CC
The patient states, “My surgeon sent me here to discuss reconstruction for cancer surgery.”
HPI
A 54-year-old male is referred from otolaryngology for evaluation of reconstructive needs in anticipation of resection of cT4aN3bM0 squamous cell carcinoma (SCC) involving the floor of the mouth, anterior mandible, and ventral tongue. The patient reports that he has developed a large neck mass over the course of the past several months, but because of difficulties obtaining insurance, he was unable to see a physician until recently. He reports that he has lost more than 25 lb in the past 6 months, has severe pain in his mouth that makes it very difficult for him to eat, and overall feels more fatigued. Since developing the mouth sore that has progressively increased in size, he switched his diet to a soft diet and then to a full liquid diet and has been drinking protein shakes to supplement his nutrition.
PMHX/PDHX/medications/allergies/SH/FH
The patient has hypertension, hyperlipidemia, chronic obstructive pulmonary disease, and benign prostatic hyperplasia. His medications include lisinopril, atorvastatin, a fluticasone–salmeterol inhaler, and tamsulosin. He has no known allergies and no surgical history.
The patient is a current daily cigarette smoker (50-pack-year history). He recently started smoking marijuana to help with pain. He drinks alcohol socially and denies illicit drug use.
His mother died at 82 years of age because of a heart attack, and his father died at age 78 years because of colon cancer.
Examination
General. Thin, tall, in no acute distress but appears uncomfortable.
Vital signs. Blood pressure is 134/86 mm Hg; heart rate is 88 bpm; oxygen saturation is 99% on room air; weight is 145 lb (65.7 kg); height is 6 ft, 2 in (187 cm); and body mass index (BMI) is 18.6.
Head. Normocephalic, atraumatic, no gross facial asymmetry.
Intraoral. Maximal incisal opening is 45 mm. Partially edentulous maxilla and mandible. Anterior floor of the mouth and ventral tongue with 6-cm ulcerative, erosive mass. Decreased tongue mobility, exquisitely tender to palpation. The mass involves the mandibular gingiva from premolar to premolar region. No gross mobility of mandibular teeth. Labial gingival recession of adjacent mandibular incisors. No other oral or oropharyngeal lesions.
Nasal fiberoptic endoscopy. No nasal, posterior oropharyngeal, or laryngeal lesions. Epiglottis, arytenoids, and aryepiglottic folds with no masses, lesions, or ulcerations. Vocal cords are symmetric with no masses, lesions, or ulcerations.
Neck. Bilateral submandibular mass, 15 cm in greatest diameter with indurated and fixed overlying skin. Mild skin erythema, no ulceration. Palpable, indurated level Ib and IIa lymph nodes on the right.
Pulmonary. No wheezes or rhonchi. Respirations even and unlabored on room air.
Cardiac. Regular rate and rhythm.
Gastrointestinal. Abdomen soft, not tender to palpation, no distension.
Extremities. Bilateral lower extremities with no edema, no varicosities, no ulceration, and no deformities. Dorsalis pedi and posterior tibial pulses 2+.
Preoperative assessment
Handheld Doppler ultrasound is used to identify perforators.
Imaging
If the patient has a palpable popliteal pulse, no further preoperative imaging is warranted before anterolateral thigh free flap harvesting. However, popliteal pulses can be challenging to palpate clinically, especially in patients with higher BMIs. If popliteal pulses cannot be palpated, the authors recommend handheld Doppler ultrasound assessment. If the Doppler signal cannot be identified, preoperative computed tomography (CT) angiography of the lower extremities could be considered.
Labs
There are no specific laboratory tests required before anterolateral thigh free flap harvest; however, standard laboratory tests should always be obtained before major surgery and typically include a complete blood count, basic metabolic profile, prothrombin time, partial thromboplastin time, international normalized ratio, type and screen, and a pregnancy test in females of childbearing age.
Assessment
cT4aN3bM0 (greatest clinical tumor dimension is >4 cm with depth of invasion >10 mm or tumor invades adjacent structures only; metastasis in a lymph node >6 cm in greatest dimension or the presence of clinically evident extranodal extension) SCC of the floor of the mouth with no mandibular marrow involvement on CT of the neck ( Fig. 80.1 ).
Treatment
Because the anticipated defect consisted of an intra- and extraoral soft tissue defect with mandibular continuity maintenance, several reconstructive options were discussed with the patient, including anterolateral thigh flap (ALT), thoracodorsal artery perforator flap (TDAP), and a combination of pectoralis major and supraclavicular flaps, as well as local tissue advancement flaps to facilitate closure of the extraoral cervical defect. The patient opted to proceed with an ALT because it appeared to have the least morbidity to him.
The ablative portion of the procedure was completed and included a tracheostomy, tumor resection, and bilateral modified radical neck dissection. The anterolateral thigh free flap was harvested simultaneously.
The patient was placed under general anesthesia and underwent a tracheostomy to secure his airway. The planned resection was outlined using a marking pen with a 1.5-cm circumferential margin intraorally and a 1-cm margin around the area of cutaneous involvement in the left neck ( Fig. 80.2 ). Modified radical neck dissections were completed bilaterally to facilitate access to the primary tumor. The composite resection included the ventral tongue, floor of the mouth, and marginal mandibulectomy, which was left in continuity with the lymph node dissection specimen to allow for appropriate margin assessment ( Fig. 80.3 ). Resection margins were confirmed to be free of residual tumor with frozen sections.
The anterolateral thigh free flap was harvested simultaneously. The ALT is based on cutaneous perforators from the lateral circumflex femoral artery (LCFA) and lateral circumflex femoral vena comitantes . Sensory reinnervation can be achieved using the lateral femoral cutaneous nerve. A large amount of skin and a variable amount of subcutaneous tissue are available for transfer, frequently obtaining primary closure with minimal donor site morbidity. This makes the ALT a good reconstructive option for a variety of soft tissue defects in the head and neck.
An elliptical skin paddle should be designed with a width permitting primary closure of the donor site. However, if wider skin paddles are required, a split-thickness skin graft can be used to repair the donor site defect. The anterolateral thigh free flap is centered around a long axis parallel to and a few centimeters lateral to a line drawn from the anterior superior iliac spine (ASIS) to the lateral border of the patella, which typically indicates the position of the intermuscular septum. LCFA cutaneous perforators are typically located within a 3- to 5-cm radius from the midpoint of this axis ( Fig. 80.4 ).
In the current patient, four cutaneous perforators were identified with the aid of a handheld Doppler probe. Yu et al. developed the “ABC” system to localize cutaneous perforators without the need for preoperative Doppler studies. In their dissection of 72 ALTs, they identified one to three cutaneous perforators in 71 of the flaps. The most consistently present perforator was located around the midpoint between the ASIS and the superolateral patella. A more proximal or more distal perforator may also be found, with each perforator being approximately 5 cm apart from each other. These were labeled as perforator A (proximal), perforator B (middle), and perforator C (distal) to help simplify discussions regarding the anatomic locations of these perforators. Studies by Yu and Adel showed that Doppler evaluation is highly sensitive (91%–100%) but not specific (0%–55%) in identifying perforator location intraoperatively. This was particularly true in patients with higher BMIs. They demonstrated the efficacy of using the previously mentioned landmarks without the need for preoperative Doppler evaluation when designing the ALT.
After the perforators were identified, the medial incision line of the skin paddle was marked out. Monopolar electrocautery was then used to make a skin incision through the subcutaneous plane and rectus femoris muscle fascia. The rectus femoris muscle was then retracted medially while the rectus femoris muscular fascia and fascia lata were retracted laterally ( Fig. 80.5 ). Subfascial dissection was carried out medially to identify the muscular septum. The LCFA was identified and noted to course on the undersurface of the vastus lateralis muscle. Cutaneous perforators were identified and the proximal pedicle was dissected out.
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