Original Research
Otolaryngology–
Head and Neck Reconstruction with
Chimeric Anterolateral Thigh Free Flap:
Indications, Outcomes, and Technical
Considerations
Bradley R. Lawson, MD1, and Mauricio A. Moreno, MD1
No sponsorships or competing interests have been disclosed for this article.
Abstract
Objective. Chimeric anterolateral thigh free flaps are com-
posed of multiple skin paddles or muscular components that
allow for the reconstruction of complex 3-dimensional
defects. We present our experience with the technique and
applications for various head and neck defects.
Study Design. Retrospective chart review.
Setting. Academic tertiary care center.
Subjects and Methods. Subjects include 24 consecutive patients
undergoing reconstruction with a chimeric anterolateral thigh
free flap by a single surgeon. Our algorithm for pharyngeal
reconstruction with this technique is described. Data include
demographics, indications, comorbidities, operative findings,
and surgical outcomes.
Results. The most frequent defects were pharyngocutaneous
(n = 12, 50%) and skull base (n = 6, 25%). The flap consisted
of a double skin paddle in 11 cases (45.3%) and a skin paddle
with an independent component of vastus lateralis muscle in
13 cases (54.7%). Revision surgery was required in 4 cases and
was associated with malnutrition (P = .022). There were no
total flap losses, but partial loss (distal skin paddle in all the
cases) was observed in 3 patients and was related to severe
congestive heart failure (P = .021) and malnutrition (P = .021).
All except 1 patient who underwent pharyngeal reconstruction
resumed oral diet and achieved alaryngeal speech.
Conclusion. Chimeric anterolateral thigh free flaps represent
an excellent option for reconstruction of complex head and
neck defects. Modifications to the technique are proposed
in patients at high risk of surgical complications.
Keywords
anterolateral thigh, free flap, chimeric, laryngectomy, vastus
lateralis, multiple skin paddle, flow-through, microvascular,
speech, outcomes
Received February 25, 2015; revised July 17, 2015; accepted August 26,
2015.
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Head and Neck Surgery
1–7
Ó American Academy of
Otolaryngology—Head and Neck
Surgery Foundation 2015
Reprints and permission:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/0194599815606438
http://otojournal.org
T
he anterolateral thigh (ALT) free flap has become a
common reconstructive technique for complex head
and neck defects.1 The versatility of the ALT free flap
has been praised since its initial description, with cutaneous,
fasciocutaneous, musculocutaneous, chimeric, and flow-
through flaps all possible on the basis of an individual
patient’s reconstructive needs.2 The ALT free flap’s anatomic
reliability and ideal characteristics for soft tissue reconstruction
have been supported by a large case series.3 In regard to upper
aerodigestive tract reconstruction, the ALT free flap has been
shown to provide superior durability to the radial forearm free
flap as well as better swallowing outcomes and reduced hospi-
tal costs as compared with the jejunal free flap.4,5
The chimeric ALT free flap technique was first described
in detail by Hallock.6 The technique involves designing 2 inde-
pendent flaps that are based on a common arterial blood
supply, and it is routinely utilized in cases of extensive 3-
dimensional defects, commonly involving a cutaneous and
mucosal surface. At our institution, we have routinely used the
chimeric ALT free flap since 2009 and developed an algorithm
for reconstruction of pharyngocutaneous defects with this tech-
nique, which is herein presented. This algorithm attempts to
systematize the intraoperative decision-making process based
on the anatomic variations found in the donor site.
Previous studies have documented the use of the chimeric
ALT free flap technique for reconstruction of specific compo-
site head and neck defects, such as skull base, through-and-
through cheek, and laryngopharyngeal defects.4,5,7-9 However,
to the best of our knowledge, no single study has described
outcomes of this technique encompassing all the clinical indi-
cations throughout the head and neck region or attempted to
identify clinical outcome predictors. As such, the relationship
1
Department of Otolaryngology–Head and Neck Surgery, University of
Arkansas for Medical Sciences, Little Rock, Arkansas, USA
This article was presented at the 2014 AAO-HNSF Annual Meeting & OTO
EXPO; September 21-24, 2014; Orlando, Florida.
Corresponding Author:
Mauricio A. Moreno, MD, Associate Professor, Department of
Otolaryngology–Head and Neck Surgery, University of Arkansas for
Medical Sciences, 4301 W Markham St, Slot 543, Little Rock, AR 72205,
USA.
Email: mamoreno@uams.edu
2 Otolaryngology–Head and Neck Surgery
Figure 1. Diagrammatic representation of chimeric anterolateral thigh free flaps. DB, descending branch; LCFA, lateral circumflex femoral
artery; Per, cutaneous perforators; SP, skin paddle; VL, segment of vastus lateralis muscle.
between comorbidities and outcomes in patients who undergo
reconstruction with this technique has not yet been investi-
gated. We sought to describe our results, particularly regarding
the use of the algorithm for pharyngolaryngeal reconstruction,
and to identify patient- and technique-related factors that may
predict surgical outcomes in this population.
Methods
The study was approved by the Institutional Review Board of
the University of Arkansas for Medical Sciences. The pro-
spectively collected departmental database was queried to
identify 24 consecutive patients who underwent reconstruc-
tion with a chimeric ALT free flap for a head and neck
defect between August 2009 and March 2014. All cases were
performed by the senior author (M.A.M.), and no cases were
excluded from the series. The information retrieved from the
medical records included demographics, surgical indications,
smoking status, comorbidities, radiation exposure, surgical
data, flap outcomes, length of hospital stay, and postoperative
complications. Functional data points included pain control,
discharge disposition, and time to resuming unrestricted oral
diet. Operative report descriptions and intraoperative photo-
graphy were reviewed to document the location and extent of
the defect, along with flap composition and size.
Statistical analysis was performed with SPSS Statistics
(version 22; IBM Corporation, Armonk, New York). All
analyses were univariate, and end points included flap loss,
revision surgery, length of hospital stay, and length of inten-
sive care unit stay. Fisher’s test was used to determine asso-
ciation between categorical variables, while correlation
between continuous variables was assessed with Student’s t
test. Statistical significance was defined at P \ .05.
Relevant Anatomy and Surgical Technique
The blood supply to the skin of the lateral thigh is provided by
perforators that typically arise from the descending branch of
the lateral circumflex femoral artery (LCFA). Depending on
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their relationship with the vastus lateralis muscle, these per-
forators may be either septo- or musculocutaneous. In nearly
80% of patients, 2 perforating vessels are identified during
the initial dissection.10 This anatomic configuration allows the
surgeon to harvest 2 independent cutaneous or fascial compo-
nents, each based on its respective perforator. After giving
origin to the perforators, the LCFA travels distally in the
septum between the vastus lateralis and vastus intermedius
muscles, giving origin to multiple branches that supply these
muscles. The distal aspect of the vastus lateralis can be har-
vested as an independent muscular component based on the
main trunk or a major branch of the LCFA, distal to the emer-
gence of the cutaneous perforators. The basic anatomic config-
uration of chimeric ALT free flaps is shown in Figure 1.
From the technique standpoint, the first step in harvesting
a chimeric ALT free flap is to explore the intermuscular
septum between the rectus femoris and vastus lateralis mus-
cles,11 which on surface anatomy corresponds to the line
between the anterior superior iliac spine and the superolat-
eral aspect of the patella. The incision is generally per-
formed medial to this line—over the rectus femoris
muscle—followed by subfascial dissection laterally to iden-
tify the cutaneous perforators. Alternatively, we have
described a video-assisted, minimally invasive technique for
the purpose of perforator identification in this initial
phase.12 Once identified, the perforators are dissected
through the intermuscular septum to their origin in the
LCFA, and their location is marked on the skin with the
purpose of designing the cutaneous component(s). In cases
where a muscular component is required, the descending
branch of the LCFA is dissected distal to origin of the
lowest perforator identified and used as the vascular supply
for a variable segment of vastus lateralis muscle.
Algorithm for Pharyngocutaneous Reconstruction
The reconstruction of pharyngocutaneous defects presents a
unique challenge to the reconstructive surgeon. In addition
Lawson and Moreno
Figure 2. Algorithm for reconstruction of pharyngocutaneous defects based on intraoperative anatomic findings.
Figure 3. Pharyngeal reconstruction with partially tubularized
anterolateral thigh skin paddle.
to concerns for tissue coverage, care must be paid to the
patient’s ability to regain swallowing function postoperatively,
a critical aspect in patients previously exposed to radiation or
those in whom adjuvant therapy is anticipated. The chimeric
ALT free flap is an excellent reconstructive option in these
cases, as it allows addressing the pharyngeal and cutaneous
defects with a single flap. However, the inherent anatomic
variability of the perforator anatomy may present a significant
challenge, particularly if the intraoperative findings are differ-
ent than expected. We present an algorithm that attempts to
systematize the reconstructive options with this flap, based on
the vascular anatomic findings (Figure 2).
A double skin paddle chimeric ALT free flap probably
represents the ideal configuration to address these defects. In
this scenario, 1 of the skin paddles is tubularized—either
fully or partially—to reconstruct the pharyngeal defect
(Figure 3), while the distal paddle is used to address the
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3
Figure 4. Resurfacing of extensive cutaneous defect with second-
ary anterolateral thigh skin paddle.
neck defect, as shown in Figure 4 and Appendix 1 (at www
.otojournal.org/supplemental). Unfortunately, this approach is
feasible only when 2 perforators are present and share the
same vascular origin, which is not the case in at least 20% of
the patients. A chimeric ALT free flap is still an option as
long as 1 perforator from the LCFA is present. In this case, a
skin paddle with a muscular component from the vastus later-
alis is harvested; the skin paddle is used for pharyngeal
reconstruction, while the muscular component is used to
cover the cutaneous defect and subsequently skin grafted
(Appendices 2 and 3). Alternatively, in the event that the
identified perforators do not share the same vascular origin, 2
skin paddles can still be harvested; then, 1 is anastomosed to
the distal stump of the descending branch of the LCFA as a
4 Otolaryngology–Head and Neck Surgery

Table 1. Surgical Defect Location and Relative Frequencies (N =

24).
Surgical Defect n %

Pharyngocutaneous (total) 12 50
Partial pharyngeal defect 6 25
Circumferential pharyngeal defect 6 25
Lateral skull base 5 20.8
Anterior skull base 2 8.3
Orbitomaxillary 2 8.3
Oral cavity (through and through) 3 12.6

Figure 5. Flow-through perforator-based anterolateral thigh flap.
The arrows depict the location of the arterial and venous anasto-
mosis on the distal stump of the descending branch of the lateral
circumflex femoral artery.
flow-through flap (Figure 5; Appendix 4). Finally, if no per-
forators are identified, no configuration would allow for a
single-flap pharyngocutaneous reconstruction, and the con-
tralateral thigh should be promptly explored.
For purposes of analysis, all 12 patients undergoing phar-
yngocutaneous reconstruction in this series were initially
planned for a double skin paddle chimeric ALT free flap.
The surgical plan was modified according to the intraopera-
tive findings of the perforator anatomy as previously
described.
At our institution, patients undergoing free flap recon-
struction of pharyngeal defects typically maintain strict nil
per os for 2 to 3 weeks, followed by a formal videofluoro-
scopic swallowing study to determine if they can resume
oral diet. Aggressive swallowing therapy encouraging oral
diet is initiated at this stage, regardless of the use of adju-
vant therapy. Alaryngeal voice rehabilitation with electrolar-
ynx is initiated within the first 2 weeks of surgery by
speech-language pathologists who will continue to follow
these patients. Potential candidates for tracheoesophageal
puncture (TEP) are assessed on the basis of their oncologic
status, speech-language pathologist evaluation, and socioe-
conomic factors. When performed, TEP is usually delayed
at least 3 months postoperatively to reduce the risk of
complications.
Results
A total of 24 patients were included in the study group; the
cohort was predominantly male (87.5%); and the mean age
was 57 years, with a range of 27 to 80 years. The most
common surgical indication was recurrent cancer, represent-
ing two-thirds of the cases (n = 16). Twelve patients (50%)
had a prior history of radiation therapy to the head and neck
region. The location of the surgical defects is presented in
Table 1. Pharyngocutaneous defects were the most common,
followed by skull base defects.
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Table 2. Frequency of Medical Comorbidities (N = 24).
Diagnosis n %
Hypertension 13 54.7
Active smoker 6 25
Coronary artery disease 4 16.7
Chronic obstructive pulmonary disease 4 16.7
Diabetes mellitus 3 12.5
Severe congestive heart failure 1 4.2
Severe malnutrition 1 4.2
Active deep vein thrombosis 1 4.2
The most prevalent comorbidities were hypertension,
coronary artery disease, and chronic obstructive pulmonary
disease, as summarized in Table 2. One patient had active
deep vein thrombosis and was receiving enoxaparin therapy
at the time of surgery. One patient had severe congestive
heart failure requiring volume restriction. Three patients had
type II diabetes mellitus treated with oral medications
alone; 1 of these was poorly controlled, with a blood glu-
cose .250 mg/dL on the day of surgery. One patient had
severe malnutrition with a measured serum albumin of 2.2
g/dL on postoperative day 1.
The chimeric ALT free flap was designed with double
skin paddles in 11 cases (45.3%) and a skin paddle with an
independent muscular component in 13 cases (54.7%). The
mean area of the primary skin paddle was 62.2 cm2 (range,
31-143 cm2). When used, the secondary skin paddle had a
mean area of 29.5 cm2 (range, 6-29 cm2). In cases where a
segment of the vastus lateralis was harvested, the mean area
of the muscle component was 44.6 cm2 (range, 20-150
cm2). The donor site was closed primarily in all but 2
patients (8.3%), and there were no significant functional
deficits at 3 weeks postoperatively.
Microvascular revision surgery was required in 3 cases,
which included an arterial revision in 2 patients and a revi-
sion of the arterial and venous microanastomosis in a third
case. A fourth patient presented with venous congestion
from an early pedicle torsion that was resolved without
Lawson and Moreno
Table 3. Speech and Swallowing Outcomes in Patients Undergoing Pharyngocutaneous Reconstruction.
Case Type of Defect Flap Designa
1 Partial pharyngectomy 1 skin Double
2 Partial pharyngectomy 1 skin Muscle
3 Partial pharyngectomy 1 skin Double
4 Partial pharyngectomy 1 skin Flow-through
5 Partial pharyngectomy 1 skin Double
6 Total pharyngectomy 1 skin Flow-though
7 Total glossopharyngectomy 1 skin Muscle
8 Total pharyngectomy 1 skin Double
9 Total pharyngectomy 1 skin Muscle
10 Partial pharyngectomy 1 skin Double
11 Partial pharyngectomy 1 skin Double
12 Partial pharyngectomy 1 skin Muscle
a
Double, chimeric anterolateral thigh with double skin paddle; flow-through, double skin paddle as flow-through free flap; muscle, chimeric anterolateral thigh
with a single skin paddle and muscular component with skin graft.
b
As assessed postoperatively by speech-language pathologist.
revising the anastomosis, while 2 additional patients were
reoperated for facial hematoma and flap reinsetting, respec-
tively. The presence of severe malnutrition was the only
predictor for microvascular revision surgery (P = .022).
There were no total flap losses in the series; however, par-
tial loss of the secondary skin paddle was observed in 3 cases
and was statistically associated with severe congestive heart
failure (P = .021) and severe malnutrition (P = .021). Of
these 3 patients, only 1 developed a fistula—orocutaneous in
that case—which was clinically apparent only after the flap
loss.
A single-flap reconstruction was successfully performed in
all 12 patients with pharyngocutaneous defects with the
assistance of the selection algorithm. A double skin paddle
flap was considered in all of these cases, but the perforator
anatomy—2 or more cutaneous perforators from a single
vascular pedicle—allowed it in only 50% of the patients (n =
6). In 2 cases, there were 2 cutaneous perforators originat-
ing from different vascular origins; in these cases, a flow-
through flap was successfully performed. In the remaining 4
cases (33%), the initial exploration of the thigh revealed only
a single cutaneous perforator, which was used to harvest a
skin paddle. As previously described, the skin paddle was
either partially or completely tubularized and used for recon-
struction of the pharyngeal defect, while a segment of the
vastus lateralis muscle with skin graft was used for resurfa-
cing of the neck. There were no cases of a negative explora-
tion requiring an alternative donor site in this series.
Two-thirds of the pharyngeal reconstruction patients (n =
8) returned to an oral diet within 3 weeks, and one quarter
(n = 3) resumed oral diet between 3 and 14 weeks post-
operatively. One patient with total glossectomy and laryngo-
pharyngectomy was unable to resume oral diet and became
gastrostomy tube dependent. Overall, patients treated the
proposed reconstructive algorithm had a 91.6% success rate
in achieving oral diet, with a mean realimentation time of
28 days.
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5
Postoperative Swallowing Function Postoperative Speech Outcomeb
Regular diet, 2 wk Tracheoesophageal speech 80% intelligible
Gastrostomy tube dependent Electrolarynx 90% intelligible
Regular diet, 3 mo Electrolarynx 75% intelligible
Regular diet, 2 wk Electrolarynx 75% intelligible
Full liquids, 2 wk Tracheoesophageal speech 100% intelligible
Regular diet, 2 wk Electrolarynx 90% intelligible
Pureed diet, 3 wk Nonverbal, refused electrolarynx
Regular diet, 2 wk Tracheoesophageal speech 100% intelligible
Regular diet, 2 wk Electrolarynx 80% intelligible
Regular diet, 3 wk Electrolarynx 100% intelligible
Pureed diet, 14 wk Electrolarynx 100% intelligible
Mechanical soft diet, 2 wk Electrolarynx 90% intelligible
Ninety-two percent of patients undergoing pharyngocuta-
neous reconstruction achieved alaryngeal speech postopera-
tively (n = 11). Eight of these patients (72%) did so with
the use of an electrolarynx, while 3 of them successfully
underwent secondary TEP. One patient employed nonverbal
communication postoperatively due to refusal of electrolar-
ynx use. A detailed description of the swallowing and
speech outcomes is presented in Table 3.
Overall, 4 of 24 patients (16%) presented with a post-
operative fistula, 1 orocutaneous and 3 pharyngocuta-
neous. The orocutaneous fistula was observed in a patient
with an extensive maxillocutaneous defect and required
reoperative management with secondary advancement
closure. Pharyngocutaneous fistula was observed in 3
patients on postoperative videofluoroscopic examination
(2 cases of partial pharyngectomy and 1 case of circum-
ferential pharyngectomy), and it was conservatively man-
aged in all 3 cases. Overall, none of the clinical variables
assessed reached statistical significance for either phar-
yngo- or orocutaneous fistula formation.
The mean length of hospital stay for the cohort was 9.5
days and was higher, though not statistically significant, in
patients with upper aerodigestive tract defects (P = .051).
The mean length of intensive care unit stay was 4.7 days
and also was not associated with any of the tested variables
(Table 4).
Discussion
This series demonstrates the versatility of the chimeric ALT
free flap for the reconstruction of complex 3-dimensional
defects of the head and neck. The clinical and functional
outcomes obtained with this technique are comparable to
those of the standard ALT free flap in head and neck recon-
struction.13 The chimeric ALT free flap offers a decisive
advantage when compared with the use of other free flaps
in terms of donor site complications. A pectoralis major or
deltopectoral flap is often used in conjunction with a radial
6 Otolaryngology–Head and Neck Surgery
Table 4. Clinical Predictors for Length of Stay: Hospital and
Intensive Care Unit.
Length of Stay, P Valuesa
Surgical Variable Hospital Intensive Care Unit
Double skin paddle .442 .465
Upper aerodigestive tract .051 .347
Recurrent disease .086 .080
Smoking status .395 .363
Through and through defect .165 .199
Preoperative radiation .690 .899
a
Student’s t test.
forearm or jejunal free flap for pharyngocutaneous defects,
whereas the chimeric ALT free flap allows for pharyngeal
reconstruction and skin resurfacing without the additional
morbidity from a second donor site.14 For skull base defects
requiring large flaps, the donor thigh is often skin grafted.
Skin grafting the ALT site is less disfiguring than grafting
the rectus abdominis myocutaneous free flap donor site and
provides more reliable graft take than that of the latissimus
dorsi myocutaneous free flap donor site.8 In our experience,
the ALT donor site can be consistently closed primarily
with defects up to 10 cm wide and requires donor site graft-
ing in \10% of the cases.
Ninety-two percent of patients in this series who underwent
pharyngeal reconstruction tolerated an oral diet without the
need for a feeding tube. With two-thirds of these patients
receiving clearance for an oral diet within 3 weeks of surgery,
the return to swallowing function was quite rapid in consider-
ation of the extensive nature of the surgical defects. Our results
compare favorably with previous series investigating the
reconstruction of pharyngeal defects with the ALT free flap,
with reports of postoperative feeding tube dependence ranging
from 9% to 33%.4,13,15,16 In terms of voice rehabilitation, all
patients except 1 were able to achieve intelligible alaryngeal
speech, predominantly with the use of electrolarynx. By
reviewing the swallowing outcomes (Table 3), it is possible to
infer that most of them could have been potential TEP candi-
dates. Unfortunately, the costs and commitments associated
with this rehabilitation option still represent significant barriers
for our patient population, and only a relatively small fraction
(27%) ultimately underwent this procedure. All of them, how-
ever, were able to achieve fluent and highly intelligible tra-
cheoesophageal speech. Overall, our voice rehabilitation
outcomes are comparable to those achieved with the standard
ALT free flap as well as the radial forearm flap.13,17,18
In this cohort, there were no total flap losses but a signifi-
cant (12.5%) incidence of partial flap loss, which exclusively
affected the secondary skin paddle. Similar incidences of par-
tial failure have been reported in previous series.4,13 While this
is probably multifactorial, we believe that the vascular anat-
omy of the thigh and its perforator system plays a major role
in its genesis. It is well established that the diameter of the
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cutaneous perforators tends to decrease as they are located
more distally on the leg; furthermore, perforators in the distal
thigh are commonly musculocutaneous, thus increasing the
chances for vascular injury during the necessary intramuscular
dissection. The longer vascular pedicle of these distal paddles
also carries an inherent risk of kinking and torsion. It is worth
noting that all the partial losses were observed in patients
undergoing reconstruction of aerodigestive tract defects. It is
possible to theorize that contamination-related thrombosis due
to the nature of the defect and potential subclinical fistulazion
may play a role in these adverse outcomes.
Our data suggest that several baseline comorbidities, such as
severe malnutrition and severe congestive heart failure, may
have a role as outcome predictors in patients undergoing recon-
struction with this technique. These findings are consistent with
the available evidence, which has identified the presence of mal-
nutrition with worse outcomes and increased need for repeat
operations in head and neck reconstructive surgery.19,20 While
preoperative optimization of such comorbidities is certainly indi-
cated, in many cases surgery may not be delayed without nega-
tively affecting the patient’s long-term oncologic outcome.
Since all of our partial flap losses affected the secondary skin
paddle, we hypothesize that harvesting a chimeric muscular
component may be indicated in patients considered at high risk
for partial flap loss. Our data also suggest—without demonstrat-
ing statistical significance—that patients with upper aerodiges-
tive tract defects have longer hospital stays, which we believe is
consistent with the higher acuity associated with these types of
lesions and the increased risk of infection of procedures within
a contaminated surgical environment.
Conclusions
The chimeric ALT free flap represents an excellent technique
for the reconstruction of complex defects of the head and
neck, particularly through-and-through defects of the upper
aerodigestive tract. The proposed algorithm for reconstruction
of pharyngocutaneous defects allows for a systematic approach
to these complex defects and yields satisfactory functional
results with a single-flap approach. Since partial flap loss was
observed only in the secondary skin paddle, a second muscle
component may be indicated in the presence of risk factors
such as malnutrition and congestive heart disease.
Author Contributions
Bradley R. Lawson, conception and design, drafting and critical
revision, final approval, accountability for work; Mauricio A.
Moreno, conception and design, drafting and critical revision,
final approval, accountability for work.
Disclosures
Competing interests: None.
Sponsorships: None.
Funding source: None.
Supplemental Material
Additional supporting information may be found at http://otojournal
.org/supplemental.
Lawson and Moreno 7

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