The free anterolateral thigh flap (ALT) has progressively become the workhorse in soft tissue reconstruction for many plastic surgeons in western countries, allowing free–style designs that can adequately fulfill the specific needs of most reconstructive cases. Ultimately, flap refining possibilities and donor site morbidity are the keys to success and these are probably the reasons why the ALT flap has so rapidly spread all over the world. Since 2001, the author has moved from the radial forearm flap to the ALT flap in most head and neck reconstructions, and shared different flap refinements in the use of the flap after tumor resection.
Refinements to prevent the development of orocervical fistulae. Although uncommon in successful reconstructions, orocutaneous fistulae are still a significant complication in patients undergoing intraoral cancer surgery. Adding a portion of vascularized vastus lateralis muscle (either as a separate pedicled miniflap or as random pattern vascularized muscle around the perforator pedicle) can indeed protect the tiny perforating vessels along their course through the oro–cervical passage and add a second–layer closure.
Flap reconstruction of complex cranio–orbito–maxillary resections. Restoration after complex orbitomaxillary exenterations is one of the most challenging aspects in head and neck reconstruction. 3-D contour reconstruction is paramount, but adequate sealing of intracranial contents away from the oral and nasal cavities is equally important. Avoidance of long–term sagging with time is another important issue that must be considered when planning the reconstruction. The author reported his experience with a refined anterolateral thigh free flap design in these particular situations.
Tongue suspension in resections of the anterior floor of the mouth. Reconstruction of excisional defects of the anterior floor of the mouth should not only provide satisfactory sealing but adequate tongue suspension as well to avoid potential long–term obstructive sleep apnea. The inclusion of a portion of vascularized fascia lata in the ALT flap allows adequate tongue suspension to the mandible and the prevention of this usually underestimated complication.
