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The optimum number of microvascular anastomoses for safe free tissue transfer is controversial. Although the case for 2 venous anastomoses versus 1 anastomosis has been argued, the use of an additional arterial anastomosis has not been examined in detail.Twelve patients who underwent 2 arterial anastomoses for a free flap transfer were identified retrospectively from the medical records of patients undergoing reconstruction for head and neck cancer. The free flaps were limited to anterolateral thigh (ALT) flaps.All flaps survived. Complications included venous thrombosis (n = 1), reexploration (n = 1), and leakage (n = 3). The vascular patterns of dual-arterialized ALT flaps were classified into 3 groups. Types 1 and 2 were ALT flaps that had 2 vascular sources from the descending and lateral branches of the lateral circumflex femoral artery. The number of accompanying veins differed between type 1 (3 veins) and type 2 (2 veins). Type 3 differed from a conventional ALT flap nourished by the descending branch of the lateral circumflex femoral artery (1 vein) by the addition of anastomosis of an artery branching from the descending branch to the vastus medialis muscle. The total operation times for these 3 types of ALT were similar.An additional arterial anastomosis to the free cutaneous flap did not cause any congestion or disturb the balance between inflow and outflow. If the surgeon considers that the first arterial anastomosis is unreliable, an additional anastomosis might be an option in ALT transfer.