DISCUSIÓN

Discussion of the article "Lateral arm flap in the reconstruction of the oral cavity"

Discusión del artículo "Colgajo lateral de brazo en la reconstrucción de la cavidad oral"

J. Arias Gallo¹, Lorena Pingarrón Martín²

¹ Médico Adjunto. Servicio de Cirugía Oral y Maxilofacial. Hospital Universitario La Paz. Madrid, España
² Médico Residente. Servicio de Cirugía Oral y Maxilofacial. Hospital Universitario La Paz. Madrid, España

The authors present a well documented prospective series of patients reconstructed using a lateral arm flap with excellent results in terms of donor zone morbidity and flap survival. This flap is currently little used in routine clinical practice, which is why it is pertinent to include the description of the surgical technique in the article. The reasons why it is little used are mainly its greater technical difficulty, particularly the shorter pedicle length compared to the forearm flap. These drawbacks usually outweigh the fact that the lateral arm flap unquestionably has much less morbidity, which is why it is likely that this flap will never be as widely used as the forearm flap.

Two aspects of the article deserve specific discussion, i.e., the problem of pedicle length and the question of alternative flaps to the flap discussed here.

With regard to pedicle length, the opinion of this reviewer is that it is preferable to use the superficial venous system because the pedicle is potentially much longer and there is no risk of jeopardizing the cleanliness of the cervical dissection when the surgeon is tempted to follow the branches of the thyrolinguofacial trunk to avoid using a venous graft. In the experience of this reviewer, it is better and oncologically safer to ligate all the branches of the internal jugular vein at its outflow point and perform end-to-side venous anastomosis to the internal jugular vein. To do this, it is necessary to ensure that pedicle length will not be a problem for reconstruction.

As for alternative flaps, it is noteworthy that the authors only mention the forearm flap. Although it is clear from their description that it was one of the main options considered in the soft-tissue reconstruction of the head and neck (and, therefore, «the king to be overthrown»), anterolateral thigh perforating flaps (ALT) and deep inferior epigastric artery flaps DIEAP) are, in fact, replacing with increasing frequency forearm flaps, which can produce major morbidity in the donor zone.

The ALT flap is based on the septocutaneous or musculocutaneous perforating vessels of the descending branch of the lateral femoral circumflex artery.¹ The pedicle length is usually about 15 cm. It is a very versatile flap. A flap about 8 cm wide and almost as long as the thigh can be obtained and used for direct closure of the donor zone. Although a fasciocutaneous flap is used most frequently, the fascia or skin can be dispensed with, or a fragment of vastus lateralis muscle can be included. The cutaneous island also can be divided into as many independent tennis racket-shaped cutaneous flaps as the number of perforating vessels dissected.

The main advantage of the ALT flap is that it greatly reduces donor zone morbidity. Since the ALT flap first began to be used in our department, in the last 2 years this reviewer has prepared thirteen ALT flaps and only three forearm flaps (in two cases for failure of the cutaneous island of a peroneal flap, situations in which surgical time should be shortened as much as possible).

It should be stressed that the thickness of the reconstruction decisively influences the aesthetic and functional result. The ALT flap is highly versatile in thickness and the amount of tissue that can be obtained from the thigh is more than sufficient for the reconstructive needs of the head and neck. In patients with a thick fat layer, the flap can be defatted considerably; in thin patients it can usually be folded to increase the thickness of the reconstruction (or a DIEAP flap, which is thicker, can be used). Both the lateral arm flap and the forearm flap can be especially useful in pharyngeal reconstruction due to their reduced thickness. However, a thicker flap may be more suitable in the oral cavity.

Reconstruction of the defects after hemiglossectomy is controversial. Three of the 10 patients in the authors’ series present such defects. Although direct closure sometimes may be acceptable, on many occasions reconstruction is preferred. The usual tendency is to use the thinnest possible graft to allow unrestricted function of the lingual remnant. Nevertheless, in our department, in which the forearm flap has practically been replaced by the anterolateral thigh flap, we have observed that the function of the remnant tongue seems to be more suitable if the entire volume excised is reconstructed, even if done with an inert tissue like fatty tissue. The forearm flap is too thin for that purpose but, however, the anterolateral thigh flap usually adapts in a surprising faithful way.

The case that illustrates this discussion is that of a 25- year-old woman without a history of interest or toxic habits, who was diagnosed of squamous-cell carcinoma of the lateral tongue. Left hemiglossectomy, functional bilateral dissection, and reconstruction with an ALT flap of the right thigh was performed. At 8 months the patient could eat and unrestricted diet and her speech was almost normal.

References

1. J.S. Chana, F.C. Wei. A review of the advantages of the anterolateral thigh flap in head and neck reconstruction. Br J Plast Surg 2004;57:603-609.        [ Links ]