br Patients and methods br Surgical

Patients and methods
Surgical technique After oral surgeons excised the main tumor, we measured the oral defect and designed the flap niclosamide on the detected perforator by a hand-held Doppler. The central axis of the flap was identified by a line drawn from the anterior superior iliac spine to the superolateral border of the patella. The major perforator was located by a hand-held Doppler at the midpoint area of this line. A longitudinal fusiform-shaped fasciocutaneous anterolateral thigh flap was designed to include the tensor fasciae latae beneath the skin paddle. The tensor fasciae latae was prepared in rectangular shape and at least 2 cm away from both cranial and caudal ends of the flap. The medial margin of the flap was incised and subfascially dissected. One of preoperatively detected perforators was selected as the donor vessel. The selected perforator was dissected retrograde to the descending branch of the lateral circumflex femoral artery. The superior and inferior margins of the flap were incised suprafascial and the tensor fasciae latae was dissected at least 2 cm cranially and caudally to obtain fascial extensions. The tensor fasciae latae was transected from both the cranial and caudal extensions. The lateral margin of the flap was incised subfascially and the flap was harvested with a vascularized fascia component. Division of the skin paddle from the tensor fasciae latae, which will decrease the vascular supply to tensor fasciae latae, was avoided. The cranial and caudal ends of the tensor fasciae latae were used as one strip or separated longitudinally into two strips depending on our suspension method. The flap was inset to reconstruct the lower lip defect and the vessels were anastomosed under a microscope. The suspension with the tensor fasciae latae was performed, as described below: The donor sites of flaps in Cases 1 and 2 were primarily closed with 2-0 Vicryl and 4-0 Nylon. The donor site of the flap in Case 3 was closed as much as possible by 2-0 vicryl and 4-0 Nylon. The left skin defect was reconstructed with a split thickness skin graft, 6 × 5 cm2 in size, 10/1000 inch in thickness, and meshed at the ratio of 1:1.5 from the left medial thigh.
Results
Case reports
Discussion The lower lip plays a more critical role as an oral barrier and for prevention of sialorrhea than the upper lip. It is, however, quite difficult to rescue the function of a large lower lip defect during reconstructive surgery because of the effect of gravity and loss of the orbicularis oris muscle. The use of regional flaps, such as double reverse Abbe flaps, Karapandzic flaps, and Webster-Bernard flaps leads to extended facial scars, severe microsomia, and sialorrhea. Thus, free flaps have replaced regional flaps for large lower lip reconstruction in most situations. Previously, the radial forearm free flap was the most widely used one for extensive lower lip reconstruction. In 1989, Sakai employed the composite radial forearm-palmaris longus tendon free flap with tendon ends fixed to the nasolabial area for static suspension. Advantages of this flap are good color texture match, glabrousness, ease of dissection, great length, and large diameter of the vascular pedicle and the possibility of becoming a sensate flap. Disadvantages include small skin paddle, sacrifice of one of two major arteries of the hand, donor site scar, and the risk of tendon exposure. Thus, Jeng and colleagues and Serkan and others reported that the composite anterolateral thigh-tensor fasciae latae flap could be a good alternative. It has the advantages of large skin paddle, a two-team approach, and less donor site morbidity when compared with a radial forearm-palmaris longus flap. Furthermore, the palmaris longus tendon may not always exist. The tensor fasciae latae is larger than the palmaris longus and easy to fix. The disadvantages of composite anterolateral thigh-tensor fasciae latae flap are a poor color match and bulky volume. In addition, such flaps are typically hair-bearing, although some patients may prefer a hairy chin. Thus, we decided to repair a large lower lip defect with a composite anterolateral thigh-tensor fasciae latae flap.