RECONSTRUCTIVE

Anatomical Variability of the Anterolateral

Thigh Flap Perforators: Vascular Anatomy
and Its Clinical Implications
Yao-Chou Lee, M.D.
Wei-Chen Chen, M.D.
Ting-Mao Chou, M.D.
Shyh-Jou Shieh, M.D., Ph.D.
Tainan, Taiwan
Background: Anatomical variability of perforators of the anterolateral thigh
flap has been reported. The authors introduce a classification based on the
number, location, and origin of the cutaneous perforators to comprehen-
sively illustrate their vascular patterns in hopes that unfavorable anatomi-
cal variations of the anterolateral thigh flap can be overcome in clinical
applications.
Methods: The authors enrolled and reviewed 110 anterolateral thigh flaps
created between September of 2010 and January of 2013 for head and neck
reconstruction after cancer ablation. The location of the perforators was
defined by Yu's ABC system. Its corresponding origin from the descending
or transverse branch of the lateral circumflex femoral artery was clarified by
Shieh's vascular anatomical classification for the anterolateral thigh flap.
Results: Of the 110 flaps, a single perforator (A or B or C) was observed in
20 flaps (18.2 percent), double perforators (A + B or B + C or A + C) were
observed in 59 flaps (53.6 percent), and triple perforators (A + B + C) in 31
flaps (28.2 percent). The origin of perforators was the descending branch
in 76 flaps (69.1 percent), the transverse branch in 10 flaps (9.1 percent),
and both descending and transverse branches in 24 flaps (21.8 percent). The
authors observed 16 vascular patterns. The most common type was double
perforators, with perforators B and C originating from the descending branch
[n = 40 (36.4 percent)].
Conclusions: The clinical significance of each pattern is delineated, and surgi-
cal technical considerations are suggested according to flap requirements and
types of vascular anatomy.  (Plast. Reconstr. Surg. 135: 1097, 2015.)

A
new free flap concept was introduced by
Song et al.1 in 1984. They believed that the
cutaneous branches of the intermuscular
septal artery, not the myocutaneous perforating
arteries, provided the major blood supply to the
skin of the extremities. Based on the septocutane-
ous artery flap concept, they introduced the antero-
medial thigh flap, anterolateral thigh flap, and
posterior thigh flap because the thigh is an ideal
donor site from which to harvest skin flaps of large
size with long and large-caliber vascular pedicles
that allow easy anastomosis and a correspondingly
From the Division of Plastic and Reconstructive Surgery, De-
partment of Surgery, and the Institute of Clinical Medicine,
National Cheng Kung University Medical College and Hospi-
tal; and the International Research Center for Wound Repair
and Regeneration (iWRR), National Cheng Kung University.
Received for publication April 7, 2014; accepted October 7,
2014.
Copyright © 2014 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000001103
high rate of success. The anterolateral thigh flap
was generally used by the authors because it is the
thinnest and easiest to raise among these three
thigh flaps. They defined the perforator anatomy
of the anterolateral thigh flap as the septocuta-
neous perforating artery originating from the
descending branch of the lateral circumflex femo-
ris artery emerging from the intermuscular space
at a fixed point situated at the junction of the mid-
dle and upper thirds of the thigh, where the rectus
femoris muscle, vastus lateralis muscle, and tensor
fasciae latae muscle meet to form a long and nar-
row triangle. However, the vascular anatomy of the
anterolateral thigh flap is not as consistent as Song
et al. suggested. Anatomical variations in the loca-
tion, course, and origin of the cutaneous perfora-
tors have been reported.
Disclosure: The authors have no financial interest to
declare in relation to the content of this article.

www.PRSJournal.com 1097

It was initially reported that the perforator
of the anterolateral thigh flap was located at the
junction of the proximal and middle thirds of
the thigh.1–3 Xu et al.4 found that 92 percent of
the Doppler-detected cutaneous perforators were
located within a circle with a radius of 3 cm, the
center of which is the midpoint of a line linking
the anterior superior iliac spine and the superolat-
eral border of the patella. Zhou et al.5 found that
the exit point of the cutaneous perforator from the
intermuscular septum or from the vastus lateralis is
generally located 2 cm lateral and 2 cm inferior to
the midpoint of the line linking the anterior supe-
rior iliac spine and the superolateral border of the
patella. Kimata et al.6 confirmed that the cutane-
ous perforators were concentrated near the mid-
point of the line linking the anterior superior iliac
spine and the superolateral border of the patella in
their report of 74 clinical cases. In 2004, Yu7 intro-
duced the ABC system to clarify the distribution
and location of the cutaneous perforators. In Yu’s
study, one to three cutaneous perforators of the
anterolateral thigh flap were identified in specific
locations and were named perforators A, B, and C,
from proximal to distal. Perforator B was located
near the midpoint of the line linking the anterior
superior iliac spine and the superolateral border of
the patella. Perforators A and C were found 5 cm
proximal and distal to perforator B, respectively.
The cutaneous perforator of the anterolateral
thigh flap was initially reported as a septocutane-
ous perforator. However, Koshima et al.2 found no
septocutaneous perforators in five of 13 patients,
and a high rate of conversion to the tensor fas-
cia latae or anteromedial thigh flap was inevi-
table in their series. Xu et al.4 pointed out that
cutaneous perforators can be classified into two
types according to their route to the skin. They
reported that 59.8 percent of the cutaneous per-
forators of the anterolateral thigh flap were the
musculocutaneous type, which pass through the
vastus lateralis muscle, and 40.2 percent were the
septocutaneous type, which traverse the inter-
muscular septum between the vastus lateralis and
rectus femoris muscles. Several clinical and ana-
tomical studies5,6,8,9 also reported that the cutane-
ous perforators of the anterolateral thigh flap are
predominantly musculocutaneous. Shieh et al.
further classified the vascular anatomical varia-
tions of the anterolateral thigh flap according to
the course and origin of the pedicle.9
It was believed that the descending branch
of the lateral circumflex femoral artery is the
vascular pedicle of the anterolateral thigh flap.
However, cutaneous perforators derived from the
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Plastic and Reconstructive Surgery • April 2015
profunda femoris artery were reported in a range
from 1.4 to 38.5 percent.2,6,7 Perforators arising
from the transverse branch of the lateral circum-
flex femoral artery were found in 4 to 32.4 per-
cent of patients.5,7,9 Recently, although the issue is
still being debated in the literature,10 an alterna-
tive branch, called the “oblique” branch from the
lateral circumflex femoral artery, was reported by
Wong et al.11 The dominant perforator supplying
the anterolateral thigh flap originated from the
oblique branch in 14 percent of their cases.
Whether the cutaneous perforator is septo-
cutaneous or musculocutaneous does not matter,
because it is always possible to trace it to the main
pedicle.8 Thus, we introduce a classification to dem-
onstrate every possible vascular pattern based on the
number, location, and origin of the cutaneous perfo-
rators. The clinical considerations for each variation
will be discussed with the hope that the unfavorable
anatomical variations of the anterolateral thigh flap
can be overcome in clinical applications.
PATIENTS AND METHODS
From September of 2010 to January of 2013,
we reviewed anterolateral thigh flaps performed
by the authors (Y.C.L., W.C.C., T.M.C., and S.J.S)
for head and neck reconstruction after cancer
ablation at National Cheng Kung University Hos-
pital. Three flaps lacking complete vascular anat-
omy records were excluded. In total, there were
110 anterolateral thigh flaps with complete vascu-
lar anatomy records for 105 men and five women.
Three hundred twenty-nine cutaneous perfora-
tors were identified, with at least one reliable per-
forator for each patient (Fig. 1). The number of
cutaneous perforators present in each flap ranged
from one to five and averaged 2.99.
Surgical Technique
The patient is placed in supine position with
the leg straight in a neutral position. A line linking
the anterior superior iliac spine and the supero-
lateral border of the patella and a circle with a
3-cm radius centered at the midpoint of the line
linking the anterior superior iliac spine and the
superolateral border of the patella are drawn. One
team performs a flap elevation and a second team
simultaneously performs a tumor resection. An
anterior skin incision is made directly above the
rectus femoris muscle. The dissection is carried
out medially approximately 1 to 2 cm in a sub-
cutaneous plane. The deep fascia is incised and
transfixed to the dermis with sutures to preserve
the prefascial plexus. The subfascial dissection
Volume 135, Number 4 • Anterolateral Thigh Flap Perforators

Fig. 1. Cutaneous distributions of the 329 anterolateral thigh perforators in the

110 patients were presented by the relative locations in between the anterior
superior iliac spine and the patella. ASIS, anterior superior iliac spine; ASIS-per-
forator, distance measured from the anterior superior iliac spine to the cutane-
ous location of the perforator; ASIS-patella, distance measured from the anterior
superior iliac spine to the superolateral border of the patella; (ASIS-perforator)/
(ASIS-patella), ratio between the distance measured from the anterior superior
iliac spine to the cutaneous location of the perforator and the distance measured
from the anterior superior iliac spine to the superolateral border of the patella.

proceeds laterally until cutaneous perforators are
identified. The intermuscular septum of the rectus
femoris and vastus lateralis muscle is dissected to
explore the descending branch of the lateral cir-
cumflex femoral artery. For the musculocutaneous
perforators, the vastus lateralis muscle above the
perforator is incised to clarify the route of penetra-
tion as described previously.6 Elevation of the per-
forator is performed with a 0.5-cm cuff of vastus
lateralis muscle attached. Flap design is finalized
only when the dimension of the defect is known.
The following measurements were taken in each
anterolateral thigh flap before the vascular pedicle
was divided: (1) the distance between the anterior
superior iliac spine and the superolateral patella,
(2) the distance between the anterior superior iliac
spine and the surface location of cutaneous perfo-
rators, (3) the pedicle length measuring from the
site where the perforator pierced the deep fascia to
the division level of the pedicle, (4) the flap thick-
ness at three different levels (i.e., midpoint of the
line linking the anterior superior iliac spine and the
superolateral border of the patella and 5 cm more
proximally and distally), (5) the class of each per-
forator based on Yu’s ABC system,7 and (6) the type
of each perforator according to Shieh’s classifica-
tion9 (type I, vertical musculocutaneous perforator
derived from the descending branch of the lateral
circumflex femoral artery; type II, horizontal muscu-
locutaneous perforator derived from the transverse

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Table 1.  Characteristics of 329 Perforators in 110 Anterolateral Thigh Flaps

Mean No. of Distance Flap
Yu ABC Perforator No. of No. of Perforators per from ASIS Pedicle Thickness
Classification Perforators (%) Patients (%) Case (Range) (cm) Length (cm) (cm)
A 55 (16.7) 47 (42.7) 1.2 (0–2) 15.3 ± 2.8 10.4 ± 2.8 1.3 ± 0.4
B 105 (31.9) 88 (80.0) 1.2 (0–2) 21.1 ± 2.6 14.6 ± 2.9 1.1 ± 0.4
C 169 (51.4) 96 (87.3) 1.8 (0–4) 28.4 ± 3.4 21.3 ± 3.9 0.9 ± 0.3
ASIS, anterior superior iliac spine.

Table 2.  Perforator Patterns According to the Shieh* and Yu† Classifications
Shieh Perforator Classification
Musculocutaneous Septocutaneous
Yu ABC Perforator
Classification Type I: Vertical (%) Type II: Horizontal (%) Type III: Vertical (%) Type IV: Horizontal (%)
A 6 (10.9) 13 (23.6) 14 (25.5) 22 (40.0)
B 61 (58.1) 21 (20.0) 19 (18.1) 4 (3.8)
C 150 (88.8) 7 (4.1) 12 (7.1) 0 (0.0)
Total 217 (66.0) 41 (12.5) 45 (13.7) 26 (7.9)
*Shieh SJ, Chiu HY, Yu JC, Pan SC, Tsai ST, Shen CL. Free anterolateral thigh flap for reconstruction of head and neck defects following cancer
ablation. Plast Reconstr Surg. 2000;105:2349–2357; discussion 2358.
†Yu P. Characteristics of the anterolateral thigh flap in a Western population and its application in head and neck reconstruction. Head Neck
2004;26:759–769.

Fig. 2. Illustrated and clinically observed vascular patterns of the anterolateral thigh flap with a single perforator. d-LCFA, descend-
ing branch of the lateral circumflex femoral artery; t-LCFA, transverse branch of the lateral circumflex femoral artery; FA, femoral
artery; DFA, deep femoral artery; SFA, superficial femoral artery; AB, ascending branch of the lateral circumflex femoral artery; TB,
transverse branch of the lateral circumflex femoral artery; DB, descending branch of the lateral circumflex femoral artery.

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branch of the lateral circumflex femoral artery; type
III, vertical septocutaneous perforator derived from
the descending branch of the lateral circumflex
femoral artery; and type IV, horizontal septocutane-
ous perforator derived from the transverse branch
of the lateral circumflex femoral artery).
RESULTS
Of the 329 perforators, when we categorized
the perforators into Yu’s ABC system, the proximal
perforator A could be identified in 42.7 percent of
the patients, the midpoint perforator B could be
identified in 80 percent of the patients, and the dis-
tal perforator C could be identified in 87.3 percent
of the patients. Perforator C accounted for 51.4
percent of the perforators, perforator B accounted
for 31.9 percent, and perforator A accounted for
16.7 percent. The mean distance from the anterior
superior iliac spine to the cutaneous location of
the perforator was 15.3 ± 2.8 cm for perforator A,
21.1 ± 2.6 cm for perforator B, and 28.4 ± 3.4 cm
for perforator C. The average pedicle length was
10.4 ± 2.8 cm if perforator A was chosen as the
most proximal perforator, 14.6 ± 2.9 cm if perfora-
tor B was chosen, and 21.3 ± 3.9 cm if perforator C
was chosen. The flap thickness gradually became
thinner from proximal to distal: 1.3 ± 0.4 cm at
the perforator A level, 1.1 ± 0.4 cm at the perfora-
tor B level, and 0.9 ± 0.3 cm at the perforator C
level (Table 1). The course and origin of the per-
forators were also categorized according to Shieh’s
classification (Table 2). Perforator A most com-
monly presented as type IV (40 percent); it was

Fig. 3. Illustrated and clinically observed vascular patterns of the anterolateral thigh flap with double perforators. d-LCFA, descend-
ing branch of the lateral circumflex femoral artery; t-LCFA, transverse branch of the lateral circumflex femoral artery; FA, femoral
artery; DFA, deep femoral artery; SFA, superficial femoral artery; AB, ascending branch of the lateral circumflex femoral artery; TB,
transverse branch of the lateral circumflex femoral artery; DB, descending branch of the lateral circumflex femoral artery.

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 Plastic and Reconstructive Surgery • April 2015

primarily septocutaneous (65.5 percent) and had
a transverse branch of the lateral circumflex femo-
ral artery origin (63.6 percent). Perforator B most
commonly presented as type I (58.1 percent); it was
primarily musculocutaneous (78.1 percent) and
had a descending branch of the lateral circumflex
femoral artery origin (76.2 percent) dominance.
Perforator C most commonly presented as type I
(88.8 percent); it was primarily musculocutaneous
(92.9 percent) and had a descending branch of
the lateral circumflex femoral artery origin (95.9
percent). Overall, musculocutaneous perforators
were more common than septocutaneous perfo-
rators (78.5 percent versus 21.6 percent), and a
descending branch of the lateral circumflex femo-
ral artery origin was more common than a trans-
verse branch of the lateral circumflex femoral
artery origin (79.7 percent versus 20.4 percent).
Of the 110 anterolateral thigh flaps, a single
perforator (A or B or C) was observed in 20 flaps
(18.2 percent), double perforators (A + B or B + C
or A + C) were observed in 59 flaps (53.6 percent),
and triple perforators (A + B + C) were observed
in 31 flaps (28.2 percent). For the 20 flaps with a
single perforator, 17 were perforator B or C with a
descending branch of the lateral circumflex femo-
ral artery origin and three were perforator A or B
with a transverse branch of the lateral circumflex

Fig. 4. Illustrated and clinically observed vascular patterns of the anterolateral thigh flap
with triple perforators. d-LCFA, descending branch of the lateral circumflex femoral artery;
t-LCFA, transverse branch of the lateral circumflex femoral artery; FA, femoral artery; DFA,
deep femoral artery; SFA, superficial femoral artery; AB, ascending branch of the lateral cir-
cumflex femoral artery; TB, transverse branch of the lateral circumflex femoral artery; DB,
descending branch of the lateral circumflex femoral artery.

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femoral artery origin (Fig. 2). The most com-
mon type was perforator C, originating from the
descending branch of the lateral circumflex femo-
ral artery [n = 10 (50 percent)]. Neither single per-
forator A with a descending branch of the lateral
circumflex femoral artery origin nor single per-
forator C with a transverse branch of the lateral
circumflex femoral artery origin was observed.
For the 59 flaps with double perforators, 47 had a
descending branch of the lateral circumflex femo-
ral artery origin, five had a transverse branch of the
lateral circumflex femoral artery origin, and seven
had a dual origin (Fig. 3). The most common type
was perforator B and C, and both originated from
the descending branch of the lateral circumflex
femoral artery [n = 40 (67.8 percent)]. We did not
observe the type of perforator A and B with a dual
origin. For the 31 flaps with triple perforators, 12
had a descending branch of the lateral circumflex
femoral artery origin, two had a transverse branch
of the lateral circumflex femoral artery origin, and
17 had a dual origin (Fig. 4). The most common
type was perforators originating from the descend-
ing branch of the lateral circumflex femoral artery
[n = 12 (38.7 percent)]. Overall, 69.1 percent of
the flaps had a descending branch of the lateral
circumflex femoral artery origin, 9.1 percent had
a transverse branch of the lateral circumflex femo-
ral artery origin, and 21.8 percent had a dual ori-
gin (Fig. 5). The most common type was double
perforator B and C originating from the descend-
ing branch of the lateral circumflex femoral artery
(36.4 percent). Theoretically, there will be 19 types
that can be illustrated. In this study, however, we
observed only 16 types; those we did not observe
show n = 0 in Figures 2 through 4 and 0 percent
in Figure 5.
DISCUSSION
Using a combination of Yu’s ABC system and
Shieh’s vascular classification, we report 19 vas-
cular branching patterns (based on the number,
location, and origin of the cutaneous perforators)
that present the characteristics of the anterolat-
eral thigh flap perforators in an Asian population.
The characteristics of the cutaneous perforators
of the anterolateral thigh flap between our study

Fig. 5. The prevalence of the 19 possible vascular patterns in the 110 anterolateral thigh flaps. d-LCFA, descending branch of the
lateral circumflex femoral artery; t-LCFA, transverse branch of the lateral circumflex femoral artery; FA, femoral artery; DFA, deep
femoral artery; SFA, superficial femoral artery; AB, ascending branch of the lateral circumflex femoral artery; TB, transverse branch
of the lateral circumflex femoral artery; DB, descending branch of the lateral circumflex femoral artery.

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 Plastic and Reconstructive Surgery • April 2015

population and Western populations are similar
for perforators A and B but not for perforator
C.7,12,13 We found that perforator C was most fre-
quent (87.3 percent of patients). This difference
may be attributable to the longer (approximately
20 cm versus approximately 15 cm in the Yu clas-
sification) anterior skin incision that permitted
a more extensive exploration of the perforators
and, perhaps, to our familiarity with the intramus-
cular dissection technique. The vascular variations
between Asian and Western populations require
additional study.
Selecting a suitable perforator for the antero-
lateral thigh flap is related to the length of the
pedicle and the thickness of the skin flap. Clini-
cally, the most proximal one is preferable for two
reasons: it has a relatively larger diameter and it
can be simply and quickly elevated.9 Saint-Cyr et
al. proposed an algorithm for perforator selection
by using a basic step-by-step approach.14 Proximal
A perforator is routinely used in most cases, and
midpoint perforator B is routinely committed
to if A is unavailable. Harvest time averages
between 30 and 45 minutes. The drawback of this
approach is the limited pedicle length: additional
pedicle length may be necessary. Ligating the rec-
tus femoris branch to provide the extra length,
however, might invite risks of unwanted rectus
femoris muscle necrosis.15,16 If a long pedicle is
necessary because of conditions at the recipient
site, distal perforators can be selected to reach a
pedicle length as long as 20 cm.6 Yu7 reported a
pedicle length of 9.7 ± 1.5 cm if perforator A was
selected as the most proximal nutrient vessel, and
of 13.2 ± 2.2 cm if perforator B was selected. Ped-
icle length was not measured if only perforator C
was selected. In our study, the pedicle length was
similar when perforator A or B was used, but it was
21.3 ± 3.9 cm if perforator C was selected as the
only nutrient vessel.
If a thinner flap is required, a perforator
that is more distal can be selected. Anterolateral
thigh flap thicknesses in Yu’s Western population
were 18.3 ± 8.8 mm (perforator A), 15 ± 7 mm

Fig. 6. Modifications in flap design to obtain sufficient pedicle length according to the location of the selected reliable perforator.
FA, femoral artery; DFA, deep femoral artery; SFA, superficial femoral artery; LCFA, lateral circumflex femoral artery; AB, ascend-
ing branch of the lateral circumflex femoral artery; TB, transverse branch of the lateral circumflex femoral artery; DB, descending
branch of the lateral circumflex femoral artery. *While taking the strategy of selecting the distal C perforator to obtain a long
pedicle length, we suggest including more than one C perforator whenever possible to ensure the flap circulation because of the
small size of the distal C perforator.

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(perforator B), and 12.5 ± 6.4 mm (perforator
C).7 Anterolateral thigh flap thicknesses in our
Asian population were 13 ± 4 mm (perforator A),
11 ± 4 mm (perforator B), and 9 ± 3 mm (perfo-
rator C). When a thin and pliable anterolateral
thigh flap is required, a thinning procedure may
be necessary in Western populations, but select-
ing distal perforators may be preferable in Asian
populations.
For flaps with only a single perforator, which
might originate either from the descending
branch of the lateral circumflex femoral artery
or the transverse branch of the lateral circum-
flex femoral artery, the flaps should be modified
according to the required flap size, pedicle length,
and flap thickness. Koshima et al.17 claimed that
a single dominant perforator can supply a skin
flap as long as 35 cm and as wide as 25 cm. We
believe that “dominant perforator” means the
perforator A or B; therefore, when a large flap
is required in the type of single perforator C, we
recommend shifting to the tensor fasciae latae,
anteromedial thigh, or contralateral anterolat-
eral thigh flap. According to our data, this type
of single perforator C was present in 9.1 percent
of the patients. When a long pedicle is required,
the flap design of a single perforator A type may
need to be modified by placing the perforator in
a proximally eccentric location or by using the
method of proximal deepithelialization to avoid
vein graft interposition (Fig. 6). When a thin skin
flap is favored, a single perforator A may need
immediate thinning or secondary debulking
surgery, whereas a single perforator C type may
already be thin enough to be pliable.
For flaps with double or triple perforators, the
perforators might originate from the descending
branch of the lateral circumflex femoral artery, the
transverse branch of the lateral circumflex femoral
artery, or both. In general, when the required skin
flap is not large, perforator selection depends on
the pedicle length and flap thickness needed. When
a long pedicle is necessary, a middle perforator B
or distal perforator C is preferable. When pedicle
length is not the concern, a proximal perforator A
is preferable because it is large and easier to harvest.
When a thin and pliable skin flap is required, a distal
anterolateral thigh flap supplied by a distal perfora-
tor C is preferable. When a bulky flap is required to
eliminate the dead space of the defects, the proximal
anterolateral thigh flap nourished by proximal per-
forator A is preferable. When a large flap is required,
a large skin flap can be safely harvested by including
multiple perforators. The potential difficulty may

Fig. 7. When a large flap is required, multiple perforators are preferred to prevent
marginal necrosis. If a common mother vessel is available, only one set of microanas-
tomoses is needed. If no common mother vessel is available, two sets of microanas-
tomoses are needed. TB, transverse branch of the lateral circumflex femoral artery;
DB, descending branch of the lateral circumflex femoral artery.

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occur in the types of perforators originating from
both the descending and transverse branches of the
lateral circumflex femoral artery, which occurred
in 21.8 percent of the patients in our series. More
extensive proximal dissection to achieve a common
mother vessel may be needed for single arterial and
venous microanastomosis. If no common mother
vessel can be identified, two sets of vascular anasto-
moses will be suggested to ensure flap circulation
(Fig. 7). If only one set of recipient vessels is avail-
able, a branch-based perforator flap conjoined by
anastomosis is required.18 When two skin paddles
are needed, a bipaddle design with multiple perfo-
rators or a bilobe design with single perforators can
be used (Fig. 8).
Primary closure of the donor-site wound should
be a goal because it precludes unwanted morbid-
ity.15,16,19 In anterolateral thigh flaps with only a
single perforator, the feasibility of primary closure
is related to flap width. Skin grafting is usually nec-
essary when the defect width is greater than 8 cm
or the width-to-thigh circumference ratio is greater
than 16 percent.9,20 In anterolateral thigh flaps with
multiple perforators, the perforators not included
in the skin flap can be used as an island flap with
V-Y advancement to facilitate donor-site closure.21
Marsh and Chana22 provided another novel clini-
cal application in the design of anterolateral thigh
flaps with multiple perforators. They designed two
narrow skin flaps nourished independently by their
corresponding perforator and then sutured side-by-
side to recreate a wider skin flap for reconstructing
a large defect. Primary closure was also possible for
the resultant donor site in their study.
CONCLUSIONS
We present the anterolateral thigh perforator
pattern in an Asian population by adopting Yu’s
ABC system and Shieh’s vascular classification to
introduce 19 vascular patterns of the anterolateral
thigh flap based on the perforator number, loca-
tion, and origin. We found a higher occurrence
of perforator C and thinner flaps compared with
Western populations. Special flap requirements
such as a long pedicle, a thin and pliable skin flap,
a large flap, and the need for two skin paddles may
not be met by some unfavorable vascular patterns.

Fig. 8. When two skin paddles are required, a bipaddle design in the case of multiple
perforators or bilobe design in the case of a single perforator can be used. FA, femoral
artery; DFA, deep femoral artery; SFA, superficial femoral artery; LCFA, lateral circumflex
femoral artery; AB, ascending branch of the lateral circumflex femoral artery; TB, trans-
verse branch of the lateral circumflex femoral artery; DB, descending branch of the lat-
eral circumflex femoral artery.

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We suggest several technical modifications to over-
come these difficulties. First, when a pedicle with a
single A perforator is short, proximal deepithelial-
ization can be used to avoid vein graft use. Second,
when a thin and pliable skin flap is preferable, the
distal perforator C based–anterolateral thigh flap
can be selected, but tedious intramuscular dissec-
tion is usually inevitable. Third, when a large flap
is required to reconstruct extensive defects, two or
more perforators should be included to prevent
marginal necrosis. In flaps with multiple perforators
originating from both the descending and trans-
verse branches of the lateral circumflex femoral
artery, two sets of recipient vessels may be necessary
if a common mother vessel is not available. Fourth,
when two skin paddles are needed, a bipaddle
design with multiple perforators or a bilobe design
with single perforators can be used. These clinical
implications can be used in combination according
to the flap requirements and the types of vascular
anatomy. We believe that a better understanding of
these anatomical variations will be helpful for flap
refinements and donor-site management.
Shyh-Jou Shieh, M.D., Ph.D.
Division of Plastic and Reconstructive Surgery
Department of Surgery
National Cheng Kung University
Medical College and Hospital and
International Research Center for
Wound Repair and Regeneration (iWRR)
National Cheng Kung University
138 Sheng-Li Road
Tainan 70403, Taiwan
sjshieh@mail.ncku.edu.tw
acknowledgment
This work was supported by National Cheng Kung
University Hospital Grant no. NCKUH-10403004,
National Cheng Kung University Top-Notch Project
Grant no. D104-35B04, and Taiwan National Science
Council Grant no. NSC-99-2314-B-006-013-MY2.
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