CME

Perforator Flaps: History, Controversies,

Physiology, Anatomy, and Use in Reconstruction
Michel Saint-Cyr, F.R.C.S.(C.)
Mark V. Schaverien, M.R.C.S.
Rod J. Rohrich, M.D.
Dallas, Texas
Learning Objectives: After studying this article, the participant should be able
to: 1. Understand the history and controversies surrounding perforator flaps. 2.
Describe the anatomy and understand the theories surrounding the physiology
of perforator flaps. 3. Understand the uses of perforator flaps in reconstruction.
4. Understand the future directions of the perforator flap concept.
Summary: Perforator flaps have the advantages of reduced donor-site morbid-
ity, versatility to accurately replace the components required at the recipient site,
a longer pedicle than is achievable with the parent musculocutaneous flap, and
freedom from orientation of the pedicle. Their development has followed our
understanding of the blood supply from a source artery to the skin, which has
been achieved because of landmark studies by Manchot, Salmon, Milton, Taylor,
and others. Many articles now attest to the safety and reliability of perforator
flaps. This review aims to outline the history and controversies surrounding
perforator flaps and to describe the anatomy of the “workhorse” perforator flaps
and their use in microsurgical reconstruction. These flaps include the deep
inferior epigastric artery, the anterolateral thigh, the thoracodorsal artery, and
the superior and inferior gluteal artery perforator flaps. (Plast. Reconstr. Surg.
123: 132e, 2009.)

P
erforator flaps represent the latest descen-
dant in a line of evolution that began with
the random pattern flap.1–3 The early ran-
dom pattern flaps were constrained by rigorous
length-to-width ratios to ensure viability4 until
1970, when Milton revealed that their survival was
dependent on the inclusion of a pedicle contain-
ing a large vessel.5 The axial pattern flap concept
was introduced by McGregor and Jackson in 1972
in their description of the groin flap,6 and was the
anatomical basis for the deltopectoral flap de-
scribed by Bakamjian.7 In the 1970s, the works of
Manchot were discovered and translated,8,9 reveal-
ing that many axial flaps were based on vessels that
he had already described. Musculocutaneous flaps
that were introduced by Ger10 and Orticochea11
rapidly became popular because of their reliability
and wide arcs of rotation. In 1981, Pontén re-
ported that greater length-to-width ratios could be
achieved in flaps from the lower leg if the deep
fascia was included.12 The anatomical basis for
these fasciocutaneous flaps was later described by
From the Department of Plastic Surgery, University of Texas
Southwestern Medical Center.
Received for publication February 12, 2007; accepted June
8, 2007.
Copyright ©2009 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0b013e31819f2c6a
Haertsch,13 Barclay et al.,14 and Cormack and
Lamberty.15 In 1987, following reappraisal of the
works of Manchot and Salmon,16,17 Taylor and
Palmer published their work defining the vascular
territories of source arteries, which they termed
angiosomes.18 Knowledge of these vascular terri-
tories has proven invaluable in flap design.
The perforator flap era began in 1989, when
Koshima and Soeda described an inferior epigas-
tric artery skin flap without rectus abdominis mus-
cle for reconstruction of floor-of-the-mouth and
groin defects, noting that a large flap without mus-
cle could survive on a single muscle perforator.19
Kroll and Rosenfield suggested that perforator flaps
combine the reliable blood supply of musculocuta-
neous flaps with the reduced donor-site morbidity of
a skin flap.20 The reduced donor-site morbidity often
leads to faster recovery and reduced postoperative
pain. Perforator flaps have the additional advantages
that they can be tailored to accurately reconstruct
the defect, including flap thinning for resurfacing
shallow defects, there is freedom of orientation of
Disclosure: None of the authors has any commer-
cial associations that might pose or create a conflict
of interest with information presented in this article.

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Volume 123, Number 4 • Perforator Flap Nomenclature
the pedicle, and a longer pedicle is harvested than
with the parent musculocutaneous flap. There is
hyperperfusion of the skin paddle,21 which may al-
low the capture of the adjacent two angiosomes,22
explaining how a single perforator can capture such
large territories.
NOMENCLATURE AND
CONTROVERSIES
Ever since their conception, there has been
debate over what constitutes a true perforator flap
and how a perforator should be defined.23,24 Pur-
ists state that a muscle perforator flap is the only
real perforator flap because of the additional ef-
fort and time needed to dissect the perforator out
from between the muscle fibers to reduce the do-
nor-site morbidity.25 A variety of terms have been
used to name perforator flaps, including anatom-
ical location (e.g., anterolateral thigh flap), arte-
rial supply (e.g., thoracodorsal artery perforator
flap), or muscle of origin, and this has led to con-
fusion in the literature. In an attempt to introduce
consistency, a standardized nomenclature has been
agreed on that describes all perforator flaps accord-
ing to the main artery of origin (Table 1)1,2:
• Cutaneous flaps are divided into either cutane-
ous flaps or musculocutaneous perforator flaps.
• Cutaneous flaps include all flaps previously de-
scribed as axial, septocutaneous, and fasciocuta-
neous (Mathes and Nahai types A and B fascio-
cutaneous flaps26). The suffix -s is added to the
flap vessel abbreviation to indicate fasciocutane-
ous and septocutaneous flaps.
• Perforator flaps are the true musculocutane-
ous perforator flaps (Mathes and Nahai type C
fasciocutaneous flaps26), in which the source
vessel to the skin arises from and passes
through the underlying muscle. Flaps are
named according to the source vessel, and the
suffix AP signifies a true musculocutaneous
perforator flap.
Table 1. Nomenclature of the Commonly Used Perforator Flaps
Common Name New Nomenclature
DIEP DIEAP
TAP TAP
ALT LCFAP-vl
S-GAP SGAP
I-GAP IGAP
DIEP, deep inferior epigastric perforator; DIEAP, deep inferior epigastric artery perforator; TAP, thoracodorsal artery perforator; ALT,
anterolateral thigh; LCFAP-vl, lateral circumflex femoral artery perforator–vastus lateralis; SGAP, superior gluteal artery perforator; IGAP,
inferior gluteal artery perforator.
• Where the flap is harvested based on direct
septal or fasciocutaneous vessels, the suffix -s is
added to the flap vessel abbreviation (e.g., an
anterolateral thigh flap harvested as a septocu-
taneous flap is abbreviated to LCFAP-s).
• The perforator flap nomenclature in correlation
to the angiosomes of the body is used according
to the descriptions by Taylor and Palmer.
• When multiple flaps are based on musculocu-
taneous perforators of the same source artery,
the muscular origin of the cutaneous vessels is
abbreviated and italicized to indicate the ana-
tomical origin of the flap (e.g., LCFAP-vl for
the vastus lateralis muscle).
• In the case of flaps based on source arteries that
have numbered segmental origins, such as the
posterior intercostal or lumbar arteries, the num-
bered source vessel requires notation. The cor-
responding vessel number is added after the flap
abbreviation (e.g., PIAP-8 flap to indicate the
eighth posterior intercostal perforator).
DEEP INFERIOR EPIGASTRIC
PERFORATOR FLAP
Background
The deep inferior epigastric artery perforator
flap, first described by Koshima and Soeda in
1989,19 was described for reconstruction of the
postmastectomy breast by Allen and Treece in
1994.27 Although breast reconstruction remains its
primary indication, the deep inferior epigastric
artery perforator flap has been described as a free
flap for reconstruction of defects in the head and
neck28 and lower limb,29 and it may also be thinned
in one stage.30 For breast reconstruction, the deep
inferior epigastric artery perforator flap offers dis-
tinct advantages to patients compared with the
transverse rectus abdominis myocutaneous flap in
terms of decreased donor-site morbidity and
shorter recovery periods. The deep inferior epi-
gastric artery perforator flap has proven reliability
and a low complication rate,31–33 although its har-
Source Artery Muscle of Origin
Deep inferior epigastric Rectus abdominis
Thoracodorsal Latissimus dorsi
Descending branch of the lateral Vastus lateralis
circumflex femoral
Superior gluteal Gluteus maximus
Inferior gluteal Gluteus maximus
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vest requires a high level of surgical expertise with
a significant learning curve. Contraindications in-
clude a history of previous abdominoplasty or ab-
dominal liposuction, multiple abdominal scars, or
active smoking. Acoustic Doppler examination
may produce a very high proportion of false-pos-
itive results because of its relatively high sensitivity
locating very small perforators.34 Computed tomo-
graphic angiography has been used for deep in-
ferior epigastric perforator35,36 flap presurgical im-
aging, and a high concordance with surgical findings
and a reduction in operating time have been re-
ported (Figs. 1 and 2).
Fig. 1. Preoperative pelvic computed tomographic angiogram
demonstrating large bilateral periumbilical perforators originat-
ing from the medial branch of the deep inferior epigastric vessels.
DIEP, deep inferior epigastric perforator.
Fig. 2. Periumbilical perforator flap for breast reconstruction
demonstrating good correlation with preoperative computed
tomographic angiography.
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Plastic and Reconstructive Surgery • April 2009
Anatomy
The deep inferior epigastric artery, which is the
most significant artery supplying the skin of the an-
terior abdominal wall, provides a pedicle that is 7.5
to 20.5 cm in length and 3.3 ⫾ 0.4 mm in diameter,
with two accompanying venae comitantes.37 It forms
two main branches in the majority of cases, with the
lateral branch giving off a lateral row of perforators
in the lateral third of the muscle and the medial
branch giving rise to a medial row of perforators in
the medial third of the muscle and an umbilical
branch.38 Several studies have noted that dominance
of the lateral branch is more common and that the
lateral division gives rise to more perforators, which
have a shorter intramuscular course39,40 than the me-
dial branch. There are generally 5 ⫾ 2 perforators
concentrated in the periumbilical region. Blondeel ad-
vises that the use of medial perforators is imperative if
zone IV is required.41
The superficial inferior epigastric vein is larger
than the deep inferior epigastric vein, suggesting
that in normal physiologic conditions venous drain-
age occurs predominantly through the superficial
system.42 The deep and superficial systems are con-
nected by the venae comitantes of the arterial per-
forators. The superficial inferior epigastric vein has
multiple lateral branches to the outer parts of the
flap but fewer medial branches of smaller caliber.
Blondeel et al. found that in 36 percent of flaps
studied there were no branches crossing the mid-
line. Severe diffuse venous congestion was encoun-
tered in 2 percent of flaps in a clinical series, and in
all these cases a particularly large superficial inferior
epigastric vein had been noted during flap harvest.43
Surgical Technique
Standard abdominoplasty markings are made
with a flap approximately 12 to 18 cm wide at the
midline and extending laterally to the anterior
superior iliac spines, and a two-team approach is
used. Most authors prefer the pedicle to be con-
tralateral to the side of the reconstruction, as this
aids flap insetting, with the thicker central adipose
layer used for the medial and inferior portions of
the breast. If large perforators from the internal
mammary artery and vein are found, these may be
prepared for anastomosis; otherwise, the internal
mammary vessels are harvested through the third
interspace or by means of excision or partial re-
section of the third intercostal cartilage. The su-
perior and inferior skin incisions are made and
the superficial inferior epigastric vessels are iden-
tified first. If these are found to be of sufficient
caliber, they are followed down to their origin
Volume 123, Number 4 • Perforator Flap Nomenclature

from the common femoral artery and a superficial

inferior epigastric artery flap is performed instead.
Superficial inferior epigastric artery flap harvest
has the advantage of staying superficial to the deep
fascia and therefore results in minimal donor-site
morbidity. Disadvantages include anatomical
variability,44,45 and some authors report that only
zones I and II are reliably perfused.46 Often, only
the superficial inferior epigastric vein is present of
sufficient size, and this is dissected for several cen-
timeters for use as a backup for additional venous
drainage if venous congestion is present after
anastomosis of the deep inferior epigastric vein.
Dissection then proceeds from lateral to medial.
The deep inferior epigastric artery perforator flap
may be raised on more than one perforator from
the same perforator row with atraumatic longitu-
dinal separation of the rectus muscle fibers. If no
suitable perforator is found, the contralateral por-
tion of the flap is raised. When a suitable perforator
is found, the perforator is dissected off the rectus
sheath and “unroofed” following intramuscular dis-
section and ligation of all intramuscular branches.
As with all perforator flap dissections, maintenance
of a bloodless field is crucial for safe deep inferior
epigastric perforator flap dissection. The segmental
intercostal nerves run medially, superficial to the
pedicle, and care must be taken to preserve them.
Dissection then continues until a pedicle of suffi-
cient length and caliber is obtained. This can occur Fig. 3. (Above) Large avulsion injury of the ankle and heel skin
at the lateral edge of the rectus muscle when a very in an 18-year-old male patient following a motorcycle acci-
cranial perforator is chosen. Sensory nerves that are dent. (Below) The defect was resurfaced with a 36 ⫻ 12-cm
found with the perforators can be harvested and single perforator– based anterolateral thigh (ALT) flap anasto-
anastomosed to an intercostal nerve.41,47 The anas- mosed to the posterior tibial vessels.
tomosis is performed and the flap inset, with deepi-
thelialization depending on the amount of native
breast skin that has been preserved. Zone IV is rou- femoris muscles, and iliac crest.58 – 60 An adjacent
tinely discarded by many authors.32 flap can also be harvested and anastomosed to a
branch of the lateral femoral circumflex artery,
ANTEROLATERAL THIGH FLAP including the groin flap or medial thigh flap, ac-
cording to the mosaic flap principle.61 The
Background LCFAP-vl flap can raised with or without fascia,
The anterolateral thigh perforator [lateral cir- can be thinned as either a one- or two- stage pro-
cumflex femoral artery perforator–vastus lateralis cedure to resurface shallow defects,62– 64 and can
(LCFAP-vl)] flap, first described by Song et al. in be combined with vascularized fibula for use as an
1984,48 is a versatile and reliable flap49 –51 that has osteocutaneous flap65 It can be used as a flow-
achieved popularity in head and neck surgery52,53 through flap to reconstruct defects of both soft
and in reconstructive surgery of the hand and tissues and major vessels in the extremities,66 and
upper and lower extremities54 –57 (Figs. 3 through as an adipofascial flap.67 It can also be pedicled
5). The chimeric principle allows the composition proximally for coverage of defects at the peri-
of the flap to be tailored to accurately match the neum, lower abdominal wall, and greater trochan-
requirements of the recipient site, with multiple ter, and distally for coverage about the knee.68 –71
components raised on different perforators from The anterior or lateral branch of the lateral cu-
the lateral femoral circumflex axis. This includes taneous nerve of the thigh can be included to
the vastus lateralis, tensor fasciae latae, and rectus provide sensation (Figs. 6 and 7). Primary closure

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 Plastic and Reconstructive Surgery • April 2009

of the donor site can be achieved if the width of

the flap does not exceed 8 cm; otherwise, skin
grafting or a V-Y local advancement flap can be
used.72 Flap harvest is associated with little or no
donor-site functional deficit.73,74 The major weak-
ness of the flap is that most series have been de-
scribed in the Asian population, where it tends to be
approximately 7 mm thick,75,76 approximately half
the thickness of the flap in the Western population,77
and one-stage thinning of the LCFAP-vl flap in the
Western population has resulted in high rates of
partial or complete flap necrosis.78,79 In the Western
population, acoustic Doppler examination has a low
accuracy related to body mass index.80
Fig. 5. Follow-up at 6 months postoperatively after flap thinning
Anatomy
using liposuction. The patient had full range of motion and was
The perforators to the anterolateral thigh flap able to wear his regular shoe.
originate from the descending branch of the lateral
femoral circumflex artery. This lies in the intermus-
cular septum between the rectus femoris and vastus patella, with the perforator that is most consistently
lateralis muscles along with the motor nerve to the present is located around the midpoint, which he
vastus lateralis, along a line drawn between the an- termed perforator B.77 Wei et al.49 and Yu and
terior superior iliac spine to the superolateral border Youssef80 have reported a learning curve, and with
of the patella.81 The length of the pedicle is typically experience a perforator can be found in almost
8 to 16 cm, with a vessel diameter of larger than 2 all cases.
mm. Septocutaneous perforators are found most
commonly,49,82 and therefore in the majority of cases
flap harvest requires a careful dissection of a suitable Surgical Technique
intramuscular perforator within the vastus lateralis Doppler examination is usually used to iden-
muscle. Yu, in a series in a Western population, tify the perforators preoperatively, with the flap
found one to three cutaneous perforators in pred- usually designed about perforator B. A longitudi-
icable locations approximately 5 cm apart and 1.5 nal skin incision is made on the medial side of the
cm lateral to the line connecting the anterior supe- flap and dissection is carried out at the suprafascial
rior iliac spine and the superolateral corner of the level. We advocate entering the intermuscular sep-

Fig. 4. Intraoperative dissection and surgical anatomy of the anterolateral thigh flap. The septum be-
tween the vastus lateralis and the rectus femoris muscles is opened in an inferior to superior direction. The
rectus femoris muscle is then reflected off the vastus lateralis medially, and this gives a clear view of the
descending branch of the lateral femoral circumflex artery (DBLFCA) and all perforators originating from it.

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Fig. 6. (Above) Photograph showing exposed hardware following wound break-

down of the lateral malleolus in a 56-year-old patient. (Below) The wound was rad-
ically débrided and covered using an anterolateral thigh (ALT) flap thinned at the
periphery only to allow better insetting. A sensate flap can be designed by incor-
porating the medial or lateral branch of the femoral cutaneous nerve.

tum distally between the rectus femoris and vastus

Fig. 7. Appearance at follow-up at 8 months postoperatively,
with stable ankle coverage and no infection.
lateralis muscles to allow direct visualization of the
descending branch and location of the perfora-
tors (Fig. 4). One or more appropriate musculo-
cutaneous or cutaneous perforators are selected
and dissected through the vastus lateralis muscle
or its investing fascia and epimysium. Some au-
thors advocate leaving a cuff of muscle around the
perforator to minimize damage and spasm during
dissection. A visible pulse and an audible arterial
and venous Doppler signal must be heard before
completing the final skin incision of the flap. The
dissection continues until the descending branch
of the lateral circumflex femoral artery and its
vena comitans are isolated with careful preserva-
tion of the motor nerve. The lateral femoral cu-
taneous nerve is incorporated if a sensate flap is
required. Koshima advocates that the descending
branch should be transected distal to the branch
to the rectus femoris muscle, to prevent possible
ischemic necrosis of the rectus femoris muscle, but
we have never seen this problem.68

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THORACODORSAL ARTERY flow-through flap.85 An osteocutaneous flap can be

PERFORATOR FLAP
Background
The thoracodorsal artery perforator flap was first
described by Angrigiani et al. in 199583 and is a safe
and extremely versatile flap with a long pedicle and
a large flap cutaneous territory.84,85 It is indicated for
defects of the head and neck, trunk, and upper and
lower extremities, and has been described as a pedi-
cled flap for breast reconstruction86 (Figs. 8 through
11). There is the potential for use of both the per-
forator and muscle flap to reconstruct two distinct
defects or as a chimeric flap pedicled on the thora-
codorsal vessels,87,88 and it can also be used as a
raised with a segment of vascularized scapula,89 and
the flap may be thinned between the deep and su-
perficial adipose layers.90 There is versatility in the
orientation of the flap design,85 and primary closure
is achievable in flaps of up to 10 cm in width. For a
sensate flap, a lateral branch of the intercostal nerve
can be included.
Anatomy
The descending branch of the thoracodorsal
artery is known to have the largest and most reliable
perforating vessels, and is found descending along a
line at approximately 2 cm behind the anterior bor-

Fig. 8. A thoracodorsal artery perforator (TDAP) flap was used for resurfacing
the dorsum of the foot following radical wound débridement. In contrast to the
thin thoracodorsal artery perforator flap donor site, the anterolateral thigh do-
nor site was too bulky for an anterolateral thigh flap to be used.

Fig. 9. The thoracodorsal artery perforator (TDAP) flap after harvest

demonstrating a pedicle length in excess of 10 cm, which allows anas-
tomosis well outside the zone of injury. The thin thoracodorsal artery
perforator donor site in this patient was selected because it offered the
best match for resurfacing the dorsum of the foot. When the anterolateral
thigh donor site is too thick, the lateral thoracic skin and subcutaneous
tissue can often provide a very thin thoracodorsal artery perforator flap
that is ideal for resurfacing dorsal foot defects.

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Fig. 10. Two-week postoperative view of the right foot after resurfacing
of the dorsum with a thoracodorsal artery perforator flap with minimal
bulk and stable coverage.

Fig. 11. Thoracodorsal artery perforator (TDAP) flap based on a direct cutaneous perfo-
rator from the descending branch of the thoracodorsal artery coursing anterior to the
lateral border of the latissimus dorsi (LD) muscle.

der of the latissimus dorsi muscle edge.91–93 Perfo-
rators are located within 8 cm of the neurovascular
hilus, 4 cm inferior to the tip of the scapula, with the
first perforator always the largest and most consis-
tent. In an anatomical study, Thomas et al. found
septocutaneous perforators from the thoracodorsal
artery supplying the skin, in addition to the muscu-
locutaneous perforators, in 60 percent of specimens.
The septocutaneous perforators originated as a sin-
gle branch from the thoracodorsal artery that was
identified near the lateral border of the muscle,
reaching the skin without penetrating the latissimus
dorsi (Fig. 11). An inverse relationship was found
between the size and number of musculocutaneous
versus septocutaneous perforators, and the ratio of
the musculocutaneous to septocutaneous perfora-
tors was 3:2.93
Surgical Technique
The flap is raised with the patient in the lateral
decubitus position. An incision anterior to the an-
terior border of the latissimus dorsi muscle enables
incorporation of either a septocutaneous or a mus-
culocutaneous perforator, and dissection continues
until the perforator cleavage line is identified on the
muscle, which appears white because of the pres-
ence of the lateral thoracodorsal nerve. If the per-

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 Plastic and Reconstructive Surgery • April 2009

forators are small, a muscle-sparing technique can
be used. Care is taken to preserve the thoracodorsal
nerve and the delicate venae comitantes, and the
distal end of the thoracodorsal pedicle, close to the
origin of the muscle, is ligated and dissected toward
the axilla. The major branches of the thoracodorsal
and subscapular vessels are then ligated up to the
axillary artery and vein until the desired pedicle
length is achieved.
superior gluteal artery perforator flap for breast
reconstruction.95 Gluteal artery perforator flaps
may be used for breast reconstruction in pa-
tients where the abdominal flaps are unsuitable,
including insufficient abdominal fatty tissue vol-
ume, abdominal incisions, or following prior
abdominoplasty. Advantages include low donor-

SUPERIOR AND INFERIOR GLUTEAL

ARTERY PERFORATOR FLAPS
Background
In 1993, Koshima et al. described the gluteal artery
perforator flap based on parasacral perforators,94 and
2 years later Allen and Tucker described the

Fig. 12. Superficial inferior epigastric artery (SIEA) flap with su- Fig. 13. (Above) Lateral malleolus defect with exposed bone.
perficial inferior epigastric artery and vein anastomosed to the (Center) Freestyle pedicled propeller perforator flap based on a
internal mammary perforator (IMAP) artery and vein. SIEV, super- large distal anterior tibial perforator. (Below) Postoperative result
ficial inferior epigastric vein. at 4 weeks demonstrating stable wound coverage of the ankle.

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site morbidity, a longer vascular pedicle than is positioned perforators are preferred, as they allow a
achievable with the musculocutaneous flap, avoid- longer pedicle.
ance of the need for vein grafts, an abundance of
adipose tissue even in thin patients, a hidden scar, Surgical Technique
and good projection of the reconstructed breast.96–100 Perforators from the superior gluteal artery
A flap width of up to 12 cm may be closed directly, and may be identified along a line drawn connecting
the flap length is usually between 24 and 26 cm. There
is also the potential for sensory reinnervation by anas-
tomosis of the nervi clunium superiores.

Anatomy
Three perforators usually supply the superior
gluteal artery perforator cutaneous territory, with a
pedicle length of 3 to 8 cm. The superior gluteal
artery usually emerges from the edge of the sacrum
approximately one-third of the distance along a line
from the posterior superior iliac spine to the greater
trochanter. Two to four perforators originating from
the inferior gluteal artery supply the cutaneous ter-
ritory of the inferior gluteal artery perforator flap,
with a typically longer pedicle of 7 to 10 cm. Laterally

Fig. 15. Photographs of a 42-year-old male patient with a

chronic unstable lumbar wound following multiple previous spi-
Fig. 14. Photographs of an 18-year-old quadriplegic patient nal operations. A suitable lumbar artery perforator was identified
with a sacral decubitus ulcer that was débrided and covered with by Doppler examination close to the defect and used to design a
a local pedicled parasacral perforator flap. pedicled lumbar artery perforator flap.

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 Plastic and Reconstructive Surgery • April 2009

the posterior superior iliac spine and the greater
trochanter using a Doppler probe. Obliquely ori-
entated incisions are associated with contour de-
formity, whereas horizontal flap designs produce
a more favorable scar. For an inferior gluteal ar-
tery perforator flap, the inferior limit of the flap
is marked 1 cm inferior and parallel to the gluteal
fold with the patient in the standing position. The
patient is then placed in the lateral position and
the Doppler probe used to identify perforators
from the inferior gluteal artery.
For unilateral reconstructions, the patient is
placed in the lateral decubitus position to permit a
two-team approach, or flap harvest can be per-
formed in the prone position after the recipient
internal mammary vessels have been dissected. The
flap is divided down to the muscle of the gluteus
maximus, with undermining as appropriate to har-
vest enough tissue for a breast reconstruction. The
flap is elevated from the muscle in the subfascial
plane and the perforators approached from lateral
to medial. A single large perforator is usually used,
but several perforators that lie in the same plane in
the direction of the gluteus maximus muscle fibers
can be used. During harvest of the inferior gluteal
artery perforator flap, there is no need to expose the
sciatic nerve. The posterior femoral cutaneous nerve
and the fat medially overlying the ischium must be
preserved.100 Once the sacral fascia is encountered,
it must be opened, revealing multiple communicat-
ing arterial and venous branches, and branches must
be ligated carefully. Dissection continues until the
pedicle is of sufficient length and diameter, with the
artery usually the limiting factor. Part of the skin

Fig. 16. (Above, left) A 20-year-old male patient suffered an open Gustilo IIIB tibial fracture that was reamed and nailed. The
patient suffered anterior tibial skin necrosis that required stable coverage of his exposed intramedullary nail. An antero-
lateral thigh flap was initially planned but the perforators were too small to safely use. The anterior medial thigh (AMT) region
was explored for suitable perforators and a large myocutaneous perforator was selected passing through the rectus femoris
muscle (below, left). This perforator was dissected until a large enough artery and vein were obtained for microanastomosis.
(Right) The patient at 6-month postoperative follow-up was ambulatory, showed no signs of infection, and had stable
coverage of his tibia.

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paddle can be designed to overlap both the superior
and inferior gluteal artery territories to increase the
number of available perforators from both systems.
Selection of the largest and most lateral perforator
will also yield the longest pedicle and facilitate mi-
croanastomosis.
Other Applications
Morbidity at the recipient site can also be de-
creased using the perforator concept. For example,
the internal mammary artery and vein perforators
can be used as recipient vessels to reduce morbidity
at the recipient site. This allows for a minimally in-
vasive free tissue autologous breast reconstruction,
especially when an superficial inferior epigastric ar-
tery flap is used (Fig. 12). Pedicled perforator flaps,
including propeller flap designs, incorporate the ad-
vantages of reduced donor-site morbidity without
recipient-site morbidity, and avoid the risks associ-
ated with microvascular anastomosis.
As with free perforator flaps, pedicled perfo-
rator flaps can also be designed in freestyle fashion
and based off any major cutaneous perforator
originating from a major source axial vessel. These
flaps can offer a wide spectrum of local flap op-
tions that would not normally be available with
traditional pedicled flaps101 (Figs. 13 through 15).
Wei and Mardini have described the freestyle
free flap, whereby perforator flaps are harvested
based only on the presence of a Doppler signal,
without the constraint of known flap designs.102
The donor site is therefore selected on the basis of
appropriate texture and color to match the defect.
In theory, any free perforator flap can be based on
a suitable perforator when dissected to an appro-
priately sized source artery and vein (Fig. 16).
Table 2. CPT Codes Commonly Used in Perforator
Flap Surgery
CPT
Code Descriptor
15732 Muscle, myocutaneous, or fasciocutaneous flap;
head and neck
15734 Muscle, myocutaneous, or fasciocutaneous flap;
trunk
15736 Muscle, myocutaneous, or fasciocutaneous flap;
upper extremity
15738 Muscle, myocutaneous, or fasciocutaneous flap;
lower extremity
Free Flaps
15756 Free muscle or myocutaneous flap with
microvascular anastomosis
15757 Free skin flap with microvascular anastomosis
15758 Free fascial flap with microvascular anastomosis
19364 Breast reconstruction with free flap
Dr. Ray Janevicius compiled this information.
CONCLUSIONS
Increased knowledge and a good understanding
of vascular anatomy will ultimately drive new flap
designs and options specifically tailored for the re-
constructive defect. CPT codes commonly used in
perforator flap surgery are listed in Table 2.
Michel Saint-Cyr, M.D.
Department of Plastic Surgery
University of Texas Southwestern Medical Center
1801 Inwood Road
Dallas, Texas 75390-9132
michel.saint-cyr@utsouthwestern.edu
REFERENCES
1. Geddes CR, Morris SF, Neligan PC. Perforator flaps: Evo-
lution, classification and applications. Ann Plast Surg. 2003;
50:90–99.
2. Blondeel PN, Morris SF, Hallock GG, Neligan PC, eds.
Perforator Flaps: Anatomy, Technique and Clinical Application.
St. Louis: Quality Medical; 2006.
3. Hallock GG. Direct and indirect perforator flaps: The history
and the controversy. Plast Reconstr Surg. 2003;111:855–865.
4. McGregor IA, Morgan G. Axial and random pattern flaps.
Br J Plast Surg. 1973;26:202–213.
5. Milton SH. Pedicled skin-flaps: The fallacy of the length:
width ratio. Br J Surg. 1970;57:502–508.
6. McGregor IA, Jackson IT. The groin flap. Br J Plast Surg.
1972;25:3–16.
7. Bakamjian VY. Total reconstruction of pharynx with medially
based deltopectoral skin flap. N Y State J Med. 1968;68:2771–2778.
8. Manchot C. Die Hautarterien des Menschlichen Körpers.
Leipzig: F.C.W. Vogel; 1889.
9. Manchot C. The Cutaneous Arteries of the Human Body. New
York: Springer-Verlag; 1983.
10. Ger R. The operative treatment of the advanced stasis ulcer:
A preliminary communication. Am J Surg. 1966;111:659–663.
11. Orticochea M. The musculo-cutaneous flap method: An
immediate and heroic substitute for the method of delay.
Br J Plast Surg. 1972;25:106–110.
12. Pontén B. The fasciocutaneous flap: Its use in soft tissue
defects of the lower leg. Br J Plast Surg. 1981;34:215–220.
13. Haertsch P. The surgical plane in the leg. Br J Plast Surg.
1981;34:464–469.
14. Barclay TL, Cardoso E, Sharpe DT, et al. Repair of lower leg
injuries with fascio-cutaneous flaps. Br J Plast Surg. 1982;35:
127–132.
15. Cormack GC, Lamberty BG. Fasciocutaneous vessels: Their
distribution on the trunk and limbs, and their clinical ap-
plication in tissue transfer. Anat Clin. 1984;6:121–131.
16. Salmon M. Artères de la Peau. Paris: Mason et Cie; 1936.
17. Salmon M. In: Taylor GI, Tempest M, eds. Arteries of the Skin.
London: Churchill Livingstone; 1988.
18. Taylor GI, Palmer JH. The vascular territories (angiosomes)
of the body: Experimental study and clinical applications.
Br J Plast Surg. 1987;40:113–141.
19. Koshima I, Soeda S. Inferior epigastric artery skin flap without
rectus abdominis muscle. Br J Plast Surg. 1989;42:645–648.
20. Kroll SS, Rosenfield L. Perforator-based flaps for low pos-
terior midline defects. Plast Reconstr Surg. 1988;81:561–566.
21. Rubino C, Coscia V, Cavazzuti AM, et al. Haemodynamic
enhancement in perforator flaps: The inversion phenom-
enon and its clinical significance. A study of the relation of
blood velocity and flow between pedicle and perforator
143e
 Plastic and Reconstructive Surgery • April 2009
vessels in perforator flaps. J Plast Reconstr Aesthet Surg. 2006;
59:636–643.
22. Morris SF, Taylor GI. Predicting the survival of experimen-
tal skin flaps with a knowledge of the vascular architecture.
Plast Reconstr Surg. 1993;92:1352–1361.
23. Taylor GI. The “Gent” consensus on perforator flap termi-
nology: Preliminary definitions (Discussion). Plast Reconstr
Surg. 2003;112:1384–1387.
24. Blondeel PN, Van Landuyt KH, Monstrey SJ, et al. The
“Gent” consensus on perforator flap terminology: Prelim-
inary definitions. Plast Reconstr Surg. 2003;112:1378–1783.
25. Wei FC, Jain V, Suominen S, et al. Confusion among per-
forator flaps: What is a true perforator flap? Plast Reconstr
Surg. 2001;107:874–876.
26. Mathes SJ, Nahai F. General principles. In: Reconstructive
Surgery: Principles, Anatomy & Technique. New York:
Churchill Livingstone; 1997:3–253.
27. Allen RJ, Treece P. Deep inferior epigastric perforator flap
for breast reconstruction. Ann Plast Surg. 1994;32:32–38.
28. Neligan PC, Lipa JE. Perforator flaps in head and neck
reconstruction. Semin Plast Surg. 2006;20:56–63.
29. Van Landuyt K, Blondeel P, Hamdi M, Tonnard P, Verpaele
A, Monstrey S. The versatile DIEP flap: Its use in lower
extremity reconstruction. Br J Plast Surg. 2005;58:2–13.
30. Koshima I, Moriguchi T, Soeda S, Tanaka H, Umeda N. Free
thin paraumbilical perforator-based flaps. Ann Plast Surg.
1992;29:12–17.
31. Granzow JW, Levine JL, Chiu ES, Allen RJ. Breast recon-
struction with the deep inferior epigastric perforator flap:
History and an update on current technique. J Plast Reconstr
Aesthet Surg. 2006;59:571–579.
32. Gill PS, Hunt JP, Guerra AB, et al. A 10-year retrospective
review of 758 DIEP flaps for breast reconstruction. Plast
Reconstr Surg. 2004;113:1153–1160.
33. Hamdi M, Rebecca A. The deep inferior epigastric artery
perforator flap (DIEAP) in breast reconstruction. Semin
Plast Surg. 2006;20:95–102.
34. Giunta RE, Geisweid A, Feller AM. The value of preoper-
ative Doppler sonography for planning free perforator
flaps. Plast Reconstr Surg. 2000;105:2381–2386.
35. Alonso-Burgos A, Garcia-Tutor E, Bastarrika G, Cano D,
Martinez-Cuesta A, Pina LJ. Preoperative planning of deep
inferior epigastric artery perforator flap reconstruction with
multislice-CT angiography: Imaging findings and initial ex-
perience. J Plast Reconstr Aesthet Surg. 2006;59:585–593.
36. Masia J, Clavero JA, Larranaga JR, et al. Multidetector-row
computed tomography in the planning of abdominal per-
forator flaps. J Plast Reconstr Aesthet Surg. 2006;59:594–599.
37. Offman SL, Geddes CR, Tang M, Morris SF. The vascular
basis of perforator flaps based on the source arteries of the
lateral lumbar region. Plast Reconstr Surg. 2005;115:1651–
1659.
38. Moon HK, Taylor GI. The vascular anatomy of rectus ab-
dominis musculocutaneous flaps based on the deep supe-
rior epigastric system. Plast Reconstr Surg. 1988;82:815–832.
39. Munhoz AM, Ishida LH, Sturtz GP, et al. Importance of
lateral row perforator vessels in deep inferior epigastric
perforator flap harvesting. Plast Reconstr Surg. 2004;113:517–
524.
40. El-Mrakby HH, Milner RH. The vascular anatomy of the
lower anterior abdominal wall: A microdissection study on
the deep inferior epigastric vessels and the perforator
branches. Plast Reconstr Surg. 2002;109:539–543.
41. Blondeel PN. One hundred free DIEP flap breast recon-
structions: A personal experience. Br J Plast Surg. 1999;52:
104–111.
144e
42. Carramenha e Costa MA, Carriquiry C, Vasconez LO, Grot-
ting JC, Herrera RH, Windle BH. An anatomic study of the
venous drainage of the transverse rectus abdominis mus-
culocutaneous flap. Plast Reconstr Surg. 1987;79:208–217.
43. Blondeel PN, Arnstein M, Verstraete K, et al. Venous con-
gestion and blood flow in free transverse rectus abdominis
myocutaneous and deep inferior epigastric perforator flaps.
Plast Reconstr Surg. 2000;106:1295–1299.
44. Taylor GI, Daniel RK. The anatomy of several free flap
donor sites. Plast Reconstr Surg. 1975;53:243–253.
45. Reardon CM, O’Ceallaigh S, O’Sullivan ST. An anatomical
study of the superficial inferior epigastric vessels in humans.
Br J Plast Surg. 2004;57:515–519.
46. Granzow JW, Levine JL, Chiu ES, Allen RJ. Breast recon-
struction using perforator flaps. J Surg Oncol. 2006;94:441–
454.
47. Yap LH, Whiten SC, Forster A, Stevenson JH. The anatom-
ical and neurophysiological basis of the sensate free TRAM
and DIEP flaps. Br J Plast Surg. 2002;55:35–45.
48. Song YG, Chen GZ, Song YL. The free thigh flap: A new free
flap concept based on the septocutaneous artery. Br J Plast
Surg. 1984;37:149–159.
49. Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin CH.
Have we found an ideal soft-tissue flap? An experience with
672 anterolateral thigh flaps. Plast Reconstr Surg. 2002;109:
2219–2226.
50. Celik N, Wei FC, Lin CH, et al. Technique and strategy in
anterolateral thigh perforator flap surgery, based on an
analysis of 15 complete and partial failures in 439 cases. Plast
Reconstr Surg. 2002;109:2211–2216.
51. Kuo YR, Seng-Feng J, Kuo FM, Liu YT, Lai PW. Versatility
of the free ALT flap for reconstruction of soft tissue defects:
Review of 140 cases. Ann Plast Surg. 2002;48:161–166.
52. Koshima I, Fukuda H, Yamamoto H, Moriguchi T, Soeda S,
Ohta S. Free anterolateral thigh flaps for reconstruction of
head and neck defects. Plast Reconstr Surg. 1993;92:421–428.
53. Chana JS, Wei FC. A review of the advantages of the an-
terolateral thigh flap in head and neck reconstruction. Br J
Plast Surg. 2004;57:603–609.
54. Javaid M, Cormack GC. Anterolateral thigh free flap for
complex soft tissue hand reconstructions. J Hand Surg (Br.)
2003;28:21–27.
55. Wang HT, Fletcher JW, Erdmann D, Levin LS. Use of the
anterolateral thigh free flap for upper-extremity reconstruc-
tion. J Hand Surg (Am.). 2005;30:859–864.
56. Adani R, Tarallo L, Marcoccio I, Cipriani R, Gelati C, In-
nocenti M. Hand reconstruction using the thin anterolat-
eral thigh flap. Plast Reconstr Surg. 2005;116:467–473.
57. Yildirim S, Taylan G, Eker G, Akoz T. Free flap choice for
soft tissue reconstruction of the severely damaged upper
extremity. J Reconstr Microsurg. 2006;22:599–609.
58. Koshima I, Yamamoto H, Hosoda M, Moriguchi T, Orita Y,
Nagayama H. Free combined composite flaps using the
lateral circumflex femoral system for repair of massive de-
fects of the head and neck regions: An introduction to the
chimeric flap principle. Plast Reconstr Surg. 1993;92:411–
420.
59. Lin CH, Wei FC, Lin YT, Yeh JT, Rodriguez Ede J, Chen CT.
Lateral circumflex femoral artery system: Warehouse for
functional composite free-tissue reconstruction of the lower
leg. J Trauma 2006;60:1032–1036.
60. Lin YT, Lin CH, Wei FC. More degrees of freedom by using
chimeric concept in the applications of anterolateral thigh
flap. J Plast Reconstr Aesthet Surg. 2006;59:622–627.
61. Koshima I, Yamamoto H, Moriguchi T, Orita Y. Extended
anterior thigh flaps for repair of massive cervical defects in-
Volume 123, Number 4 • Perforator Flap Nomenclature
volving pharyngoesophagus and skin: An introduction to the
“mosaic” flap principle. Ann Plast Surg. 1994;32:321–327.
62. Kimura N, Satoh K. Consideration of a thin flap as an entity
and clinical applications of the thin anterolateral thigh flap.
Plast Reconstr Surg. 1996;97:985–992.
63. Kimura N, Satoh K, Hasumi T, Ostuka T. Clinical applica-
tion of the free thin anterolateral thigh flap in 31 consec-
utive patients. Plast Reconstr Surg. 2001;108:1197–1208.
64. Adani R, Tarallo L, Marcoccio I, Cipriani R, Gelati C, In-
nocenti M. Hand reconstruction using the thin anterolat-
eral thigh flap. Plast Reconstr Surg. 2005;116:467–473; dis-
cussion 474 – 477.
65. Koshima I, Hosoda S, Inagawa K, Urushibara K, Moriguchi
T. Free combined anterolateral thigh flap and vascularized
fibula for wide, through-and-through oromandibular de-
fects. J Reconstr Microsurg. 1998;14:529–534.
66. Koshima I, Kawada S, Etoh H, Kawamura S, Moriguchi T,
Sonoh H. Flow-through anterior thigh flaps for one-stage
reconstruction of soft-tissue defects and revascularization of
ischemic extremities. Plast Reconstr Surg. 1995;95:252–260.
67. Hsieh CH, Yang CC, Kuo YR, Tsai HH, Jeng SF. Free an-
terolateral thigh adipofascial perforator flap. Plast Reconstr
Surg. 2003;112:976–982.
68. Gravvanis AI, Tsoutsos DA, Karakitsos D, et al. Application
of the pedicled anterolateral thigh flap to defects from the
pelvis to the knee. Microsurgery 2006;26:432–438.
69. Hallock GG. The proximal pedicled anterolateral thigh flap
for lower limb coverage. Ann Plast Surg. 2005;55:466–469.
70. Pan SC, Yu JC, Shieh SJ, Lee JW, Huang BM, Chiu HY.
Distally based anterolateral thigh flap: An anatomic and
clinical study. Plast Reconstr Surg. 2004;114:1768–1775.
71. Yildirim S, Avci G, Akan M, Misirlioglu A, Akoz T. Anterolat-
eral thigh flap in the treatment of postburn flexion contrac-
tures of the knee. Plast Reconstr Surg. 2003;111:1630–1637.
72. Yamada N, Kakibuchi M, Kitayoshi H, Matsuda K, Yano K,
Hosokawa K. A new way of elevating the anterolateral thigh
flap. Plast Reconstr Surg. 2001;108:1677–1682.
73. Kimata Y, Uchiyama K, Ebihara S, et al. Anterolateral thigh
flap donor-site complications and morbidity. Plast Reconstr
Surg. 2000;106:584–589.
74. Kuo YR, Jeng SF, Kuo MH, et al. Free anterolateral thigh flap
for extremity reconstruction: Clinical experience and func-
tional assessment of donor site. Plast Reconstr Surg. 2001;
107:1766–1771.
75. Koshima I. Free anterolateral thigh flap for reconstruction
of head and neck defects following cancer ablation (Dis-
cussion). Plast Reconstr Surg. 2000;105:2358–2360.
76. Nakayama B, Hyodo I, Hasegawa Y, et al. Role of the an-
terolateral thigh flap in head and neck reconstruction: Ad-
vantages of moderate skin and subcutaneous thickness.
J Reconstr Microsurg. 2002;18:141–146.
77. Yu P. Characteristics of the anterolateral thigh flap in a
Western population and its application in head and neck
reconstruction. Head Neck 2004;26:759–769.
78. Ross GL, Dunn R, Kirkpatrick J, et al. To thin or not to thin:
The use of the anterolateral thigh flap in the reconstruction
of intraoral defects. Br J Plast Surg. 2003;56:409–413.
79. Van Landuyt K. The anterolateral thigh flap for lower ex-
tremity reconstruction. Semin Plast Surg. 2006;20:127–132.
80. Yu P, Youssef A. Efficacy of the handheld Doppler in pre-
operative identification of the cutaneous perforators in the
anterolateral thigh flap. Plast Reconstr Surg. 2006;118:928–
933.
81. Xu DC, Zhong SZ, Kong JM, et al. Applied anatomy of the
anterolateral femoral flap. Plast Reconstr Surg. 1988;82:
305–310.
82. Kimata Y, Uchiyama K, Ebihara S, Nakatsuka T, Harii K.
Anatomic variations and technical problems of the antero-
lateral thigh flap: A report of 74 cases. Plast Reconstr Surg.
1998;102:1517–1523.
83. Angrigiani C, Grilli D, Siebert J. Latissimus dorsi musculo-
cutaneous flap without muscle. Plast Reconstr Surg. 1995;96:
1608–1614.
84. Kim JT. Latissimus dorsi perforator flap. Clin Plast Surg.
2003;30:403–431.
85. Koshima I, Saisho H, Kawada S, Hamanaka T, Umeda M,
Moriguchi T. Flow-through thin latissimus dorsi perforator
flap for repair of soft-tissue defects in the legs. Plast Reconstr
Surg. 1999;103:1483–1490.
86. Hamdi M, Van Landuyt K, Monstrey S, Blondeel P. Pedicled
perforator flaps in breast reconstruction: A new concept.
Br J Plast Surg. 2004;57:531–539.
87. Kim JT. Two options for perforator flaps in the flank donor
site: Latissimus dorsi and thoracodorsal perforator flaps.
Plast Reconstr Surg. 2005;115:755–763.
88. Van Landuyt K, Hamdi M, Blondeel P, Monstrey S. The
compound thoracodorsal perforator flap in the treatment
of combined soft-tissue defects of sole and dorsum of the
foot. Br J Plast Surg. 2005;58:371–378.
89. Momeni A, Krischak S, Bannasch H. The thoracodorsal
artery perforator flap with a vascularized scapular segment
for reconstruction of a composite lower extremity defect.
Microsurgery 2006;26:515–518.
90. Kim JT, Koo BS, Kim SK. The thin latissimus dorsi perfo-
rator-based free flap for resurfacing. Plast Reconstr Surg.
2001;107:374–382.
91. Guerra AB, Metzinger SE, Lund KM, Cooper MM, Allen RJ,
Dupin CL. The thoracodorsal artery perforator flap: Clin-
ical experience and anatomic study with emphasis on har-
vest techniques. Plast Reconstr Surg. 2004;114:32–41.
92. Heitmann C, Guerra A, Metzinger SW, Levin LS, Allen RJ.
The thoracodorsal artery perforator flap: Anatomic basis
and clinical application. Ann Plast Surg. 2003;51:23–29.
93. Thomas BP, Geddes CR, Tang M, Williams J, Morris SF. The
vascular basis of the thoracodorsal artery perforator flap.
Plast Reconstr Surg. 2005;116:818–822.
94. Koshima I, Moriguchi T, Soeda S, Kawata S, Ohta S, Ikeda
A. The gluteal perforator-based flap for repair of sacral
pressure sores. Plast Reconstr Surg. 1993;91:678–683.
95. Allen RJ, Tucker C Jr. Superior gluteal artery perforator free
flap for breast reconstruction. Plast Reconstr Surg. 1995;95:
1207–1212.
96. Guerra AB, Allen RJ, Dupin CL. Breast reconstruction with
the superior gluteal artery perforator (S-GAP) flap. Semin
Plast Surg. 2002;16:27–34.
97. Guerra AB, Metzinger SE, Bidros RS, Gill PS, Dupin CL,
Allen RJ. Breast reconstruction with gluteal artery perfora-
tor (GAP) flaps: A critical analysis of 142 cases. Ann Plast
Surg. 2004;52:118–125.
98. Allen RJ, Levine JL, Granzow JW. The in-the-crease inferior
gluteal artery perforator flap for breast reconstruction. Plast
Reconstr Surg. 2006;118:333–339.
99. Granzow JW, Levine JL, Chiu ES, Allen RJ. Breast recon-
struction with gluteal artery perforator flaps. J Plast Reconstr
Aesthet Surg. 2006;59:614–621.
100. Allen RJ, LoTempio MM, Granzow JW. Inferior gluteal per-
forator flaps for breast reconstruction. Semin Plast Surg.
2006;20:89–94.
101. Quaba O, Quaba A. Pedicled perforator flaps for the lower
limb. Semin Plast Surg. 2006;20:103–111.
102. Wei FC, Mardini S. Free-style free flaps. Plast Reconstr Surg.
2004;114:910–916.
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