Alternate Soft-Tissue Free Flaps for Head and Neck Reconstruction: The Next Generation of Workhorse Flaps

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This retrospective single-surgeon study evaluated “alternate” soft-tissue free flaps for head and neck reconstruction when standard workhorse flaps such as the radial forearm free flap or anterolateral thigh flap were not suitable. Over 10 years, 155 patients underwent 156 free flaps: 60 ulnar artery perforator (UAP), 28 lateral arm perforator (LAP), 33 medial sural artery perforator (MSAP), and 35 profunda artery perforator (PAP) flaps.<br /><br />The most common indications were tongue, oral cavity, parotid, pharyngeal, and facial defects, often after cancer resection. Overall flap success was high, with only two total flap losses (one LAP and one MSAP), and several threatened flaps were salvaged. Donor-site complications were generally limited and usually healed with conservative care, though they included partial skin graft loss after UAP harvest, delayed wound healing or compartment syndrome after MSAP harvest, temporary radial nerve palsy after LAP harvest, and delayed wound healing after PAP harvest.<br /><br />Each flap had practical strengths and limitations:<br />- UAP: thin, pliable, can be sensate, useful when slightly more bulk than a radial forearm flap is needed; caution near the ulnar nerve and rare anatomic variants.<br />- MSAP: useful for thin oral defects and often avoids a skin graft, but has the most variable anatomy and cannot reliably be made sensate.<br />- LAP: provides intermediate thickness and can be sensate; however, pedicle length is shorter and radial nerve injury is a concern.<br />- PAP: reliable thigh-based option when ALT is unsuitable; provides more bulk, longer pedicle, and can be chimeric, but donor-site closure and vessel caliber require attention.<br /><br />The authors conclude that these four flaps represent a reliable “next generation” of workhorse options and should be part of the reconstructive microsurgeon’s armamentarium for complex head and neck defects.

Keywords

head and neck reconstruction

free flap

ulnar artery perforator

lateral arm perforator

medial sural artery perforator

profunda artery perforator

microsurgery

donor-site complications

oral cavity defects

cancer resection