|Year : 2021 | Volume
| Issue : 2 | Page : 95-101
A comparative study between anterolateral thigh flap and radial forearm free flap in head-and-neck reconstruction
Sushrut Tated, Mohammed Yaseen, Mohammed Fahud Khurram
Department of Plastic Surgery, Jawaharlal Nehru Medical College and Hospital, Aligarh, Uttar Pradesh, India
|Date of Submission||02-Apr-2020|
|Date of Acceptance||28-Jun-2020|
|Date of Web Publication||26-Mar-2021|
Dr. Sushrut Tated
Department of Plastic Surgery, Jawaharlal Nehru Medical College and Hospital, Aligarh, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background: Several decades have witnessed the use of free flaps in clinical science. With the advancement and refinement in operative techniques, survival rates of free flaps have increased. There is a need to compare the efficacy and safety of anterolateral thigh (ALT) flap and radial forearm free flap (RFFF) in head-and-neck reconstruction surgeries. Objective: The objective of this study was to compare the ALT flap and RFFF in head-and-neck reconstruction. Materials and Methods: This prospective study was carried out among 25 patients posted for head-and-neck reconstruction in whom either a RFFF or an ALT free flap (ALTF) was performed. Group A had 16 patients reconstructed using the RFFF. Group B had 9 patients reconstructed using ALTF. Results: Majority of the cases were of buccal mucosa cancer. Majority of the RFFFs were performed in buccal mucosa carcinoma patients (43.75%). Majority of the patients with squamous cell carcinoma of the scalp underwent ALTF. RFFFs were most commonly performed in oral cavity (43.75%). Most of the cases of ALTF were performed in the midface and scalp. Mean values of pedicle length, flap length, flap width, and flap thickness were significantly less in the RFFF group compared to the ALTF group. However, the mean time of harvest (min) was significantly less in the RFFF group allowing quick harvest. The difference in donor-site complications in the two groups was not statistically significant except donor-site social stigma. Patients of the RFFF group complained of donor-site social stigma due to ugly looking Split thickness skin graft (STSG) patch at the donor site. The average stay in the hospital after surgery was not found to be statistically significant. Conclusion: ALTF allows a harvest of large tissue for reconstruction as compared to RFFF. Donor-site morbidity is comparable in both the groups except donor-site appearance. RFFFs are harvested easily in less time as compared to Anterolateral thigh free flap (ALTF) due to the complex anatomy of ALTF.
Keywords: Anterolateral thigh free flap, comparison, harvest, radial forearm free flap
|How to cite this article:|
Tated S, Yaseen M, Khurram MF. A comparative study between anterolateral thigh flap and radial forearm free flap in head-and-neck reconstruction. Turk J Plast Surg 2021;29:95-101
|How to cite this URL:|
Tated S, Yaseen M, Khurram MF. A comparative study between anterolateral thigh flap and radial forearm free flap in head-and-neck reconstruction. Turk J Plast Surg [serial online] 2021 [cited 2021 Apr 23];29:95-101. Available from: http://www.turkjplastsurg.org/text.asp?2021/29/2/95/312184
| Introduction|| |
Several decades have witnessed the use of free flaps in clinical science. With the advancement and refinement in the operative techniques, the survival rates of these flaps have increased. Thus, the free flaps are now gold standard in the reconstruction of the head and neck. Survival rates have increased to more than 90%.
With the advancement in the free-flap technique, inoperable conditions like recurrent or advanced disease patients can now be operated. Now, it is possible for oncologists to resect tumors with adequate margins. This is possible with the availability of the single-stage reconstructive solutions in most of the cases.
The most commonly used free flaps are anterolateral thigh free flap (ALTF) and radial forearm free flap (RFFF) for the head-and-neck reconstruction.
RFFF is a fasciocutaneous flap that is elevated from the volar region of the forearm and based on the radial artery and concomitant venous pedicle. The disadvantage is that there may be damage to the radial artery. There are several reasons for the current popularity of RFFF: (1) the presence of an adequate caliber vascular pedicle, (2) the flexibility and pliability of the tissue, and (3) the anatomical location of the flap allowing simultaneous harvesting with the ablative team.,,,
ALTF is based on the septocutaneous vessels or musculocutaneous perforators from the descending branch of the lateral circumflex femoral artery. This flap allows the transfer of different tissues in significant amount with a vascular pedicle of suitable length and diameter and low donor-site morbidity. In most of the cases, these residual thigh wounds tolerate direct closure, and this is hypothesized to decrease the time required for wound healing and thus decrease donor-site morbidity. The anterolateral thigh (ALT) flap may also be raised with or without fascia, and it has been reported that taking this flap without the fascia decreases patient morbidity.
Nowadays, more attention is paid to the care of the donor site as survival after using free flaps is satisfactory.
Herein, we compared ALTF and RFFF in head-and-neck reconstruction.
| Materials and Methods|| |
This prospective study was carried out from November 2017 to November 2019 at the Postgraduate Department of Burns, Plastic and Reconstructive Surgery, Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh. Twenty-five patients were included in this study in whom either an RFFF or an ALTF was performed. In each patient, informed consent was obtained for the same.
The institution's Ethics Committee permission was obtained.
Patients were divided into either the RFFF or the ALTF group depending on the following factors:
- Pedicle length to be required
- Surface area to be covered at the recipient site
- Suitability of donor tissue at the recipient site
- Intraoperative decision.
Group A: 16 Patients reconstructed using the RFFF.
Group B: 9 Patients reconstructed using ALTF.
- Patients with anaesthetic fitness
- Patients with unaesthetic and painful scars or soft-tissue defect in the head, neck, and face regions
- Patients giving consent of any sex and any age.
- Patients having metastasis
- Patients not fit for surgery and anesthesia
- Patients not giving consent
- Patients with unrealistic expectations
- Patients with apparent psychiatric conditions.
Medical history was recorded for all participants including diagnostic information, disease progression, medication compliance, patient awareness of complication, any aggravating factor leading to the illness, clinical diagnosis and history of any previous medical disorder, and any surgical intervention in the past.
The general and local screening was conducted. Routine investigations and Doppler were performed. Computed tomography scan, biopsy, or magnetic resonance imaging was done if indicated.
Length of pedicle, flap length, flap width, flap thickness, total time of harvest of flap, perforator type (for ALTF), and donor-site closure (primary closure/split-thickness skin grafting) were assessed intraoperatively. Flap monitoring and texture/color of flap were assessed postoperatively. Complications related to flap and donor site were assessed. Patients were followed for 6 months while assessing follow-up outcome at the 2nd and 4th weeks.
In most of the cases of the head, neck, and face reconstructions, the facial artery was used as recipient artery. If not facial artery, then superior thyroid artery was used as recipient vessel. In scalp reconstruction, superficial temporal artery was used as recipient vessel. In case of RFFF, local veins in the donor forearm were used as vein grafts, if required. In case of ALT free flap (ALTF), short saphenous vein was used as vein graft, if required.
In cancer patients, neck dissection was done according to the ICMR guidelines. A modified radical neck dissection was done in majority of the patients.,
The data were entered in the Microsoft Excel worksheet and analyzed using proportions. A Chi-square test was applied for categorical data where the proportion was used. For comparison of mean values, Student's t-test was applied. P < 0.05 was taken as statistically significant. If the cell value in any category was found to be zero, then the statistical test was not applied.
| Results|| |
In both the groups, patients were comparable for age and sex. The mean age difference was statistically not significant [Table 1].
Majority of the cases were of carcinoma of the buccal mucosa (8 cases) [Table 2] and [Figure 1].
|Figure 1: Carcinoma of the buccal mucosa treated by radial forearm free flap. (a) Intraoperative photo showing markings for excision of growth, (b) Radial forearm free flap after complete harvest, (c) Follow-up after 6 months|
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|Table 2: Distribution of patients as per the site of primary tumor (malignancy)|
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Majority of the RFFFs were performed in carcinoma of buccal mucosa patients (7, 43.75%). Majority of the patients with squamous cell carcinoma of the scalp underwent ALTF. Overall, the most common etiology for free flaps in our study was malignancy [Table 3].
|Table 3: Distribution of study participants in the radial forearm free flap group as per indications|
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RFFFs were most commonly performed in oral cavity of 7 cases (43.75%) [Figure 2], [Figure 3] and [Figure 4]. Most of the cases of ALTF were performed in the midface [Figure 5] and scalp [Figure 6]. Oral cavity was most commonly reconstructed defect site overall in our study [Table 4].
|Figure 3: Case 3: carcinoma of the tongue treated by radial forearm free flap. (a) Preoperative photo showing carcinoma of the tongue, (b) Intraoperative photo after left hemiglossectomy, (c) Follow-up at 6 months|
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|Figure 4: Carcinoma of the lower lip treated by radial forearm free flap. (a) preoperative photograph, (b) Follow-up photo at 6 months|
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|Figure 5: Squamous cell carcinoma of the scalp treated by anterolateral thigh flap. (a) Preoperative photo showing squamous cell carcinoma of the scalp, (b) Follow-up photos at 6 months|
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|Figure 6: Electrical burn over the face treated by anterolateral thigh flap. (a) Electrical burn over the face (on the injury day), (b) Follow-up photo at 6 months of procedure|
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|Table 4: Distribution of study participants in the radial forearm free flap group as per defect site|
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Mean values of pedicle length, flap length, flap width, and flap thickness and mean time of harvest (min) were significantly less in the RFFF group compared to the ALTF group [Table 5].
All RFFF donor sites were closed by STSG, i.e., 16 (100%). In the ALTF group, 4 (44.4%) donor sites were closed by STSG and 5 (55.6%) donor sites were closed primarily.
The difference in the postoperative findings of the two groups was not found to be statistically significant [Table 6].
The average stay in the hospital after surgery was statistically insignificant in the two groups or was not found to be statistically significant [Table 7].
Complete flap loss was observed in 2 (22.7%) patients of the ALTF group. No patients of the RFFF group suffered complete flap loss.
| Discussion|| |
As found in our study, a large skin paddle was harvested in ALTF as compared to RFFF. The mean skin paddle length was 16 cm, mean skin paddle width was 11 cm, and mean paddle thickness was 4.66 cm. This was comparable with Lueg study. Our mean pedicle length of the ALTF group was 8.22 cm, and this was found to be significantly more than RFFF. The mean time required for harvest of ALTF was 162 min as against 67 min in the RFFF group. We also found the ALTF as considerably thicker than that of the RFFF. These findings correlate with those of Valentini et al.
Gad et al. study showed the mean skin paddle width as 10 cm (range, 7–15 cm) and length as 13 cm (range, 10–16 cm) in ALTF. The donor site in all cases had been closed primarily. Lueg noted in their study that the mean skin paddle length using ALTF was 14.1 cm, thickness was 11 mm, and width was 10.3 cm. The mean width of the muscle was 4 cm and mean length of pedicle was 13.2 cm. Gad et al. observed that in ALTF, the average time required for harvesting was 113 min. Lueg observed that in ALTF, the mean time required for harvesting was 50 min. Liu et al. noted that ALTFs were thicker than RFFF limiting their use for buccal defects and some small defects in the oral cavity. They found no differences in the mean pedicle lengths of RFFF and ALTF (7.5 vs. 9 cm). In our study, we found the mean pedicle length as 6.68 cm versus 8.22 cm in RFFF and ALTF, respectively (P < 0.05).
Novak et al. in their study were able to harvest the mean flap width for the ALTF as 7.8 cm and for RFFF as 5.1 cm. The mean flap length for the ALTF was 12.5 cm and for the RFFF was 8.4 cm. The ALT flaps were statistically significantly wider and longer than the radial forearm flaps.
All the abovementioned studies confirm that ALTF provides with more amount of tissue and longer pedicle length for reconstruction. However, RFFF is more easily harvested in less time. This saves the time and exposure of a patient to general anesthesia. This correlates with our findings.
Oranges et al. performed a retrospective study of 36 patients with major head-and-neck defects who underwent either RFFF or ALTF reconstructions. The Authors found that RFFF harvesting is easy to perform. ALTF dissection is more difficult due to intramuscular dissection for musculocutaneous perforator, which is found in majority of cases. We also encountered the same finding, and hence, we required more time for harvest of ALTF as against RFFF.
Shimizu et al. described 41 cadaver studies for studying anatomy of ALTF. Of them, musculocutaneous perforators were found in 51%, and septocutaneous perforators were found in 49%. Kimata et al. reported that the septocutaneous perforators were encountered in 26.3% and musculocutaneous perforators in 73.7% of the 38 clinical cases. Shieh et al. found that the perforator was a musculocutaneous in 83.8% of cases and a septocutaneous one in 16.2% of cases of the 37 patients. In our study, we found musculocutaneous perforators in 5 (55.6%) cases and septocutaneous perforators in 4 (44.4%) cases.
The mean ALT Flap harvest time in case of MC perforators was 179 min and in case of SC perforators was 142 min in our study. However, this was not statistically significant.
In our study, the donor defects were closed primarily in 5 (55.6%) patients of the ALTF group and skin grafted in 4 (44.4%) cases. All patients of the RFFF group were skin grafted at their donor site. Our findings correlate with most of other studies. Novak et al. found that majority of the donor-site wounds in the ALT were closed by primary closure and in the radial forearm using a skin graft. The proportion of patients who had primary wound closure was significantly greater in the ALT flap group (P < 0.001). Valentini et al. highlighted that the donor defect can be closed directly, with minimal morbidity, in most of the cases of ALTF without causing a noticeable scar.
Oranges et al. found a re-exploration rate of 10% for RFF and 30% for ALT flaps, with no significant statistical difference between classes. There was, however, a trend toward a higher rate of re-exploration in the ALT community, which author was expected to correlate with the high number of patients receiving preoperative radiation therapy in the examined small sample. Re-exploration for vascular compromise was performed in 7 cases (2.8%). Four of the seven flaps were successfully salvaged (57%). In our study, re-exploration was done in 4 cases (16%). Two of the four flaps were successfully salvaged.
In the study of 250 cases conducted by Classen and Ward, the total flap loss was seen in 11 cases (4.4%). Partial flap loss occurred in 10 cases (4%). In our study, the total flap loss was seen in 2 cases (8%) and partial flap loss was seen in one case (4%). The patients suffered total flap loss. One of the patients was treated with local flap and another patient was lost in follow-up.
The anterolateral thigh free flap (ALTF) was suggested by Loreti et al. as an ideal soft-tissue flap in oral reconstruction, with functional findings comparable to those of the RFFF at the receiving site but with additional advantages of reduced donor-site morbidity and higher patient satisfaction. Several authors have supported the idea that the RFFF is most associated with donor-site morbidity and aesthetic deformity.
In our study, we also found the same thing. The complication of hypertrophic scarring at the donor site occurred in 3 (33.4%) patients of the ALTF group. No patient of the RFFF group suffered from the problem of hypertrophic scarring as all of them were skin grafted. The donor-site dehiscence was seen in only one patient of the ALTF group. The wound healed with time, and the patient has no donor-site-related complaint. About 7 (43.8%) patients of the RFFF group complained of donor-site social stigma. They complained of being a bit shy of wearing half sleeves. However, no patients of the RFFF group complained of difficulty in wearing bangles or watches in the forearm. Donor-site paresthesia was observed in 6 (37.5%) versus 1 (11.1%) in the RFFF versus ALTF group, with a P value of 0.34. The problem of numbness did not trouble the patients. Although the difference is not significant, the morbidity of the donor site was found to be much less in the ALTF group than those with RFFF.
Although our findings coincide with the above studies, still there are other authors who found that the donor-site complications were similar in both the groups, and there is no difference.
Morrissey et al. also observed that there was no significant difference in donor-site complications in both the RFFF and ALTF groups.
Oranges CM et al. found no significant difference in terms of microsurgical outcomes expressed as flap survival rates between RFF and ALT, showing that the anatomic variability of ALT perforators did not influence survival rates.
ALTF was found to be extremely versatile. As shown in our study, a large skin paddle can be harvested. Its pedicle length is also adequate and found to be significantly more than RFFF though we found that the color match was not up to the mark, especially in fair individuals.
Squamous cell carcinoma was the most frequent histological diagnosis, while the oral cavity was the most frequent site of reconstruction in both the groups. We also encountered the same finding in our study.
Novak et al. in their study were able to harvest the mean flap width for the ALTF as 7.8 cm and for the RFFF as 5.1 cm. The mean flap length for the ALTF was 12.5 cm and the RFFF was 8.4 cm. The ALT flaps were statistically significantly wider and longer than the radial forearm flaps.
Gad et al. study showed the duration of postoperative hospital stay from 12 to 14 days. Novak et al. in their study got the mean hospital stay of the patients overall as 11 days. In our study also, we found that patients of the RFFF group get discharged earlier than those with RFFF. However, the association was not significant statistically.
| Conclusion|| |
Overall, ALTF was found to be more effective in terms of pedicle length and amount of tissue to be harvested for reconstruction. However, RFFF was harvested in less time. Regarding donor-site morbidity, both the flaps were found to be similar except donor-site social stigma. Patients of RFFF complained of ugly patch of skin graft at the donor site. They found it difficult to wear half sleeves, especially women. Apart from this, patients of both the groups were satisfied with donor-site functions with regard to the function of donor-site extremity.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Lamaris GA, Knackstedt R, Couto RA, Abedi N, Durand P, Gastman B. The anterolateral thigh flap as the flap of choice for scalp reconstruction. J Craniofac Surg 2017;28:472-6.
Zaretski A, Wei FC, Lin CH, Cheng MH, Tsao CK, Wallace CG. Anterolateral thigh perforator flaps in head and neck reconstruction. Sem Plast Surg2006;20:64-72.
Llorente JL, López F, Suárez V, Fueyo A, Carnero S, Martín C, et al
. Free flap reconstruction in the head and neck. Indications, technical aspects and outcomes. Acta Otorrinolaringol Esp 2014;65:33-42.
Orlik JR, Horwich P, Bartlett C, Trites J, Hart R, Taylor SM. Long-term functional donor site morbidity of the free radial forearm flap in head and neck cancer survivors. J Otolaryngol Head Neck Surg 2014;43:1.
Lutz BS, Wei FC, Chang SC, Yang KH, Chen IH. Donor site morbidity after supra-fascial elevation of the radial forearm flap: a prospective study in 95 consecutive cases. Plast Reconstr Surg1999;103:132-7.
Webster HR, Robinson DW. The radial forearm flap without fascia and other refinements. Eur J Plast Surg 1995;18:11-3.
Chang SCN, Miller G, Halbert CF, Yang KH, Chao WC, Wei FC. Limiting donor site morbidity by supra-fascial dissection of the radial forearm flap. Microsurgery. J Int Microsurg Soc Eur Fed Soc Microsurg 1996;17:136-40.
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;37:149-59.
Loreti A, Di Lella G, Vetrano S, Tedaldi M, Dell'Osso A, Poladas G. 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;66:1093-8.
Lipa JE, Novak CB, Binhammer PA. Patient-reported donor-site morbidity following anterolateral thigh free flaps. J Reconstr Microsurg 2005;21:365-70.
Camaioni A, Loreti A, Damiani V, Bellioni M, Passali FM, Viti C. Anterolateral thigh cutaneous flap vs. radial forearm free-flap in oral and oropharyngeal reconstruction: an analysis of 48 flaps. Acta Otorhinolaryngol Ital 2008;28:7-12.
Rath GK, Parikh PM, Hukku S, Rajan B, Kumar S, Malhotra H, et al
. Indian council of medical research consensus document for the management of buccal mucosa cancer. Indian J Med Paediatr Oncol 2014;35:136-9.
] [Full text]
D'Cruz AK, Sharma S, Agarwal JP, Thakar A, Teli A, Arya S et al
. Indian council of medical research. Consensus document for management of tongue cancer. Indian J Med Pediatr Oncol 2015;36:140-5.
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;130:813-8.
Valentini V, Cassoni A, Marianetti TM, Battisti A, Terenzi V, Iannetti G. Anterolateral thigh flap for the reconstruction of head and neck defects: alternative or replacement of the radial forearm flap? J Craniofac Surg 2008;19:1148-53.
Gad SS, Ghareeb FM, Elsheikh YM, El-Nahas MA. Free anterolateral thigh flap in head and neck reconstruction. Menoufia Med J 2015;28:74. [Full text]
Liu WW, Li H, Guo ZM, Zhang Q, Yang AK, Liu XK et al
. Reconstruction of soft-tissue defects of the head and neck: radial forearm flap or anterolateral thigh flap? European Arch Oto-Rhino-Laryngol 2011;268:1809-12.
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;27:651-4.
Oranges CM, Ling B, Tremp M, Wettstein R, Kalbermatten DF, Schaefer DJ. Comparison of anterolateral thigh and radial forearm free flaps in head and neck reconstruction. In Vivo
Shimizu T, Fisher DR, Carmichael SW, Bite U. An anatomic comparison of septocutaneous free flaps from the thigh region. Ann Plast Surg 1997;38:604-10.
Kimata Y, Uchiyama K, Ebihara S, Sakuraba M, Iida H, Nakatsuka T, et al
. Anterolateral thigh flap donor-site complications and morbidity. Plast Reconstr Surg 2000;106:584-9.
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;105:2349-57.
Classen DA, Ward H. Complications in a consecutive series of 250 free flap operations. Ann Plast Surg 2006;56:557-61.
Morrissey AT, O'Connell DA, Garg S, Seikaly H, Harris JR. Radial forearm versus anterolateral thigh free flaps for laryngopharyngectomy defects: prospective, randomized trial. J Otolaryngol Head Neck Surg 2010;39:448-53.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]