Anterolateral Thigh Flap Reconstruction of
Large External Facial Skin Defects: A Follow-
Up Study on Functional and Aesthetic
Recipient- and Donor-Site Outcome
Marc A. M. Mureau, M.D., Ph.D., Nicole A. S. Posch, M.D., Cees A. Meeuwis, M.D., Ph.D., and
Stefan O. P. Hofer, M.D., Ph.D.
Rotterdam, The Netherlands
Background: The purpose of this study
was to investigate the subjective and the
objective functional and aesthetic fol-
low-up results of the recipient and donor
sites after reconstruction of extensive facial
defects with the anterolateral thigh flap.
Methods: Between December of 2001
and April of 2003, the anterolateral thigh
flap was used to reconstruct large facial skin
defects after malignant tumor resection in
23 white patients. All patients had a stan-
dardized interview, physical examination,
and clinical photographs.
Results: The mean flap size was 108
cm2. Fasciocutaneous anterolateral thigh
flaps were used in 15 patients and muscu-
locutaneous flaps were used in eight pa-
tients with exposed dura, open sinuses, or
orbital defects. An extra free osteocutane-
ous fibula flap was necessary to reconstruct
the affected mandible in 10 patients. The
donor site was skin grafted in 18 patients.
The flap survival rate was 96 percent. At
follow-up, color mismatch (71 percent)
and flap bulkiness (50 percent) were en-
countered most often. Four of five patients
with speech problems had received an ad-
ditional free osteocutaneous fibula flap.
From the Departments of Plastic and Reconstructive Surgery and Otorhinolaryngology, Head and Neck Surgery, Erasmus Medical Center
Rotterdam. Received for publication March 18, 2004; revised July 12, 2004.
Presented at the World Congress of the International Confederation of Plastic, Reconstructive, and Aesthetic Surgery, in Sydney, Australia,
August 10 to 15, 2003.
DOI: 10.1097/01.PRS.0000156153.17258.CE
1077
Three flap contractures were seen in the
neck region. A contour defect of the upper
leg was encountered in five patients. Sen-
sory disturbances of the upper leg were
observed in 12 patients. Cold intolerance
occurred three times after skin grafting. No
significant impairment was found in range
of motion and muscle strength of the do-
nor leg.
Conclusions: Careful patient selection
may further improve aesthetic outcome of
the anterolateral thigh flap. The versatility
in design and composition of the antero-
lateral thigh flap and the low donor-site mor-
bidity and satisfactory recipient-site outcome
make it a valuable option in reconstruction
of external skin defects in the head and
neck region. (Plast. Reconstr. Surg. 115:
1077, 2005.)
Reconstruction of external skin loss in the
facial and forehead area poses an aesthetic and
surgical challenge. The aim of reconstruction
of these defects is to achieve optimal function
and aesthetic appearance combined with min-
imal donor-site morbidity. For reconstruction
of small defects, locoregional flaps usually offer
the optimal solution. In larger defects with
1078
exposed bone or dura, the advantages of free
flaps for head and neck reconstruction have
been demonstrated in several studies.1–5 An
ideal soft-tissue free flap for head and neck
reconstruction should have the following char-
acteristics6,7: versatility in design, adequate tis-
sue stock, superior texture, minimal donor-site
morbidity, availability of diverse tissue types on
one pedicle, potential for reinnervation, large
and long pedicle, feasibility of a two-team ap-
proach, and consistent anatomy for an easy
and safe flap dissection. Except for the latter,
the anterolateral thigh flap8 has been sug-
gested to have all of these qualities,9 which
prompted us to start using this flap for recon-
structing large skin defects of the face and
forehead after malignant tumor resection. Al-
though others have used the anterolateral
thigh flap for this purpose, mainly in an Asian
population,7,10 –13 objective follow-up studies on
functional and aesthetic outcomes of the recip-
ient site14,15 or donor site16,17 are scarce. An-
other study presented the results of the antero-
lateral thigh flap in reconstructing various
head and neck defects in 34 white North Amer-
ican patients; however, no details on functional
or aesthetic outcome were given.18 The aim of
this study was to investigate the subjective and
the objective functional and aesthetic fol-
low-up results of the recipient and donor sites
TABLE I
Characteristics, Indication for Surgery, and Extent of Defects in 23 Patients
PLASTIC AND RECONSTRUCTIVE SURGERY, April 1, 2005
after reconstruction of extensive facial defects
with the anterolateral thigh flap.
PATIENTS AND METHODS
Patient Sample Characteristics
From December of 2001 to April of 2003, the
anterolateral thigh flap was used in 23 consec-
utive white patients to reconstruct large facial
defects after malignant tumor resection. There
were 18 male and five female patients; their
age ranged from 48 to 78 years (mean, 62
years). Seven patients had a primary tumor,
eight experienced local recurrence, and eight
presented with osteoradionecrosis. A total of
12 patients had received local radiotherapy in
the past (60 to 70 Gy). Six patients had previ-
ously undergone one operation, two patients
had undergone two operations, seven patients
had undergone three operations, and one pa-
tient had undergone four operations. A classi-
fication was made according to the location of
the defect: I, frontal; IIa, midface/orbit; IIb,
cheek/temporal; and III, chin/neck (Table I).
Table I further clarifies the extent of tumor
growth and osteoradionecrosis showing ex-
posed bone in 22 patients, exposed dura in
four patients, open sinuses in eight patients,
and orbital exenteration in six patients. Of the
23 patients, 14 participated in the follow-up

Age Location Previous Previous Exposed Orbital

Case Sex (yr) Indication of Defect RT Operation Exposed Bone Dura Open Sinus Exenteration

1 M 61 ORN III Yes 3 Mandible No No No

2 M 62 SCC-r III Yes 1 Mandible No No No
3 M 66 AS IIa No — Orbit/maxilla No Frontal Yes
4 M 48 SCC-p III No — Mandible No No No
5 F 78 BCC-p I No — Skull Yes Frontal No
6 M 57 BCC-r II b No 1 Skull No No No
7 F 71 SCC-r III Yes 2 Mandible No No No
8 M 57 SCC-r II a Yes 3 Orbit/maxilla Yes Frontal Yes
9 M 67 BCC-r I Yes 1 Skull No No No
10 M 56 SCC-p III No — Mandible No No No
11 M 50 BCC-p II a No — Orbit/maxilla No Maxillary Yes
12 M 69 ORN I Yes 1 Skull No No No
13 F 69 ORN III Yes 3 Mandible No No No
14 M 51 BCC-r II b No 1 Orbit/skull Yes No No
15 M 70 SCC-r II a No 3 Orbit/skull No Frontal Yes
16 M 64 SCC-r II a No 3 Orbit/skull No Frontal Yes
17 M 65 ORN III Yes 2 Mandible No No No
18 M 61 ORN III Yes 3 Mandible No No No
19 M 63 ORN III Yes 3 Mandible No No No
20 F 48 SCC-p III No — Mandible No No No
21 F 62 BCC-p II a No — Orbit/maxilla No Maxillary Yes
22 M 66 ORN II b Yes 4 Skull Yes Labyrinth No
23 M 56 ORN II b Yes 1 No No No No
AS, angiosarcoma; ORN, osteoradionecrosis; SCC-p, primary squamous cell carcinoma; BCC-p, primary basal cell carcinoma; SCC-r, recurrent squamous cell
carcinoma; BCC-r, recurrent basal cell carcinoma; I, frontal; IIa, midface/orbit; IIb, cheek/temporal; III, chin/neck; RT, radiotherapy.
Vol. 115, No. 4 / ANTEROLATERAL THIGH FLAP
study, four had died (two because of tumor
recurrence), and five refused to participate.
To rule out a possible selection bias, several
patient characteristics (age, sex, indication, lo-
cation of defect, flap sort and size, number of
operations, radiotherapy, and postoperative
complications) between responders and non-
responders were compared. Chi-square and
Fisher’s exact tests and Mann-Whitney U tests
did not reveal statistically significant differ-
ences (data not shown) between the respond-
ers and nonresponders, so we presume the
participants are representative of the total
group.
Flap Anatomy and Dissection
Flap anatomy and harvesting have been de-
scribed in detail previously.7–9,13,18 In short, the
anterolateral thigh flap is supplied by perforat-
ing vessels arising from the descending branch
of the lateral circumflex femoral artery, which
runs downward in the intramuscular space be-
tween the rectus femoris and the vastus latera-
lis muscles. In the midportion of the lateral
thigh, the descending branch provides a num-
ber of septocutaneous or more often musculo-
cutaneous perforators to the skin. The length
of the pedicle is 8 to 16 cm and it usually has
two venae comitantes.
Preoperatively, the skin perforators of the
lateral thigh were mapped with Doppler, using
the midpoint of a line drawn between the an-
terior superior iliac spine and the lateral aspect
of the patella as a landmark. A skin flap was
outlined around the marked perforators. In
elevation of a fasciocutaneous flap, a medial
incision was first made down to the deep fascia,
which was included in the flap. Next, dissection
proceeded laterally toward the intramuscular
septum between the rectus femoris and vastus
lateralis muscles until perforators were identi-
fied, which were classified as septocutaneous or
musculocutaneous and subsequently dissected
free until the main pedicle was reached. In
elevation of a musculocutaneous flap, there
was no need for dissection of the septocutane-
ous or musculocutaneous perforator, because
the portion of vastus lateralis muscle contain-
ing a skin perforator was included in it. In-
stead, the portion of vastus lateralis muscle
needed was cut, with attention paid to the in-
tramuscular branches that had to be ligated.
1079
Procedure
A letter was mailed to all patients explaining
the study and asking them to participate. All
consenting patients were invited to the outpa-
tient clinic for a standardized interview, physi-
cal examination, and clinical photographs of
their face and leg.
Measures
Medical data. All patient files were retrieved,
and patient characteristics, medical history, sur-
gical data, and complications were scored me-
ticulously on a standardized form.
Subjective function and satisfaction. To as-
sess subjective function and satisfaction, we
developed a standardized semistructured in-
terview with preformulated questions. Re-
ported problems of facial functioning
(speech and eating) were scored. Satisfaction
with the appearance of the face and donor leg
was measured using a five-point scale (1 ⫽
very dissatisfied; 5 ⫽ very satisfied), as was the
occurrence of tiredness and weakness of the
donor leg during walking and climbing stairs
(1 ⫽ always; 5 ⫽ never).
Objective function and appearance of the face and
leg. To determine objective function and ap-
pearance of the face and leg, we developed a
standardized physical examination form. Facial
appearance was assessed through scoring the
occurrence of sagging, color mismatch, hair
growth, contour defect, and bulkiness of the
flap. Facial function was assessed by scoring the
frequency of speech problems, oral inconti-
nence, eating problems, pain, obstruction, and
flap contracture. The occurrence of hypertro-
phic scars, hypopigmentation or hyperpigmen-
tation, and contour defects were used to assess
donor-site appearance. As in the protocol of
Kimata et al.,16 leg function was determined by
measuring the range of motion of the hip and
knee joints in degrees and by performing the
manual muscle test (M0 ⫽ paralysis; M5 ⫽ ex-
cursion against full resistance) for hip anteflex-
ion and knee extension on both the donor leg
side and the contralateral side as a control. Fur-
thermore, gait pattern (normal, slight limp, or
use of a cane) and the occurrence of sensory
disturbances and cold intolerance of the upper
leg were scored. Standardized preoperative and
postoperative clinical photographs of the face
and leg were taken by a medical photographer.
1080 PLASTIC AND RECONSTRUCTIVE SURGERY, April 1, 2005
TABLE II
Postoperative Complications, Treatment, and Outcome

No. of
Patients Case Time* Treatment Outcome
Recipient site
Total flap necrosis 1 4 Early Pedicled pectoralis major flap Uneventful
Hemorrhage 2 5, 18 Early Hematoma evacuation and hemostasis Uneventful
Arterial occlusion 1 11 Early Thrombectomy and reanastomosis Stroke
Local abscess 2 1, 13 Early Abscess drainage and antibiotics Uneventful
Exposed bone/plate 2 2, 19 Late Plate removal and debridement Uneventful
Bulky flap 1 3 Late Thinning of flap Uneventful
Donor site
SSG necrosis (partial) 2 1, 5 Early Débridement and SSG Uneventful
Wound infection 2 12, 12 Early Débridement and SSG Uneventful
Dog-ears 1 3 Late Dog-ear correction Uneventful
* Early, within 30 days after surgery.
SSG, split-thickness skin graft.

RESULTS Two patients developed a local recurrence at

Medical Data
Flap and patient characteristics. Flap size var-
ied from 40 to 228 cm2 (mean, 108 cm2). Fas-
ciocutaneous anterolateral thigh flaps were
used in 15 patients (65 percent), and muscu-
locutaneous anterolateral thigh flaps including
part of the vastus lateralis muscle were used in
the remaining eight (35 percent). In these lat-
ter eight cases, musculocutaneous anterolateral
thigh flaps were used to reconstruct skin defects
with either exposed dura, open sinuses, mid-
face/orbit defects following orbital exentera-
tion, or a combination of these three. A free
osteocutaneous fibula flap as a second free flap
was necessary to reconstruct the affected man-
dible in all 10 cases with a chin/neck defect. A
total of 13 patients received postoperative ra-
diotherapy (66 Gy), three of whom already had
been irradiated in the past (70 Gy). The donor
site was primarily closed in five patients (22
percent) and skin grafted in 18 (78 percent).
Postoperative complications. Total flap necro-
sis caused by spasm of the pedicle occurred
once (case 4) (Table I), leading to a flap survival
rate of 96 percent. In this patient, the resulting
defect at the chin was reconstructed with a pedi-
2 months (case 10) (Table I) and at 7 months
postoperatively (case 16) (Table I), which were
locally resected followed by primary closure
and reconstruction with a free rectus abdomi-
nis flap, respectively. At follow-up, they showed
no evidence of disease.
Follow-Up Results
Recipient-site outcome. Mean follow-up was 10
months (range, 3 to 16 months). Table III shows
the objective functional and aesthetic follow-up
results of the recipient site. Color mismatch (71
percent) and flap bulkiness (50 percent) were
encountered most often. Interestingly, five of
seven flaps that were considered bulky were
fasciocutaneous flaps. Four of five patients with
speech problems had received an additional
free osteocutaneous fibula flap. A considerable
portion of the lower lip or oral commissure was
resected in all three patients with oral inconti-
TABLE III
Objective Functional and Aesthetic Recipient-Site Follow-
Up Results in 14 Patients*
No. of Patients
(%)

cled pectoralis major musculocutaneous flap Aesthetic outcome

Sagging of flap 1 (7)
with a satisfactory result. Other early recipient- Color mismatch 10 (71)
site complications were hemorrhage (two Hair growth flap 4 (29)
cases), occlusion of the arterial anastomosis Contour defect 3 (21)
Flap bulkiness 7 (50)
(one case), and a local abscess (two cases). Ta- Functional outcome
ble II lists the early and late complications of the Speech problems 5 (36)
recipient and donor site, their treatment, and Oral incontinence 3 (21)
Eating problems 2 (14)
their outcome. In total, 14 complications oc- Facial pain 3 (21)
curred in 10 patients (43 percent); nine pa- Nasal obstruction 2 (14)
tients had to undergo reoperatation once and Flap contracture 3 (21)
three patients, twice. * In some patients, more than one problem was observed.
Vol. 115, No. 4 / ANTEROLATERAL THIGH FLAP
TABLE IV
Objective Functional and Aesthetic Donor-Site Follow-Up
Results in 14 Patients*
No. of Patients
Aesthetic outcome
Hypertrophic scar
Hypopigmentation/hyperpigmentation
Keloid
Contour defect
Functional outcome
Slightly limping gait
Sensory disturbances
Cold intolerance
* In some patients, more than one problem was observed.
nence. Flap contractures (one after radiother-
apy) were all seen in the neck region (three
cases).
Nine patients (64 percent) reported to be
(very) satisfied with the aesthetic result of their
facial reconstruction, three (21 percent) were
neither satisfied nor dissatisfied, and two (14
percent) were (very) dissatisfied. Regarding
the functional result of the facial reconstruc-
tion, 10 patients (71 percent) were (very) sat-
isfied and four (29 percent) were (very)
dissatisfied.
Donor-site outcome. Table IV shows the objec-
tive functional and aesthetic donor-site fol-
low-up results. A contour defect of the upper leg
was encountered in five patients (36 percent);
three times after harvesting a musculocutane-
ous anterolateral thigh flap and twice following
a fasciocutaneous anterolateral thigh flap. All of
these flaps were larger than 100 cm2. Sensory
disturbances of the lateral side of the upper leg
were observed in many patients (86 percent).
Cold intolerance occurred three times after
skin grafting and never following primary clo-
sure (Fisher’s exact test, p ⫽ 0.547).
Apart from knee excursion, no statistically
significant differences were found between the
donor-site leg and the contralateral side (Table
TABLE V
Range of Motion and Muscle Strength of Hip and Knee Joints of Donor-Site Leg and Contralateral Leg in 14 Patients
Donor-Site Leg
Mean
Range of motion, degrees
Hip joint 130.4
Knee joint 134.3
Muscle strength†
Hip joint 4.6
Knee joint 4.9
* Wilcoxon signed rank test.
† Six-point scale (manual muscle test): 0 ⫽ paralysis, 5 ⫽ excursion against full resistance.
1081
V). A total of 10 (71 percent) and 11 patients
(79 percent) never experienced tiredness dur-
ing walking and climbing stairs, respectively.
Although six patients (43 percent; two muscu-
locutaneous flaps and four fasciocutaneous
(%) flaps) occasionally experienced muscle weak-
ness in the donor leg, no statistically significant
1 (7) differences in muscle strength were found dur-
2 (14)
0 (0) ing physical examination using the manual
5 (36) muscle test (Table V). Nine patients (64 per-
cent) reported being (very) satisfied with the
1 (7)
12 (86) appearance of their upper leg, two (14 per-
3 (21) cent) were neutral, and three (21 percent)
were (very) dissatisfied. Figures 1 through 3
show average examples of the aesthetic recipi-
ent sites.
DISCUSSION
The current study presents in detail objec-
tive and subjective aesthetic and functional
outcomes of recipient and donor sites follow-
ing reconstruction of extensive facial and fore-
head defects with the anterolateral thigh flap
in 23 patients. The anterolateral thigh flap was
chosen in the current study patients because a
large skin area could be harvested11,13 and a
muscular part could be added if necessary.7,13
Previous reports have extensively dealt with the
vascular anatomy.7–9,13,18 In short, our experi-
ence was that the anterolateral thigh flap had a
vascular pedicle with a branching perforator
that ran through the medial portion of vastus
lateralis muscle in approximately 87 percent of
all cases.13 Dissection of such a perforator was
facilitated by an “open roof” technique in
which the muscle above the perforator was
transected. This only included a minor part of
the vastus lateralis muscle, leading to no do-
nor-site morbidity as pointed out before by
others.7,13
In this study, total flap loss was seen once,
leading to a flap survival rate of 96 percent,
Contralateral Leg
SD Mean SD Z* p
12.5 131.8 13.4 –0.95 0.343
9.6 136.4 10.6 –2.45 0.014
0.6 4.7 0.5 –1.00 0.317
0.3 4.9 0.3 0.00 1.00
1082 PLASTIC AND RECONSTRUCTIVE SURGERY, April 1, 2005

FIG. 1. (Above, left) A 67-year-old man with a recurrent temporofrontal superficial spreading
basal cell carcinoma following a previous resection and local radiotherapy (case 9, Table I).
(Above, right) After radical tumor resection with exposed skull. (Below, left) Fasciocutaneous
anterolateral thigh flap in place. (Below, right) Follow-up view at 1 year 3 months shows a good
aesthetic result, with color mismatch of the flap, which the patient hides with makeup. Currently,
the color mismatch is treated with dermatography.

which is comparable to previously reported
rates varying from 95 to 98 percent.7,11,13,18
However, recipient-site complications leading
to reoperations occurred nine times (39 per-
cent) in the present study, which is consider-
ably higher in comparison with earlier reports
(13 to 23 percent).7,11,18 This high complication
rate may be explained by the poor general
condition of many patients in the current study
because of previous radiotherapy (12 cases),
previous major operations (16 patients), or lo-
cal tumor recurrence (eight cases). Further-
more, in many patients, extensive defects
(mean size, 108 cm2) with exposed bone, ex-
posed dura, open sinuses, orbital exenteration,
or a combination of these characteristics had
to be reconstructed, which in 10 cases even
necessitated a concomitant second free flap.
These kinds of defects have been associated
with an increased possibility of spinal fluid
Vol. 115, No. 4 / ANTEROLATERAL THIGH FLAP 1083

FIG. 2. (Above, left) A 70-year-old man with a recurrent frontal moderately differentiated
squamous cell carcinoma with orbital invasion following three previous resections without
radiotherapy (case 15, Table I). (Above, right) After radical tumor resection and orbital exen-
teration with exposed frontal bone, frontal sinus, and orbital cavity. (Below, left) Musculocuta-
neous anterolateral thigh flap in place. (Below, right) Five-month follow-up view after 70-Gy
radiotherapy shows a satisfactory aesthetic result. The shaded glasses hide the missing right eye.

leakage and ascending infections from ex-
posed paranasal sinuses.10 In our study, eight of
nine patients (one had a stroke) had an un-
eventful outcome after their reoperation.
During follow-up, flap color mismatch was
noted in as many as 71 percent of the patients.
Color mismatch resulted in skin color that was
either too light or too dark. This may well be
explained by the fact that all patients in the
current study were white Dutch patients with a
discrepancy in facial and upper leg skin color,
contrary to earlier reports in which most pa-
tients were Asians in whom this discrepancy is
reported to be less apparent.7,11,13,15 Further-
more, color mismatch was probably also re-
lated to radiotherapy, because nine of 10 pa-
tients with color mismatch had been
irradiated. Two other studies using the antero-
lateral thigh flap for head and neck reconstruc-
tion in a white population did not provide any
1084 PLASTIC AND RECONSTRUCTIVE SURGERY, April 1, 2005

FIG. 3. (Left) A 56-year-old man with a primary T4N2M0 moderately differentiated squamous cell carcinoma of the anterior
floor of the mouth with mandibular invasion and extensive involvement of the chin skin, for which en bloc tumor resection and
bilateral neck dissection were performed (case 10, Table I). A double-paddled fasciocutaneous anterolateral thigh flap was
designed to reconstruct the inner and outer lining, because no perforators to the fibula flap skin island were available. (Center)
After free fibula mandibular reconstruction with the anterolateral thigh flap in place showing the inner and outer lining
reconstruction. (Right) Follow-up view at 1 year 4 months after 70-Gy radiotherapy shows an excellent aesthetic result.

details on flap color mismatch.14,18 In contrast,
various skin-bearing flaps and skin-grafted mus-
cle flaps, with or without irradiation, have
problems with color match in the head and
neck area.19,20
Flap bulkiness (50 percent) was another
common objective aesthetic outcome at follow-
up. Interestingly, five of seven flaps that were
considered bulky were fasciocutaneous flaps.
Bulky flaps were thinned intraoperatively when
necessary and feasible. More vigorous flap thin-
ning as reported in recent literature may fur-
ther reduce flap bulk21; however, in a number
of patients, flap thinning was performed ag-
gressively, but still the thick thigh skin could
not be thinned sufficiently to match the miss-
ing thin facial skin. Alternatively, musculocuta-
neous or skin-grafted muscle flaps have been
reported to be too bulky before decreasing in
size.7,22 Because of muscle atrophy following
denervation, these flaps often shrink down to
end up with a contour defect and a skeleton-
like appearance.22 This characteristic makes
them perfect for the scalp region3,5 but, in our
experience, less favorable for the midface
region.
In all patients with speech problems (36 per-
cent), oral incontinence (21 percent), or eat-
ing problems (14 percent), either a consider-
able portion of the lip and oral commissure
was resected or an extra free osteocutaneous
fibula flap was used to reconstruct a segmental
composite mandibular defect. These results
corroborate the findings from a previous study
on reconstructing through-and-through cheek
defects involving the oral commissure showing
oral incontinence in 33 percent and eating
difficulties in 44 percent.15 In our opinion,
these findings indicate that the above-men-
tioned functional problems are more related
to the difficult area to be reconstructed, re-
gardless of the method of reconstruction, than
to a specific complication of the anterolateral
thigh flap.
Flap contracture (21 percent) only occurred
in the neck region and did not cause any func-
tional problems such as impaired neck dorsi-
flexion. Ideally, to prevent this complication,
the entire neck unit should be resurfaced,
which would require flap sizes up to 27 ⫻ 17
cm, making flap preexpansion necessary.23 In
our opinion, this is not a good option in most
oncology patients. Thus, flap contracture in
the neck area is more a specific problem for
this region than a complication specific for the
anterolateral thigh flap, especially when local
radiotherapy is given.
In the present study, the donor site was pri-
marily closed in only 22 percent of all cases,
compared with 56 to 97 percent in earlier stud-
ies.7,11,14,15,18 One explanation for this differ-
ence is that most flaps in the current study
Vol. 115, No. 4 / ANTEROLATERAL THIGH FLAP
were much wider than 8 cm, above which pri-
mary closure is usually impossible. Another ex-
planation for this difference is that in a num-
ber of flaps a rather proximal perforator was
chosen to be the most adequate for flap perfu-
sion. In these types of proximal anterolateral
thigh flaps, primary skin closure is even more
difficult because there is less excess skin com-
pared with the distal thigh. In the present
study, skin grafting of the upper leg sometimes
resulted in cold intolerance and a contour de-
fect. Currently, more attention is focused on
design of the anterolateral thigh flap and plan-
ning of remaining thigh skin transposition, so
that primary closure is more often possible.24,25
In contrast, skin flaps of these large dimensions
can only be harvested from the abdomen with-
out donor-site closure problems. In the group
of malnourished head and neck cancer pa-
tients, however, this is usually not a viable
option.
In accordance with other studies, sensory
disturbances of the upper leg were reported
quite often (86 percent)11,16; however, in the
current study, most patients did not seem to be
bothered by this. Except for a small clinically
insignificant decrease in average range of mo-
tion of the knee joint (from 136 degrees to 134
degrees), no statistically significant impair-
ment in range of motion of the hip joint or in
muscle strength of the hip and knee could be
found in the present study. These findings cor-
roborate the results from earlier studies on
donor-site morbidity following anterolateral
thigh flap harvesting,16,17 indicating that the
long-term morbidity of the donor site is very
low.
The anterolateral thigh donor site can only
be matched by the rectus abdominis musculo-
cutaneous flap donor site. Both donor sites
yield large skin areas, where abdominal skin
and subcutaneous tissue often are bulkier (ap-
proximately 14 mm) compared with the mod-
erately thick thigh skin and subcutaneous tis-
sue (approximately 7 mm).26 Thinning of the
anterolateral thigh flap can be performed reli-
ably27 but is not a safe option for abdominal
skin unless it is performed in multiple postop-
erative debulking procedures.7 The vastus late-
ralis and rectus abdominis offer a similar mus-
cle bulk, where all or part of the muscle can be
harvested.28,29 However, donor-site morbidity
after rectus abdominis muscle harvesting may
be significant, such as hernia development and
deterioration of pulmonary function in certain
1085
patients.29,30 In contrast, in accordance with the
present study, vastus lateralis muscle removal
has been described not to affect leg function,
because it is a synergist of the other three knee
extensors.7,13
CONCLUSIONS
Careful patient selection, taking into ac-
count the thickness of the thigh skin compared
with the facial skin in addition to the tissues to
be reconstructed, may further improve aes-
thetic outcome. We agree with Demirkan et al.7
that there is no ideal soft-tissue free flap in
head and neck reconstruction, as the defects in
this region can vary tremendously in composi-
tion and texture with short distances. Still, in
conclusion, the versatility in design and com-
position of the anterolateral thigh flap in com-
bination with the low donor-site morbidity and
satisfactory recipient-site outcome make it a
valuable option in reconstruction of external
skin defects in the head and neck region.
Stefan O. P. Hofer, M.D., Ph.D.
Department of Plastic and Reconstructive Surgery
Erasmus Medical Center Rotterdam
P.O. Box 2040
3000 CA Rotterdam, The Netherlands
sophofer@hotmail.com
ACKNOWLEDGMENT
This work was supported financially by the Foundation
“Vereniging Trustfonds Erasmus Universiteit Rotterdam,”
Rotterdam, The Netherlands.
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