The anterolateral thigh flap is a septocutaneous artery flap based on the septocutaneous or muscle perforators of the lateral circumflex femoral system. Little has been reported about the variations in its vascular anatomy and its application for head and neck reconstruction. We report 22 cases in which this flap was used for the reconstruction of head and neck defects. Based on our clinical and cadevaric experiences, the derivation of the vascular pedicle of this flap has four variations by which the septocutaneous perforators are derived from the descending branch of the lateral circumflex femoral system and/or from the transverse branch of that system, or for which there are no septocutaneous perforators but there are muscle perforators originating from the lateral circumflex femoral system. Clinically, the vascular variations and the locations of perforators of this system can be determined preoperatively with stereoangiograms or simple angiograms and Doppler audiometry. The anterolateral thigh fasciocutaneous flap is suitable for reconstruction of defects in an oral floor with tongue and esophageal deficits, scalp defects with dural defects, and for large full thickness defects of the lip. The advantages of this flap are safe elevation, a long and wide vascular pedicle, skin that is generally thin, and good pliability. Even if the skin is thick, a thinner flap can be created by sacrificing a large amount of fatty tissue. Furthermore, the skin territory is very wide and long. The donor defect can often be closed directly with its scar being less noticeable. The disadvantage of this flap is that the anatomy of the pedicle vessels has irregular derivation from the main vessels. This can be overcome, however, by employing preoperative stereoangiograms.

Our experience with 9 patients who have undergone reconstruction with free flap transfers following resection of squamous cell carcinoma in the head and neck area is presented. The dorsalis pedis flap was used in 3 patients, the iliofemoral (groin) flap in 4, and the latissimus dorsi myocutaneous flap in 2. Four patients had received preoperative irradiation. Despite minor partial flap necrosis in 3 patients and the development of oral cutaneous fistulas in 2, all the flaps were successful in providing the necessary coverage. Reoperation in 1 patient was necessary because of thrombosis of the venous anastomosis.

Postirradiation alteration of oral flora is well documented in the literature. Infection as a complication leading to partial or complete loss of a flap used to reconstruct a defect in the oral cavity is a worrisome outcome. We describe how a flap that was judged clinically to be viable became overwhelmingly infected with the Klebsiella oxytoca, an oral cavity pathogen encountered in this patient following irradiation. Local and systemic changes led to detachment of the flap. This complication may be explained, in view of the absence of venous congestion or arterial ischemia both clinically and pathologically, by the proven contamination of the flap by the Klebsiella pathogen. Local factors resulted in lower resistance and subsequent overwhelming infection. Discussion of the case, review of pertinent literature, and proposed solutions are presented.

The Ivy loop is a simple, safe, expeditious, multistaged procedure for closing large through-and-through defects of the cheek. It permits three-layered closure with good bulk and minimal deformity at the donor site. A cervical tubed pedicle is migrated into the defect in stages, looping the pedicle around the defect. The loop is then opened eccentrically on its inner rim and closed in layers. The broad-based attachment around the rim of the defect minimizes the danger of tissue loss in irradiated areas. Credit for this procedure must be given to Dr. Robert Ivy. The Ivy loop has its place in selected cases. Two examples are presented.

A study of the dorsalis pedis free flap and the procedure used to raise it, including a discussion of its difficulties, is presented. Three cases are reviewed in which it was used with encouraging results.

A new one-stage technique of reconstruction of the floor of the mouth, in which a free dorsalis pedis artery flap is used, was performed in five cases. The indications, implications and possibilities of this technique are discussed.

Sixty consecutive patients in whom a free radial forearm flap was used to reconstruct an intraoral defect have been reviewed. The ages ranged from 54 to 85 years, the majority of patients presenting with intraoral carcinoma. There were 6 microvascular failures, and the remaining 54 patients (90 percent) healed uneventfully, with no incidence of fistula. Intraoral healing time was reduced to 11 days on average, and hospitalization was similarly reduced to 17.8 days. A slower postoperative recovery did not appear to be related to age or to the site of the defect within the oral cavity but closely paralleled the extent of excisional surgery. The postoperative mortality was less than 2 percent, but the overall prognosis remained poor, with a 21.6 percent mortality at follow-up (minimum 15 months). Thirty-nine patients (72 percent) underwent early postoperative radical radiotherapy without any evidence of intraoral wound breakdown or problems with flap viability. The results demonstrate the effectiveness of this method of intraoral reconstruction and indicate that such complicated and prolonged surgical techniques do not increase the risks associated with major head and neck surgery.

In the past 15 years dynamic changes have taken place in primary reconstructive procedures for head and neck cancer. We have here described the latest techniques used at the Tata Memorial Hospital in reconstruction of major defects in head and neck cancer surgery.

Advances in technique, training and instrumentation have improved the patency rates for small vessel anastomosis. This, together with the introduction of more reliable donor sites for free tissue transfer, have resulted in success rates in excess of 90%. The technique is not associated with an increase in mortality or morbidity; on the contrary there is the advantage of primary reconstruction with a wide choice of donor sites offering the correct amount and type of tissue required. Single-stage, effective reconstruction, aimed at primary wound healing remains the aim of the reconstructive surgeon and free tissue transfer offers the most versatile and reliable method currently available.

The effect of gravity and the process of ageing necessitate the support of flaps used for the reconstruction of facial tissues. Perioral and cheek reconstructions exemplify this problem. Support can be obtained using vascularized tendons with free tissue transfers. The radial-forearm neurocutaneous flap with the vascularized palmaris longus tendon and the neurocutaneous lateral arm flap with the vascularized triceps tendon are useful options for resurfacing of these defects. We present 6 cases to highlight the use of the vascularized tendon transfer with free neurocutaneous tissue transfers as composite flaps in perioral and cheek reconstructions.

A prospective study of 220 consecutive pectoralis major myocutaneous flaps used for oral cavity reconstruction from March of 1990 to February of 1991 showed that 89 patients (40.5 percent) developed flap-related complications and 33 patients (15 percent) had complications unrelated to the flap; 92 patients (42 percent) had an uneventful recovery and there were 6 (2.7 percent) postoperative deaths. Sixty patients (27 percent) developed flap necrosis, of whom only 6 (2.7 percent) had total flap loss. Major partial loss occurred in 20 patients (9 percent) and minor flap loss occurred in 34 (15.5 percent). Flap necrosis was significantly lower in the purely myocutaneous flaps (p < 0.00000) vis-à-vis the bipedicled and osteocutaneous flaps. Fistula formation, wound infection, dehiscence at the flap margin, and postoperative hematomas occurred with comparable frequency in both groups. The female gender, primary tongue cancer, subtotal or total glossectomy, bipedicling of flaps, prior chemotherapy, and presence of systemic disease (diabetes) emerged as significant risk factors for flap necrosis on multivariate analysis (p < 0.005).

Two case histories are presented in which cigarette smoking in the early postoperative period following digital replantation led to vasospasm and thus compromise of the microvascular anastomoses.

These results show that administration of isoxsuprine at least 13 days prior to flap elevation and continuance at least 7 days postoperatively does lead to completre survival of the abdominal neurovascular island skin flap in the rat.

Methods of finger reconstruction using a free toe transplantation are described. The thumb, and in some particular cases also the index finger, can be successfully replaced by toes using microsurgical techniques for vascular and nervous anastomosis. Functional results are quite satisfactory and allow the patient to recover complete use of the hand.

Pedicle skin flaps in dogs were delayed and venous outflow measured at various times following a delay procedure. An initial small but significant decrease in blood flow was noted in the first 48 hours postoperatively in several flaps suggesting that a denervation supersensitivity-arteriovenous shunt mechanism may be active at this time. In all flaps after the second day, total flap blood flow markedly increased compared to the initial measurement. This suggests that the most significant haemodynamic event occurring during the delay period is the development of vascular collaterals.