Surgical Technique for Anterolateral Thigh Flap Harvesting: A Questionnaire Study From 263 International Microsurgeons

Abstract

Background

The anterolateral thigh (ALT) flap is a very popular perforator flap, but variations in design and in harvest techniques result in a broad spectrum of approaches that considerably differ from literature descriptions. We therefore designed this study to assess the differences in surgical techniques and practice preferences toward this flap across world regions.

Methods

The study was conducted via an online questionnaire covering demographic data, surgical techniques, and preferences in 21 questions. The participants were divided into six geographical regions that were compared. Two questions that are the subject of debate amongst microsurgeons (limitation of vasopressor use and anticoagulation before flap division) were further analyzed using a logistic regression to identify predicting variables.

Results

There were 263 respondents worldwide with notable differences in demographics, experience, level, and technique across different world regions. The main differences were noted in intraoperative evaluation of perforators, in the primary instrument for dissection, and in the use of loupe magnification. Microsurgeons in North America with limited experience were more likely to limit vasopressor use during flap harvest. There were also discrepancies regarding the use of systemic anticoagulation prior to flap division, but not of the same magnitude.

Conclusion

This study is the first attempt to offer a clinical reference to apprehend differences in surgical preferences regarding ALT flap harvest techniques. Vasopressor use is notably limited by microsurgeons in North America, as well as by less experienced microsurgeons, despite available clinical evidence.

Keywords

surgical training - anterolateral thigh - perforator flaps

Publikationsverlauf

Eingereicht: 25. März 2025

Angenommen: 09. September 2025

Accepted Manuscript online:
17. September 2025

Artikel online veröffentlicht:
08. Oktober 2025

• References

• 1 Song YG, Chen GZ, Song YL. The free thigh flap: a new free flap concept based on the septocutaneous artery. Br J Plast Surg 1984; 37 (02) 149-159
• 2 Gedebou TM, Wei FC, Lin CH. Clinical experience of 1284 free anterolateral thigh flaps. Handchir Mikrochir Plast Chir 2002; 34 (04) 239-244
• 3 Koshima I, Fukuda H, Yamamoto H, Moriguchi T, Soeda S, Ohta S. Free anterolateral thigh flaps for reconstruction of head and neck defects. Plast Reconstr Surg 1993; 92 (03) 421-428 , discussion 429–430
• 4 Demirkan F, Chen HC, Wei FC. et al. The versatile anterolateral thigh flap: a musculocutaneous flap in disguise in head and neck reconstruction. Br J Plast Surg 2000; 53 (01) 30-36
• 5 Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin CH. Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps. Plast Reconstr Surg 2002; 109 (07) 2219-2226 , discussion 2227–2230
• 6 He J, Qing L, Wu P. et al. Customized reconstruction of complex soft tissue defects in the upper extremities with variants of double skin paddle anterolateral thigh perforator flap. Injury 2021; 52 (07) 1771-1777
• 7 Lee SH, Suh JT, Ahn TY, Hong SM, Lee HY. Differences between the upper extremity and the lower extremity in reconstruction using an anterolateral thigh perforator flap. Clin Orthop Surg 2017; 9 (03) 348-354
• 8 Hong JP. The use of supermicrosurgery in lower extremity reconstruction: the next step in evolution. Plast Reconstr Surg 2009; 123 (01) 230-235
• 9 He J, Wu P, Zhou Z. et al. Versatile design of compound vastus lateralis muscle and anterolateral thigh musculocutaneous perforator free flaps for customized reconstruction of complex skin and soft tissue defects in the extremities. Microsurgery 2020;
• 10 Song D, Li J, Pafitanis G, Li Z. Bilateral anterolateral thigh myocutaneous flaps for giant complex chest wall reconstruction. Ann Plast Surg 2021; 87 (03) 298-309
• 11 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
• 12 Meuli JN, Hubner M, Martineau J. et al. Impact of etiology leading to abdominoperineal resection with anterolateral thigh flap reconstruction: a retrospective cohort study. J Surg Oncol 2023; 127 (01) 40-47
• 13 Jakubietz R, Jakubietz M, Vater A, Kocot A, Kübler H, Kalogirou C. Complex soft tissue defects in operative urology: pedicled perforator flaps of the anterior lateral thigh for tissue reconstruction of the lower trunk. Urol Int 2021; 105 (5–6): 477-482
• 14 Perrault D, Kin C, Wan DC, Kirilcuk N, Shelton A, Momeni A. Pelvic/perineal reconstruction: time to consider the anterolateral thigh flap as a first-line option?. Plast Reconstr Surg Glob Open 2020; 8 (04) e2733
• 15 Bonapace-Potvin M, Govshievich A, Tessier L, Karunanayake M, Tremblay D, Chollet A. Canadian trends in free flap management for microsurgical lower limb reconstruction. Plast Surg (Oakv) 2023; 31 (01) 70-77
• 16 Čebron U, AbdelRahman M, Kwon SH. et al. The preferred reconstructive choice for a lower third tibial exposure defect: an online survey of 356 microsurgeons. J Reconstr Microsurg 2023; 39 (07) 540-548
• 17 Kwon SH, Lee CH, Hsu ATW. et al. Use of social media and an online survey to discuss complex reconstructive surgery: a case of upper lip reconstruction with 402 responses from international microsurgeons. J Reconstr Microsurg 2018; 34 (06) 413-419
• 18 Kwon SH, Lao WWK, Hsu ATW. et al. The preferred management of a single-digit distal phalanx amputation. J Reconstr Microsurg 2020; 36 (04) 301-310
• 19 Tang ETH, Goh M, Goh R. et al. International Microsurgery Club: an effective online collaboration system. J Reconstr Microsurg 2020; 36 (06) 412-419
• 20 Kwon SH, Goh R, Wang ZT. et al. Tips for making a successful online microsurgery educational platform: the experience of International Microsurgery Club. Plast Reconstr Surg 2019; 143 (01) 221e-233e
• 21 Pratt GF, Rozen WM, Chubb D, Ashton MW, Alonso-Burgos A, Whitaker IS. Preoperative imaging for perforator flaps in reconstructive surgery: a systematic review of the evidence for current techniques. Ann Plast Surg 2012; 69 (01) 3-9
• 22 Yu P, Youssef A. Efficacy of the handheld Doppler in preoperative identification of the cutaneous perforators in the anterolateral thigh flap. Plast Reconstr Surg 2006; 118 (04) 928-933
• 23 Pestana IA, Coan B, Erdmann D, Marcus J, Levin LS, Zenn MR. Early experience with fluorescent angiography in free-tissue transfer reconstruction. Plast Reconstr Surg 2009; 123 (04) 1239-1244
• 24 Schoeffl H, Lazzeri D, Schnelzer R, Froschauer SM, Huemer GM. Optical magnification should be mandatory for microsurgery: scientific basis and clinical data contributing to quality assurance. Arch Plast Surg 2013; 40 (02) 104-108
• 25 Vitkos EN, Kounatidou NE, Konsolaki E, Printza A, Kyrgidis A, Haßfeld S. Can loupe magnification be a viable alternative to operative microscope magnification for vascular anastomosis in reconstructive surgery? A systematic review and meta-analysis. J Stomatol Oral Maxillofac Surg 2024; 125 (3S): 101845
• 26 Revol M, Servant JM, Banzet P. Naked eye free tissue transfers. Eur J Plast Surg 1995; 18 (04) 147-151
• 27 Michelle L, Bitner BF, Pang JC. et al. Outcomes of perioperative vasopressor use for hemodynamic management of patients undergoing free flap surgery: a systematic review and meta-analysis. Head Neck 2023; 45 (03) 721-732
• 28 Goh CSL, Ng MJM, Song DH, Ooi ASH. Perioperative vasopressor use in free flap surgery: a systematic review and meta-analysis. J Reconstr Microsurg 2019; 35 (07) 529-540
• 29 Le JP, Truong N, Newland M, Lorenz FJ, Goyal N. The influence of vasopressors on free flap outcomes in head and neck cancer patients. Otolaryngol Head Neck Surg 2024; 171 (04) 1008-1016
• 30 Zhu A, Perrotta A, Choi V. et al. Intraoperative vasopressor use does not increase complications in microvascular post-mastectomy breast reconstruction: experience in 1729 DIEP flaps at a single center. J Plast Reconstr Aesthet Surg 2023; 84: 1-8
• 31 Fang L, Liu J, Yu C, Hanasono MM, Zheng G, Yu P. Intraoperative use of vasopressors does not increase the risk of free flap compromise and failure in cancer patients. Ann Surg 2018; 268 (02) 379-384
• 32 Dastagir N, Obed D, Bucher F, Schmidt JL, Dastagir K, Vogt PM. Vasopressor use in partial flap necrosis in free flap transplant patients with vascular comorbidities: a retrospective study. JPRAS Open 2024; 41: 276-284
• 33 Cordeiro PG, Santamaria E, Hu QY, Heerdt P. Effects of vasoactive medications on the blood flow of island musculocutaneous flaps in swine. Ann Plast Surg 1997; 39 (05) 524-531
• 34 Godden DRP, Little R, Weston A, Greenstein A, Woodwards RTM. Catecholamine sensitivity in the rat femoral artery after microvascular anastomosis. Microsurgery 2000; 20 (05) 217-220
• 35 Thiem DGE, Stephan D, Ziebart A. et al. Effects of volume management on free flap perfusion and metabolism in a large animal model study. Lab Anim (NY) 2024; 53 (10) 268-275
• 36 Kotsougiani D, Banz CM, Hundepool CA. et al. Influence of postoperative vasoactive agent administration on free flap outcomes. Eur J Plast Surg 2016; 39 (06) 421-428
• 37 Nelson JA, Fischer JP, Grover R. et al. Intraoperative vasopressors and thrombotic complications in free flap breast reconstruction. J Plast Surg Hand Surg 2017; 51 (05) 336-341
• 38 Chang CS, Chu MW, Nelson JA. et al. Complications and cost analysis of intraoperative arterial complications in head and neck free flap reconstruction. J Reconstr Microsurg 2017; 33 (05) 318-327
• 39 Motakef S, Mountziaris PM, Ismail IK, Agag RL, Patel A. Perioperative management for microsurgical free tissue transfer: survey of current practices with a comparison to the literature. J Reconstr Microsurg 2015; 31 (05) 355-363
• 40 Kearns MC, Baker J, Myers S, Ghanem A. Towards standardization of training and practice of reconstructive microsurgery: an evidence-based recommendation for anastomosis thrombosis prophylaxis. Eur J Plast Surg 2018; 41 (04) 379-386
• 41 Greenberg BM, Masem M, May Jr JW. Therapeutic value of intravenous heparin in microvascular surgery: an experimental vascular thrombosis study. Plast Reconstr Surg 1988; 82 (03) 463-472
• 42 Tapking C, Kowalewski KF, Hundeshagen G, Kneser U, Hirche C. A systematic review of learning curves in plastic and reconstructive surgery procedures. Ann Plast Surg 2020; 85 (03) 324-331
• 43 Li S, Zhang S, Zhang X. et al. The learning curve of the MS-TRAM/DIEP breast reconstruction by dual-trained breast surgeons. BMC Surg 2024; 24 (01) 53
• 44 Demir A, Kucuker I, Keles MK, Demirtas Y. The effect of learning curve on flap selection, re-exploration, and salvage rates in free flaps; a retrospective analysis of 155 cases. Microsurgery 2013; 33 (07) 519-526
• 45 Han SH, Kim YC, Kwon TK, Lee DY. Cumulative sum analysis of the learning curve of free flap reconstruction in head and neck cancer patients. Clin Exp Otorhinolaryngol 2022; 15 (02) 177-182
• 46 Ratnagiri R, Jena S, Parvathi P, Srikanth R, Raju GSN. Reconstruction in head-and-neck cancers - analysis of the learning curve. Natl J Maxillofac Surg 2018; 9 (02) 191-195
• 47 Saad N, McGill M, Karamitros G. et al. Surface to perforator index: assessing the importance of the number of perforators in successful harvesting of the anterolateral thigh flap. J Reconstr Microsurg 2024; 40 (05) 392-397