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

Background: There is little debate regarding the workhorse flaps for soft-tissue defects in head and neck reconstruction. However, in certain circumstances, the workhorse flaps are not available or suitable, and an alternate flap is needed. Methods: The author performed a retrospective review of a single-surgeon experience with alternate soft-tissue flaps performed over a 10-year period. Results: Overall, 156 alternate soft-tissue free flaps were performed in 155 patients. The distribution of free flaps was 60 ulnar artery perforator (UAP), 28 lateral arm perforator (LAP), 33 medial sural artery perforator (MSAP), and 35 profunda artery perforator (PAP) flaps, with one patient receiving two PAP flaps. Defects included glossectomy, facial defects following parotidectomy or resection of cutaneous malignancies, and other intraoral defects. Eleven patients had donor-site complications: two patients with UAP flap with partial skin graft loss, two patients with delayed wound healing in the MSAP donor-site group and one who developed compartment syndrome with primary closure of the MSAP donor site, one patient with a radial nerve palsy following an LAP flap, and six patients with delayed wound healing in the PAP donor site, which healed secondarily with conservative management. There was one total flap loss each of an LAP and MSAP flap. Conclusion: Reconstructive microsurgeons performing high-volume head and neck reconstruction may need to incorporate alternate donor sites into their armamentarium when the primary workhorse flaps are not suitable or available. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.