Anterolateral Thigh Flap for Reconstruction of an Oropharyngectomy Defect

INTRODUCTION

The anterolateral thigh (ALT) flap has become the workhorse flap for soft-tissue reconstruction of head and neck defects.¹ This perforator-based fasciocutaneous flap is ideal due to its thin, pliable nature and long vascular pedicle. It can include the vastus lateralis muscle for added bulk or tensor fasciae latae for strength, or can be thinned to skin and subcutaneous fat.¹ The vascular pedicle supply is the descending branch of the lateral circumflex femoral artery with a length as long as 18 cm.² Up to 10 × 25 cm of skin paddle can be harvested without compromising closure of the donor site.³ It can also be made into a sensate flap via the anterior branch of the lateral cutaneous nerve of the thigh.² It results in minimal donor site morbidity when harvested in either the sub- or suprafascial plane, without functional muscle loss.⁴ Finally, the ALT also allows for a two-team surgical approach, yielding a more efficient operative experience for the patient and surgeons involved. (See Video 1 [online], which displays introduction and indications for an anterolateral thigh flap for head and neck reconstruction.)

Video 1. ALT introductions and indications. Video 1 from “Anterolateral Thigh Flap (ALT) for Reconstruction of an Oropharyngectomy Defect.” This video displays the introduction and indications for an anterolateral thigh flap for head and neck reconstruction.

Download video file ^{(2MB, mp4)}

PREOPERATIVE MARKINGS

Skin perforators for the ALT flap vary from one to three perforators and should be localized with a Doppler before anesthesia induction and its associated hypotension. Perforators are often located approximately midway on a line drawn from the anterior-superior iliac spine to the lateral patella, corresponding to the septum between the rectus femoris and vastus lateralis muscles.⁵ The flap is then drawn as an ellipse, to match the required defect size, often centering the ellipse over the strongest Dopplerable perforator(s). (See Video 2 [online], which displays patient case report presentation with demonstration of anterolateral thigh flap preoperative markings and initial flap dissection.)

Video 2. Patient case report presentation. Video 2 from “Anterolateral Thigh Flap (ALT) for Reconstruction of an Oropharyngectomy Defect.” This video displays the patient case report presentation with demonstration of anterolateral thigh flap pre-operative markings and initial flap dissection.

Download video file ^{(56.3MB, mp4)}

FLAP HARVEST AND MICROSURGERY

Perforator harvest of the ALT requires meticulous intramuscular dissection to follow the perforator from the skin to its main vascular pedicle, which is demonstrated in vivid detail in the educational video included in this article. (See Video 3 [online], which displays intramuscular perforator dissection and microsurgical technique for the anterolateral thigh flap.)

Video 3. Microsurgical technique. Video 3 from “Anterolateral Thigh Flap (ALT) for Reconstruction of an Oropharyngectomy Defect.” This video demonstrates intramuscular perforator dissection and microsurgical technique for the anterolateral thigh flap.

Download video file ^{(102.6MB, mp4)}

CASE REPORT

We present a patient case of a 76-year-old man with a history of smoking who complained of right-sided odynophagia and otalgia. Biopsy and radiographic scan revealed a T2N1p16+ squamous cell carcinoma of the right tonsil. He was initially treated with chemotherapy and radiation. Several months later, he was found to have a recurrence and was treated with radical robotic surgical tonsillectomy with clear margins. Several months following surgical resection, he was found to have a second recurrence of his squamous cell carcinoma.

The second recurrence required a two-team surgical approach. The otolaryngologists performed oncologic ablative surgery including a right oropharygectomy and neck dissection of lymph node levels I–IV. At the same time, the plastic surgeons raised an ALT flap on musculocutaneous perforators. The ALT provided adequate coverage of the oropharyngeal defect. (See Video 4 [online], which displays intraoral anterolateral thigh flap inset). All the surgical steps are described in vivid detail in our supplemental videos (See Videos 1, 2, 3, 4 [online]).

Video 4. ALT inset. Video 4 from “Anterolateral Thigh Flap (ALT) for Reconstruction of an Oropharyngectomy Defect.” This video demonstrates intra-oral anterolateral thigh flap inset.

Download video file ^{(40.2MB, mp4)}

CONCLUSIONS

The ALT has become a “workhorse” flap in head and neck cancer reconstruction due to its long vascular pedicle, large skin paddle, pliability, thin nature, and ability to be raised as a composite tissue free flap, if necessary. Understanding the salient points of ALT harvest technique is essential for the head and neck reconstructive surgeon to master.