ABSTRACT Background Accurate preoperative localization of perforators is crucial for the success of perforator‐based flaps. While handheld Doppler (HHD) is commonly used, newer modalities like infra‐red (IR) thermography and indocyanine green (ICG) angiography may offer greater accuracy and precision. We aimed to compare the diagnostic accuracy of HHD, IR thermography, and ICG angiography in identifying perforators in the anterolateral thigh (ALT) flap. Methods This was a single‐centre, three‐arm parallel randomized controlled trial conducted from May 2023 to April 2025 in the Department of Burns and Plastic Surgery at a tertiary care center. Sixty patients undergoing ALT flap reconstruction were randomized (1:1:1) to HHD, IR thermography, or ICG angiography groups. The primary outcome was the diagnostic accuracy of each modality in perforator localization (defined as spatial concordance with intra‐operative location). Secondary outcomes included flap complications and duration of flap harvest. Data were analyzed using ANOVA and chi‐square tests. Results Oncological resection was the most common indication for flap surgery (53.3%), and the head and neck region was the commonest site of reconstruction. ICG angiography demonstrated the highest diagnostic accuracy (85%), sensitivity (94.4%), and positive predictive value (89.47%) compared to IR thermography (50%, 100%, and 50%) and HHD (15%, 75%, and 15.79%) ( p < 0.0001). There was no significant difference in flap complication rates or hospital stay between groups. Diagnostic accuracy was lower in obese patients across all modalities. Conclusion The accuracy of ICG was better than IR Thermography and HHD in detecting perforators pre‐operatively in patients undergoing ALT flap surgery. Trial Registration CTRI/2023/05/053290
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