Optimizing Primary Closure of Anterolateral Thigh Flap Donor Sites Through Literature Review and Clinical Analysis.

Background: The anterolateral thigh (ALT) flap is widely used in reconstructive surgery due to its reliable vascular pedicle, abundant perforators, and favorable donor site. Although skin grafting is common for donor-site closure, it has limitations such as reduced durability and functional restrictions. This study proposed a comprehensive algorithm for ALT flap donor-site closure. Methods: A literature review was performed to summarize existing strategies for ALT flap donor-site closure. Based on these findings, an initial algorithm was proposed to guide donor-site closure. This algorithm was subsequently applied in clinical practice by a single surgeon between 2021 and 2023. A retrospective analysis of patients who underwent ALT flap reconstruction during this period was conducted to evaluate clinical outcomes. Results: A total of 37 patients were managed using the initial clinical algorithm, most of whom were men and underwent reconstruction for head and neck cancer. Primary closure was achieved in 91.9% of cases, including 70.3% by direct closure. In cases where direct closure was not feasible, supplementary flaps were used to achieve tension-free closure. Both flap width and postharvest defect width were identified as key factors influencing the feasibility of direct closure, with an optimal flap width cutoff of 7.75 cm. These findings guided the refinement of the clinical decision-making algorithm. Conclusions: Donor site management remains an important consideration in ALT flap reconstruction. A stepwise approach combining planning and surrounding supplementary flaps enabled primary closure in most cases.