Cranial Vault and Scalp Reconstruction Utilizing Anterolateral Thigh Free Tissue Transfer

OBJECTIVES: Composite cranioplasty reconstruction must protect underlying neural tissue, create a watertight dural barrier, and recreate the natural contour of the scalp/skull. Harvested as a fasciocutaneous, adipofascial, or fascial flap, the anterolateral thigh (ALT) free flap offers a versatile solution to multiple cranial defect types. This study compares utilization and outcomes of cranioplasty reconstruction utilizing three different ALT flap types at a single institution. METHOD: A retrospective review was completed of patients undergoing ALT cranioplasty at a single institution between 01/01/2019 and 2/1/2025. Flaps were performed as fascia lata only, adipofascial, or fasciocutaneous depending on the nature of the defect. Trends in utilization, outcomes, and complications were collected. RESULTS: A total of 72 patients underwent 79 ALT free tissue transfers categorized as fascia lata (n = 22), fasciocutaneous (n = 35), or adipofascial (n = 22). Defects most commonly involved the scalp/skull for all flap types. Although not reaching statistical significance, fasciocutaneous and adipofascial flaps tended to experience high overall complications (29% and 27%, respectively, vs. 5% for fascial alone). Most complications were due to infection or dehiscence. Similarly, flap failure rates did not differ significantly but tended to be higher for fasciocutaneous flap reconstruction (11%, vs. adipofascial 5% vs. fascial alone 0%). CONCLUSION: The ALT free flap with perforator harvest and minimal access recipient vessel procurement technique offers an adaptable and effective reconstructive option for a wide variety of complex scalp and cranial vault defects.