A Defect Oriented Approach to Utilizing the Myocutaneous ALT in Head and Neck Reconstruction: Review of 146 Cases.
Ian L. Valerio, MD, MS, MBA1, Jerrod Keith, MD1, Sejal Patel, MD2, Jason Prigozen, MD3, Ming-Heui Cheng, MD, MHA, FACS4.
1University of Pittsburgh Medical Center, Pittsburgh, PA, USA, 2University of California Irvine, Irvine, CA, USA, 3Cleveland Clinic, Cleveland, OH, USA, 4Chang Gung Memorial Hospital, Linkou, Taiwan.
Background: The anterolateral thigh flap (ALT) has become a “workhorse flap” for a many reconstructive defects. Complex composite tissue defects in head and neck reconstructions pose difficult challenges, some of which may be addressed through use of a myocutaneous ALT (ALT-MC). In this paper, the advantages and disadvantages of the ALT-MC flap will be discussed, with an emphasis on defect oriented applications of this flap in head and neck reconstruction.
Methods: This study is a retrospective review of a single surgeon’s experience in treating complex composite head and neck defects with an ALT-MC. Patient demographics, etiologies of head and neck reconstruction needs, and defect recipient sites were analyzed. The clinical outcomes evaluated included overall success rates of flap transfer, acute complications such as total and partial flap loss, venous and arterial insufficiency, and infection rates. The outcomes for the ALT-MC flaps were compared to results for fasciocutaneous ALT (ALT-FC) flaps.
Results: Over a 13 year period (1997-2010), a total of 146 patients underwent reconstruction of head and neck defects with an ALT-MC flap. The overall success rate of transfer was 96.6%, Partial failures were seen in 2.1%, venous congestion in 6.8%, and arterial insufficiencies in 6.2% of cases. The infection rate was 2.1% for all cases. When comparing the ALT-MC with our experience using the ALT-FC, there was no statistical difference when comparing the outcomes of the two groups (p<0.8). Table 1 outlines the ALT-MC flap success and complication rates, while Table 2 exhibits the type of defects reconstructed with ALT-MC flaps.
Conclusion: The ALT flap is truly a diverse flap: its relatively long pedicle length, ability to incorporate sensation, and variable skin paddle size make this an attractive reconstructive option. In addition, it allows a two-team surgical approach during head and neck reconstruction. Further refinements of this flap, specifically its myocutaneous derivation, provide well vascularized muscle that can be used to obliterate dead space, while also providing healthy skin for both intraoral lining and external coverage. Furthermore, the ALT and its variations provide sufficient soft tissue bulk to assist in wound healing, while allowing head and neck oncology patients to receive necessary radiotherapy in a timely manner.
Table 1: Overall ALT-MC Flap Success Rate and Outline of Complications
|Success||Total loss||Partial loss||Vein insufficiency||Artery insufficiency||Infection|
Table 2: Defect Recipient Sites for ALT-MC flap Placement
|Flap Type (n=146)||Flap %|
Mutliple Recipient Sites
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