Reconstruction of Complex Orofacial Defects: A Preliminary Experience with Composite Tissue Flaps Based on the Anterolateral Thigh Flap

Summary

This study details the synergistic combinations of the versatile anterolateral thigh flap with other flaps (pectoralis major, fibular, auricular, bilateral anterolateral thigh) for reconstructing extensive orofacial defects. We present a clinical framework that emphasizes anatomical design, surgical technique, and functional-aesthetic integration to facilitate reconstruction in severe cases.

Abstract

This study presents a systematic summary of composite tissue flap reconstruction strategies centered on the versatile anterolateral thigh (ALT) flap for complex orofacial defects. Through a retrospective analysis of 21 patients (mean age 56.4 years) at a single center, it details the rationale, surgical protocol, and outcomes of four synergistic flap combinations. These include: 1) ALT with pectoralis major myocutaneous flap for large oropharyngeal-cervical through-and-through defects; 2) ALT with fibular osteomyocutaneous flap for composite mandibular and soft tissue defects; 3) ALT with free auricular composite flap for combined large soft tissue and specialized subunit (e.g., alar rim) defects; and 4) double ALT flaps for extensive, three-dimensionally complex soft tissue defects. The procedural framework elaborates on precise indication selection, anatomical design based on perforator mapping, meticulous sequential flap harvest via standardized approaches, and key technical aspects of microvascular anastomosis. Representative results from the cohort demonstrated a 100% flap survival rate. Postoperative complications were manageable (9.5%), including one orocutaneous fistula and one donor-site seroma, neither compromising final outcomes. The findings establish a practical, individualized clinical framework that integrates reliable surgical techniques with functional-aesthetic goals, offering a practical and adaptable approach for the precise reconstruction of severe, multifaceted orofacial defects.

Introduction

With the advancement of microvascular anastomosis techniques, free flap transplantation has become a critical method for reconstructing oral and maxillofacial defects^1,2. Among various free flap options, the anterolateral thigh (ALT) flap has emerged as a commonly used choice for head and neck reconstruction due to its notable anatomical and functional advantages³.

The advantages of this flap are mainly reflected in the following aspects: first, it provides ample soft tissue volume and can be flexibly prepared as a muscle island to fill dead space or as a fat....

Protocol

A retrospective study was conducted involving 21 patients with complex maxillofacial defects who underwent reconstruction at the Second Xiangya Hospital of Central South University from January 2005 to December 2025. All patients received simultaneous reconstruction using the anterolateral thigh free flap as the primary component, combined with additional flap types. The study protocol received approval from the Ethics Committee of the Second Xiangya Hospital of Central South University (Approval No. 2020030), and written consent for publication of clinical photographs was obtained from all participants

1. Preoperativ....

Results

Study participants and flap selection
This study included 21 male patients with composite tissue defects resulting from radical resection of oral and maxillofacial tumors. The mean age was 56.4 years (range: 48–65 years). The reconstructive strategy employed personalized combinations of flaps based on the defect's location, extent, and functional requirements: 14 patients underwent reconstruction with a fibular osteomyocutaneous flap combined with an anterolateral thigh (ALT) flap for simultaneous ma.......

Discussion

In this study, the consecutive use of multiple flaps centered around the ALT flap is presented as a set of reproducible technical strategies rather than a comparative clinical series. The representative cases illustrate how these configurations can be applied across different defect patterns, emphasizing procedural feasibility, flap integration, and reconstructive flexibility rather than comparative outcome superiority.

Versatility of the anterolateral thigh flap as a reconstructive co.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
curved scissors	Shuanglu Medical	SL0014	used for sharp dissection of soft tissues
curved hemostat	Shuanglu Medical	SL0006	used for grasping and clamping larger vessels and tissue bundles.
curved mosquito hemostat	Shuanglu Medical	SL002S	used for precise clamping of delicate vessels and hemostasis in confined spaces.
cefperazone-Sulbactam	Harbin Pharmaceutical Group Co., Ltd	H19980085	used for perioperative antimicrobial prophylaxis to prevent surgical site infection.
doppler ultrasound	Bestman	BV-520T	used for preoperative perforator mapping and postoperative flap perfusion assessment.
low molecular heparin	Nanjing King-Friend	H20153092	used for  anticoagulation prophylaxis to prevent thrombosis.
micro forceps	Jinzhong surgical instrument	WCC010	used for handling delicate vessels and nerves during microsurgery.
micro needle Holders	Jinzhong surgical instrument	WBA350	used for performing microvascular anastomosis with fine sutures.
micro scissors	Jinzhong surgical instrument	WA1030	used for microvascular dissection and trimming of vessels ends.
micro sutures	Johnson	W2777	used for performing microvascular arterial and venous anastomoses.
needle holders	Shuanglu Medical	SL0035	used for suturing soft tissues and wound closure.
oscillating saw or piezoelectric system	Aesculap	GD670	used for performing precise bone osteotomies
scalpel handle	Shuanglu Medical	SL0075	used for making skin and tissue incisions.
surgical drain	Bainus	A-100	used for postoperative fluid evacuation
suture	Ethicon	VCP311H	used for soft tissue approximation and wound closure.
temperature monitoring probe	Med-linket	W0004LS	used for continuous postoperative monitoring of flap skin temperature.
tissue retractor	Jinzhong surgical instrument	J50130	used for exposure of the surgical field and tissue retraction.
titanium reconstruction plates and screws	Biomet Microfixation	44-1018	used for bridging and rigid fixation of mandibular used for performing precise bone osteotomies.
vascular clamps	KingSung Medical	KCMASB	used for temporary occlusion of vessels during anastomosis.