Table of Contents  
Year : 2019  |  Volume : 15  |  Issue : 2  |  Page : 35-38

Perforator flap: a useful tool in reconstructive surgery − our experience

1 Plastic and Reconstructive Surgery Unit, Department of Surgery, Federal Medical Centre Owerri, Imo State, Nigeria
2 Department of Plastic Surgery, National Orthopaedic Hospital, Enugu, Enugu State, Nigeria

Date of Submission10-Mar-2019
Date of Acceptance12-Aug-2019
Date of Web Publication17-Jul-2020

Correspondence Address:
Dr. Chimaobi Markson Isiguzo
FWACS, Plastic and Reconstructive Surgery Unit, Department of Surgery, Federal Medical Centre Owerri, Imo State
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njps.njps_3_19

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Context: Perforator flaps is now a very versatile tool for the reconstruction of challenging tissue defects. The beauty of the tool lies in the minimization of morbidity in comparison to conventional pedicled flaps surgery. Also the inherent property of ease of rotation through 180° gives it excellent versatility in repair of defects that would have been difficult with conventional pedicled flaps. Aims: This article discusses our experience and encourages more plastic surgeons to develop the skill and use it in solving complex reconstructive challenges. Methods and Material: This a case series involving 16 cases of complex wounds (chronic and acute) that presented at our unit. Results: A total of 16 cases were selected for surgical treatment. It involved 12 males and four females. The average age of the patients was 42.4 years. The most common site of reconstruction was in the lower limb with the left being more frequent. Posterior tibia artery was the most common axial vessel that the perforators were based. The most common complication in our series was superficial epidermolysis. There was no flap loss. Conclusions: Perforator flaps are indispensable tools in managing complex defects. This is the next available option to free flap transfer as long a perforator vessel can be identified in a skin tissue just large enough to cover a defect. Due to poor development of free flap surgery, we are encouraging surgeons − old and new − to pick up the skill. We have opened opportunities for training in our institution.

Keywords: Challenging wounds, improving skill, perforator flap

How to cite this article:
Isiguzo CM, Opara K, Okoye C, Ogbonnaya IS. Perforator flap: a useful tool in reconstructive surgery − our experience. Nigerian J Plast Surg 2019;15:35-8

How to cite this URL:
Isiguzo CM, Opara K, Okoye C, Ogbonnaya IS. Perforator flap: a useful tool in reconstructive surgery − our experience. Nigerian J Plast Surg [serial online] 2019 [cited 2021 Apr 15];15:35-8. Available from:

  Introduction Top

A perforator flap is a vascularized tissue transfer nourished by adequate cutaneous perforator.[1] The word perforator was derived from two Latin words “per” (through) and “forare” (to pierce or bore), and hence any vessel that passes through a definite opening in the deep fascia is a perforator vessel irrespective of the source.[2] Over 400 cutaneous perforators have been described in the human body.[3] The initial definition of perforator flaps by Wei et al.[4] showed that perforating vessels are 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. This excluded perforators arising from septocutaneous branches of the deep source artery. However, it is now known that whether the perforator arises from either musculocutaneous, septocutaneous, or direct cutaneous branches of the source artery they end up in nourishing the five known plexuses that are directly responsible for nourishing the skin and subcutaneous tissues, namely, subepidermal, dermal, subdermal, subcutaneous, and fascial (suprafascial and subfascial).[5],[6],[7],[8] Summarily, therefore, perforator flaps are based on vessels found in the subdermal and subcutaneous plexus whereas the conventional flaps are based on those proximal to it.

This advancement has increased the options for flap donor sites since a flap can be based anywhere a suitable perforator can be found. The conventional donor sites have become “universal donor sites.” In fact, this has minimized the idea of “flap of choice” in reconstruction of specific defects. This implies that perforator flaps from any site can be modified or prefabricated to suit reconstructive needs.[7],[9] Wei and Mardini,[10] Mardini et al.,[11] and Wallace et al.[12] described that free style flaps implying any region of the body with an audible pulsatile Doppler signal can be chosen as a donor site to meet any reconstructive need in principle.

The concept of perforator flap is a paradigm shift from conventional flaps. The truth is that they are not totally different from conventional flaps that are based on known axial vessels (axial pattern flaps) or “so-called unknown” random pattern vessels. The random flaps were actually perfused by perforators at the pedicle which were not dissected out whereas axial flap are nourished by the downstream branches. This concept developed as a result of the advancement in understanding of the anatomy of blood supply to the skin and microsurgical techniques. Flap dissection is usually tedious and, as such, presents a steep learning curve to the trainee.

Another additional advantage of the perforator-based flap is the minimization of donor site morbidity associated with conventional flaps. Inclusion of fascia and muscles in the conventional flaps results in loss of already existing function. This results in additional morbidity on the already existing condition.

Interestingly, in situations where paucity of skin and muscle tissue is norm, notably in the lower extremity, the perforator flaps have turned out to be very valuable. The lower half of the leg is notorious for this deficiency. The solution to the challenge lay in the development of perforator flaps because the lower extremity is the largest donor site region in the body for perforator flap harvest.[13]

Microsurgical instrumentation is capital intensive and is necessary for execution of this reconstructive option. This may be a significant challenge in a resource-poor setting due a heavy case load. The case burden of chronic wounds/defect is heavy in the region due to ignorance, lack of access to healthcare, or unorthodox care (traditional treatment).

  Patients and methods Top

This is a case series of selected patients with extensive and complex soft tissue defect of the extremities who presented at two tertiary health facilities, namely, Federal Medical Centre Owerri and National Orthopaedic Hospital, Enugu, both in South East Nigeria, from June 2015 to October 2017. Selection was based on presence of extensive soft tissue defect that could not be closed primarily. Surgeries were done by authors in both the institutions. Informed consents were given by the patients. Patients with evidence of peripheral vascular disease were excluded as evidenced by audible Doppler wave pattern generated from the handheld Doppler. Triphasic and biphasic waveforms were acceptable whereas monophasic waveform was a contraindication. A total of 16 cases were selected.

  Results Top

There were 16 cases in all with a male-to-female ratio of 3:1 and age range of 2 to 70 years. The average age of series was 41.3 years. The complication rate was 33.33%. The most common complications were tip necrosis (5.5%) and superficial epidermolysis (27.7%). The complications were associated with perforator flaps localized to the leg precisely. SSG for the donor site was done in 62.5% of the cases whereas primary closure was achieved in the remaining cases. Skin grafting was indicated in all the cases involving the leg region precisely. Trauma accounted for 100% of the etiology (87.5% was road traffic and 12.5% was post burn). More than 80% of the perforator flap reconstruction was carried out on the lower limbs. There was no case of complete flap loss. The lower limb perforators were the greatest contributors of the perforator flaps (posterior tibial artery − 62.5%, genicular artery − 18.75%, peroneal artery − 6.25%, axillary artery and radial recurrent artery − 6.25%, respectively). Average angle of rotation was 122.5°. The lower limb benefitted more from the reconstruction (87.5%). [Table 1] presents a summary of the cases.
Table 1 Summary of cases

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  Discussion Top

Perforator flap is an innovation that has provided the much needed solution in dealing with some previously challenging reconstructive problems. These challenges were mainly that of unavailability of enough tissue for cover and the resulting morbidity, if available conventional flaps are used. The earlier challenge is usually solved by free flap surgery. Interestingly, the free flap solution is not feasible or unavailable or worst and is still impossible in most centers in the sub-Saharan region. The morbidity resulting from use of conventional fasciocutaneous/musculocutaneous (i.e., loss of muscle function or bulk deformities) also has significant impact on the patient in the postoperative period because of aesthetic concerns. Our region is in short supply of free tissue transfer equipment and skills. Hence, development of this innovation is necessary in dealing with defects that would have ended up with severe complications.

Since the lower limbs are the largest donor site for perforator flaps, it makes it possible to cover most exposed bones (case 6) or tendons especially in lower third of the leg (cases 1, 2, and 3). The resource should be harnessed. The intrinsic property of the perforator flaps to rotate through a wide angle (up to 180°) makes it easily available even in the most difficult sited defects. In my experience, it is one property that adds to the versatility of the perforator flap.

Following healing and fibrosis in the post-trauma era, raising large fasciocutaneous flaps may be nearly impossible. Fibrosis makes dissection difficult and increases the risk of destroying source and/or perforator vessels. But with the perforator flap, any strip of remaining normal skin that is centered on a good perforator can be dissected out suprafascially and then put to good use in covering an exposed structure due to its rotational maneuverability. The study showed that the average angle of rotation was 122.5° which explains the later. This will invariably improve healing of a bone/tendon or make reoperation through normal skin instead of a scar possible (cases 4 and 5).

Due to the paucity of good skin in an already traumatized leg or presence of large areas of fibrous scar, donor defects are not usually closed primarily. The split skin grafting (SSG) is useful in achieving donor site closure in such cases. The donor defect has fascial bed that easily accepts a SSG. SSG was also useful in resurfacing perforator flaps with extensive superficial epidermolysis (case 6). The skin-grafted donor defect can also be utilized as a facial flap if there is a need in future. The most common predictor of source vessel used is the location of the defect and availability of donor skin.

Our series also demonstrates the usefulness of the perforator flaps in both the very young and old. There are no limitations to its usefulness as long as there are perforators and these reduce or eliminate the morbidities of conventional flaps. The safety of perforator in our series is demonstrable because of no incidence of total flap loss. The most common complications were superficial epidermolysis and marginal tip necrosis which in no way side-tracks from the aim of achieving adequate skin cover. As long as appropriate instruments and good skills are put to good use, the results are almost predictable.

To achieve any success in the use of perforator flaps, the following are needed, namely, appropriate instruments, training, and the much-needed patience to carry out the tedious

dissection. The minimum instrumentation is a good loupe (>2.5x) fine instruments (microvascular instruments inclusive to aid skeletonization of the perforator vascular pedicle if need be). Skeletonization of vessel aids the angle of flap rotation to cover defects. For a small-angle rotation, there may not be any need for complete skeletonization.

A handheld Doppler with an invasive and noninvasive probes are indispensable (Mini Doppler ES-1000vx, Koven Technology, St. Louis, MO, USA, with 5.8 to 10 mHz frequency). The noninvasive probes are useful in preoperative planning and identification of perforator whereas the invasive are useful intraoperative in ensuring vascular integrity of perforators during dissection. The fact is that the cost of instrumentation is lower in comparison to that required for free microvascular tissue transfer. It is a cheaper reconstructive option in resource-poor settings as long as there is a perforator and a tissue to rotate. Also some perforator-based flaps are used as free flaps currently and the process of dissecting the vascular pedicle out in both cases are same.[10],[11] The act of dissecting them helps the surgeon to gain confidence to harvest a free flap for transfer. This is the beginning of demystification of free flap transfer. Therefore, based on the all aforesaid, we are encouraging plastic surgeons and residents to embrace the innovation in the region. This will add more options to their reconstructive tool bag.

Presentation at a meeting

This article was presented at the 24th Annual AGM and Scientific Conference National Association of Plastic Aesthetic and Reconstructive Surgeon, Ado Ekiti, Ekiti State, Nigeria, on August 27 to 30, 2018; and at the 9th Biannual Congress, World Society for Reconstructive Microsurgery, Seoul, South Korea, on June 13 to 17, 2017.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Geddes CR, Morris SF, Neligan PC. Perforator flaps: evolution, classification and application. Ann Plast Surg 2003;50:90-9.  Back to cited text no. 1
Geoffrey GH. Anatomy of perforator flaps. In Jeffrey W, editor. Plastic Surgery Secrets Plus. Philadelphia: Mosby Elsevier 2010. pp. 704-11.  Back to cited text no. 2
Morris SF, Tang M, Almutairi K, Geddes C, Yang D. The anatomic basis of perforator flaps. Ann Plast Surg 2010;37:553-70.  Back to cited text no. 3
Wei FC, Jain V, Suominen S, Chen HC. Confusion among perforator flaps: what is a true perforator flap? Plast Reconstru Surg 2001;107:874-6.  Back to cited text no. 4
Daniel RK, Kerrigan CL. Principles and physiology of skin flap surgery. In: McCarthy JG, editor. Plastic Surgery. Philadelphia: WB Saunders 1990. p. 275.  Back to cited text no. 5
Grover R, Nelson JA, Fischer JP, Kovach SJ, Serletti JM, Wu LC. The impact of perforator number on deep inferior epigastric perforator flap breast reconstruction. Arch Plast Surg 2014;41:63-70.  Back to cited text no. 6
Jeong TK, Sang WK. Perforator flap versus conventional flap. J Korean Med Sci 2015;30:514-22.  Back to cited text no. 7
Saint-Cyr M, Schaverien MV, Rohrich RJ. Perforator flaps: history, controversies, physiology, anatomy, and use in reconstruction. Plast Reconstr Surg 2009;123:132e-45e.  Back to cited text no. 8
Wang C, Yang S, Pu L. Pre-expanded super thin perforator flaps. Clin Plast Surg 2017;44:31-40.  Back to cited text no. 9
Wei FC, Mardini S. Free style free flaps. Plast Reconstr Surg 2004;114:910-6.  Back to cited text no. 10
Mardini S, Tsai FC, Wei FC. The thigh as a model for free style free flaps. Clin Plast Surg 2003;30:473-80.  Back to cited text no. 11
Wallace CG, Kao HK, Jeng SF, Wei FC. Free style flaps: a further step forward for perforator flap surgery. Plast Reconstr Surg 2009;124:e419-26.  Back to cited text no. 12
Geddes RC, Tang M, Yang D, Morris SF. Anatomy of integuments of the lower extremity. In: Blondeel PN, Morris SF, Hallock GG, Neligan PC, editors. Perforator Flaps: Anatomy, Technique and Clinical Application, 2nd edition. St Louis, Missouri: QMP; 2013. p. 668-703.  Back to cited text no. 13


  [Table 1]


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