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Anterolateral Thigh Free Flap

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					Anterolateral Thigh
    Free Flap
        Garrett Hauptman M.D.
     Vicente A. Resto, M.D., Ph.D.
   University of Texas Medical Branch
    Department of Otolaryngology
      Grand Rounds Presentation
              April 2, 2008
Head & Neck Reconstruction Goals
 #1 = Wound healing



 #2 = Function



 #3 = Cosmesis
      Reconstructive Ladder
Secondary intention
Primary closure
Skin grafting
Local flaps
Distant pedicled flaps
Free tissue transfer
               Overview
Anatomy
Flap Design
Literature Review
Comparisons
Complications
Applications
Anatomy of the Leg
Muscular Anatomy
Vascular Anatomy
Sensory Innervation
History and
Emergence
 Nomenclature Clarification
ALT                         Lateral Thigh
 1984 - Song                  1983 - Baek

 Anterolateral thigh skin     Posterolateral thigh skin

 Lateral circumflex           Profunda femoris → 3rd
 femoral → Descending         cutaneous perforator
 branch
                              Repositioning or flexed
 No repositioning             internally rotated hip with
                              flexed knee
      Emergence of the ALT
Very popular reconstructive flap in Asia
Limited reports of use in Western countries,
particularly United States
  Possible reasons
     Vascular anatomy variations
     Difficult dissection
     Thick thigh fat
Creatures of Habitus
      Workhorse Attributes
No repositioning

Remote from defect

Long pedicle
Flap Design
             Tale of the Tape
Maximum size
  From horizontal line at greater trochanter to horizontal line
  3cm above patella
  25cm X 40cm
Vascular pedicle
  Length = 16cm
  Diameter
     Artery = 2.1mm
     Vein = 2.6mm
Donor site defect can be closed primarily if width <
8cm
                Vascular Pedicle
Lateral circumflex femoral a. → Descending branch →
                      Perforators

Descending branch
   Runs superior to inferior in intramuscular space between rectus femoris
   and vastus lateralis
   Terminates in vastus lateralis just above knee
Perforators: 2 types
   Septocutaneous: run between rectus femoris and vastus lateralis and
   traverse the fascia lata to skin
   Musculocutaneous: traverse vastus lateralis and deep fascia to skin
Details
   8 – 16cm
   2 venae commitantes
                   Landmarks
Line drawn between anterior superior
iliac spine (ASIS) and lateral border of
patella
   Approximates septum between rectus
   femoris and vastus lateralis
Skin perforators mapped by Doppler
   Accuracy decreases as BMI increases
               Yu P. Plast Reconstr Surg 2006
          Perforator Mapping




70 pts.




                       Kimata Y. Plast Reconstr Surg 1998
Perforator Mapping




72 pts.

                Yu P. Head Neck 2004
             Perforator Mapping
Most consistently present perforator midway between ASIS and
superolateral patella
Another perforator may be found more distally and more
proximally
   All within 5cm apart from each other
   Perforators labeled A, B, and C
      A = most proximal
      C = most distal
Perforators range between 0 and 3 per patient with 2.04 being
the mean per patient
   0 = 2%
   1 = 22%
   2 = 54%
   3 = 22%

                                              Yu P. Head Neck 2004
    Cutaneous Perforator Origin
3 Different Origins

  Type I: descending branch of lateral circumflex femoris
  artery (90%)

  Type II: single cutaneous perforator originates from the
  transverse branch of lateral circumflex femoris artery
  and travels longitudinally in vastus lateralis (4%)

  Type III: single perforator from profundus femoris
  artery pierces through rectus femoris (4%)
                                      Yu P. Head Neck 2004
Cutaneous Perforator Origin




                   Yu P. Head Neck 2004
              Type I




Right Thigh


                       Yu P. Head Neck 2004
             Type II




Left Thigh


                       Yu P. Head Neck 2004
              Type III




Right Thigh



                         Yu P. Head Neck 2004
       Perforator Classification
Type 1 (50%): extends
perpendicularly to subdermal
plexus

Type 2 (35%): branch in
adipose and extends to
subdermal plexus

Type 3 (15%): extend along
deep fascia and gradually into
adipose

                                 Kimura N et al. Plast Reconstr Surg 2001
            Flap Harvesting
Initial skin incision on medial flap aspect
Lateral dissection
  Suprafascial technique for thin flap carried laterally
  until perforators identified
  Fasciocutaneous flap (subfascial) involves incision
  through deep fascia with lateral dissection until
  perforators identified
Flap Harvesting
Flap Harvesting
             Flap Harvesting
Skin incisions completed upon perforator identification
Retrograde dissection of pedicle to descending branch
  May involve dissection of vastus lateralis- cuff of muscle may
  be left to protect perforating branches
Lateral femoral cutaneous nerve of thigh may be used
for sensation
Thinning performed in deep fat layer to avoid pedicle
injury
             Sensory Innervation
Lateral femoral cutaneous nerve

  Direct branch of lumbar plexus (L2-L3)
  Enters thigh deep to lateral aspect of inguinal
  ligament near anterior superior iliac spine
  Follows path of deep circumflex iliac artery
  and vein
  Lies along line connecting ASIS to lateral
  patella
  Travels in deep subcutaneous layer
  immediately superficial to deep fascia
Sensory Innervation




                  Yu P. Head Neck 2004
         Flap Composition
Subcutaneous

Fasciocutaneous

Myocutaneous

Adipofascial
Modifications
Two Independent Flaps




               Chou EK. Plast Recostr Surg 2006
Use of Tissue Expander to Allow
        Primary Closure




                     Hallock G. Ann Plast Surg 2004
The Survey Says
          RF’s “Big Brother”
34 consecutive cases
  2 flaps with partial necrosis
  No flap failures
  No significant donor morbidity
Skin
  Large – 40cm X 25cm
  Moderately thick
  Uniform
  Sensate potential
  Multipaddle skin potential


                               Lueg E. Arch Otolaryngol Head Neck Surg 2004
         Largest Case Series
672 ALTs in 660 pts.
87% musculocutaneous perforators & 13%
septocutaneous perforators
439 flaps cutaneous/fasciocutaneous based on
musculocutaneous perforators
Flap failure (15)
  Total = 1.8%
  Partial = 2.5%




                                  Wei F. Plast Reconstr Surg 2002
                Septocutaneous –vs-
                 Musculocutaneous
                Amount & Type     Septocutaneous (%) Musculocutaneous (%)
Song 1984            9 flaps             100                  0
Xu 1988            42 cadavers           40                   60
Koshima 1989         13 flaps           61.5                 38.5
Zhou 1991            32 flaps            37                   63
Wolff 1992         100 cadavers          10                   90
Pribaz 1995          44 flaps            36                   64
Shimizu 1997       41 cadavers           49                   51
Kimata 1997          38 flaps           26.3                 73.7
Sheih 1998           37 flaps           16.2                 83.8
Kimata 1998          70 flaps            18                   82
Luo 1999            152 flaps            18                   82
Demirkan 2000        59 flaps            12                   88
Wei 2002            672 flaps            13                   87
Makitie 2003         39 flaps            23                   77
                Septocutaneous –vs-
                 Musculocutaneous
                Amount & Type     Septocutaneous (%) Musculocutaneous (%)
Song 1984            9 flaps             100                  0
Xu 1988            42 cadavers           40                   60
Koshima 1989         13 flaps           61.5                 38.5
Zhou 1991            32 flaps            37                   63
Wolff 1992         100 cadavers          10                   90
Pribaz 1995          44 flaps            36                   64
Shimizu 1997       41 cadavers           49                   51
Kimata 1997          38 flaps           26.3                 73.7
Sheih 1998           37 flaps           16.2                 83.8
Kimata 1998          70 flaps            18                   82
Luo 1999            152 flaps            18                   82
Demirkan 2000        59 flaps            12                   88
Wei 2002            672 flaps            13                   87
Makitie 2003         39 flaps            23                   77
ALT Versus
ALT –vs- RF for Intraoral Defects
 No functional difference with speech or swallow in
 20 pts. – 10 ALT, 10 RF

 ALT                            RF
   Increased learning curve        Potential tendon exposure
   Primary closure                 Sacrifice dominant distal
   Morbidity related to            forearm blood supply
   vastus lateralis damage         Usually close with STSG
   Potential dysfunction           Potential dysfunction
       Quadriceps                       Hand stiffness
       Pain                             Pain
       Disto-lateral thigh              Anesthesia/parasthesia
       anesthesia/parasthesia
                                Farace F. J Plast Reconstr Aesth Surg 2007
    Advanced Tongue Cancer
Reconstruction: Functional Outcome




                        Chien C. J Cancer Surg 2006
    Advanced Tongue Cancer
Reconstruction: Functional Outcome




                     Chien C. J Cancer Surg 2006
        Reconstruction Trends:
           Pharyngectomy
153 pharyngectomy pts.
  85 partial
  68 circumferential




                          Clark J. Laryngoscope 2006
Reconstruction Trends:
   Pharyngectomy




                  Clark J. Laryngoscope 2006
Pharyngoesophageal Reconstruction:
      ALT –vs- Jejunal Flaps
 57 circumferential reconstructions
   26 ALT & 31 FJT
 Results
   Better function
   Quicker recovery
   More cost-effective
   Similar complication rates



                                Yu P. Plast Reconstr Surg 2006
Complications: ALT –vs- FJT




                   Yu P. Plast Reconstr Surg 2006
TEP Speech: ALT –vs- FJT

    ALT = 89%   FJT = 22%




                     Yu P. Plast Reconstr Surg 2006
Swallowing: ALT –vs- FJT




                 Yu P. Plast Reconstr Surg 2006
Hospital Course: ALT –vs- FJT




                  Yu P. Plast Reconstr Surg 2006
New Sensation
Implications of Sensory Innervation




                           Yu P. Head Neck 2004
Implications of Sensory Innervation
Superior sensory recovery in all testing
modalities
  2 point discrimination
  Monofilament testing
  Pain
  Temperature
Improves swallow function
Improves patient satisfaction
Post-op XRT may delay sensory recovery
                                  Yu P. Head Neck 2004
Complications
       ALT Failure Etiology
Inadvertent perforator division at fascial plane

Inadvertent perforator injury during
intramuscular dissection

Pedicle twisting during inset

Vessel size mismatch
                                Celik N. Plast Reconstr Surg 2002
ALT Failure Rates
                Failure (%)

Sheih 2000         2.7

Demirkan 2000      3.3

Wei 2002           2.2

Makitie 2003       2.6
         Donor-Site Morbidity
37 pts. with free or pedicled ALT
32 primary closure & 5 STSG closure
Results
  Primary closure
     All normal ADLs
     87.5% appearance satisfaction
     1 pt. with ↓ ROM
  STSG
     3/5 with ↓ ROM
     Less appearance satisfaction
  Sensation deficit in 87.5% of entire group

                                       Kimata Y. Plast Reconstr Surg 2000
        Donor-Site Morbidity:
           ALT –vs- RF
37 pts. : 18 ALT, 19 RF
Telephone questionnaire
Results
  Bothered by cold
    RF: 26% -vs- ALT: 0%
  Shape difference bothersome
    RF: 32% -vs- ALT: 11%



                                Novak C. Microsurgery 2007
                  Complications
Necrosis of lower limb- case
report
Obstructed superficial
femoral artery by
angiography
   Lateral circumflex femoral
   artery supplied critical
   collaterals
Importance of checking
popliteal pulsations
   Absence necessitates
   angiography

                                Hage J. Ann Plast Surg 2004
       Post-Operative Complications




23 patients




                         Mureau M. Plast Reconstr Surg 2005
Objective Functional and Aesthetic
    Follow-up: Recipient Site




  14 patients
                     Mureau M. Plast Reconstr Surg 2005
Objective Functional and Aesthetic
      Follow-up: Donor Site




   14 patients

                    Mureau M. Plast Reconstr Surg 2005
Post-Op Scar
Flap Smorgasbord
                   AVM
Pre-operative selective embolization




Resection & ALT reconstruction 6 months post-
embolization



                                Koshima I. Ann Plast Surg 2003
     Buccal Mucosa Defects




Mouth opening and oral intake preserved




                       Chuang HC. Otolaryngol Head neck Surg 2007
Buccal Through-and-Through
Lower Lip




       Yildirim S. Plast Reconstr Surg 2006
Pharyngoesophageal Reconstruction




               Genden E. Arch Otolaryngol Head Neck Surg 2005
Lateral Skull Base Defects




                   Malata C. Ann Plast Surg 2006
Tongue and FOM




          Agostini V. Brit J Plast Surg 2003
Anterior Skull Base
Scalp




        Calikapan G. Microsurgery 2006
Scalp
Combined with Fibula Free Flap
How About Us?
“We’re Doing ’em”
Anterior Skull Base
Total Glossectomy-Total
     Laryngectomy
Total Glossectomy – Total
 Laryngopharyngectomy
Questions
                                                       Bibliography
Hallock GG. The preexpanded anterolateral thigh free flap. Ann Plast Surg. 2004 Aug;53(2):170-3.
                                                                                    Aug;53(2):170-
Lueg EA. The anterolateral thigh flap: radial forearm's "big brother" for extensive soft tissue head and neck defects. Arch Otolaryngol Head Neck Surg. 2004 Jul;130(7):813-8.
                                                                        for                                                                                       Jul;130(7):813-
Lin DT, Coppit GL, Burkey BB. Use of the anterolateral thigh flap for reconstruction of the head and neck. Curr Opin Otolaryngol Head Neck Surg. 2004 Aug;12(4):300-4. Review.
                                                                                                head                                                           Aug;12(4):300-
Rodrí guez-
Rodríguez-Vegas JM, Trillo Bohajar E, Ruiz Alonso E, Casado Pérez C. Refining the anterolateral thigh free flap to prevent orocervical fistula in head and neck reconstruction. Plast Reconstr
            Jul;114(1):174-
Surg. 2004 Jul;114(1):174-7. No abstract available.
Hage JJ, Woerdeman LA. Lower limb necrosis after use of the anterolateral thigh free flap: is preoperative angiography indicated? Ann Plast Surg. 2004 Mar;52(3):315-8.
                                                                                         flap:                                                              Mar;52(3):315-
Yu P. Reinnervated anterolateral thigh flap for tongue reconstruction. Head Neck. 2004 Dec;26(12):1038-44.
                                                          reconstruction.                   Dec;26(12):1038-
                                                                   population
Yu P. Characteristics of the anterolateral thigh flap in a Western population and its application in head and neck reconstruction. Head Neck. 2004 Sep;26(9):759-69.
                                                                                                                                    Head              Sep;26(9):759-
                                                                                                                                                                          Nov;129(5):547-
Mäkitie AA, Beasley NJ, Neligan PC, Lipa J, Gullane PJ, Gilbert RW. Head and neck reconstruction with anterolateral thigh flap. Otolaryngol Head Neck Surg. 2003 Nov;129(5):547-55.
                                                                                                                                         15;112(4):976-
Hsieh CH, Yang CC, Kuo YR, Tsai HH, Jeng SF. Free anterolateral thigh adipofascial perforator flap. Plast Reconstr Surg. 2003 Sep 15;112(4):976-82.
                                                                                                                                        Sep;56(6):614-
Agostini V, Dini M, Mori A, Franchi A, Agostini T. Adipofascial anterolateral thigh free flap for tongue repair. Br J Plast Surg. 2003 Sep;56(6):614-8.
Koshima I, Nanba Y, Tsutsui T, Takahashi Y, Watanabe A, Ishii R. Free perforator flap for the treatment of defects after resection of huge arteriovenous malformations in the head and neck
                                                                                                                             resection
                                Aug;51(2):194-
regions. Ann Plast Surg. 2003 Aug;51(2):194-9.
Ross GL, Dunn R, Kirkpatrick J, Koshy CE, Alkureishi LW, Bennett N, Soutar DS, Camilleri IG. To thin or not to thin: the use of the anterolateral thigh flap in the reconstruction of intraoral
                               Jun;56(4):409-
defects. Br J Plast Surg. 2003 Jun;56(4):409-13.
                                                                                                                      Nov;24(11):975-
Baek CH, Kim BS, Son YI, Ha B. Pharyngoesophageal reconstruction with lateral thigh free flap. Head Neck. 2002 Nov;24(11):975-81.
                                                                                                    tumor-                                     2002;22(6):258-
Lutz BS. Aesthetic and functional advantages of the anterolateral thigh flap in reconstruction of tumor-related scalp defects. Microsurgery. 2002;22(6):258-64.
                                                                                     soft-
Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin CH. Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps. Plast Reconstr Surg. 2002 Jun;109(7):2219-26;
                                                                                                                                                        Plast                      Jun;109(7):2219-
           2227-
discussion 2227-30.
Celik N, Wei FC, Lin CH, Cheng MH, Chen HC, Jeng SF, Kuo YR. Technique and strategy in anterolateral thigh perforator flap surgery, based on an analysis of 15 complete and partial failures
                                                                                                                                     surgery,
                                         Jun;109(7):2211-               2217-
in 439 cases. Plast Reconstr Surg. 2002 Jun;109(7):2211-6; discussion 2217-8.
Rajacic N, Gang RK, Krishnan J, Lal Bang R. Thin anterolateral thigh free flap. Ann Plast Surg. 2002 Mar;48(3):252-7.
                                                                                                        Mar;48(3):252-
                                                Three-
Cipriani R, Contedini F, Caliceti U, Cavina C. Three-dimensional reconstruction of the oral cavity using the free anterolateral thigh flap. Plast Reconstr Surg. 2002 Jan;109(1):53-7.
                                                                                                                   anterolateral                                       Jan;109(1):53-
                                                                                                                                                               Oct;108(5):1197-                 1209-
Kimura N, Satoh K, Hasumi T, Ostuka T. Clinical application of the free thin anterolateral thigh flap in 31 consecutive patients. Plast Reconstr Surg. 2001 Oct;108(5):1197-208; discussion 1209-
10.
Kim HG, Ha B, Baek CH, Park YJ, Hyon WS, Kim JJ, Shin MS. The short head of the biceps femoris as a monitor for the free lateral thigh flap in pharyngoesophageal reconstruction. Br J Plast     Plast
            Jan;54(1):62-
Surg. 2001 Jan;54(1):62-6.
Kimata Y, Uchiyama K, Ebihara S, Sakuraba M, Iida H, Nakatsuka T, Harii K. Anterolateral thigh flap donor-site complications and morbidity. Plast Reconstr Surg. 2000 Sep;106(3):584-9.
                                                                                                          donor-                                                               Sep;106(3):584-
Shieh SJ, Chiu HY, Yu JC, Pan SC, Tsai ST, Shen CL. Free anterolateral thigh flap for reconstruction of head and neck defects following cancer ablation. Plast Reconstr Surg. 2000
                                                                                                                     neck
Jun;105(7):2349-                 2358-
Jun;105(7):2349-57; discussion 2358-60.
Demirkan F, Chen HC, Wei FC, Chen HH, Jung SG, Hau SP, Liao CT. The versatile anterolateral thigh flap: a musculocutaneous flap in disguise in head and neck reconstruction. Br J Plast Surg.
      Jan;53(1):30-
2000 Jan;53(1):30-6.
                                                             De-
Ao M, Uno K, Maeta M, Nakagawa F, Saito R, Nagase Y. De-epithelialised anterior (anterolateral and anteromedial) thigh flaps for dead space filling and contour correction in head and neck
                                       Jun;52(4):261-
reconstruction. Br J Plast Surg. 1999 Jun;52(4):261-7.
Hayden RE, Deschler DG. Lateral thigh free flap for head and neck reconstruction. Laryngoscope. 1999 Sep;109(9):1490-4.
                                                                                       Laryngoscope.        Sep;109(9):1490-
                                                                                                                              1999;19(5):232-
Luo S, Raffoul W, Luo J, Luo L, Gao J, Chen L, Egloff DV. Anterolateral thigh flap: A review of 168 cases. Microsurgery. 1999;19(5):232-8.
Ha B, Baek CH. Head and neck reconstruction using lateral thigh free flap: flap design. Microsurgery. 1999;19(3):157-65.
                                                                              flap                       1999;19(3):157-
Kimata Y, Uchiyama K, Ebihara S, Nakatsuka T, Harii K. Anatomic variations and technical problems of the anterolateral thigh flap: a report of 74 cases. Plast Reconstr Surg. 1998
Oct;102(5):1517-
Oct;102(5):1517-23.
                                                                                                                     Feb;118(2):203-
Truelson JM, Leach JL. Lateral thigh flap reconstruction in the head and neck. Otolaryngol Head Neck Surg. 1998 Feb;118(2):203-10.
                                                     Bibliography
                                                                                                                                                                       2007;27(8):651-
Novak CB, Lipa JE, Noria S, Allison K, Neligan PC, Gilbert RW. Comparison of anterolateral thigh and radial forearm free flap donor site morbidity. Microsurgery. 2007;27(8):651-4.
Chuang HC, Su CY, Jeng SF, Chien CY. Anterior lateral thigh flap for buccal mucosal defect after resection of buccal cancer. Otolaryngol Head Neck Surg. 2007 Oct;137(4):632-5.
                                                                                                    resection                                                       Oct;137(4):632-
Posch NA, Mureau MA, Dumans AG, Hofer SO. Functional and aesthetic outcome and survival after double free flap reconstruction in advanced head and neck cancer patients. Plast Reconstr
            Jul;120(1):124-
Surg. 2007 Jul;120(1):124-9.
                                                                                                                                                     Functional
Farace F, Fois VE, Manconi A, Puddu A, Stomeo F, Tullio A, Meloni F, Pisanu G, Rubino C. Free anterolateral thigh flap versus free forearm flap: Functional results in oral reconstruction. J
                                2007;60(6):583-
Plast Reconstr Aesthet Surg. 2007;60(6):583-7. Epub 2007 Jan 24.
                                                                                                                    Oct;118(5):122e-
Hurvitz KA, Kobayashi M, Evans GR. Current options in head and neck reconstruction. Plast Reconstr Surg. 2006 Oct;118(5):122e-133e. Review.
Yu P, Youssef A. Efficacy of the handheld Doppler in preoperative identification of the cutaneous perforators in the anterolateral thigh flap. Plast Reconstr Surg. 2006 Sep 15;118(4):928-33;
                                                                                                                                               Plast                          15;118(4):928-
            934-
discussion 934-5.
Malata CM, Tehrani H, Kumiponjera D, Hardy DG, Moffat DA. Use of anterolateral thigh and lateral arm fasciocutaneous free flaps in lateral skull base reconstruction. Ann Plast Surg. 20062006
Aug;57(2):169-
Aug;57(2):169-75; discussion 176.
Calderón W, Borel C, Roco H, Piñeros JL, Olguin F. Primary closure of donor site in anterolateral cutaneous thigh free flap. Plast Reconstr Surg. 2006 Jun;117(7):2528-9. No abstract available.
Calderó                           Piñ                                                                                                                    Jun;117(7):2528-
Chou EK, Ulusal B, Ulusal A, Wei FC, Lin CH, Tsao CK. Using the descending branch of the lateral femoral circumflex vessel as a source of two independent flaps. Plast Reconstr Surg. 2006
                                                                                                                          vessel
May;117(6):2059-
May;117(6):2059-63.
            Gideroğ                                      Akö                              thigh-                                           forearm-
Yildirim S, Gideroğlu K, Aydogdu E, Avci G, Akan M, Aköz T. Composite anterolateral thigh-fascia lata flap: a good alternative to radial forearm-palmaris longus flap for total lower lip
                                            May;117(6):2033-
reconstruction. Plast Reconstr Surg. 2006 May;117(6):2033-41.
Spyriounis PK. The extended approach to the vascular pedicle of the anterolateral thigh perforator flap: anatomical and clinical study. Plast Reconstr Surg. 2006 Mar;117(3):997-1001; discussion
                                                                      anterolateral                                                                               Mar;117(3):997-
1002-
1002-3.
                                                                                                      costs                                                        anterolateral
Yu P, Lewin JS, Reece GP, Robb GL. Comparison of clinical and functional outcomes and hospital costs following pharyngoesophageal reconstruction with the anterolateral thigh free flap
                                                   Mar;117(3):968-
versus the jejunal flap. Plast Reconstr Surg. 2006 Mar;117(3):968-74.
Calikapan GT, Yildirim S, Aköz T. One-stage reconstruction of large scalp defects: anterolateral thigh flap. Microsurgery. 2006;26(3):155-9.
                             Akö      One-                                                                                 2006;26(3):155-
                                                                                                                    Microsurgery. 2006;26(3):182-
Ozkan O, Mardini S, Chen HC, Cigna E, Tang WR, Liu YT. Repair of buccal defects with anterolateral thigh flaps. Microsurgery. 2006;26(3):182-9.
Clark JR, Gilbert R, Irish J, Brown D, Neligan P, Gullane PJ. Morbidity after flap reconstruction of hypopharyngeal defects. Laryngoscope. 2006 Feb;116(2):173-81.
                                                                                                                                                   Feb;116(2):173-
Chien CY, Su CY, Hwang CF, Chuang HC, Jeng SF, Chen YC. Ablation of advanced tongue or base of tongue cancer and reconstruction with free flap: functional outcomes. Eur J Surg Oncol.
                                                                                                                            reconstruction                                                 Oncol.
2006 Apr;32(3):353-7. Epub 2006 Feb 7.
      Apr;32(3):353-
                                                                                       Mar;35(3):199-
Lyons AJ. Perforator flaps in head and neck surgery. Int J Oral Maxillofac Surg. 2006 Mar;35(3):199-207. Epub 2005 Nov 15. Review.
                                                                                                                                                       Sep;131(9):796-
Genden EM, Jacobson AS. The role of the anterolateral thigh flap for pharyngoesophageal reconstruction. Arch Otolaryngol Head Neck Surg. 2005 Sep;131(9):796-9.
Posch NA, Mureau MA, Flood SJ, Hofer SO. The combined free partial vastus lateralis with anterolateral thigh perforator flap reconstruction of extensive composite defects. Br J Plast Surg. 2005
                                                                                                            thigh                                                       defects.
Dec;58(8):1095-
Dec;58(8):1095-103. Epub 2005 Jul 25.
Chen CM, Chen CH, Lai CS, Lin SD, Huang IY, Shieh TY. Anterolateral thigh flaps for reconstruction of head and neck defects. J Oral Maxillofac Surg. 2005 Jul;63(7):948-52.
                                                                                                                           defects.                             Jul;63(7):948-
                                                                                                                                                        May;115(6):1547-
Sekido M, Yamamoto Y, Sugihara T. Arterial blood flow changes after free tissue transfer in head and neck reconstruction. Plast Reconstr Surg. 2005 May;115(6):1547-52.
Mureau MA, Posch NA, Meeuwis CA, Hofer SO. Anterolateral thigh flap reconstruction of large external facial skin defects: a follow-up study on functional and aesthetic recipient- and donor-
                                                                                                             facial             follow-                                      recipient-    donor-
                                           Apr;115(4):1077-
site outcome. Plast Reconstr Surg. 2005 Apr;115(4):1077-86.

				
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