CLINICAL ARTICLE Head and neck soft tissue reconstruction with anterolateral thigh flaps with various components: Development of an algorithm for flap selection in different clinical scenarios Armando De Virgilio MD, PhD 1,2 | Oreste Iocca MD, DDS 1 | Pasquale Di Maio MD 3 | Luca Malvezzi MD 1 | Raul Pellini MD 4 | Giuseppe Mercante MD 1 | Giuseppe Spriano MD 1 1 Otorhinolaryngology - Head and Neck Surgery, Humanitas Clinical and Research Hospital-IRCCS, Rozzano (MI), Italy 2 Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI), Italy 3 Giovanni Borea Civil Hospital, Department of Otolaryngology-Head and Neck Surgery, Sanremo, Italy 4 Department of Otolaryngology-Head and Neck Surgery, Regina Elena National Cancer Institute, Rome, Italy Correspondence Armando De Virgilio, Otorhinolaryngology - Head and Neck surgery, Humanitas Clinical and Research Hospital-IRCCS, Viale Manzoni 56, Rozzano (MI), Italy. Email: armando.devirgilio@gmail.com Abstract Objectives: The antero-lateral thigh free flap (ALT) is conventionally designed as a fasciocutaneous flap (FALT). However, the thickness of the flap can be designed in at least in two more variants: myocutaneous (MYALT), and myofascial (MALT). The aim of this study was to evaluate the use of ALT flap as a universal solution for head and neck soft tissue reconstruction and development of an algorithm for flap selection in different clinical scenarios. Patients and methods: Forty patients, 29 males, 11 females, with mean age of 61.6 years (range 36–77) were enrolled. Thirty-three patients were affected by muco- sal squamous cell carcinoma (24 oral cavity, 8 larynx, 1 hypopharynx), four by cutaneous squamous cell carcinoma, two by sarcoma of the orbit, one by adenoid cystic carcinoma of the parotid gland. MALT was used for tongue reconstructions thicker than 2 cm. When vastus lateralis was not thick enough we used MYALT, which was used for bulky head and neck reconstruction requiring mucosa and/or skin. FALT was performed for oral and mucosal defects thinner than 2 cm. We performed 19 MYALT, 11 FALT, and 10 MALT. We proposed ALT reconstruction to all patients requiring soft tissue replace- ment, for this reason selection bias is excluded. Statistical analysis was conducted to ana- lyze any difference in defect size, flap volume, functional, and cosmetic results. Results: Overall mean follow-up was 18.9 months (range 3–48). Follow-up of single flaps was as follow: MALT 20.3 (range 3–48), MYALT 17.6 (range 4–45), FALT 19.1 (range 3–48), mean time of follow-up was not significant among the three groups (p .82). Mean size of the defect in cm 3 was 188.5 (range 25–495), Mean sizes of the defects were: tongue 177.7 (range 48–360), oral floor/check 128.3 (range 25–432), larynx hypopharynx 315.7 (range 184–495), and maxilla 232.0 (range 224–240). Mean volume difference was significantly different between oral floor defects and Received: 12 March 2019 Revised: 21 June 2019 Accepted: 28 June 2019 DOI: 10.1002/micr.30495 Microsurgery. 2019;1–8. wileyonlinelibrary.com/journal/micr © 2019 Wiley Periodicals, Inc. 1