BACKGROUND: During the free flap surgery obtaining a suitable recipient vein is an important factor for successful outcome. As in all other flaps even in ALT flap, single or double venous anastomosis, superficial or deep venous anastomosis is still a matter of debate among the micro vascular surgeons. Though dual vein anastomosis is a time-tested method, single vein anastomosis has the advantage of reducing the operative time and hospitalization cost. Similarly, in situation where the deep veins are dubious superficial veins are savior. This study explores the outcome of ALT flap using different system of recipient veins. PATIENTS AND METHODS: Retrospective analysis of the 54 free ALT flaps performed over a period of 5 years from June 2017 till June 2022, was carried out. Out of 54, 38 (63%) were male patients and 16 (37%) were females. The outcome of the flaps was evaluated in single or dual anastomosis group. Similarly, the outcome of the flaps with deep or superficial vein anastomosis was also evaluated. The flaps outcomes are evaluated as favorable (successful as well as partial loss are considered as favorable) and unfavorable (complete loss of the flap). RESULTS: Among the 54 flaps, 31 patients had lower limb reconstruction, majority were post-traumatic defects. Twenty patients had head and neck reconstruction following post malignancy excision. Three patients had upper-limb reconstruction for post traumatic and burn injury defects. The outcome was analyzed. Twenty patients had dual vein anastomosis, 90% (18 out of 20) of patients had favorable outcome and 10% (2 out of 20) had unfavorable outcome. Thirty-four patients underwent single vein anastomosis, 94% had favorable outcome and 6% had unfavorable outcome. The result was not statistically significant as p < .05. Seven patients underwent superficial vein recipient anastomosis, and all flaps were (100%) successful and no failure, whereas out of 27 patients who had undergone deep vein anastomosis 25 (92%) had favorable outcome and 2 (8%) had unfavorable outcome. The results were not statistically significant as p > .05. CONCLUSION: As in other free flaps venous anastomosis compromise is the cause for flap failure in majority of the times. Whenever possible, dual vein anastomosis should be considered. But when impervious, single vein anastomosis can be resorted to without any hesitation. Similarly, unavailability of deep veins should not deter the surgeons. Superficial veins were a savior in such situation and can be advantageous too.