Reconstruction surgery after head and neck cancer resection is always challenging.

The RFF and ALT are two types of free flaps frequently used for complex reconstruction; the decision about the appropriate flap should consider the restoration of integrity, form and function of the demolition site and it is crucial to obtain optimal long-term outcomes. Flap reliability and surgical technique also are two variable that should influence the reconstructive decision. One of the preferred flaps in the defects of small volume and great surface is the radial forearm flap; according to Valentini et al. [6], its thinness permits to achieve great outcomes when used as a thin intraoral lining flap for reconstruction of the floor of the mouth defects. However, since its introduction the ALT flap has become the preferred donor site for soft tissue reconstruction for several authors [7,8] thanks to its versatility and especially when more soft tissue bulk is needed. The purpose of this study is to present a single institution experience in comparing outcomes in terms of free-flap survival, complications and morbidity of the donor site after head and neck reconstruction with ALT or RFF flaps and to show how ALT flap has become the preferred one thanks to its versatility for soft tissue reconstruction. Nevertheless, the main limits of this study are the limited number of patients included and the unequal distribution of patients between the two groups.

First, directions to use one or the other flap to restore surgical gap could be different. As ALT can provide soft tissue with sufficient volume and versatile shapes, it should be used for relatively large defects; it has good pliability and can be designed as either a single skin paddle for one-layer defect reconstruction or double-skin paddles for full-thickness defects supported by one or multiple perforators. Radial forearm free flap has the advantages of thinness, pliability, reliability of survival and a long constant pedicle, but skin paddle is usually smaller.

Surgical harvesting technique is important to be considered. While RFF harvesting is relatively easy to perform, ALT dissection is more difficult, due primarily to the anatomy of the perforator originating from the descending branch of the lateral circumflex femoral artery. Studies have described the anatomical variability of this perforator vessel, but few reports have shown the absence of this perforator [9-11]. Nevertheless, the arterial vessel which is always accompanied by two veins has diameters that usually facilitates an easier microvascular anastomosis.

Allen test is a valid instrument to understand practicability of RFF since disposal of a major artery to the hand is another drawback of this flap. When abnormal clinical Allen test is obtained, a modified surgical Allen's test could be performed to assess collateral flow to the hand.

A sterile pulse oximeter is placed on one finger of the hand where flow must be evaluated and saturation is registered. Radial artery is surgically exposed and a vascular clamp is applied. After deflation of the tourniquet, hand and digit perfusion is assessed with return of color, turgor and saturation value. With normal collateral perfusion a radial forearm flap could be harvested.

On the other hand, doppler ultrasound could be used to localize the perforator vessel; it could help to perform a faster and safer muscular dissection and preparation of the ALT flap that in our hands could be harvested in about 90 minutes. Although this advantage, in our experience many times wasn’t possible to find correspondence between the vessels evidenced with ultrasound test and the ones found during surgical procedures. Doppler ultrasound certainly offers a valid support during surgical preparation, but it couldn’t be considered necessary.

Moreover, the anatomical variability of anterolateral thigh perforators doesn’t influence microsurgical outcomes in our experience. Shieh et al. [12] have classified the vascular variation of the ALT pedicle into four types based on the derived perforator and the direction in which it crossed the vastus lateralis muscle; In type 1 (vertical musculocutaneous perforator), the perforator is vertically derived from the descending branch of the lateral circumflex femoral artery. In type 2 (horizontal musculocutaneous perforator), the perforator is derived from the transverse branch of the lateral circumflex femoral artery and runs parallel with the vastus lateralis muscle. In type 3 (vertical septocutaneous perforator), the origin of the perforator is the descending branch of the lateral circumflex femoral artery. In type 4 (horizontal septocutaneous perforator), the perforator is derived from the transverse branch of the lateral circumflex femoral artery and runs parallel with the vastus lateralis muscle.

Furthermore, variability of ALT perforators vessels sometimes could be a benefit.

When large demolition surgery is performed, the resulting shape of the defect could not be favorable for the insetting of the flap and reconstruction with RFF couldn’t be possible. The possibility to harvest ALT flap with two or more perforators vessels permits to obtain a chimeric flap such as the one performed in our department to repair a large surgical defect in maxillary carcinoma in which mucosal and skin gap had to be replaced.

Results indicate versatility of the ALT flap also related to receiving site; in our experience different kind of reconstruction could be performed with this flap, from intraoral defects to large cranial defects also with dural exposition. Moreover, depending on the surgical gap that must be replaced, preoperatory programme could be changed during surgical procedure when ALT flap harvesting is performed. In fact, versatility of this flap permits the surgeon to decide dimensions and geometry of the flap expressed in length, width and thickness of the tissues in the operatory room. In our experience, surgical demolition programme could not always be respected due to differences between preoperatory radiological finding and intraoperative finding in oncological patient.

This versatility is an important advantage of ALT flap that could not be obtained with RFF harvesting that is especially indicated as a thin lining flap.

Results show that there’s no significant differences in terms of flap survival rates between RFF and ALT; approximately in line with the results achieved by Liu et al. [13], our study demonstrates that there was no flap failure.

Hospitalization expressed in terms of days, could be influenced by different variable, including operating time which is one of the most variable data. Depending on surgeon experience but mostly on demolition surgery, removal of a tumor could require more or less time determined by dimensions, localization and important structures proximity. However, from 6 to 19 days could be necessary; when approaching small tumors, localized in areas that do not require extra procedures, such as ventilatory support tracheotomy, few days of hospitalization are sufficient. Similar results could be reached when the patient is young and healthy.

Surgical treatment of a larger tumor, older patient or comorbidity are factors affecting days of hospital stay. In our experience longer hospitalization was necessary in two patients when systemic complications occurred, consisting in nosocomial pneumonia. One of these two patients got complicated with respiratory failure, but both patients had underlying systemic conditions which could facilitated development of complications. Otherwise, all patients of our study that submitted an oral cancer ablation immediately underwent a logopedic first evaluation and following controls to restore deglutition reflex and speech as soon as possible without consequences. A strict programme of prophylactic exercises and the teaching of swallowing maneuvers can reduce specific impairments, maintain functions and enable a faster recovery ensuring post-treatment rehabilitation. A restorative protocol should be targeted at specific physiological deficits and volitional control to compensate for changes of the anatomy and physiology of the body. This can reduce the risk of aspiration, malnutrition and improve quality of life of those patients. Logopedic figures, restorative dental surgeon and/or prosthetic technician should work closely together to get the best outcomes for patients.

One last determinant that our study consider is donor site morbidity. Although primary closure is usually achieved with the harvesting of anterolateral thigh flap, wound dehiscence was the most frequent complication that occurred in others despite of ten of eighteen patients that didn’t manifest morbidities. In these patients, a very large defect had to be corrected after demolition surgery.

In one case in which skin graft was harvested, its loss was registered; underlying systemic disorder and patient collaboration are two factors that should be considered when thinking about this solution. In other patients second intention healing was obtained without additional patient discomfort. Just in one case, a female patient manifested an infection of the donor-site 52 days after surgery. Debridement and surgical curettage in local anesthesia were performed and antibiotic intravenous therapy was administered.

In contrast, as observed by Yang et al. [14], primary repair of the donor site is not usually possible with radial forearm free flap harvesting and the scar cannot be easily hidden. Even though the use of an acellular dermal matrix (such as Hyalomatrixâ in our experience) in a forearm defect after radial forearm free flap harvesting can improve skin elasticity and moisture, it still leaves a conspicuous scar resulting in a painful wound and numbness that is visible on the forearm. Furthermore, split-thickness skin grafts from the forearm can result in restriction of range of motion of the interested arm and disability because dense scars form on the skin and graft tendon adhesions may develop.

Risk of exposing important structures, such as arm’s tendons and nerves has to be considered.

Moreover, the strategy implemented in our department provides for early mobilization of the patient in order to have a rapid recovery and a return to a good quality of life as soon as possible.

It also provides short hospitalization reducing risk of nosocomial infections.

Nevertheless, early mobilization of the patient could be counterproductive in term of wound healing of the donor site in case of ALT flap harvesting when a skin graft is required. While a radial forearm skin graft could be secured with a plaster cast and patient mobilization could start safer, inevitably an ALT skin graft suffers from movement and delayed healing occurs more easily.

Finally, something to keep in mind is donor site paresthesia. Due to its anatomical location, the medial branch of the lateral cutaneous nerve of the thigh can be injured or sacrificed during ALT flap elevation, or may be included to make the flap sensate, leading to lateral thigh paresthesia. When injured, different techniques could be suitable to restore the integrity of the nerve [15].

Therefore, depending on the setting, paresthesia may not be considered a complication as much as an anticipated consequence of surgery and donor site morbidity is not significant following an anterolateral thigh free flap.