The anterolateral thigh flap has numerous advantages in head and neck reconstruction, including versatility, good tissue coverage, and relative ease of elevation. However, it has not yet come into widespread use, especially in North America, due to the anatomic variations of its perforators and possible donor site morbidity. In addition, donor site morbidity (decreased range of motion, cutaneous anesthesia) is more common if the donor site is closed with a skin graft. We describe a method of preoperative assessment to determine beforehand if the donor site can be closed primarily or with a skin graft based on the patient’s thigh size and anticipated oncologic defect. Furthermore, we describe our experience with the anterolateral thigh free flap and its advantages over other flaps classically used for head and neck reconstruction. Eleven anterolateral thigh flaps were transferred for eleven patients from September 1999 to May 2001. Resections were performed for a variety of head and neck tumors including squamous cell carcinomas of the maxilla, mandible, tongue, buccal mucosa, floor of mouth, oropharynx, ewing’s sarcoma of the infratemporal fossa, and liposarcoma of the temporal region and infratemporal fossa. Patient age ranged from 12-81, with an average of 57. Nine men and 3 women were included in the study. Defect size ranged from 8x5 cm to 16x12 cm, with an average of 10x11 cm. All operations were performed by the same surgeons in a tertiary care medical center. Six of the donor sites were closed primarily while five required skin grafts. The defect size did not correlate with the method of closure selected, but was determined at the time of operation. Preliminary findings suggest that thigh circumference may be a better predictor for primary closure versus skin grafting. We believe this is relevant preoperative information since donor site morbidity is related to closure by skin grafts.