title: Sandwich Fascial Anterolateral Thigh Flap in Head and Neck Reconstruction: Evolution or Revolution?
abstract: BACKGROUND
  The anterolateral thigh perforator flap (ALT) represents the workhorse for most reconstructive efforts in the head and neck regions. The main advantages of this flap are its versatility, the length of the pedicle, and the low morbidity of the donor site. The major drawback is the bulkiness of this flap with the frequent need for secondary revisions. To overcome this, we have developed a novel way to harvest and inset the ALT, called the sandwich fascial ALT flap (SALT).
  
  
  METHODS
  All patients undergoing head and neck reconstruction using the SALT flap from January 2013 to March 2016 were included in this retrospective analysis. The SALT flap was harvested as a composite flap including the superficial fascia, the subscarpal fat, and the deep fascia. At the recipient site, the flap was inset with the deep fascia facing out. A split thickness skin graft (± dermal substitute) was used to cover the deep fascia and the pedicle.
  
  
  RESULTS
  Eleven patients were included: 8 cases of orbital exenteration, 1 case of forehead reconstruction, and 2 cases of palatal reconstruction after radical maxillectomy. Flap survival was 100%. One patient required an early take back for venous thrombosis. The reconstruction was effective in all cases, allowing a prosthetic rehabilitation when required. Donor-site morbidity was minimal.
  
  
  CONCLUSIONS
  The reconstruction of head and neck defects with a bulky fasciocutaneous ALT flap might not be the best option in every case. The SALT flap could represent a valid alternative for selected cases, with encouraging functional and cosmetic outcomes.
authors.affiliation: Division of Plastic and Reconstructive Surgery (M.C., F.M., M.C., F.T., E.M., L.V.) and Head and Neck Surgery & Forensic Dissection Research Center (M.C., M.T.-Z., P.B., P.C., L.V.), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy; Division of Plastic & Reconstructive Surgery, Transgender Health Program, Oregon Health & Science University, Portland, Oregon (J.B.); and Division of Otorhinolaryngology - Head & Neck Surgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy (M.T.-Z., P.B., P.C.).
authors.forename: Mario
authors.initials: M
authors.lastname: Cherubino
authors.affiliation: Division of Plastic and Reconstructive Surgery (M.C., F.M., M.C., F.T., E.M., L.V.) and Head and Neck Surgery & Forensic Dissection Research Center (M.C., M.T.-Z., P.B., P.C., L.V.), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy; Division of Plastic & Reconstructive Surgery, Transgender Health Program, Oregon Health & Science University, Portland, Oregon (J.B.); and Division of Otorhinolaryngology - Head & Neck Surgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy (M.T.-Z., P.B., P.C.).
authors.forename: Jens
authors.initials: J
authors.lastname: Berli
authors.affiliation: Division of Plastic and Reconstructive Surgery (M.C., F.M., M.C., F.T., E.M., L.V.) and Head and Neck Surgery & Forensic Dissection Research Center (M.C., M.T.-Z., P.B., P.C., L.V.), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy; Division of Plastic & Reconstructive Surgery, Transgender Health Program, Oregon Health & Science University, Portland, Oregon (J.B.); and Division of Otorhinolaryngology - Head & Neck Surgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy (M.T.-Z., P.B., P.C.).
authors.forename: Mario
authors.initials: M
authors.lastname: Turri-Zanoni
authors.affiliation: Division of Plastic and Reconstructive Surgery (M.C., F.M., M.C., F.T., E.M., L.V.) and Head and Neck Surgery & Forensic Dissection Research Center (M.C., M.T.-Z., P.B., P.C., L.V.), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy; Division of Plastic & Reconstructive Surgery, Transgender Health Program, Oregon Health & Science University, Portland, Oregon (J.B.); and Division of Otorhinolaryngology - Head & Neck Surgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy (M.T.-Z., P.B., P.C.).
authors.forename: Paolo
authors.initials: P
authors.lastname: Battaglia
authors.affiliation: Division of Plastic and Reconstructive Surgery (M.C., F.M., M.C., F.T., E.M., L.V.) and Head and Neck Surgery & Forensic Dissection Research Center (M.C., M.T.-Z., P.B., P.C., L.V.), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy; Division of Plastic & Reconstructive Surgery, Transgender Health Program, Oregon Health & Science University, Portland, Oregon (J.B.); and Division of Otorhinolaryngology - Head & Neck Surgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy (M.T.-Z., P.B., P.C.).
authors.forename: Francesca
authors.initials: F
authors.lastname: Maggiulli
authors.affiliation: Division of Plastic and Reconstructive Surgery (M.C., F.M., M.C., F.T., E.M., L.V.) and Head and Neck Surgery & Forensic Dissection Research Center (M.C., M.T.-Z., P.B., P.C., L.V.), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy; Division of Plastic & Reconstructive Surgery, Transgender Health Program, Oregon Health & Science University, Portland, Oregon (J.B.); and Division of Otorhinolaryngology - Head & Neck Surgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy (M.T.-Z., P.B., P.C.).
authors.forename: Martina
authors.initials: M
authors.lastname: Corno
authors.affiliation: Division of Plastic and Reconstructive Surgery (M.C., F.M., M.C., F.T., E.M., L.V.) and Head and Neck Surgery & Forensic Dissection Research Center (M.C., M.T.-Z., P.B., P.C., L.V.), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy; Division of Plastic & Reconstructive Surgery, Transgender Health Program, Oregon Health & Science University, Portland, Oregon (J.B.); and Division of Otorhinolaryngology - Head & Neck Surgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy (M.T.-Z., P.B., P.C.).
authors.forename: Federico
authors.initials: F
authors.lastname: Tamborini
authors.affiliation: Division of Plastic and Reconstructive Surgery (M.C., F.M., M.C., F.T., E.M., L.V.) and Head and Neck Surgery & Forensic Dissection Research Center (M.C., M.T.-Z., P.B., P.C., L.V.), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy; Division of Plastic & Reconstructive Surgery, Transgender Health Program, Oregon Health & Science University, Portland, Oregon (J.B.); and Division of Otorhinolaryngology - Head & Neck Surgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy (M.T.-Z., P.B., P.C.).
authors.forename: Edoardo
authors.initials: E
authors.lastname: Montrasio
authors.affiliation: Division of Plastic and Reconstructive Surgery (M.C., F.M., M.C., F.T., E.M., L.V.) and Head and Neck Surgery & Forensic Dissection Research Center (M.C., M.T.-Z., P.B., P.C., L.V.), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy; Division of Plastic & Reconstructive Surgery, Transgender Health Program, Oregon Health & Science University, Portland, Oregon (J.B.); and Division of Otorhinolaryngology - Head & Neck Surgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy (M.T.-Z., P.B., P.C.).
authors.forename: Paolo
authors.initials: P
authors.lastname: Castelnuovo
authors.affiliation: Division of Plastic and Reconstructive Surgery (M.C., F.M., M.C., F.T., E.M., L.V.) and Head and Neck Surgery & Forensic Dissection Research Center (M.C., M.T.-Z., P.B., P.C., L.V.), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy; Division of Plastic & Reconstructive Surgery, Transgender Health Program, Oregon Health & Science University, Portland, Oregon (J.B.); and Division of Otorhinolaryngology - Head & Neck Surgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy (M.T.-Z., P.B., P.C.).
authors.forename: Luigi
authors.initials: L
authors.lastname: Valdatta