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As a distal portion of the descending branch of the lateral circumflex femoral system (LCFS), the role of the distal run-off vessel in anterolateral thigh (ALT) flap surgery has long been overlooked.Recently, however, the distal run-off vessel has been increasingly used in many aspects of ALT flap surgery, and it has exhibited superior properties in solving some difficult problems. Methods:Fourteen ALT flaps utilizing the distal run-off vessel of the descending branch of the LCFS for extremity defects were retrospectively reviewed, and recent reports on utilizing the distal run-off vessel were reviewed to determine the role of this vessel in ALT flap surgery. Results:In our series, the distal run-off vessel was utilized as a flow-through pattern in 10 cases, as a recombined chimeric flap in 2 cases, and as a backup vessel for flap salvage in 2 cases.All of the ALT flaps completely survived.None of the donor sites presented with additional morbidity as a result of harvesting the distal run-off vessel.In the literature review, the following are five other options for utilizing the distal run-off vessel: in interposition artery and vein grafts, as the pedicle of the reverse-flow ALT flap, as the recipient vessel, to avoid twisting, and as a monitoring method.