2-3.5 2.5 2 1.0-1.5
5.5 5.2 13, 20a N/A N/A N/A
S/M M S/M M M S/M
Abbreviations: M, musculocutaneous; N/A, not available; S, septocutaneous. a Male, female.
different from the previous surgical technique described.5 We found that in this way, it was easier to locate the septocutaneous perforator. Patients with peripheral artery occlusive disease were excluded from the use of this flap. We usually took a detailed history of high-risk patients with a history of tobacco use, diabetes mellitus, dyslipidemia, or hypertension and those presenting with symptoms and signs of claudication and chronic ulcer. Clinically, if there were noticeable changes in color or temperature of the affected limb, as well as diminished hair and nail growth, these were suggestive of peripheral arterial disease. The peripheral pulses were palpated and the ankle-brachial index (ABI) measured. Any patients with an ABI less than 0.9, by definition, have some degree of peripheral arterial occlusive disease. The ABI decreases with worsening peripheral artery disease. If peripheral arterial disease was diagnosed both clinically and with an ABI less than 0.9, we then avoided the use of this flap. Although angiography remains the gold standard in arterial imaging study used in the diagnosis of peripheral artery disease, this test was usually reserved for the planning of an intervention (either endovascular or traditional open bypass surgery). However, diabetes mellitus and old age did not prevent us from the use of this flap. We used this flap in 5 diabetic patients and in 4 patients older than 65 years. Besides the anterolateral thigh flap, several other perforator flaps can be used for head and neck soft tissue reconstruction, each with its own advantages and disadvantages.17-22 Among these, the medial sural artery perforator flap21,22 has thickness similar to that of the proximal lateral leg flap, as well as a longer pedicle with larger vessels. But there is difficulty in the mapping of a reliable perforator for this flap, owing to variations in perforator anatomy. Chen et al22 even suggested the use of an endoscope to aid in the identification of a reliable perforator. There is also a need for tedious intramuscular dissection, resulting in a much longer flap-harvesting time. These are the major drawbacks to using this flap. A comparison of the different perforators flaps used for head and neck reconstruction is shown in Table 1.6,7,17-22
Conclusion The free proximal lateral leg flap has following advantages: (1) the flap is thin and flexible; (2) there is no need to sacrifice any main arteries in the lower leg; (3) it has constant
anatomic structures and blood supply; (4) it is possible to close the skin defect at the donor site primarily if the width of flap is less than 6 cm, with a good linear scar; (5) there is minimal donor site morbidity; and (6) it can be harvested in the supine position, allowing a simultaneous 2-team approach. The disadvantages of this flap include (1) small vessel diameter (and short in some cases) and (2) hairy skin in some patients, although this is not very common in Asian patients. We suggest that the free proximal lateral leg flap is a useful option for selected patients with small and thin defects of the head and neck region. In these selected cases, it may be used as an alternative to the radial forearm flap. Author Contributions Honda Hsu, contributing surgeon, conception and design, data analysis, drafting of manuscript and final approval, responsible for content of manuscript; Peir-Rong Chen, contributing surgeon, data analysis and review and revising of manuscript, final approval, responsible for content of manuscript; Sou-Hsin Chien, contributing surgeon, data analysis and review and revising of manuscript, final approval, responsible for content of manuscript; Jiunn-Tat Lee, chief surgeon, conception and design, data analysis and final approval, drafting of manuscript as well as revising it critically for important intellectual content, responsible for content of manuscript.
Disclosures Competing interests: None. Sponsorships: None. Funding source: None.
Supplemental Material Additional supporting information may be found at http://otojournal .org/supplemental.
References 1. Richardson D, Fisher SE, Vaughan ED, et al. Radial forearm flap donor-site complications and morbidity: a prospective study. Plast Reconstr Surg. 1997;99:109-115. 2. Timmons MJ, Missotten FE, Poole MD, et al. Complications of radial forearm flap donor sites. Br J Plast Surg. 1986;39: 176-178. 3. Lutz BS, Wei FC, Chang SC, et al. Donor site morbidity after suprafascial elevation of the radial forearm flap: a prospective
Downloaded from oto.sagepub.com at MICHIGAN STATE UNIV LIBRARIES on April 5, 2015
796
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Otolaryngology–Head and Neck Surgery 151(5) study in 95 consecutive cases. Plast Reconstr Surg. 1999;103: 132-137. Lee JT, Chen PR, Cheng LF, et al. A comparison between proximal lateral leg flap and radial forearm flap for intraoral reconstruction. Ann Plast Surg. 2013;71(1):S43-S47. Yajima H, Ishida H, Tamai S.Proximal lateral leg flap transfer utilizing major nutrient vessels to the soleus muscle. Plast Reconstr Surg. 1994;93:1442-1448. Wei FC, Jain V, Celik N, et al. Have we found an ideal softtissue flap? An experience with 672 anterolateral thigh flaps. Plast Recosntr Surg. 2002;109:2219-2226. Yu PU.Characteristics of the anterolateral thigh flap in a Western population and its application in head and neck reconstruction. Head Neck. 2004:26:759-769. Loreti A, Di Lella G, Vetrano S, et al. Thinned anterolateral thigh cutaneous flap and radial fasciocutaneous forearm flap for reconstruction of oral defects: comparison of donor site morbidity. J Oral Maxillofac Surg. 2008;66:1093-1098. Ross GL, Dunn R, Kirkpatrick J, et al. To thin or not to thin: the use of the anterolateral thigh flap in the reconstruction of intraoral defects. Br J Plast Surg. 2003;56:409-413. Sharabi SE, Hatef DA, Koshy JC, et al. Is primary thinning of the anterolateral thigh flap recommended? Ann Plast Surg. 2010;65:555-559. Yoshimura M, Imura S, Shimamura K, et al. Peroneal flap for reconstruction in the extremity: preliminary report. Plast Reconstr Surg. 1984;74:402-409. Kawamura K, Yajima H, Kobata Y, et al. Clinical applications of free soleus and peroneal perforatos flaps. Plast Reconstr Surg. 2005;115:114-119. Kawamura K, Yajima H, Kobata Y, et al. Coverage of big toe defects after wrap-around flap transfer with a free soleus perforator flap. J Reconstr Microsurg. 2005;21:225-229.
14. Ensat F, Babl M, Conz C, et al. The efficacy of color duplex sonography in preoperative assessment of anterolateral thigh flap. Microsurg. 2012;32:605-610. 15. Smit JM, Klein S, Werker PM.An overview of methods for vascular mapping in the planning of free flaps. J Plast Reconstr Aesthet Surg. 2010;63:e674-e682. 16. Vasile JV, Newman TM, Prince MR, et al. Contrast-enhanced magnetic resonance angiography. Clin Plast Surg. 2011;38: 263-275. 17. Guerra AB, Lyons GD, Dupin CL, et al. Advantages of perforator flaps in reconstruction of complex defects of the head and neck. Ear Nose Throat J. 2005;84:441-447. 18. Louie O, Dickinson B, Granzow J, et al. Reconstruction of total laryngopharyngectomy defects with deep inferior epigastric perforator flaps. J Reconstr Microsurg. 2009;25:555-558. 19. Bach CA, Wagner I, Lachiver X, et al. The free thoracodorsal artery perforator flap in head and neck reconstruction. Eur Ann Otorhinolaryngol Head Neck Dis. 2012;129:167-171. 20. 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;71:375-379. 21. Kao HK, Chang KP, Wei FC, et al. Comparison of the medial sural artery perforator flap with the radial forearm flap for head and neck reconstructions. Plast Reconstr Surg. 2009;124: 1125-1132. 22. Chen SL, Chen TM, Dai NT, et al. Medial sural artery perforator flap for tongue and floor of mouth reconstruction. Head Neck. 2008;30:351-357.
Downloaded from oto.sagepub.com at MICHIGAN STATE UNIV LIBRARIES on April 5, 2015
Application of Proximal Lateral Leg Perforator Flaps for Head and Neck Reconstructions
Otolaryngology– Head and Neck Surgery 2014, Vol. 151(5) 791–796 Ó American Academy of Otolaryngology—Head and Neck Surgery Foundation 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0194599814549731 http://otojournal.org
Honda Hsu, MBChB1,2, Peir-Rong Chen, MD2,3, Sou-Hsin Chien, MD2,4, and Jiunn-Tat Lee, MD2,5
No sponsorships or competing interests have been disclosed for this article.
Abstract Objective. Analyze the reliability, complications, and donor site morbidity of the proximal lateral leg flap when applied to head and neck reconstruction. Study Design. Case series and chart review. Setting. Tertiary care teaching hospital. Subjects and Methods. Nineteen patients who underwent reconstruction of various head and neck defects with this flap were analyzed. The patient demographics, flap characteristics, method of donor site closure, scars of the donor area, complication rates, as well as functional results at the recipient site were assessed. Results. The flap size ranged from 4 3 4 cm to 11 3 8 cm. Vascular pedicle length ranged from 5 to 9 cm. The mean distance of the perforator from the fibula head was 9.2 cm. The mean thickness of this flap was 5.5 mm. All the donor wounds were closed primarily. The flap survival rate was 100%. Conclusion. This flap has the advantages of thinness, short harvesting time, minimal donor site morbidity, and primary closure at the donor site when the flap width is less than 6 cm. This flap may be useful for reconstruction in selected patients with small and thin heads and neck defects. Keywords
allowed the reconstructive surgeon to harvest flaps without sacrificing underlying muscle and major vasculature. Yajima et al introduced the proximal lateral leg flap in 1994.5 They found that there were usually 1 or 2 perforators located at the distal portion of the proximal third of the lower lateral leg along the posterior margin of the fibula. This flap was based on these perforator vessels, thus preserving the peroneal artery. If a thin and pliable flap is required in head and neck reconstruction, the proximal lateral leg flap will do as well as the radial forearm flap in selected cases but is associated with minimal donor site morbidity. In this study, we analyzed the reliability, complications, and donor site morbidity of the proximal lateral leg flap when applied to head and neck reconstruction.
Materials and Methods A retrospective study of medical records was performed at Hualien Tzu Chi General Hospital from September 2005 to June 2012. The institutional review board of Hualien Tzu Chi General Hospital approved the review of charts. Nineteen patients with various head and neck defects were reconstructed with a proximal lateral leg flap. Most patients had T1 or T2 intraoral malignancies. Indications for the usage of this flap were as follows: first, in patients with thin, small- to medium-sized defects with a width of less than 6 cm, which allowed direct closure of the donor site over the lateral leg; second, in those patients where donor site morbidity and cosmesis are important issues. We usually performed a pinch test to determine if the donor site
proximal lateral leg, perforator flap, head and neck 1
Received March 13, 2014; revised July 24, 2014; accepted August 12, 2014.
S
ince the 1980s, free tissue transfer has provided the reconstructive surgeon with an alternative treatment option for patients with head and neck cancer. If the defect to be reconstructed is small and thin, then the radial forearm free flap is a good and reliable choice. However, the main disadvantage of this flap is that the radial artery has to be sacrificed. It is also associated with a myriad of donor site morbidities.1-4 Nowadays, perforator flaps have
Division of Plastic Surgery, Buddhist Dalin Tzu Chi Hospital, Dalin, Taiwan School of Medicine, Tzu Chi University, Hualien, Taiwan 3 Department of Otolaryngology, Buddhist Tzu Chi General Hospital, Hualien, Taiwan 4 Division of Plastic Surgery, Buddhist Taichung Tzu Chi General Hospital, Taichung, Taiwan 5 Division of Plastic Surgery, Buddhist Tzu Chi General Hospital, Hualien, Taiwan 2
Corresponding Author: Jiunn-Tat Lee, MD, Division of Plastic Surgery, Buddhist Tzu Chi General Hospital, Hualien Tzu Chi University, No. 707, Sec. 3, Chung Yang Rd., Hualien 970, Taiwan, ROC Email: [email protected]
Downloaded from oto.sagepub.com at MICHIGAN STATE UNIV LIBRARIES on April 5, 2015
792
Otolaryngology–Head and Neck Surgery 151(5)
Figure 1. (A) The location of the perforators can be easily detected with a handheld Doppler flowmeter. One or two perforators are usually located near the distal portion of the proximal third of the lateral leg. (B) Cross-section anatomy showing that the flap can be based on a musculocutaneous or septocutaneous perforator.
could be closed primarily. A handheld Doppler flowmeter was used to localize the perforators preoperatively. The patient’s age, sex, etiology, tumor location, histology, stage, size of defect, flap size, flap dissection time, flap thickness, pedicle length, diameter of the vascular pedicle, as well as the distance of the pedicle from the fibula head were recorded. The method of donor site closure was also recorded. The complication rates and flap failure rates were noted. Functional results at the recipient site, including diet and speech, were evaluated at 1-year postsurgery. Clinical assessment of the motor function of the leg, the range of motion of the ankle joint, and cosmesis of the donor sites were evaluated too. All the linear scars of the donor area were assessed for width, height, vascularity, and pigmentation. The patients were asked to self-evaluate the cosmesis of the donor site subjectively.
Surgical Procedure Based on a 2-team approach, the proximal lateral leg flap was harvested simultaneously with oncologic resection. The patient was placed in the supine position with the hip and knee flexed. The outline of the fibula was marked out and divided into 3 equal parts. The location of perforator vessels was identified preoperatively with a handheld Doppler flowmeter. There were usually 1 or 2 points near the distal portion of the proximal third of the lateral leg along the posterior margin of the fibula,5 usually 7 to 15 cm from the fibula head, where a perforator could be located. The perforator could be located without difficulty and with accuracy because of the thinness of the skin at this area. The outline of the flap was then designed to include the marked-out points (Figure 1A). Tourniquet was not applied, as this would hinder us from visualizing the perforator, as well as its pulsatile strength, with clarity. The skin was incised anteriorly to the posterior septum and the flap elevated subfascially. After the presence of the perforator vessels was confirmed, the flap was elevated from the posterior border. The perforator vessel was dissected intramuscularly with ligation of the muscular branches if it
was found to be traversing the soleus muscle. If a septocutaneous perforator was found, then the dissection was straightforward (Figure 1B). When more than 1 perforator was present, the larger perforator or the septocutaneous perforator was chosen. The soleus muscle was then detached from the fibula, and the bifurcation of the perforator vessels from the main artery was located. The flap was elevated after the perforator vessels were ligated at their bifurcation. The peroneal nerve could at times be encountered during proximal dissection of the flap. This must be carefully protected to avoid potential injury to the peroneal nerve. The donor site was closed primarily in all our cases.
Results A total of 19 cases were included in the study. The flap was used for coverage of intraoral soft tissue defects in 16 patients; these included 12 primary malignancies (Figure 2) and 4 second primary malignancies, the face in 1 patient, the chin in 1 patient, and the scalp in 1 patient (Figure 3). There were 14 men and 5 women, with a mean age of 53 years old (range, 20 to 70 years). The final pathology for all 16 patients with oral cancer was squamous cell carcinoma. The patients’ data are shown in Table S1 (available at otojournal.org). The flap size ranged from 4 3 4 cm to 11 3 8 cm. The mean thickness of the flap was 5.5 mm (range, 3.5 to 7 mm). The mean distance of the perforator from the fibula head was 9.2 cm (range, 7 to 15 cm), and the mean length of the vascular pedicle was 7 cm (range, 5 to 9 cm). The mean time of flap harvesting was 48 minutes (range, 30 to 80 minutes). In 47% of the cases, a septocutaneous perforator was used, and in 53%, a musculocutaneous perforator was used. The mean diameter of the perforator artery was 1.4 mm (range, 0.8 to 2.0 mm). Five flaps had only a single vein; the other 14 flaps had 2 veins. The diameter of the vena comitans ranged from 1.2 to 2.8 mm (mean, 1.9 mm). No vein graft was used in all these cases. Venous thrombosis developed in a patient with primary oral cancer. This flap was successfully salvaged. The flap survival rate was 100%. The donor site was closed primarily
Downloaded from oto.sagepub.com at MICHIGAN STATE UNIV LIBRARIES on April 5, 2015
Hsu et al
793 intelligible, and comprehensible in all patients by their families and the hospital staff. Only 1 secondary debulking procedure was required, in an obese female patient with a relatively thick flap. As no significant amount of soleus muscle was damaged, even in the presence of a musculocutaneous perforator, the motor function of the donor leg was not affected, and the ankle’s range of motion was within normal limits. No peroneal nerve was injured, and no sensory deficits were seen in this series, as the common peroneal nerve was well protected when a more proximally located flap was harvested and the lateral sural nerve was not encountered during the dissection of this flap in our series. None of the patients complained of circulatory or cold intolerance problems. Three patients (16%) had hypertrophic or depressed scar, and 4 (21%) had hyperpigmentation of the scar of the donor leg. Subjectively, all the patients were satisfied with the cosmesis of the scar over the donor leg.
Discussion
Figure 2. (A) A 30-year-old man (case 9) with primary squamous cell carcinoma of the right tongue, post–wide excision, with resultant defect measuring 6 3 4 cm. (B) A flap based on a musculocutaneous perforator was elevated. (C) Six-month postoperative photograph showing a well-healed thin flap contouring the tongue well.
in all 19 cases. Two cases developed wound dehiscence, both of which healed with conservative treatment. The mean follow-up time was 15 months. The functional results at the intraoral recipient site were satisfactory. All patients returned to normal diet. Speech was deemed clear,
For head and neck reconstruction, the anterolateral thigh flap6 and the radial forearm flap have become the workhorse flaps in the past decade at our center. The former is especially useful when a larger and thicker flap is required, while the latter is still the favored flap for small and shallow defects. However, the long-term donor site morbidity1-3 of the radial forearm flap, including functional and aesthetic outcome, offsets many of the benefits of this flap. In the Asian population, where hyperpigmentation and hypertrophic scar commonly occur, cosmesis remains a major problem. We recently performed a comparison between proximal lateral leg flap and the radial forearm flap and found that 48% of patients complained of either functional deficit or poor cosmesis of the radial forearm donor site. In contrast, 83% of patients had excellent or good outcome in the proximal lateral leg donor site.4 The anterolateral thigh perforator flap is at times too bulky for certain intraoral defects, especially in female and obese patients. In the Caucasian population, it is bulky—with an average thickness of 13 mm in males and 20 mm in females. This may preclude its use for certain intraoral defects, such as those in the anterior mouth floor and the buccal mucosa.7 Some surgeons applied thinned anterolateral thigh flap for the reconstruction of oral defects.8 However, in our experience and that of others, primary thinning runs the risk of damaging the subdermal plexus and can result in flap ischemia and partial necrosis.9,10 A number of perforator flaps have been described, but thin perforator flaps are still uncommon. Yoshimura et al introduced the peroneal flap in 1984.11 This flap can be harvested with the fibular bone as an osteocutaneous flap or with the fibula bone and the soleus muscle as a osteomyocutaneous flap. The pedicle, which is the peroneal artery, is sacrificed in the harvesting of this flap. In 1994, Yajima et al described the proximal lateral leg flap.5 They based the flap on the cutaneous branches of the major nutrient vessel to the soleus muscle, thereby
Downloaded from oto.sagepub.com at MICHIGAN STATE UNIV LIBRARIES on April 5, 2015
794
Otolaryngology–Head and Neck Surgery 151(5)
Figure 3. (a) A 20-year-old woman (case 3) presented with scalp defect and exposure of prosthetic cranium (methylmethacrylate). The prosthesis was removed, and the wound was covered with a flap measuring 4 3 4 cm. (b) The flap survived well and resulted in stable wound coverage. (c) Two-year follow-up of the donor site: Only a good linear scar is visible.
sparing the peroneal artery. With the introduction of the concept of perforator flaps, Kawamura with Yajima and others in 2005 described in 2 separate reports the use of this flap and renamed it the ‘‘soleus perforator flap.’’12,13 According to our experiences in this series, 47% of the flap perforator used were septocutaneous. These perforator vessels do not necessarily have to penetrate the soleus muscle. We do not use the term ‘‘peroneal perforator flap’’ either, because (1) there is a potential to harvest multiple perforator flaps from this vessel from multiple areas of the lower leg and (2) at the proximal lateral leg, the perforator can originate from several different source arteries other than the peroneal artery. We therefore recommend the use of its original name: the proximal lateral leg flap.5 This is in accordance to the location of the flap. This flap was chosen for patients with T1 or T2 primary intraoral malignancies of the buccal mucosa, mouth floor, and tongue, as well as for small- to medium-sized superficial head and neck defects, usually with a width of less than 6 cm. Before the reconstruction, we always held discussions with the patients and their families to explain the advantages and disadvantages of both the radial forearm flap and the proximal lateral leg flap. In those patients where the functional and cosmetic morbidities of the radial forearm donor site were of immense concern, the proximal lateral leg flap could be used. The learning curve for elevating the proximal lateral leg perforator flap is short. The flap can be elevated within 30 minutes with experience. Due to the short pedicle of this flap, we chose the lingual artery and the facial artery as the recipient vessels in most cases. Numerous veins can be used in this area. The average size of the perforator arteries was 1.4 mm, although it may at times be less than 1.0 mm. The small diameter of the pedicle vessels was the main challenge for anastomosis, but it was not especially difficult in the hands of an experienced microsurgeon. Venous thrombosis was seen in 5 of 18 flaps (28%) in Kawamura’s series.12 These 5 flaps were successfully salvaged, and all 18 flaps
survived completely. In our series, 1 flap developed venous thrombosis, and this was successfully salvaged. We prefer to perform 2 venous anastomoses where possible, to reduce the possibility of venous thrombosis. Our flap survival rate was 100%, which is comparable to the use of the radial forearm flap or the anterolateral thigh flap. When compared to the ‘‘peroneal perforator flap’’ located at distal lower leg in Kawamura’s study,12 the proximal lateral leg flap has the advantage of being located in a region where the surrounding skin is looser. This permits a slightly larger flap to be harvested while still allowing for primary closure of the donor site. The proximal lateral leg flap also has a longer pedicle than the ‘‘peroneal perforator flap’’ described by Kawamura et al. Although we used the proximal lateral leg flap in 4 patients who had second primary malignancies, it is often more difficult to dissect out an adequate recipient vessel in patients who had undergone previous surgery or radiotherapy, owing to diffuse fibrosis. In secondary free flap transfer, the shorter and smaller pedicle of the proximal lateral leg flap increases the difficulty with anastomosis and ultimately may increase the risk of flap failure. We suggest that this flap be used as an alternative to the radial forearm flap for selected patients with primary head and neck malignancies where a small and thin flap is required. Some surgeons recommend the use of color duplex ultrasound,14 computed tomographic angiography,15 or magnetic resonance angiography16 for perforator flaps with variable anatomy, such as anterolateral thigh flap and deep inferior epigastric perforator flap. However, because the vascular anatomy of this flap is simple and the skin at the proximal lateral leg is thin, even if the perforator was a musculocutaneous type, the intramuscular course was short. We did not perform any of the aforementioned diagnostic tools in our series. In all our cases, 1 or 2 perforator vessels could easily be located by Doppler flowmeter preoperatively. We made the anterior incision first, which is an important modification
Downloaded from oto.sagepub.com at MICHIGAN STATE UNIV LIBRARIES on April 5, 2015
Hsu et al
795
Table 1. Comparison of Different Perforator Flaps for Head and Neck Reconstruction. Name of Flap Proximal lateral leg flap Medial sural artery perforator flap21,22 Anterolateral thigh flap6,7 Deep inferior epigastric perforator flap17,18 Thoracodorsal artery perforator flap17,19 Anteromedial thigh flap20
Pedicle Length, cm
Arterial Diameter, mm
Flap Thickness, mm
Perforator Type
7 9-16 15 8-12 15 7-13
1.4 1-2 2-3.5 2.5 2 1.0-1.5
5.5 5.2 13, 20a N/A N/A N/A
S/M M S/M M M S/M
Abbreviations: M, musculocutaneous; N/A, not available; S, septocutaneous. a Male, female.
different from the previous surgical technique described.5 We found that in this way, it was easier to locate the septocutaneous perforator. Patients with peripheral artery occlusive disease were excluded from the use of this flap. We usually took a detailed history of high-risk patients with a history of tobacco use, diabetes mellitus, dyslipidemia, or hypertension and those presenting with symptoms and signs of claudication and chronic ulcer. Clinically, if there were noticeable changes in color or temperature of the affected limb, as well as diminished hair and nail growth, these were suggestive of peripheral arterial disease. The peripheral pulses were palpated and the ankle-brachial index (ABI) measured. Any patients with an ABI less than 0.9, by definition, have some degree of peripheral arterial occlusive disease. The ABI decreases with worsening peripheral artery disease. If peripheral arterial disease was diagnosed both clinically and with an ABI less than 0.9, we then avoided the use of this flap. Although angiography remains the gold standard in arterial imaging study used in the diagnosis of peripheral artery disease, this test was usually reserved for the planning of an intervention (either endovascular or traditional open bypass surgery). However, diabetes mellitus and old age did not prevent us from the use of this flap. We used this flap in 5 diabetic patients and in 4 patients older than 65 years. Besides the anterolateral thigh flap, several other perforator flaps can be used for head and neck soft tissue reconstruction, each with its own advantages and disadvantages.17-22 Among these, the medial sural artery perforator flap21,22 has thickness similar to that of the proximal lateral leg flap, as well as a longer pedicle with larger vessels. But there is difficulty in the mapping of a reliable perforator for this flap, owing to variations in perforator anatomy. Chen et al22 even suggested the use of an endoscope to aid in the identification of a reliable perforator. There is also a need for tedious intramuscular dissection, resulting in a much longer flap-harvesting time. These are the major drawbacks to using this flap. A comparison of the different perforators flaps used for head and neck reconstruction is shown in Table 1.6,7,17-22
Conclusion The free proximal lateral leg flap has following advantages: (1) the flap is thin and flexible; (2) there is no need to sacrifice any main arteries in the lower leg; (3) it has constant
anatomic structures and blood supply; (4) it is possible to close the skin defect at the donor site primarily if the width of flap is less than 6 cm, with a good linear scar; (5) there is minimal donor site morbidity; and (6) it can be harvested in the supine position, allowing a simultaneous 2-team approach. The disadvantages of this flap include (1) small vessel diameter (and short in some cases) and (2) hairy skin in some patients, although this is not very common in Asian patients. We suggest that the free proximal lateral leg flap is a useful option for selected patients with small and thin defects of the head and neck region. In these selected cases, it may be used as an alternative to the radial forearm flap. Author Contributions Honda Hsu, contributing surgeon, conception and design, data analysis, drafting of manuscript and final approval, responsible for content of manuscript; Peir-Rong Chen, contributing surgeon, data analysis and review and revising of manuscript, final approval, responsible for content of manuscript; Sou-Hsin Chien, contributing surgeon, data analysis and review and revising of manuscript, final approval, responsible for content of manuscript; Jiunn-Tat Lee, chief surgeon, conception and design, data analysis and final approval, drafting of manuscript as well as revising it critically for important intellectual content, responsible for content of manuscript.
Disclosures Competing interests: None. Sponsorships: None. Funding source: None.
Supplemental Material Additional supporting information may be found at http://otojournal .org/supplemental.
References 1. Richardson D, Fisher SE, Vaughan ED, et al. Radial forearm flap donor-site complications and morbidity: a prospective study. Plast Reconstr Surg. 1997;99:109-115. 2. Timmons MJ, Missotten FE, Poole MD, et al. Complications of radial forearm flap donor sites. Br J Plast Surg. 1986;39: 176-178. 3. Lutz BS, Wei FC, Chang SC, et al. Donor site morbidity after suprafascial elevation of the radial forearm flap: a prospective
Downloaded from oto.sagepub.com at MICHIGAN STATE UNIV LIBRARIES on April 5, 2015
796
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Otolaryngology–Head and Neck Surgery 151(5) study in 95 consecutive cases. Plast Reconstr Surg. 1999;103: 132-137. Lee JT, Chen PR, Cheng LF, et al. A comparison between proximal lateral leg flap and radial forearm flap for intraoral reconstruction. Ann Plast Surg. 2013;71(1):S43-S47. Yajima H, Ishida H, Tamai S.Proximal lateral leg flap transfer utilizing major nutrient vessels to the soleus muscle. Plast Reconstr Surg. 1994;93:1442-1448. Wei FC, Jain V, Celik N, et al. Have we found an ideal softtissue flap? An experience with 672 anterolateral thigh flaps. Plast Recosntr Surg. 2002;109:2219-2226. Yu PU.Characteristics of the anterolateral thigh flap in a Western population and its application in head and neck reconstruction. Head Neck. 2004:26:759-769. Loreti A, Di Lella G, Vetrano S, et al. Thinned anterolateral thigh cutaneous flap and radial fasciocutaneous forearm flap for reconstruction of oral defects: comparison of donor site morbidity. J Oral Maxillofac Surg. 2008;66:1093-1098. Ross GL, Dunn R, Kirkpatrick J, et al. To thin or not to thin: the use of the anterolateral thigh flap in the reconstruction of intraoral defects. Br J Plast Surg. 2003;56:409-413. Sharabi SE, Hatef DA, Koshy JC, et al. Is primary thinning of the anterolateral thigh flap recommended? Ann Plast Surg. 2010;65:555-559. Yoshimura M, Imura S, Shimamura K, et al. Peroneal flap for reconstruction in the extremity: preliminary report. Plast Reconstr Surg. 1984;74:402-409. Kawamura K, Yajima H, Kobata Y, et al. Clinical applications of free soleus and peroneal perforatos flaps. Plast Reconstr Surg. 2005;115:114-119. Kawamura K, Yajima H, Kobata Y, et al. Coverage of big toe defects after wrap-around flap transfer with a free soleus perforator flap. J Reconstr Microsurg. 2005;21:225-229.
14. Ensat F, Babl M, Conz C, et al. The efficacy of color duplex sonography in preoperative assessment of anterolateral thigh flap. Microsurg. 2012;32:605-610. 15. Smit JM, Klein S, Werker PM.An overview of methods for vascular mapping in the planning of free flaps. J Plast Reconstr Aesthet Surg. 2010;63:e674-e682. 16. Vasile JV, Newman TM, Prince MR, et al. Contrast-enhanced magnetic resonance angiography. Clin Plast Surg. 2011;38: 263-275. 17. Guerra AB, Lyons GD, Dupin CL, et al. Advantages of perforator flaps in reconstruction of complex defects of the head and neck. Ear Nose Throat J. 2005;84:441-447. 18. Louie O, Dickinson B, Granzow J, et al. Reconstruction of total laryngopharyngectomy defects with deep inferior epigastric perforator flaps. J Reconstr Microsurg. 2009;25:555-558. 19. Bach CA, Wagner I, Lachiver X, et al. The free thoracodorsal artery perforator flap in head and neck reconstruction. Eur Ann Otorhinolaryngol Head Neck Dis. 2012;129:167-171. 20. 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;71:375-379. 21. Kao HK, Chang KP, Wei FC, et al. Comparison of the medial sural artery perforator flap with the radial forearm flap for head and neck reconstructions. Plast Reconstr Surg. 2009;124: 1125-1132. 22. Chen SL, Chen TM, Dai NT, et al. Medial sural artery perforator flap for tongue and floor of mouth reconstruction. Head Neck. 2008;30:351-357.
Downloaded from oto.sagepub.com at MICHIGAN STATE UNIV LIBRARIES on April 5, 2015
