The efficacy of the use of the pedicled ALT flap for buttock defects has not been established in the literature. Here, we present a case of a successful reconstruction of a large gluteal defect after sarcoma resection using a pedicled ALT flap assisted by preoperative computed tomographic angiography (CTA) and intraoperative indocyanine green (ICG) angiography. A 94-year-old man underwent resection of a large soft tissue tumor in the gluteal region resulting in a 19 × 15 cm defect. Based on three-dimensional reconstructed images of the preoperative CTA, the length of the pedicle of an ALT flap was estimated. Perfusion of the whole flap was confirmed using intraoperative ICG angiography. The flap was inserted through a subcutaneous tunnel and covered the defect completely. The postoperative course was uneventful. The patient resumed ambulation 1 week after the operation. The follow-up at 2 months showed complete flap survival, and the patient was able to walk with a cane. The pedicled ALT flap transfer may be a reliable alternative for gluteal reconstruction when guided by pre- and intraoperative imaging modalities.

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