Free anterolateral thigh flap for reconstruction of head and neck defects: preliminary results and a comparison with the radial forearm flap

BACKGROUND: The authors present their personal preliminary experience with the free anterolateral thigh flap in the reconstruction of head and neck defects and compare these first cases with the radial forearm flaps. METHODS: Seventeen patients undergoing free flap reconstruction between December 1998 and September 2001 have been selected for this retrospective study and evaluated. In fourteeen patients reconstruction was performed with a radial forearm flap. In three patients an anterolateral thigh flap was used. Six dissections on cadavers have also been performed in order to study the anatomical variations of the perforators of the lateral circumflex femoral system. RESULTS: All flaps survived, without any major vascular impairment. CONCLUSIONS: Despite a laborious dissection of the pedicle the anterolateral thigh is a versatile flap, with a minimal morbidity of the donor area. Even if the radial forearm is overall accepted as the gold standard for head and neck reconstruction, the anterolateral thigh flap is suggested as a good and safe surgical option, especially when a large flap is requested or in female patients concerned with the cosmetic result in the forearm donor area.     

Comparison of anterolateral thigh and radial forearm free flap donor site morbidity

This study evaluated patient-reported outcome of the donor site in patients following head and neck cancer reconstruction. Patients who had undergone cancer reconstruction using either an anterolateral thigh or a radial forearm free flap and who were at least 6 months postsurgery were included and contacted by telephone. There were 37 patients (mean age 61 years, standard deviation 16 years) with 18 anterolateral thigh flaps and 19 radial forearm flaps. The majority of patients were not bothered by scar appearance, light touch, numbness or pain. Significantly more females (P = 0.038) and more patients with radial forearm flaps (P = 0.045) were bothered by the cold at the donor site and more females reported that the shape of the operated extremity was different (P = 0.009). Donor site morbidity is not significant following a radial forearm or anterolateral thigh free flap and the reconstruction should be based upon individual patient factors and surgeon expertise.     

Clinical use of a pedicled anterolateral thigh flap.

BACKGROUND: Anterolateral thigh flap is a safe and reliable flap for soft tissue reconstruction. It has successfully been used as free flap reconstruction for defects in the head and neck region, the upper extremities and lower extremities. However, there were only a few reports in the literature concerning the clinical application of this flap for regional reconstruction. METHODS: The authors describe their experience of using the pedicled island anterolateral thigh flap for reconstruction of soft tissue defects in neighbouring areas. Representative cases are presented for illustration. RESULT: Between July 2005 and September 2006, seven patients underwent an immediate reconstruction with pedicled anterolateral thigh flap. The patients were between 49 and 69 years old. The size of the flaps measured from 5 x 8 cm to 15 x 15 cm. They were prepared as myocutaneous flaps in three cases and as perforator flaps in four cases. One patient, who had the largest flap harvested, needed skin grafting of the donor site. Primary closure was performed for all other cases. All flaps survived without any vascular compromise and the donor site healed without complication. CONCLUSION: Our study has shown that the pedicled anterolateral thigh flap is a safe and reliable flap for repair of defects at the internal pelvis, lateral thigh, groin, and genitoperineal region. The long vascular pedicle and having no restriction to the arc of rotation are keys to the successful transposition of the flap for immediate reconstruction of soft tissue defects in neighbouring areas.     

Soft-tissue reconstruction using a free anterolateral thigh flap: experience with 28 patients

The authors present their experience using the free anterolateral thigh fasciocutaneous flap for head and neck and extremity reconstruction. From January 2000 through March 2002, 28 free anterolateral thigh flaps were transferred to reconstruct various soft-tissue defects. All patients were operated by two teams. All flaps were elevated based on one perforator only. The sizes of the flaps ranged from 9 x 11 to 20 x 26 cm. The success rate was 96.5% (27 of 28), with one partial failure. The cutaneous perforators were always found. Septocutaneous perforators were found in 3 of 28 patients (10.7%). Musculocutaneous perforators (89.3%) were found in the remaining patients, and the number of perforators ranged from two to five (average, three perforators). In 4 patients, flaps were used for sensate reconstruction. The authors used the anterolateral thigh flap as a thin flap in 10 patients. Mean follow-up was 13.5 months (range, 2-25 months). Soft-tissue reconstruction with the free anterolateral thigh flap in various regions of the body provides an excellent functional and cosmetic result with minimal donor site morbidity. The anterolateral thigh flap has many advantages over other conventional free flaps and it seems to be an ideal choice for the reconstruction of soft-tissue defects.     

吻合血管的股前外侧皮瓣修复头颈肿瘤术后复杂缺损

目的：评价吻合血管的股前外侧皮瓣在头颈肿瘤术后复杂缺损修复中的作用。方法：1990年5月-2001年4月，应用吻合血管的股前外侧皮瓣移植，修复口颊癌、喉癌、面部皮肤癌、上颌窦癌术后大面积软组织复杂缺损21例。结果：19例成功，1例皮瓣部分坏死，1例失败。随诊6个月到10年，9例无瘤生存，外观及功能满意；2例带瘤生存；5例死于局部复发；4例分别死于颈淋巴结转移、脑转移、第二原发癌及脑血管意外；1例失访。结论：吻合血管的股前外侧皮瓣可提供充足的组织量、存活率高、供区隐蔽、不牺牲重要血管，适用于修复头颈肿瘤术后复杂缺损。     

The versatile anterolateral thigh flap: a musculocutaneous flap in disguise in head and neck reconstruction.

In search of an alternative soft tissue free flap donor site to radial forearm flap and rectus abdominis flap in head and neck reconstruction, we used the anterolateral thigh flap for reconstruction of various defects in the head and neck in 59 patients. The aim was to demonstrate the versatility of this donor site and propose a new approach to achieve a safer flap dissection. With the exception of three cases, all defects resulted from excision of malignant tumours. The defects were categorised as full thickness defects of the mandible (33.9%), full thickness defects of the cheek (52.5%) and others (13.6%). During the flap dissection a direct septocutaneous pedicle was observed in 12% of the cases. In the remaining cases there were only musculocutaneous perforators and the flaps were raised either as a split vastus lateralis musculocutaneous flap (72%) or as a perforator flap (16%), depending on the required thickness. Total flap survival was 96.7% with one total and one partial failure and two re-explorations (3.3%). The mean follow-up time was 7.1 months (range: 1-12 months). In conclusion, the anterolateral thigh flap is a versatile and dependable flap that can be adapted to any type of defect by modifying the flap design and composition. It should be considered to be a musculocutaneous flap of the vastus lateralis muscle that can also be raised as a perforator flap. When harvested and used in this context, the flap dissection becomes very safe and consistent, nullifying the only major disadvantage associated with this donor site.     

股前外侧游离穿支皮瓣修复头面部和四肢肿瘤切除后软组织缺损

目的探讨应用股前外侧穿支皮瓣,修复头面部和四肢肿瘤切除术后的方法及其效果。方法2004年4月-2006年4月,收治头面部及四肢肿瘤切除术后造成的软组织缺损,采用股前外侧穿支皮瓣游离移植共16例,男13例,女3例;年龄26-72岁。头面部肿瘤9例,其中头顶部基底细胞癌1例,面部鳞状细胞癌4例（包括肿瘤复发1例）,腮腺癌4例;软组织缺损范围8cm×6cm-20cm×13cm,病程6-24个月。四肢肉瘤7例,其中上肢2例,下肢4例,小腿复发1例;软组织缺损范围10cm×7cm-21cm×12cm,病程2-18个月。结果16例应用股前外侧穿支皮瓣游离移植修复,15例皮瓣全部成活,1例皮瓣远端约2.5cm宽范围缺血坏死;14例创口期愈合;2例创口期愈合,其中1例经切除坏死组织,直接缝合后期愈合,另1例创口有3cm裂口,经换药后期愈合。术后随访1-18个月,肿瘤无复发,供受区外观良好,平整,无明显瘢痕及功能影响;受区修复效果满意。结论股前外侧穿支皮瓣游离移植,修复效果好,对供区损伤小,是一种较理想的修复头面和四肢肿瘤切除术后软组织缺损的方法。     

游离股前外侧皮瓣与改良胸大肌皮瓣在修复头颈肿瘤术后缺损中的选择与改进

目的探讨游离股前外侧皮瓣与改良胸大肌皮瓣在头颈肿瘤术后缺损修复中的应用及效果。方法2011年11月至2016年11月湖南省肿瘤医院头颈外科收治头颈部肿瘤患者394例,男性286例,女性108例,年龄25~79岁。分别采用游离股前外侧皮瓣(306例)、改良胸大肌皮瓣(88例)修复头颈肿瘤术后缺损。采用t检验法分析不同方法修复的效果及患者生存质量,总结2种皮瓣修复的优缺点及适应证。结果本组394例,游离股前外侧皮瓣组皮瓣成活率97.1%(297/306),改良胸大肌皮瓣组成活率97.7%(86/88);手术总时间2组相近,游离股前外侧皮瓣组3~4 h,改良胸大肌皮瓣组1.5~2.5 h;术后1年,UW-QOL评分游离股前外侧皮瓣组与胸大肌皮瓣组相比,在外观、言语功能及肩部运动方面有显著优势,差异有统计学意义(P<0.05)。结论头颈部肿瘤术后缺损修复中,游离股前外侧皮瓣及改良胸大肌皮瓣都具有较高的成功率,游离股前外侧皮瓣适用于复杂缺损的修复,改良胸大肌皮瓣对血管条件、全身状况不佳的患者,更具有安全性。     

Role of the anterolateral thigh flap in head and neck reconstruction: advantages of moderate skin and subcutaneous thickness

Skin-flap thickness is an important consideration when choosing a free flap for head and neck reconstruction. The anterolateral thigh flap, the rectus abdominis flap, and the radial forearm flap, which included the epidermis, the dermal, and the subcutaneous layers, were measured using ultrasonography in 31 patients. The mean skin and subcutaneous thickness of the anterolateral thigh flap was 7.1 mm; the rectus abdominis flap was 13.7 mm; and the radial forearm flap was 2.1 mm. Further analysis revealed a statistically significant difference among the skin and subcutaneous thickness of the three flap groups. Of the 44 anterolateral thigh flap transfers done for head and neck reconstruction after cancer ablative surgery, 41 (93.2 percent) were transferred successfully. The anterolateral thigh flap creates a moderately thick skin flap, and is less variable in thickness across its area than is the rectus abdominis flap. The flap is adaptable for reconstruction of head and neck soft-tissue defects.     

An ideal and versatile material for soft-tissue coverage: experiences with most modifications of the anterolateral thigh flap

Free anterolateral thigh flaps are a popular flap used for the reconstruction of various soft-tissue defects. From April, 2002 to June, 2003, 32 free anterolateral thigh flaps were used to reconstruct soft-tissue defects. Twenty-three of these flaps were used for lower extremity reconstruction, and nine were used for head and neck reconstruction. There were 24 male and eight female patients, with ages between nine and 82 years. The size of the flaps ranged from 11 to 32 cm in length and 6 to 18 cm in width. Five flaps required reoperation for vascular compromise in four patients and for twisting of the pedicle in another patient. While four of these were salvaged, one flap was lost due to recipient vessel problems. Musculocutaneous perforators were found in 23 cases, and septocutaneous perforators were found in nine cases. In four cases, thinning of the flap was performed. The flap was used as a flow-through type for lower extremity reconstruction in three patients. In two patients, the flap was used as a neurosensory type for foot reconstruction. Eighteen cases underwent split-thickness skin grafting of the donor site and, in the remaining cases, the donor sites were closed primarily. In three patients, the donor areas required a partial skin regrafting procedure. No infections or hematomas were observed. Despite some variations in its vascular anatomy, the anterolateral thigh flap offers the following advantages: 1) it has a long and large-caliber vascular pedicle; 2) it has a wide, reliable skin paddle; 3) it may be harvested as a neurosensory flap; 4) it can be harvested whether its pedicle is septocutaneous or musculocutaneous; 5) it can be designed as a flow-through flap; 6) it can be elevated as a thin or musculocutaneous flap; and 7) the procedure can be performed by two teams working simultaneously, and no positional changes are required.     

The utility of the anterolateral thigh donor site in reconstructing the United States trauma patient

BACKGROUND: Identification of a single donor site capable of providing all the components of the soft tissue envelope and the ability to selectively harvest a subset of these components is a central requirement for the microvascular reconstruction of the trauma patient. The anterolateral thigh (ALT) flap's long pedicle and adaptability in supporting a variety of tissues (muscle, fascia, soft tissue) make it a valuable tool for microsurgical reconstruction in these challenging patients. We investigated the utility of the ALT as a donor for microvascular tissue reconstruction in a Level I trauma center. METHODS: We conducted a retrospective chart review on all trauma patients treated by the plastic surgery service at the R Adams Cowley Shock Trauma Center who required microsurgical free flap coverage from July 2002 to March 2005. Fifty-eight patients underwent reconstruction of traumatic deformities with 62 microvascular free flaps from the ALT region. RESULTS: Of the 58 patients, 42 were male and 16 were female with an average age of 39 years. Recipient site locations for the 62 flaps were lower extremity, upper extremity, trunk, and head and neck. Analysis of flap anatomy revealed that 43 were fasciocutaneous, 14 were myocutaneous, 2 were adipofascial, and 3 were myofascial (vastus lateralis muscle). Six flaps were based on septocutaneous perforators, whereas the remainder contained myocutaneous perforators. Nine thigh donor sites required a split thickness skin graft, and 53 were closed primarily. The size of the flaps ranged from 36 cm2 to 600 cm2. CONCLUSIONS: The ALT is a predictable donor site that facilitates a 2-team approach. ALT displays minimal donor site morbidity and in most cases provided sufficient tissue to cover the entire traumatic defect. Our results suggest the ALT is a reliable tissue source and an ideal donor site for the management of complex traumatic wounds in the United States.     

Characteristics of the anterolateral thigh flap in a Western population and its application in head and neck reconstruction

BACKGROUND: Although the anterolateral thigh flap has been extensively used for head and neck reconstruction in Asia, reported variations of vascular anatomy seem confusing and may have contributed to the unpopularity of this flap in the United States. The purposes of this study are to classify the vascular anatomy and to assess the suitability of this flap for head and neck reconstruction in a Western population. METHODS: Seventy-two consecutive anterolateral thigh flaps for head and neck reconstruction was retrospectively reviewed. RESULTS: The number of cutaneous perforators for the anterolateral thigh flap ranged from one to three. On the basis of their location and origin, a simple classification system is introduced to assist flap dissection. Of the 72 thighs explored, 68 flaps (94%) were raised successfully. CONCLUSIONS: The vascular anatomy of the flap follows predictable patterns. The anterolateral thigh flap is well suited for head and neck reconstruction in Westerners.     

Clinical outcome of reconstruction of the lateral oropharyngeal wall with an anterolateral thigh free flap

The anterolateral thigh (ALT) free flap is widely used for various reconstructions in the head and neck. However, its use in the oropharynx has not been widely evaluated, so we have reviewed our experience. We retrospectively reviewed the medical records of 28 patients with oropharyngeal cancer, who were treated with immediate reconstruction with an ALT free flap after excision. We recorded history, stage of tumour, course of operation, postoperative period, oncological treatment, clinical outcome, and follow-up. The mean age of the patients was 61 years (range 44-83). Ten of the patients had clinically relevant coexisting conditions. Most of the patients had T3-4 tumours and involved neck nodes. The operations included resection of the tumour, neck dissection, and reconstruction of the oropharynx with an ALT free flap. All donor sites were closed primarily. Eight patients (29%) developed early local complications that required reoperation. Ten patients (36%) had postoperative cardiopulmonary problems. Twenty-seven flaps succeeded; one was lost. There were no other complications or late problems of the donor site except one seroma. Twenty-one patients were given postoperative radiotherapy. After the mean follow-up period of 40 months (range 13-68) 20 patients (71%) were disease-free. Three patients required a permanent gastrostomy and one a permanent tracheostomy. We conclude that the ALT free flap can be used successfully for reconstruction of a lateral oropharyngeal defect with manageable postoperative morbidity.     

穿支游离皮瓣修复头颈肿瘤术后缺损

目的 探索更为理想的穿支游离皮瓣修复技术，运用于头颈肿瘤术后缺损。方法 2003年12月-2005年5月用于头颈部手术缺损修复的穿支游离皮瓣共14例（股前外侧皮瓣8例，腹壁下深动脉穿支皮瓣6例）。其中10例为复发后挽救手术，12例曾行放疗（平均63．5Gy）。头颈部肿瘤手术缺损部位分别为舌体3例，颊黏膜3例，口咽壁3例，舌根2例，颅底、头皮以及中面部各1例。受区供吻合动脉主要是甲状腺上动脉和面动脉；静脉为颈内静脉。结果 13例穿支游离皮瓣成功（93％），有1例穿支皮瓣因吻合侧的颈内静脉血栓形成导致皮瓣坏死。受区未发现其它明显并发症。供区均直接缝合关闭并一期愈合，未发现腹壁疝和运动受限等手术并发症。结论 穿支游离皮瓣保留了供区的肌肉、筋膜和神经，将供区的并发症降到最低限度，是头颈部缺损修复新的可靠技术。     

Simultaneous reconstruction of head and neck defects following tumor resection and trismus release with a single anterolateral thigh donor site utilizing a lateral approach to flap harvest

Background: An anterolateral thigh (ALT) flap has gradually become the workhorse flap of reconstructions at different anatomical locations because of its reliability and versatility. In this study, we introduced the concepts: one is the ALT flap harvest from a lateral approach and the other is the reconstruction of extensive head and neck defects with a single ALT donor site. Methods: A lateral approach ALT flap was harvested in 13 patients who had buccal cancer and/or tumors of the lower lip combined with buccal trismus. Three types of ALT flaps (type I: two skin paddles, one pedicle; type II: two skin paddles, two pedicles; type III: one skin paddle, one pedicle) were used in one‐stage reconstructions of these extensive head and neck defects. Results: In our series, there were four type I, five type II, and four type III flaps. All flaps survived and no major postoperative complication occurred. Four of the 13 donor sites were repaired with a split‐thickness skin graft harvested from the contralateral thigh. The immediate interincisor distance increase was 21.4 and 16.5 mm at 1‐year follow‐up. Conclusions: Different types of ALT flap from a single donor site can be designed by means of a lateral approach; and the satisfactory results of reconstruction for extensive head and neck defects following the tumor resection and trismus release can be achieved. © 2012 Wiley Periodicals, Inc. Microsurgery, 2012.     

Anterolateral thigh free flap for "head-to-toe" reconstruction

Since its conception the anterolateral thigh (ALT) free flap has become a cornerstone in the reconstruction of complex head and neck defects. It has quickly gained further uses because of its variability in size, malleability, 2-team approach to the operation, and low-morbidity donor site. The ALT lends itself well to reconstructing complex defects throughout the body, from the lower extremities up to the head and neck, and a variety of indications, from oncologic defects to burns and traumatic injuries. Twenty patients (18 male, 2 female; average age 57.74 years [range, 17-86 years]) had ALT free-flap harvest for scalp defects (5), trunk defects (1), head and neck defects (11), lower extremity defects (3). Sixteen patients had oncologic-related defects, 2 from traumatic injuries, and 2 from burn-related injuries. The average flap area was 157 cm, the average number venous anastomoses was 1.47, and the average vein diameter was 2.65 mm (range, 1.5-3.5 mm). The objective of this article is to review our institutional review board-approved case series at the University of Florida and further elucidate the widespread adaptability of the ALT flap. We share our experience in indications for use, recipient-site variables, donor-site management, complications, and outcomes. We also review other applications of this useful flap described in the literature.     

Free tensor fascia lata perforator flap as a backup procedure for head and neck reconstruction

Free tissue transfer is an essential part of the head and neck reconstruction. Despite several flap options, free perforator flaps have become very popular for head and neck. Anterolateral thigh perforator flap has multiple advantages among other options and is preferred by most of the reconstructive microsurgeons. Besides its advantages, sometimes it is impossible to harvest an anterolateral thigh perforator flap, and the surgeon has to shift to another option. Between January 2002 and June 2005, 5 tensor fascia lata perforator flaps were used for head and neck reconstruction because anterolateral thigh perforator flap could not be elevated due to absence or insufficient musculocutaneous perforators. Only 1 flap was reexplored and salvaged by redoing the venous anastomosis. All flaps survived without any other problem. Donor sites were covered by split-thickness skin grafts in 4 patients and closed directly in 1 of them. Doppler examination is important in planning of anterolateral thigh perforator; if the signals of the perforators are absent or very weak, the surgeon can shift to another flap. This decision may also be made during the operation when insufficient perforators are seen. Based on our experience, tensor fascia lata perforator flap is a safe alternative when anterolateral thigh perforator harvest is not possible. Tensor fascia lata perforator flap can be harvested from the same anatomic region with almost same morbidity.     

Anterolateral thigh flap for breast reconstruction: review of the literature and case reports

More women than ever before are undergoing mastectomies secondary to increased awareness and screening. This has also caused a corresponding increase in the number of breast reconstructions requested each year. The demand for improved results has fueled recent advances in new techniques. Aside from implant reconstruction, the methods now being employed are related to autogenous donations and reconstruction. Currently, the most commonly used techniques for autogenous breast reconstruction are the DIEP (deep inferior epigastric perforator) and TRAM (transverse rectus abdominis myocutaneous) flaps from the lower abdomen. The anterolateral thigh flap is a type of perforator flap usually described for use in head and neck reconstruction. The authors have discovered this flap's utility as an alternative in autogenous breast reconstruction when the abdomen is not available as a donor site. A review of the literature reveals a dearth of experience in using the anterolateral thigh flap for breast reconstruction. The article reviews the literature with regard to current uses of the anterolateral thigh flap, and then reports three case studies which highlight the thigh flap as an excellent alternative for breast reconstruction in selected patients.     

Microsurgical free flap in head and neck reconstruction

Microsurgical free flaps are today considered state of the art in head and neck reconstruction after composite tumor resections. Free flaps provide superior functional and aesthetic restoration with less donor‐site morbidity. This article details our approach to this challenging and complex procedure. Free tissue transfer can be viewed as consisting of 4 essential stages: (1) defect assessment, (2) preparation of recipient vessels, (3) flap selection and harvest, and (4) flap inset and microsurgical anastomoses. The essential details of each step are highlighted. Meticulous attention to each step is important because each plays a crucial role in the overall success of the procedure. Workhorse flaps in our practice are the anterolateral thigh, radial forearm, fibula, and jejunum flaps. Unique issues related to postoperative care and monitoring of head and neck free flaps are discussed. The management of complications, in particular those threatening flap survival, are reviewed in detail. © 2009 Wiley Periodicals, Inc. Head Neck, 2010