British Journal of Plastic Surgery (2005) 58, 431–440

New nomenclature concept of perforator flap*

Jeong Tae Kim*

Department of Plastic and Reconstructive Surgery, College of Medicine, Hanyang University, Haengdang-
Dong 17, Seongdong-Gu, Seoul 133-792, South Korea

Received 29 September 2003; accepted 15 December 2004

KEYWORDS Summary Confusion regarding the perforator flap concept has arisen partly from
Perforator flap; the use of ill-defined nomenclature without consistency; flaps have been named
Nomenclature according to either the proximal vessel, the location harvested or the muscle
dissected. Since, a variety of conflicting terms can distort the exact understanding of
the flap and the true perforator concept, a precise and scientific system of
nomenclature is promptly needed.
In order to remedy such confusion, the author reviewed 54 recently published
articles and 38 abstracts for vague or inaccurate nomenclatures, and compared the
perforator flaps with the conventional flaps. A new nomenclature was then drawn up
according to three perforator types: direct cutaneous, septocutaneous and
musculocutaneous perforator. Even though only musculocutaneous perforators
were considered to be true perforators in the initial concept, some perforator
flaps have subsequently been added based on septocutaneous or direct cutaneous
perforators. Discrimination is necessary and made possible by use of the following
nomenclature: a perforator flap based on a musculocutaneous perforator is named
according to the name of the muscle perforated, and perforator flaps based on other
types of perforators, are named according to the name of the proximal vessel. The
term ‘perforator based’ further defines those flaps harvested without sacrificing the
proximal vessel.
This new nomenclature concept would be a great help in discriminating among the
various patterns of perforator flaps and also in preventing confusion arising from the
misnaming of new perforator flaps in the future. Furthermore, the perforator pattern
used in the flap can easily be comprehended, and especially in extremities, various
perforator flaps, based on the musculocutaneous or septocutaneous perforator, can
plainly be distinguished with this new nomenclature concept.
Q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All
rights reserved.

*
Presented at the 6th International Course of Perforator Flap, Taipei, Taiwan, October 24–26, 2002. And II Congress of World Society
for Reconstructive Microsurgery, Heidelberg, Germany, May 12–15, 2003. And the 13th International Congress of the International
Confederation for Plastic, Reconstructive and Aesthetic Surgery, Sydney, Australia, August 10–15, 2003. And 2004 American Society for
Reconstructive Microsurgery, Palm Springs, USA, January 17–20, 2004.
* Tel.: C82 2 2290 8560/8563; fax: C82 2 2293 8560.
E-mail address: jtkim@hanyang.ac.kr.

S0007-1226/$ - see front matter Q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjps.2004.12.009
432 J.T. Kim

Table 1 Comparison of conventional and new nomenclature

Conventional flap name Flap name according to new con-
cept (perforator pattern selected)
Lateral chest wall
Latissimus dorsi perforator (based) flap/latissimus dorsi musculocuta- Latissimus dorsi perforator flap
neous flap without muscle/thoracodorsal (artery) perforator flap (MCp)
Thoracodorsal perforator flap (SCp)
Latissimus dorsi perforator-based flap Latissimus dorsi perforator based
flap (MCp) or latissimus dorsi per-
forator based island flap
Abdomen
Paraumbilical perforator (based) flap/periumbilical rectus abdominis Rectus abdominis perforator flap
perforator flap/inferior epigastric artery skin flap without rectus (MCp)
abdominis muscle/deep inferior epigastric artery skin flap/deep inferior
epigastric (artery) p. flap
Paraumbilical perforator flap without deep inferior epigastric vessels Rectus abdominis perforator based
flap (MCp) or rectus abdominis
perforator based island flap
Thigh
Anterolateral thigh perforator flap Rectus femoris perforator flap or
vastus lateralis perforator flap
(MCp)
Lateral circumflex femoral per-
forator flap or descending perfora-
tor flap (SCp)
Tensor fasciae latae perforator (based) flap Tensor fasciae latae perforator flap
(MCp)
Posterior thigh perforator flap Biceps femoris perforator flap
(MCp)
Deep femoral perforator flap (SCp)
Buttock
Superior/inferior gluteal perforator (based) flap (Superior/inferior) gluteus maximus
perforator flap (MCp)
Pedicled perforator flap/perforator-based flap in gluteal area Gluteus maximus perforator based
island flap
Lumbar artery perforator based island flap Erector spinae perforator based
island flap
Leg
Medial sural artery perforator Flap Medial gastrocnemius perforator
flap (MCp)
Gastrocnemius perforator-based flap
Anterolateral leg perforator flap33 Anterio tibial perforator flap (SCp)
Posterior tibial perforator flap Posterior tibial perforator flap
(SCp), soleus perforator flap (MCp)
Flexor digitorum longus p. flap
(MCp)
Lateral leg perforator flap Peroneal perforator flap (SCp)
Peroneus longus perforator flap
(MCp)
Forearm
Radial artery perforator flap/perforator-based forearm flap Radial perforator flap (SCp) or
flexor carpi radialis perforator flap
(MCp)
Antecubital fascio-cutaneous flap34 Inferior cubital perforator flap
(SCp)
MCp, musculocutaneous perforator; SCp, septocutaneous perforator; p, perforator
New nomenclature concept of perforator flap
Inconsistent nomenclature of perforator flaps hin-
ders communication and causes difficulty in devel-
oping the perforator flap concept. For instance, the
deep inferior epigastric perforator flap is named
after the proximal vessel, however, sometimes it
has also been named the paraumbilical or perium-
bilical perforator flap.1,2 As for the perforator flaps
from the lateral chest wall, the name of latissimus
dorsi perforator flap has been used, along with the
other nomenclature of thoracodorsal perforator
flap.3,4 Since, anterolateral thigh perforator flap is
named after the region where it is harvested, two
perforator dissections based on the septocutaneous
perforator (SCp) or musculocutaneous perforator
(MCp) are not distinguished by the nomenclature.
Various perforator flaps have been described on
the limbs. It is difficult to understand exactly when
they were first mentioned during discussion or
described in the literature. Especially, in posterior
thigh perforator flap5 or medial circumflex femoral
perforator flap,6 it is difficult to understand how to
elevate the flap or which perforator is used.
Confusion also occurs between sural artery per-
forator flap7 and peroneal perforator flap.8 The
nomenclature of radial artery perforator flap9 is
vague and inaccurate, therefore, the exact harvest-
ing procedure can hardly be understood unless
reading the entire article. Since, an ideal nomen-
clature should be consistent and accurate, scien-
tific and detailed information about the pedicle
course and perforator used are prerequisites in the
new nomenclature concept.
Materials
Fifty-four articles and 38 abstracts were reviewed
for the usage of nomenclature. Similar perforator
flaps were classified and their names were com-
pared from the anatomical standpoint. Vague and
inaccurate expressions were exposed, and conven-
tional flaps were compared with perforator flaps for
the purpose of determining whether the nomen-
clature could faithfully represent the character of
the flap and distinguish the one from the other.
Results
The nomenclature of perforator flaps on the
extremities is extremely disorganised (Table 1).
On the thigh, the anterolateral thigh perforator flap
is named according to the region, whilst the tensor
fascia lata perforator flap is named according to the
muscle, even though both flaps are based on
433
perforators from the same proximal vascular
system. Furthermore, the perforator type used in
the flap dissection such as MCp or SCp is not
accurately described in the nomenclature.10 Some
flaps such as tensor fascia lata perforator flap,11
posterior tibial perforator flap12 or medial sural
artery perforator flap13 manifest the name of the
proximal artery in the nomenclature, but the
perforator pattern is not exactly described. Con-
versely, the lateral leg perforator flap14 or posterior
thigh perforator flap5 are named according to the
region.
Popular perforator flaps in the abdomen and
lateral chest wall have various kinds of nomencla-
tures. The DIEP flap is known to be one of the most
popular flaps but, many nomenclatures have been
used, including paraumbilical perforator flap,1,15
paraumbilical perforator-based flap,16 deep
inferior epigastric perforator flap (DIEP),17–19 deep
inferior epigastric artery perforator flap,20 inferior
epigastric artery skin flaps without rectus abdomi-
nis muscle,21 and deep inferior epigastric artery
skin flap.22 In the lateral chest wall area, the name
‘latissimus dorsi musculocutaneous flap without
muscle’23 was introduced first, but its expression
was somewhat contradictory, because of inclusion
of both ‘musculocutaneous’ and ‘without muscle’.
Next, the name ‘latissimus dorsi perforator flap’3
was introduced, and also ‘thoracodorsal (artery)
perforator flap’ was used, following the customary
nomenclature of DIEP flap.24–26
An inappropriately long description was required
for exact description in some perforator flaps, such
as the paraumbilical perforator flap without deep
inferior epigastric vessels,15 the gluteal fold flap
nourished by skin perforators of the internal
pudendal artery,27 or the posterior interosseous
flap based on a septal perforator.28 Some areas are
vague in the perforator concept, and various
subcutaneous or fascia pedicled flaps have been
introduced as perforator flaps. These inadequate
terms, such as ‘distally pedicled cutaneous-subcu-
taneous perforator forearm flap’,29 ‘turn-over flap
based on perforators of the dorsalis pedis’,30
‘perforator based V–Y advancement flap’31 and
‘perforator-based forearm and hand adipofascial
flap’32 have caused serious confusion in the per-
forator concept.
New nomenclature system
Any new standardised nomenclature should be
accurate and simple to understand, moreover, the
perforator pattern used and dissection course
should be easily understood from the
434 J.T. Kim

Figure 1 New nomenclature system of the perforator flap. Perforator flap based on the DCp or SCp is named based on
its proximal vessel, but the flap based on the MCp is named according to the muscle perforated. Perforator ‘based’ flap
means the flap based on a perforator itself without further proximal dissection, and its name according to the perforator
type in above principle. (A) Direct cutaneous perforator (DC-p) from its proximal vessel (X). (B) ‘X perforator flap’ based
on the DC-p is named from proximal vessel X. (D) Septocutaneous perforator (SC-p) from proximal vessel (Y). (E) ‘Y
perforator flap’ based on the SC-p is named from proximal vessel Y. (G) Musculocutaneous perforator (MC-p) variant of
the septocutaneous perforator. (H) ‘B perforator flap’ is named from the muscle B perforated by alternative
transmuscular course of septocutaneous perforator. (J) Musculocutaneous perforator (MC-p) sprouted from the muscle
(C). (K) ‘C perforator flap’ is named from the muscle C perforated. (C), (F), (I) and (L) Perforator ‘based’ flap based on
each perforator type.
New nomenclature concept of perforator flap 435

nomenclature. Since, the sprouting point of the
perforator is variable and unpredictable, new
nomenclature should accommodate such variety
within a framework of definite principle.
Perforators can be categorised as direct
cutaneous perforator (DCp), septocutaneous per-
forator (SCp) and muculocutaneous perforator
(MCp). DCp is the perforator sprouting from the
proximal vessel to dermis without traversing the
muscle or deep fascia, and mostly found in face,
perineum and so on. SCp is the one piercing
between the neighboring muscles, and mostly
found in extremities. MCp, a true perforator
piercing the muscle, is the pedicle for genuine
perforator flap, and should be discriminated from
the two former types, DCp and SCp, by a different
nomenclature.
For the flap based on the DCp or SCp, it is
desirable to name it according to the proximal
vessel; submental perforator flap35 from the sub-
mental artery or medial plantar perforator flap36
from medial plantar artery (Fig. 1(A), (B), (D) and
(E)). It is important for these two patterns to be
distinguished from MCp by different nomenclature
system, because their dissections are not so
difficult as MCp. But, for the flap based on the
MCp, it is named according to the name of muscle
perforated (Fig. 1(J) and (K)). In the anterolateral
thigh flap, it can also be elevated in two patterns
according to its variable anatomy, such as the SCp
or MCp (Fig. 1(G) and (H)). Therefore, the vastus
lateralis perforator flap means that the flap is
elevated based on the MCp through transmuscular
dissection of vastus lateralis, however, the lateral
circumflex femoral perforator flap implies that the
flap is elevated based on the SCp.
The term, ‘perforator based’ is used for the flap,
when it is truly based on the perforator itself with
the proximal vessel saved, and the flap is named
according to the perforator type as described above
(Fig. 1(C), (F), (I) and (L)). This distinction would
also solve the current confusion caused by disorga-
nised usage of ‘perforator flap’ and ‘perforator
based flap’.
Discussion
Perforator flaps have been developed to reduce the
sacrifice of donor structure, and to enable versatile
design or thickness as required. However, it proved
to require meticulous and challenging transmuscu-
lar dissection technique compared to conventional
flaps. Some authors proposed to define the per-
forator flaps as exclusively those based on MCp.37
The question of whether the flap based on DCp or
SCp should be excluded has been an issue of
controversy, and debates on the perforator flap
category are still being continued. At first, this
author also thought that MCp was the real perfora-
tor and the flaps based on other perforators should

Figure 2 Conventional flap and perforator flap in forearm. (A) Forearm fasciocutaneous flap including the deep fascia
and septum containing septocutaneous perforator (SCp). MCp, musculocutaneous perforator. (B) Forearm septocuta-
neous flap excluding the deep fascia. (C) Radial perforator flap based on the SCp with the septum and deep fascia
excluded. (D) Flexor carpi radialis (FCR) perforator flap based on MCp sprouting from the FCR muscle.
436 J.T. Kim

be excluded from the perforator concept to prevent
confusion. However, some perforators vary
between MCp and SCp because of the anatomical
variability. Furthermore, some of the conventional
fasciocutaneous or cutaneous island flaps based on
the perforator or narrowed septal pedicle, includ-
ing several perforators, have been already used,
such as forearm or saphenous flap. Therefore, the
perforator flap based on the MCp should better be
discriminated by different nomenclature from
those based on other perforators.
Generally, SCp has been accepted to be a pedicle
within the perforator concept. Giunta and Geisweid
suggested a simple system to discriminate two

Figure 3 Conventional and perforator flap in thigh. LCFA, lateral circumflex femoral artery; Ds, descending branch;
VL, vastus lateralis; MCp, musculocutaneous perforator; SCp, septocutaneous perforator. (A) Conventional flap of
anterolateral thigh (musculocutaneous) flap can be easily distinguished from perforator flap with its nomenclature. (B)
Vastus lateralis perforator flap based on MCp of VL. (C) Descending perforator flap based on SCp without sacrifice of
transverse branch and proximal LCFA. (D) Lateral circumflex femoral perforator flap with longer pedicle and proximal
branching system for chimeric pattern. (E) Vastus lateralis perforator based flap based on MCp with sparing of proximal
descending branch by limited dissection. (F) Descending perforator based flap based on SCp with sparing of descending
branch depending on the recipient status.
New nomenclature concept of perforator flap
perforator flaps, such as ‘musculocutaneous per-
forator flap (type A)’ and ‘septocutaneous perfora-
tor flap (type B)’.38 Geddes et al. proposed that all
perforator flaps should be named according to the
main artery with the suffix of muscle name, and
addition of suffix-s is recommended to overcome
potential limitation for SCp.39 In the system
suggested, however, there is no appropriate term
corresponding to the perforator based flap and,
flaps between two perforator patterns are not
easily distinguished. The concept of perforator
patterns can also be modified, such as direct and
indirect perforators.40 Since, the nomenclature
needs to be simple and consistent for general
usage by operators, the new nomenclature system
in this article emphasises that the name is relevant
to the muscle in MCp based perforator flap and to
the vessel in flaps based on other perforators.
Simplicity of the nomenclature is likely to avoid the
debate on complicated perforator concept and
encourage widespread usage of perforator flaps,
not restricted by confusion in nomenclature.
The forearm flap, it is named conventionally as a
fasciocutaneous flap with septum and deep fascia
included for flap reliability (Fig. 2(A)). However,
the septum alone proved to be enough for flap
survival without much of deep fascia, and the
nomenclature of ‘septocutaneous flap’ was popu-
larised (Fig. 2(B)). With the perforator concept, the
flap can be available even based on a single
perforator instead of longitudinal inclusion of
septum, and it is called as ‘radial perforator flap’
according to the name of proximal vessel (Fig.
2(C)). If based on a single MCp perforating the flexor
carpi radialis, the flap is named as ‘flexor carpi
radialis perforator flap’ according to the muscle
name (Fig. 2(D)). In this regards, the perforator
concept has greatly contributed to the revolution of
conventional flaps.
In the thigh, the anterolateral thigh flap can be
elevated based on SCp or MCp according to its
variable anatomy, and it is a common nomenclature
without accurate discrimination between musculo-
cutaneous or septocutaneous flap. After introduc-
tion of the perforator concept, another confusion
occurred between the conventional septocuta-
neous flap and the perforator flap based on SCp,
even though they are the same flap. More confusion
in nomenclature would be expected if the SCp is
excluded from perforator concept: If only the flap
based on the MCp is regarded as the perforator flap
called as ‘anterolateral thigh perforator flap’
compared with ‘anterolateral thigh flap’ for con-
ventional musculocutaneous flap, there would be
no appropriate nomenclature for the flap based on
SCp. Therefore, with this new nomenclature
437
concept, conventional musculocutaneous flap can
easily be distinguished from perforator flaps by the
term ‘perforator’ (Fig. 3(A)). Clear discrimination
can be achieved with new nomenclature concept;
‘vastus lateralis perforator flap’ based on MCp (Fig.
3(B)) and ‘descending perforator flap’ based on
SCp. Conventional septocutaneous flap or perfora-
tor flap based on SCp is named according to the
name of the proximal vessel. The name of proximal
vessel can also vary depending on the extent of
proximal dissection and on the pedicle length
needed, or its diameter for anastomosis. For
instance, descending perforator flap implies the
flap based on the descending branch system without
sacrificing transverse branch and proximal lateral
femoral circumflex femoral artery (Fig. 3(C)). When
a longer pedicle with larger diameter is necessary
or proximal branching system is required for a
chimeric pattern, the dissection should proceed
proximally, and the flap is named as the lateral
circumflex femoral perforator flap (Fig. 3(D)).
Sometimes, the flap can be elevated based on the
MCp from the rectus femoris, and then it can be
named as a rectus femoris perforator flap. Depend-
ing on the recipient status, if the perforator at the
level of deep fascia has a diameter enough for
anastomosis, the dissection can be stopped without
further transmuscular dissection, and the flap is
named as ‘perforator based flap’ such as vastus
lateralis perforator based flap (MCp, Fig. 3(E)) or
descending perforator based flap (SCp, Fig. 3(F)),
which implies no sacrifice of descending branch.
Tensor fasciae latae perforator flap is a good
example of this new nomenclature.11,41 For the
medial circumflex femoral perforator flap6 elev-
ated based on MCp from gracilis, the name of
gracilis perforator flap is easier to understand.
Many other MCps or SCps originated from medial
circumflex femoral artery can be used as a pedicle
of perforator flap. Therefore, medial circumflex
femoral perforator flap is not accurate and, gracilis
perforator flap is more precise to understand the
flap. And the flap based on SCp from medial
circumflex femoral artery, such as medial circum-
flex femoral perforator flap, is also easily discrimi-
nated from gracilis perforator flap with different
nomenclature.
The posterior thigh perforator-based flap5 is
better named the biceps femoris perforator flap
or deep femoral perforator flap, if based on the MCp
or SCp. The posterior tibial perforator-based flap42
is one of the popular perforator flaps in medial leg,
but it is also better to differentiate between the
posterior tibial perforator flap based on SCp, and
the soleus or flexor digitorum longus perforator flap
based on MCp.
438 J.T. Kim

In the abdomen, DIEP flap for breast reconstruc-
tion can be named as rectus abdominis perforator
flap, and rectus abdominis perforator-based flap
means DIEP flap without sacrifice of deep inferior
epigastric artery.
In the lateral chest wall area, two nomenclatures
are also debated: latissimus dorsi or thoracodorsal
perforator flap. With the new nomenclature sys-
tem, flap based on the MCp through latissimus dorsi
is properly named as latissimus dorsi perforator
flap. Since, SCp originated from the thoracodorsal
system is located anterior to lateral border of the
latissimus dorsi muscle, perforator flap based on it
is named as thoracodorsal perforator flap.
In the gluteal region, two definite perforator
flaps are used for breast reconstruction; superior or
inferior gluteal perforator flap based on the MCp
from superior or inferior gluteal vessels. According
to the new nomenclature, these are all gluteus
maximus perforator flaps (sometimes it can be
gluteus medius perforator flap), however, they can
easily be distinguished by adding the description of
the perforating site in front of the flap name: such
as superior or inferior gluteus maximus perforator
flap, instead of superior or inferior gluteal perfora-
tor flap. Even though MCp can be originated from
other proximal vessels except superior or inferior
gluteal artery, it has been used as a pedicle of island
flap without transmuscular dissection, and the flap
can be named as gluteus maximus perforator based
island flap according to this nomenclature system.
Various nomenclatures of flaps that have been
used for lumbosacral defect, such as pedicled
perforator flap43 and perforator-based flap44 are
also named as gluteus maximus perforator based
island flap, if MCp is selected as a pedicle without
transmuscular dissection. As lumbar artery perfora-
tor based island flap45 is based on MCp, erector
spinae perforator based island flap is a correct
term.
Until now, the term ‘based’ has been used for all
the perforator flaps to discriminate them from
other conventional flaps, however, it has also been
intermittently used without defined guidelines. In
this new nomenclature system, it implies that the
dissection is stopped at the level of fascia or muscle
without sacrifice of proximal vessel. Depending on
the recipient status, the perforator dissection does
not necessarily proceed to the underlying proximal
vessel in the abdomen, lateral chest wall and
lateral thigh region, because some perforators
have enough diameter for pedicle anastomosis
(Fig. 4). For instance, the rectus abdominis per-
forator based flap signifies the flap elevated based
on the perforator itself with no further transmus-
cular dissection or no sacrifice of deep inferior
epigastric artery. This view is in accordance with the
‘supermicrosurgery’ concept proposed by Koshima.

Figure 4 Latissimus dorsi perforator based flap. (A) A 29-year-old patient was presented with lymphatic malformation
of left lateral thigh. (B) During the radical resection of the skin lesion, the large perforator was found in lateral thigh and
was planned for recipient vessels. (C) Postoperative view of flap inset after vascular anastomosis. A 13!7 cm latissimus
dorsi perforator based flap was harvested with the proximal vessel saved for resurfacing the defect. Long pedicle with
large diameter was not necessary for vascular anastomosis on the recipient bed, therefore, perforator pedicle dissection
was limited just underneath the latissimus dorsi muscle. (D) Postoperative view after resurfacing.
New nomenclature concept of perforator flap
Another confusion comes from extraordinarily
emphasised terminology of flap thickness with
various unscientific expressions, such as
‘thinned’,16 ‘thin’,3,46 ‘superthin’,47,48 ‘extremely
thinned’,49 ‘microdissected thin’41 and ‘thinning’.24
At least in the nomenclature, such expressions are
inappropriate for exactly presenting the flap,
especially to beginners or training doctors. Since,
perforator flaps from the back or extremities are
already known to be thin enough for resurfacing,
these unnecessary expressions should be simplified
as ‘thin’. Thin perforator flap implies the perforator
flap as a thin pattern without much of adipose layer
at flap elevation or trimming after elevation. For
instance, thin latissimus dorsi perforator flap means
the perforator flap elevated based on MCp
through the transmuscular dissection, excluding
much of the adipose tissue.
This concept of nomenclature has several advan-
tages. It accurately represents the dissected
muscle and differentiates the perforator pattern
used. And it can also prevent future confusion
possibly arising from innumerable perforator flaps
introduced in the future, especially in the extre-
mities. This nomenclature is simple to understand
by discriminating MCp from other perforators with
different names according to the muscle or prox-
imal vessel. With this new nomenclature, it is very
simple to discriminate the perforator flap and
conventional flaps, and also to appreciate the flap
character or dissection course, when the name is
mentioned. Finally, vague concepts of perforators
can be organised in a rational direction with
systematic nomenclature.
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2. Saulis AS, Dumanian GA. Periumbilical rectus abdominis
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