Chimeric Free Flap for Reconstruction of a Challenging Neck Defect: A Case Report
Avelina I. Mario*
*Correspondence to: Avelina I. Mario, Division of Plastic and Reconstructive Surgery, University Hospital of Geneva and University of Geneva School of Medicine, Geneva, Switzerland.
Copyright.
© 2026 Avelina I. Mario, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 06 July 2026
Published: 01 August 2026
DOI: https://doi.org/10.5281/zenodo.21715110
Abstract
Introduction: Reconstruction of extensive head and neck defects is frequently constrained by prior oncological treatment, depletion of recipient vessels within a previously irradiated and dissected neck, and earlier harvest of regional and free flaps. When two distinct defects must be addressed simultaneously in a vessel-depleted neck, the available options are limited.
Case report: We report a 59-year-old man with multiply recurrent pharyngolaryngeal squamous cell carcinoma who required salvage total pharyngolaryngectomy with extensive resection of cervical skin and soft tissue. Reconstruction was performed with a chimeric anterolateral thigh (ALT) and tensor fasciae latae (TFL) free flap based on a single lateral circumflex femoral artery (LCFA) pedicle. The ALT component reconstructed the pharynx and the TFL component resurfaced the anterior neck and protected the carotid artery, using a single set of microanastomoses to the left facial artery and external jugular vein.
Conclusion: The chimeric ALT/TFL flap enabled reliable, functional reconstruction of two separate defects through a single donor site and a single vascular anastomosis, sparing the pectoralis major and avoiding a second free tissue transfer in a vessel-depleted neck.
Keywords: free flap; chimeric flap; pharyngolaryngectomy; neck reconstruction; anterolateral thigh flap.
Introduction
Advances in reconstructive surgery have expanded surgeons’ ability to achieve complete oncological clearance and thereby improve survival in patients with head and neck malignancy.[1]
Patient-related factors—previous treatment for head and neck cancer, vascular limitations within the irradiated and previously dissected neck, and prior harvest of regional and free flaps—can substantially restrict the reconstructive options available for an extensive neck defect.
We present a patient with multiply recurrent pharyngolaryngeal squamous cell carcinoma (SCC) and limited reconstructive options who required extensive salvage ablative surgery and was treated with a chimeric free flap.
Case Report
A 59-year-old man was treated with chemoradiation for a T2N2bM0 SCC of the right pyriform sinus. He subsequently developed a right-sided nodal recurrence, which was managed with salvage radical neck dissection. One year later, a metachronous T4aN0M0 glotto-subglottic laryngeal SCC was diagnosed. The tumour board recommended total laryngectomy with partial hypopharyngectomy, primary closure of the pharynx reinforced with a pedicled pectoralis major flap, and selective neck dissection on the left.
A pharyngocutaneous fistula developed three weeks after surgery. Definitive histology demonstrated positive anterior margins through the strap muscles and a second focus of SCC at the posterior left edge of the thyroid cartilage. Further salvage surgery was therefore required, comprising resection of a large patch of cervical skin and subcutaneous tissue (compromised by tumour infiltration, radiotherapy, and the fistula), of the underlying pectoralis major flap, and of the left thyroid lobe, together with completion of the hypopharyngeal resection.
The principal reconstructive challenges were the extent of the composite defect—pharynx, larynx, and a large defect of the neck soft tissues—and the vascular limitations of the neck following multiple ablative procedures and radiotherapy (Fig 1), compounded by extensive arteriosclerosis of the upper limb.
Reconstruction was performed with a chimeric free flap comprising an anterolateral thigh (ALT) flap and a tensor fasciae latae (TFL) flap sharing a common vascular pedicle arising from the LCFA. The flaps were raised from the right thigh along the iliopatellar line (Fig 2). In addition to the pre-measured skin paddle, a wider cuff of fascia lata was included in the subfascial dissection to allow a two-layered, watertight closure of the suture line, as described by Ho et al.2 The neopharynx thus created was secured to the prevertebral fascia. After division of the common pedicle trunk, which measured only 1 cm (Fig 3), the neck anastomoses were performed to the only remaining suitable vessels—the left facial artery and the left external jugular vein. The lumen of the tubed ALT was sutured proximally to the base of the tongue and distally to the cervical oesophagus (Fig 4). The TFL flap was used to reconstruct the anterior cervical skin defect, to cover the ALT anteriorly, and, by virtue of its bulk, to isolate and protect the right carotid artery. The thigh donor site was closed primarily.
Despite healing difficulties at the junction between the cervical skin and the TFL flap—managed with local dressings and daily hyperbaric oxygen therapy—and a revision of the lower anastomosis between the ALT and the cervical oesophagus on postoperative day 8, the final outcome was highly satisfactory in terms of both tissue integration and function. The reconstructed anterior neck healed with good colour match and contour (Fig 5). The patient was discharged six weeks after surgery. Exclusive oral feeding was permitted eight weeks after surgery, following a videofluoroscopic study that demonstrated no leakage and a satisfactory lumen of the pharyngeal reconstruction (Fig 6). The thigh donor site healed with a single linear scar (Fig 7). The patient was followed for two months by the reconstructive surgery team, with subsequent open-ended oncological surveillance by the otolaryngology service; the early follow-up was uneventful.
Discussion
Combined perforator flaps are broadly divided into conjoined and chimeric types. A chimeric perforator flap comprises multiple independent perforasomes, each supplied by its own perforator and connected to the others only through a common vascular source.[6]
In our patient, reconstruction of the pharynx and of the neck soft-tissue defect required two distinct tissue components. Advanced atherosclerosis precluded the use of either forearm flap. A jejunal free flap is a reliable and effective option for pharyngo-oesophageal reconstruction;[3,4] however, it is technically demanding, poorly tolerant of prolonged ischaemia owing to its high metabolic demand, and requires temporary parenteral feeding; moreover, it would not have addressed the neck soft-tissue defect, thereby necessitating more than one flap. The remaining pectoralis major could have been used, but it was deliberately preserved as a reliable regional option for salvage should the chosen reconstruction fail.
First described by Song et al in 1984,[7] the ALT flap has become increasingly popular and is our workhorse soft-tissue flap. Wei et al reported the largest series to date and confirmed its reliability.[5,8] The anatomy of the LCFA lends itself to chimeric flap design, a principle developed by Koshima and Hallock on the LCFA perforator system.[9,10] Our chimeric ALT/TFL flap was harvested from a single donor site without significant morbidity. A single pair of microvascular anastomoses allowed pharyngeal reconstruction with the ALT component and neck reconstruction with the TFL component, avoiding the need for two free flaps and two sets of anastomoses in a patient with limited recipient vessels. The donor site was closed primarily and the pectoralis major was preserved.
Potential indications should be limited to complex reconstructions requiring two flaps—for example, neopharyngeal or tongue reconstruction combined with a concomitant, significant soft-tissue defect. Our design avoided the technically demanding and time-consuming anastomosis of two separate pedicles, which was particularly advantageous given the vascular restrictions and the previous use of regional flaps. Selection of this flap demands considerable surgical expertise, as the harvest may be delicate and a failure could effectively result in the loss of two flaps in a patient with already limited reconstructive options.
Conclusion
The chimeric ALT/TFL flap is a valuable option when two separate defects require reconstruction in the head and neck, particularly when vascular limitations preclude multiple microanastomoses in the neck and when local and regional flap options are exhausted. In our patient, who had diffuse atherosclerosis and a history of radiotherapy and multiple ablative and reconstructive neck operations, it enabled a reliable, functional, and aesthetically acceptable reconstruction after total pharyngolaryngectomy and extensive resection of the neck soft tissues.
References