Perforator flap surgery is a technique used in reconstructive surgery where skin and/or

subcutaneous fat are removed from a distant or adjacent part of the body to reconstruct the
excised part.[1] The vessels that supply blood to the flap are isolated perforator(s) derived from a
deep vascular system through the underlying muscle or intermuscular septa. Some perforators
can have a mixed septal and intramuscular course before reaching the skin. The name of the
particular flap is retrieved from its perforator and not from the underlying muscle.[1] If there is a
potential to harvest multiple perforator flaps from one vessel, the name of each flap is based on
its anatomical region or muscle. For example a perforator that only traverses through the septum
to supply the underlying skin is called a septal perforator. Whereas a flap that is vascularised by a
perforator traversing only through muscle to supply the underlying skin is called a muscle
perforator.[1] According to the distinct origin of their vascular supply, perforators can be classified
into direct and indirect perforators. Direct perforators only pierce the deep fascia, they don't
traverse any other structural tissue. Indirect perforators first run through other structures before
piercing the deep fascia.[1]

Contents

1 Overview
2 Classification
o

2.1 Direct cutaneous

2.2 Indirect cutaneous

2.2.1 Muscle and musculocutaneous

2.2.2 Septal and septocutaneous

2.3 Nomenclature

3 Method of application
o

3.1 Free perforator flaps

3.2 Pedicled perforator flaps

3.2.1 Translation

3.2.2 Rotation

4 Fields of application
o

4.1 Oncological background

4.2 Traumatic background

5 Advantages and disadvantages

6 Indications and contra-indications

6.1 Relative contra-indications[30]

7 Examples of perforator flaps

8 See also

9 References

Overview
Soft tissue defects due to trauma or after tumor extirpation are important medical and cosmetic
topics. Therefore reconstructive surgeons have developed a variety of surgical techniques to
conceal the soft tissue defects by using tissue transfers, better known as flaps. In the course of
time these flaps have rapidly evolved from "random-pattern flaps with an unknown blood supply,
through axial-pattern flaps with a known blood supply to muscle and musculocutaneous
perforator flaps" for the sole purpose of optimal reconstruction with minimum donor-site
morbidity.[2] Koshima and Soeda were the first to use the name perforator flaps in 1989 [3] and
since then perforator flaps have become more popular in reconstructive microsurgery.[1] Thus
perforator flaps, using autologous tissue with preservation of fascia, muscle and nerve represent
the future of flaps.[4] The most frequently used perforator flaps nowadays are the deep inferior
epigastric perforator flap (DIEP flap),[5][6] and both the superior and inferior gluteal (SGAP/
IGAP) flap,[7] all three mainly used for breast reconstruction; the lateral circumflex femoral
artery perforator (LCFAP) flap (previously named Anterolateral thigh or ALT flap)[8] and the
thoracodorsal artery perforator (TAP) flap,[9] mainly for the extremities and the head and neck
region as a free flap and for breast and thoracic wall reconstruction as a pedicled perforator flap.

Classification
Perforator flaps can be classified in many different ways. Regarding the distinct origin of their
blood supply and the structures they cross before they pierce the deep fascia, perforators can
either be direct perforators or indirect perforators.[10] We will discuss this classification based on
the perforators' anatomy below.

Direct and indirect perforators

Direct cutaneous

Direct cutaneous perforators only perforate the deep fascia, they do not traverse any other
structural tissue.[10]
It s questionable whether these perforators are true perforators, because it might be more logical
to not include these perforators. The surgical approach needed for direct perforators is slightly
different from the one needed for indirect perforators. When direct perforators are not included,
surgeons can focus on the anatomy of the perforator and the source vessel.[1]

Indirect cutaneous
Indirect cutaneous perforators traverse other structures before going through the deep fascia.
These other structures are deeper tissues, and consist of mainly muscle, septum or epimysium.[10]
According to the clinical relevance, two types of indirect cutaneous perforators need to be
distinguished.[1] We will clarify these two types below.
Muscle and musculocutaneous
Musculocutaneous perforators supply the overlying skin by traversing through muscle before
they pierce the deep fascia.[1]
A perforator which traverses muscle before piercing the deep fascia can do that either
transmuscular or transepimysial. This latter subdivision is however not taken into account during
the dissection of the perforator. Only the size, position, and course of the perforator vessel are
considered then.[1]
When a flaps blood supply depends on a muscle perforator, this flap is called a muscle
perforator flap.[1]
Septal and septocutaneous
Septocutaneous perforators supply the overlying skin by traversing through an intermuscular
septum before they pierce the deep fascia. These perforators are cutaneous side branches of
muscular vessels and perforators.[1]
When a flap's blood supply depends on a septal perforator, this flap is called a septal perforator
flap.[1]

Nomenclature
Due to confusion about the definition and nomenclature of perforator flaps, a consensus meeting
was held in Gent, Belgium, on September 29, 2001. Regarding the nomenclature of these flaps,
the authors stated the following:
"A perforator flap should be named after the nutrient artery or vessels and not after the
underlying muscle. If there is a potential to harvest multiple perforator flaps from one vessel, the
name of each flap should be based on its anatomical region or muscle." [1]

This so-called 'gent consensus' was needed because the lack of definitions and standard rules on
terminology created confusion in communication between surgeons.[1]

Method of application
Flaps can be transferred either free or pedicled. Regarding the nomenclature, one is free to add
the type of transfer to the name of a flap.[1]

Free perforator flaps

A free flap is defined as a tissue mass that has been taken away from the original site to be used
in tissue transplantation.[11] When a surgeon uses a free flap, the blood supply is cut and the
pedicle reattached to recipient vessels, performing a microsurgical anastomosis.[12]
For more information on free flaps, see also free flap.

Pedicled perforator flaps

Pedicled perforator flaps can be transferred either by translation or rotation. These two types will
be discussed separately below.
Translation
This type of transfer is also called "advancement".The surgeon disconnects the flap from the
body, except for the perforators. After this procedure, the flap is advanced into the defect.[13]
Rotation
The subgroup of pedicled perforator flaps, transferred in the defect by rotation is the so-called
"propeller flap". Confusion concerning definition, nomenclature and classification of propellor
flaps led to a consensus meeting similar to the "gent consensus meeting. The consensus that was
reached is named "the tokyo consensus". This article stipulates the definitions of propeller flaps
and especially perforator propeller flaps.[14] The definition that was set up is cited below:
"A propeller flap can be defined as an island flap that reaches the recipient site through an
axial rotation. Every skin island flap can become a propeller flap. However, island flaps that
reach the recipient site through an advancement movement and flaps that move through a
rotation but are not completely islanded are excluded from this definition. " [14]

Propeller flap

Regarding the classification of propeller flaps, the surgeon should specify several aspects of
these flaps. It is important that the type of nourishing pedicle, the degree of skin island rotation
and, when possible, the artery of origin of the perforator vessel are mentioned.[14]
The perforator propeller flap is the propeller flap which is used most commonly. It is a perforator
flap with a skin island, which is separated in a larger and smaller paddle by the nourishing
perforator. These paddles can rotate around the perforator (pedicle), for as many degrees as the
anatomical situation requires (90-180 degrees). This flap looks like a propeller when the two
paddles are not too different in size.[14]

Fields of application
Trauma, oncological treatments or pressure ulcers can result in severe tissue defects. Those
defects can be covered and closed by using autologe tissue transposition. The fact that each
tissue defect is different makes it necessary for each tissue defect to be assessed individually. The
choice of the type of tissue transposition depends on the location, nature, extent and status of the
deformity.[15]
However, the health of the patient and possible contra-indications play an important role as well.
Due to the development and improvement of cutaneous, myocutanous and fasciocutaneous tissue
transpositions plastic surgeons are able to successfully restore the defect to its original shape.[15]
Nevertheless, functional recovery is not guaranteed in all patients. For the optimal renewal of
shape and function, a suitable flap can be chosen to reconstruct the defect. In the case of using a
so-called perforator flap, a reliable vascularization and the possibility of sensory (re) innervation
can be combined with less donor-site morbidity and limited loss of function in the donor area.[15]

Oncological background
The surgical removal of both benign and malignant tumors often result in serious tissue defects
involving not only soft tissue but also parts of the bone.[16] Depending on the location aneligible
flap can be selected. In breast reconstruction for example, perforator flaps have raised the
standard by replacing like with like.[17] When taking breast reconstruction into consideration,
several surgical options are available to achieve lasting natural results with decreased donor-site
deformities. The broad option of donor-sites makes practically all patients candidates for
autogenous perforator flap reconstruction.[17] Some examples include, Deep inferior epigastric
perforator flap (DIEP flap), superior gluteal (SGAP) flaps and inferior gluteal (IGAP) flaps.

Traumatic background
Treatment of tissue defects caused after a trauma present major surgical challenges especially
those of the upper and lower limb, due to the fact that they often not only cause damage to the
skin but also to bones, muscles/tendons, vessels and/or nerves.[18]
If there is extensive destruction a fasciotomy is needed, therefore it is generally accepted that the
best way to cover these types of tissue defects is a free flap transplantation.[3][18][19] Nevertheless,
over the years surgeons have tried to increase the application of perforator flaps, due to their

proven advantages. In the case of upper limb surgery, perforator flaps are successfully used in
minor and major soft tissue defects provided that in major defects the flap is precisely planed.[18]
[20]

In lower limb surgery there have also been reports of successful use of perforator flaps.[21][22]

Advantages and disadvantages

Twenty three years after the first perforator flap was described by Koshima and Soeda,[3] there
has been a significant step towards covering tissue defects by using only cutaneous tissue.[23]
Results obtained from studies done on musculocutaneous and septocutaneous perforator flaps
have shown a reduction of donor-site morbidity to a minimum [23][24] due to refined perforator flap
techniques that allow collection of tissue without scarifying the underlying muscles.[23][25] As a
matter of fact, preventing damage to the underlying muscle including its innervation, has led to
less cases of abdominal hernia,[25] the absence of postoperative muscle atrophy [26] and a better
vascularised and functioning donor muscle.[17] Furthermore patients have shown decreased
postoperative pain and accelerated rehabilitation [17][24] Nevertheless there will always be a chance
that the displaced tissue partially or completely dies considering the fact that the perfusion of the
flap is difficult to assess intraoperatively.[27] Furthermore when using this technique additional
scars are made. Thus considering the complexity and length of this procedure microsurgical
expertise is required and patients need to undergo a longer period of anesthetics that of course
could result in increased risk factors.

Indications and contra-indications

Indications:

the need to cover exposed vital components such as tendons, vessels, joint surfaces and
bone free from periosteum
the need to reestablish function

the need to restore structure and shape, like after a mastectomy

Contraindications:[28][29]
Associated with the patient:

condition that could be harmful to the patients' life (critically ill, sepsis, peripheral
vascular disease and renal disease)
condition that enlarge the possibility of reconstructive failure (peripheral vascular disease
and renal disease)
patient s ability to withstand sustained anesthesia (severe respiratory disease is an
absolute contraindication)

Relative contra-indications[30]

Any condition that probably increases the risk of intraoperative or postoperative complications:

cardiovascular disease
diabetes mellitus

Raynaud syndrome

scleroderma

other collagen vascular diseases

smoking

radiation

ongoing infections

By inducing thrombogenic state through vasoconstriction of the microvasculature, tobacco

influences blood flow, wound healing and the survival of pedicled flaps. On the contrary there is
no published data on damaging effects of cigarette smoke on free tissue transfer.[31][32]

Examples of perforator flaps

Deep inferior epigastric perforator flap (DIEP flap)

Thoracodorsal artery perforator (TAP) flap

Superior gluteal (SGAP) flaps

Inferior gluteal (IGAP) flaps

See also

Flap (surgery)
DIEP flap

List of plastic surgery flaps

Breast reconstruction

Free flap

References
1.
Blondeel PN, Van Landuyt KH, Monstrey SJ, et al. (October 2003). "The "Gent" consensus
on perforator flap terminology: preliminary definitions". Plast. Reconstr. Surg. 112 (5): 137883;

quiz 1383, 1516; discussion 13847. doi:10.1097/01.PRS.0000081071.83805.B6.

PMID 14504524.
Morris S (2008). "Perforator flaps: a microsurgical innovation". Medscape J Med 10 (11):
266. PMC 2605127. PMID 19099016.
Koshima I, Soeda S (November 1989). "Inferior epigastric artery skin flaps without
rectus abdominis muscle". Br J Plast Surg 42 (6): 6458. doi:10.1016/0007-1226(89)90075-1.
PMID 2605399.
Wei FC, Celik N (July 2003). "Perforator flap entity". Clin Plast Surg 30 (3): 3259.
doi:10.1016/s0094-1298(03)00033-6. PMID 12916589.
Granzow JW>Granzow JW, Levine JL, Chiu ES, Allen RJ (2006). "Breast reconstruction
with the deep inferior epigastric perforator flap: history and an update on current technique". J
Plast Reconstr Aesthet Surg 59 (6): 5719. doi:10.1016/j.bjps.2006.01.004. PMID 16716950.
Man LX, Selber JC, Serletti JM (September 2009). "Abdominal wall following free
TRAM or DIEP flap reconstruction: a meta-analysis and critical review". Plast. Reconstr. Surg.
124 (3): 75264. doi:10.1097/PRS.0b013e31818b7533. PMID 19342994.
Allen RJ, Tucker C (June 1995). "Superior gluteal artery perforator free flap for breast
reconstruction". Plast. Reconstr. Surg. 95 (7): 120712. doi:10.1097/00006534-19950600000010. PMID 7761507.
Kuo YR, Yeh MC, Shih HS, et al. (July 2009). "Versatility of the anterolateral thigh flap
with vascularized fascia lata for reconstruction of complex soft-tissue defects: clinical experience
and functional assessment of the donor site". Plast. Reconstr. Surg. 124 (1): 17180.
doi:10.1097/PRS.0b013e3181a80594. PMID 19568063.
Angrigiani C, Grilli D, Siebert J (December 1995). "Latissimus dorsi musculocutaneous
flap without muscle". Plast. Reconstr. Surg. 96 (7): 160814. doi:10.1097/00006534-19951200000014. PMID 7480280.
Hallock GG (February 2003). "Direct and indirect perforator flaps: the history and the
controversy". Plast. Reconstr. Surg. 111 (2): 85565; quiz 866.
doi:10.1097/01.PRS.0000040462.38363.C7. PMID 12560714.
"Free flaps". Pubmed MESH terms database.
Guyuron, Bahman; Eriksson,, Elok; Persing, John A. (2009). "Ch. 9: Microsurgery and
Free Flaps". Plastic Surgery: Indications and practice 1. Saunders Elsevier. ISBN 978-1-41604081-1.
Guyuron, Bahman; Elof Eriksson, John A. Persing (2009). Chapter 8: Flaps. Plastic
Surgery: Indications and Practice. Saunders Elsevier. ISBN 978-1-4160-4081-1
Pignatti M, Ogawa R, Hallock GG, et al. (February 2011). "The "Tokyo" consensus on
propeller flaps". Plast. Reconstr. Surg. 127 (2): 71622. doi:10.1097/PRS.0b013e3181fed6b2.
PMID 21285776.
Klein S, Hage JJ, de Weerd L (October 2005). "[Perforator flaps--the evolution of a
reconstructive surgical technique]". Ned Tijdschr Geneeskd (in Dutch; Flemish) 149 (43): 2392
8. PMID 16277128.
Schulten EA, Winters HA, Koch AE (April 2008). "[Reconstruction after surgical
treatment of head and neck cancer: surgical and prosthetic possibilities]". Ned Tijdschr
Tandheelkd (in Dutch; Flemish) 115 (4): 21523. PMID 18512520.
Granzow JW, Levine JL, Chiu ES, LoTempio MM, Allen RJ (July 2007). "Breast
reconstruction with perforator flaps". Plast. Reconstr. Surg. 120 (1): 112.
doi:10.1097/01.prs.0000256044.66107.a6. PMID 17572536.

 Georgescu AV, Capota I, Matei I, et al. (June 2009). "The place of local/regional
perforator flaps in complex traumas of the forearm". J Hand Microsurg 1 (1): 2531.
doi:10.1007/s12593-009-0007-6. PMC 3453204. PMID 23129928.
Giunta R, Geisweid A, Lukas B, Feller AM (November 2000). "[Perforator flap-plasty
and applications to hand surgery]". Handchir Mikrochir Plast Chir (in German) 32 (6): 399403.
doi:10.1055/s-2000-10908. PMID 11189893.
Auclair E, Guelmi K, Selinger R, Mitz V, Lemerle JP (June 1994). "[Free transfer in the
emergency treatment of complex injuries of the arm. Apropos of 18 cases]". Ann Chir Plast
Esthet (in French) 39 (3): 33845. PMID 7717669.
Rad AN, Christy MR, Rodriguez ED, Brazio P, Rosson GD (February 2010). "The
anterior tibialis artery perforator (ATAP) flap for traumatic knee and patella defects: clinical
cases and anatomic study". Ann Plast Surg 64 (2): 2106. doi:10.1097/SAP.0b013e3181a13dd6.
PMID 20098108.
Quaba O, Quaba A (May 2006). "Pedicled Perforator Flaps for the Lower Limb". Semin
Plast Surg 20 (2): 103111. doi:10.1055/s-2006-941717.
LoTempio MM, Allen RJ (August 2010). "Breast reconstruction with SGAP and IGAP
flaps". Plast. Reconstr. Surg. 126 (2): 393401. doi:10.1097/PRS.0b013e3181de236a.
PMID 20679825.
Guerra AB, Lyons GD, Dupin CL, Metzinger SE (July 2005). "Advantages of perforator
flaps in reconstruction of complex defects of the head and neck". Ear Nose Throat J 84 (7): 441
7. PMID 16813036.
Granzow JW, Levine JL, Chiu ES, Allen RJ (November 2006). "Breast reconstruction
using perforator flaps". J Surg Oncol 94 (6): 44154. doi:10.1002/jso.20481. PMID 17061279.
Neligan PC, Lipa JE (May 2006). "Perforator Flaps in Head and Neck Reconstruction".
Semin Plast Surg 20 (2): 5663. doi:10.1055/s-2006-941711.
Liu DZ, Mathes DW, Zenn MR, Neligan PC (July 2011). "The application of indocyanine
green fluorescence angiography in plastic surgery". J Reconstr Microsurg 27 (6): 35564.
doi:10.1055/s-0031-1281515. PMID 21717392.
Moran SL, Illig KA, Green RM, Serletti JM (March 2002). "Free-tissue transfer in
patients with peripheral vascular disease: a 10-year experience". Plast. Reconstr. Surg. 109 (3):
9991006. doi:10.1097/00006534-200203000-00031. PMID 11884824.
Moran SL, Salgado CJ, Serletti JM (June 2004). "Free tissue transfer in patients with
renal disease". Plast. Reconstr. Surg. 113 (7): 200611. PMID 15253190.
Brian A Janz, MD. Principles of microsurgery, chapter Contra-indications.
http://emedicine.medscape.com/article/1284724-overview#a5
Chang LD, Buncke G, Slezak S, Buncke HJ (October 1996). "Cigarette smoking, plastic
surgery, and microsurgery". J Reconstr Microsurg 12 (7): 46774. doi:10.1055/s-2007-1006620.
PMID 8905547.
Yaffe B, Cushin BJ, Strauch B (1984). "Effect of cigarette smoking on experimental
microvascular anastomoses". Microsurgery 5 (2): 702. doi:10.1002/micr.1920050203.
PMID 6748936.