title: Reconstruction of complex total parotidectomy defects using the free anterolateral thigh flap: a classification system and algorithm.
abstract: BACKGROUND
  Composite defects resulting from total parotidectomy present unique reconstructive challenges. This study reviews our experience using the anterolateral thigh (ALT) flap with adjacent fascia and nerve grafts to reconstruct these defects, and establishes a classification system and treatment algorithm that simplifies reconstruction.
  
  
  METHODS
  Between July 2005 and November 2009, 22 patients underwent total parotidectomy and immediate reconstruction with the extended ALT flap. Of total, 21 patients had concomitant neck dissection. Defects were classified as follows: Type I, significant soft-tissue loss (n = 4); Type II, significant soft-tissue loss with facial nerve excision (n = 2); Type III, significant soft-tissue loss with resection of surrounding bone(s) (n = 5); and Type IV, significant soft-tissue loss, bone resection, and facial nerve excision (n = 11). Reconstruction procedures included free ALT (n = 9); ALT with fascia lata sling (n = 4); ALT with nerve grafting (n = 5); and ALT, fascia lata sling, and nerve grafting (n = 4). Complications, functional outcome, and patient satisfaction were assessed by chart review and prospective surveys.
  
  
  RESULTS
  Fourteen of 22 patients participated in surveys. There was 1 flap loss. Donor site complications included the following: 4 patients (29%) with minor numbness of the lateral thigh skin, and 1 (7%) seroma. There was no leg weakness or infection. Recipient site morbidity included 2 patients (14%) with Frey syndrome, 3 (21%) with delayed wound healing, 5 (36%) with facial numbness, and 5 with mild oral incompetence. Smile asymmetry was present in 7 patients (50%). Ten patients (71%) reported being "very happy" with their appearance.
  
  
  CONCLUSIONS
  The ALT flap, used with adjacent nerve and fascia, offers a versatile option for reconstructing complex parotidectomy defects. The procedure involves minimal donor site morbidity, and results in sound functional outcomes and high degrees of patient satisfaction.
authors.affiliation: Division of Plastic Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA.
authors.forename: River M
authors.initials: RM
authors.lastname: Elliott
authors.forename: Gregory S
authors.initials: GS
authors.lastname: Weinstein
authors.forename: David W
authors.initials: DW
authors.lastname: Low
authors.forename: Liza C
authors.initials: LC
authors.lastname: Wu
mesh_terms: D000328:Adult; D000368:Aged; D000465:Algorithms; D015331:Cohort Studies; D004954:Esthetics; D000071938:Fasciotomy; D005260:Female; D005500:Follow-Up Studies; D058752:Free Tissue Flaps / Q000098:blood supply*; D006084:Graft Rejection; D006085:Graft Survival; D006801:Humans; D008297:Male; D008875:Middle Aged; D037981:Neck Dissection; D010306:Parotid Gland / Q000601:surgery*; D010307:Parotid Neoplasms / Q000473:pathology / Q000601:surgery*; D017060:Patient Satisfaction; D019651:Plastic Surgery Procedures / Q000009:adverse effects / Q000145:classification* / Q000379:methods*; D012189:Retrospective Studies; D018570:Risk Assessment; D013848:Thigh / Q000601:surgery; D020858:Tissue and Organ Harvesting; D016896:Treatment Outcome; D014945:Wound Healing / Q000502:physiology