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Anterolateral Thigh (ALT) Flap

The anterolateral thigh (ALT) flap is a versatile 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 and pelvic reconstruction after oncologic resection, vulvovaginal reconstruction, Fournier's gangrene coverage and complex genital defect repair. It offers a large skin paddle and a potentially less conspicuous donor-site scar, but sensory symptoms, wound-closure needs and functional morbidity vary with harvest and patient factors.[2][3][4][37]

Vascular Anatomy and Flap Design​

The ALT is usually based on perforators from the descending branch of the lateral circumflex femoral artery (LCFA), which courses between rectus femoris and vastus lateralis; transverse-branch or combined branch patterns also occur.[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%[6]
  • Origin from the descending branch alone in 69.1%, the transverse branch in 9.1% and both in 21.8%[6]
  • Most common pattern (36.4%) was double perforators "B and C" from the descending branch[6]

Perforator types. Musculocutaneous perforators (traversing the vastus lateralis) predominate in the descending branch (77%). The transverse branch has more septocutaneous (41.2%) and direct cutaneous (51.5%) perforators, and harvest time was shorter for flaps pedicled on it.[5]

Pedicle characteristics​

ParameterDetail
Pedicle length9–15 cm in a series of 16 pedicled vulvar flaps.[4]
Artery diameter~2–3 mm
Practical implicationA pedicled ALT may reach selected perineal or pelvic defects without microvascular anastomosis when the pedicle permits tension-free inset.[2][4][45] Contralateral-groin transfer has been described after extended proximal pedicle dissection.[46] Inadequate reach may require free transfer.[45][29]

Flap configurations​

ConfigurationCompositionBest for
ALT fasciocutaneous (ALT-FC)Skin and subcutaneous tissue; subfascial harvest may include fascia lataSkin resurfacing; less bulk than muscle-bearing ALT variants[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, including vulvar defects[8]

Application 1 — Phalloplasty​

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

Technique​

The ALT is typically used as a pedicled flap for phalloplasty, which avoids microsurgical anastomosis. The flap is harvested from the ipsilateral thigh and tunneled to the perineum. Urethral reconstruction is the principal challenge, because 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 reported the largest single-center series (93 ALT phalloplasties over 13 years) and compared the urethral-reconstruction approaches used:[9]

Urethral techniquenUrethral complication rateNotes
Tube-in-tube ALT520%Feasible only in thin patients; used in 5/86 urethral reconstructions (5.8%) and 5/93 total phalloplasties (5.4%)
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%Regional adjunct without urethral free-flap anastomosis
ALT + skin from prior phalloplasty616.7%Uses existing penile skin; smallest comparator group

Tube-in-tube construction was used in 5 of 86 cases with urethral reconstruction (5.8%; the authors report it was not possible in the other 94.2%), and 7 of the 93 phalloplasties had no urethral reconstruction.[9] The authors used the SCIP flap or RFFF urethra when tube-in-tube construction was not possible. In a later series from the same center, complete SCIP urethral-flap loss occurred in 5/33 ALT-shaft/SCIP-urethra cases, and the authors stopped routinely pairing these flaps after 2019.[47] They emphasize tension-free ALT shaft tubularization to avoid constricting the SCIP urethra.[47] With the reported techniques, 91.86% of patients eventually voided while standing.[9]

Staged skin-graft urethroplasty​

Robinson 2023 reported 24 patients with a three-stage approach (stage I, single-tube pedicled ALT; stage II, vaginectomy, pars fixa urethroplasty, scrotoplasty and urethral plate construction with STSG; stage III, urethral tubularization):[11]

  • 87.5% achieved standing micturition in Robinson’s 24-patient series at the time of data collection[11]
  • Eleven patients had at least one urologic complication requiring another operation; fistulae occurred in 8/24 (33.3%) and strictures in 5/24 (20.8%).[11]

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 reported 19 patients with one-stage pedicled ALT (shaft) and RFFF (urethra). At a median follow-up of 35 months there were 2 total RFFF failures and 1 total ALT failure, and long-term urinary complications occurred in 10/19 (53%), including 9 strictures. The advantage is a less conspicuous forearm scar, with a smaller RFFF used only for the 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)Flap survival not reported; partial neophallus loss: 5/64 (7.8%) vs. 5/149 (3.4%) (at least 6 months' follow-up)Overall urethral complications: 21/64 (32.8%) vs. 36/149 (24.2%)ALT was associated with higher odds of fistula (OR 2.50, p = 0.024), wound dehiscence (OR 5.03, p = 0.026), and 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); serious selection bias and low evidence certainty
Wang 2026[16]57 (10 ALT, 25 RFFF, 22 abdominal)—Fistula: ALT 20% / RFFF 48% / abdominal 9.1% (p = 0.011); stricture: 20% / 44% / 22.7% (p = 0.24)Overall complications: RFFF 80%, ALT 60%, abdominal 40.9% (p = 0.023); mostly 90-day assessment (minimum 30 days), with staged RFFF urethroplasty in every abdominal-flap patient

The Netshiongolwe systematic review favored RFFF when feasible but rated the observational evidence low and noted that heterogeneous reporting precludes a definitive choice.[15]

When to choose ALT over RFFF​

  • Patient strongly desires a hidden donor-site scar (thigh versus conspicuous forearm)
  • In exstrophy-epispadias reconstruction, forearm tissue judged too thin for later inflatable-prosthesis coverage; this indication comes from a small 11-patient ALT/RFFF series.[17]
  • Need for additional bulk (for example, bladder-exstrophy patients with deficient pubic tissue)
  • Microsurgical expertise unavailable: a pedicled ALT shaft avoids a microvascular anastomosis only when the urethral plan also avoids a free flap; a free RFFF urethra still requires microsurgery.[9]
  • Inadequate forearm vasculature. An abnormal clinical Allen test warrants further assessment rather than automatic exclusion of the forearm; Doppler testing can clarify collateral flow before choosing ALT instead of RFFF.[10][17][42]

Bladder exstrophy​

Harris 2021 reported 11 patients (8 classic exstrophy, 3 cloacal): 5 pedicled ALT and 6 RFFF, and all flaps survived. One patient in the ALT group died of acute pulmonary embolism, and the other 4 ALT patients required at least 1 debulking procedure. The authors prefer RFFF when feasible and accept ALT when the 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). Before pedicled transfer, assess prior thigh surgery and pelvic or thigh vascular disease. Create a wide tunnel beneath rectus femoris and sartorius, and confirm that the pedicle is neither compressed nor under tension at inset.[48][49]

ALT vs. VRAM​

  • Pang 2014. In 19 consecutive patients (10 ALT, 9 VRAM), there were no significant differences in infection, hematoma, bleeding, necrosis or LOS (mean LOS 9.7 days for ALT versus 13.4 days for VRAM, not significant). The authors call ALT an "acceptable alternative" to VRAM.[18]
  • Galbraith 2023. Among 122 patients (12 APR, 40 ELAPE, 70 pelvic exenteration), 64 received flap closure: VRAM 21, gluteal 22, thigh 19 (3 ALT, 3 ALT with vastus lateralis/fascia lata, 1 vastus lateralis, 12 gracilis), one oblique rectus, and one multiple-flap reconstruction. Infection was less frequent after flap closure despite more preoperative radiotherapy (p < 0.05); the comparison pooled different flaps.[19]

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

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

  • ALT and 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​

Four patients had APR for rectal cancer (4 of 4 with prior surgery or stomas that precluded VRAM). Recipient vessels were the deep inferior epigastric artery and vein. All four free ALT flaps survived; the two male patients received buried flaps for intrapelvic soft-tissue reconstruction, and the two female patients received flaps 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 22 flaps survived; venous congestion occurred in 3/9 VL-MC flaps, from two hematomas and one pedicle torsion; reexploration salvaged all three.[3]
  • 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 was combined with bilateral lotus petal flaps for perineal skin coverage, a complementary strategy after pelvic exenteration.[22]

Application 3 — Vulvar Reconstruction​

Gentileschi 2017 reported 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 occurred among 16 flaps. Three partial wound dehiscences healed with dressings; one obese patient had donor-site wound edge necrosis requiring secondary grafting. Follow-up ranged from 1 month to 2 years.[4]
  • Global performance and pain scores improved postoperatively
  • The 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[4]

Split ALT. Filobbos described a split free ALT flap for a vulvar defect after excision of recurrent tumor.[8] An earlier 11-patient oncologic vulvar series had already included split ALT designs.[52]

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 for defects where 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. Ten patients with large perineoscrotal defects (72–198 cm²) were reconstructed with pedicled ALT perforator flaps. 10 of 10 flaps survived, one hematoma occurred, and the scrotal contour was natural.[25]
  • Scaglioni 2017. A massive perineoscrotal and medial-thigh defect (27 × 30 cm) was reconstructed with bilateral pedicled ALT (30 × 9 cm) and bilateral sartorius muscle flaps, with complete survival and no recipient or donor-site morbidity at 6 months.[26]
  • Guiotto 2020. This case report described penile suspensory-ligament reconstruction using a composite ALT with vascularized fascia lata after Fournier's gangrene, and the patient returned to normal sexual life.[27]
  • Kadota 2019. A 36 × 18 cm defect was reconstructed with bilateral pedicled ALT and DIEP flaps in a single case, an example of a multi-flap strategy for a massive defect.[28]

Keyhole skin-paddle design. For defects around a preserved anus (after wide perianal resection) or a preserved penis (during extensive scrotal skin excision), the ALT skin paddle can be designed with a keyhole or slit aperture so the preserved structure passes through the flap while it resurfaces the surrounding perineal or scrotal skin.[41]

Application 5 — Vaginal Reconstruction (Neovagina)​

Wong 2009. In 18 patients, pelvic-exenteration defects were reconstructed with pedicled ALT-VL flaps:[29]

  • All 18 patients (5 men, 13 women) had preoperative chemoradiation; 9 received intraoperative pelvic brachytherapy
  • Perineal route (10 patients) for concomitant perineal-vaginal reconstruction
  • Inguinal route (6 patients): VL muscle tunneled over the inguinal ligament into the pelvis (buried)
  • 5 small perineal wound dehiscences (healed spontaneously); 1 flap failure from pedicle tension (obese patient, short thigh); 1 enterocutaneous fistula and 1 ileal conduit leak (healed spontaneously)
  • No hernias
  • The authors suggest that obese patients with short thighs may not be good candidates

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

Application 6 — Bladder and Urinary-Tract Reconstruction​

The ALT is used mainly for coverage and dead-space obliteration around the urinary tract; a prefabricated urethral-repair case has also been reported:

  • Zelken 2016 reported urinary leakage in all three bladder-wall reconstructions using VL-MC, two requiring revision. The authors excised deep vastus fascia to expose muscle for urothelial coverage; they suggested adjacent bladder injury or perioperative inflammation as possible causes and advised bladder decompression and a watertight repair when possible.[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 authors described it in 2009 as the only report of an ALT flap used for a urethral defect.[30]

Flap Thinning and Debulking​

For genital reconstruction, a thick thigh subcutaneous layer can limit tube-in-tube urethral construction; assess flap thickness when selecting ALT.[9][10][14]

StrategyNotes
Suprafascial harvestIn Maruccia's extremity-reconstruction cohort, suprafascial flaps were thinner than subfascial flaps (mean 13.9 versus 26.2 mm) and fewer required debulking (1/26 versus 20/34, p < 0.01). In a separate head-and-neck cohort, Chen reported fewer donor-thigh sensory disturbances and better donor-site satisfaction after suprafascial harvest.[31][32]
Ultrathin ALT (Cha 2023)Elevation through the superficial fat layer gave a mean flap thickness of 5.8 mm. Mean thickness did not differ significantly from the superthin (7.9 mm) and thin (7.8 mm) planes (p = 0.29); the authors suggest the ultrathin plane for patients with thicker thighs or a high BMI. Retrospective distal-extremity series.[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. No partial necrosis in 18 thinned flaps (mean 261 cm²; 10 flaps over 240 cm²); one total loss was attributed to hematoma during therapeutic heparin. Retrospective single-institution series.[35]

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

Donor-Site Morbidity​

Donor-site trade-offs include scar location, closure method, sensory change and potential motor morbidity.[36][37][38] During intramuscular perforator dissection, identify and preserve motor branches to the remaining vastus lateralis when feasible.[53]

  • Motor function. Townley 2011 (100 flaps) found peak quadriceps contraction similar between donor and unoperated thighs. Noel 2018 found no significant difference in isometric quadriceps contraction (p = 0.49) and no change in lower-extremity function scores at 12 months. Bai 2018 (33 flaps, isokinetic testing) reported significantly lower values for most knee strength measures on the donor side at 1 year, with a compensatory increase on the normal side.[36][37][38]
  • Sensory. Reduced sensibility around the scar is the most common complaint: 82% endorsed some numbness or tingling (Noel) and 70% had decreased LFCN conduction or no response (Bai). Townley described the reduced sensibility as rarely troublesome.[37][38]
  • Donor-site closure algorithm (Chang 2025). Based on the flap-width-to-thigh-circumference ratio (FW/TCR), the algorithm proposes direct closure for < 16%, locoregional flaps for 16–30%, and skin grafting or "kiss" (split skin paddle) flaps above 30%.[39] The review notes that comparative studies are needed to validate these thresholds.[39] Donor-site compartment syndrome has occurred after primary closure of 7- and 9-cm ALT harvests; monitor the thigh early for tension, swelling and pain, which epidural analgesia can mask.[50]
  • Specific complications (Agostini 2013 systematic review). Donor-site morbidity is minimal overall but increases with skin paddles wider than 10–12 cm, 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 for a pedicled ALT alone; yes if combined with a free urethral flap[9][13]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 suitabilityDescribed as a secondary option when RFFF is unsuitable[15]The review calls RFFF the most reliable option, with low-certainty evidence[15]Gracilis muscle described in a four-patient composite phalloplasty technique[43]Related inferiorly based rectus abdominis flap described in a penile cancer reconstruction case report[44]No
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 urethraStanding voiding and urethral complications vary by cohort, urethral technique, follow-up, and revision; see the study-specific results above[9][11][15]
Phalloplasty (exstrophy / congenital)Pedicled5/5 ALT flaps survived; 4/4 surviving ALT patients required at least one debulking procedure[17]
Perineal reconstruction (APR / exenteration)Pedicled ALT-MC or VL-MCAn alternative when abdominal donor tissue is unavailable; a small retrospective ALT–VRAM comparison found no statistically significant difference in the measured complications[3][18][19]. In a separate retrospective total pelvic exenteration cohort, severe pelvic abscess occurred after 2/40 (5%) pedicled ALT reconstructions versus 12/54 (22.2%) primary closures.[51]
Vulvar cancer reconstructionPedicled ALT-FC or ALT-MCNo flap necrosis in the 16-flap Gentileschi series; its authors proposed first-line use for complex defects[4]
Fournier's gangrenePedicled ALT ± sartorius / other flapsLin's selected 10-patient ALT series reported complete flap survival and natural scrotal contour; combined ALT and sartorius coverage and suspensory-ligament repair with fascia lata have each been described in case reports.[25][26][27]
Vaginal reconstructionPedicled (perineal route) or freePelvic exenteration series (18 patients): 1 flap failure in an obese, short-thigh patient[29]
Urethral reconstructionPrefabricated pedicled ALTSingle case report[30]

Key Takeaways​

  1. Phalloplasty. The ALT is the main alternative to RFFF, chosen when donor-site concealment is prioritized or additional bulk is needed. Urethral reconstruction often requires a second flap (SCIP, RFFF) or a staged approach.[9][10][15]
  2. Perineal and pelvic reconstruction. The ALT is an option when the abdominal wall is unavailable or must be preserved. A small retrospective comparison found no significant difference in measured ALT and VRAM outcomes.[18]
  3. Fournier's gangrene. The ALT provides reliable coverage for large perineoscrotal defects and can include fascia lata for structural reconstruction.[24][25][27]
  4. Trade-offs. The ALT's thickness necessitates debulking in phalloplasty, and tube-in-tube urethral construction was possible in only about 6% of patients (5 of 93) in D'Arpa's series. Its long pedicle and large skin paddle suit 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;95(6):661–666. 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

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