Pedicle Lengthening with Reducing Size Mismatch in Free Anterolateral Free Flap

When plastic surgeons reconstruct the defects for recurrent cancer, a longer vascular pedicle is often necessary because usable vessels are sacrificed in previous surgeries or radiotherapy. In this case, we would like to present another method for free anterolateral thigh flap pedicle elongation. A 59-year-old man was referred to our clinic for reconstruction after unilateral total maxillectomy and orbital exenteration due to recurrent squamous cell carcinoma. We need to cover the full-thickness defect in the left orbital area (8×7 cm sized), intraoral area (5×7 cm sized), and orbital floor. Due to prior surgeries and radiotherapy, we needed a vascular pedicle up to 15 cm for a distant recipient vessel. When harvesting the flap, we transected just proximal to the bifurcation site, harvested a muscular branch to vastus intermedius together, and used it for pedicle elongation by vessel turning over. A 17×6 cm sized musculocutaneous flap was harvested, and the total length of the pedicle was 15 cm. As the anastomosis was done at the distal portion of the vastus intermedius branch, there was no size mismatch with the superior thyroid artery. Both skin defects and the orbital floor were covered without any tension. The reconstruction was successful without any flap compromise 1 year after surgery. This case suggests another option for microsurgeons to lengthen the flap pedicle and reduce size mismatch using anatomical variability of the lateral circumflex femoral artery.