Purpose: To evaluate the protective and aesthetic benefits of augmenting the neck with a de-epithelialized portion of the anterolateral thigh (ALT) free flap designed to resurface intraoral defects.

Methods: In this prospective study, two groups of 30 patients each with intraoral carcinoma were selected matched for age and extent of ablative surgery. Group I patients underwent augmentation of the neck with a de-epithelialized portion of the ALT in addition to restoring intraoral lining. Patients of Group II underwent reconstruction of the intraoral defect only. Early postoperative results and long-term appearance was evaluated and compared. Results: In Group I, the average size of the ALT flap harvested was 7.5 by 21 cms of which 47% was de-epithelialized and used to cover skeletonized vessels of the neck. The postoperative recovery was unremarkable for 28 patients. Two re-explorations were undertaken resulting overall with one partial flap failure and one (3.3%) orocutaneous fistula. In Group II, the average ALT flap size was shorter, however there were three re-explorations, resulting in 1 partial failure, and 4 (13%) orocutaneous fistulas. In both groups, there were no carotid arterial blowouts, and during an average follow-up period of 10 months no cancer recurrence. On final analysis, the aesthetic quality of the augmented necks of patients in Group I was universally superior to those in Group II. There were no donor site complications recorded given that primary closure was possible in all. Discussion: The ablative effort in management of intraoral carcinoma presents a multifaceted challenge to the reconstructive surgeon. In addition to restoration of intraoral lining, protection of neck vessels and aesthetic restoration of the neck should be considered. Prevention of potentially disastrous complications such as orocutaneous fistulas or carotid artery blow-out should be under prime consideration when selecting a reconstructive method. As one of our most versatile soft-tissue flaps, the ALT allows for providing enough length with minimal expense. By providing a well-vascularized buttress to the suture line, this method reduced the rate of fistulas in our series. Furthermore, the sunken-in appearance that follows neck dissection and irradiation was not apparent in the augmented group. Conclusion: When the extirpation of intraoral carcinoma involves neck dissection, a single ALT free flap can reconstruct both the intraoral defect as well as augment the neck, which may reduce the rates of complications associated with neck dissection.