Perforator Flaps: A Microsurgical Innovation

Steven Morris, MD


November 21, 2008

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Perforator flaps have become increasingly popular in reconstructive microsurgery.[1,2] To close soft-tissue defects left by trauma or after the excision of tumors, reconstructive surgeons have employed a number of surgical techniques. These tissue transfers, which are also known as "flaps," have evolved over the past century from random-pattern flaps with an unknown blood supply, through axial-pattern flaps with a known blood supply to muscle and musculocutaneous flaps.[3] The quest has always been to find the best tissue transfer with a dependable blood supply, which can be transferred reliably to close a defect. Most recently, musculocutaneous perforator flaps have emerged as the best technique to reconstruct challenging wounds. Perforator flaps can be based on any of approximately 400 cutaneous perforators to the skin.[4] Thus, there are now many more flap options. Surgeons can optimize the flap color match, thickness, and the proximity to the wound to optimally perform the reconstruction.

For example, in breast reconstruction, the deep inferior epigastric perforator flap, based of the deep inferior epigastric vessels, is gradually replacing the pedicled TRAM flap.[5,6] There is no need to sacrifice the important rectus abdominis muscles to harvest the abdominal tissue to reconstruct the breast. The DIEP flap represents a significant advancement over pedicled TRAM flap for breast reconstruction. Studies of abdominal function following the DIEP flap show a significant improvement over the pedicled TRAM flap.[7]

Perforator flaps thus represent the further evolution of flaps used by reconstructive microsurgeons to optimally reconstruct wounds, while lessening the donor site "cost" of the reconstruction. The results obtained from perforator flaps demand our attention. This is a significant surgical improvement.

That's my opinion. I am Dr. Steven Morris, Professor of Surgery, Dalhousie University.

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