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A new method: perforator-based tissue expansion for a preexpanded free cutaneous perforator flap
Burns 29 (2003) 845–848
A new method: perforator-based tissue expansion for a preexpanded free cutaneous perforator flap Feng-Chou Tsai∗ Department of Plastic Surgery, LinKou Burn Center, Chang Gung Memorial Hospital, 5 Fu-Hsin St., Kweishan, Taoyuan, Taiwan Accepted 17 June 2003
Abstract Recent advances in concepts of preexpanded free flaps have made it possible to replace larger postburn contracture area. Free anterolateral thigh (ALT) cutaneous perforator flaps are popular due to constant, reliable anatomy and various clinical applications in our department. Combination of preexpansion, perforator-based prefabrication of tissue expansion and a free anterolateral thigh flap is first introduced and developed to resurface the large territory of postburn cervical contracture in a 33-year-old female patient with second to third degree flame burn with a 45% total body surface area (TBSA) involvement. The limited lateral flexion and rotation was noted despite aggressive rehabilitation for 6 months. The 650 cm3 kidney-shaped tissue expander was inserted around the myocutaneous perforator under the fascia via the midlateral thigh incision in first stage. Two months later right lateral neck scar (size = 25 cm × 13 cm) was excised after serial clinic saline injection. The preexpanded free flap (size = 29 cm × 15 cm) combined with z plasty and capsulectomy was harvested and covered in the contracture defect. A flap totally survived. One-staged resurfacing was achieved with immediate postoperative improvement. The hospital stay was 6 days. The donor site was closed primarily. After 6 months follow-up, the functional improvement was assessed as follows: an increase in rotation of 14◦ (preoperative 74◦ to postoperative 88◦ ); and an increase in lateral flexion of 10◦ (preoperative 30◦ to postoperative 40◦ ). The prefabrication of the free cutaneous perforator flap by perforator-based tissue expansion above the muscle has several advantages: (1) it provides accurate and safe expansion without damage of any perforator compared with the blunt dissection; (2) larger territory of free flaps can be used for burn reconstruction; (3) donor site is primarily closed with low tension; (4) it is not a random expanded flap due to direct expansion of specific skin territory around the perforator. The disadvantages are two-staged procedures, complications of tissue expansion (e.g. infection, extrusion), the possibility of compression of pedicles. © 2003 Elsevier Ltd and ISBI. All rights reserved. Keywords: Free flaps; Contracture; Burns; Prefabrication; Tissue expansion
1. Introduction Since tissue expanders were developed to gain extra skin tissue for coverage of defects, the preexpansion and free flaps were combined together to overcome the limitation of single reconstructive modality like local flaps and skin grafts [1–5]. The traditional preexpanded free cutaneous flaps that were based on the concepts of blunt dissection and random flaps are easier to cause the incidental damage of perforators. In addition, the preexpanded free myocutaneous flaps are too bulky to demanding secondary thinning procedure. Therefore, the blunt dissection is not accurate and random flap is dangerous for reliability of the free flap. ∗
Tel.: +886-3-3281200x3221; fax: +886-3-3287260. E-mail address: [email protected] (F.-C. Tsai).
0305-4179/$30.00 © 2003 Elsevier Ltd and ISBI. All rights reserved. doi:10.1016/S0305-4179(03)00197-9
Prefabricated free flaps using a perforator-based tissue expansion technique could provide thin, large, pliable tissue for reconstruction of postburn scar contracture with excellent functional and aesthetic outcomes.
2. Case report A 33-year-old male patient suffered from flame burns that caused a second and third degree burn of neck, chest, back and upper arm with a 45% total body surface area (TBSA) involvement. Limited lateral flexion and rotation occurred following meshed split thickness skin grafts (STSG) procedures despite aggressive rehabilitation. He was admitted for replacement of right extensive cervical hypertrophic scar (Fig. 1A and B). The midlateral thigh incision as an anterolateral thigh (ALT) flap harvest was performed to
846
F.-C. Tsai / Burns 29 (2003) 845–848
Fig. 1. (A and B) Preoperative photograph: lateral cervical contracture with limited lateral flexion and rotation; (C) a tissue expander was inserted via the small midlateral thigh incision; (D) over the 8 weeks of serial saline injection, a maximum expansion volume of 750 cm3 was reached; (E) the fibrotic capsule surrounded the perforator with tissue expander; (F) flap harvest; (G) the scar was completely replaced with the free flap; (H and I) postoperative photograph after 6 months follow-up.
dissect the perforator free and create the pocket for insertion of kidney-shaped tissue expander (650 cm3 ) just under the fascia (Fig. 1C). The partial fasciectomy and fascia scoring was performed for improvement of extensibility and thinning during tissue expansion. Over the 8 weeks of serial saline injection in clinic, a maximum expansion volume of 750 cm3 was reached (Fig. 1D). No painful disability over right thigh was complaint. In second stage, a 25 cm × 13 cm scar contracture was completely excised and stretched out for full range of motion. A free ALT cutaneous perforator flap (29 cm × 15 cm) was harvested with only one perforator from the right thigh. Because the capsule adhered the perforator, more careful intramuscular perforator dissection was necessary (Fig. 1E and F). The capsulectomy and fascia removal was performed. The transverse cervical artery and branch of internal jugular vein were used as recipient vessels with end-to-end microsurgical anastomosis using 9-0 Nylon. The scar was replaced with the flap (Fig. 1G). The hospital
stay was 6 days. After 6 months follow-up, an improved range of motion was achieved (Fig. 1H and I) (Table 1). The donor site was closed primarily with linear scar (Fig. 2). Table 1 CMA Pre Post Extension Pre Post Lateral flexion Pre Post Rotation Pre Post
N N N N 30 40 74 88
CMA: cervico-mandibular angle, Pre: preoperative, Post: postoperative, N: normal.
F.-C. Tsai / Burns 29 (2003) 845–848
Fig. 2. The donor site of right thigh with linear scar after 6 months follow-up.
3. Discussion Postburn scar contracture remains a great challenge to reconstructive microsurgeon. Although a single free flap can provide ideal soft, pliable tissue for reconstruction, there are some residual extensive defects after contracture release not to be replaced in one-staged procedure [6–11]. The prefabrication of flaps expands the usage of traditional flaps by tissue expansion, vascular induction and surgical delay [12]. A preexpanded free flap is a good option of resurfacing large postburn scar contracture. The pretransfer expansion of a flap increases flap vascularity, extends the safety of distally random portion of skin flap, and permits primary closure of the donor site. Since Leighton et al. demonstrated applications pretransfer tissue expansion in 1986, preexpanded free flaps were found to be useful for resurfacing the defects resulting from trauma, burns and surgical ablation [13]. Larger free flaps of specialized tissue may be transferred safely with reduced donor site morbidity by this technique. However, the traditional preexpanded free tissue transfer is based on
847
the concepts of tissue expander using the blunt dissection with the capsulofasciocutaneous flap or the myocutaneous flap. The incidental damage of perforators or random flap of distal skin portion is noted. So, the accurate positioning of perforators is reasonable for insertion of tissue expander in the first stage. The precise insertion of tissue expansion over central or eccentric portion of the skin paddle supplied by perforators increases the reliability of flaps without the problems of random flaps (Fig. 3). Limited extensibility of the traditional preexpanded free flap is due to the dual effect of capsule and fascia. It makes the possibility of poor functional outcome and difficulty of primary closure of donor site. Fibrosis formation during the saline injection makes the dissection more difficult than the usual flap harvest. Dissection should be along the surgical plane between capsule and neurovascular pedicles. The pretransfer fasciectomy makes the skin paddle more extensible and thinner at the same time. The posttransfer capsulectomy over the flap and donor region is of no problem to flap viability and primary closure of donor site. The anterolateral thigh flap offers the constant anatomy of perforators that pierce the fascia straightly, not obliquely from the muscle [14–20]. The equal subfascial space around the perforator makes the tissue expander easily inserted and avoids incidental damage of perforators during dissection and postoperative saline injection. Besides, the subfascial dissection can avoid the “step-ladder” phenomenon of skin components because the skin receives different forces of tissue expansion. The traditional suprafascial dissection to place the tissue expander makes the skin like the random flap that easily pushes the blood supply away from the axial vessels, even causes venous congestion postoperatively similar to many reports of preexpanded flaps described. The protection of perforators was achieved by tenting sutures that separate the perforators and tissue expander and slower postoperative expansion rate. The effect of tissue expansion over the thigh is compensated by elastic consistency of soft and large muscle. So the gain of extra skin after tissue expansion is less than the preexpanded scapular cutaneous or latissimus dorsi myocutaneous flap because the hard thoracic cage cannot absorb the expansion force of tissue expanders and makes the expansion focus on the skin. The maximal width of ALT flaps can be increased from 9 to 15 cm without large tension. The prefabrication of the free cutaneous perforator flap by perforator-based tissue expansion above the muscle has several advantages: (1) it provides accurate and safe expansion without damage of any perforator compared with the blunt dissection; (2) larger territory of free flaps can be used for burn reconstruction; (3) donor site is primarily closed with low tension; (4) it is not a random expanded flap due to direct expansion of specific skin territory around the perforator. The disadvantages are two-staged procedures, complications of tissue expansion (e.g. infection, extrusion), the possibility of compression of pedicles.
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F.-C. Tsai / Burns 29 (2003) 845–848
Fig. 3. Perforator-based tissue expansion: the tissue expander is inserted around the perforator after accurate subfascial dissection and localization of pedicles. TE: a tissue expander; mcp: a myocutaneous perforator; VLm: Vastus lateralis muscle; LCFA: lateral circumflex femoral artery.
In summary, perforator-based tissue expansion could be safely applied to free cutaneous perforator flaps for the purpose of preexpansion.
[11] [12]
References [1] Masser MR. The preexpanded radial free flap. Plast Reconstr Surg 1990;86(2):295–301. [2] Laitung JK, Batchelor AG. Successful pre-expansion of a free scapular flap. Ann Plast Surg 1990;25(3):205–7. [3] Kenney JG, DiMercurio S, Angel M. Tissue expanded radial forearm free flap in neck burn contracture. J Burn Care Rehabil 1990;11(5):443–5. [4] Balakrishnan C. The preexpanded radial free flap. Plast Reconstr Surg 1991;88(1):171. [5] Hyakusoku H, Pennington DG, Gao JH. Microvascular augmentation of the super-thin occipito-cervico-dorsal flap. Br J Plast Surg 1994;47(7):465–9. [6] Kobus K. Surgery of postburn defects and deformities of the face. Ann Plast Surg 1987;19(2):162–72. [7] Kobus K, Stepniewsky J. Free flaps versus conventional surgery. Ann Plast Surg 1985;15(1):14–34. [8] Lin JY, Yang JY, Tsai F-C. Reconstruction of anterior cervical contractures with a free thin anterolateral thigh flap combined cervicoplasty. J Plast Surg Assoc ROC 2001;10(3):186–93. [9] Liao HT, Tsai F-C, Chen HC. A free ultrathin latissimus dorsi perforator flap (LDPF) for reconstruction of soft tissue defect in the hand. J Plast Surg Assoc ROC 2001;10(3):205–10. [10] Yang JY, Tsai F-C, Chana JS. Use of free thin anterolateral thigh flaps combined with cervicoplasty for reconstruction of postburn
[13]
[14]
[15]
[16]
[17]
[18]
[19]
[20]
anterior cervical contractures. Plast Reconstr Surg 2002;110(1): 39–46. De Lorenzi F, van der Hulst R, Boeckx W. Free flaps in burn reconstruction. Burns 2001;27(6):603–12. Abbase EA, Shenaq SM, Spira M, et al. Prefabricated flaps: experimental and clinical review. Plast Reconstr Surg 1995;96(5):1218–25. Leighton WD, Russel RC, Marcus DE, et al. Experimental pretransfer expansion of free-flap donor sites. I. Flap viability and expansion characteristic. Plast Reconstr Surg 1988;82(1):69–75. Hallock GG. Simultaneous transposition of anterior thigh muscle and fascia flaps: an introduction to the chimera flap principle. Ann Plast Surg 1991;27(2):126–31. Koshima I, Yamamoto H, Hosoda M, et al. Free combined composite flaps using the lateral circumflex femoral system for repair of massive defects of the head and neck regions: an introduction to the chimeric flap principle. Plast Reconstr Surg 1993;92(3):411–20. Koshima I, Hosoda M, Moriguchi T, et al. A combined anterolateral thigh flap, anteromedial thigh flap, and vascularized iliac bone graft for a full-thickness defect of the mental region. Ann Plast Surg 1993;31(2):175–80. Song YG, Chen GZ, Song YL. The free thigh flap: a new free flap concept based on the septocutaneous artery. Br J Plast Surg 1984;37(2):149–59. Kimata Y, Uchiyama K, Ebihara S, et al. Anatomic variations and technical problems of the anterolateral thigh flap: a report of 74 cases. Plast Reconstr Surg 1998;102(5):1517–23. Koshima I, Fukuda H, Yamamoto H, et al. Free anterolateral thigh flaps for reconstruction of head and neck defects. Plast Reconstr Surg 1993;92(3):421–8. Kimata Y, Uchiyama K, Ebihara S, et al. Versatility of the free anterolateral thigh flap for reconstruction of head and neck defects. Arch Otolaryngol Head Neck Surg 1997;123(12):1325–31.
A new method: perforator-based tissue expansion for a preexpanded free cutaneous perforator flap Feng-Chou Tsai∗ Department of Plastic Surgery, LinKou Burn Center, Chang Gung Memorial Hospital, 5 Fu-Hsin St., Kweishan, Taoyuan, Taiwan Accepted 17 June 2003
Abstract Recent advances in concepts of preexpanded free flaps have made it possible to replace larger postburn contracture area. Free anterolateral thigh (ALT) cutaneous perforator flaps are popular due to constant, reliable anatomy and various clinical applications in our department. Combination of preexpansion, perforator-based prefabrication of tissue expansion and a free anterolateral thigh flap is first introduced and developed to resurface the large territory of postburn cervical contracture in a 33-year-old female patient with second to third degree flame burn with a 45% total body surface area (TBSA) involvement. The limited lateral flexion and rotation was noted despite aggressive rehabilitation for 6 months. The 650 cm3 kidney-shaped tissue expander was inserted around the myocutaneous perforator under the fascia via the midlateral thigh incision in first stage. Two months later right lateral neck scar (size = 25 cm × 13 cm) was excised after serial clinic saline injection. The preexpanded free flap (size = 29 cm × 15 cm) combined with z plasty and capsulectomy was harvested and covered in the contracture defect. A flap totally survived. One-staged resurfacing was achieved with immediate postoperative improvement. The hospital stay was 6 days. The donor site was closed primarily. After 6 months follow-up, the functional improvement was assessed as follows: an increase in rotation of 14◦ (preoperative 74◦ to postoperative 88◦ ); and an increase in lateral flexion of 10◦ (preoperative 30◦ to postoperative 40◦ ). The prefabrication of the free cutaneous perforator flap by perforator-based tissue expansion above the muscle has several advantages: (1) it provides accurate and safe expansion without damage of any perforator compared with the blunt dissection; (2) larger territory of free flaps can be used for burn reconstruction; (3) donor site is primarily closed with low tension; (4) it is not a random expanded flap due to direct expansion of specific skin territory around the perforator. The disadvantages are two-staged procedures, complications of tissue expansion (e.g. infection, extrusion), the possibility of compression of pedicles. © 2003 Elsevier Ltd and ISBI. All rights reserved. Keywords: Free flaps; Contracture; Burns; Prefabrication; Tissue expansion
1. Introduction Since tissue expanders were developed to gain extra skin tissue for coverage of defects, the preexpansion and free flaps were combined together to overcome the limitation of single reconstructive modality like local flaps and skin grafts [1–5]. The traditional preexpanded free cutaneous flaps that were based on the concepts of blunt dissection and random flaps are easier to cause the incidental damage of perforators. In addition, the preexpanded free myocutaneous flaps are too bulky to demanding secondary thinning procedure. Therefore, the blunt dissection is not accurate and random flap is dangerous for reliability of the free flap. ∗
Tel.: +886-3-3281200x3221; fax: +886-3-3287260. E-mail address: [email protected] (F.-C. Tsai).
0305-4179/$30.00 © 2003 Elsevier Ltd and ISBI. All rights reserved. doi:10.1016/S0305-4179(03)00197-9
Prefabricated free flaps using a perforator-based tissue expansion technique could provide thin, large, pliable tissue for reconstruction of postburn scar contracture with excellent functional and aesthetic outcomes.
2. Case report A 33-year-old male patient suffered from flame burns that caused a second and third degree burn of neck, chest, back and upper arm with a 45% total body surface area (TBSA) involvement. Limited lateral flexion and rotation occurred following meshed split thickness skin grafts (STSG) procedures despite aggressive rehabilitation. He was admitted for replacement of right extensive cervical hypertrophic scar (Fig. 1A and B). The midlateral thigh incision as an anterolateral thigh (ALT) flap harvest was performed to
846
F.-C. Tsai / Burns 29 (2003) 845–848
Fig. 1. (A and B) Preoperative photograph: lateral cervical contracture with limited lateral flexion and rotation; (C) a tissue expander was inserted via the small midlateral thigh incision; (D) over the 8 weeks of serial saline injection, a maximum expansion volume of 750 cm3 was reached; (E) the fibrotic capsule surrounded the perforator with tissue expander; (F) flap harvest; (G) the scar was completely replaced with the free flap; (H and I) postoperative photograph after 6 months follow-up.
dissect the perforator free and create the pocket for insertion of kidney-shaped tissue expander (650 cm3 ) just under the fascia (Fig. 1C). The partial fasciectomy and fascia scoring was performed for improvement of extensibility and thinning during tissue expansion. Over the 8 weeks of serial saline injection in clinic, a maximum expansion volume of 750 cm3 was reached (Fig. 1D). No painful disability over right thigh was complaint. In second stage, a 25 cm × 13 cm scar contracture was completely excised and stretched out for full range of motion. A free ALT cutaneous perforator flap (29 cm × 15 cm) was harvested with only one perforator from the right thigh. Because the capsule adhered the perforator, more careful intramuscular perforator dissection was necessary (Fig. 1E and F). The capsulectomy and fascia removal was performed. The transverse cervical artery and branch of internal jugular vein were used as recipient vessels with end-to-end microsurgical anastomosis using 9-0 Nylon. The scar was replaced with the flap (Fig. 1G). The hospital
stay was 6 days. After 6 months follow-up, an improved range of motion was achieved (Fig. 1H and I) (Table 1). The donor site was closed primarily with linear scar (Fig. 2). Table 1 CMA Pre Post Extension Pre Post Lateral flexion Pre Post Rotation Pre Post
N N N N 30 40 74 88
CMA: cervico-mandibular angle, Pre: preoperative, Post: postoperative, N: normal.
F.-C. Tsai / Burns 29 (2003) 845–848
Fig. 2. The donor site of right thigh with linear scar after 6 months follow-up.
3. Discussion Postburn scar contracture remains a great challenge to reconstructive microsurgeon. Although a single free flap can provide ideal soft, pliable tissue for reconstruction, there are some residual extensive defects after contracture release not to be replaced in one-staged procedure [6–11]. The prefabrication of flaps expands the usage of traditional flaps by tissue expansion, vascular induction and surgical delay [12]. A preexpanded free flap is a good option of resurfacing large postburn scar contracture. The pretransfer expansion of a flap increases flap vascularity, extends the safety of distally random portion of skin flap, and permits primary closure of the donor site. Since Leighton et al. demonstrated applications pretransfer tissue expansion in 1986, preexpanded free flaps were found to be useful for resurfacing the defects resulting from trauma, burns and surgical ablation [13]. Larger free flaps of specialized tissue may be transferred safely with reduced donor site morbidity by this technique. However, the traditional preexpanded free tissue transfer is based on
847
the concepts of tissue expander using the blunt dissection with the capsulofasciocutaneous flap or the myocutaneous flap. The incidental damage of perforators or random flap of distal skin portion is noted. So, the accurate positioning of perforators is reasonable for insertion of tissue expander in the first stage. The precise insertion of tissue expansion over central or eccentric portion of the skin paddle supplied by perforators increases the reliability of flaps without the problems of random flaps (Fig. 3). Limited extensibility of the traditional preexpanded free flap is due to the dual effect of capsule and fascia. It makes the possibility of poor functional outcome and difficulty of primary closure of donor site. Fibrosis formation during the saline injection makes the dissection more difficult than the usual flap harvest. Dissection should be along the surgical plane between capsule and neurovascular pedicles. The pretransfer fasciectomy makes the skin paddle more extensible and thinner at the same time. The posttransfer capsulectomy over the flap and donor region is of no problem to flap viability and primary closure of donor site. The anterolateral thigh flap offers the constant anatomy of perforators that pierce the fascia straightly, not obliquely from the muscle [14–20]. The equal subfascial space around the perforator makes the tissue expander easily inserted and avoids incidental damage of perforators during dissection and postoperative saline injection. Besides, the subfascial dissection can avoid the “step-ladder” phenomenon of skin components because the skin receives different forces of tissue expansion. The traditional suprafascial dissection to place the tissue expander makes the skin like the random flap that easily pushes the blood supply away from the axial vessels, even causes venous congestion postoperatively similar to many reports of preexpanded flaps described. The protection of perforators was achieved by tenting sutures that separate the perforators and tissue expander and slower postoperative expansion rate. The effect of tissue expansion over the thigh is compensated by elastic consistency of soft and large muscle. So the gain of extra skin after tissue expansion is less than the preexpanded scapular cutaneous or latissimus dorsi myocutaneous flap because the hard thoracic cage cannot absorb the expansion force of tissue expanders and makes the expansion focus on the skin. The maximal width of ALT flaps can be increased from 9 to 15 cm without large tension. The prefabrication of the free cutaneous perforator flap by perforator-based tissue expansion above the muscle has several advantages: (1) it provides accurate and safe expansion without damage of any perforator compared with the blunt dissection; (2) larger territory of free flaps can be used for burn reconstruction; (3) donor site is primarily closed with low tension; (4) it is not a random expanded flap due to direct expansion of specific skin territory around the perforator. The disadvantages are two-staged procedures, complications of tissue expansion (e.g. infection, extrusion), the possibility of compression of pedicles.
848
F.-C. Tsai / Burns 29 (2003) 845–848
Fig. 3. Perforator-based tissue expansion: the tissue expander is inserted around the perforator after accurate subfascial dissection and localization of pedicles. TE: a tissue expander; mcp: a myocutaneous perforator; VLm: Vastus lateralis muscle; LCFA: lateral circumflex femoral artery.
In summary, perforator-based tissue expansion could be safely applied to free cutaneous perforator flaps for the purpose of preexpansion.
[11] [12]
References [1] Masser MR. The preexpanded radial free flap. Plast Reconstr Surg 1990;86(2):295–301. [2] Laitung JK, Batchelor AG. Successful pre-expansion of a free scapular flap. Ann Plast Surg 1990;25(3):205–7. [3] Kenney JG, DiMercurio S, Angel M. Tissue expanded radial forearm free flap in neck burn contracture. J Burn Care Rehabil 1990;11(5):443–5. [4] Balakrishnan C. The preexpanded radial free flap. Plast Reconstr Surg 1991;88(1):171. [5] Hyakusoku H, Pennington DG, Gao JH. Microvascular augmentation of the super-thin occipito-cervico-dorsal flap. Br J Plast Surg 1994;47(7):465–9. [6] Kobus K. Surgery of postburn defects and deformities of the face. Ann Plast Surg 1987;19(2):162–72. [7] Kobus K, Stepniewsky J. Free flaps versus conventional surgery. Ann Plast Surg 1985;15(1):14–34. [8] Lin JY, Yang JY, Tsai F-C. Reconstruction of anterior cervical contractures with a free thin anterolateral thigh flap combined cervicoplasty. J Plast Surg Assoc ROC 2001;10(3):186–93. [9] Liao HT, Tsai F-C, Chen HC. A free ultrathin latissimus dorsi perforator flap (LDPF) for reconstruction of soft tissue defect in the hand. J Plast Surg Assoc ROC 2001;10(3):205–10. [10] Yang JY, Tsai F-C, Chana JS. Use of free thin anterolateral thigh flaps combined with cervicoplasty for reconstruction of postburn
[13]
[14]
[15]
[16]
[17]
[18]
[19]
[20]
anterior cervical contractures. Plast Reconstr Surg 2002;110(1): 39–46. De Lorenzi F, van der Hulst R, Boeckx W. Free flaps in burn reconstruction. Burns 2001;27(6):603–12. Abbase EA, Shenaq SM, Spira M, et al. Prefabricated flaps: experimental and clinical review. Plast Reconstr Surg 1995;96(5):1218–25. Leighton WD, Russel RC, Marcus DE, et al. Experimental pretransfer expansion of free-flap donor sites. I. Flap viability and expansion characteristic. Plast Reconstr Surg 1988;82(1):69–75. Hallock GG. Simultaneous transposition of anterior thigh muscle and fascia flaps: an introduction to the chimera flap principle. Ann Plast Surg 1991;27(2):126–31. Koshima I, Yamamoto H, Hosoda M, et al. Free combined composite flaps using the lateral circumflex femoral system for repair of massive defects of the head and neck regions: an introduction to the chimeric flap principle. Plast Reconstr Surg 1993;92(3):411–20. Koshima I, Hosoda M, Moriguchi T, et al. A combined anterolateral thigh flap, anteromedial thigh flap, and vascularized iliac bone graft for a full-thickness defect of the mental region. Ann Plast Surg 1993;31(2):175–80. Song YG, Chen GZ, Song YL. The free thigh flap: a new free flap concept based on the septocutaneous artery. Br J Plast Surg 1984;37(2):149–59. Kimata Y, Uchiyama K, Ebihara S, et al. Anatomic variations and technical problems of the anterolateral thigh flap: a report of 74 cases. Plast Reconstr Surg 1998;102(5):1517–23. Koshima I, Fukuda H, Yamamoto H, et al. Free anterolateral thigh flaps for reconstruction of head and neck defects. Plast Reconstr Surg 1993;92(3):421–8. Kimata Y, Uchiyama K, Ebihara S, et al. Versatility of the free anterolateral thigh flap for reconstruction of head and neck defects. Arch Otolaryngol Head Neck Surg 1997;123(12):1325–31.