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• W2312688889 abstract "Sir:FigureThe versatility and reliability of the anterolateral thigh flap has made it an essential tool for the reconstructive head and neck surgeon. At our institution, the anterolateral thigh donor site is the preferred free flap for pharyngoesophageal reconstruction because of its excellent functional outcomes and low rate of fistula and stricture formation.1 In the senior author's experience of 250 anterolateral thigh flaps; however, 4.3 percent of thighs had no perforators in the anterolateral thigh flap territory.2 The anteromedial thigh free flap is a viable alternative for soft-tissue coverage in head and neck reconstruction.3 We present a 67-year-old man with the recent diagnosis of a nearly obstructing T3N2M0 squamous cell carcinoma of the larynx that required emergent tracheostomy. The patient's medical history included myocardial infarction, congestive heart failure (ejection fraction, 28 percent), severe atherosclerosis with carotid stenosis following endarterectomy, emphysema, peripheral vascular disease, and severe malnutrition with a body mass index of 15. Tumor ablation resulted in bilateral neck dissection, a nearly circumferential defect of the hypopharynx, a cervical esophagus 9 cm in length, and part of the base of tongue, and a lower neck skin defect. Note that we prefer to incorporate a posterior strip of the pharynx, 2 cm in this case, into a reconstruction when available to help prevent stricture formation.2 A standard anterolateral thigh flap was designed and the thigh explored; however, only an extremely small insufficient perforator B was present. Further exploration of the medial thigh demonstrated two large-caliber (>1 mm) musculocutaneous perforators, B and C, through the sartorius muscle. This perforator was traced back to its main vessel, which originated from the proximal end of the descending branch near its origin from the lateral circumflex femoris artery. This artery travels between the rectus femoris and the sartorius muscles and provided branches to supply both muscles, and is consistent with the rectus femoris branch. We proceeded to design and elevate a 7 × 15-cm skin paddle centered on the two anteromedial thigh perforators along with vascularized fascia slightly larger in size, and a 10-cm length of sartorius muscle (Fig. 1). The fasciocutaneous flap was then divided into two separate skin islands based on the two main perforators, to achieve a 3-cm-diameter neopharynx pharyngeal reconstruction and a second skin paddle for replacement of neck skin (Fig. 2). Inset of the flap was performed in a proximal-to-distal fashion with a second layered closure of fascia over the mucosal/flap suture line and the sartorius muscle to obliterate the dead space. Vascular anastomoses were performed to the superior thyroid artery (2.5 mm) and a branch of the internal jugular vein (3 mm). The donor site was closed primarily.Fig. 1: A 7 × 15-cm anteromedial thigh free flap with vascularized fascia and a 10-cm section of sartorius muscle supplied by the rectus femoris branch of the lateral circumflex femoral system.Fig. 2: Inset of the flap. Note the layered closure of fascia and sartorius muscle over the mucosal/flap suture line. A second skin paddle is used for neck skin coverage inferiorly.The patient did well, without complications of the donor or recipient site (Fig. 3); ambulated on postoperative day 3; and was discharged to home on postoperative day 5. Oral intake was initiated at 2 weeks, with no leakage confirmed by swallow study. Like the anterolateral thigh flap, the anteromedial thigh flap does not require abdominal surgery and the associated donor-site morbidity of the jejunal flap, and may be elevated with extra soft tissue and muscle compared with the radial forearm flap. Use of the thigh as a donor site expedites postoperative recovery and reduces hospital costs.4 We present the reconstruction of this challenging patient with multiple severe comorbid diseases as a first report of the two–skin island anteromedial thigh fasciocutaneous flap with sartorius muscle for pharyngeal reconstruction.Fig. 3: Postoperative result.Mark W. Clemens, M.D. Peirong Yu, M.D. Department of Plastic Surgery, M. D. Anderson Cancer Center, Houston, Texas DISCLOSURE The authors have no commercial associations or financial disclosures that might pose or create a conflict of interest with information presented in this article. No funding was received for this work." @default.
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• W2312688889 date "2012-03-01" @default.
• W2312688889 modified "2023-09-24" @default.
• W2312688889 title "Nearly Circumferential Pharyngoesophagectomy Reconstruction with a Double–Skin Paddle Anteromedial Thigh and Sartorius Muscle Free Flap" @default.
• W2312688889 doi "https://doi.org/10.1097/prs.0b013e3182419d60" @default.
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