Introduction. Ischial pressure ulcers are considered the most difficult type of pressure ulcers (PUs) to treat. Objective. The authors report the use of a pedicled anterolateral thigh (pALT) myocutaneous ﬂap as an alternative for covering an ischial PU. Materials and Methods. The authors retrospectively collected the data of 21 patients with an indurated recurrent ischial ulcer or a fresh ischial ulcer. A pALT myocutaneous ﬂap was harvested without intramuscular dissection and skeletonization of the perforators for the ischial defect reconstruction. Two modiﬁed ﬂap-insetting techniques, an open-route method and a subcutaneous tunnel method, were used for the ischial defect reconstruction. The open-route flap-insetting was used for a recurrent ulcer status after other surgical procedures, and the subcutaneous tunnel method was used for fresh ulcers. Results. The mean follow-up period was 10 months (range, 4–14 months). During the postoperative follow-up, all open-route reconstructions resulted in flap take; however, poor healing with seroma was noted in 2 patients who had undergone pALT reconstruction with subcutaneous tunneling after other previous surgical reconstructions. Conclusions. In the authors’ experience, because of constant blood supply, sufﬁcient bulk, easy elevation, longer pedicle for the arc of rotation, primary closure of the donor site without morbidity, and a non-weightbearing flap donor site, the pALT myocutaneous flap for ischial ulcer reconstruction can serve as a primary treatment and secondary salvage.