Anterolateral Thigh Perforator Flap in Palatal Reconstruction

Palatal defects requiring free tissue transfer are usually secondary to tumor ablation, trauma, or complicated palatal fistulas following unsuccessful cleft palate repair. Numerous recent reports have described the successful use of the radial forearm flap to reconstruct these complicated defects. The donor defect of the radial forearm flap has been criticized, however, for both functional and aesthetic reasons, particularly in the younger patient population. The author has used the anterolateral thigh perforator flap in four patients over the past 3 years for successful soft tissue reconstruction of the palate.

Four patients had attempted reconstruction of their palatal defects using this flap. Their ages ranged from 14 to 46 years and they were evenly divided between males and females. One patient had a large defect following surgery and radiation therapy for a squamous cell cancer; two patients had persistent fistulas following cleft palate repair despite multiple prior procedures; and one patient had a post-traumatic palatal defect. One of the cleft palate patients had undergone a previous attempt at reconstruction with a radial forearm flap that failed and refused use of the other wrist as she was very unhappy with the donor defect. Three flaps successfully addressed the reconstructive goals. One patient was re-explored the evening of surgery and lost the tip of the flap secondary to insetting that was too tight, but the persistent palatal fistula was closed. A second patient became agitated and combative on the second postoperative night, which was believed to contribute to venous occlusion and flap failure (the flap was very difficult to see secondary to ankylosed TM joints). This flap had been raised on a small, short perforator that may have contributed to the failed reconstruction. There were no donor site complications and each of the patients preferred a leg scar that could be hidden to a scar and skin graft on the forearm.

The anterolateral thigh perforator flap is an ideal flap in thin patients for palatal and intraoral reconstruction. A large amount of tissue can be transferred based on a lengthy and reliable pedicle, and the donor site is less morbid and less conspicuous than the radial forearm flap donor site. Patients with palatal defects who have undergone multiple prior operations and scarring require careful preoperative planning and adequate pedicle length to avoid tension and the risk of flap failure.