Young-Hoon Joo, MD; Kwang-Jae Cho, MD; Jun-Ook Park, MD; Min-Sik Kim, MD

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1 The Laryngoscope VC 2013 The American Laryngological, Rhinological and Otological Society, Inc. Usefulness of the Anterolateral Thigh Flap With Vascularized Fascia Lata for Reconstruction of Orbital Floor and Nasal Surface After Total Maxillectomy Young-Hoon Joo, MD; Kwang-Jae Cho, MD; Jun-Ook Park, MD; Min-Sik Kim, MD Objectives/Hypothesis: The aim of this study was to describe a technique using the fascia lata (FL) component of the anterolateral thigh (ALT) flap to re-create the orbital floor and lateral nasal wall after total maxillectomy. Study Design: Retrospective analysis of medical records. Methods: A total of 22 patients underwent maxillary reconstruction using a composite ALT-FL flap following cancer resection. All patients underwent total maxillectomies via the Weber Ferguson approach. The ALT flap was harvested with the deep fascia of the thigh with the aim of using it for lining of the orbital floor and lateral nasal cavity. The FL was sutured to the palatine bone inferiorly, nasal bone and zygomatic bone superiorly, and nasopharyngeal mucosa posteriorly to provide an orbital floor and make a neonasal cavity. Results: There was 100% free flap survival. Speech was normal in eight (36%) patients, near normal in 10 (46%), and intelligible in four (18%). Seventeen (77%) patients gained a good facial appearance, and five (23%) a fair appearance. Sixteen (73%) patients complained of mild nasal crust formation, and the rest (27%) developed moderate crust. Conclusions: Microvascular reconstruction using a composite ALT-FL flap provided a reliable fascial component for orbital floor and nasal surface reconstruction of total maxillectomy defects. Key Words: Maxilla, reconstructive surgical procedures, free tissue flaps, treatment outcome. Level of Evidence: 4. Laryngoscope, 123: , 2013 From the Department of Otolaryngology Head and Neck Surgery, College of Medicine, Catholic University of Korea, Seoul, Korea. Editor s Note: This Manuscript was accepted for publication September 19, The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Min-Sik Kim, MD, PhD, Department of Otolaryngology-HNS, 505 Banpodong Seochogu Seoul St. Mary s Hospital, Catholic University of Korea, Seoul, Korea entkms@catholic.ac.kr DOI: /lary INTRODUCTION Reconstruction after total maxillectomy with extensive orbital floor represents a significant challenge for the reconstructing surgeon, from both the functional and esthetic points of view. The primary goal of reconstruction of total maxillectomy defect is to provide adequate support to the preserved globe. When the orbital floor defect is small, no reconstruction is needed. However, for larger defects, a rigid support is necessary for the preserved orbital contents to prevent complications like ectropion, enophthalmos, and diplopia. Several techniques have been described for the reconstruction of total maxillary defects, including the use of maxillary prostheses, pedicled flaps, soft tissue free flaps, and bonecontaining free flaps. 1 4 Immediate surgical reconstruction of maxillary defects is increasingly preferred by surgeons. The choice of method is decided by various factors such as amount, location, and quality of residual hard and soft tissue of the midface, as well as the postoperative function. These include use of free bone grafts covered by a soft tissue flap, titanium mesh covered by a soft tissue flap, pedicled vascularized bone, and free vascularized flaps. 5 9 In our institution, reconstruction using an anterolateral thigh fascia lata (ALT-FL) flap has been carried out primarily by emphasizing soft tissue filling and postoperative function. The goals of reconstruction using ALT-FL are to provide oronasal separation and adequate bulk to restore the facial contour, and to recreate adequate orbital support and neonasal cavity. Since its introduction by Song et al. in 1984, the ALT flap has gained widespread use in reconstruction of soft tissue defects in the head and neck after ablative surgery. 10 It is considered a highly versatile and reliable flap that allows a two-team approach and is associated with minimal donor site morbidity. The ALT flap is particularly suitable for maxillary reconstruction, because it provides a large surface area and volume of soft tissue that is pliable. 11,12 Here, we describe a technique using the FL component of the ALT flap to provide orbital support and neonasal cavity and designed to improve postoperative function. MATERIALS AND METHODS Patients The records of 22 consecutive patients who underwent maxillary reconstruction using an ALT-FL flap for sinonasal cancer performed by the senior author (M.-S.K) between May 2125

nonoperative side in contour and symmetry with no ectropion or enophthalmos. Minimal defects included only minor soft tissue and skeletal asymmetry with minor ectropion or enophthalmos.

Severe deformity consisted of gross soft tissue asymmetry, gross skeletal deformation, or severe ectropion or enophthalmos. Nasal crusts were graded as none, mild, moderate, or severe.

2 nonoperative side in contour and symmetry with no ectropion or enophthalmos. Minimal defects included only minor soft tissue and skeletal asymmetry with minor ectropion or enophthalmos. Moderate deformity involved a closed orbit with moderate ectropion or enophthalmos, and moderate soft tissue asymmetry or skeletal deformity as compared with the nonoperative side. Severe deformity consisted of gross soft tissue asymmetry, gross skeletal deformation, or severe ectropion or enophthalmos. Nasal crusts were graded as none, mild, moderate, or severe. The patients were staged according to the 2002 American Joint Committee on Cancer staging system. Fig. 1. Total maxillectomy defect for maxillary cancer. OF ¼ orbital fat; P ¼ palate; S ¼ nasal septum and June 2011 at the Department of Otolaryngology Head and Neck Surgery, College of Medicine, Catholic University of Korea, Seoul, Korea, were reviewed retrospectively. We excluded the maxillary defect including orbital exenteration. No patient had radiological evidence of distant metastases at presentation, and all were treated with curative intent. Functional and esthetic results were evaluated a minimum of 6 months postoperatively. The speech understandability scale was modified from List et al. 13 : always understandable; understandable most of the time with occasional repetition necessary; usually understandable but face-to-face contact necessary; or difficult to understand. Ability to eat solid foods was evaluated using the following criteria: full range of solids with no restrictions; minimally restricted solids with few specific exclusions (eg, bread crumbs); minced, moist, or soft diet; pureed solids; and liquid. Facial contour and aesthetic results were assessed using a modified scale originally described by Funk et al. 14 Patients were graded as: no deformity; minimal deformity; moderate deformity; or severe deformity. Patients with no deformity had an operative side that resembled the appearance of the Surgical Procedures and Reconstructions All patients underwent total maxillectomies via the Weber Ferguson approach with simultaneous reconstruction using the ALT-FL flap. The orbital contents, including the cheek skin, and the contralateral palate were preserved, and the orbital floor was resected (Fig. 1). Twenty patients (91%) had defects of the orbital rim that were >30% to 40% of the entire rim, and the rest (9%) had those <30% to 40% of the orbital rim. The orbital periosteum was resected in 13 (59%) patients. The ALT flap is the flap with the descending branch of the lateral femoral circumflex artery as the pedicle, which is nourished by the vascular system perforating the quadriceps femoris muscle and elevated as the perforator flap. 15 A standard ALT flap is harvested using the techniques of flap planning and dissection, described previously in the literature It is possible to elevate the flap without the deep fascia of the thigh, but in this report, the flap was elevated with the deep fascia of the thigh with the aim of using it for lining of the orbital floor and lateral nasal cavity (Fig. 2). All the flaps were harvested with one skin paddle to reconstruct the palate (Fig. 3). The pedicle was tunneled in a retromandibular space between the mandibular angle and oral mucosa to reach neck recipient vessels (Fig. 4). The FL is secured to the palatine bone inferiorly and nasopharyngeal mucosa posteriorly with absorbable sutures such as 3/0 Vicryl (Fig. 5). The FL is then organized horizontally across the nasal bone and zygomatic bone to re-create the orbital floor as shown in Figures 6 and 7. The repair must have adequate tension to prevent ptosis of orbital contents. Microvascular anastomoses were performed end to end, with the facial artery or lingual artery and with the retromandibular vein or external jugular vein. The flap was harvested proximal to the bifurcation of the transverse and descending branches of the lateral circumflex femoral artery, which resulted in a perfect Fig. 2. Design of an anterolateral thigh free flap. FL ¼ vascularized fascia lata; VP ¼ vascular pedicle. 2126

The donor thighs could be closed directly when the width of the flap was approximately 5 to 8 cm, depending on whether the patient was thin or obese. Fig. 3. Palatal reconstruction.

3 pedicle length with careful preservation of the marginal mandibular and lower facial nerve divisions. The retromandibular vein can often be secured as a venous recipient with reliable location and large caliber. The donor thighs could be closed directly when the width of the flap was approximately 5 to 8 cm, depending on whether the patient was thin or obese. Fig. 3. Palatal reconstruction. ALT ¼ anterolateral thigh free flap; FL ¼ vascularized fascia lata; P ¼ palate. match and considerably simplified the subsequent anastamosis. The facial vessels are often the favored recipients, as they can be easily traced over the antegonial notch to achieve maximal RESULTS The median age was 54.2 years (range, years), and there were 16 males and 6 females. The clinicopathological profiles of the patients are summarized in Table I. The histopathologic diagnosis varied, with the majority of patients being treated for a squamous cell carcinoma (11 of 22, 50%). There were two (9%), seven (32%), and 13 (59%) patients with stage T2 to T4 cancers, respectively. Cervical lymph node metastasis was present in one of the 22 cases (5%). Preoperative radiotherapy was performed in two cases, and full-dose postoperative radiotherapy was indicated for 16 patients. The mean flap size was cm 2 (range, cm 2 ). There was no perioperative mortality, and there was 100% free flap survival. One patient (5%) required re-exploration for vascular compromise, and another patient (5%) developed marginal necrosis of the flap, which resulted in palatal fistula that was managed by Fig. 4. Pedicle delivery. Pedicle was passed to the neck medial to the mandible, spaced between mandible, mylohyoid muscle, and resected medial pterygoid muscle (curved arrow in inset). 2127

Fig. 5. Nasal cavity reconstruction. The fascia lata is secured to the nasopharyngeal mucosa posteriorly. FL ¼ vascularized fascia lata.

No infection or exposure of the FL developed in any of the cases. The functional outcome in terms of speech, swallowing, esthetics, and nasal crust was analyzed (Table II).

understand. All patients take an oral diet; 14 (64%) of these eat a regular Fig. 7. Orbital floor reconstruction. The fascia lata is secured to the zygomatic bone superolaterally.

4 Fig. 5. Nasal cavity reconstruction. The fascia lata is secured to the nasopharyngeal mucosa posteriorly. FL ¼ vascularized fascia lata. healing with secondary intention after debriding the necrotic tissue in the flap. One patient (5%) developed donor site infection associated with the procedure. No infection or exposure of the FL developed in any of the cases. The functional outcome in terms of speech, swallowing, esthetics, and nasal crust was analyzed (Table II). As evaluated through conversations with the patients, eight patients (36%) had normal speech, 10 (46%) were easily understood with minimal abnormality, and four (18%) were occasionally difficult to understand. All patients take an oral diet; 14 (64%) of these eat a regular Fig. 7. Orbital floor reconstruction. The fascia lata is secured to the zygomatic bone superolaterally. FL ¼ vascularized fascia lata; ZB ¼ zygomatic bone. diet. Six (27%) are able to eat soft food, and two (9%) eat primarily pureed foods. According to the surgeon evaluation, 17 patients (77%) gained an excellent or good facial appearance, and the rest (23%) a fair appearance with malar depression (Fig. 8A). In general, patients who had postoperative radiotherapy had the poorer esthetic results. Slightly diplopia developed in one cases (5%) and enophthalmos in two cases (9%), but they did not complain of any disability in daily life. The contact surface to the nasal cavity was covered with FL of the ALT flap through re-epithelialization 2 months postoperatively (Fig. 8B,C). Sixteen (73%) patients complained of mild crust formation or mucous stagnation, and the rest (27%) among patients who had postoperative radiotherapy developed moderate crust formation and dryness. Fig. 6. Orbital floor reconstruction. The fascia lata is secured to the nasal bone superomedially. FL ¼ vascularized fascia lata; NB ¼ nasal bone DISCUSSION Maxillary cancers represent a rare form of head and neck malignancy that can have a profound impact on the quality of life. The direct effects of the cancer, as well as the therapeutic interventions required for treatment, can result in significant facial disfigurement as well as functional disability involving both swallowing and speech. 19 The goals in reconstructing maxillectomy defects are to prevent functional impairment, provide support for orbital content, restore the separation of oral and nasal cavities, reconstruct the palatal surface, and achieve facial symmetry with good esthetic results. The priority among these is the orbital support, because an inadequately supported globe can be associated with significant morbidity of enophthalmos, global ptosis, diplopia, and ectropion. 6 8 Various techniques have been described to support the orbit. Free bone grafts such as rib, calvarium covered by temporalis muscle flaps, and free soft tissue flaps such as rectus abdominis flaps have been described. 7 However, bone grafts tend to resorb and are generally less resistant to infection, especially after

5 TABLE I. Demographic Profiles. Case Gender/Age, yr ptnm Pathology Radiotherapy Flap Size, cm 1 M/71 T3N0M0 Squamous cell carcinoma Postoperative F/39 T2N0M0 Adenoid cystic carcinoma Postoperative M/16 T4aN0M0 Rhabdomyosarcoma Postoperative M/62 T4aN0M0 Adenoid cystic carcinoma Postoperative M/50 T3N1M0 Adenoid cystic carcinoma Postoperative M/61 T4aN0M0 Squamous cell carcinoma Postoperative M/49 T4aN0M0 Carcinoma ex pleomorphic adenoma Preoperative M/56 T3N0M0 Squamous cell carcinoma Postoperative F/33 T3N0M0 Squamous cell carcinoma M/61 T4aN0M0 Squamous cell carcinoma Preoperative M/37 T4aN0M0 Squamous cell carcinoma M/72 T4aN0M0 Squamous cell carcinoma Postoperative M/59 T3N0M0 Squamous cell carcinoma Postoperative F/37 T4aN0M0 Adenoid cystic carcinoma Postoperative F/61 T4aN0M0 Salivary duct carcinoma Postoperative M/66 T4aN0M0 Adenoid cystic carcinoma Postoperative M/54 T4aN1M0 Squamous cell carcinoma Postoperative M/68 T4aN0M0 Squamous cell carcinoma Postoperative F/70 T4aN0M0 Spindle cell carcinoma M/49 T3N0M0 Mucoepidermoid carcinoma F/70 T2N0M0 Mucoepidermoid carcinoma Postoperative M/52 T3N0M0 Squamous cell carcinoma Postoperative 8 17 F ¼ female; M ¼ male; ptnm ¼ pathological tumor lymph node metastasis. radiotherapy. Titanium mesh along with soft tissue flaps has been used to provide support to the globe. 6 However, the potential disadvantages of foreign body reaction and mesh infection were a significant concern. 20 In our institution, we employed microsurgical techniques for free tissue transfer under these circumstances. The radial forearm, rectus abdominis, and ALT are flaps with different amounts and types of soft tissues. The scapula, iliac crest, and fibula are all wellestablished donor sites with an adequate amount of soft tissue and good-quality bone that can be contoured by osteotomies and allow anchorage of dental implants. Although bony reconstruction seems functionally and esthetically ideal, we are not certain if it benefits patients from the viewpoint of total quality of life. We consider that surgical procedures that cause large systemic stress are undesirable, and priority should be given to filling of defects with soft tissues. Previously, we typically used the rectus abdominis free flap. More recently, this flap has been gradually replaced by the ALT flap in maxillary reconstructions. Advantages of the ALT flap, such as a long pedicle, reliable anatomy, suitable vessel diameter, the availability of large amounts of soft tissue (skin, muscle, and fascia), skin-to-skin closure, adaptability as a sensate and/or compound (composite and combined) flap, adaptable volume and thickness, no repositioning of the patient during operation, simultaneously working in two teams, and good TABLE II. Functional Outcomes. Parameters No. (%) Speech Normal 8 (36) Near normal 10 (46) Intelligible 4 (18) Unintelligible 0 (0) Swallowing Unrestricted 10 (46) Minimally restricted 4 (18) Soft 6 (27) Pureed 2 (9) Liquid 0 (0) Esthetic result No deformity 5 (23) Minimal deformity 12 (54) Moderate deformity 5 (23) Severe deformity 0 (0) Nasal crust Absent 1 (5) Mild 15 (68) Moderate 6 (27) Severe 0 (0) 2129

Fig. 8. Postoperative pictures at 1 year after surgery. (A) Frontal view of the patient. (B) Intraoral picture of palatal paddle. (C) Intranasal picture with good internal mucosal lining.

6 Fig. 8. Postoperative pictures at 1 year after surgery. (A) Frontal view of the patient. (B) Intraoral picture of palatal paddle. (C) Intranasal picture with good internal mucosal lining. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] esthetic outcome, are well known. 11,12,15 18 The use of the ALT flap has been widely described and today is considered the first choice for midfacial defect reconstruction worldwide. Bianchi et al. demonstrated the combined use of ALT flaps and nonvascularized bone grafts for the reconstruction of total maxillary defects with good functional results. 11 Rodrıguez-Vegas et al. reported the versatility of ALT-vastus lateralis flaps for reconstruction of complex orbitomaxillary defects. 12 Malata et al. and Amin et al. reported their experience with ALT flaps for skull base and craniofacial defect reconstruction, focusing on the large amount of well-revascularized tissue provided for the filling of dead spaces, the low rate of complications, and the stability of the results obtained. 21,22 In this study, we present the novel use of the ALT flap harvested with vascularized FL component for reconstruction of orbital floor and nasal surface following total maxillectomy. Fixation of the FL to the nasal bone and zygomatic bone creates a platform to support orbital contents. This static reconstruction maintains predictable orbital cavity volume. By using vascularized fascia, moreover, we could avoid the complications of nasal crusts, mucus stagnation, and unpleasant odors associated with nasal reconstruction with a myocutaneous flap. Our study has several limitations. The main limitation was the retrospective analysis. Another limitation was the small number of patients with maxillary reconstruction using ALT-FL flaps. Further studies with a large number of subjects should be made to elucidate postoperative function after total maxillectomy with ALT-FL flaps. CONCLUSION In the present study, we have found composite ALT- FL flaps to be a reliable and safe method for the reconstruction of orbital floor and nasal surface after total maxillectomy. This simple adaptation of the ALT-FL flap achieved good functional outcomes. BIBLIOGRAPHY 1. Ali A, Fardy MJ, Patton DW. Maxillectomy: to reconstruct or obturate? Results of a UK survey of oral and maxillofacial surgeons. Br J Oral Maxillofac Surg 1995;33: Curioni C, Toscano P, Fioretti C. Reconstruction of the orbital floor with the muscle bone flap (temporal muscle with coronoid process). J Oral Maxillofac Surg 1983;11: Genden EM, Wallace DI, Okay D, Urken ML. Reconstruction of the hard palate using the radial forearm free flap: indications and outcomes. Head Neck 2004;26: Brown JS, Jones DC, Summerwill A. Vascularized iliac crest with internal oblique muscle for immediate reconstruction after maxillectomy. Br J Oral Maxillofac Surg 2002;40: Lee HB, Hong JP, Kim KT, et al. Orbital floor and infraorbital rim reconstruction after total maxillectomy using a vascularized calvarial bone flap. Plast Reconstr Surg 1999;104: Hashikawa K, Tahara S, Ishida H, et al. Simple reconstruction with titanium mesh and radial forearm flap after globe-sparing total maxillectomy: a 5-year follow-up study. Plast Reconstr Surg 2006;117: Cinar C, Arslan H, Ogur S, et al. Free rectus abdominis myocutaneous flap with anterior rectus sheath to provide the orbital support in globesparing total maxillectomy. J Craniofac Surg 2006;17: Bilen BT, Kilinc H, Arslan A, et al. Reconstruction of orbital floor and maxilla with divided vascularised calvarial bone flap in one session. J Plast Reconstr Aesthet Surg 2006;59: Cordeiro PG, Santamaria E. A classification system and algorithm for reconstruction of maxillectomy and midfacial defects. Plast Reconstr Surg 2000;105: Song YG, Chen GZ, Song YL. The free thigh flap: a new free flap concept based on the septocutaneous artery. Br J Plast Surg 1984;37: Bianchi B, Ferri A, Ferrari S, Copelli C, Sesenna E. Maxillary reconstruction using anterolateral thigh flap and bone grafts. Microsurgery 2009; 29: Rodriguez-Vegas JM, Angel PA, Manuela PR. Refining the anterolateral thigh free flap in complex orbitomaxillary reconstructions. Plast Reconstr Surg 2008;121: List MA, Ritter-Sterr C, Lansky SB. A performance status scale for head and neck cancer patients. Cancer 1990;66: Funk GF, Laurenzo JF, Valentino J, McCulloch TM, Frodel JL, Hoffman HT. Free-tissue transfer reconstruction of midfacial and cranio-orbitofacial defects. Arch Otolaryngol Head Neck Surg 1995;121: 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;102: 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;109: Koshima I, Fukuda H, Utunomiya R, Soeda S. Free anterolateral thigh flaps for reconstruction of head and neck defects. Plast Reconstr Surg 1993;92: Yu P. Characteristics of the anterolateral thigh flap in a Western population and its application in head and neck reconstruction. Head Neck 2004;26: Irish J, Sandhu N, Simpson C, et al. Quality of life in patients with maxillectomy prostheses. Head Neck 2009;31: Nakayama B, Hasegawa Y, Hyodo I, et al. Reconstruction using a three dimensional orbitozygomatic skeletal model of titanium mesh plate and soft-tissue free flap transfer following total maxillectomy. Plast Reconstr Surg 2004;114: 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 2006;57: Amin A, Rifaat M, Civantos F, Weed D, Abu-Sedira M, Bassiouny M. Free anterolateral thigh flap for reconstruction of major craniofacial defects. J Reconstr Microsurg 2006;22:

A review of the advantages of the anterolateral thigh flap in head and neck reconstruction

The British Association of Plastic Surgeons (2004) 57, 603 609 A review of the advantages of the anterolateral thigh flap in head and neck reconstruction Jagdeep S. Chana, Fu-chan Wei* Department of Plastic