Outcomes of Different Donor Site Closure Techniques for Anterolateral Thigh (ALT) Free Flaps: A Systematic Review and Meta-analysis

Introduction: The anterolateral thigh (ALT) flap is a versatile option in reconstructive surgery, yet donor site closure remains a subject of debate. While primary direct closure (PDC) is straightforward, secondary techniques—such as skin grafts (STG), V-Y closure, local flaps, and artificial dermis—may offer better outcomes for selected patients. Methods We conducted a systematic review and meta-analysis following PRISMA guidelines, screening PubMed, Scopus, and Cochrane databases for studies published up to July 2025. Eligible studies compared donor site complications between PDC and alternative closure techniques in ALT flap harvest. Data extraction and risk of bias assessment were performed independently by two reviewers. Pooled odds ratios (OR) with 95% confidence intervals (CI) were calculated for key complications, including scar hypertrophy, spread scar, paresthesia, hypoesthesia, motor deficit, and muscle herniation. Results Thirty-two studies (n = 1509 patients) met the inclusion criteria. Compared to PDC, skin grafting significantly reduced the odds of scar hypertrophy (OR 0.41, 95% CI 0.23–0.73) and spread scar (OR 0.49, 95% CI 0.28–0.85), and lowered motor deficits (OR 0.51, 95% CI 0.27–0.96). However, STG was associated with a higher risk of muscle herniation (OR 3.12, 95% CI 1.15–8.45). V-Y closure and other local flap techniques demonstrated promising outcomes in limited studies but lacked sufficient pooled evidence. Conclusions No single closure method is universally optimal. Skin grafting offers advantages in reducing certain scar-related complications but may increase the risk of muscle herniation. Closure choice should be guided by flap size, defect width, and patient-specific factors. Future randomized controlled trials are needed to refine donor site closure algorithms and improve functional and aesthetic outcomes.