Perforator flaps

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.{{cite journal |author=Morris S |title=Perforator flaps: a microsurgical innovation |journal=Medscape J Med |volume=10 |issue=11 |page=266 |year=2008 |pmid=19099016 |pmc=2605127 }}

Koshima and Soeda were the first to use the name “perforator flaps” in 1989 {{cite journal |vauthors=Koshima I, Soeda S |title=Inferior epigastric artery skin flaps without rectus abdominis muscle |journal=Br J Plast Surg |volume=42 |issue=6 |pages=645–8 |date=November 1989 |pmid=2605399 |doi=10.1016/0007-1226(89)90075-1}} and since then perforator flaps have become more popular in reconstructive microsurgery. Thus perforator flaps, using autologous tissue with preservation of fascia, muscle and nerve represent the future of flaps.{{cite journal |vauthors=Wei FC, Celik N |title=Perforator flap entity |journal=Clin Plast Surg |volume=30 |issue=3 |pages=325–9 |date=July 2003 |pmid=12916589 |doi=10.1016/s0094-1298(03)00033-6}} The most frequently used perforator flaps nowadays are the deep inferior epigastric perforator flap (DIEP flap),{{cite journal |vauthors=Granzow JW, Levine JL, Chiu ES, Allen RJ |title=Breast reconstruction with the deep inferior epigastric perforator flap: history and an update on current technique |journal=J Plast Reconstr Aesthet Surg |volume=59 |issue=6 |pages=571–9 |year=2006 |pmid=16716950 |doi=10.1016/j.bjps.2006.01.004 }}{{cite journal |vauthors=Man LX, Selber JC, Serletti JM |title=Abdominal wall following free TRAM or DIEP flap reconstruction: a meta-analysis and critical review |journal=Plast. Reconstr. Surg. |volume=124 |issue=3 |pages=752–64 |date=September 2009 |pmid=19342994 |doi=10.1097/PRS.0b013e31818b7533 |s2cid=26114453 }} and both the superior and inferior gluteal (SGAP/ IGAP) flap,{{cite journal |vauthors=Allen RJ, Tucker C |title=Superior gluteal artery perforator free flap for breast reconstruction |journal=Plast. Reconstr. Surg. |volume=95 |issue=7 |pages=1207–12 |date=June 1995 |pmid=7761507 |doi=10.1097/00006534-199506000-00010|s2cid=13358838 }} all three mainly used for breast reconstruction; the lateral circumflex femoral artery perforator (LCFAP) flap (previously named anterolateral thigh or ALT flap){{cite journal |vauthors=Kuo YR, Yeh MC, Shih HS, etal |title=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 |journal=Plast. Reconstr. Surg. |volume=124 |issue=1 |pages=171–80 |date=July 2009 |pmid=19568063 |doi=10.1097/PRS.0b013e3181a80594 |s2cid=5279225 }} and the thoracodorsal artery perforator (TAP) flap,{{cite journal |vauthors=Angrigiani C, Grilli D, Siebert J |title=Latissimus dorsi musculocutaneous flap without muscle |journal=Plast. Reconstr. Surg. |volume=96 |issue=7 |pages=1608–14 |date=December 1995 |pmid=7480280 |doi=10.1097/00006534-199512000-00014|s2cid=36267006 }} 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.

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.{{cite journal |author=Hallock GG |title=Direct and indirect perforator flaps: the history and the controversy |journal=Plast. Reconstr. Surg. |volume=111 |issue=2 |pages=855–65; quiz 866 |date=February 2003 |pmid=12560714 |doi=10.1097/01.PRS.0000040462.38363.C7 }} We will discuss this classification based on the perforators' anatomy below. File:Direct and indirect perforators.png{{cn|date=February 2022}}

Direct cutaneous perforators only perforate the deep fascia, they do not traverse any other structural tissue.

It is 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.

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. According to the clinical relevance, two types of indirect cutaneous perforators need to be distinguished. We will clarify these two types below.{{cn|date=February 2022}}

Musculocutaneous perforators supply the overlying skin by traversing through muscle before they pierce the deep fascia.

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.

When a flaps’ blood supply depends on a muscle perforator, this flap is called a muscle perforator flap.

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.

When a flap's blood supply depends on a septal perforator, this flap is called a septal perforator flap.

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."

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

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.

A free flap is defined as a tissue mass that has been taken away from the original site to be used in tissue transplantation.{{cite web |title=Free flaps |work=Pubmed MESH terms database |url=https://www.ncbi.nlm.nih.gov/mesh?term=free%20flaps}} When a surgeon uses a free flap, the blood supply is cut and the pedicle reattached to recipient vessels, performing a microsurgical anastomosis.{{cite book |last1=Guyuron |first1=Bahman |first2=Elok |last2=Eriksson |first3=John A. |last3=Persing |chapter=Ch. 9: Microsurgery and Free Flaps |title=Plastic Surgery: Indications and practice |publisher=Saunders Elsevier |volume=1 |year=2009 |isbn=978-1-4160-4081-1 }}

For more information on free flaps, see also free flap.

Pedicled perforator flaps can be transferred either by translation or rotation. These two types will be discussed separately below.{{cn|date=February 2022}}

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.Guyuron, Bahman; Elof Eriksson, John A. Persing (2009). Chapter 8: Flaps. Plastic Surgery: Indications and Practice. Saunders Elsevier. {{ISBN|978-1-4160-4081-1}}

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 propeller 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.{{cite journal |vauthors=Pignatti M, Ogawa R, Hallock GG, etal |title=The "Tokyo" consensus on propeller flaps |journal=Plast. Reconstr. Surg. |volume=127 |issue=2 |pages=716–22 |date=February 2011 |pmid=21285776 |doi=10.1097/PRS.0b013e3181fed6b2 |s2cid=34314915 }} 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. "

File:Propeller flap.png

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.

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.

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.{{cite journal |vauthors=Klein S, Hage JJ, de Weerd L |title=[Perforator flaps--the evolution of a reconstructive surgical technique] |language=nl |journal=Ned Tijdschr Geneeskd |volume=149 |issue=43 |pages=2392–8 |date=October 2005 |pmid=16277128 }}

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. 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.

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.{{cite journal |vauthors=Schulten EA, Winters HA, Koch AE |title=[Reconstruction after surgical treatment of head and neck cancer: surgical and prosthetic possibilities] |language=nl |journal=Ned Tijdschr Tandheelkd |volume=115 |issue=4 |pages=215–23 |date=April 2008 |pmid=18512520 }} 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.{{cite journal |vauthors=Granzow JW, Levine JL, Chiu ES, LoTempio MM, Allen RJ |title=Breast reconstruction with perforator flaps |journal=Plast. Reconstr. Surg. |volume=120 |issue=1 |pages=1–12 |date=July 2007 |pmid=17572536 |doi=10.1097/01.prs.0000256044.66107.a6 |s2cid=34675486 }}{{Retracted|doi=10.1097/01.prs.0000318081.24460.65|pmid=18454036|intentional=yes}}{{better source|date=March 2025}} 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.{{better source|date=March 2025}} Some examples include, Deep inferior epigastric perforator flap (DIEP flap), superior gluteal (SGAP) flaps and inferior gluteal (IGAP) flaps.{{cn|date=February 2022}}

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.{{cite journal |vauthors=Georgescu AV, Capota I, Matei I, etal |title=The place of local/regional perforator flaps in complex traumas of the forearm |journal=J Hand Microsurg |volume=1 |issue=1 |pages=25–31 |date=June 2009 |pmid=23129928 |pmc=3453204 |doi=10.1007/s12593-009-0007-6 }}

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.

{{cite journal|last1=Koshima|first1=Isao|last2=Moriguchi|first2=Takahiko|last3=Etoh|first3=Hisashi|last4=Tsuda|first4=Kuniyoshi|last5=Tanaka|first5=Hitoshi|title=The Radial Artery Perforator-based Adipofascial Flap for Dorsal Hand Coverage|journal=Annals of Plastic Surgery|volume=35|issue=5|year=1995|pages=474–479|issn=0148-7043|doi=10.1097/00000637-199511000-00005|pmid=8579264|s2cid=44601964}}{{cite journal |vauthors=Giunta R, Geisweid A, Lukas B, Feller AM |title=[Perforator flap-plasty and applications to hand surgery] |language=German |journal=Handchir Mikrochir Plast Chir |volume=32 |issue=6 |pages=399–403 |date=November 2000 |pmid=11189893 |doi=10.1055/s-2000-10908 |s2cid=260155610 }} 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.{{cite journal |vauthors=Auclair E, Guelmi K, Selinger R, Mitz V, Lemerle JP |title=[Free transfer in the emergency treatment of complex injuries of the arm. Apropos of 18 cases] |language=French |journal=Ann Chir Plast Esthet |volume=39 |issue=3 |pages=338–45 |date=June 1994 |pmid=7717669 }}

In lower limb surgery there have also been reports of successful use of perforator flaps.{{cite journal |vauthors=Rad AN, Christy MR, Rodriguez ED, Brazio P, Rosson GD |title=The anterior tibialis artery perforator (ATAP) flap for traumatic knee and patella defects: clinical cases and anatomic study |journal=Ann Plast Surg |volume=64 |issue=2 |pages=210–6 |date=February 2010 |pmid=20098108 |doi=10.1097/SAP.0b013e3181a13dd6 |s2cid=29990851 }}{{cite journal |vauthors=Quaba O, Quaba A |title=Pedicled Perforator Flaps for the Lower Limb |journal=Semin Plast Surg |volume=20 |issue=2 |pages=103–111 |date=May 2006 |doi=10.1055/s-2006-941717 |pmc=2884776 }}

Twenty three years after the first perforator flap was described by Koshima and Soeda, there has been a significant step towards covering tissue defects by using only cutaneous tissue.{{cite journal |vauthors=LoTempio MM, Allen RJ |title=Breast reconstruction with SGAP and IGAP flaps |journal=Plast. Reconstr. Surg. |volume=126 |issue=2 |pages=393–401 |date=August 2010 |pmid=20679825 |doi=10.1097/PRS.0b013e3181de236a |s2cid=20950415 }} Results obtained from studies done on musculocutaneous and septocutaneous perforator flaps have shown a reduction of donor-site morbidity to a minimum {{cite journal |vauthors=Guerra AB, Lyons GD, Dupin CL, Metzinger SE |title=Advantages of perforator flaps in reconstruction of complex defects of the head and neck |journal=Ear Nose Throat J |volume=84 |issue=7 |pages=441–7 |date=July 2005 |pmid=16813036 |doi=10.1177/014556130508400717 |doi-access=free }} due to refined perforator flap techniques that allow collection of tissue without scarifying the underlying muscles.{{cite journal |vauthors=Granzow JW, Levine JL, Chiu ES, Allen RJ |title=Breast reconstruction using perforator flaps |journal=J Surg Oncol |volume=94 |issue=6 |pages=441–54 |date=November 2006 |pmid=17061279 |doi=10.1002/jso.20481 |s2cid=24974920 }} As a matter of fact, preventing damage to the underlying muscle including its innervation, has led to less cases of abdominal hernia, the absence of postoperative muscle atrophy {{cite journal |vauthors=Neligan PC, Lipa JE |title=Perforator Flaps in Head and Neck Reconstruction |journal=Semin Plast Surg |volume=20 |issue=2 |pages=56–63 |date=May 2006 |doi=10.1055/s-2006-941711 |pmc=2884771 }} and a better vascularised and functioning donor muscle.{{better source|date=March 2025}} Furthermore, patients have shown decreased postoperative pain and accelerated rehabilitation {{better source|date=March 2025}} 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.{{cite journal |vauthors=Liu DZ, Mathes DW, Zenn MR, Neligan PC |title=The application of indocyanine green fluorescence angiography in plastic surgery |journal=J Reconstr Microsurg |volume=27 |issue=6 |pages=355–64 |date=July 2011 |pmid=21717392 |doi=10.1055/s-0031-1281515 |s2cid=260193952 }} 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.{{cn|date=February 2022}} Microsurgical expertise in perforator flap dissection can be acquired using perforator flap training models in living tissue.{{Cite journal |last1=Nistor |first1=Alexandru |last2=Jiga |first2=Lucian P. |last3=Miclaus |first3=Gratian D. |last4=Hoinoiu |first4=Bogdan |last5=Matusz |first5=Petru |last6=Ionac |first6=Mihai E. |date=2022-04-11 |editor-last=Lumenta |editor-first=David Benjamin |title=Experimental swine models for perforator flap dissection in reconstructive microsurgery |journal=PLOS ONE |language=en |volume=17 |issue=4 |pages=e0266873 |doi=10.1371/journal.pone.0266873 |issn=1932-6203 |pmc=9000060 |pmid=35404988|doi-access=free |bibcode=2022PLoSO..1766873N }}

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:{{cite journal |vauthors=Moran SL, Illig KA, Green RM, Serletti JM |title=Free-tissue transfer in patients with peripheral vascular disease: a 10-year experience |journal=Plast. Reconstr. Surg. |volume=109 |issue=3 |pages=999–1006 |date=March 2002 |pmid=11884824 |doi=10.1097/00006534-200203000-00031|s2cid=41801050 }}{{cite journal |vauthors=Moran SL, Salgado CJ, Serletti JM |title=Free tissue transfer in patients with renal disease |journal=Plast. Reconstr. Surg. |volume=113 |issue=7 |pages=2006–11 |date=June 2004 |pmid=15253190 |doi=10.1097/01.prs.0000122214.55090.16 |s2cid=9975910 }}

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)

Any condition that probably increases the risk of intraoperative or postoperative complications:{{EMedicine|article|1284724|Principles of Microsurgery}}

• 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.{{cite journal |vauthors=Chang LD, Buncke G, Slezak S, Buncke HJ |title=Cigarette smoking, plastic surgery, and microsurgery |journal=J Reconstr Microsurg |volume=12 |issue=7 |pages=467–74 |date=October 1996 |pmid=8905547 |doi=10.1055/s-2007-1006620 |s2cid=38357412 }}{{cite journal |vauthors=Yaffe B, Cushin BJ, Strauch B |title=Effect of cigarette smoking on experimental microvascular anastomoses |journal=Microsurgery |volume=5 |issue=2 |pages=70–2 |year=1984 |pmid=6748936 |doi=10.1002/micr.1920050203|s2cid=10008050 }}

• Deep inferior epigastric perforator flap (DIEP flap)
• Thoracodorsal artery perforator (TAP) flap
• Superior gluteal (SGAP) flaps
• Inferior gluteal (IGAP) flaps

• Flap (surgery)
• DIEP flap
• List of plastic surgery flaps
• Breast reconstruction
• Free flap

{{reflist}}

{{Skin and subcutaneous tissue procedures |state=collapsed}}

Category:Plastic surgery

Category:Surgical procedures and techniques