New Nomenclature Concept of Perforator Flap

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: [email protected].

Table 1 Comparison of conventional and new nomenclature Conventional flap name Flap name according to new concept (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 perforator 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 perforator flap or descending perforator 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 433

Inconsistent nomenclature of perforator flaps hin- perforators from the same proximal vascular ders communication and causes difficulty in devel- system. Furthermore, the perforator type used in oping the perforator flap concept. For instance, the the flap dissection such as MCp or SCp is not deep inferior epigastric perforator flap is named accurately described in the nomenclature.10 Some after the proximal vessel, however, sometimes it flaps such as tensor fascia lata perforator flap,11 has also been named the paraumbilical or perium- posterior tibial perforator flap12 or medial sural bilical perforator flap.1,2 As for the perforator flaps artery perforator flap13 manifest the name of the from the lateral chest wall, the name of latissimus proximal artery in the nomenclature, but the dorsi perforator flap has been used, along with the perforator pattern is not exactly described. Con- other nomenclature of thoracodorsal perforator versely, the lateral leg perforator flap14 or posterior flap.3,4 Since, anterolateral thigh perforator flap is thigh perforator flap5 are named according to the named after the region where it is harvested, two region. perforator dissections based on the septocutaneous Popular perforator flaps in the abdomen and perforator (SCp) or musculocutaneous perforator lateral chest wall have various kinds of nomencla- (MCp) are not distinguished by the nomenclature. tures. The DIEP flap is known to be one of the most Various perforator flaps have been described on popular flaps but, many nomenclatures have been the limbs. It is difficult to understand exactly when used, including paraumbilical perforator flap,1,15 they were first mentioned during discussion or paraumbilical perforator-based flap,16 deep described in the literature. Especially, in posterior inferior epigastric perforator flap (DIEP),17–19 deep 5 thigh perforator flap or medial circumflex femoral inferior epigastric artery perforator flap,20 inferior 6 perforator flap, it is difficult to understand how to epigastric artery skin flaps without rectus abdomi- elevate the flap or which perforator is used. nis muscle,21 and deep inferior epigastric artery Confusion also occurs between sural artery per- skin flap.22 In the lateral chest wall area, the name 7 8 forator flap and peroneal perforator flap. The ‘latissimus dorsi musculocutaneous flap without 9 nomenclature of radial artery perforator flap is muscle’23 was introduced first, but its expression vague and inaccurate, therefore, the exact harvest- was somewhat contradictory, because of inclusion ing procedure can hardly be understood unless of both ‘musculocutaneous’ and ‘without muscle’. reading the entire article. Since, an ideal nomen- Next, the name ‘latissimus dorsi perforator flap’3 clature should be consistent and accurate, scien- was introduced, and also ‘thoracodorsal (artery) tific and detailed information about the pedicle perforator flap’ was used, following the customary course and perforator used are prerequisites in the nomenclature of DIEP flap.24–26 new nomenclature concept. An inappropriately long description was required for exact description in some perforator flaps, such as the paraumbilical perforator flap without deep Materials inferior epigastric vessels,15 the gluteal fold flap nourished by skin perforators of the internal 27 Fifty-four articles and 38 abstracts were reviewed pudendal artery, or the posterior interosseous 28 for the usage of nomenclature. Similar perforator flap based on a septal perforator. Some areas are flaps were classified and their names were com- vague in the perforator concept, and various pared from the anatomical standpoint. Vague and subcutaneous or fascia pedicled flaps have been inaccurate expressions were exposed, and conven- introduced as perforator flaps. These inadequate tional flaps were compared with perforator flaps for terms, such as ‘distally pedicled cutaneous-subcu- 29 the purpose of determining whether the nomen- taneous perforator forearm flap’, ‘turn-over flap 30 clature could faithfully represent the character of based on perforators of the dorsalis pedis’, 31 the flap and distinguish the one from the other. ‘perforator based V–Y advancement flap’ and ‘perforator-based forearm and hand adipofascial flap’32 have caused serious confusion in the perforator concept. Results

Thenomenclatureofperforatorflapsonthe New nomenclature system extremities is extremely disorganised (Table 1). On the thigh, the anterolateral thigh perforator flap Any new standardised nomenclature should be is named according to the region, whilst the tensor accurate and simple to understand, moreover, the fascia lata perforator flap is named according to the perforator pattern used and dissection course muscle, even though both flaps are based on 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 lateralis perforator flap means that the flap is perforator is variable and unpredictable, new elevated based on the MCp through transmuscular nomenclature should accommodate such variety dissection of vastus lateralis, however, the lateral within a framework of definite principle. circumflex femoral perforator flap implies that the Perforators can be categorised as direct flap is elevated based on the SCp. cutaneous perforator (DCp), septocutaneous per- The term, ‘perforator based’ is used for the flap, forator (SCp) and muculocutaneous perforator when it is truly based on the perforator itself with (MCp). DCp is the perforator sprouting from the the proximal vessel saved, and the flap is named proximal vessel to dermis without traversing the according to the perforator type as described above muscle or deep fascia, and mostly found in face, (Fig. 1(C), (F), (I) and (L)). This distinction would perineum and so on. SCp is the one piercing also solve the current confusion caused by disorga- between the neighboring muscles, and mostly nised usage of ‘perforator flap’ and ‘perforator found in extremities. MCp, a true perforator based flap’. 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. Discussion For the flap based on the DCp or SCp, it is desirable to name it according to the proximal Perforator flaps have been developed to reduce the vessel; submental perforator flap35 from the sub- sacrifice of donor structure, and to enable versatile mental artery or medial plantar perforator flap36 design or thickness as required. However, it proved from medial plantar artery (Fig. 1(A), (B), (D) and to require meticulous and challenging transmuscu- (E)). It is important for these two patterns to be lar dissection technique compared to conventional distinguished from MCp by different nomenclature flaps. Some authors proposed to define the per- system, because their dissections are not so forator flaps as exclusively those based on MCp.37 difficult as MCp. But, for the flap based on the The question of whether the flap based on DCp or MCp, it is named according to the name of muscle SCp should be excluded has been an issue of perforated (Fig. 1(J) and (K)). In the anterolateral controversy, and debates on the perforator flap thigh flap, it can also be elevated in two patterns category are still being continued. At first, this according to its variable anatomy, such as the SCp author also thought that MCp was the real perfora- or MCp (Fig. 1(G) and (H)). Therefore, the vastus 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 septocutaneous 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 such as forearm or saphenous flap. Therefore, the confusion. However, some perforators vary perforator flap based on the MCp should better be between MCp and SCp because of the anatomical discriminated by different nomenclature from variability. Furthermore, some of the conventional those based on other perforators. fasciocutaneous or cutaneous island flaps based on Generally, SCp has been accepted to be a pedicle the perforator or narrowed septal pedicle, includ- within the perforator concept. Giunta and Geisweid ing several perforators, have been already used, 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 437 perforator flaps, such as ‘musculocutaneous per- concept, conventional musculocutaneous flap can forator flap (type A)’ and ‘septocutaneous perfora- easily be distinguished from perforator flaps by the tor flap (type B)’.38 Geddes et al. proposed that all term ‘perforator’ (Fig. 3(A)). Clear discrimination perforator flaps should be named according to the can be achieved with new nomenclature concept; main artery with the suffix of muscle name, and ‘vastus lateralis perforator flap’ based on MCp (Fig. addition of suffix-s is recommended to overcome 3(B)) and ‘descending perforator flap’ based on potential limitation for SCp.39 In the system SCp. Conventional septocutaneous flap or perfora- suggested, however, there is no appropriate term tor flap based on SCp is named according to the corresponding to the perforator based flap and, name of the proximal vessel. The name of proximal flaps between two perforator patterns are not vessel can also vary depending on the extent of easily distinguished. The concept of perforator proximal dissection and on the pedicle length patterns can also be modified, such as direct and needed, or its diameter for anastomosis. For indirect perforators.40 Since, the nomenclature instance, descending perforator flap implies the needs to be simple and consistent for general flap based on the descending branch system without usage by operators, the new nomenclature system sacrificing transverse branch and proximal lateral in this article emphasises that the name is relevant femoral circumflex femoral artery (Fig. 3(C)). When to the muscle in MCp based perforator flap and to a longer pedicle with larger diameter is necessary the vessel in flaps based on other perforators. or proximal branching system is required for a Simplicity of the nomenclature is likely to avoid the chimeric pattern, the dissection should proceed debate on complicated perforator concept and proximally, and the flap is named as the lateral encourage widespread usage of perforator flaps, circumflex femoral perforator flap (Fig. 3(D)). not restricted by confusion in nomenclature. Sometimes, the flap can be elevated based on the The forearm flap, it is named conventionally as a MCp from the rectus femoris, and then it can be fasciocutaneous flap with septum and deep fascia named as a rectus femoris perforator flap. Depend- included for flap reliability (Fig. 2(A)). However, ing on the recipient status, if the perforator at the the septum alone proved to be enough for flap level of deep fascia has a diameter enough for survival without much of deep fascia, and the anastomosis, the dissection can be stopped without nomenclature of ‘septocutaneous flap’ was popu- further transmuscular dissection, and the flap is larised (Fig. 2(B)). With the perforator concept, the named as ‘perforator based flap’ such as vastus flap can be available even based on a single lateralis perforator based flap (MCp, Fig. 3(E)) or perforator instead of longitudinal inclusion of descending perforator based flap (SCp, Fig. 3(F)), septum, and it is called as ‘radial perforator flap’ which implies no sacrifice of descending branch. according to the name of proximal vessel (Fig. Tensor fasciae latae perforator flap is a good 2(C)). If based on a single MCp perforating the flexor example of this new nomenclature.11,41 For the carpi radialis, the flap is named as ‘flexor carpi medial circumflex femoral perforator flap6 elev- radialis perforator flap’ according to the muscle ated based on MCp from gracilis, the name of name (Fig. 2(D)). In this regards, the perforator gracilis perforator flap is easier to understand. concept has greatly contributed to the revolution of Many other MCps or SCps originated from medial conventional flaps. circumflex femoral artery can be used as a pedicle In the thigh, the anterolateral thigh flap can be of perforator flap. Therefore, medial circumflex elevated based on SCp or MCp according to its femoral perforator flap is not accurate and, gracilis variable anatomy, and it is a common nomenclature perforator flap is more precise to understand the without accurate discrimination between musculo- flap. And the flap based on SCp from medial cutaneous or septocutaneous flap. After introduc- circumflex femoral artery, such as medial circum- tion of the perforator concept, another confusion flex femoral perforator flap, is also easily discrimi- occurred between the conventional septocuta- nated from gracilis perforator flap with different neous flap and the perforator flap based on SCp, nomenclature. even though they are the same flap. More confusion The posterior thigh perforator-based flap5 is in nomenclature would be expected if the SCp is better named the biceps femoris perforator flap excluded from perforator concept: If only the flap or deep femoral perforator flap, if based on the MCp based on the MCp is regarded as the perforator flap or SCp. The posterior tibial perforator-based flap42 called as ‘anterolateral thigh perforator flap’ is one of the popular perforator flaps in medial leg, compared with ‘anterolateral thigh flap’ for con- but it is also better to differentiate between the ventional musculocutaneous flap, there would be posterior tibial perforator flap based on SCp, and no appropriate nomenclature for the flap based on the soleus or flexor digitorum longus perforator flap SCp. Therefore, with this new nomenclature based on MCp. 438 J.T. Kim

In the abdomen, DIEP flap for breast reconstruc- can be named as gluteus maximus perforator based tion can be named as rectus abdominis perforator island flap according to this nomenclature system. flap, and rectus abdominis perforator-based flap Various nomenclatures of flaps that have been means DIEP flap without sacrifice of deep inferior used for lumbosacral defect, such as pedicled epigastric artery. perforator flap43 and perforator-based flap44 are In the lateral chest wall area, two nomenclatures also named as gluteus maximus perforator based are also debated: latissimus dorsi or thoracodorsal island flap, if MCp is selected as a pedicle without perforator flap. With the new nomenclature sys- transmuscular dissection. As lumbar artery perfora- tem, flap based on the MCp through latissimus dorsi tor based island flap45 is based on MCp, erector is properly named as latissimus dorsi perforator spinae perforator based island flap is a correct flap. Since, SCp originated from the thoracodorsal term. system is located anterior to lateral border of the Until now, the term ‘based’ has been used for all latissimus dorsi muscle, perforator flap based on it the perforator flaps to discriminate them from is named as thoracodorsal perforator flap. other conventional flaps, however, it has also been In the gluteal region, two definite perforator intermittently used without defined guidelines. In flaps are used for breast reconstruction; superior or this new nomenclature system, it implies that the inferior gluteal perforator flap based on the MCp dissection is stopped at the level of fascia or muscle from superior or inferior gluteal vessels. According without sacrifice of proximal vessel. Depending on to the new nomenclature, these are all gluteus the recipient status, the perforator dissection does maximus perforator flaps (sometimes it can be not necessarily proceed to the underlying proximal gluteus medius perforator flap), however, they can vessel in the abdomen, lateral chest wall and easily be distinguished by adding the description of lateral thigh region, because some perforators the perforating site in front of the flap name: such have enough diameter for pedicle anastomosis as superior or inferior gluteus maximus perforator (Fig. 4). For instance, the rectus abdominis per- flap, instead of superior or inferior gluteal perfora- forator based flap signifies the flap elevated based tor flap. Even though MCp can be originated from on the perforator itself with no further transmus- other proximal vessels except superior or inferior cular dissection or no sacrifice of deep inferior gluteal artery, it has been used as a pedicle of island epigastric artery. This view is in accordance with the flap without transmuscular dissection, and the flap ‘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 439

Another confusion comes from extraordinarily perforator flap: the medial groin flap. Proceedings of the emphasised terminology of flap thickness with 6th international course on perforator flaps, Taiwan, Oct various unscientific expressions, such as 23–26 2002. 16 3,46 47,48 7. Umemoto Y, Adachi Y. Sural artery perforator flap. ‘thinned’, ‘thin’, ‘superthin’, ‘extremely Proceedings of the 6th international course on perforator 49 41 24 thinned’, ‘microdissected thin’ and ‘thinning’. flaps, Taiwan, Oct 23–26 2002. At least in the nomenclature, such expressions are 8. Yajima H, Kobata Y, Kawamura K, Takakura Y, Tamai S. inappropriate for exactly presenting the flap, Clinical applications of the free soleus and peroneal especially to beginners or training doctors. Since, perforator flaps. Proceedings of the 6th international perforator flaps from the back or extremities are course on perforator flaps, Taiwan, Oct 23–26 2002. 9. Bauer TR, Schoeller T, Wechselberger G, Papp C. The radial already known to be thin enough for resurfacing, artery perforator free flap. Plast Reconstr Surg 1999;104: these unnecessary expressions should be simplified 885. as ‘thin’. Thin perforator flap implies the perforator 10. Celik N, Wei FC, Lin CH, et al. Technique and strategy in flap as a thin pattern without much of adipose layer anterolateral thigh perforator flap surgery, based on an at flap elevation or trimming after elevation. For analysis of 15 complete and partial failures in 439 cases. instance, thin latissimus dorsi perforator flap means Plast Reconstr Surg 2002;109:2211–6. 11. Deiler S, Pfadenhauer A, Widmann J, et al. Tensor fasciae the perforator flap elevated based on MCp latae perforator flap for reconstruction of composite through the transmuscular dissection, excluding Achilles tendon defects with skin and vascularized fascia. much of the adipose tissue. Plast Reconstr Surg 2000;106:342–9. This concept of nomenclature has several advan- 12. Hung LK, Lao J, Ho PC. Free posterior tibial perforator flap: tages. It accurately represents the dissected anatomy and a report of 6 cases. Microsurgery 1996;17: muscle and differentiates the perforator pattern 503–11. 13. Cavadas PC, Sanz-Gimenez-Rico JR, Camara AG, et al. The used. And it can also prevent future confusion medial sural artery perforator free flap. Plast Reconstr Surg possibly arising from innumerable perforator flaps 2001;108:1609–15. introduced in the future, especially in the extre- 14. Tsai FC, Yang JY, Chuang SS, Chang SY, Huang WC. Combined mities. This nomenclature is simple to understand method of free lateral leg perforator flap with cervico- by discriminating MCp from other perforators with plasty for reconstruction of anterior cervical scar contrac- different names according to the muscle or prox- ture: a new flap. Proceedings of the 6th international course on perforator flaps, Taiwan, Oct 23–26 2002. imal vessel. With this new nomenclature, it is very 15. Koshima I, Inagawa K, Urushibara K, Moriguchi T. Para- simple to discriminate the perforator flap and umbilical perforator flap without deep inferior epigastric conventional flaps, and also to appreciate the flap vessels. Plast Reconstr Surg 1998;102:1052–7. character or dissection course, when the name is 16. Koshima I, Moriguchi T, Fukuda H, Yoshikawa Y, Soeda S. mentioned. Finally, vague concepts of perforators Free, thinned, paraumbilical perforator-based flaps. can be organised in a rational direction with Reconstr Microsurg 1991;7:313–6. 17. Allen RJ, Treece P. Deep inferior epigastric perforator flap systematic nomenclature. for breast reconstruction. Ann Plast Surg 1994;32:32–8. 18. Kroll S. Fat necrosis in free transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flaps. Plast Reconstr Surg 2000;106:576–83. References 19. Blondeel N, Vanderstraeten GG, Monstrey SJ, et al. The donor site morbidity of free DIEP flaps and free TRAM flaps for breast reconstruction. Br J Plast Surg 1997;50:322–30. 1. Koshima I, Inagawa K, Yamamoto M, Moriguchi T. New 20. Feller AM, Galla T. The deep inferior epigastric artery microsurgical breast reconstruction using free paraumbilical perforator flap. Clin Plast Surg 1998;25:197–206. perforator adiposal flaps. Plast Reconstr Surg 2000;106: 21. Koshima I, Soeda S. Inferior epigastric artery skin flaps 61–5. without rectus abdominis muscle. Br J Plast Surg 1989;42: 2. Saulis AS, Dumanian GA. Periumbilical rectus abdominis 645–8. perforator preservation significantly reduces superficial wound complications in ‘separation of parts’ hernia repairs. 22. Itoh Y, Arai K. The deep inferior epigastric artery free skin Plast Reconstr Surg 2002;109:2275–80. flap: anatomic study and clinical application. Plast Reconstr 3. Kim JT, Koo BS, Kim SK. The thin latissimus dorsi perforator- Surg 1993;91:853–63. based free flap for resurfacing. 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