The anterolateral thigh (ALT) flap has never gained popularity in the United States due to the variations of vascular anatomy and thick thigh fat in Westerners. To address these issues, ten ALT free flaps were performed for head and neck reconstruction: seven for tongue and three for temporal-orbital-maxillary reconstruction. The mean age was 60 ± 12 years with body mass index of 26.4 ± 4.9. A perforator near the midpoint between the anterior superior iliac spine and superolateral patella (perforator B) was present in all the cases; all but one of the perforators were musculocutaneous. A more distal perforator (perforator C) was present in eight cases, which was musculocutaneous in each case, while a more proximal one (perforator A) was present in five cases with three being septocutaneous. The average pedicle length to the perforator A was 9.8 ± 1.5 cm, while that to the perforator B was 13.4 ± 2.5 cm. The average thickness of the flap at the level of the perforator B was 16.3 ± 3.9 mm (range 10 to 22 mm). The lateral femoral cutaneous nerve was included as a sensate flap in four patients. Complications included one case of venous congestion, which was salvaged via re-exploration, and one small contained leak, which healed spontaneously. It was concluded that the ALT flap is well suited for head and neck reconstruction. The advantages of this flap include minimal donor-site morbidity, great pedicle length and size, possible sensory reinnervation, retaining of bulk with minimal atrophy, and easy simultaneous two-team approach. Unlike with abdominal fat, the thickness of the ALT flap remains relatively constant in patients having a wide range of body habitus. The relatively thick thigh fat in Westerners is actually advantageous for head and neck reconstruction, especially for near total glossectomy defects where bulk is needed.
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