Perforator flaps: History, controversies, physiology, anatomy, and use in reconstruction

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 morbidity, 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.