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Tamaki A, Zender CA. Free Flap Donor Sites in Head and Neck Reconstruction. Otolaryngol Clin North Am 2023:S0030-6665(23)00047-6. [PMID: 37173238 DOI: 10.1016/j.otc.2023.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Microvascular free tissue transfer, also referred to as free flaps surgery, is a reconstructive technique that has become a foundational component of complex head and neck reconstruction. There have been considerable advancements in the field over the last 30 years including the number and variety of free flaps. Each of these free flaps has unique characteristics that must be considered for the defect when selecting a donor site. Here, the authors focus on the most common free flaps used in head and neck reconstruction.
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Affiliation(s)
- Akina Tamaki
- Department of Otolaryngology- Head and Neck Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, LKS 5045, Cleveland, OH 44106, USA.
| | - Chad A Zender
- Department of Otolaryngology - Head and Neck Surgery, University of Cincinnati Medical Center, 231 Albert Sabin Way, MSB 6408, Cincinnati, OH 45229, USA
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Xu F, Deng D, Li B, Li L, Liu J, Li B, Liu J, Chen F. Adipofascial anterolateral thigh free flap in hypopharyngeal and oropharyngeal reconstruction. Microsurgery 2022; 42:586-592. [PMID: 35043476 DOI: 10.1002/micr.30863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 11/14/2021] [Accepted: 01/07/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND The anterolateral thigh (ALT) flap is a popular choice for head and neck reconstruction surgery, but its ungainly thickness makes it of limited value in some intracavitary reconstructions. The ALT adipofascial flap is an improved flap without skin or muscle. Here, we seek to further illustrate the ALT adipofascial flap as an alternate method of hypopharyngeal and oropharyngeal reconstruction in head and neck. METHODS A retrospective review of 9 patients (7 men, 2 women) ranging from 28 to 67 years (mean age, 53.1 years) who underwent reconstruction with the ALT adipofascial flap after hypopharyngeal carcinoma (4 patients) or oropharyngeal carcinoma (5 patients) resections from August 2018 to December 2019 was performed. Surgical outcomes and functional resoration were assessed. RESULTS The size of the flaps ranged from 6 × 4 cm2 to 6 × 12 cm2 . The average flap thickness was 0.14 cm (range, 0.1-0.2 cm) and the average pedicle length was 9.8 cm (range, 7-12 cm). The postoperative course was uneventful in eight patients. Reconstruction was successful in all cases during 7-23 months of follow-up (mean time, 14.3 months). All patients resumed oral feeding for 2-8 weeks (mean time, 4.9 weeks) and the tracheal cannula was successfully removed 0.5-4 months postsurgery (mean time, 2.4 months). CONCLUSION The ALT adipofascial flap is a viable choice for hypopharyngeal and oropharyngeal reconstructions and is thinner than the ALT flap. It could be harvested as a single-pedicled double-island flap for complex defect reconstruction.
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Affiliation(s)
- Feng Xu
- Department of Otolaryngology, Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Di Deng
- Department of Otolaryngology, Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Baofei Li
- Department of Otolaryngology, Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Linke Li
- Department of Otolaryngology, Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jifeng Liu
- Department of Otolaryngology, Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Bo Li
- Department of Otolaryngology, Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jun Liu
- Department of Otolaryngology, Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Fei Chen
- Department of Otolaryngology, Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China
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Reconstruction of the tongue and mouth floor with the myofascial vastus lateralis free flap after cancer ablation. Int J Oral Maxillofac Surg 2016; 45:951-4. [DOI: 10.1016/j.ijom.2016.03.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Revised: 03/05/2016] [Accepted: 03/16/2016] [Indexed: 11/19/2022]
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Revenaugh PC, Haffey TM, Seth R, Fritz MA. Anterolateral thigh adipofascial flap in mucosal reconstruction. JAMA FACIAL PLAST SU 2016; 16:395-9. [PMID: 25124477 DOI: 10.1001/jamafacial.2014.447] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE This study describes a reliable technique for mucosal reconstruction of large defects using components of a common free flap technique. OBJECTIVE To review the harvest technique and the varied scenarios in which the anterolateral thigh adipofascial flap (ALTAF) can be used for mucosal restoration in oral cavity and nasal reconstruction. DESIGN, SETTING, AND PARTICIPANTS A retrospective review of the medical records of 51 consecutive patients was conducted. The patients had undergone ALTAF head and neck reconstruction between January 2009 and June 2013. Each case was reviewed, and flap survival and goal-oriented results were evaluated. RESULTS Thirty patients met the inclusion criteria and were included in the analysis. The mean patient age was 60.6 years. Reconstruction sites included the tongue, palate, gingiva, floor of the mouth, and nasal mucosa. All mucosal reconstructions maintained function and form of replaced and preserved tissues. One patient (3%) experienced flap failure that was reconstructed with a contralateral adipofascial flap with excellent outcome. Three patients (10%) required minor flap revisions. There were no other complications. CONCLUSIONS AND RELEVANCE The ALTAF is a versatile flap easily harvested for use in several types of mucosal reconstructions.
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Affiliation(s)
- Peter C Revenaugh
- Head and Neck Institute, Department of Otolaryngology-Head and Neck Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Timothy M Haffey
- Head and Neck Institute, Department of Otolaryngology-Head and Neck Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Rahul Seth
- Head and Neck Institute, Department of Otolaryngology-Head and Neck Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Michael A Fritz
- Head and Neck Institute, Department of Otolaryngology-Head and Neck Surgery, Cleveland Clinic, Cleveland, Ohio
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Oropharyngeal reconstruction with a pedicled submandibular gland flap. Br J Oral Maxillofac Surg 2015; 54:388-93. [PMID: 26388070 DOI: 10.1016/j.bjoms.2015.08.267] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 08/29/2015] [Indexed: 11/20/2022]
Abstract
Locoregional flaps are widely used for reconstruction of small and medium defects in the oral cavity. The submandibular gland flap is a pedicled flap, which derives its blood supply from the facial artery, based on the submandibular gland. We describe the use of the flap in 20 patients who required oropharyngeal reconstruction with a pedicled submandibular gland flap after resection of a tumour between July 2012 and October 2014. Patients with squamous cell carcinoma were excluded. All flaps were pedicled on the facial vessels (inferiorly in 17 patients and superiorly in 3). The indications were: reconstruction of intraoral mucosal defects (n=13), filling the parapharyngeal dead space (n=6), and obliteration of the mastoid (n=1). All the flaps atrophied, but with no clinical effect. One patient developed partial loss of the flap, and one early leakage. There were no cases of xerostomia, and no signs of recurrence during the postoperative follow-up period of 3-26 months. The flap is useful, as it is simple and reliable for reconstruction of small to medium oropharyngeal defects in carefully selected cases, and gives good cosmetic and functional results.
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Kekatpure VD, Hedne N, Chavre S, Pillai V, Trivedi N, Kuriakose MA. Versatility of adipofascial anterolateral thigh flap for reconstruction of maxillary defects with infratemporal fossa extension. Craniomaxillofac Trauma Reconstr 2014; 7:213-7. [PMID: 25136410 DOI: 10.1055/s-0034-1371973] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Accepted: 07/07/2013] [Indexed: 10/25/2022] Open
Abstract
Tumors arising from the posterior hard palate or posterolateral maxilla may extend to involve the infratemporal fossa (ITF). Resection of these tumors results in infrastructural maxillectomy with ITF defects. In this study, we describe the use of an adipofascial anterolateral thigh flap (ALT) specifically for such defects. This case series includes four patients who underwent an infrastructure maxillectomy with ITF clearance and the resultant defects were reconstructed using adipofascial anterolateral thigh flaps. The complications as well as the functional outcomes were assessed. This study included patients with lesions involving the hard palate, posterolateral part of maxilla with extension into the ITF. The mean flap dimension was 150 cm(2) (range, 120-180 cm(2)). All flaps were harvested based on a single perforator. The flap was used to obliterate the ITF defect and also to achieve oroantral separation. All flaps mucosalized well within 6 weeks. All patients were on oral diet and had adequate mouth opening. There were no donor-site complications. Adipofascial ALT is an excellent choice for infrastructural maxillectomy defects with ITF extension. The intraoral part got mucosalized well and provided a smooth and taut surface. A large adipofascial tissue flap helps obliterate the ITF, thus minimizing complications.
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Affiliation(s)
- Vikram D Kekatpure
- Department of Head and Neck Oncology, Mazumdar Shaw Cancer Center, Narayana Hrudayalaya, Bangalore, Karnataka, India
| | - Naveen Hedne
- Department of Head and Neck Oncology, Mazumdar Shaw Cancer Center, Narayana Hrudayalaya, Bangalore, Karnataka, India
| | - Sachin Chavre
- Department of Head and Neck Oncology, Mazumdar Shaw Cancer Center, Narayana Hrudayalaya, Bangalore, Karnataka, India
| | - Vijay Pillai
- Department of Head and Neck Oncology, Mazumdar Shaw Cancer Center, Narayana Hrudayalaya, Bangalore, Karnataka, India
| | - Nirav Trivedi
- Department of Head and Neck Oncology, Mazumdar Shaw Cancer Center, Narayana Hrudayalaya, Bangalore, Karnataka, India
| | - Moni Abraham Kuriakose
- Department of Head and Neck Oncology, Mazumdar Shaw Cancer Center, Narayana Hrudayalaya, Bangalore, Karnataka, India
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Adipofascial anterolateral thigh flap safety: applications and complications. Arch Plast Surg 2013; 40:91-6. [PMID: 23533103 PMCID: PMC3605567 DOI: 10.5999/aps.2013.40.2.91] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2012] [Revised: 12/23/2012] [Accepted: 12/24/2012] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND A thinned anterolateral thigh (ALT) flap is often harvested to achieve optimal skin resurfacing. Several techniques have been described to thin an ALT flap including an adipocutaneous flap, an adipofascial flap and delayed debulking. METHODS By systematically reviewing all of the available literature in English and French, the present manuscript attempts to identify the common surgical indications, complications and donor site morbidity of the adipofascial variant of the ALT flap. The studies were identified by performing a systematic search on Medline, Ovid, EMBASE, the Cochrane Database of Systematic Reviews, Current Contents, PubMed, Google, and Google Scholar. RESULTS The study selection process was adapted from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, and 15 articles were identified using the study inclusion criteria. These articles were then reviewed for author name(s), year of publication, flap dimensions and thickness following defatting, perforator type, type of transfer, complications, thinning technique, number of cases with a particular area of application and donor site morbidity. CONCLUSIONS The adipofascial variant of the ALT flap provides tissue to fill large defects and improve pliability. Its strong and safe blood supply permits adequate immediate or delayed debulking without vascular complications. The presence of the deep fascia makes it possible to prevent sagging by suspending and fixing the flap for functional reconstructive purposes (e.g., the intraoral cavity). Donor site morbidity is minimal, and thigh deformities can be reduced through immediate direct closure or liposuction and direct closure. A safe blood supply was confirmed by the rate of secondary flap debulking.
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Lam DK, Cheng A, Berty KE, Schmidt BL. Sliding Anterior Hemitongue Flap for Posterior Tongue Defect Reconstruction. J Oral Maxillofac Surg 2012; 70:2440-4. [DOI: 10.1016/j.joms.2011.11.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2011] [Revised: 11/03/2011] [Accepted: 11/03/2011] [Indexed: 10/14/2022]
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Anterolateral thigh flap as the ideal flap to full-thickness cheek reconstruction. J Craniofac Surg 2011; 21:1897-8. [PMID: 21119450 DOI: 10.1097/scs.0b013e3181f4af80] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
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.
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A Strategic Approach for Tongue Reconstruction to Achieve Predictable and Improved Functional and Aesthetic Outcomes. Plast Reconstr Surg 2010; 126:1967-1977. [DOI: 10.1097/prs.0b013e3181f44742] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Correction of hemifacial atrophy using free anterolateral thigh adipofascial flap. J Plast Reconstr Aesthet Surg 2010; 63:1110-6. [DOI: 10.1016/j.bjps.2009.06.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2008] [Revised: 05/29/2009] [Accepted: 06/08/2009] [Indexed: 11/19/2022]
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Agostini T, Agostini V. Adipofascial versus fasciocutaneous anterolateral thigh flap in oral cavity reconstruction. Focus on the vascular supply. J Plast Reconstr Aesthet Surg 2008; 62:e633-4. [PMID: 19019752 DOI: 10.1016/j.bjps.2008.10.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2008] [Accepted: 10/10/2008] [Indexed: 11/15/2022]
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Further experience with adipofascial ALT flap for oral cavity reconstruction. J Plast Reconstr Aesthet Surg 2008; 61:1164-9. [DOI: 10.1016/j.bjps.2008.03.038] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2007] [Revised: 03/26/2008] [Accepted: 03/27/2008] [Indexed: 11/18/2022]
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Choi SW, Park JY, Hur MS, Park HD, Kang HJ, Hu KS, Kim HJ. An anatomic assessment on perforators of the lateral circumflex femoral artery for anterolateral thigh flap. J Craniofac Surg 2007; 18:866-71. [PMID: 17667679 DOI: 10.1097/scs.0b013e3180a03304] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The anterolateral thigh flap was originally described in 1984 as a septocutaneous flap based on the descending branch of the lateral femoral circumflex artery (LCFA). This flap has many advantages for head and neck reconstruction. However, it is not widely used as a result of the broad range of anatomic variation of the cutaneous perforators and because dissection of these perforators is tedious when they are small. The purposes of this study are to classify the vascular anatomy of the LCFA and to assess the suitability of the anterolateral thigh flap for head and neck reconstruction in Koreans. From 38 thigh dissections of Korean cadavers, the LCFA commonly arose from the deep femoral artery and divided into ascending, transverse, and descending branches. In five cases, the LCFA arose directly from the femoral artery. The cutaneous perforators were present in 37 cases except one and the septocutaneous perforators were found in 17 of the 38 cases. Of the 160 perforators, 28 (17.5%) were the septocutaneous perforators and 132 (82.5%) were the musculocutaneous perforators. The average number of cutaneous perforators for the anterolateral thigh flap was 4.2 (range, 0-8), and these perforators were concentrated in the middle third of the anterolateral thigh. The septocutaneous perforators were located more proximally than the musculocutaneous perforators. The average length of the vascular pedicle derived from the descending branch or the transverse branch was 83.3 mm (range, 53.4-124.3 mm). The results of this study suggest that the vascular anatomy of the anterolateral thigh flap was reliable and well suited for head and neck reconstruction in Koreans.
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Affiliation(s)
- Sung-Weon Choi
- Oral Cancer Clinic, Research Institute and Hospital, National Cancer Center, Koyang, Korea
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Giessler GA, Doll S, Germann G. Macroscopic and microangiographic anatomy of the teres major muscle: a new free functional muscle flap? Plast Reconstr Surg 2007; 119:941-9. [PMID: 17312500 DOI: 10.1097/01.prs.0000252268.06443.61] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The teres major can be seen as an additional head of the latissimus dorsi muscle for three-dimensional movement of the arm. It gained importance in pedicled muscle transfers for the treatment of plexus palsies and shoulder instability. Its supplying vessels belong to the subscapular system. According to the literature, the muscle was transferred only once as a free microvascular but nonfunctional graft. METHODS Eleven flaps from fresh cadavers were dissected and perfused with radiopaque media. The detailed macroscopic and microangiographic anatomy was investigated to determine its potential use as a free functional muscle flap. RESULTS Three different access routes are possible. The mean length of the flap was 158 mm, and the distal and proximal tendinous widths were 24 mm and 52 mm, respectively. A Taylor type 1 nerve and Mathes type 2 vessel distribution was found in all specimens. The main pedicle is situated in the middle third of the superomedial border of the flap and derives almost exclusively from the circumflex scapular artery. Radioangiograms indicate possible splitting of the muscle in the transverse and longitudinal directions. The nerve could always be isolated to a considerable length (66 mm) before reaching the posterior cord. CONCLUSIONS This anatomical study indicates that the teres major can be seen as a separate entity in the subscapular system and can be transferred as a free flap either alone or in combination. According to what is known from pedicled transfers, the donor-site morbidity should be low if the latissimus dorsi is left intact.
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Affiliation(s)
- Goetz A Giessler
- Department for Hand, Plastic, and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic and Hand Surgery, University of Heidelberg, Ludwigshafen, Germany.
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Lin DT, Coppit GL, Burkey BB. Use of the anterolateral thigh flap for reconstruction of the head and neck. Curr Opin Otolaryngol Head Neck Surg 2004; 12:300-4. [PMID: 15252250 DOI: 10.1097/01.moo.0000130575.10656.97] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The anterolateral thigh free flap has achieved recent popularity in North America for the reconstruction of head and neck defects after ablative surgery. The flap is most often based on either the septocutaneous or musculocutaneous perforators of the descending branch of the lateral circumflex femoral artery. Its versatility allows for a subcutaneous, fasciocutaneous, myocutaneous, or adipofascial flap to be obtained. RECENT FINDINGS Recent publications have described the utility of the anterolateral thigh flap for reconstruction of head and neck defects. It has been used successfully in the reconstruction of the laryngopharynx, oral cavity, oropharynx, external skin, and maxilla. Furthermore, when a thinner flap is needed, a suprafascial anterolateral thigh flap may be raised or the flap may be thinned after it is obtained. SUMMARY The anterolateral thigh flap is a highly versatile and reliable flap for use in the reconstruction of various soft tissue defects of the head and neck. This flap has gained great popularity in mainland China, Taiwan, and Japan given its versatility, ability for a two-team approach, and minimal donor site morbidity. However, it has not met the same enthusiasm in Europe and North America because of the relative difficulty in perforator dissection, reported variations of the vascular anatomy, and the presumed increased thickness of the anterolateral thigh tissue in the Western population in comparison with the patient population of the Far East. These obstacles may be overcome by increased surgical experience and by the ability to create a thinner suprafascial flap or thinning the flap after it has been obtained.
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Affiliation(s)
- Derrick T Lin
- Vanderbilt University Medical Center, Nashville, Tennessee 37232-5555, USA.
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