INTRODUCTION: Coverage of large, complex defects with durable skin and soft tissues can be a reconstructive challenge. The TRAM flap can be use reliably for this purpose; however, sufficient abdominal tissues are not always available. Although regional and microvascular free flaps based on perforating vessels from the tensor fascia lata muscle are well described, few series have described the use of an extended skin paddle design to transfer large amounts of skin and soft tissues. Over the last 10 years we have used the TFL flap in situations when the TRAM flap is not available or not sufficient to provide substantial amounts of skin and soft tissues. The purpose of this study was to review our experience with the extended TFL flap and to highlight the utility of this reliable flap. METHODS: This was a retrospective review of all patients treated with an extended TFL flap (defined as a skin paddle area greater than 200 cm2) between 1989 and 2002. Patient demographics, reconstructive goals, complications, and outcomes were analyzed. RESULTS: Twelve extended TFL flaps were performed during the study period. Flaps were performed for cancer reconstruction in 9 cases, radiation necrosis in 2 cases, and trauma in one case. Defects included: breast (6), chest-wall (3), shoulder girdle (1), traumatic lower extremity (1), and abdominal/groin (1). Extended TFL flaps used in this series were centered on the lateral thigh and often included a significant portion of the skin and soft tissues both medially and laterally (25 cm in one case). In our experience, the length of the flap could also be extended reliably to a point approximately 10 cm above the lateral aspect of the knee (the longest flap in our series was 37cm). Mean flap skin surface area was 387 cm2 (range 200-875 cm2). All flaps were transferred based on the lateral femoral circumflex artery; in 2 cases the skin flap included identifiable perforators from both the transverse and descending circumflex branches of the lateral circumflex femoral artery. There were no vascular thromboses; nor were there any partial or total flap losses. Complications included superficial wound infection (1), suture line dehiscence (1), rectus femoris ischemia (1), recurrent seroma under the flap (1), lymphocutaneous fistula, and self extubation/cardiac arrest (1). There were no deaths. The donor site was closed primarily in 6 cases; none of these developed persistent seromas. The remaining donor sites were skin grafted. There were no reconstructive failures. Adjuvant therapy was not delayed in any patient. DISCUSSION: We have found that the extended free TFL flap can be used for a wide variety of reconstructive applications, especially when the principle challenge is coverage of a large surface-area defect. With the increasing popularity of the TRAM flap for breast reconstruction, as well as lower threshold for radiation therapy, we anticipate that our needs for a method to deliver large amounts of well vascularized tissues (without the need for skin grafting) will also increase. The extended TFL flap is an ideal choice in these circumstances.