The Evolutionary Trajectory of the ALT Flap in Nasal Reconstruction: A Literature Review and Clinical Experience

IntroductionReconstruction of complex nasal defects involves restoring external skin, internal lining, and support within a 3D framework. While the forehead flap is considered the gold standard, free tissue transfer is used when local tissues are unavailable. Historically, the radial forearm flap (RFF) was favored for its thinness and pliability. The anterolateral thigh (ALT) flap, once limited by bulkiness, has been refined. This study examines the evolution and current role of the ALT flap in the nasal reconstruction algorithm.MethodsA sequence of patients with nasal defects received reconstruction with a free ALT flap. Additionally, a targeted literature review was performed to explore recent advances in perforator dissection, flap thinning, and chimeric design relevant to nasal reconstruction. The study assessed flap configuration, thinning techniques, structural repair, complications, and long-term results.ResultsEighteen flaps were performed: twelve for nasal reconstruction and six for adjacent facial subunits. Five patients required total nasal reconstruction. The mean flap thickness decreased from 24.6 ± 5.5 mm to 5.7 ± 2.4 mm after combined primary and microdissection thinning, a 77% reduction. Chimeric and multi-paddle configurations enabled simultaneous restoration of skin, lining, and composite defects. Flaps were viable with no partial necrosis. Long-term follow-up over 1 to 8 years demonstrated stable airway function and maintained satisfactory contour.ConclusionsThe ALT flap has evolved from a secondary reconstructive option to a refined material for complex nasal defects. Advances in perforator-based thinning and hybrid designs have expanded its use, making it a viable alternative to traditional forearm reconstruction in some patients.