Advancing Education, Research, and Quality of Care for the Head and Neck oncology patient.
Introduction: The anterolateral thigh (ALT) flap has been amongst the most versatile components of the reconstructive surgeon’s armamentarium for laryngectomy defects. Many harvest techniques have been described in the literature; however, few studies compare various harvest techniques to clinical outcomes following total laryngectomy reconstruction. The objective of our study is to 1) characterize the rate of postoperative salivary leak and return to the operating room for management and 2) prospectively determine patient-reported leg functional outcomes of four distinct ALT flaps: perforator-based fasciocutaneous ALT flap, perforator-based chimeric fasciocutaneous ALT with pedicled vastus lateralis muscle, myofasciocutaneous ALT flap, and myofascial ALT flap.
Methods: A single institution retrospective chart review was performed of patients who underwent total laryngectomy with partial or complete pharyngectomy and anterolateral thigh microvascular free flap reconstruction between 2019 and 2024. We collected data on age, gender, history of pre-operative radiation, type of pharyngeal reconstruction (primary closure with vascularized on-lay reconstruction, patch reconstruction, tubed reconstruction), incidence of postoperative salivary leak, and return to the operating room for the management of salivary leak. For a subset of these patients based on flap type, we prospectively collected donor site-specific functional outcomes at least six months following surgery using a modified version of the validated lower extremity functional scale. Patients answered five Likert scale questions about persistent donor-site pain, numbness/tingling, leg weakness and interference with daily activities, and wound-related complications. Statistical analysis was performed using SPSS version 27 (IBM Corp., Armonk, NY, USA). The chi-square test was used to compare categorical variables.
Results: A total of 81 patients were included in the study group; the cohort was predominantly male (85.2%); and the mean age was 63 years, with a range of 37 to 85 years. The most common type of pharyngeal reconstruction included patched reconstruction (56.8%), followed by primary closure with vascularized on-lay (27.2%) and tubed reconstruction (16%). History of pre-operative radiation (P=0.735) and type of pharyngeal reconstruction (P=0.292) were not associated with a postoperative salivary leak. There were no differences in the type of ALT flap harvested and rates of postoperative salivary leaks (P=0.168) or return to the operating room to manage the salivary leak (P=0.719). There were no differences in six-month donor site morbidity, including pain, numbness/tingling, leg weakness, or wound healing complications when stratified by type of ALT (P>0.05) based on preliminary subgroup analysis.
Conclusion: Although there were no differences in clinical and donor-site functional outcomes based on flap type, it is essential to understand the advantages and disadvantages of each flap type based on the total laryngectomy defect. The perforator-based chimeric fasciocutaneous ALT with pedicled vastus lateralis flap is increasingly utilized in the reconstructive paradigm of laryngeal reconstruction as it negates the need for tenuous intramuscular perforator dissection and confers the flexibility to reconstruct large composite defects. Further exploration is necessary to understand the implications of ALT flap type on patient-reported donor site morbidity.