The anterolateral thigh flap can provide a large skin paddle nourished by a long and large-caliber pedicle and can be harvested by two-team work. Most importantly, the donor-site morbidity is minimal. However, the anatomic variations decreased its popularity. By adapting free-style flap concepts, such as preoperative mapping of the perforators and being familiar with retrograde perforator dissection, this disadvantage had been overcome gradually. Furthermore, several modifications widen its clinical applications: the fascia lata can be included for sling or tendon reconstruction, the bulkiness could be created by including vastus lateralis muscle or deepithelization of skin flap, the pliability could be increased by suprafascial dissection or primary thinning, the pedicle length could be lengthening by proximally eccentric placement of the perforator, and so forth. Combined with these technical and conceptual advancements, the anterolateral thigh flap has become the workhorse flap for soft-tissue reconstructions from head to toe. 1. Introduction Since Song et al. [1] introduced the anterolateral thigh flap in 1984, it gains popularity because of several advantages [2, 3]. First, the flap can be harvested simultaneously as two-team work. The operation time could be shortened. Second, the pedicle length is long enough to anastomosis with recipient vessels. The vein graft could be avoided. Third, the large caliber of pedicle vessels makes microanastomosis easier. Fourth, the flap could serve as fasciocutaneous, adipofascial, or myocutaneous flap as needed. Fifth, the flap can have great volume variability. Pliability could be achieved by primary thinning. Bulkiness could be added by incorporation of the deepithelialized skin or a portion of muscle cuff. Sixth, the lateral femoral cutaneous nerve can be included to provide as a sensate flap. Seventh, the flap pedicle could bridge the vascular gap as flow-through flap, especially in mangled extremities. Eighth, the donor site morbidity is minimal. 2. Flap Anatomy 2.1. Perforator Both septocutaneous and musculocutaneous perforators were identified in the anterolateral thigh flaps. Initially, it was thought that septocutaneous route composes the dominance [1, 4]. Recently, the anatomic studies suggested that musculocutaneous route takes the majority [2, 5–7]. In Shieh et al.’s and Wei et al.’s reports, 83.2% and 87.1% of perforators were found to be musculocutaneous, respectively [2, 3]. The differences between each studies might relate to the bias of the selection of the perforators by different authors.
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