Dear Editor, To ensure full transparency and adherence to best practices in artificial intelligence (AI)-related research reporting, this study complies with the TITAN Guidelines 2025 for transparency in the reporting of AI1. The anterolateral thigh (ALT) perforator flap has evolved into one of the most widely used flaps in reconstructive microsurgery. It is routinely applied for the reconstruction of limb, maxillofacial, and breast defects2. Following flap harvest, donor-site closure is essential; however, primary closure is not always feasible, especially when large flaps are harvested or when the donor-site skin has limited laxity. Forced primary closure may lead to delayed wound healing or even ischemic necrosis of the rectus femoris. Alternatively, skin grafting may be employed, but this requires sacrificing a secondary donor site3. With over a decade of experience in limb reconstruction using ALT perforator flaps4, our team has adopted an alternative strategy: harvesting regional pedicled perforator flaps adjacent to the ALT donor site to assist closure. This technique allows for tension-free closure without grafting, thereby preserving the integrity of a second donor site. In 11 patients where direct primary closure of the ALT donor site was not possible, we successfully employed this method (Supplemental Digital Content Table 1, available at: https://links.lww.com/JS9/G960). Only one case required minimal supplementary skin grafting (patient 11). The pedicled perforator flaps were designed in a freestyle manner by identifying perforators in areas of relatively low skin tension, such as the lateral or medial supra-knee and the medial thigh. After disassociating the perforators, the flaps were transposed, directly, or with an angle of rotation, to assist closure at the region of highest tension – typically the mid-to-lower third of the thigh. The size of these regional pedicled flaps ranged from 6 × 4.5 cm to 12 × 4 cm (Supplemental Digital Content Table 1, available at: https://links.lww.com/JS9/G960). The flap designs can be generally classified into three categories (Fig. 1A): Lateral supra-knee perforator kite flaps – based on stable perforators close to the mid-lower thigh and purposely designed by including the distal “triangle” zone – an area normally resected during closure to avoid dog-ear deformity – to utilize otherwise discarded tissue. After minimal pedicle dissection, these triangular flaps were advanced proximally in a V-Y fashion (like a kite flap) with or without slight rotation, to effectively cover the high-tension proximal area (n = 4; Fig. 1B–D). Anteromedial thigh perforator propeller flaps – designed in the proximal-to-mid anteromedial thigh, rotated nearly 120–180° after pedicle dissection to cover the distal portion of the donor site under greatest tension (n = 4; Fig. 2). Medial supra-knee perforator propeller flaps – harvested near the medial knee and rotated nearly 180° laterally to reinforce lateral closure (n = 3; Supplemental Digital Content Figure 1, available at: https://links.lww.com/JS9/G960). Figure 1.: (A) Three distinct local pedicled perforator flap transpositions were utilized to facilitate donor-site closure following harvest of anterolateral thigh perforator flap. (B–D) Type 1 closure. (B) High tension prevented primary closure of the anterolateral thigh donor site. (C) A lateral supra-knee (LSK) perforator kite flap was dissected and elevated as a regional pedicled perforator flap. (D) Immediate tension-free closure was achieved following LSK flap transfer. Points “a” and “b” indicate the two vertices of the flap.Figure 2.: Type 2 closure. An anteromedial thigh (AMT) perforator propeller flap was harvested as a regional pedicled flap to close the anterolateral thigh (ALT) donor site. (A) High tension prevented primary closure of the ALT donor site. (B, C) The flap before and after transfer with approximately 120° rotation to the mid-to-lower third of the thigh. (D) Immediate tension-free closure after AMT flap transfer. (E) One-year follow-up after surgical closure. Points “a” and “b” indicate the two vertices of the flap. All these cases involved large hand or foot soft-tissue defects necessitating wide ALT flap harvests, indirectly leading to donor-site closure difficulty. By using our freestyle pedicled perforator flaps, however, the ALT donor sites were all successfully closed. All flaps – across the three described subtypes – achieved complete survival, with no instances of vascular compromise, delayed healing, or donor-site morbidities (wound dehiscence or musculoskeletal dysfunction). Importantly, the concept of perforator flap allowed us to preserve the deep fascia during flap harvest, reducing the risk of postoperative muscle hernia and distinguishing our techniques from traditional fascial pedicled flaps5. We acknowledge that we did not systematically record operative time, pedicle lengths, flap sizes, or arc of rotation. Nonetheless, we believe this experience offers valuable insights for microsurgeons whoever harvest flaps from the ALT. Compared with skin grafting, our approach avoids secondary donor-site morbidity and problems of color mismatch or contour irregularities often seen with skin grafting6. While it remains uncertain whether the operative time is longer or shorter compared to alternatives such as skin grafting, our technique effectively avoids the complications associated with forced closure and offers a cost-effective and reliable option for reconstruction. Our technique also stands in contrast to the double-paddle ALT flap, another closure approach that stacks paddles side-by-side to halve the donor-site width7. We instead harvest ALT flap as a single, continuous unit followed by our closure techniques, thereby avoiding visible junctions between skin paddles, ensuring superior aesthetics, integrity, and simplicity. The present study outlines three procedural types to standardize this freestyle technique, which obviates the need for deliberate perforator tracing by leveraging the existing donor incision. Given that this technique is employed for donor-site closure following a free ALT flap harvest, the target surgeons are already thoroughly familiar with the local perforasome anatomy, thus naturally resulting in a short learning curve and low technical demands. In summary, the use of freestyle regional pedicled perforator flaps provides a practical and reliable solution for challenging ALT donor-site closures. This technique minimizes morbidity, avoids secondary donor sites, and ensures tension-free healing, thereby offering microsurgeons an effective and economical strategy for optimizing reconstructive outcomes. Future studies should directly compare this technique to alternatives, with long-term follow-up and patient-reported outcomes, to definitively establish its benefits.
Ou et al. (2026) studied this question.