Background <p>Atypical lipomatous tumors (ALTs) are lipomatous neoplasms of the trunk and extremities with higher local recurrence rate than lipomas. Although wide resection is no longer routinely performed, there remains considerable variability in the extent of tissue resection during marginal excision.</p> Methods <p>We retrospectively identified patients with histologically proven ALT of the trunk or extremities treated with surgery between 1993 and 2021. We compared wide resection, expanded marginal excision, and simple marginal excision. Expanded marginal excision involved the removal of tissue infiltrated by fat, which can include the fascia, epimysium, or even muscle if it was involved.</p> Results <p>We included 105 patients with median follow-up of 5.5 years. Local recurrence occurred in 15 patients (14.3%). Dedifferentiation occurred in 13% of recurrent patients (2/15), and none of these metastasized. Five- and 10-year local recurrence-free survival (LRFS) were 88.6% and 75.6%, respectively, and did not improve with the use of radiation therapy (RT). Five-year LRFS was 100% for both wide resection and expanded marginal excision. When compared with simple marginal excision, expanded marginal excision showed a trend toward higher 5-year LRFS (100% vs. 86.9%, <i>p</i> = 0.2). Risk factors for local recurrence included sclerosing subtype (adjusted odds ratio (aOR) 5.47) and tumors with previous recurrence (aOR 4.92).</p> Conclusion <p>Expanded marginal excision showed noninferior local control rates to wide resection without the additional morbidity of the latter, while suggesting to be superior to simple marginal resection. Future investigations featuring longer follow-up times should compare long-term local control rates by use of RT, type of resection, and ALT subtype.</p> Level of Evidence <p>III.</p>