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Surgical Algorithmic Approach to Facilitate Primary Closure of the Anterolateral Thigh Flap Donor Site in Head and Neck Reconstruction

Hung, Kuo-Shu, MD*; Chen, Szu-Han, MD*; Chen, Wei-Chen, MD; Tseng, Wan-Ling, MD*; Lee, Yao-Chou, MD, MSc*

doi: 10.1097/SAP.0000000000001729
Reconstructive Surgery

Background Use of the anterolateral thigh (ALT) flap has gained popularity in head and neck reconstruction. However, donor sites that cannot achieve primary closure are reported to have poorer functional and aesthetic outcomes. Therefore, we propose an algorithm to facilitate primary closure of the donor site.

Methods Since May 2013, when an attempt at donor site direct closure failed, we have used a VY advancement flap or a propeller flap for primary closure of the donor site, using the remnant lateral thigh perforator or nearby medial thigh perforator. Otherwise, a skin graft was used. A total of 91 patients were enrolled in this algorithmic approach. We retrospectively reviewed patients with head and neck cancer who underwent cancer ablation and immediate ALT flap reconstruction since August 2010. The patients were then categorized into a “before” group and an “after” group according to the application time of the algorithm. Their demographics, intraoperative findings, and postoperative outcomes were analyzed.

Results A total of 321 patients (309 men, 12 women) were enrolled, with 230 patients in the before group and 91 patients in the after group, with a mean age of 52.9 years. The mean size of the flap was 130 cm2, with a mean width of 8.1 cm. No statistical difference existed between the groups. The donor site was directly closed in 82 patients (35.7%) in the before group. Using the perforator-based flap in 21 patients (23.1%), the donor site was closed primarily in 72 patients (79.1%) in the after group, contributing to a significantly higher donor site closure rate (P < 0.001). The average operative time was 348.7 minutes. The overall flap survival rate was 97.2%, donor-site complication rate was 6.9%, and hospitalization length was 23.5 days. None showed statistical differences between the groups.

Conclusions The proposed algorithm may considerably increase the primary closure rate of the ALT flap donor site.

From the *Division of Plastic and Reconstructive Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan; and

Department of Plastic and Reconstructive Surgery, Ditmanson Medical Foundation Chiayi Christian Hospital, Chiayi City, Taiwan.

Received September 5, 2018, and accepted for publication, after revision October 5, 2018.

Conflicts of interest and sources of funding: This study was funded by National Cheng Kung University Hospital (NCKUH-10706013). The authors declare no conflict of interest.

Reprints: Yao-Chou Lee, MD, MSc, Division of Plastic and Reconstructive Surgery, Department of Surgery, National Cheng Kung University Hospital, 138 Sheng-Li Road, Tainan 70403, Taiwan. E-mail:

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