Full-thickness cheek defect (FTCD) after oncological resection represents a challenge for head and neck reconstructive surgeons because it involves both the oral mucosa and the skin of the face, and poses relevant functional problems in chewing, swallowing, and speech. In the literature, there is no systematization of the problem, and the surgical techniques proposed are heterogeneous [1].
Free flaps folded with double skin paddle for internal and external lining are relatively recognized as the gold standard for reconstruction of large soft-tissues FTCDs [2]. Noteworthy, several authors proposed a combination of local and regional pedicle flaps [3]. These options frequently resulted in relevant bulky effect with minimal aesthetic and functional performance as well as greater morbidity for the donor sites [4].
In the present work, we describe a technique for reconstruction of a wide soft-tissues FTCDs with single-skin paddle anterolateral thigh free flap (ALTFF), with ileotibial tract for internal lining.
In the case illustrated, by way of example, a relapsing oral squamous cell carcinoma of the cheek mucosa with infiltration to the skin of the face required a wide full-thickness surgical resection, included a marginal mandibulectomy (Fig. 1).
Fig. 1.
Size of the full-thickness defect after resection
For the reconstruction, an ALTFF is harvested from the left lower limb. The skin paddle is drawn with the precise aspect of the external defect. The flap is based on a single central perforating pedicle, searched with minidoppler. During the harvesting, fascia lata from ileotibial tract underlying the skin paddle is carefully preserved bound to the flap. In a second phase, the fascia lata is detached from the subcutaneous tissue of the paddle, except for an area of 2 cm of diameter around the pedicle: afterwards, the fascia lata is remodelled to adapt to internal defect. Residual mandible is reinforced with a titanium plate, and the flap is doubly sutured “on horseback” over the mandible, with the fascia lata bounded to oral mucosa with resorbable stitches (Fig. 2) and the skin paddle positioned to fill the external aspect of the resection (Fig. 3). The fascia lata is sutured with adequate tension between the mandibular condyle and the lip commissure to prevent its lowering and incontinence. Finally, the microvascular anastomoses are realized (termino-terminal on the superior thyroid artery and termino-lateral on the internal jugular vein).
Fig. 2.
Internal layer of fascia lata is placed and sutured with the oral mucosa
Fig. 3.
External final view after reconstruction. The skin paddle perfectly fills the defect
One month after surgery, the healing process is perfectly achieved, and the internal reconstruction appeared resurfaced by normal mucosa (Fig. 4). This reconstruction technique guarantees a significantly less bulky effect, and although the aesthetic result is not ideal due to the unavoidable large discoloured skin area, the patient is able to rehabilitate effectively and very quickly chewing, swallowing, and speech.
Fig. 4.
One month postoperative control shows the fascia lata reconstruction resurfaced by normal mucosa
Compliance with Ethical Standards
Conflict of interest
The authors declare that they have no conflict of interest.
Ethical Approval
Ethical approval was received.
Informed Consent
Informed consent of the patient was obtained.
Footnotes
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References
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