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Perforator Flap versus Conventional Flap.

Kim JT, Kim SW - J. Korean Med. Sci. (2015)

Bottom Line: Moreover, depending on the surgeon's ability, any flap can be utilized as a perforator-based island flap whose source vessel has been completely preserved.The application of perforator flap technique enables more precise dissection, and allows more selective harvesting of thinner flaps, which will expand options in reconstructive surgery.No doubt the technique will continue to evolve.

View Article: PubMed Central - PubMed

Affiliation: Department of Plastic and Reconstructive Surgery, College of Medicine, Hanyang University, Seoul, Korea.

ABSTRACT
The introduction of perforator flaps represented a significant advance in microsurgical reconstruction. However, confusion has developed due to the erroneous belief that perforator flaps are different from conventional flaps. The concept of the perforator is not new, but is an idea that evolved from the conventional flap. In fact, some of the flaps used by microsurgeons were perforator flaps. The only difference is the anatomical level of the blood vessels involved; the perforator concept is focused on the distal circulation, so-called 'perforator'. Therefore, thinner sections of tissue can be taken from the conventional donor sites of myocutaneous flaps. With the use of perforators, there are no longer "flap of choice" for specific reconstructions, because conventional donor sites have become universal donor sites, enabling the harvesting of a variety of flaps. Moreover, depending on the surgeon's ability, any flap can be utilized as a perforator-based island flap whose source vessel has been completely preserved. Therefore, tissues can be efficiently customized and tailored into any configuration required for reconstruction. The application of perforator flap technique enables more precise dissection, and allows more selective harvesting of thinner flaps, which will expand options in reconstructive surgery. No doubt the technique will continue to evolve.

No MeSH data available.


Related in: MedlinePlus

Diagram of a conventional flap and its derived perforator flap. The ALP MC flap and LCF perforator flap (SCp-based) were commonly used flaps before the perforator concept was introduced. After the perforator concept was introduced, the LCF perforator flap was regarded as a perforator flap, and the VL perforator flap (MCp-based) and ALT perforator based flaps were challenged. The LCF perforator flap is now included in both concepts and it is a perforator flap. Therefore, perforators can not be completely distinguished from the conventional flaps and some classical flaps were in fact perforator flaps, even though they were described by different names. ALT MC flap, anterolateral thigh myocutaneous flap; LCF perforator flap, lateral femoral circumflex perforator flap; SCp, septocutaneous perforator; VL perforator flap, vastus lateralis perforator flap; MCp, musculocutaneous perforator.
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Figure 1: Diagram of a conventional flap and its derived perforator flap. The ALP MC flap and LCF perforator flap (SCp-based) were commonly used flaps before the perforator concept was introduced. After the perforator concept was introduced, the LCF perforator flap was regarded as a perforator flap, and the VL perforator flap (MCp-based) and ALT perforator based flaps were challenged. The LCF perforator flap is now included in both concepts and it is a perforator flap. Therefore, perforators can not be completely distinguished from the conventional flaps and some classical flaps were in fact perforator flaps, even though they were described by different names. ALT MC flap, anterolateral thigh myocutaneous flap; LCF perforator flap, lateral femoral circumflex perforator flap; SCp, septocutaneous perforator; VL perforator flap, vastus lateralis perforator flap; MCp, musculocutaneous perforator.

Mentions: Based on the path taken by the perforating vessel, perforators can be categorized as direct cutaneous, septocutaneous, and musculocutaneous perforators (10). The exact definition of perforator is still controversial. When the concept of the perforator was first introduced, Wei el al. (11) defined perforating vessels as those of which the source artery is deep and the branch that carries blood directly to the fasciocutaneous tissues, in its course to reach the skin, passes through the overhanging muscular tissue without exclusively following the intermuscular septum. By this definition, only musculocutaneous perforators are considered true perforators, and flaps based on other types of perforator are not regarded as perforator flaps. However, this rigid definition has caused confusion about the concept of the perforator. The anterolateral thigh (ALT) flap, one of the most popular perforator flaps, is a representative example that demonstrates the differences between perforator flaps and conventional flaps. The anterolateral thigh flap is based on a perforator connected to the descending branch of the lateral circumflex femoral system (6, 12, 13). Most of the time, the perforator comes through the vastus lateralis muscle (82%) and is therefore musculocutaneous, or it is a septocutaneous perforator, which is easier to harvest and use than the musculocutaneous perforator (14). According to strict definitions, the flap based on the musculocutaneous perforator is a perforator flap and the flap based on the septocutaneous perforator is not a perforator flap. These flaps differ from each other in terms of the ease of pedicle dissection - tedious transmuscular dissection in musculocutaneous flaps, as opposed to easy and rapid dissection between muscles in septocutaneous flaps (6, 14). Most microsurgeons tried to select septocutaneous perforators to save operating time before the development of the perforator concept, but now transmuscular dissection is more popular due to the reliability of the perforator. Moreover, when the perforator is reliable and the length is sufficient, pedicle dissection stops at the level of the perforator without requiring transmuscular dissection (6). Therefore, the ALT flap has evolved from a myocutaneous flap, to a range of flaps based on either septocutaneous or musculocutaneous perforators. As it is important to distinguish between these flaps, workers have named the different flaps 'ALT myocutaneous flaps,' 'lateral circumflex femoral perforator flaps,' 'vastus lateralis perforator flaps,' and 'ALT perforator based flaps,' depending on the perforators involved (10). The former two patterns are conventional flaps while the latter three are perforator flaps. The lateral circumflex femoral flap can be included in both groups: it was initially designated an ALT (conventional) flap but is now considered a perforator flap, which illustrates the confusion surrounding the perforator concept. That is the reason why we insist that the concept of the perforator flap is not completely distinct from that of the conventional flap concept (Fig. 1). We therefore conclude that flaps previously described as conventional flaps were in fact perforator flaps, and that flaps based on septocutaneous perforators should be considered perforator flaps (3, 10).


Perforator Flap versus Conventional Flap.

Kim JT, Kim SW - J. Korean Med. Sci. (2015)

Diagram of a conventional flap and its derived perforator flap. The ALP MC flap and LCF perforator flap (SCp-based) were commonly used flaps before the perforator concept was introduced. After the perforator concept was introduced, the LCF perforator flap was regarded as a perforator flap, and the VL perforator flap (MCp-based) and ALT perforator based flaps were challenged. The LCF perforator flap is now included in both concepts and it is a perforator flap. Therefore, perforators can not be completely distinguished from the conventional flaps and some classical flaps were in fact perforator flaps, even though they were described by different names. ALT MC flap, anterolateral thigh myocutaneous flap; LCF perforator flap, lateral femoral circumflex perforator flap; SCp, septocutaneous perforator; VL perforator flap, vastus lateralis perforator flap; MCp, musculocutaneous perforator.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4414633&req=5

Figure 1: Diagram of a conventional flap and its derived perforator flap. The ALP MC flap and LCF perforator flap (SCp-based) were commonly used flaps before the perforator concept was introduced. After the perforator concept was introduced, the LCF perforator flap was regarded as a perforator flap, and the VL perforator flap (MCp-based) and ALT perforator based flaps were challenged. The LCF perforator flap is now included in both concepts and it is a perforator flap. Therefore, perforators can not be completely distinguished from the conventional flaps and some classical flaps were in fact perforator flaps, even though they were described by different names. ALT MC flap, anterolateral thigh myocutaneous flap; LCF perforator flap, lateral femoral circumflex perforator flap; SCp, septocutaneous perforator; VL perforator flap, vastus lateralis perforator flap; MCp, musculocutaneous perforator.
Mentions: Based on the path taken by the perforating vessel, perforators can be categorized as direct cutaneous, septocutaneous, and musculocutaneous perforators (10). The exact definition of perforator is still controversial. When the concept of the perforator was first introduced, Wei el al. (11) defined perforating vessels as those of which the source artery is deep and the branch that carries blood directly to the fasciocutaneous tissues, in its course to reach the skin, passes through the overhanging muscular tissue without exclusively following the intermuscular septum. By this definition, only musculocutaneous perforators are considered true perforators, and flaps based on other types of perforator are not regarded as perforator flaps. However, this rigid definition has caused confusion about the concept of the perforator. The anterolateral thigh (ALT) flap, one of the most popular perforator flaps, is a representative example that demonstrates the differences between perforator flaps and conventional flaps. The anterolateral thigh flap is based on a perforator connected to the descending branch of the lateral circumflex femoral system (6, 12, 13). Most of the time, the perforator comes through the vastus lateralis muscle (82%) and is therefore musculocutaneous, or it is a septocutaneous perforator, which is easier to harvest and use than the musculocutaneous perforator (14). According to strict definitions, the flap based on the musculocutaneous perforator is a perforator flap and the flap based on the septocutaneous perforator is not a perforator flap. These flaps differ from each other in terms of the ease of pedicle dissection - tedious transmuscular dissection in musculocutaneous flaps, as opposed to easy and rapid dissection between muscles in septocutaneous flaps (6, 14). Most microsurgeons tried to select septocutaneous perforators to save operating time before the development of the perforator concept, but now transmuscular dissection is more popular due to the reliability of the perforator. Moreover, when the perforator is reliable and the length is sufficient, pedicle dissection stops at the level of the perforator without requiring transmuscular dissection (6). Therefore, the ALT flap has evolved from a myocutaneous flap, to a range of flaps based on either septocutaneous or musculocutaneous perforators. As it is important to distinguish between these flaps, workers have named the different flaps 'ALT myocutaneous flaps,' 'lateral circumflex femoral perforator flaps,' 'vastus lateralis perforator flaps,' and 'ALT perforator based flaps,' depending on the perforators involved (10). The former two patterns are conventional flaps while the latter three are perforator flaps. The lateral circumflex femoral flap can be included in both groups: it was initially designated an ALT (conventional) flap but is now considered a perforator flap, which illustrates the confusion surrounding the perforator concept. That is the reason why we insist that the concept of the perforator flap is not completely distinct from that of the conventional flap concept (Fig. 1). We therefore conclude that flaps previously described as conventional flaps were in fact perforator flaps, and that flaps based on septocutaneous perforators should be considered perforator flaps (3, 10).

Bottom Line: Moreover, depending on the surgeon's ability, any flap can be utilized as a perforator-based island flap whose source vessel has been completely preserved.The application of perforator flap technique enables more precise dissection, and allows more selective harvesting of thinner flaps, which will expand options in reconstructive surgery.No doubt the technique will continue to evolve.

View Article: PubMed Central - PubMed

Affiliation: Department of Plastic and Reconstructive Surgery, College of Medicine, Hanyang University, Seoul, Korea.

ABSTRACT
The introduction of perforator flaps represented a significant advance in microsurgical reconstruction. However, confusion has developed due to the erroneous belief that perforator flaps are different from conventional flaps. The concept of the perforator is not new, but is an idea that evolved from the conventional flap. In fact, some of the flaps used by microsurgeons were perforator flaps. The only difference is the anatomical level of the blood vessels involved; the perforator concept is focused on the distal circulation, so-called 'perforator'. Therefore, thinner sections of tissue can be taken from the conventional donor sites of myocutaneous flaps. With the use of perforators, there are no longer "flap of choice" for specific reconstructions, because conventional donor sites have become universal donor sites, enabling the harvesting of a variety of flaps. Moreover, depending on the surgeon's ability, any flap can be utilized as a perforator-based island flap whose source vessel has been completely preserved. Therefore, tissues can be efficiently customized and tailored into any configuration required for reconstruction. The application of perforator flap technique enables more precise dissection, and allows more selective harvesting of thinner flaps, which will expand options in reconstructive surgery. No doubt the technique will continue to evolve.

No MeSH data available.


Related in: MedlinePlus