The free anterolateral thigh musculocutaneous flap for head and neck reconstruction: One surgeon's experience in 92 cases

THE FREE ANTEROLATERAL THIGH MUSCULOCUTANEOUS FLAPFOR HEAD AND NECK RECONSTRUCTION: ONE SURGEON’SEXPERIENCE IN 92 CASES

BERNARDO BIANCHI, M.D.,1 ANDREA FERRI, M.D.,1* SILVANO FERRARI, M.D.,1 CHIARA COPELLI, M.D.,1 PIETRO BONI, M.D.,1

TEORE FERRI, M.D.,2 and ENRICO SESENNA, M.D.1

Background: Applications of the free anterolateral thigh (ALT) musculocutaneous flap have been largely underestimated compared withindications for fasciocutaneous or perforator flaps. In this article, the authors critically review the experience of a single surgeon with thefree ALT musculocutaneous flap for head and neck reconstruction, focusing on its applications in different cephalic areas and on advan-tages and disadvantages of this technique. Patients and methods: Ninety-two patients were treated using a free ALT musculocutaneousflap. Reconstructed areas included tongue, oropharynx, mandible, maxilla, hypopharynx, cheek, and skull base. Results: Flap survivalrate was 97.8%. Donor site morbidity consisted in two cases of partial necrosis of the skin graft used its closure with a final donor sitecomplication rate of 2.2%. Overall results showed an 89% of patients returned to a normal or a soft diet. Speech was good or intelli-gible in 88% and cosmesis resulted good or acceptable in 89% of cases. Conclusion: The free ALT musculocutaneous flap offersunique advantages in head and neck reconstructions including adequate bulk when needed, obliteration of dead space, support for thesoft tissues of the face, low donor-site morbidity, and harvesting without needing for perforators dissection, allowing for optimal patientoutcome. Excessive bulky and thickness of subcutaneous tissue, especially in occidental population, have to be considered as the maindisadvantages of this technique, finally the high incidence of hairy skin in thigh area in male patients and donor site scars associatedwith the use of skin grafts have to be considered as supplementary minor drawbacks. VVC 2012 Wiley Periodicals, Inc. Microsurgery32:87–95, 2012.

The reconstruction of head and neck defects represents a

challenge because of the critical role of this area both

esthetically and functionally. In the past, attempts were

made to achieve functional restoration of resected head

and neck areas with acceptable cosmesis using local and

locoregional flaps.1,2 Free flap techniques represented a

revolution in reconstructive surgery as they enabled the

harvesting of a large amount of revascularized tissue; it

could be tailored to the defect and allowed for more

complex reconstructive procedures, while simultaneously

permitting more extensive head and neck resections.3 Pro-

gresses in microsurgery led to the possibility of recon-

structing virtually all defects of the head and neck by

harvesting soft tissue or bone-containing free flaps. The

choice of the flap to use is key to the reconstructive pro-

cedure. The ideal soft tissue free flap should be reliable

and pliable, with low donor-site morbidity and should

provide sufficient tissue for the reconstruction. Further-

more, it should have a long vascular pedicle containing

vessels of a diameter suitable for vascular anastomosis.

Finally, it should be easy and fast to harvest, and allow

two teams to work simultaneously.4 Over the last 30

years, several attempts have been made to find the ideal

soft tissue free flap: the rectus abdominis free flap has

long been the workhorse of many surgeons, especially for

reconstructing wide defects that require bulk and vol-

ume5; the radial forearm free flap is the flap of choice

for all defects when pliability and reliability are the goals

of the procedure.6

Song et al.7 introduced the anterolateral thigh (ALT)

flap in 1984, and it immediately attained worldwide ac-

ceptance. It has unique features that allow for the har-

vesting of different kinds of flap from the same donor

site. It can be harvested as a perforator,8 fasciocutane-

ous,9 musculocutaneous,10 adipofascial,11 or chimeric

flap,12 and this versatility makes this flap suitable for

reconstructing almost all defects of the head and neck.

Given these features, the ALT flap has been advo-

cated as the ideal soft tissue free flap for cervicofacial

reconstruction, especially in the Asian international liter-

ature.13 However, the applications of the free ALT mus-

culocutaneous flap have been largely underestimated

compared with the well-recognized indications for fas-

ciocutaneous or perforator flaps. Furthermore, few stud-

ies have reported on large case series involving occiden-

tal populations.14 Finally, a ‘‘one-surgeon experience’’

ensures more critical comprehension of the free ALT

musculocutaneous flap applications in the head and neck

area.

In this article, the authors critically review the expe-

rience of a single surgeon (B. Bianchi) with the free

ALT musculocutaneous flap for head and neck recon-

struction, focusing on its applications in different ce-

phalic area and on the advantages and disadvantages of

this technique.

1Maxillo-Facial Surgery Division, Head and Neck Department, UniversityHospital of Parma, Parma, Italia2Otolaryngology Head Neck Surgery Division, Head and Neck Department,University Hospital of Parma, Parma, Italia

*Correspondence to: Andrea Ferri, M.D., via Gramsci 14, 43100 Parma,Italia. E-mail: [email protected]

Received 30 May 2011; Accepted 1 August 2011

Published online 20 January 2012 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/micr.20952

VVC 2012 Wiley Periodicals, Inc.

PATIENTS AND METHODS

From 1 January 2003 to 31 December 2009, 92

patients were treated for head and neck malignancies or

secondary reconstruction using a free ALT musculocuta-

neous flap at the Maxillo-Facial Surgery Division, Head

and Neck Department, University and Hospital of Parma,

Italy. Data concerning patients’ population are summar-

ized in Table 1. All of the flaps were harvested by the

first author, B.B. The patients were evaluated retrospec-

tively after follow-up ranging from 12 to 84 months

(mean, 34.6 months).

The subjects consisted of 58 males and 34 females

ranging in age from 12 to 82 years, with a mean age of

69.4 years. The patients were treated for secondary recon-

struction in three cases: in two patients, an ALT muscu-

locutaneous flap was used to correct trismus that devel-

oped after surgery and radiation therapy for oral cavity

malignancies, while the ALT musculocutaneous flap was

used to reconstruct a facial contour defect in the third

patient who was treated for a mandibular malignancy. In

the other 89 cases, the patients were treated for head and

neck malignancies. The histology was squamous cell car-

cinoma in 79 patients, basal cell carcinoma in seven

patients, sarcoma in two patients, and undifferentiated

carcinoma of the submandibular gland in one patient. The

primary tumor was located in the tongue in 26 cases, the

oropharynx in 18 (including the soft palate, tonsil, retro-

molar trigon, and pharyngeal wall), the mandible in 17,

the maxilla in 10, hypopharynx in six, cheek and skull

base in five cases each, and inferior lip and submandibu-

lar gland in one case each.

Twenty-eight patients were treated previously with

surgery alone (n 5 14), radiation therapy alone (n 5 6),

surgery and radiotherapy (n 5 5), or chemoradiation ther-

apy (n 5 3).

Surgical Technique

The design of the skin paddle was based on the size

and three-dimensional features of the defect. When

needed, we preferred to delay the de-epithelialization

until after transplanting the flap to maximize the custom-

ization of the flap, so we designed the skin paddle in an

elliptical or bilobed shape.

Working with a second team to resect the tumor and

prepare the recipient site simultaneously, the dissection

began in the medial border of the flap, incising only 5 to

6 cm of skin initially and the underlying superficial fas-

cia. After identifying the rectus femoris, we followed the

intermuscular septum until the pedicle of the flap (the de-

scending branch of the lateral circumflex femoral artery

with its two venae comitantes and the anterior branch of

the lateral cutaneous nerve) was identified (Fig. 1).

At this point, independent of the presence of a septo-

cutaneous perforator, which may be suitable for harvest-

ing a septocutaneous perforator flap, we completed the

medial skin incision and dissected the vascular pedicle,

distally to proximally. After incising the fascia lata, the

vastus lateralis muscle were transected distally, and the

distal part of the pedicle was isolated, ligated, and cut.

The dissection proceeded distally to proximally. The flap

was taken in the hand of the first operator and the vastus

lateralis muscle was harvested based on the need for

reconstruction. At this point, the anterior branch of the

lateral cutaneous nerve was dissected and preserved in 62

cases, transected in 18, and transected and repaired in the

remaining 12. The entire procedure took 30 to 40

minutes.

The donor site was usually closed directly after plac-

ing a drain. In our experience, a skin graft was needed

only when the minor axis (oriented perpendicular to the

septum) of the flap was larger than 10 to 13 cm.

The free ALT musculocutaneous flap was harvested

from the right thigh in 89 cases; the left thigh was used

in the remaining three because anomalies were detected

during the preoperative mapping of the skin perforators.

The skin paddle measured from 4 3 5 to 12 3 23

cm2, and the amount of muscle harvested ranged from a

minimum of 4 cm in length and 2 cm in width to the

entire muscular belly (12 3 6 cm2). Muscular cuff played

a major role in tongue reconstruction, when it was placed

with the skin component to restore an adequate bulk into

the oral cavity (Fig. 2). When used for neck vessels and

anastomosis protection, the muscle was placed in the

neck and fixed with resorbable sutures to sternocleido-

mastoid muscle (when present) and supra-hyoid muscles.

In case of hypopharyngeal reconstruction after total laryn-

gectomy, muscle component was spread over the tracheal

stoma creating a muscular layer between the tubulized

skin of the flap used for the reconstruction of hypophar-

ynx and the stoma, ensuring a good fixation to surround-

ing tissues and obliteration of dead spaces. When oro-

mandibular reconstruction was performed, the muscular

cuff was placed in the submandibular area fixing it to the

periostium of the residual mandible and to the oral cavity

residual soft tissues, taking care to roll the muscle around

the reconstructive plate when it was used to restore the

mandibular arch defect (Fig. 3). For maxillary defect

reconstruction, the muscle was placed into the maxillary

defect to fill it completely and sutured to the periostium

of preserved bone structures (zygoma, nasal bone, and or-

bital rim); if bone grafts or alloplastic prosthesis were

used, muscle was positioned taking care to ensure a good

contact with grafts reducing dead spaces and providing

well vascularized tissue for integration of grafts and pros-

thesis, thus preventing infections and reabsorption

(Fig. 4). Finally, when used for skull base reconstruction,

88 Bianchi et al.

Microsurgery DOI 10.1002/micr

Table

1.Patients:Population,Treatm

ents,andComplications

Location

No.

Previous

treatm

ents

Associatedtechnique

Donorsite

directclosure

Postoperative

treatm

ents

Complications

Tongue

26

Surgery:7

None

21(80%)

RT:7

Flaplost:1(3.8%)

Surgery

þRT:2

Marginalnecrosis:1(3.8%)

RT:2

RTþ

CT:8

Dehiscence:3(11.5%)

RTþ

CT:1

Donorsiteskin

graftnecrosis:0

Oropharynx

18

Surgery:2

None

15(83%)

RT:4

Flaplost:0

Surgery

þRT:2


RT:4

RTþ

CT:7

Dehiscence:3(16.6%)

RTþ

CT:1

Donorsiteskin

graftnecrosis:0

Oromandibulararea

17

Surgery:2

Plate:12

15(88%)

RT:5

Flaplost:0

Surgery

þRT:1

Fibula:4


RT:0

Cervicopectoralflap:2

RTþ

CT:6

Dehiscence:3(17.6%)

RTþ

CT:0

Donorsiteskin

graftnecrosis:0

Maxilla

10

Surgery:1

Bonegrafts:8

7(70%)

RT:5

Flaplost:1(10%)

Surgery

þRT:0

Marginalnecrosis:0

RT:0

RTþ

CT:3

Dehiscence:2(20%)

RTþ

CT:0

Donorsiteskin

graftnecrosis:1(10%)

Hypopharynx

6Surgery:0

None

4(67%)

RT:2

Flaplost:0

Surgery

þRT:0

Marginalnecrosis:0

RT:0

RTþ

CT:3

Dehiscence:0

RTþ

CT:1

Donorsiteskin

graftnecrosis:0

Cheek

5Surgery:1

Cervicopectoralflap:1

3(60%)

RT:2

Flaplost:0

Surgery

þRT:0

Marginalnecrosis:0

RT:0

RTþ

CT:3

Dehiscence:1(20%)

RTþ

CT:0

Donorsiteskin

graftnecrosis:0

SkullBase

5Surgery:0

None

1(20%)

RT:1

Flaplost:0

Surgery

þRT:0

Marginalnecrosis:0

RT:0

RTþ

CT:2

Dehiscence:0

RTþ

CT:0

Donorsiteskin

graftnecrosis:1(20%)

Trism

usrelease

2Surgery:0

None

0RT:0

Flaplost:0

Surgery

þRT:2

Marginalnecrosis:0

RT:0

RTþ

CT:0

Dehiscence:0

RTþ

CT:0

Donorsiteskin

graftnecrosis:0

Facialcontourdefect

1Surgery:0

None

0RT:0

Flaplost:0

Surgery

þRT:0

Marginalnecrosis:0

RT:0

RTþ

CT:0

Dehiscence:0

RTþ

CT:0

Donorsiteskin

graftnecrosis:0

RT:radiotherapy;

CT:chemotherapy;RTþ

CT:chemo-radiationtherapy.

ALT Musculocutaneous Flap 89


muscular cuff was placed over the defect filling all the

surgical gap and suturing it to surrounding bone and peri-

ostium to prevent ptosis and dehiscences (Fig. 5).

Direct closure of the donor site was achieved in 71

patients, while in the other 21, a partial-thickness free

skin graft was harvested from the contralateral internal

side of the thigh and used for donor site closure.

In 27 patients, the flap was associated with another

reconstructive technique: with a titanium plate in 12

patients, free bone grafts in eight, a fibula osteocutaneous

free flap in four, and a locoregional cervicopectoral flap

in the other three patients.

The microvascular anastomosis was performed by the

same surgeon (first author, B.B.) using the artery and

only one vein. The superior thyroid artery was chosen as

the recipient artery 42 times (contralateral to the defect

five times), the facial artery 29 times (contralateral to the

defect 10 times), the lingual artery 12 times, and the

external carotid artery nine times (contralateral to the

defect twice). The internal jugular vein was the preferred

recipient vein and was used 74 times: in 48 cases, an

end-to-side anastomosis was performed (contralateral to

Figure 1. Intraoperative picture showing flap harvesting. (A) Muscu-

lar anatomy. RF: rectus femori muscle; VL: vastus lateralis muscle;

the painted blue line between the two muscles represents the inter-

muscular septum. (B) The neurovascular pedicle. (C) The final har-

vesting of the free ALT musculocutaneous flap. [Color figure can be

viewed in the online issue, which is available at wileyonlinelibrary.

com.]

Figure 2. Musculocutaneous ALT flap for tongue reconstruction.

(A) Intraoperative picture of the surgical defect following a subtotal

glossectomy. (B) Postoperative results after adjuvant radiation ther-

apy. The bulk of the flap enable patient’s oral cavity functions as

speech and swallow. [Color figure can be viewed in the online

issue, which is available at wileyonlinelibrary.com.]

90 Bianchi et al.


the defect 12 times), and in 26 cases, an end-to-end anas-

tomosis to a proximal affluent trunk was used (contralat-

eral to the defect five times). The facial vein was used

10 times, while the external jugular vein was used eight

times.

RESULTS

Of the 92 free ALT musculocutaneous flaps harvested

and transplanted, major complications resulted in the loss

of two flaps due to venous thrombosis: one occurred in-

traoperatively during the reconstruction of a submandibu-

lar gland tumor resection and the second on the second

postoperative day after the reconstruction of an inferior

lip tumor resection. The final survival rate was 97.8%

(90 of 92). Minor complications included marginal necro-

sis of the skin paddle (4.3%; n 5 4), dehiscence of the

suture (13%; n 5 12), and partial necrosis of the skin

graft used for donor site closure (2.2%; n 5 2). All these

minor complications were managed with wound dressing

or suture replacement under local anesthesia and required

no further surgical procedure. No major donor site com-

plication occurred, and all the patients returned to their

daily activities in around 4 weeks without limitation due

to donor-site morbidity.

In all cases, excess bulk was present in the first post-

operative weeks, but a large part of the muscular compo-

nent atrophied, optimizing the result in a few months.

This time was reduced drastically if adjuvant radiotherapy

was performed.

The length of hospitalization ranged from 6 to 31

days (mean, 12 days).

Postoperative adjuvant radiation therapy was per-

formed in 58 patients, 32 of whom also received concom-

itant chemotherapy (cisplatin in all cases).

Follow-up ranged from 12 to 84 months, with a mean

of 34.6 months. Of the 92 patients, 29 died of their dis-

ease, 10 are alive with disease (four local recurrences on

palliative chemotherapy and six distant metastases on

chemotherapy), and 53 show no evidence of disease.

Patient’s postoperative functions were evaluated on alive

patients by medical examination, and questionnaire and

results are summarized in Table 2. Deglutition was

assessed by the patient diet that was classified as normal,

soft, or gastrostomy tube-dependent. Speech evaluation

was based on the capability of the patient to be under-

stood, and the results were classified as good, intelligible,

or unintelligible. Aesthetic outcome was valued by the

Figure 4. Musculocutaneous ALT flap for maxillary reconstruction.

Intraoperative picture showing flap insetting: the skin is used for

palatal and nasal mucosal lining reconstruction; the muscle and a

portion of de-epithelializated skin paddle is used for maxillary

defect filling providing adequate bulk and enrolling bone grafts used

for floor of the orbit reconstruction. [Color figure can be viewed in

the online issue, which is available at wileyonlinelibrary.com.]

Figure 3. Musculocutaneous ALT flap and titanium plate for oro-

mandibular reconstruction. Intraoperative picture showing the role

of the different flap components: the skin is used for oral mucosa

defect reconstruction; fascia lata is used for plate enrollment and

flap suspension; muscular component is placed in the submandibu-

lar area obliterating dead spaces and preventing oro-cervical fistu-

las and infections. [Color figure can be viewed in the online issue,

which is available at wileyonlinelibrary.com.]



Figure 5. Musculocutaneous ALT flap for skull base reconstruction. (A) Skull base defect after tumor resection. (B) Reconstruction of the through

and through defect using the ALT flap: the muscular component is used to fill all the defect preventing fistulas and infections obliterating all the

dead areas of the surgical gap, while the skin is placed externally to reconstruct the cutaneous defect. [Color figure can be viewed in the online

issue, which is available at wileyonlinelibrary.com.]

Table 2. Functional and Esthetic Results

Location No. Diet Speech Cosmesis

Tongue 16 Normal: 19% (n 5 3) Good: 31% (n 5 5) Excellent: 37% (n 5 6))

Soft: 62% (n 5 10) Intelligible: 50% (n 5 8) Acceptable: 50% (n 5 8)

GT dependant: 19% (n 5 3) Unintelligible:19% (n 5 3) Poor: 13% (n 5 2

Oropharynx 13 Normal: 31% (n 5 4) Good: 54% (n 5 7) Excellent: 38% (n 5 5)


GT dependant: 15% (n 5 2) Unintelligible: 8% (n 5 1) Poor: 15% (n 5 2)

Oromandibular area 11 Normal: 64% (n 5 6) Good: 36% (n 5 5) Excellent: 18% (n 5 2)


GT dependant: 0 Unintelligible: 0 Poor: 9% (n 5 1)

Maxilla 9 Normal: 44% (n 5 4) Good: 67% (n 5 6) Excellent: 44% (n 5 4)


GT dependant: 0 Unintelligible: 0 Poor: 0

Hypopharynx 4 Normal: 0 Good: 0 Excellent: 0

Soft: 50% (n 5 2) Intelligible: 0 Acceptable: 75% (n 5 3)

GT dependant: 50% (n 5 2) Unintelligible: 25% (n 5 1)

Laryngectomy: 75%(n 5 3)

Poor: 25% (n 5 1)

Cheek 5 Normal: 80% (n 5 4) Good: 100% (n 5 5) Excellent: 60% (n 5 3)



Skull base 2 Normal: 100% (n 5 2) Good: 100% (n 5 2) Excellent: 0

Soft: 0 Intelligible: 0 Acceptable: 50% (n 5 1)

GT dependant: 0 Unintelligible: 0 Poor: 50% (n 5 1)

Trismus release 2 Normal: 50% (n 5 1) Good: 100% (n 5 2) Excellent: 50% (n 5 1)



Facial contour defect 1 Normal: 100% (n 5 1) Good: 100% (n 5 1) Excellent: 100% (n 5 1)

Soft: 0 Intelligible: 0 Acceptable: 0


Overall results 63 Normal: 39% (n 5 25) Good: 52% (n 5 33) Excellent: 36% (n 5 22)


GT dependant: 11% (n 5 7) Unintelligible: 12% (n 5 8) Poor: 11% (n 5 7)

GT dependant: gastrostomy tube dependant.

92 Bianchi et al.


surgeon and by the patient’s own perception as excellent,

acceptable, or poor. Overall results showed an 89% of

patients that returned to a normal or a soft diet and only

11% that are gastrostomy tube dependant. Speech was

good or intelligible in 88% of patients and unintelligible

in the remaining 12% (three of these patients—5%—were

submitted to a total laryngectomy during tumor resec-

tion). Concerning cosmetic results, good or acceptable

cosmesis was achieved in 89% of cases.

DISCUSSION

The advantages of the ALT free flap and its applica-

tions are well documented. Wong and Wei15 reported

their experience in head and neck reconstruction with the

ALT flap, emphasizing the use of this flap with perforator

harvesting. Kimata et al.16 described the advantages of

the perforator ALT free flap in the reconstruction of post-

oncologic cervicofacial defects. Although the advantages

of the perforator technique are well documented, only a

few studies have reported on free ALT musculocutaneous

flap applications, and none of them dealt with Western

populations. Wei et al.13 reported a large case series deal-

ing with 672 ALT flaps harvesting; however, only 95 of

these (14%) were musculocutaneous flaps, and protection

of musculocutaneous perforators was advocated as the

main advantage of muscle harvesting. Demirkan et al.10

were the first in 2000 to emphasize the versatility of the

ALT musculocutaneous flap underlining the advantage of

a safe flap harvesting without needing for perforators dis-

section and independently from anatomic vascular varia-

tions and the usefulness of muscle component for volume

restoration and dead space obliteration. The same

approach was proposed 1 year later by Kuo et al.17 that

used the musculocutaneous version of the ALT flap in

62.1% of their reported patients, describing the advan-

tages of this technique when bulky flap was needed.

Wong et al.18 described in 2009 a technical note for the

ALT musculocutaneous flap harvesting, underlining the

importance of musculocutaneous perforators identification

and preservation at the beginning of the dissection that

has to be performed opening the intermuscular septum

and unroofing the musculocutaneous perforators. We

recently described the use of the free ALT musculocuta-

neous flap and bone grafts association for maxillary

reconstruction;19 however, as far as we know, other

articles dedicated specifically to free ALT musculocutane-

ous flap patients series were published only in the last

year and only in Chinese literature. Xia et al.20 reported

their experience with ALT musculocutaneous flap for

tongue and mouth floor reconstruction in 14 cases, while

Liu et al.21 reported a series of 109 free ALT musculocu-

taneous flaps for reconstruction of soft tissue defects fol-

lowing en block resection of tongue cancer. In both

articles, a detailed description of ALT musculocutaneous

flap advantages was performed, focusing on bulky and

obliteration of dead space provided with the technique.

However, both articles dealt only with tongue defects

without considering other areas of head and neck.

Following the international literature, in our first

experiences with the ALT free flap, we started with the

use of the perforator variant, which requires a long oper-

ating time and tedious, difficult intramuscular dissection

of the perforator vessels in cases when a septocutaneous

perforator is not present22 (70 to 80% of the literature

reported cases). Although optimal results were obtained

with this flap, we started to modify our approach by har-

vesting a cuff of vastus lateralis muscle in almost all

cases. This has at least two great advantages: the dissec-

tion time decreases from 2 to 3 hours for the perforator

flap to between 30 and 40 minutes for the musculocuta-

neous flap, and the harvested muscle can be used in the

reconstruction in several ways, depending on the site of

the defect and the need for bulk in its reconstruction.

The free ALT musculocutaneous flap is now our first-

choice flap for reconstructing almost all soft tissues

defects of the head and neck, replacing the rectus abdom-

inis free flap and radial forearm fasciocutaneous free flap

(RFFF). Several discussions exist in the literature about

replacing the RFFF with the ALT flap.23 We use the

RFFF only for the smallest oral cavity defects, and only

when extreme pliability and thinning are critical for the

patient’s functional outcome (e.g., for small defects of

the cheek, floor of the mouth, or soft palate), preferring it

to a perforator ALT flap; for all other defects, the free

ALT musculocutaneous flap is used.

When we deal with hypopharyngeal defects recon-

struction, the main goal is restoring the digestive tract by

tubularizing the flap used.24 In three patients of the

reported list, the skin component of the ALT musculocu-

taneous flap was used for pharyngeal mucosal defect

reconstruction, and only a small amount of muscle was

harvested, to avoid compressing the tubularized skin,

which increases the risk of stenosis. The muscular cuff

was placed in the neck to protect the great vessels and

anastomosis. In the remaining three patients, a larger

hypopharyngeal defect associated with a laryngectomy

was present, and the muscular component was used to

separate the airway from the digestive tract to prevent

pharyngo-stomal or neck-pharyngeal fistulas.

When the resection involves the tongue, reconstruction

of partial or total glossectomies is one of the best indica-

tions for the use of a free ALT musculocutaneous flap.

Given the physiology of speech and deglutition, one of the

main objectives of such reconstructions is to restore

adequate bulk, which should not be excessive to allow mo-

bility of the flap together with the residual structures.

Enough bulk should exist to permit the lingual-palatal con-



tact that represents the first and most important step in the

oral phase of deglutition. The muscular component of the

ALT musculocutaneous flap is very useful for this purpose,

especially when the tongue base is involved in the resec-

tion, as in 19 of the 26 reported patients. Furthermore, the

muscle can be used to obliterate any submandibular dead

spaces, ensuring optimal separation between the oral cavity

and neck, thereby preventing fistulas and infections.

For oromandibular defects, we usually use bone-con-

taining free flaps to optimize the esthetic and functional

outcome.25 When bone reconstruction is not indicated,

we prefer a free ALT musculocutaneous flap, alone or in

association with a titanium reconstructive plate.26 In such

cases, the muscular component of the flap plays a major

role, it protects the plate with a large amount of well

revascularized tissue, thereby preventing plate infections

and exposure, while simultaneously providing bulky

reconstruction of the defect and reducing the asymmetry

of the oral cavity resulting from the mandibular resection.

In the patients list reported here, any of the 12 plates

used in association with the flap underwent exposure and

esthetically, the bulk of the flap allowed an adequate fa-

cial contour restoration also when the flap was used alone

(n 5 5).

Also maxillary reconstruction is usually performed

using bone-containing free flaps;27 however, in elderly

patients or those with a poor prognosis, a free ALT mus-

culocutaneous flap can be useful. When a wide residual

cavity is present, muscle harvesting permits filling of the

entire space, thereby preventing air communication and

providing cheek soft tissue support. In eight of our

patients, the large amount of revascularized muscle was

rolled around bone grafts or alloplastic prosthesis for the

floor of the orbit or zygoma reconstruction, avoiding

infections and resorption also after radiation therapy. Fur-

thermore, the ALT flap can be harvested with two skin

paddles as in two of the reported patients, when recon-

struction of the external coverage of the cheek is needed.

Finally, the fascia lata may be used for flap suspension,

preventing ptosis of the flap in the oral cavity and ensur-

ing adequate functional reconstruction of the soft palate.

In the reconstruction of the skull base, the free ALT

musculocutaneous flap offers unique advantages over the

perforator ALT flap and other musculocutaneous flaps.28

It provides a large amount of revascularized muscle,

which is essential for obliterating the space in the skull

base, preventing fistulas and infections. The pedicle is

long enough to reach the recipient vessels in the neck;

also, the large amount of skin included can be used for

cutaneous defects, and the fascia lata can be used for flap

suspension preventing ptosis of the flap typical when this

area is approached.

Independently on the area to reconstruct, the low

donor-site morbidity and the possibility of harvesting the

flap simultaneously with the resection have been recog-

nized worldwide as the main advantages of the ALT

flap.29 With the musculocutaneous version of the flap, the

harvesting of the muscular component does not increase

the donor-site morbidity; the cutaneous defect can usually

be closed primarily when a skin paddle of up to between

12 and 13 cm is harvested, and the functional outcome is

usually optimal without interfering with the patient’s

daily activities, even when a large amount of vastus later-

alis is harvested as recently described by Hanasono

et al.30 These authors reported only an 8% of weakness

after muscle harvesting that was not associated with the

degree of muscle harvested or motor nerve transection,

probably because the synergistic effect of the remaining

three muscle bellies of the quadriceps.

Despite the great advantages of the free ALT muscu-

locutaneous flap, excessive bulky may result if redundant

amount of muscle is harvested, thus requiring a careful

planning of the reconstruction and a harvesting tailored

on the size of the defect and on the reconstructive need-

ing. This disadvantage may be particularly significant in

occidental population because of the major thickness of

the subcutaneous fat tissue, when compared with oriental

one and become critical in obese patients. Finally, the

high incidence of hairy skin in thigh area in male patients

and donor site scars associated with the use of skin grafts

in large defects have to be considered as supplementary

minor drawbacks of this technique.

CONCLUSIONS

The free ALT musculocutaneous flap offers unique

advantages in head and neck reconstruction, including

adequate bulk when needed, obliteration of dead space

thus preventing fistulas and infections, protection of

plates and bone grafts, support for the soft tissues of the

face allowing for optimal patient outcome. Based on our

experience, we would like to emphasize the major role

played by the free ALT musculocutaneous flap that is

nowadays largely underestimated.

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The free anterolateral thigh musculocutaneous flap for head and neck reconstruction: One surgeon's experience in 92 cases