Four Decades of the Anterolateral Thigh Flap: Celebrating a Milestone in Reconstructive Microsurgery.

Background: During the past 4 decades, the anterolateral thigh (ALT) flap has evolved into a cornerstone of reconstructive microsurgery. Since its first description in 1984, advances in perforator dissection and flap design have broadened its applications. Commemorating the 40th anniversary of the ALT flap, this review outlines key anatomical, technical, and clinical milestones that have shaped its evolution and enduring significance. Methods: A narrative review of clinical studies on the ALT flap was conducted, focusing on human, English-language publications from the past 40 years. Studies were selected based on relevance, innovation, and clinical impact. Data were extracted on technique, anatomy, and applications to highlight key advancements in flap evolution. Results: From 2712 articles screened, 138 met the inclusion criteria. Key advancements were categorized into anatomy and perforator patterns, composite and functional flap variants, vascular modifications, refinements in flap thickness, and novel applications with imaging integration. Conclusions: After 4 decades, the ALT flap remains a cornerstone in reconstructive microsurgery due to its reliable anatomy, design versatility, and low donor-site morbidity. Ongoing advances in imaging and surgical planning are expected to further optimize outcomes and expand its applications across complex reconstructive challenges.