Adipofascial anterolateral thigh free flap in head and neck reconstruction: a case series

Abstract

Background: The adipofascial anterolateral thigh (AF-ALT) free flap represents a versatile technique in head and neck reconstructions, with its applications increasingly broadening. The objective was to detail the novel utilization of the AF-ALT flap in orbital and skull base reconstruction, along with salvage laryngectomy onlay in our case series.

Method: We conducted a retrospective analysis at Roswell Park Comprehensive Cancer Center, spanning from July 2019 to June 2023, focusing on patient demographics and reconstructive parameters data.

Results: The AF-ALT flap was successfully employed in eight patients (average age 59, body mass index [BMI] 32.0) to repair various defects. Noteworthy outcomes were observed in skull base reconstructions, with no flap failures or major complications over an average 12-month follow-up. Donor sites typically healed well with minimal interventions.

Conclusion: Our series is the first to report the AF-ALT flap's efficacy in anterior skull base and orbital reconstructions, demonstrating an additional innovation in complex head and neck surgeries.

Keywords: cancer; head and neck surgery; naso-pharynx; skull base reconstruction.

Figure 1:

Harvesting of the Adipofascial Anterolateral thigh (AF-ALT) free flap with use of the ABC Perforator method . (A) A line is drawn from anterior superior iliac spine (ASIS) to superolateral border of patella. At the midpoint, perforator B is marked; perforator A and C are marked 5 cm on both sides along the same line. The incision is planned 3 cm medially to include the three perforators. (B) The medial flap border incision is made first, down to the rectus fascia. (C) Dissection is performed in the subfascial plane from medial to lateral to identify perforators; in this case 3 were identified and labeled as (p). Perforator dissection is then performed. (D) The adipofascial flap is sharply separatef from the skin, leaving a small cup of fat under the dermis with careful attention around the perforators. (E) The AF-ALT free flap and its pedicle are ready for inset and micro vascular anastomoses.

Figure 2:

AF-ALT Reconstruction of Maxillectomy Defect (Case #1). (A) A 61-year-old female with SCC of the right upper alveolar ridge, post-resection. (B) Flap at time of harvest, (C) inset and (D) at 2 months post-operatively.

Figure 3:

AF-ALT Reconstruction of anterior skull base with orbital exenteration defect (Case #6). (A) Coronal and (B) sagittal MRI images depicting the tumor; (C) Defect site post-resection and duraplasty; (D) Harvested AF-ALT free flap; (E) Defect site post-flap placement with overlying split thickness skin graft; (F) Defect site at follow-up 40 days post-operatively.