Skip to main content Skip to main navigation menu Skip to site footer

An anterolateral thigh free flap for reconstruction of extensive neck defect in diabetic patient: a case report

Abstract

Introduction: Reconstruction of the head and neck has challenges due to its three-dimensional structure, tissue complexity, extent of the defect, and clinical scenarios. Advances in microsurgical techniques make free tissue transfer reconstruction a popular choice to address these issues. Anterolateral thigh perforator flap (ALT) is a workhorse flap for head and neck reconstruction due to its long and reliable pedicle, large volume, versatility in composition, and low donor morbidity. However, diabetes mellitus may contribute to developing postoperative complications, such as vascular occlusions and thrombosis, that endanger free flap survival and are associated with poor wound healing. This case report demonstrates the successful utilization of this approach in the closure of extensive neck defects in a diabetic patient.

Case Presentation: A 56-year-old male was referred with a 21 cm x 15 cm defect following an odontogenic submandibular abscess. The flaw was extended from the intrabuccal, neck, and one-third of the upper anterior thorax, involving the skin, subcutaneous tissue, and exposed mandibular bone. The patient had previously uncontrolled diabetes mellitus. Surgical debridement, antibiotics, insulin for glucose control, and wound bed preparation were performed. A free fasciocutaneous ALT flap was used for defect closure. The flap was raised template-based, sized 24 × 15 cm, with a pedicle from the descending branch of a lateral circumflex femoral vessel. End-to-end anastomosis of one artery and vein of the superior thyroid vessel was performed. The donor site was closed using a split-thickness skin graft. The surgery and recovery were uneventful. Flap refinement was carried out one month later. The patient underwent a three-month follow-up period, expressing satisfaction with the aesthetic and functional outcomes.

Conclusions: Anterolateral thigh perforator flap (ALT) is a workhorse flap for reconstruction of head and neck reconstruction due to its long and reliable pedicle, large tissue volume with various compositions, and low donor morbidity. The LD  flap presents as an alternative for free tissue transfer. Regional pedicled flaps can be chosen where microsurgery is not available or suitable. However, vascular compromise and flap failure remain a challenge. Identifying and managing risk factors such as diabetes mellitus are needed to minimize significant complications.

Section

References

  1. Vytla S, Gebauer D. Clinical guideline for the management of odontogenic infections in the tertiary setting. Australian Dental Journal. 2017;62(4):464–70. Available from: http://dx.doi.org/10.1111/adj.12538
  2. Beckler AD, Blackwell KE. Microvascular Surgery [Internet]. Oral, Head and Neck Oncology and Reconstructive Surgery. Elsevier; 2018. p. 195–207. Available from: http://dx.doi.org/10.1016/b978-0-323-26568-3.00010-5
  3. Gabrysz-Forget F, Tabet P, Rahal A, Bissada E, Christopoulos A, Ayad T. Free versus pedicled flaps for reconstruction of head and neck cancer defects: a systematic review. Journal of otolaryngology - head & neck surgery = Le Journal d’oto-rhino-laryngologie et de chirurgie cervico-faciale. 2019;48(1):13. Available from: https://pubmed.ncbi.nlm.nih.gov/30871637
  4. Chiu, T.-H., Tsao, C.-K., Chang, S.-N., Lin, J.-W., & Hwang, J.-J. (2021). Clinical consequences of head and neck free-flap reconstructions in the DM population. Scientific Reports, 11(1). doi:10.1038/s41598-021-85410-3 (https://doi.org/10.1038/s41598-021-85410-3)
  5. Brady JS, Govindan A, Crippen MM, Filimonov A, Eloy JA, Baredes S, Park RCW. Impact of diabetes on free flap surgery of the head and neck: A NSQIP analysis. Microsurgery. 2018 Jul;38(5):504-511. doi: 10.1002/micr.30276. Epub 2017 Dec 8. PMID: 29218804.
  6. Rosado P, Cheng HT, Wu CM, Wei FC. Influence of diabetes mellitus on postoperative complications and failure in head and neck free flap reconstruction: a systematic review and meta-analysis. Head Neck. 2015 Apr;37(4):615-8. doi: 10.1002/hed.23624. Epub 2014 Apr 3. PMID: 24532197.
  7. Lim BJ, Shin JY, Roh SG, Lee NH, Chung YK. Clinical analysis of factors affecting the failure of free flaps used in head and neck reconstruction. Arch Craniofac Surg. 2023 Aug;24(4):159-166. doi: 10.7181/acfs.2023.00325. Epub 2023 Aug 20. PMID: 37654235; PMCID: PMC10475704.
  8. Wei, F. C., & Mardini, S. 2016. Flaps and reconstructive surgery E-book. Elsevier Health Sciences.
  9. Khadakban D, Kudpaje A, Thankappan K, Jayaprasad K, Gorasia T, Vidhyadharan S, Mathew J, Sharma M, Iyer S. Reconstructive Indications of Anterolateral Thigh Free Flaps in Head and Neck Reconstruction. Craniomaxillofac Trauma Reconstr. 2016 Mar;9(1):40-5. doi: 10.1055/s-0035-1558455. Epub 2015 Jul 24. PMID: 26889347; PMCID: PMC4755731.
  10. Horn D, Jonas R, Engel M, Freier K, Hoffmann J, Freudlsperger C. A comparison of free anterolateral thigh and latissimus dorsi flaps in soft tissue reconstruction of extensive defects in the head and neck region. Journal of Cranio-Maxillofacial Surgery. 2014;42(8):1551–6. Available from: http://dx.doi.org/10.1016/j.jcms.2013.11.017
  11. Jiao H, Liu L, Gan C, Fan J, Zhang T, Liu L. Anterolateral Thigh Myocutaneous Flap for Reconstruction of a Large Anterior Neck Sinus Caused by Tuberculous Lymphadenitis: a Case Report. SN Comprehensive Clinical Medicine. 2020;2(2):249–52. Available from: http://dx.doi.org/10.1007/s42399-019-00152-8
  12. Caliceti U, Sgarzani R, Cipriani R, Cantore S, Contedini F, Pinto V, et al. Single stage reconstruction of complex head and neck defects involving the skin with a single ALT flap: A ten-year review. JPRAS open. 2019;22:55–64. Available from: https://pubmed.ncbi.nlm.nih.gov/32158897
  13. Chan RCL, Chan JYW. Deltopectoral flap in the era of microsurgery. Surgery research and practice. 2014/01/02. 2014;2014:420892. Available from: https://pubmed.ncbi.nlm.nih.gov/25374953
  14. Mikami T, Kagimoto S, Yabuki Y, Yasumura K, Iwai T, Maegawa J, et al. Deltopectoral flap revisited for reconstruction surgery in patients with advanced thyroid cancer: a case report. BMC surgery. 2017;17(1):101. Available from: https://pubmed.ncbi.nlm.nih.gov/28915833
  15. Liu M, Liu W, Yang X, Guo H, Peng H. Pectoralis Major Myocutaneous Flap for Head and Neck Defects in the Era of Free Flaps: Harvesting Technique and Indications. Scientific reports. 2017;7:46256. Available from: https://pubmed.ncbi.nlm.nih.gov/28387356
  16. Kruse AL, Luebbers HT, Obwegeser JA, Bredell M, Grätz KW. Evaluation of the pectoralis major flap for reconstructive head and neck surgery. Head & neck oncology. 2011;3:12. Available from: https://pubmed.ncbi.nlm.nih.gov/21352590
  17. Driessen, C., Hout, N., Kuppenveld, P., Cristobal, L., Liu, T., Mani, M., & Rodriguez Lorenzo, A. (2020). Usefulness of a template‐based anterolateral thigh flap for reconstruction of head and neck defects. Microsurgery. doi:10.1002/micr.30637 (https://doi.org/10.1002/micr.30637)
  18. Lese, I., Biedermann, R., Constantinescu, M., Grobbelaar, A. O., & Olariu, R. (2020). Predicting risk factors that lead to free flap failure and vascular compromise: A single unit experience with 565 free tissue transfers. Journal of Plastic, Reconstructive & Aesthetic Surgery. doi:10.1016/j.bjps.2020.08.126 (https://doi.org/10.1016/j.bjps.2020.08.126)
  19. Dortch, J. D., Eck, D. L., Ladlie, B., & TerKonda, S. P. (2016). Perioperative Glycemic Control in Plastic Surgery: Review and Discussion of an Institutional Protocol. Aesthetic Surgery Journal, 36(7), 821–830. doi:10.1093/asj/sjw064 (https://doi.org/10.1093/asj/sjw064)
  20. Schuderer JG, Dinh HT, Spoerl S, Taxis J, Fiedler M, Gottsauner JM, Maurer M, Reichert TE, Meier JK, Weber F, Ettl T. Risk Factors for Flap Loss: Analysis of Donor and Recipient Vessel Morphology in Patients Undergoing Microvascular Head and Neck Reconstructions. J Clin Med. 2023. Aug 10;12(16):5206. doi: 10.3390/jcm12165206. PMID: 37629249; PMCID: PMC10455344

How to Cite

Santoso, R. D., Hamid, A. R. R. H. ., & Sanjaya, I. G. P. H. . (2023). An anterolateral thigh free flap for reconstruction of extensive neck defect in diabetic patient: a case report. Indonesia Journal of Biomedical Science, 17(2), 206–210. https://doi.org/10.15562/ijbs.v17i2.492

HTML
57

Total
73

Share

Search Panel

Rosalyn Devina Santoso
Google Scholar
Pubmed
IJBS Journal


Agus Roy Rusly Hariantana Hamid
Google Scholar
Pubmed
IJBS Journal


I Gusti Putu Hendra Sanjaya
Google Scholar
Pubmed
IJBS Journal