Fundamentals of perforator flaps

Jonathan Velazquez Mujica MD, MSc

Plastic and Reconstructive Microsurgery and lymphedema
Assistant Professor China Medical University Hospital
Definition PERFORATOR

latin: per: means through and forare: means to pierce

Perforator flap: Vascularized area of skin and

subcutaneous tissue that receives its blood supply
from a perforator from a named source vessel below
the deep fascia that supplies an angiosome

Sinna R, Boloorchi A, Mahajan AL, Qassemyar Q, Robbe M. What should define a perforator flap?
Plast Reconstr Surg. 2010;126(6):2258–2263. PMID: 21124168.
Classification Mathes and Nahai:

Tyoe A: direct cutaneous vessel

Type B: septocutaneous vessel

Tyoe C: musculocuateneous vessel

Nakajima

Type D:myocutaneous perforators

Type E: direct septocutaneous

Type F: perforating cutaneous branch from muscle

vessels
Classification Fasciocutaneous flaps: includes the fascia

Perforator flaps: exclude the fascia

Angiosome: 3Dmendionak block of composite tissue

(including skin and underlying tissue) supplied by all
the perforators (40 described)

Perforsome: more than 300 individual perforators that

supplies its own territory

Saint-Cyr M, Wong C, Schaverien M, et al. The perforasome theory: vascular anatomy and
clinical implications. Plast Reconstr Surg 124:1529-1544, 2009.
Angiosome vs Perforasome
Radial flap principle of perforasome

Each perforator originating from the source vessel supplies its own vascular territory
Free style perforator Include propeller flaps

Available and usefulness depends on the location and

flaps quality of the perforator In relationship with the defect
The common perforator
flaps
Advantage Reduce the donor site morbidity

Decrease Post operative pain

Faster recovery / shorter hospital stay

Can be pedicle flaps, pedical flaps in stage

reconstruction or free tissue transfer

Donor site can be close primary or arrange STSG

A detailed knowledge of anatomy allows the surgeon

to tailor the most convinient flap
Flap success Dependent on an appropriate perforator (quality,
quantity and location)

Elevation technique and harvest technique

Limit in vessel manipulation

Flap design (size limit)

Complications and Inflow problems:

Inadequate perforator (size and quantity)

salvage Vessel spasm

Twisting, pressure, tension or compression of the

arterial perforator

Conversion to a muscle flap may salvage the flap

Complications and Outflows problems

Twisting, pressure, tension or compression of vein

salvage Inadequate interconnection between the deep and
superficial system

Other large perforator or superficial vein should be

identified to either supercharge or superdrain
Commonly used perforator flaps