Vittorugo Agostini

Adipofascial anterolateral thigh free flap for tongue repair

With the advent of microsurgery fasciocutaneous free flaps have become a well known and accepted option for the repair of tongue defects. Many authors have tried to recover tongue function by modifying this approach. An innovative method for the repair of tongue defects using an adipofascial anterolateral thigh free flap is presented in this paper. The results are compared with those of tongue reconstructions implementing traditional fasciocutaneous free flaps performed at our institution. The histological features of the flaps were investigated postoperatively. Although this preliminary report has to be confirmed by further experience, it seems to solve many tongue-reconstruction related problems.

Current roles of adipofascial anterolateral thigh flap in head and neck reconstructions.

To the Editor: It is with interest that we read the article published by Wong and Wei, titled ‘‘Anterolateral Thigh Flap,’’ in the May issue of Head and Neck. The report is focused on technical aspects regarding vascular and surgical anatomy and pitfalls of harvesting, giving an almost unique guide to flap rising. The anterolateral thigh (ALT) flap can be classified in different clinical configurations equipped with well-defined indications based on the receiving site: fasciocutaneous, myocutaneous, and cutaneous. The cutaneous variant of this flap is harvested as thinned or ultrathinned, depending on the defatting procedures, and its main advantage relies on the preservation of the deep fascia, reducing the risk for muscle herniation. Because of the thinning procedures and the possibility of harvesting a sensate flap (the lateral cutaneous femoral nerve), the flap is ideal for reconstructing oral cavity defects. This flap can be harvested as a flow-through type 1 and type 2, making it feasible to reconstruct through-and-through defects of the mandible. In 2003 V. Agostini and colleagues pioneered the concept of adipofascial anterolateral thigh (AALT) flap in oral cavity reconstruction: the first report describes a hemiglossectomy defect reconstructed with an adipofascial ALT flap. The A-ALT flap is harvested as a fasciocutaneous ‘‘leaf shape’’ flap with 1to 2-cm fascia around the pedicle to preserve the fascial plexus because the main blood supply to the skin arises from the outer fascial layer, passing as fasciocutaneous or muscolocutaneous perforators with branches perpendicularly oriented or radiated. The flap is thinned to fit the defect resulting from tumor excision (extreme thinning should be avoided in anticipation of postoperative radiotherapy), and meticulous hemostasis is achieved before pedicle section. The main portion of the flap is reversesutured in the oral cavity at the level of the lamina propria of the native mucosa to obtain obstacle-free advancement of the neomucosa over the deep fascia. The vascular pedicle is tunneled into the neck well protected from saliva. The A-ALT flap represents a valid alternative to oral cavity reconstruction, supplying a functional, hairless tissue 45 days later, observing the principle of ‘‘replace tissue with like tissue’’ and avoiding the ‘‘patch effect’’ of fasciocutaneous flaps. The idea of reconstructing oral cavity defects using fascial flaps has been previously tested by others who studied the remucosalization of the myofascial pectoralis major flap. The histologic results proved the flap was covered with a thin layer of squamous mucosa 1 month after surgery not influenced by postoperative radiotherapy. Flap thinning has had a major impact in the Western countries compared with Eastern countries because of the higher incidence of obesity in the West. Alkureishi and colleagues experienced partial or total necrosis of the distal skin from the perforator of thinned fasciocutaneous ALT flaps to oral cavity reconstructions, probably attributable to saliva interference with the subdermal plexus. A-ALT advantages include volume preservation over time, thus maintaining the palatal contact and the propulsive proprieties of a neo-tongue enhancing the residual mobility and re-creation of the hyoid mandibular tension arch with improved stability of the larynx–hyoid bone complex. Because neomucosa is a functional tissue, the lateral cutaneous femoral nerve dissection can be avoided. It does not preclude muscle harvesting (vastus lateralis/rectus medialis) in the mioadipofascial configuration for more demanding reconstructions. Moreover, the A-ALT flap avoids prelamination with unjustified delayed tumor resection and double-paddle flaps to throughand-through defects of the cheek and the floor of the mouth. Twelve patients underwent reconstruction with the A-ALT flap after squamous cell carcinoma resection of the oral cavity between December 2005 and August 2010 (Table 1). All patients underwent postoperative radiotherapy with flap volume and function maintenance. To limit wound contraction and impaired function, we always dissected more fascia compared with soft tissue. Thinning was uneventful, without partial or marginal necrosis, and we did not experience fascial slough that required debridement. One patient presented a scarring bridle without functional loss after reconstruction of the entire mobile tongue, which did not require surgery, and patient 4 had an orocutaneous fistula with spontaneous healing. One flap failed as the result of venous thrombosis, despite re-exploration. All underwent comparative biopsies (colored with hematoxylin and eosin stain) between the neomucosa and the native mucosa, showing a squamous epithelial lining and a mild inflammatory infiltrate charged to the lamina propria. Our results show the hot, cold, and touch sensitivities of Head & Neck 33: 595–597, 2011 Published online 7 March 2011 in Wiley Online Library (wileyonlinelibrary.com) DOI 10.1002/hed.21710 VC 2011 Wiley Periodicals, Inc.

Delayed free flap salvage after venous thrombosis.

The incidence of free flap failure is reported at 4% to 5%,but pedicle thrombosis occurs in a higher percentage, with the difference resulting from successful salvage of failing flaps. Often, these failures are attributed to postoperative venous thrombosis with salvage reported at 42%. The venous engorgement of the flap and the resulting microvascular changes lead to a more rapid and less reversible no-reflow phenomenon established within 6 hours. However, this report shows successful free flap salvage with thrombolytic drugs after 6 hours, highlighting that the mechanisms of free flap failure are still poorly understood.

Adipofascial versus fasciocutaneous anterolateral thigh flap in oral cavity reconstruction. Focus on the vascular supply

Figure 1 The eccentric proximal perforator provides a longer vascular pedicle in a leaf ‘shape configuration’. The skin is excised and haemostasis performed. The flap is thinned to fill the defect with care to harvest 2 cm of fascia around the pedicle to preserve the vascularization. The first goal is a radical excision of the tumor followed by an immediate reconstruction which should aim to restore function and cosmesis at both donor and recipient sites. The success of the radial forearm flap resides in the replacement of the thin oral lining with a thin and pliable tissue. Since 1984 several methods to thin the anterolateral thigh flap (ALT) are described in literature for the lower and upper limbs, neck and oral cavity reconstruction. The different constitution of the Orientals explains the widespread use of the ALT flap by the Asiatic colleagues; indeed the high incidence of obesity limited the diffusion in our countries and as a consequence an extensive thinning is necessary to obtain the desired thickness. Alkureishi and co-workers demonstrated the inadequate arterial supply in the subdermal plexus of the skin distal to the perforator in thinned ALT flaps (surrounded by a fascial cuff of 2 cm as recommended by the Asiatic colleagues). Moreover they proved a fascial cuff of 1 cm around the perforator resulted in greater damages to the vascular architecture. After the preliminary results on cadaver dissections the applications in oral cavity reconstruction confirmed the partial or total necrosis of the skin. Evidently the main problem with the thinned cutaneous anterolateral flap is the possibility of marginal and total skin necrosis due to an excessive damage to the subcutaneous vascular network. For these reasons Ross et al. hypothesized the distal skin from the perforator receives blood from the subdermal plexus of the adjacent tissue (similar to a graft) and saliva could interfere with this neovascularisation. In our experience the adipofascial configuration of the ALT flap proved a safety method for oral cavity reconstruction since the thinning procedures were uneventful without partial or marginal necrosis. The adipofascial ‘leaf shaped’ ALT flap is raised with particular care to leave a 2 cm fascial cuff around the

Anterolateral thigh flap as the ideal flap to full-thickness cheek reconstruction.

Reconstruction of the cheek presents a number of challenges when seeking to recreate form and function. The use of the anterolateral thigh flap in various and novel configurations is argued as being the ideal reconstruction, illustrated by case reports.

Ischemic optic neuropathy and implications for plastic surgeons: report of a new case and review of the literature.

Background:Postoperative visual loss is a rare and devastating complication after nonocular as well as ocular surgery. A case of such a complication arising as a consequence of nonocular surgery prompted a review of the literature, and an appraisal of current theories on etiology, risk factors, and potential treatment options, as well as implications for informed consent. It is clear from our review that all patients undergoing both reconstructive and cosmetic surgery are at risk. Methods:A literature review was performed to identify all cases of ischemic optic neuropathy (both anterior and posterior subtypes) subsequent to any type of plastic, reconstructive, and aesthetic surgery procedures. An analysis of current knowledge regarding risk factors, etiology, prevention, and treatment options was undertaken. Results:A total of 38 patients aged between 16 and 76 years affected by ischemic optic neuropathy were identified, many as a consequence of routine and sometimes minor operative procedures. Conclusions:Ischemic optic neuropathy can be a devastating complication of surgery. Plastic surgeons need to be aware of the risks, as well as the signs and symptoms, and counsel at-risk patients accordingly because of the potentially devastating nature of this complication. There are significant implications in relation to informed consent, underscored by the legal case of Rogers v Whitaker, 67 ALJR 47 (Aust 1992), which highlights the importance within the consent process of complications threatening sight, no matter how small.

Preventing septorhinoplasty complications: evaluating the personal experience.

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