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Anterolateral Thigh (ALT) Flap

The anterolateral thigh (ALT) flap is one of the most versatile flaps in reconstructive surgery, serving as a pedicled or free fasciocutaneous, myocutaneous, or composite flap based on the lateral circumflex femoral artery (LCFA) system.[1][2] In urologic and urogynecologic practice, the ALT is used for phalloplasty, perineal / pelvic reconstruction after oncologic resection, vulvovaginal reconstruction, Fournier's gangrene coverage, and complex genital defect repair — offering a large, reliable skin paddle with a hidden donor-site scar and minimal functional morbidity.[2][3][4]

This page is the foundations-level deep dive on the ALT as a cross-application reconstructive flap. Site-specific technique pages — phalloplasty, perineal reconstruction, GAS — link back here.

Vascular Anatomy and Flap Design​

The ALT is based on perforators from the descending branch of the lateral circumflex femoral artery (LCFA-db), which courses in the intermuscular septum between the rectus femoris and vastus lateralis muscles.[5][6][7]

Perforator anatomy​

Lee 2015 classified 110 ALT flaps and identified 16 distinct vascular patterns:[6]

  • Single perforator 18.2%; double 53.6%; triple 28.2%
  • Origin from the descending branch alone in 69.1%, transverse branch in 9.1%, both in 21.8%
  • Most common pattern (36.4%) was double perforators "B and C" from the descending branch

Perforator types. Musculocutaneous perforators (traversing the vastus lateralis) predominate in the descending branch (77%), while the transverse branch offers more septocutaneous (41.2%) and direct cutaneous (51.5%) perforators — making harvest technically easier and faster.[5]

Pedicle characteristics​

ParameterDetail
Pedicle length9–15 cm (among the longest of any flap)
Artery diameter~2–3 mm
Practical implicationAllows the flap to reach the perineum, pelvis, and contralateral groin as a pedicled flap without microsurgical anastomosis[2][4]

Flap configurations​

ConfigurationCompositionBest for
ALT fasciocutaneous (ALT-FC)Skin + subcutaneous tissueSkin resurfacing; thinnest option[2][3]
ALT myocutaneous (ALT-MC)+ cuff of vastus lateralisModerate pelvic dead space[3]
Vastus lateralis myocutaneous (VL-MC)+ entire vastus lateralisMaximum bulk for large pelvic defects[3]
Composite ALT+ fascia lata, motor nerve (n. to VL), or sensory nerve (LFCN)Structural reconstruction (fascia lata), functional muscle, or sensate skin paddle[2]
Split ALTSkin paddle split into two islands on separate perforatorsComplex 3D defects, bilateral vulvar defects from a single flap[8]

Application 1 — Phalloplasty​

The pedicled ALT is the principal alternative to the radial forearm free flap (RFFF) for total phallic reconstruction, offering a hidden donor-site scar as its primary advantage.

Technique​

The ALT is typically used as a pedicled flap for phalloplasty, avoiding microsurgical anastomosis. The flap is harvested from the ipsilateral thigh and tunneled to the perineum. The principal challenge is urethral reconstruction, since the ALT's thickness usually precludes the tube-in-tube design that works well with the thinner RFFF.[9][10]

Urethral-reconstruction strategies in ALT phalloplasty​

D'Arpa 2019 — the largest single-center series (93 ALT phalloplasties, 13 years) — systematically evaluated different urethral-reconstruction approaches:[9]

Urethral techniquenUrethral complication rateNotes
Tube-in-tube ALT520%Feasible only in thin patients (5.8% of cases)
Prelaminated ALT + skin graft887.5%High stricture rate — second-choice option
ALT + free RFFF urethra2937.9%Reliable but requires microsurgery
ALT + pedicled SCIP flap urethra3826.3%Best complication profile; no microsurgery needed
ALT + skin from prior phalloplasty616.7%Lowest rate; uses existing penile skin

Tube-in-tube was possible in only 5.8% of cases because of flap thickness. The SCIP flap emerged as the preferred urethral-reconstruction method, with the lowest complication rate among de novo techniques. After revision procedures, 91.9% of patients achieved standing micturition.

Staged skin-graft urethroplasty​

Robinson 2023 — 24 patients with a three-stage approach (Stage I single-tube pedicled ALT; Stage II vaginectomy + urethral plate construction with STSG; Stage III urethral tubularization):[11]

  • 87.5% achieved standing micturition
  • Urethrocutaneous fistulae 33.3%, strictures 20.8%

Wu 2022 — 49 patients (micropenis, trauma, iatrogenic)​

Urethral techniques: tube-in-tube (6), SCIP (26), pudendal-thigh (11), scrotal flap (6). Complication rates: tube-in-tube 66.7%, SCIP 46.2%, pudendal-thigh 38.5%, scrotal 50%. After revision, all patients could urinate while standing.[12]

ALT + RFFF double flap​

van der Sluis 2017 — 19 patients with one-stage pedicled ALT (shaft) + RFFF (urethra). Median follow-up 35 months: 2 total RFFF failures, 1 total ALT failure. Long-term urinary complications in 53% (9 strictures). Advantage: less conspicuous forearm scar (smaller RFFF used only for urethra).[13]

ALT vs. RFFF — head-to-head comparisons​

StudynFlap survival (ALT vs. RFFF)Urethral complicationsKey differences
Ascha 2018[14]213 (64 ALT, 149 RFFF)92.2% vs. 96.6%32.8% vs. 31.5% (similar)ALT: higher fistula (OR 2.50, p = 0.024), wound dehiscence (OR 5.03, p = 0.026), nonurethral complications (OR 2.38, p = 0.027)
Netshiongolwe 2025[15]769 (155 pALT, 614 RFFF)99.4% vs. 98.1% (p = 0.348)—Satisfaction similar (76.2% vs. 78%, NS); ALT shorter OR time (290 vs. 516 min)
Wang 2026[16]57 (10 ALT, 25 RFFF, 22 abdominal)—ALT 40% / RFFF 60% / abdominal 32%RFFF highest overall complications (80%); ALT intermediate (60%); abdominal lowest (40.9%, p = 0.023)

The Netshiongolwe SR concluded: "The RFF remains the most reliable technique for phalloplasty, with the pALT serving as a secondary option when the RFF is not feasible."

When to choose ALT over RFFF​

  • Patient strongly desires a hidden donor-site scar (thigh vs. conspicuous forearm)
  • Thin forearm with high risk of penile-prosthesis extrusion through thin RFFF tissue
  • Need for additional bulk (e.g., bladder-exstrophy patients with deficient pubic tissue)
  • Microsurgical expertise unavailable (pedicled ALT avoids microsurgery)
  • Inadequate forearm vasculature (abnormal Allen test)[10][17]

Bladder exstrophy​

Harris 2021 — 11 patients (8 classic exstrophy, 3 cloacal): 5 pedicled ALT, 6 RFFF; all flaps survived. One mortality from acute pulmonary embolism (ALT group). 4 of 4 surviving ALT patients required ≥ 1 debulking procedure. RFFF preferred when feasible; ALT acceptable when forearm is overly thin.[17]

Application 2 — Perineal and Pelvic Reconstruction​

The ALT is an established option for perineal reconstruction after APR, ELAPE, and pelvic exenteration, particularly when the rectus abdominis is unavailable (prior laparotomy, stomas, abdominal-wall compromise).

ALT vs. VRAM​

  • Pang 2014 — 19 consecutive patients (10 ALT, 9 VRAM): no significant differences in infection, hematoma, bleeding, necrosis, or LOS (mean LOS ALT 9.7 vs. VRAM 13.4 days, NS). ALT is an "acceptable alternative" to VRAM.[18]
  • Galbraith 2023 — 122 patients (40 APR, 70 exenteration); 64 received flap closure (VRAM 22, gluteal 21, thigh including ALT and gracilis 19). Infection rates lower in the flap group despite higher RT rates (p < 0.05).[19]

Transabdominal-pelvic-perineal (TAPP) ALT flap — di Summa 2016​

A novel technique for anteroposterior pelvic defects after extended APR + sacrectomy:[20]

  • ALT + vastus lateralis delivered transabdominally through the pelvis to the perineum
  • 6 patients with high-grade tumors invading perineum, pelvis, and sacrum
  • 1 partial flap necrosis; no fistulas or perineal hernias
  • No significant flap atrophy on serial CT volumetric analysis
  • The fascia lata component supports the pelvic floor

Free ALT for intrapelvic reconstruction — Wong & Sbitany 2020​

For 4 patients after APR for rectal cancer, all with prior surgery / stomas precluding VRAM. Recipient vessels: deep inferior epigastric artery and vein. 100% flap survival; used for dead-space obliteration and posterior vaginal-wall reconstruction. The authors proposed updating Cordeiro's vaginal-reconstruction algorithm to include free ALT for type IB defects when rectus is unavailable.[21]

Algorithmic approach — Zelken 2016​

22 patients with lower abdominal, perineal, and groin defects (5 ALT-FC, 8 ALT-MC, 9 VL-MC):[3]

  • All flaps survived; venous congestion in 3 VL-MC (mechanical cause)
  • Proposed algorithm: ALT-FC for skin-only defects; ALT-MC for moderate dead space; VL-MC for large pelvic dead space

Combined ALT + lotus petal — Contedini 2015​

Pedicled ALT for pelvic dead-space obliteration combined with bilateral lotus petal flaps for perineal skin coverage — a complementary strategy after pelvic exenteration.[22]

Application 3 — Vulvar Reconstruction​

Gentileschi 2017 — the most focused series on ALT for vulvar cancer reconstruction (15 patients, 16 pedicled ALT flaps):[4]

  • Flap size 12 × 8 cm to 22 × 15 cm; pedicle length 9–15 cm
  • Vastus lateralis included in 2 cases for dead space after pelvic exenteration
  • No flap necrosis; 3 partial wound dehiscences (healed with dressings)
  • Global performance and pain scores improved postoperatively
  • Authors concluded that ALT should be a first-line option for complex vulvar cancer defects given reliability, versatility, long pedicle outside the radiotherapy field, and low donor-site morbidity

Split ALT for bilateral vulvar defects (Filobbos 2012) — first description of splitting the ALT skin paddle into two islands on separate perforators to reconstruct bilateral vulvar defects from a single flap.[8]

In the broader vulvar reconstruction algorithm, the ALT is reserved for large or complex defects that exceed local fasciocutaneous flaps (lotus petal, V-Y advancement) and when the gracilis provides insufficient skin coverage.[4][23]

Application 4 — Fournier's Gangrene​

The ALT is among the most commonly utilized regional flaps for Fournier's gangrene reconstruction per the 2026 SR (619 patients, 625 flaps).[24]

  • Lin 2016 — 10 patients with large perineoscrotal defects (72–198 cm²); pedicled ALT perforator flaps. All survived; one hematoma; natural scrotal contour.[25]
  • Scaglioni 2017 — massive perineoscrotal + medial-thigh defect (27 × 30 cm) reconstructed with bilateral pedicled ALT (30 × 9 cm) + bilateral sartorius muscle flaps; complete survival, no recipient or donor-site morbidity at 6 months.[26]
  • Guiotto 2020 — first reported case of penile suspensory-ligament reconstruction using a composite ALT with vascularized fascia lata after Fournier's gangrene; the patient returned to normal sexual life.[27]
  • Kadota 2019 — 36 × 18 cm defect reconstructed with bilateral pedicled ALT + DIEP flap, demonstrating ALT's role in multi-flap strategies for massive defects.[28]

Application 5 — Vaginal Reconstruction (Neovagina)​

Wong 2009 — 18 patients with pelvic-exenteration defects reconstructed with pedicled ALT-VL flaps:[29]

  • All received preoperative chemoradiation; 9 received intraoperative brachytherapy
  • Perineal route (10 patients) for concomitant perineal-vaginal reconstruction
  • Inguinal route (6 patients) — VL muscle tunneled over inguinal ligament into pelvis (buried)
  • 5 small perineal wound dehiscences (healed spontaneously); 1 flap failure (obese patient, short thigh)
  • No hernias

The Wong & Sbitany 2020 free ALT series also included posterior vaginal-wall reconstruction in 2 female patients after APR with rectovaginal fistulae — 100% flap survival.[21]

Application 6 — Bladder and Urinary-Tract Reconstruction​

The ALT is used for coverage and dead-space obliteration around the urinary tract rather than direct mucosal replacement:

  • Zelken 2016 reported 3 cases of bladder reconstruction using ALT flaps — urinary leak occurred in all 3, highlighting the limitation of using skin flaps for urinary-tract lining.[3]
  • Prefabricated ALT for urethral reconstruction (Ozkan 2009) — a pedicled ALT prefabricated with a skin graft was used to create a mucosal-lined tube for a full-thickness urethral defect (2.5 × 4 cm) in the proximal penile region. The only reported case of ALT used directly for urethral defect repair outside of phalloplasty.[30]

Flap Thinning and Debulking​

The ALT's principal disadvantage in genital reconstruction is its thickness, particularly in Western and obese patients.

StrategyNotes
Suprafascial harvestDissection above the deep fascia produces a thinner flap (mean 13.9 mm vs. 26.2 mm subfascial) with significantly fewer debulking procedures (1/26 vs. 20/34, p < 0.05). Maruccia 2017 / Chen 2016 confirmed fewer sensory disturbances and better satisfaction.[31][32]
Ultrathin ALT (Cha 2023)Elevation through the superficial fat layer achieves flap thickness as low as 5.8 mm — particularly useful in patients with thicker thighs.[33]
Honeycomb (Fan 2018)CUSA removes adipose while preserving the subcutaneous vascular plexus. In overweight patients (BMI > 25), significantly fewer hypoperfusion events vs. microdissection (2/19 vs. 9/21, p = 0.034).[34]
Peripheral pruning (Viviano 2018)Sharp excision of sub-Scarpa's fat at the periphery with a central cuff protecting the perforator. 0% partial necrosis in 18 thinned flaps (mean 261 cm²). Safe for extra-large flaps.[35]

For phalloplasty specifically, debulking is frequently required: Harris reported that 4 of 4 surviving ALT phalloplasty patients in the exstrophy cohort required at least one debulking procedure.[17]

Donor-Site Morbidity​

Generally well-tolerated, with morbidity significantly lower than the RFFF forearm scar.

  • Motor function — Townley 2011 (100 flaps) found peak quadriceps contraction was similar between donor and unoperated thighs; Noel 2018 confirmed no significant difference in isometric quadriceps contraction (p = 0.49) and no impact on lower-extremity function scores at 12 months.[36][37]
  • Sensory — reduced sensibility around the scar is the most common complaint; 82% endorsed some numbness / tingling (Noel) and 70% had decreased LFCN conduction (Bai); rarely functionally troublesome.[37][38]
  • Donor-site closure algorithm (Chang 2025) — based on flap-width-to-thigh-circumference ratio (FW/TCR): < 30% primary closure; ≥ 30% skin grafting or "kiss" / split skin paddle flaps.[39]
  • Specific complications (Agostini 2013 SR) — donor-site morbidity is minimal overall but increases with skin paddles > 10–12 cm wide, sacrifice of motor branches, proximal pedicle development, excessive fascia inclusion, or inadequate hemostasis.[40]

Comparison with Other Flaps​

FeatureALT (pedicled)RFFF (free)GracilisVRAMLotus petal
Tissue typeFasciocutaneous ± muscleFasciocutaneousMusculocutaneousMusculocutaneousFasciocutaneous
Skin paddle sizeUp to 25 × 15 cmUp to 15 × 10 cmUp to 8 × 30 cmUp to 12 × 25 cmUp to 6 × 12 cm
ThicknessThick (thinnable)ThinModerateModerate-thickThin
Pedicle length9–15 cmUp to 20 cm5–6 cm8–10 cm3–5 cm
Microsurgery neededNo (pedicled)YesNoNoNo
Donor-site visibilityHidden (thigh)Conspicuous (forearm)Hidden (medial thigh)Abdominal scar + hernia riskHidden (perineum)
Sensory potentialModerate (LFCN)Excellent (3 nerves)PartialNoYes (perineal nerves)
Phalloplasty suitabilityGood (secondary option)Excellent (gold standard)NoNoNo
Pelvic dead spaceExcellent (with VL)N/AModerateExcellentLimited
Neovagina creationYesN/AYesYesYes
Fistula interpositionLimitedN/AExcellentGoodLimited

Summary of Key Applications​

ApplicationALT configurationKey outcome
Phalloplasty (gender-affirming)Pedicled single-tube ± SCIP / RFFF urethra92% standing micturition; 26–53% urethral complications; debulking often needed[9][11][15]
Phalloplasty (exstrophy / congenital)Pedicled100% flap survival; 4/4 required debulking[17]
Perineal reconstruction (APR / exenteration)Pedicled ALT-MC or VL-MCComparable to VRAM; lower donor-site morbidity; no abdominal-wall compromise[3][18][19]
Vulvar cancer reconstructionPedicled ALT-FC or ALT-MCNo flap necrosis in 16 flaps; first-line for complex defects[4]
Fournier's gangrenePedicled ALT ± sartorius / other flapsAll flaps survived; natural scrotal contour; can reconstruct suspensory ligament[25][26][27]
Vaginal reconstructionPedicled (perineal route) or freeGood vaginal caliber; 1 failure in obese / short-thigh patient[29]
Urethral reconstructionPrefabricated pedicled ALTCase reports only; high urinary leak risk[30]

Key Takeaways​

  1. Phalloplasty — the leading alternative to RFFF, preferred when donor-site concealment is prioritized or when additional bulk is needed; urethral reconstruction often requires a second flap (SCIP, RFFF) or staged approach.[9][10][15]
  2. Perineal / pelvic reconstruction — an excellent alternative to VRAM when the abdominal wall is unavailable or must be preserved, with comparable outcomes and lower donor-site morbidity.[18][19]
  3. Fournier's gangrene — provides reliable coverage for large perineoscrotal defects with the unique ability to include fascia lata for structural reconstruction.[24][25][27]
  4. Trade-offs — the ALT's thickness necessitates debulking in phalloplasty and limits tube-in-tube urethral construction to ~6% of patients, while its long pedicle and large skin paddle make it uniquely suited for extensive pelvic and perineal defects that exceed local-flap capacity.[9][10][31]

See Also​

References​

1. Wang C, Lin X, Chen L, Wang Z, Cai J. "Anterolateral Thigh (ALT) Flaps in Global Reconstructive Surgery: A Bibliometric Analysis." Medicine (Baltimore). 2026;105(3):e47187. doi:10.1097/MD.0000000000047187

2. Ali RS, Bluebond-Langner R, Rodriguez ED, Cheng MH. "The Versatility of the Anterolateral Thigh Flap." Plast Reconstr Surg. 2009;124(6 Suppl):e395–e407. doi:10.1097/PRS.0b013e3181bcf05c

3. Zelken JA, AlDeek NF, Hsu CC, et al. "Algorithmic Approach to Lower Abdominal, Perineal, and Groin Reconstruction Using Anterolateral Thigh Flaps." Microsurgery. 2016;36(2):104–114. doi:10.1002/micr.22354

4. Gentileschi S, Servillo M, Garganese G, et al. "Versatility of Pedicled Anterolateral Thigh Flap in Gynecologic Reconstruction After Vulvar Cancer Extirpative Surgery." Microsurgery. 2017;37(6):516–524. doi:10.1002/micr.30077

5. Huang Y, Cao Y, Yang L, et al. "Comparative Study of the Morphological Characteristics of Perforators of the Transverse and Descending Branches of the Lateral Circumflex Femoral Artery in Anterolateral Thigh Flap Surgery." Ann Plast Surg. 2024;92(3):306–312. doi:10.1097/SAP.0000000000003766

6. Lee YC, Chen WC, Chou TM, Shieh SJ. "Anatomical Variability of the Anterolateral Thigh Flap Perforators: Vascular Anatomy and Its Clinical Implications." Plast Reconstr Surg. 2015;135(4):1097–1107. doi:10.1097/PRS.0000000000001103

7. Valdatta L, Tuinder S, Buoro M, et al. "Lateral Circumflex Femoral Arterial System and Perforators of the Anterolateral Thigh Flap: An Anatomic Study." Ann Plast Surg. 2002;49(2):145–150. doi:10.1097/00000637-200208000-00006

8. Filobbos G, Chapman T, Khan U. "Split Anterolateral Thigh (ALT) Free Flap for Vulva Reconstruction: A Case Report." J Plast Reconstr Aesthet Surg. 2012;65(4):525–526. doi:10.1016/j.bjps.2011.08.019

9. D'Arpa S, Claes K, Lumen N, et al. "Urethral Reconstruction in Anterolateral Thigh Flap Phalloplasty: A 93-Case Experience." Plast Reconstr Surg. 2019;143(2):382e–392e. doi:10.1097/PRS.0000000000005278

10. Xu KY, Watt AJ. "The Pedicled Anterolateral Thigh Phalloplasty." Clin Plast Surg. 2018;45(3):399–406. doi:10.1016/j.cps.2018.03.011

11. Robinson I, Chao BW, Blasdel G, et al. "Anterolateral Thigh Phalloplasty With Staged Skin Graft Urethroplasty: Technique and Outcomes." Urology. 2023;177:204–212. doi:10.1016/j.urology.2023.03.038

12. Wu Q, Yang Z, Ma N, Wang W, Li Y. "Urethra Reconstruction and Revision Urethroplasty in Pedicled Anterolateral Thigh Flap Penile Reconstruction." Ann Plast Surg. 2022;89(2):201–206. doi:10.1097/SAP.0000000000003100

13. van der Sluis WB, Smit JM, Pigot GLS, et al. "Double Flap Phalloplasty in Transgender Men: Surgical Technique and Outcome of Pedicled Anterolateral Thigh Flap Phalloplasty Combined With Radial Forearm Free Flap Urethral Reconstruction." Microsurgery. 2017;37(8):917–923. doi:10.1002/micr.30190

14. Ascha M, Massie JP, Morrison SD, Crane CN, Chen ML. "Outcomes of Single Stage Phalloplasty by Pedicled Anterolateral Thigh Flap Versus Radial Forearm Free Flap in Gender Confirming Surgery." J Urol. 2018;199(1):206–214. doi:10.1016/j.juro.2017.07.084

15. Netshiongolwe T, Mitchell S, Kathiravelupillai S, et al. "Pedicled Flaps Versus Free Radial Forearm Flap for Phalloplasty in Female to Male Gender-Confirming Surgery: A Systematic Review." Ann Plast Surg. 2025. doi:10.1097/SAP.0000000000004502

16. Wang E, Cleff B, Basta A, et al. "Flap Choice in Gender Affirming Phalloplasty Affects Postoperative Complication Rates." Microsurgery. 2026;46(1):e70154. doi:10.1002/micr.70154

17. Harris TGW, Manyevitch R, Wu WJ, et al. "Pedicled Anterolateral Thigh and Radial Forearm Free Flap Phalloplasty for Penile Reconstruction in Patients With Bladder Exstrophy." J Urol. 2021;205(3):880–887. doi:10.1097/JU.0000000000001404

18. Pang J, Broyles JM, Berli J, et al. "Abdominal- Versus Thigh-Based Reconstruction of Perineal Defects in Patients With Cancer." Dis Colon Rectum. 2014;57(6):725–732. doi:10.1097/DCR.0000000000000103

19. Galbraith NJ, McCollum C, Di Mascio L, et al. "Effect of Differing Flap Reconstruction Strategies in Perineal Closure Following Advanced Pelvic Oncological Resection: A Retrospective Cohort Study." Int J Surg. 2023;109(11):3375–3382. doi:10.1097/JS9.0000000000000617

20. di Summa PG, Matter M, Kalbermatten DF, Bauquis O, Raffoul W. "Transabdominal-Pelvic-Perineal (TAPP) Anterolateral Thigh Flap: A New Reconstructive Technique for Complex Defects Following Extended Abdominoperineal Resection." J Plast Reconstr Aesthet Surg. 2016;69(3):359–367. doi:10.1016/j.bjps.2015.10.044

21. Wong A, Sbitany H. "Reconstruction of Intrapelvic Defects Using the Free Anterolateral Thigh Flap: Expanding the Traditional Algorithm." Ann Plast Surg. 2020;84(5):554–558. doi:10.1097/SAP.0000000000002048

22. Contedini F, Negosanti L, Pinto V, et al. "Reconstruction of a Complex Pelvic Perineal Defect With Pedicled Anterolateral Thigh Flap Combined With Bilateral Lotus Petal Flap: A Case Report." Microsurgery. 2015;35(2):154–157. doi:10.1002/micr.22304

23. Jędrasiak A, Juniewicz H, Raczek W, et al. "Reconstruction of the Vulva and Perineum — Comparison of Surgical Methods." J Clin Med. 2025;14(13):4456. doi:10.3390/jcm14134456

24. Alammar A, Laing K, Somasundaram J, Wallace DL, Rogers AD. "Flap Reconstruction Following Fournier's Gangrene: A Systematic Review of Techniques and Outcomes." Burns. 2026;52(3):107888. doi:10.1016/j.burns.2026.107888

25. Lin CT, Chang SC, Chen SG, Tzeng YS. "Reconstruction of Perineoscrotal Defects in Fournier's Gangrene With Pedicle Anterolateral Thigh Perforator Flap." ANZ J Surg. 2016;86(12):1052–1055. doi:10.1111/ans.12782

26. Scaglioni MF, Fakin RM, Barth AA, Giovanoli P. "Bilateral Pedicle Anterolateral Thigh (ALT) Flap Combined With Bilateral Sartorius Muscle Flap for Reconstruction of Extensive Perineoscrotal and Medial Thigh Defect Because of Fournier's Gangrene." Microsurgery. 2017;37(6):669–673. doi:10.1002/micr.30083

27. Guiotto M, Watfa W, Raffoul W, di Summa PG. "Anterolateral Thigh Flap With Vascularized Fascia Lata Associated With Thigh Flaps: A Case Report of an All-in-One Reconstruction of the Suspensory Ligament and Penoscrotal District After Fournier Gangrene." Ann Plast Surg. 2020;85(6):e44–e47. doi:10.1097/SAP.0000000000002533

28. Kadota H, Momii K, Hanada M, et al. "Simultaneous Deep Inferior Epigastric and Bilateral Anterolateral Thigh Perforator Flap Reconstruction of an Extended Perineoscrotal Defect in Fournier's Gangrene: A Case Report." Microsurgery. 2019;39(3):263–266. doi:10.1002/micr.30409

29. Wong S, Garvey P, Skibber J, Yu P. "Reconstruction of Pelvic Exenteration Defects With Anterolateral Thigh-Vastus Lateralis Muscle Flaps." Plast Reconstr Surg. 2009;124(4):1177–1185. doi:10.1097/PRS.0b013e3181b5a40f

30. Ozkan O, Ozkan O. "The Prefabricated Pedicled Anterolateral Thigh Flap for Reconstruction of a Full-Thickness Defect of the Urethra." J Plast Reconstr Aesthet Surg. 2009;62(3):380–384. doi:10.1016/j.bjps.2008.03.065

31. Maruccia M, Fallico N, Cigna E, et al. "Suprafascial Versus Traditional Harvesting Technique for Free Antero Lateral Thigh Flap: A Case-Control Study to Assess the Best Functional and Aesthetic Result in Extremity Reconstruction." Microsurgery. 2017;37(8):851–857. doi:10.1002/micr.30248

32. Chen YC, Scaglioni MF, Carrillo Jimenez LE, et al. "Suprafascial Anterolateral Thigh Flap Harvest: A Better Way to Minimize Donor-Site Morbidity in Head and Neck Reconstruction." Plast Reconstr Surg. 2016;138(3):689–698. doi:10.1097/PRS.0000000000002496

33. Cha HG, Hur J, Ahn C, Hong JP, Suh HP. "Ultrathin Anterolateral Thigh Free Flap: An Adipocutaneous Flap With the Most Superficial Elevation Plane." Plast Reconstr Surg. 2023;152(4):718e–723e. doi:10.1097/PRS.0000000000010295

34. Fan S, Zhang HQ, Li QX, et al. "The Use of a Honeycomb Technique Combined With Ultrasonic Aspirators and Indocyanine Green Fluorescence Angiography for a Superthin Anterolateral Thigh Flap: A Pilot Study." Plast Reconstr Surg. 2018;141(6):902e–910e. doi:10.1097/PRS.0000000000004411

35. Viviano SL, Liu FC, Therattil PJ, Lee ES, Keith JD. "Peripheral Pruning: A Safe Approach to Thinning Extra-Large Anterolateral Thigh Flaps." Ann Plast Surg. 2018;80(4 Suppl 4):S164–S167. doi:10.1097/SAP.0000000000001401

36. Townley WA, Royston EC, Karmiris N, Crick A, Dunn RL. "Critical Assessment of the Anterolateral Thigh Flap Donor Site." J Plast Reconstr Aesthet Surg. 2011;64(12):1621–1626. doi:10.1016/j.bjps.2011.07.015

37. Noel CW, Vosler PS, Hong M, et al. "Motor and Sensory Morbidity Associated With the Anterolateral Thigh Perforator Free Flap." Laryngoscope. 2018;128(5):1057–1061. doi:10.1002/lary.26865

38. Bai S, Zhang ZQ, Wang ZQ, et al. "Comprehensive Assessment of the Donor-Site of the Anterolateral Thigh Flap: A Prospective Study in 33 Patients." Head Neck. 2018;40(7):1356–1365. doi:10.1002/hed.25109

39. Chang C, Rodriguez-Mantilla I, Herrera AC, et al. "Donor Site in Anterolateral Thigh (ALT) Free Flaps: A Systematic Review of Closure Techniques and Introduction of a Management Algorithm." J Plast Reconstr Aesthet Surg. 2025;105:243–259. doi:10.1016/j.bjps.2025.04.008

40. Agostini T, Lazzeri D, Spinelli G. "Anterolateral Thigh Flap: Systematic Literature Review of Specific Donor-Site Complications and Their Management." J Cranio-Maxillo-Facial Surg. 2013;41(1):15–21. doi:10.1016/j.jcms.2012.05.003