Head and neck soft tissue reconstruction with anterolateral thigh flaps with various components: Development of an algorithm for flap selection in different clinical scenarios
Armando De Virgilio MD, PhD  Oreste Iocca MD, DDS  Pasquale Di Maio MD  Luca Malvezzi MD  Raul Pellini MD  Giuseppe Mercante MD  Giuseppe Spriano MD
First published: 31 July 2019 https://doi.org/10.1002/micr.30495
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Abstract
Objectives
The antero‐lateral thigh free flap (ALT) is conventionally designed as a fasciocutaneous flap (FALT). However, the thickness of the flap can be designed in at least in two more variants: myocutaneous (MYALT), and myofascial (MALT). The aim of this study was to evaluate the use of ALT flap as a universal solution for head and neck soft tissue reconstruction and development of an algorithm for flap selection in different clinical scenarios.

Patients and methods
Forty patients, 29 males, 11 females, with mean age of 61.6 years (range 36–77) were enrolled. Thirty‐three patients were affected by mucosal squamous cell carcinoma (24 oral cavity, 8 larynx, 1 hypopharynx), four by cutaneous squamous cell carcinoma, two by sarcoma of the orbit, one by adenoid cystic carcinoma of the parotid gland. MALT was used for tongue reconstructions thicker than 2 cm. When vastus lateralis was not thick enough we used MYALT, which was used for bulky head and neck reconstruction requiring mucosa and/or skin. FALT was performed for oral and mucosal defects thinner than 2 cm. We performed 19 MYALT, 11 FALT, and 10 MALT. We proposed ALT reconstruction to all patients requiring soft tissue replacement, for this reason selection bias is excluded. Statistical analysis was conducted to analyze any difference in defect size, flap volume, functional, and cosmetic results.

Results
Overall mean follow‐up was 18.9 months (range 3–48). Follow‐up of single flaps was as follow: MALT 20.3 (range 3–48), MYALT 17.6 (range 4–45), FALT 19.1 (range 3–48), mean time of follow‐up was not significant among the three groups (p .82). Mean size of the defect in cm3 was 188.5 (range 25–495), Mean sizes of the defects were: tongue 177.7 (range 48–360), oral floor/check 128.3 (range 25–432), larynx hypopharynx 315.7 (range 184–495), and maxilla 232.0 (range 224–240). Mean volume difference was significantly different between oral floor defects and larynx/hypopharynx (mean volume difference 187.4 95% CI −352.0—2.7 p < .001). Mean sizes of the flaps in cm3 were: FALT 51.5 (range 25–72), MYALT 270.7 (range 90–495), and MALT 250.0 (range 90–495). Mean volume difference was significantly different among the three groups (p < .001). No major complications were experienced, four minor complications were reported (2/19 in MYALT, 1/10 MALT, 1/10 FALT) and results were not significant among the three groups (p .20). Gastrostomy tube dependence occurred in 4/19 (21%) of tongue cases, and none in all the other cases (p < .001). Speech was unintelligible in 3/19 (16%) of patients with tongue reconstruction, 1/7 (15%) of patients with larynx/hypopharynx reconstruction, and none regarding the other defects reconstructed (p < .001). Cosmesis was poor in 2/19 (11%) of tongue cases, and acceptable or higher in the other cases (p < .001). Tracheostomy dependence rate was 27% (7/7 patients submitted to a total laryngectomy with hypopharyngectomy and 4/19 patients submitted to total glossectomy, p < .001).

Conclusions
ALT offers unique advantages in head and neck reconstruction, including adequate bulk when needed, different coating surfaces, and optimal functional results with minimal morbidity. On the base of our case series, which showed that the ALT flap is highly versatile and a successful reconstructive option, we propose a decision making‐flow chart in order to choose the best specific flap variant adequate for every specific clinical scenario.