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Vastus Lateralis (VL) Flap

The pedicled vastus lateralis (VL) and combined anterolateral thigh–vastus lateralis (ALT-VL) flaps provide muscle bulk for selected pelvic, perineal and groin defects, including when an abdominal donor is unsuitable. They commonly use the lateral circumflex femoral artery (LCFA) system also used by the ALT flap. VL may be transferred as muscle alone, with an ALT skin paddle, or in a muscle-sparing design, depending on the defect and donor anatomy.

See the overview article: Flaps in GU Reconstruction. Related pages: Anterolateral Thigh (ALT) Flap, Gracilis Flap, VRAM.

Anatomy and Vascular Supply​

The vastus lateralis is the largest component of the quadriceps, originating from the greater trochanter and lateral lip of the linea aspera and inserting into the quadriceps tendon.

Dominant Pedicle — Descending Branch of the LCFA​

The same pedicle that supplies the ALT flap:[4][5][6]

FeatureValue
ArteryDescending branch of the lateral circumflex femoral artery
Mean arterial diameter2.1 mm (range 2.0–2.5 mm)
Dominant VL pedicle lengthMean 56.8 mm in 30 cadaveric dissections[4]
Pedicle entry (from pubic symphysis)~119 mm distal
Pedicle entry (from greater trochanter)~156 mm
Venae comitantesPaired, 2.5–4 mm caliber

Accessory Pedicles​

  • Proximal minor pedicles. Ascending and transverse branches of the LCFA, mean 1.8–2.0 mm diameter.[4]
  • Distal minor pedicles. Three large branches from the deep femoral artery, 7.9–15.4 cm proximal to the patella (2.2–2.8 mm), providing the anatomic basis for distally based VL flaps.[7]

Segmental Anatomy​

The vastus lateralis has three distinct anatomical partitions with constant segmental neurovascular supply, enabling muscle-sparing or segmental harvest.[5] This is the anatomic basis for the "just-enough-muscle" technique that preserves function at the donor site.

Motor Innervation​

Femoral nerve branch enters the muscle approximately 195 mm from the ASIS.[4]

GU Reconstructive Applications​

The following GU defects have been reconstructed with flaps based on the LCFA system. The bladder and pelvic dead-space reports used VL or ALT-VL, while the cited scrotal and penile reports include ALT flaps without VL harvest; the ALT page covers those applications separately.[1][2][3][8][9][11][29]

  1. Scrotal reconstruction. Fournier's gangrene, scrotal trauma, scrotal oncology
  2. Perineal reconstruction. APR, pelvic exenteration, extensive radiation wounds
  3. Bladder reconstruction. Posttraumatic bladder wall and overlying soft-tissue coverage
  4. Penile reconstruction and penoscrotal coverage
  5. Groin defects with exposed femoral vessels
  6. Vaginal reconstruction after oncologic resection

When a Muscle Component May Be Useful[1]​

  • Deep defects requiring dead-space obliteration
  • Contaminated wounds benefiting from well-vascularized muscle
  • Selected traumatic bladder defects. A four-patient case series used the muscle undersurface with soft-tissue coverage.[2]
  • Exposed vital structures (femoral vessels, testes, urethra)
  • Large surface-area defects, when bulk as well as surface cover is required; a >100 cm² threshold was an inclusion criterion in one composite-flap series[3]

Published Flap-Selection Scheme for Lower Abdominal, Perineal, and Groin (LAPG) Reconstruction[1]​

The first four rows are simplified examples from Zelken and colleagues' retrospective 22-patient flap-selection scheme (5 ALT-FC, 8 ALT-MC, 9 VL-MC). The vessel-coverage and pelvic-exenteration rows summarize separate reports by Scaglioni and Wong.[1][8][10]

Defect characteristicsPreferred flapRationale
Superficial, small–moderate sizeALT-FC (fasciocutaneous)Thin, pliable, minimal donor morbidity
Moderate depth, moderate sizeALT-MC (myocutaneous with muscle cuff)Additional bulk, reliable perfusion
Deep defects, large size, dead spaceVL-MC (vastus lateralis myocutaneous)Maximum bulk, dead-space obliteration
Bladder reconstructionVL-MCMuscle undersurface as bladder-wall substitute
Exposed femoral vesselsChimeric ALT + VLMuscle wraps vessels, skin provides closure
Pelvic exenterationALT-VL compositeFills pelvic dead space, prevents herniation

Bladder Reconstruction​

Pedicled VL-MC has been reported in four patients with complex traumatic bladder tissue loss plus lower abdominal or perineal soft-tissue injury.[2]

Principle. The undersurface of the vastus lateralis substitutes for the missing bladder wall; the remaining muscle and subcutaneous fat provide bulk to obliterate dead space and cover the external defect.

Wu 2010 series (4 patients):[2]

  • No major complications
  • Intact bladders on postop cystogram
  • 3 of 4 (75%) voiding normally within 1 year[2]

In Zelken's separate 22-patient mixed-flap series, all three VL-MC bladder-wall reconstructions developed a urinary leak; two patients achieved spontaneous voiding after revision bladder repair.[1]

Scrotal, Penile, and Perineoscrotal Reconstruction​

Fournier's Gangrene and Major Scrotal Defects​

The cited perineoscrotal reports primarily concern ALT fasciocutaneous or perforator flaps.[11][12][13][14]

  • Flap survival: small ALT series report high survival; 100% is not a VL-specific rate[11]
  • Natural scrotal contour with adequate testicular coverage
  • Minor posterior perineal wound dehiscence from fecal contamination and skin maceration occurred in three of seven patients in Yu's series and healed secondarily

Systematic Review of Fournier Reconstruction (619 Patients, 625 Flaps)[15]​

  • Flap loss: 1.6% pooled across multiple flap designs[15]
  • Most common flaps: medial thigh, pudendal thigh, ALT, gracilis
  • Flap choice depends on defect, reach and available donor tissue
  • Primary indications: coverage of exposed vital structures (52%), functional restoration (39%), cosmesis (4%)[15]

Penile Suspensory Ligament Reconstruction[16]​

A composite ALT flap including fascia lata has been described for reconstructing the penile suspensory ligament after Fournier's gangrene. In the single reported patient, healing was uneventful and erection and intercourse were satisfactory.

Pelvic Exenteration — ALT-VL as a VRAM Alternative​

The ALT-VL composite is a reported alternative to VRAM when the rectus abdominis donor is unavailable or unsuitable, including some large pelvic-exenteration defects. Reach, vascular anatomy, muscle volume and donor morbidity still require individual assessment.[8]

Delivery Routes[8]​

  • Inguinal route. VL tunneled over the inguinal ligament into the pelvis when the perineal defect is small enough for primary closure.
  • Perineal route. ALT-VL tunneled over the medial thigh to the defect when perineal-vaginal reconstruction is required in the same operation.
  • Bilateral approach. One flap via each route for very large defects.

Wong 2009 Series (18 Patients, All With Preoperative Chemoradiation)[8]​

  • Flap failure: 1 case (5.6%); pedicle tension in an obese patient with short thigh[8]
  • Perineal wound dehiscence: 5 cases (28%), all healed spontaneously[8]
  • No hernias

Comparative APR Reconstruction Evidence​

StudynComparisonKey finding
Pang 2014[21]19 (10 ALT, 9 VRAM)ALT vs VRAM, not isolated VLNo significant differences reported in small nonrandomized groups
Galbraith 2023[22]122 patients; 64 received flap closure (21 VRAM, 22 gluteal, 19 thigh, one oblique rectus, one composite)VRAM vs gluteal vs thigh designs (including ALT/gracilis)—
Nelson 2009 (MD Anderson)[23]133 (114 VRAM, 19 mixed thigh)VRAM vs mixed thigh flapsMajor complications 15% vs 42%, pelvic abscess 6% vs 32%, major wound dehiscence 5% vs 21% in this cohort
Guillier 2026[35]24 (10 ORAM, 14 ALT-VL)ORAM vs ALT-VL for complex perineal defects after major resection or debridementOverall perineal complication rates 40% vs 28.6% (P = 0.439); donor-site bulging in 3 ORAM patients versus one seroma with ALT-VL (P = 0.178); two-center retrospective series
Johnstone 2017 meta-analysis[24]PooledVRAM vs gluteal vs gracilisAny perineal wound or flap complication: 35.8% VRAM vs 43.7% gluteal vs 52.9% gracilis (p = 0.041)

Transabdominal-Pelvic-Perineal (TAPP) ALT-VL — di Summa 2016[25]​

A novel technique for massive anteroposterior defects after extended APR and sacrectomy: the ALT and VL flap is delivered transabdominally through the pelvis to the perineum.

  • A six-patient technical series of extensive pelvic or perineal defects
  • 1 partial flap necrosis; no late fistulas or perineal hernias
  • No significant flap atrophy on serial CT volumetric analysis
  • The fascia lata component supports the pelvic floor

Vulvar / Vaginal Reconstruction​

  • Gentileschi 2017. The authors reported 16 pedicled ALT flaps in 15 patients after vulvar cancer surgery, adding VL muscle in two pelvic-exenteration cases for dead-space filling. No flap necrosis and three partial wound dehiscences were reported across the mixed cohort.[26]
  • Wong & Sbitany 2020. Free ALT for posterior vaginal-wall reconstruction after APR with rectovaginal fistula in 2 female patients; 100% flap survival.[27]
  • The VL is also among the musculocutaneous flap options listed by Höckel and Dornhöfer for vulvovaginal reconstruction, though less commonly used than gracilis or VRAM for this indication.[28]

Phalloplasty and Urethral Reconstruction​

The following are ALT phalloplasty reports; see the ALT page for procedure-specific interpretation:

  • D'Arpa 2019. 93 ALT phalloplasties (largest series). Urethral reconstruction used tube-in-tube ALT in 5 of 93 phalloplasties (5.4%), a SCIP flap in 38 of 93 (40.9%), or a radial forearm flap in 29 of 93 (31.2%). D’Arpa’s retrospective series reports that 91.9% of patients treated with its urethral reconstruction approaches eventually voided while standing. Urethral complication rates (fistula or stricture) were 20% with tube-in-tube ALT, 87.5% with prelaminated ALT, 37.9% with a radial forearm urethra, 26.3% with a SCIP urethra and 16.7% with skin from a previous phalloplasty.[29]
  • Harris 2021. Five patients with exstrophy-epispadias complex underwent pedicled ALT phalloplasty; all five flaps survived. One patient died from acute pulmonary embolism, and the other four required at least one debulking procedure. The authors preferred RFFF and considered ALT acceptable when an overly thin forearm raised concern for inflatable penile prosthesis extrusion.[30]
  • Morrison 2014 "mushroom flap". A tube-in-tube ALT design with a semicircular extension creates a neoglans with natural anatomic landmarks, enabling single-stage neophallus, neoglans and neourethra construction without microsurgery.[31]
  • Ozkan 2009 prefabricated ALT. Pedicled ALT prefabricated with skin graft for a full-thickness urethral defect in a single patient, reported as stable coverage with a patent tube.[32]

See the ALT page for the full phalloplasty workflow including ALT versus RFFF head-to-head comparisons.

Large Perineal Defects — Combined ALT + VL Flap​

In di Summa's retrospective series, 23 patients underwent 25 ALT+VL reconstructions for large defects; three patients lacked six-month follow-up, leaving 20 patients/22 reconstructions for outcome analysis (mean defect area 182 cm²; >100 cm² was an inclusion criterion):[3]

  • Flap necrosis: 4.5% (1/22)[3]
  • Partial necrosis: 1 case (venous congestion)
  • Peripheral wound dehiscence: 27% (6/22; managed with debridement followed by STSG or advancement local flaps)[3]
  • Satisfactory coverage at mean 14-month follow-up was reported among those analyzed, including after complementary procedures in two cases[3]
  • No functional deficit was reported in this small followed group

Factors associated with complications and length of stay. In this retrospective series, larger defects were associated with more postoperative complications and longer hospitalization, particularly among patients who had received preoperative radiotherapy.[3]

Surgical Technique​

Standard Pedicled VL-MC Harvest[17][18][19]​

  1. Positioning. Supine, ipsilateral hip slightly elevated on a roll.
  2. Skin paddle design. Centered over the lateral thigh along the ASIS–patella axis. In a mixed pedicled ALT series, skin paddles ranged from 8 × 5 to 11 × 18 cm; a separate mixed LCFA-system series reported flaps up to 38 × 20 cm.[9][19]
  3. Incision along the anterior skin-paddle border; dissect through subcutaneous fat to the fascia lata.
  4. Identify the intermuscular interval between rectus femoris and vastus lateralis.
  5. Locate the descending branch of LCFA and accompanying venae comitantes in the intermuscular septum.
  6. Dissect the pedicle proximally toward its LCFA origin as needed for reach; for segmental VL harvest, identify and preserve motor branches to retained VL partitions; assess usable length for the harvested flap.[5]
  7. Muscle harvest options:
    • Full muscle. Entire VL
    • Segmental. One of three anatomical partitions (muscle-sparing)
    • ALT-MC with a minimal VL perforator cuff. An ALT myocutaneous variant, distinct from segmental or whole-VL muscle-bulk harvest.[1][33]
  8. Flap transfer:
    • Proximal pedicle. Arc of rotation reaches lower abdomen, perineum, scrotum, groin
    • Subcutaneous tunnel or passage beneath rectus femoris
    • Inguinal route (over inguinal ligament) for pelvis; perineal route (over medial thigh) for perineum. Before final inset and closure, confirm that the pedicle is untwisted, uncompressed and reaches without tension.[1][8]
  9. Donor-site closure. Primary closure was achieved in 34 of 42 mixed pedicled ALT flaps (81%) and 20 of 23 mixed LCFA-system pedicled flaps (87%). STSG was used for donor sites that could not be closed primarily.[9][19]

Chimeric ALT + VL[10]​

When the defect needs both bulk and skin coverage with different orientations:

  • Two separate perforators (one musculocutaneous, one pure muscular) on the same LCFA pedicle.
  • Muscle component wraps vessels or fills dead space.
  • Fasciocutaneous component provides tension-free skin closure.
  • Can be designed as a sensate flap by including the lateral femoral cutaneous nerve.

Distally-Based VL Flap[7]​

Based on distal accessory pedicles arising from the deep femoral artery 7.9–15.4 cm proximal to the patella, used for knee coverage rather than urologic reconstruction.

Preoperative Planning[3][8]​

  • CT angiography maps perforator anatomy when ALT / ALT-VL reliability is in question.
  • Assess thigh length in obese patients; short thighs increase pedicle-tension risk.
  • Bilateral harvest for very large defects.

Outcomes​

Selected small series report high flap survival, but the cited studies mix ALT-FC, ALT-MC and VL-MC designs, defect sites and follow-up; a single 94–100% VL-specific survival range is not established by them.[1][3][9][20]

Complications[1][3][8][20]​

ComplicationRate
Venous congestion (mechanical cause)3/9 VL-MC in Zelken's 22-patient mixed-ALT series[1]
Wound infection6/22 patients in the same mixed-ALT series[1]
Peripheral wound dehiscence6/22 followed reconstructions (27%) in di Summa's ALT+VL composite series; some required debridement, grafting or advancement[3]
Total/partial flap necrosis—

Donor-Site Morbidity​

Donor-site findings vary by whether the operation takes skin alone, a small VL cuff, a segment or most of the muscle.[5][18][33][34]

ParameterFinding
Reported musculoskeletal dysfunctionNearly one in 20 after mixed ALT/VL harvest in the background evidence summarized by Puladi[34]
Lower Extremity Functional Scale (segmental harvest)67.7 to 67.4, nonsignificant, in Toia's 23 selected free-flap patients (14 segmental VL, nine chimeric ALT-VL)[5]
Modeled muscle reduction (elderly/fragile)Puladi's predictive gait simulation cautioned against 50% or greater VL reduction[34]
Modeled muscle reduction (young/athletic)A 10% simulated reduction had no relevant modeled effect; more than 30% produced relevant modeled quadriceps weakening[34]
Hanasono 2010 — 220 mixed ALT flaps25% skin-only, 38% minimal muscle, 33% superficial half, 4% whole VL; donor seroma 5%, dehiscence 2%, hematoma 1%, infection 1% across all designs[33]
Sensory and gait effectsIn Hanasono's 220 mixed ALT free flaps, 84% reported sensory loss in the lateral femoral cutaneous nerve distribution, and weakness or instability at the first visit (8%) resolved within 6 months; counsel each patient individually[33]
Primary donor closure81% (34/42 flaps) and 87% (20/23 flaps) in two pedicled series[9][19]
Skin-graft cosmesisCan be poor — discuss at consent

Comparison With Alternatives​

ALT-VL vs VRAM for Pelvic Reconstruction[8]​

FeatureALT-VLVRAM
Abdominal-wall integrityPreservedCompromised
Donor-site hernia riskPreserves abdominal fascia, but thigh harvest has its own risksAbdominal-wall hernia/bulge risk varies with technique, closure and follow-up; no universal 15–17% comparator is established here
Availability with ostomies or prior abdominal surgeryExcellentMay be limited
Pedicle length9–16 cm in one mixed-design pedicled ALT series[9]Variable
Bulk for dead spaceExcellentExcellent
Donor morbidityThigh wound, sensory and quadriceps effects vary by harvested tissueAbdominal-wall wound and hernia/bulge effects vary; no universal rank

ALT-VL's principal advantage is preserving the abdominal wall, particularly in patients with stomas, prior rectus harvest, or planned adjuvant therapy requiring intact abdominal fascia.

VL vs Gracilis for Perineal Reconstruction​

  • VL. Can provide more muscle bulk for a large dead space, at the cost of a larger quadriceps donor-site harvest
  • Gracilis. Often offers a smaller donor footprint and useful perineal reach, but less muscle volume
  • Neither flap has universally low morbidity or proven superiority for all defects; compare actual reach, vessels, prior treatment and functional consequences
  • Practical planning shorthand: consider VL when bulk is limiting and gracilis when reach and smaller harvest are priorities, then verify patient-specific suitability

Key Takeaways​

  1. VL and ALT-VL are reported VRAM alternatives for selected pelvic defects when abdominal-wall preservation matters.
  2. LCFA descending branch. The shared ALT/VL pedicle; in 30 cadaveric dissections its dominant VL artery averaged 2.1 mm in diameter and its pedicle 56.8 mm. The 8–20 cm neurovascular pedicle range is described for free VL segments; assess the selected segment and transfer route.[4][6][8]
  3. Three anatomical partitions permit segmental harvest; Toia's selected 23-patient cohort had no significant mean LEFS change.
  4. VL-MC supplies bulk for selected deep defects and dead-space filling; >100 cm² was the enrollment threshold in one series.
  5. Bladder reconstruction. A four-case traumatic series used muscle undersurface for bladder tissue loss; three patients voided normally by one year. This is preliminary case experience.
  6. Fournier or scrotal reconstruction. ALT-only and mixed-flap reports should not be quoted as VL-specific outcomes; the 1.6% pooled loss spans multiple designs.[15]
  7. Pelvic exenteration. Wong's 18-patient ALT-VL series described inguinal and perineal routes; one pedicle-tension failure in an obese short-thigh patient warrants reach assessment.
  8. Chimeric ALT and VL enables simultaneous skin and muscle coverage with different orientations on one LCFA pedicle.
  9. VL versus gracilis. Bulk and reach are useful planning considerations, not an evidence-based universal ranking.
  10. Outcome and donor-site estimates depend on the exact flap and cohort; pedicle tension is one reported failure mechanism, alongside wound and perfusion complications.

References​

1. 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):104–14. doi:10.1002/micr.22354

2. Wu CW, Lin CH, Lin CH. "One-Stage Posttraumatic Bladder Reconstruction and Soft-Tissue Coverage of the Lower Abdomen or Perineum." Ann Plast Surg. 2010;64(1):65–8. doi:10.1097/SAP.0b013e3181a1471a

3. di Summa PG, Tremp M, Meyer Zu Schwabedissen M, et al. "The Combined Pedicled Anterolateral Thigh and Vastus Lateralis Flap as Filler for Complex Perineal Defects." Ann Plast Surg. 2015;75(1):66–73. doi:10.1097/SAP.0b013e3182a884c8

4. Tayfur V, Magden O, Edizer M, Atabey A. "Anatomy of Vastus Lateralis Muscle Flap." J Craniofac Surg. 2010;21(6):1951–3. doi:10.1097/SCS.0b013e3181f4ee7f

5. Toia F, D'Arpa S, Brenner E, et al. "Segmental Anatomy of the Vastus Lateralis — Guidelines for Muscle-Sparing Flap Harvest." Plast Reconstr Surg. 2015;135(1):185e–198e. doi:10.1097/PRS.0000000000000842

6. Wolff KD, Grundmann A. "The Free Vastus Lateralis Flap — An Anatomic Study With Case Reports." Plast Reconstr Surg. 1992;89(3):469–75. doi:10.1097/00006534-199203000-00012

7. Wang Y, Begue T, Masquelet AC. "Anatomic Study of the Distally Based Vastus Lateralis Muscle Flap." Plast Reconstr Surg. 1999;103(1):101–3. doi:10.1097/00006534-199901000-00017

8. 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

9. Lin CT, Wang CH, Ou KW, et al. "Clinical Applications of the Pedicled Anterolateral Thigh Flap in Reconstruction." ANZ J Surg. 2017;87(6):499–504. doi:10.1111/ans.12973

10. Scaglioni MF, Franchi A, Giovanoli P. "Pedicled Chimeric Sensitive Fasciocutaneous ALT and Vastus Lateralis Muscle Flap for Groin Defect Reconstruction." Microsurgery. 2018;38(4):423–426. doi:10.1002/micr.30157

11. Yu P, Sanger JR, Matloub HS, Gosain A, Larson D. "Anterolateral Thigh Fasciocutaneous Island Flaps in Perineoscrotal Reconstruction." Plast Reconstr Surg. 2002;109(2):610–6. doi:10.1097/00006534-200202000-00030

12. Yao H, Zheng D, Wen J, et al. "Reconstruction of Major Scrotal Defects by Anterolateral Thigh Flap." Cell Biochem Biophys. 2014;70(2):1331–5. doi:10.1007/s12013-014-0060-z

13. Spyropoulou GA, Jeng SF, Demiri E, Dionyssopoulos A, Feng KM. "Reconstruction of Perineoscrotal and Vaginal Defects With Pedicled Anterolateral Thigh Flap." Urology. 2013;82(2):461–5. doi:10.1016/j.urology.2013.04.044

14. 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

15. 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

16. Guiotto M, Watfa W, Raffoul W, di Summa PG. "Anterolateral Thigh Flap With Vascularized Fascia Lata Associated With Thigh Flaps — 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

17. Waterhouse N, Healy C. "Vastus Lateralis Myocutaneous Flap for Reconstruction of Defects Around the Groin and Pelvis." Br J Surg. 1990;77(11):1275–7. doi:10.1002/bjs.1800771125

18. Schmidt AB, Fromberg G, Ruidisch MH. "Applications of the Pedicled Vastus Lateralis Flap for Patients With Complicated Pressure Sores." Spinal Cord. 1997;35(7):437–42. doi:10.1038/sj.sc.3100483

19. Acartürk TO, Bengür FB. "Individually Tailored Approach to Reconstruction of Complex Defects Using Versatility of the Lateral Circumflex Femoral Artery System-Based Pedicled Flaps." J Plast Reconstr Aesthet Surg. 2022;75(1):199–209. doi:10.1016/j.bjps.2021.08.035

20. Hsu H, Chien SH, Wang CH, et al. "Expanding the Applications of the Pedicled Anterolateral Thigh and Vastus Lateralis Myocutaneous Flaps." Ann Plast Surg. 2012;69(6):643–9. doi:10.1097/SAP.0b013e3182749d31

21. 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

22. 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

23. Nelson RA, Butler CE. "Surgical Outcomes of VRAM Versus Thigh Flaps for Immediate Reconstruction of Pelvic and Perineal Cancer Resection Defects." Plast Reconstr Surg. 2009;123(1):175–183. doi:10.1097/PRS.0b013e3181904df7

24. Johnstone MS. "Vertical Rectus Abdominis Myocutaneous Versus Alternative Flaps for Perineal Repair After Abdominoperineal Excision of the Rectum in the Era of Laparoscopic Surgery." Ann Plast Surg. 2017;79(1):101–106. doi:10.1097/SAP.0000000000001137

25. 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

26. 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

27. 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

28. Höckel M, Dornhöfer N. "Vulvovaginal Reconstruction for Neoplastic Disease." Lancet Oncol. 2008;9(6):559–568. doi:10.1016/S1470-2045(08)70147-5

29. 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

30. 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

31. Morrison SD, Son J, Song J, et al. "Modification of the Tube-in-Tube Pedicled Anterolateral Thigh Flap for Total Phalloplasty: The Mushroom Flap." Ann Plast Surg. 2014;72(Suppl 1):S22–S26. doi:10.1097/SAP.0000000000000072

32. 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

33. Hanasono MM, Skoracki RJ, Yu P. "A Prospective Study of Donor-Site Morbidity After Anterolateral Thigh Fasciocutaneous and Myocutaneous Free Flap Harvest in 220 Patients." Plast Reconstr Surg. 2010;125(1):209–214. doi:10.1097/PRS.0b013e3181c495ed

34. Puladi B, Ooms M, Geijtenbeek T, et al. "Tolerable Degree of Muscle Sacrifice When Harvesting a Vastus Lateralis or Myocutaneous Anterolateral Thigh Flap." J Plast Reconstr Aesthet Surg. 2023;77:94–103. doi:10.1016/j.bjps.2022.10.036

35. Guillier D, Morelli Coppola M, Watfa W, et al. "Oblique Rectus Abdominis Myocutaneous Versus Anterolateral Thigh-Vastus Lateralis Flap for Perineal Reconstruction: A Retrospective Comparative Study." Plast Reconstr Surg Glob Open. 2026;e7686. doi:10.1097/GOX.0000000000007686