Perforator Flaps: Anatomy, Technique, & Clinical Applications

Cover
Title Page
Perforator Flaps, 3rd edition
Copyright
Title
Copyright
Dedication
Contents
Foreword
Preface to the Third Edition
Preface to the Second Edition
Preface to the First Edition
Acknowledgments
Contributors
1 History of Perforator Flap Surgery
	1.1 EARLY HISTORY
	1.2 RENAISSANCE PERIOD
	1.3 NINETEENTH CENTURY
	1.4 TWENTIETH CENTURY
	1.5 1960S AND 1970S
	1.6 1970S TO THE PRESENT 1.6.1 Muscle Flaps
	1.6.2 Fasciocutaneous Flaps
	1.6.3 Perforator Flaps
	1.7 CONCLUSION
2 The Vascular Territories of the Integument
	2.1 BACKGROUND
	2.1.1 The Study of the Vascular Anatomy of the Integument
	2.2 THE FASCIAL ARRANGEMENT OF THE SOFT TISSUE INTEGUMENT AND ITS RELEVANCE TO PERFORATOR LOCATION AND ANATOMY
	2.3 MICROCIRCULATION OF THE INTEGUMENT
	2.4 THE ANGIOSOME CONCEPT AND ITS IMPORTANCE IN UNDERSTANDING PERFORATOR FLAP SURVIVAL 2.4.1 Angiosome Concept
	2.4.2 Venous Drainage
	2.5 THE INTERCONNECTIONS BETWEEN ANGIOSOMES AND THE RELEVANCE OF THE FUNCTIONAL ANGIOSOME
	2.6 IDENTIFYING TRUE AND CHOKE ANASTOMOSES BETWEEN ANGIOSOMES
	2.7 DELAY
	2.8 APPLIED ANATOMY OF THESE CONCEPTS 2.8.1 Musculocutaneous Flaps
	2.8.2 Fasciocutaneous Flaps
	2.9 MICROVASCULAR TISSUE TRANSFER AND PERFORATOR FLAPS
	2.10 ANATOMIC WORK ON PERFORATOR FLAPS
	2.11 SUMMARY
	2.12 CONCLUSION
	2.13 PEARLS
	2.14 PITFALLS
3 Perforator Flaps: Overview, Definitions, Classifications, and Nomenclature
	3.1 THE PURSUIT OF THE PERFORATOR IN THE PERFORATOR FLAP
	3.2 CLASSIFICATION OF SOFT TISSUE FLAPS 3.2.1 Skin Flaps
	3.2.2 Muscle and Musculocutaneous Flaps
	3.2.3 Fasciocutaneous Flaps
	3.2.4 Perforator Flaps
	3.3 DEFINITIONS AND NOMENCLATURE FOR PERFORATOR FLAPS
	3.4 DEFINITION OF A PERFORATOR FLAP
	3.5 BASIC NOMENCLATURE
	3.6 SECONDARY NOMENCLATURE 3.6.1 Paramuscular Perforator
	3.6.2 Perforator Angiosome
	3.6.3 Functional Perforator Angiosome
	3.6.4 Compound Perforator Flaps
	3.6.5 Conjoined Perforator Flaps
	3.6.6 Chimeric Perforator Flaps
	3.6.7 Propeller Flaps
	3.6.8 Perforator-Plus Flaps
	3.6.9 Keystone Flaps
	3.6.10 Capillary Perforator Flaps
	3.6.11 Pure Skin Perforator Flaps
	3.6.12 Hybrid Perforator Flaps
	3.7 CONCLUSION
4 Instructional Models for Learning Dissection Techniques for Perforator Flaps
	4.1 INTRODUCTION
	4.2 PREOPERATIVE ANIMAL MANAGEMENT CONSIDERATIONS
	4.3 SPECIFIC RAT MANAGEMENT REQUIREMENTS
	4.4 SPECIFIC PIG MANAGEMENT REQUIREMENTS
	4.5 DETAILS FOR THE HARVEST OF SPECIFIC FLAP MODELS 4.5.1 Deep Inferior Epigastric Artery Perforator Flap
	4.5.2 Superior Gluteal Artery Perforator Flap9
	4.5.3 Intercostal Artery Perforator Flap
	4.5.4 Thoracodorsal Artery Perforator Flap Model
	4.6 CONCLUSION
5 How to Find the Perforator: Preoperative and Intraoperative
	PART A 5.1.1 Introduction
	PART B 5.2.1 Color Duplex/Ultrasound
	PART C 5.3.1 CT Angiography and MRI
	PART D 5.4.1 Thermography
	PART E 5.5.1 Indocyanine Green (ICG)
6 How to Dissect a Perforator Vessel and Avoid Complications
	6.1 DISSECTING THE PERFORATOR
	6.2 AVOIDING COMPLICATIONS
	6.3 GOLDEN RULES TO PREVENT COMPLICATIONS IN PERFORATOR FLAPS 6.3.1 Try to Map the Perforators
	6.3.2 Try to Identify the Main Perforator by Making a Limited Incision
	6.3.3 Preserve Each Perforator until You Encounter a Larger One
	6.3.4 Selection of the Best Perforator
	6.3.5 Consider the Easiest Dissection
	6.3.6 Transect Other Perforators after the Entire Pedicle Is Dissected
	6.4 FLAP DISSECTION
	6.5 HOW TO DEAL WITH INTRAOPERATIVE COMPLICATIONS
	6.5.1 Variable Vascular Anatomy
	6.5.2 Choice of Recipient Vessels
	Post”-Anastomotic Problems
	6.5.3
	6.5.4 Rare Problems
	6.6 CONCLUSION
7 Local Perforator Flaps
	PART A 7.1.1 Introduction to Local Perforator Flaps
	PART B 7.2.1 The Peninsular Perforator Flap
	PART C 7.3.1 The Perforator Plus Flaps
	PART D 7.4.1 The Keystone Perforator Island Flap
	PART E 7.5.1 The Propeller Flap Concept
8 Various Planes for Perforator Flap Elevation and the Concept of Perforator-to-Perforator Flaps
	8.1 INTRODUCTION
	8.2 PLANES FOR ELEVATION OF PERFORATOR FLAPS
	8.2.1 Anatomy of Subcutaneous Fat Tissue
	8.2.2 Preoperative Evaluation
	8.2.3 Flap Elevation Plane: Terminology and Technique
	8.2.4 Conclusions
	8.3 PERFORATOR-TO-PERFORATOR CONCEPT AND FLAPS
	8.3.1 Preoperative Evaluation
	8.3.2 Isolating the Perforator as a Recipient
	8.3.3 Selecting the Flaps Allowing Perforator-to-Perforator Approach
	8.3.4 Anastomosis
	8.3.5 Postoperative Management
	8.3.6 Predictors for Flap Failure When Using Perforator-to-Perforator Supermicrosurgery
	8.4 CONCLUSION
9 Perforator Flaps and Lymphatics
	9.1 LYMPHATIC PERFORATOR FLAPS
	9.2 LYMPH NODE TRANSFER
	9.3 LYMPH VESSEL TRANSFER
	9.4 LYMPH-INTERPOSITIONAL-FLAP TRANSFER
	9.5 SUMMARY
10 Pure Skin Perforator Flap
	10.1 INTRODUCTION
	10.2 HISTORY OF THE THIN FLAP
	10.3 VARIOUS TYPES OF PSP FLAPS
	10.4 ANATOMY OF SCIA-BASED PURE SKIN PERFORATORS
	10.5 FLAP DESIGN AND DIMENSION EXPECTATIONS
	10.6 PREOPERATIVE IMAGING OF PURE SKIN PERFORATORS
	10.7 ELEVATION OF A SCIA-BASED PSP FLAP 10.7.1 Pedicle Dissection and PSP Identification
	10.7.2 Flap Elevation: Supra-Superficial Fascia Elevation
	10.7.3 Flap Thinning: Temporary Clamping and Microdissection
	10.8 PSP FLAP CASE EXAMPLE 10.8.1 Thumb Arteriovenous Malformation
	10.9 PEARLS AND PITFALLS 10.9.1 Steps for Safe PSP Flap Elevation
	10.9.2 Back-Up Plan if PSP Flap Aborted
	10.10 VASCULARIZED AREOLAR FLAP CASE EXAMPLE 10.10.1 Great Toe Donor Site Coverage
	10.11 CONCLUSION
11 Kiss and Sequential Flaps for Perforator Flap Donor Site Primary Closure and Management
	PART A 11.1.1 The Kiss Flap
	PART B 11.2.1 The Sequential Flap
	11.2.2 Introduction
	11.2.3 Indications
	11.2.4 Surgical Technique
	11.2.5 Expert Pearls
	11.2.6 Potential Pitfalls
	11.2.7 Conclusion
12 Vascular Anatomy of he Integument of the Head and Neck
	12.1 OVERVIEW 12.1.1 The Head
	12.1.2 The Neck
	12.2 PERFORATORS WITH SOURCE VESSELS
	12.2.1 The Scalp
	12.2.2 The Face
	12.2.3 The Neck
	12.2.4 Nuchal Region
	12.3 ANATOMIC BASIS OF HEAD AND NECK PERFORATOR FLAPS
	12.4 FLAPS IN THE HEAD AND FACE
	12.4.1 Direct Perforator Flaps
	12.4.2 Facial Artery Perforator Flap
	12.4.3 Indirect Perforator Flaps
	12.5 FLAPS IN THE NECK
	12.5.1 Direct Perforator Flaps
	12.5.2 Musculocutaneous Flaps
	12.6 FLAP OPTIONS
	12.6.1 The Reverse Submental Perforator–Based Flap
	12.6.2 Retroauricular Flap Based on the Upper Auricular Branch of the Superficial Temporal Artery
13 Temporoparietal Artery Perforator Flap
	13.1 INTRODUCTION
	13.2 ANATOMICAL CONSIDERATIONS 13.2.1 Regional Anatomy
	13.2.2 Arterial Anatomy
	13.2.3 Venous Anatomy
	13.2.4 Nerve Anatomy
	13.3 SURGICAL TECHNIQUE 13.3.1 Preoperative Considerations and Markings
	Video 13.1)
	13.3.2 Flap Harvest (
	13.3.3 Postoperative Care
	13.4 VARIANTS 13.4.1 Tissue Expansion
	13.4.2 Composite Flaps
	13.4.3 Endoscopic Harvest
	13.5 PITFALLS
	13.6 INDICATIONS 13.6.1 Pedicled Flap
	13.6.2 Free Flap
	13.7 CONTRAINDICATIONS
	13.8 EXPERT PEARLS
	13.9 CASE EXAMPLE: CONGENITAL MICROTIA RECONSTRUCTION
	13.10 CONCLUSION
14 Facial Artery Perforator Flap
	14.1 INTRODUCTION
	14.2 ANATOMICAL CONSIDERATIONS
	14.3 ANATOMICAL VARIANTS
	14.4 SURGICAL TECHNIQUE 14.4.1 Preoperative Investigations/Landmark Schematics
	14.4.2 Flap Design
	14.4.3 Flap Harvest
	14.4.4 Specific Postoperative Care Protocols
	14.5 POTENTIAL PITFALLS
	14.6 CASE EXAMPLES 14.6.1 Case 1
	14.6.2 Case 2
	14.7 CONCLUSION
15 Facial Artery Musculomucosal Flap
	15.1 INTRODUCTION
	15.2 ANATOMICAL CONSIDERATIONS
	15.2.1 Muscles
	15.2.2 Nerves
	15.2.3 Arteries
	15.2.4 Veins
	15.2.5 Parotid Duct
	15.3 ANATOMICAL VARIANTS
	VIDEO 15.1)
	15.4 SURGICAL TECHNIQUE (
	15.4.1 Modifications
	15.4.2 Oronasal Fistula
	15.4.3 Lip and Vermilion Reconstruction
	15.4.4 Floor of Mouth, Tongue, and Tonsillar Reconstruction
	15.4.5 Nasal Lining for Septal or Total Nasal Reconstruction
	15.4.6 Orbital Reconstruction
	15.4.7 Skull Base Reconstruction
	15.5 EXPERT PEARLS
	15.6 POTENTIAL PITFALLS
	15.7 CASE EXAMPLES 15.7.1 Case 1
	15.7.2 Case 2
	15.7.3 Case 3
	15.7.4 Case 4
	15.7.5 Case 5
	15.8 CONCLUSION
16 Submental Artery Perforator Flap
	16.1 INTRODUCTION
	16.2 ANATOMICAL CONSIDERATIONS
	16.3 ANATOMICAL VARIANTS
	16.4 SURGICAL TECHNIQUE 16.4.1 Preoperative Investigations
	16.4.2 Flap Design
	16.4.3 Flap Harvest
	16.5 POTENTIAL PITFALLS
	16.6 CASE EXAMPLES 16.6.1 Case 1
	16.6.2 Case 2
	16.7 CONCLUSIONS
17 The Ascending Helical Rim Flap
	17.1 INTRODUCTION
	17.2 ANATOMICAL CONSIDERATIONS AND ANATOMICAL VARIANTS 17.2.1 Vessels
	17.2.2 Nerves
	17.3 SURGICAL TECHNIQUE 17.3.1 Preoperative Investigations/Landmark Schematics (for Perforator Identification)
	17.3.2 Flap Design (Include Alterations According to Desired Use)
	17.3.3 Flap Harvest (Stepwise Description, Including Back-Up Plan,
	Video 17.1)
	17.3.4 Specific Postoperative Care Protocols
	17.4 EXPERT PEARLS
	17.5 POTENTIAL PITFALLS
	17.6 CASE EXAMPLES 17.6.1 Case 1 (
	Fig. 17.3)
	Fig. 17.4)
	17.6.2 Case 2 (
	17.7 CONCLUSION
18 Supraclavicular Perforator Flap
	18.1 INTRODUCTION
	18.2 ANATOMICAL CONSIDERATIONS
	18.3 ANATOMIC VARIANTS
	18.4 SURGICAL TECHNIQUE
	18.5 EXPERT PEARLS
	18.6 POTENTIAL PITFALLS AND COMPLICATIONS
	18.7 CASE EXAMPLES
	18.8 CONCLUSION
19 Supratrochlear Artery and Supraorbital Artery Perforator Flaps
	19.1 INTRODUCTION
	19.2 ANATOMICAL CONSIDERATIONS 19.2.1 Arterial Supply
	19.2.2 Venous Drainage
	19.2.3 Anatomical Variants
	19.3 SURGICAL TECHNIQUE 19.3.1 Preoperative Investigations
	19.3.2 Flap Design
	19.3.3 Flap Harvest (
	Video 19.1)
	19.3.4 Back-up Plan
	19.3.5 Specific Postoperative Care Protocols
	19.4 EXPERT PEARLS
	19.5 POTENTIAL PITFALLS
	19.6 CASE EXAMPLES 19.6.1 Case 1
	19.6.2 Case 2
	19.6.3 Case 3
	19.7 CONCLUSION
20 Chimeric Flaps for the Head and Neck
	20.1 INTRODUCTION
	20.2 FUNDAMENTALS
	20.3 SUBSTANCE LOSS ANALYSIS
	20.4 CHOOSING THE DONOR SITE
	20.5 FIBULAR DONOR SITE (
	VIDEO 20.1)
	20.6 THE THORACODORSAL DONOR SITE
	20.7 THE ANTEROLATERAL PERFORATOR CHIMERIC THIGH FLAP
	20.8 HOW TO CHOOSE THE RIGHT CHIMERIC PERFORATOR FLAP
	20.9 CONCLUSION
21 Vascular Supply of the Integument of the Upper Extremity
	21.1 OVERVIEW OF VASCULAR ANATOMY
	21.2 AXILLARY ARTERY
	21.3 BRACHIAL ARTERY
	21.4 RADIAL ARTERY
	21.5 ULNAR ARTERY
	21.6 ANTERIOR INTEROSSEOUS ARTERY
	21.7 POSTERIOR INTEROSSEOUS ARTERY
	21.8 DEEP PALMAR ARCH
	21.9 SUPERFICIAL PALMAR ARCH
	21.10 DORSAL CARPAL ARCH
	21.11 PERFORATOR GROUPS WITH SOURCE VESSELS
	21.12 ANATOMY SUBREGIONS
	21.12.1 Shoulder and Arm
	21.13 THORACOACROMIAL ARTERY TERRITORY
	21.14 POSTERIOR CIRCUMFLEX HUMERAL ARTERY TERRITORY
	21.15 SUPERIOR ULNAR COLLATERAL ARTERY OR BRACHIAL ARTERY TERRITORY
	21.16 PROFUNDA BRACHIAL ARTERY TERRITORY
	21.17 BRACHIAL ARTERY TERRITORY
	21.18 POSTERIOR RADIAL COLLATERAL ARTERY TERRITORY
	21.18.1 The Forearm
	21.19 INFERIOR ULNAR COLLATERAL AND ULNAR RECURRENT ARTERY TERRITORIES
	21.20 RADIAL RECURRENT AND INTEROSSEOUS RECURRENT ARTERY TERRITORIES
	21.21 RADIAL ARTERY TERRITORY
	21.22 ULNAR ARTERY TERRITORY
	21.23 POSTERIOR INTEROSSEOUS ARTERY TERRITORY
	21.24 ANTERIOR INTEROSSEOUS ARTERY TERRITORY
	21.24.1 The Hand
	21.25 SUPERFICIAL PALMAR ARCH TERRITORY
	21.26 DEEP PALMAR ARCH TERRITORY
	21.27 DORSAL METACARPAL AND DORSAL CARPAL ARCH TERRITORY
	21.28 VARIABILITY IN VASCULAR ANATOMY
22 Lateral Arm Perforator Flap
	22.1 INTRODUCTION
	22.2 ANATOMICAL CONSIDERATIONS
	22.3 ANATOMICAL VARIANTS
	VIDEO 22.1) 22.4.1 Preoperative Investigations/Landmark
	22.4 SURGICAL TECHNIQUE (
	22.4.2 Flap Design
	22.4.3 Flap Harvest
	22.4.4 Specific Postoperative Care Protocols
	22.5 POTENTIAL PITFALLS
	22.6 CASE EXAMPLES 22.6.1 Case 1
	22.6.2 Case 2
	22.6.3 Case 3
	22.7 CONCLUSION
23 Posterior Interosseous Artery Perforator Flap
	23.1 INTRODUCTION
	23.2 ANATOMY
	23.2.1 Cutaneous Branches—Perforators—of the PIOA
	23.3 ANATOMICAL VARIATIONS
	23.4 SURGICAL TECHNIQUE
	23.4.1 Preoperative Investigations
	23.4.2 Flap Design
	23.4.3 Flap Elevation
	23.4.4 Postoperative Care
	23.5 EXPERT PEARLS
	23.6 PITFALLS
	23.7 CASE EXAMPLES 23.7.1 Case 1
	23.7.2 Case 2
	23.7.3 Case 3
	23.8 CONCLUSION
24 Ulnar Artery Perforator Flap
	24.1 INTRODUCTION
	24.2 ANATOMICAL CONSIDERATIONS
	24.3 ANATOMICAL VARIANTS
	24.4 SURGICAL TECHNIQUE
	24.4.1 Preoperative Investigations
	24.4.2 Proximally Based Fasciocutaneous Ulnar Artery Perforator Flap for Elbow Defects
	24.4.3 Free Proximal Ulnar Artery Perforator Flap for Hand Defects
	24.4.4 Ulnar Artery Perforator Flap from the Middle Third Forearm for Distal Forearm Defects
	24.4.5 Ulnar Artery Perforator Flap from the Middle Third Forearm for Head and Neck Defects
	24.4.6 Ulnar Artery Perforator Flap from the Distal Third Forearm for Hand andWrist Defects
	24.4.7 Free Hypothenar Perforator Flap for Fingertip Defects
	24.4.8 Specific Postoperative Care Protocols
	24.4.9 Modifications
	24.5 EXPERT PEARLS
	24.6 POTENTIAL PITFALLS
	24.7 CASE EXAMPLES 24.7.1 Case 1
	24.7.2 Case 2
	24.7.3 Case 3
	24.7.4 Case 4
	24.8 CONCLUSIONS
25 Radial Artery Perforator Flap
	25.1 INTRODUCTION
	25.2 ANATOMY
	25.3 SURGICAL TECHNIQUE
	25.3.1 Preoperative Investigations
	25.3.2 Proximally Based Radial Artery Perforator Flap
	25.3.3 Distal Based Radial Artery Perforator Flap
	25.3.4 Free Superficial Palmar Branch of the Radial Artery Perforator Flap
	25.3.5 Free Thenar Perforator Flap
	25.3.6 Specific Postoperative Care Protocols
	25.3.7 Modifications
	25.4 EXPERT PEARLS
	25.5 POTENTIAL PITFALLS
	25.6 CASE EXAMPLES 25.6.1 Case 1
	25.6.2 Case 2
	25.6.3 Case 3
	25.6.4 Case 4
	25.6.5 Case 5
	25.7 CONCLUSIONS
26 Perforator Flaps of the Hand
	26.1 INTRODUCTION
	26.2 RADIAL ARTERY PERFORATOR FREE FLAP (RASP FREE FLAP), THENAR FREE FLAP, I-RASP FREE FLAP 26.2.1 Introduction
	26.2.2 Anatomical Considerations
	26.2.3 Anatomical Variants
	26.2.4 Surgical Technique
	26.3 EXPERT PEARLS
	26.3.1 Potential Pitfalls
	26.3.2 Conclusion
	26.4 FOURTH COMMON DIGITAL ARTERY PERFORATOR FREE FLAP (HYPOTHENAR FREE FLAP, ULNAR PALMAR ARTERY PERFORATOR FREE FLAP, COMMON D
	26.4.2 Advantages and Disadvantages
	26.4.3 Anatomical Considerations
	26.4.4 Anatomical Variants
	26.4.5 Surgical Technique
	26.4.6 Expert Pearls
	26.4.7 Potential Pitfalls
	26.4.8 Conclusion
	26.5 DORSAL METACARPAL ARTERY PERFORATOR FLAP 26.5.1 Introduction
	26.5.2 Indication
	26.5.3 Contraindication
	26.5.4 Anatomical Considerations
	26.5.5 Anatomical Variants
	26.5.6 Surgical Technique
	26.5.7 Expert Pearls
	26.5.8 Conclusion
	26.6 SECOND TOE PULP FREE FLAP 26.6.1 Introduction
	26.6.2 Anatomical Considerations
	26.6.3 Anatomical Variants
	26.6.4 Surgical Technique
	26.6.5 Surgical Variations
	26.6.6 Conclusion
27 Anatomy of the Integument of the Trunk
	27.1 REGIONAL OVERVIEW 27.1.1 Chest
	27.1.2 Internal Thoracic (Mammary) Artery
	27.1.3 Abdomen
	27.1.4 Upper Back
	27.1.5 Lumbar Region
	27.1.6 External Genitalia and Perineum
28 Thoracoacromial Artery Perforator Flap
	28.1 INTRODUCTION
	28.2 ANATOMICAL CONSIDERATIONS
	28.3 ANATOMICAL VARIANTS
	28.4 SURGICAL TECHNIQUE 28.4.1 Preoperative Investigations/Landmark Schematics
	28.4.2 Flap Design
	28.4.3 Flap Harvest
	28.4.4 Specific Postoperative Care Protocols
	28.5 EXPERT PEARLS 28.5.1 Back-up Options for TAAP Flap
	28.5.2 Motor Innervation
	28.6 POTENTIAL PITFALLS 28.6.1 Donor Site Complications
	28.6.2 Suitability for Females
	28.6.3 Confusion with Lateral Thoracic Artery Perforators
	28.7 CASE EXAMPLES 28.7.1 Case 1: Pedicled TAAP Flap
	28.7.2 Case 2: Free TAAP Flap
	28.8 CONCLUSION
29 Internal Mammary Artery Perforator Flap
	29.1 INTRODUCTION
	29.2 ANATOMIC CONSIDERATIONS
	29.3 ANATOMIC VARIANTS
	29.4 SURGICAL TECHNIQUE 29.4.1 Preoperative Investigations and Landmarks
	29.4.2 Flap Design
	29.4.3 Flap Harvest
	29.4.4 Specific Postoperative Care Protocols
	29.5 POTENTIAL PITFALLS
	29.6 CASE EXAMPLES 29.6.1 Case 1
	29.6.2 Case 2
	29.7 CONCLUSION
30 Superior Epigastric Artery Perforator Flap
	30.1 INTRODUCTION
	30.2 ANATOMICAL CONSIDERATIONS AND VARIANTS
	30.3 SURGICAL TECHNIQUE 30.3.1 Preoperative Positioning and Pertinent Surface Landmarks
	30.3.2 Flap Design
	30.3.3 Flap Harvest
	30.3.4 Specific Postoperative Care Protocols
	30.4 EXPERT PEARLS
	30.5 POTENTIAL PITFALLS 30.5.1 Vertical Dimensions
	30.5.2 Horizontal Dimensions
	30.5.3 Donor Site Closure
	30.5.4 Internal Mammary Artery Absence
	30.6 CASE EXAMPLES 30.6.1 Case 1: Lower Medial ChestWall
	30.6.2 Case 2: Xiphoid Region
	30.7 CONCLUSION
31 Deep Inferior Epigastric Artery Perforator Flap
	31.1 INTRODUCTION
	31.2 ANATOMY
	31.3 SURGICAL TECHNIQUE 31.3.1 Preoperative Investigation/Landmark Schematics
	31.3.2 Flap Design
	31.3.3 Flap Harvest
	31.3.4 Suprafascial Dissection
	31.3.5 Intramuscular Dissection
	31.3.6 Submuscular Dissection
	31.3.7 Donor Site Closure and Fashioning the Umbilicus
	31.4 CASE EXAMPLES 31.4.1 Case 1: Deep Inferior Epigastric Artery Perforator Flap for Immediate Bilateral Breast Reconstruction
	31.4.2 Case 2: Deep Inferior Epigastric Artery Perforator Flap for Lymphedema
	31.5 MODIFICATIONS
	31.6 PITFALLS AND RISK FACTORS
	31.7 CONCLUSION
32 Superficial Inferior Epigastric Artery Flap
	32.1 INTRODUCTION
	32.2 ANATOMICAL CONSIDERATIONS
	32.2.1 Arterial Anatomy
	32.2.2 Venous Anatomy
	32.2.3 Sensory Innervation
	32.3 SURGICAL TECHNIQUE 32.3.1 Preoperative Investigations
	32.3.2 Patient Marking
	32.3.3 Intraoperative Algorithm for Flap Selection
	32.3.4 Flap Harvest
	32.3.5 Breast Reconstruction
	32.3.6 Other Reconstructions
	32.3.7 Specific Postoperative Care Protocols
	32.4 POTENTIAL PITFALLS AND EXPERT PEARLS
	32.4.1 Inconsistent Vascular Anatomy
	32.4.2 Short and Small Pedicle
	32.4.3 Vasospasm
	32.4.4 SIEA Flap Re-Exploration and Salvage Technique
	32.5 CASE EXAMPLES
	32.6 CONCLUSION
33 Deep Circumflex Iliac Artery Perforator Flap
	33.1 INTRODUCTION
	33.2 ANATOMICAL CONSIDERATIONS
	33.3 ANATOMICAL VARIANTS
	33.4 SURGICAL TECHNIQUE 33.4.1 Preoperative Investigations/Landmark Schematics
	33.4.2 Flap Design
	33.4.3 Flap Harvest
	33.4.4 Specific Postoperative Care Protocols
	33.5 EXPERT PEARLS
	33.6 POTENTIAL PITFALLS
	33.7 CASE EXAMPLES 33.7.1 Case 1
	33.7.2 Case 2
	33.8 CONCLUSION
34 Superficial Circumflex Iliac Artery Perforator Flap
	34.1 INTRODUCTION
	34.2 ANATOMICAL CONSIDERATIONS
	34.3 ANATOMICAL VARIANTS
	VIDEO 34.1) 34.4.1 Preoperative Investigations
	34.4 SURGICAL TECHNIQUE (
	34.4.2 Flap Design
	34.4.3 Flap Harvest
	34.4.4 Closure of Donor Site
	34.4.5 Specific Postoperative Care Protocols
	34.5 EXPERT NOTES
	34.5.1 Minimizing the Risk for Variable Vascular Anatomy within the SCIA System
	34.5.2 Overcoming the Short Pedicle
	34.5.3 Backup Plans in the Operating Room
	34.5.4 Elevating in Various Planes
	34.6 CASE EXAMPLES 34.6.1 Case 1
	34.6.2 Case 2
	34.6.3 Case 3
	34.6.4 Case 4
	34.7 CONCLUSION
35 Circumflex Scapular Artery Perforator Flap
	35.1 INTRODUCTION
	35.2 ANATOMICAL CONSIDERATIONS 35.2.1 Vascular
	35.2.2 Nerve
	35.2.3 Bone
	35.3 SURGICAL TECHNIQUE 35.3.1 Surface Landmarks for Perforator Identification
	35.3.2 Specific Flap Design and Harvest
	35.4 POSTOPERATIVE CARE PROTOCOLS
	35.5 EXPERT PEARLS 35.5.1 Local Pedicled Flap
	35.5.2 Thin Flap
	35.5.3 Vascularized Bone
	35.5.4 Conjoined Flaps
	35.5.5 Chimeric Flaps
	35.5.6 Donor Site Management
	35.5.7 Microvascular Recipient Site
	35.6 POTENTIAL PITFALLS 35.6.1 Operating Table Position
	35.6.2 Perforator Location
	35.6.3 Source Vessel origin
	35.6.4 Pre-transfer Donor Site Tissue Expansion
	35.6.5 Donor Site Aesthetics
	35.6.6 Bone Harvest
	35.7 CONCLUSION
36 Dorsal Scapular Artery Perforator Flap
	36.1 INTRODUCTION
	36.2 ANATOMICAL CONSIDERATIONS
	36.3 ANATOMICAL VARIANTS
	36.4 SURGICAL TECHNIQUE 36.4.1 Preoperative Investigations/Landmark Schematics
	36.4.2 Flap Design
	36.4.3 Flap Harvest
	36.4.4 Modifications
	36.4.5 Specific Postoperative Care Protocols
	36.5 EXPERT PEARLS/PITFALLS
	36.6 CASE EXAMPLE
	36.7 CONCLUSION
37 Thoracodorsal Artery Perforator Flap
	37.1 INTRODUCTION
	37.2 ANATOMY
	37.3 SURGICAL TECHNIQUE 37.3.1 Surface Landmarks
	37.3.2 Neighboring Anatomic Structures
	37.3.3 Specific Postoperative Care Protocols
	37.3.4 TDAP Flap as a Pedicled Flap
	37.4 EXPERT PEARLS
	37.5 POTENTIAL PITFALLS
	37.6 CASE EXAMPLES
	37.7 CONCLUSION
38 Intercostal Artery Perforator Flaps
	38.1 INTRODUCTION
	38.2 ANATOMIC CONSIDERATIONS
	38.2.1 Vertebral Segment
	38.2.2 Costal Groove Segment
	38.2.3 Intermuscular Segment
	38.2.4 Rectus Segment
	38.2.5 Anterior Intercostal Vessels
	38.2.6 Subcostal Artery
	38.3 CLASSIFICATION OF FLAPS
	38.3.1 Surgical Technique and Planning
	38.3.2 Dorsal Intercostal Artery Perforator Flap
	38.3.3 Dorsolateral Intercostal Artery Perforator Flap
	38.3.4 Lateral Intercostal Artery Perforator Flap
	38.3.5 Anterior Intercostal Artery Perforator Flap
	38.3.6 Subcostal Artery Perforator Flap
	38.4 EXPERT PEARLS
	38.5 POTENTIAL PITFALLS
	38.6 CONCLUSION
39 Lumbar Artery Perforator Flaps
	39.1 INTRODUCTION
	39.2 ANATOMICAL CONSIDERATIONS
	39.3 SURGICAL TECHNIQUE
	39.3.1 Preoperative Investigations/Landmark Schematics
	39.3.2 Flap Design
	39.3.3 Flap Harvest
	39.3.4 Specific Postoperative Care Protocols
	39.4 EXPERT PEARLS
	39.5 POTENTIAL PITFALLS
	39.6 PATIENT EXAMPLE
	39.7 CONCLUSION
40 Gluteal Artery Perforator Flaps
	40.1 INTRODUCTION
	40.2 THE SGAP FLAP
	40.2.1 Anatomical Considerations
	40.2.2 Anatomical Variations
	40.2.3 Surgical Technique
	40.2.4 Specific Postoperative Care Protocols
	40.2.5 Potential Pitfalls
	40.3 THE IGAP FLAP
	40.3.1 Anatomic Considerations
	40.3.2 Anatomic Variants
	40.3.3 Surgical Technique
	40.3.4 Potential Pitfalls
	40.4 CASE EXAMPLES 40.4.1 Case 1
	40.4.2 Case 2
	40.5 CONCLUSION
41 Anatomy of the Integument of the Lower Extremity
	41.1 CUTANEOUS VASCULAR TERRITORIES OF THE LOWER EXTREMITY
	41.1.1 Gluteal Region
	41.1.2 Hip and Thigh Region
	41.1.3 Knee and Leg Region
	41.1.4 Ankle and Foot Region
42 The Lateral Thigh Perforator Flap
	42.1 INTRODUCTION
	42.1.1 Historical Background
	42.1.2 Indications and Contraindications
	42.2 ADVANTAGES AND DISADVANTAGES
	42.3 ANATOMY AND ANATOMICAL VARIANTS 42.3.1 LTP Compartments
	42.3.2 TFL Arterial Supply
	42.3.3 Buttock and Thigh Innervation
	42.3.4 TFL Innervation
	42.4 SURGICAL TECHNIQUE 42.4.1 Preoperative Investigations
	42.4.2 Flap Design
	42.4.3 Flap Harvest
	42.5 POSTOPERATIVE CARE
	42.6 EXPERT PEARLS AND POTENTIAL PITFALLS
	42.7 PEARLS AND POTENTIAL PITFALLS
	42.8 CASE EXAMPLES 42.8.1 Case 1: Tertiary Bilateral LTP Flap Breast Reconstruction
	42.8.2 Case 2: Primary Bilateral LTP Flap Breast Reconstruction
	42.9 CONCLUSION
43 Lateral Circumflex Femoral Artery—Tensor Fascia Lata Perforator Flap
	43.1 INTRODUCTION
	43.2 ANATOMICAL CONSIDERATIONS AND VARIANTS
	43.3 SURGICAL TECHNIQUE 43.3.1 Surface Landmarks
	43.3.2 Vascular Exploration
	43.3.3 Musculocutaneous Perforator Dissection
	43.3.4 Skin Paddle Design
	43.4 MODIFICATIONS 43.4.1 Combinations with Vascularized Fascia Lata
	43.4.2 Megaflaps (Conjoined Flaps)
	43.4.3 Sensate Flap
	43.4.4 Thin Flap
	43.5 CASE EXAMPLES AND CLINICAL APPLICATIONS 43.5.1 Head and Neck Free Flap
	43.5.2 Free Flap Breast Reconstruction
	43.5.3 Pedicled Flaps for Regional Reconstruction
	43.6 EXPERT TIPS
	43.7 PITFALLS AND TIPS 43.7.1 Dissection Technique
	43.7.2 Lengthening the Short Pedicle
	43.7.3 Supermicrosurgery
	43.8 CONCLUSION
44 Lateral Circumflex Femoral Artery–Vastus Lateralis Perforator Flap
	44.1 INTRODUCTION
	44.2 ANATOMICAL CONSIDERATIONS 44.2.1 Vascular Anatomy
	44.2.2 Innervation
	44.3 ANATOMICAL VARIATIONS
	44.4 SURGICAL TECHNIQUE 44.4.1 Preoperative Preparation
	44.4.2 Surface Landmarks
	44.4.3 Positioning and Flap Design
	44.4.4 Flap Harvest—Perforator Selection
	44.4.5 Flap Harvest—Plane of Dissection
	44.4.6 Donor Site Closure
	44.5 SURGICAL MODIFICATIONS 44.5.1 Local Flap
	44.5.2 Adipofascial and Facial-Only Flap
	44.5.3 Thin Flap and Primary Thinning
	44.5.4 Bulk
	44.5.5 Vascularized Fascia
	44.5.6 Sensate Flap
	44.5.7 Split Cutaneous Perforator Flaps for Extremely Wide or Two Separate Defects
	44.5.8 Flow-Through Flap
	44.6 POTENTIAL PITFALLS AND EXPERT PEARLS
	44.6.1 Inadequate Skin Vessels
	44.6.2 Skin Vessel Injury
	44.6.3 Pedicle Twisting
	44.6.4 Motor Function
	44.6.5 Sensory Disturbances
	44.6.6 Thinning and Risk of Vascular Compromise/Necrosis
	44.7 CASE EXAMPLES
	44.7.1 Head and Neck
	44.7.2 Abdominal Wall
	44.7.3 Upper Extremity
	44.7.4 Lower Extremity and Perineal Reconstruction
	44.7.5 Breast Reconstruction
	44.7.6 Pediatric Patients
	44.8 CONCLUSION
45 Superficial Femoral Artery Perforator Flap
	45.1 INTRODUCTION
	45.2 ANATOMICAL CONSIDERATIONS
	45.3 ANATOMICAL VARIANTS
	45.4 SURGICAL TECHNIQUE 45.4.1 Preoperative Investigations
	45.4.2 Flap Design
	45.4.3 Flap Harvest
	45.5 INSTRUMENTAL EVALUATIONS
	45.6 CASE EXAMPLES 45.6.1 Case 1: Pedicled Lower Medial Thigh Perforator Flap for Knee Region Reconstruction
	45.6.2 Case 2: Free Lower Medial Thigh Perforator Flap for Plantar Foot Reconstruction
	45.6.3 Case 3: Free Lower Medial Thigh Perforator Flap for Oral Reconstruction
	45.7 EXPERT PEARLS AND PITFALLS 45.7.1 Anomalous Blood Supply
	45.7.2 Pedicle Length
	45.7.3 Donor Site Closure
	45.8 CONCLUSION
46 Profunda Femoris Artery Perforator Flap
	46.1 INTRODUCTION
	46.2 ADVANTAGES AND DISADVANTAGES
	46.3 ANATOMICAL CONSIDERATIONS
	46.3.1 Muscles
	46.3.2 Vascular Anatomy
	46.3.3 Skin Vascular Supply
	46.4 ANATOMICAL VARIANTS
	46.5 SURGICAL TECHNIQUE (
	VIDEO 46.2) 46.5.1 Preoperative Investigations for Perforator Identification
	46.5.2 Flap Design
	46.5.3 Flap Harvest
	46.5.4 Specific Postoperative Care Protocols
	46.6 EXPERT PEARLS 46.6.1 Patient Positioning
	46.6.2 tPAP Enhancement
	46.6.3 Volume Augmentation
	46.6.4 Sensate PAP Flap
	46.7 POTENTIAL PITFALLS 46.7.1 Exposure
	46.7.2 Bulk
	46.7.3 Pedicle Length
	46.7.4 Donor Site Closure
	46.7.5 Nerve Injury
	46.7.6 Venous Thromboembolic Disease (VTE)
	46.8 OUTCOMES
	46.9 CASE EXAMPLES 46.9.1 Bilateral dPAP Breast Reconstruction
	46.9.2 Unilateral tPAP Breast Reconstruction
	46.10 CONCLUSIONS
47 The Medial Femoral Condyle and Descending Genicular Artery Perforator Flap
	47.1 INTRODUCTION
	47.2 ANATOMICAL CONSIDERATIONS 47.2.1 Arterial Anatomy
	47.2.2 Venous Anatomy
	47.3 ANATOMICAL VARIANTS 47.3.1 Descending Genicular Artery Origin
	47.3.2 Superior Medial Geniculate Artery Pedicle
	VIDEO 47.1) 47.4.1 Preoperative Landmarks
	47.4 SURGICAL TECHNIQUE (
	47.4.2 Flap Design
	47.4.3 Flap Harvest
	47.4.4 Postoperative Care Protocols
	47.5 EXPERT PEARLS
	47.6 POTENTIAL PITFALLS
	47.7 CASE EXAMPLES 47.7.1 Case 1: Upper Extremity: Chimeric DGAP and Medial Femoral Condyle Flap
	47.7.2 Case 2: Lower Extremity: Combined DGAP and Medial Femoral Condyle Flap
	47.8 CONCLUSION
48 Superior Lateral Genicular Artery Perforator Flap
	48.1 INTRODUCTION
	48.2 ANATOMICAL CONSIDERATIONS
	48.2.1 Anatomical Variants
	48.3 SURGICAL TECHNIQUE 48.3.1 Preoperative Investigations/Landmark Schematics
	48.3.2 Flap Design
	48.3.3 Flap Harvest
	48.3.4 Specific Postoperative Care Protocols
	48.4 EXPERT PEARLS
	48.5 POTENTIAL PITFALLS
	48.6 CASE EXAMPLES 48.6.1 Case 1
	48.6.2 Case 2
	48.7 CONCLUSION
49 The Medial Sural Artery Perforator Flap
	49.1 INTRODUCTION
	49.2 ANATOMICAL CONSIDERATIONS
	49.2.1 Arterial
	49.2.2 Venous
	49.2.3 Innervation
	49.3 ANATOMICAL VARIANTS 49.3.1 Perforator Existence
	49.3.2 Distal Perforator Origin
	49.3.3 Venous Outflow
	49.4 SURGICAL TECHNIQUE 49.4.1 Step #1: Preoperative Perforator Identification
	49.4.2 Step #2: Flap Design
	49.4.3 Step #3: Perforator Site Confirmation
	49.4.4 Step #4: MSAP Flap Elevation
	49.4.5 Step #5: Pedicle Dissection
	49.4.6 Step #6: Flap Harvest
	49.5 VARIATIONS/INDICATIONS 49.5.1 Contour Preference
	49.5.2 Surgical Position
	49.5.3 Pedicled Island Flap
	49.5.4 Propeller Flap
	49.5.5 Adipofascial
	49.5.6 Chimeric Flap
	49.5.7 Free Flap
	49.6 EXPERT PEARLS 49.6.1 Muscle Viability Preservation
	49.6.2 Venous Outflow Security
	49.7 POTENTIAL PITFALLS 49.7.1 Perforator Absence
	49.7.2 Perforator Caliber
	49.7.3 Venous Outflow with Midline Perforators
	49.8 CONCLUSION
50 Distally Based Sural Artery Flap
	50.1 INTRODUCTION
	50.2 ANATOMICAL CONSIDERATIONS AND VARIATIONS
	50.3 SURGICAL TECHNIQUE 50.3.1 Preparation, Flap Design, and Marking (
	Video 50.1)
	50.3.2 Flap Harvest
	50.3.3 Variations in the Inset
	50.3.4 Delay
	50.3.5 Postoperative Protocols
	50.4 EXPERT PEARLS AND POTENTIAL PITFALLS
	50.5 CASE EXAMPLES
	50.6 CONCLUSION
51 Medial Plantar Artery Perforator Flaps with Emphasis on the Medialis Pedis Flap
	51.1 INTRODUCTION
	51.2 MEDIALIS PEDIS FLAP
	51.2.1 Medialis Pedis Flap for Hand and Finger Reconstruction5,6,7,8
	51.2.2 Medialis Pedis Flap for Foot Reconstruction9,10
	51.3 INSTEP FLAP
	51.4 ABDUCTOR HALLUCIS MUSCLE FLAP
	51.5 ANATOMY 51.5.1 Arterial Blood Supply
	51.5.2 Venous Drainage
	51.5.3 Innervation
	51.6 SURGICAL TECHNIQUE 51.6.1 Medialis Pedis Flap (
	Video 51.1)
	51.6.2 Instep Flap and Abductor Hallucis Muscle Flap
	51.6.3 Neighboring Anatomic Structures
	51.7 CLINICAL APPLICATIONS 51.7.1 Medialis Pedis Flap
	51.7.2 Instep Flap
	51.8 MODIFICATIONS 51.8.1 Orthograde Extension to Increase Medialis Pedis Flap Pedicle Length
	51.8.2 Reverse Flow by Y-V Pedicle Extension in the Medialis Pedis Flap
	51.8.3 Flow-Through Medialis Pedis Free Flap6
	51.8.4 Chimeric Flap
	51.8.5 Combined Medialis Pedis and Instep Flap
	51.8.6 Free Medial Plantar Artery Perforator (MPAP) Flap8,23
	51.9 PITFALLS 51.9.1 Medialis Pedis Flap
	51.9.2 Instep Flap
	51.9.3 Restoring Blood Flow to Lateral Plantar Artery after Raising Instep Flap or Medialis Pedis Flap
	51.10 CASE EXAMPLE
	51.11 CONCLUSION
52 Flap Options and Technical Considerations in Head and Neck Reconstruction
	PART A 52.1.1 Introduction
	PART B 52.2.1 Scalp Reconstruction
	PART C 52.3.1 Upper Face Reconstruction
	52.3.2 Midface Reconstruction
	52.3.3 Lower Face Reconstruction
	PART D 52.4.1 Neck Reconstruction
	PART E 52.5.1 Oral Cavity Reconstruction
	PART F 52.6.1 Pharyngoesophageal Reconstruction
53 Flap Options and Technical Considerations in the Upper Extremity
	PART A 53.1.1 Introduction
	PART B 53.2.1 Shoulder and Upper Arm Reconstruction
	PART C 53.3.1 Elbow and Forearm Reconstruction
	PART D 53.4.1 Hand andWrist Reconstruction
54 Flap Options and Technical Considerations in the Trunk
	54.1 INTRODUCTION
	54.2 VENTRAL TRUNK 54.2.1 Deep Inferior Epigastric Artery Perforator (DIEAP) Flap
	54.2.2 Superficial Inferior Epigastric Artery Perforator (SIEAP) Flap
	54.2.3 Superficial Circumflex Iliac Artery Perforator (SCIAP) Flap
	54.2.4 Deep Circumflex Iliac Artery Perforator (DCIAP) Flap
	54.2.5 Superior Epigastric Artery Perforator (SEAP) Flap
	54.2.6 Internal Mammary Artery Perforator (IMAP) Flap
	54.2.7 Anterior Intercostal Artery Perforator (AIAP) Flap
	54.2.8 Thoraco-acromial Artery Perforator (TAAP) Flap
	54.3 DORSAL AND LATERAL TRUNK 54.3.1 Thoracodorsal Artery Perforator (TDAP) Flap
	54.3.2 Circumflex Scapular Artery Perforator (CSAP) Flap
	54.3.3 Dorsal Scapular Artery Perforator (DSAP) Flap
	54.3.4 Dorsal Intercostal Artery Perforator (DICAP) Flap
	54.3.5 Lateral Intercostal Artery Perforator (LICAP) Flap
	54.3.6 Lumbar Artery Perforator (LAP) Flap
	54.3.7 Parasacral Artery Perforator (PSAP) Flap
	54.3.8 Superior Gluteal Artery Perforator (SGAP) Flap and Inferior Gluteal Artery Perforator (IGAP) Flap
55 Breast Reconstruction
	PART A 55.1.1 Partial Breast Reconstruction
	PART B 55.2.1 Total Breast Reconstruction
56 Trunk Reconstruction
	PART A 56.1.1 Anterior ChestWall Reconstruction
	PART B 56.2.1 Abdominal Wall Reconstruction
	PART C 56.3.1 Back Reconstruction
57 Perforator Flaps in Pelvic Reconstruction
	57.1 INTRODUCTION
	57.2 ANATOMICAL DETAILS OF THE RECIPIENT SITE
	57.3 CHOICE OF FLAPS
	57.4 CASE REPORT
	57.5 ADVANTAGES OVER POSSIBLE ALTERNATIVE 57.5.1 Sacrum
	57.5.2 Ischium
	57.5.3 The Greater Trochanter
	57.5.4 Free Style and Distant/Free Flap
	57.6 RECIPIENT VESSELS AND ANASTOMOSIS
	57.7 DISADVANTAGES AND PITFALLS
58 Perineogenital Reconstruction
	58.1 INTRODUCTION TO PERINEOGENITAL RECONSTRUCTION
	58.1.1 Anatomy of the Perineogenital Region
	58.2 PERFORATOR FLAPS FOR PERINEOGENITAL RECONSTRUCTION
	58.2.1 Flap Choice, Inset, andWound Closure
	58.2.2 Application of Perforator Flaps in Vulvar Reconstruction
	58.2.3 Application in Perineoscrotal Reconstruction
	58.2.4 Total Pelvic Exenteration
	58.2.5 Application in Penile Reconstruction
	58.2.6 Case Examples
	58.3 CONCLUSION
59 Flap Options and Technical Considerations in the Lower Extremity
	PART A 59.1.1 Introduction to the Role of Perforator Flaps in Lower Extremity Reconstruction
	PART B 59.2.1 Perforator Flap Selection for Thigh Reconstruction
	PART C 59.3.1 Perforator Flap Selection for Knee and Proximal Leg Reconstruction
	PART D 59.4.1 Perforator Flap Selection for the Middle and Distal Leg
	PART E 59.5.1 Perforator Flap Selection for the Foot and Ankle
Index