CME The "Gent" Consensus on Perforator Flap Terminology: Preliminary Definitions
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CME
The “Gent” Consensus on Perforator Flap
Terminology: Preliminary Definitions
Phillip N. Blondeel, M.D., Ph.D., Koen H. I. Van Landuyt, M.D., Stan J. M. Monstrey, M.D., Ph.D.,
Moustapha Hamdi, M.D., Guido E. Matton, M.D., Robert J. Allen, M.D., Charles Dupin, M.D.,
Axel-Mario Feller, M.D., Ph.D., Isao Koshima, M.D., Naci Kostakoglu, M.D., and Fu-Chan Wei, M.D.
Gent, Belgium; New Orleans, La.; Munich, Germany; Okayama, Japan; Ankara, Turkey; and Taipei, Taiwan
Due to its increasing popularity, more and more articles morbidity as a consequence of the preservation
on the use of perforator flaps have been reported in the of muscle innervation, vascularization, and
literature during the past few years. Because the area of
perforator flaps is new and rapidly evolving, there are no functionality of the donor muscle. In addition,
definitions and standard rules on terminology and no- it has been observed that patients in general
menclature, which creates confusion when surgeons try to have less postoperative pain and a swifter reha-
communicate and compare surgical techniques. This ar- bilitation. The advantages of harvesting rela-
ticle attempts to represent the opinion of a group of tively large and thin skin flaps include the ab-
pioneers in the field of perforator flap surgery. This con-
sensus was reached after a terminology consensus meeting sence of postoperative muscle atrophy as seen
held during the Fifth International Course on Perforator in myocutaneous flaps, the presence of long
Flaps in Gent, Belgium, on September 29, 2001. It stipu- vascular pedicles based on well-known source
lates not only the definitions of perforator vessels and vessels, and the possibility of harvesting sensory
perforator flaps but also the correct nomenclature for nerves with the flap, providing a tool to per-
different perforator flaps. The authors believe that this
consensus is a foundation that will stimulate further dis- form more accurate and precise reconstruc-
cussion and encourage further refinements in the tions. Given that an ideal reconstruction
future. (Plast. Reconstr. Surg. 112: 1378, 2003.) should replace “like with like,” and the knowl-
edge that about 80 percent of free flaps are
used for resurfacing purposes and only a mi-
In 1989, Koshima and Soeda1 used the ter- nority of patients need a free flap to fill up
minology “perforator flaps” for the first time in dead space or deep defects, free flaps consist-
a clinical setting. In two cases, Koshima and ing of skin and subcutaneous fat tissue are
Soeda had used a paraumbilical skin and fat predominantly needed in a daily practice.
island based on a muscular perforator to re- In the pioneer phase, the principles of a
construct the groin and the tongue. Koshima perforator flap were defined as a free flap con-
introduced the concept of perforator flaps to sisting of skin and subcutaneous fat only, based
differentiate them from fasciocutaneous flaps, on a transmuscular perforator vessel that was
as he was convinced that the fascial vascular dissected by splitting the muscle and not har-
plexus did not contribute to the vascularization vesting it. Both vascularization and innervation
of the flap. Since the first applications and the of that muscle were left intact. A perforator
popularization of the use of perforator-based flap was seen as an ultimate upgrade of a myo-
lower abdominal wall skin flaps in breast recon- cutaneous flap because it preserved all the in-
struction,2– 4 the principle of perforator flaps trinsic advantages of its myocutaneous ana-
has become more and more popular over the logue. In the last few years, the plastic surgery
last decade. Its growing popularity is mainly journals have been filled with reports of new
related to the important decrease in donor-site perforator flaps. Slowly, perforator flaps have
Received for publication October 3, 2002.
Presented at the Fifth International Course on Perforator Flaps, in Gent, Belgium, September 27 to 29, 2001, and at the Inaugural Congress
of the World Society for Reconstructive Microsurgery, in Taipei, Taiwan, October 30 to November 3, 2001.
DOI: 10.1097/01.PRS.0000081071.83805.B6
1378Vol. 112, No. 5 / TERMINOLOGY OF PERFORATOR FLAPS 1379
become a common denominator for any type deep fascial perforators into six patterns of
of skin flap that is dissected on a single vascular vascular supply. Despite the very accurate and
pedicle consisting of one artery and one vein. precise description of the main target of each
The origin and the route the perforators fol- vessel and its course through the deeper tis-
lowed have become less relevant and confusion sues, we do not believe such a complex classi-
has increased. The exact definition of a perfo- fication is necessary. From a surgical point of
rator flap is not clear, and the terminology and view (i.e., surgical elevation of the perforator
the classification of the different perforator flap), it is important to know which surgical
flaps have not yet been identified. In this arti- plane to follow during dissection by recogniz-
cle, we attempt to address these issues. ing the tissues through which the perforators
are passing. All perforators will eventually per-
DEFINITION OF A PERFORATOR FLAP forate the deep fascia. Therefore, we suggest
differentiating among the following five types
Before we could come up with a clear defi-
of perforators (Fig. 1):
nition of a perforator flap, it was important to
define what a “perforating vessel” is. A perfo- • Direct perforators perforate the deep fascia
rating vessel, or, in short, a perforator, is a only.
vessel that has its origin in one of the axial • Indirect muscle perforators predominantly
vessels of the body and that passes through supply the subcutaneous tissues.
certain structural elements of the body, besides • Indirect muscle perforators predominantly
interstitial connective tissue and fat, before supply the muscle but have secondary
reaching the subcutaneous fat layer. Hallock5 branches to the subcutaneous tissues.
defines a perforator as any vessel that enters • Indirect perimysial perforators travel within
the superficial plane through a defined fenes- the perimysium between muscle fibers be-
tration in the deep fascia, regardless of origin. fore piercing the deep fascia.
Hallock discerns direct and indirect perfora- • Indirect septal perforators travel through
tors according to the distinct origin of their the intermuscular septum before piercing
vascular supply and the structures they traverse the deep fascia.
before piercing the deep fascia. Perforators
that pierce the deep fascia without traversing It is very important to establish good defini-
any other structural tissue are called direct per- tions and a correct terminology of perforator
forators. All other perforators that first run flaps to make it possible for reconstructive sur-
through deeper tissues, mainly muscle, sep- geons to communicate with each other and to
tum, or epimysium, are called indirect perfo- talk about the same thing at the same moment.
rators. In 1986, Nakajima et al.6 classified the Equally important is the ability to understand
FIG. 1. Schematic drawing of the different types of direct and indirect perforator vessels with regard to their surgical
importance. 1, Direct perforators perforate the deep fascia only; 2, indirect muscle perforators predominantly supply the
subcutaneous tissues; 3, indirect muscle perforators predominantly supply the muscle but have secondary branches to the
subcutaneous tissues; 4, indirect perimysial perforators travel within the perimysium between muscle fibers before piercing the
deep fascia; 5, indirect septal perforators travel through the intermuscular septum before piercing the deep fascia.1380 PLASTIC AND RECONSTRUCTIVE SURGERY, October 2003 the surgical anatomy of each flap, its preoper- the anterolateral thigh perforator flap, where ative planning, and the necessary surgical ap- the perforators from the descending branch of proach.7 For this reason, Wei et al.7 defined a the lateral circumflex femoris artery can par- perforator flap as a flap supplied by fascial tially run in the septum in the proximal part perforators that have required an intramuscu- and turn into the vastus lateralis muscle before lar dissection during elevation. With the knowl- piercing the deep fascia into the skin in the edge and the distinction of the different per- more distal part. In those cases, we would talk forating vessels (Fig. 1), we defined a about a muscle perforator and only talk about perforator flap as follows: a septal perforator if the perforator itself would Definition 1: A perforator flap is a flap consisting run through the intramuscular septum only. of skin and/or subcutaneous fat. The vessels that After the previous two definitions, the follow- supply blood to the flap are isolated perforator(s). ing two important definitions were established: These perforators may pass either through or in be- Definition 4: A flap that is vascularized by a tween the deep tissues (mostly muscle). muscle perforator is called a muscle perforator flap. This definition of a perforator flap is very Definition 5: A flap vascularized by a septal per- general. It is important to note that a perfora- forator is called a septal perforator flap. tor flap can consist of skin and fat, but if skin is The purists among us stated that a muscle not included, the flap can consist of Scarpa perforator flap is the only real perforator flap. fascia and subcutaneous fat. The principle that additional effort and time Taking into account the different types of need to be spent to dissect the perforator out perforators, it would be easy to classify them from between the muscle fibers to reduce the accordingly. Nevertheless, we believe it is im- donor morbidity was the main argument for portant that the classification of perforator the statement. However, the term “muscle per- flaps reflect the clinical relevance of the differ- forator flap” clearly opposes the term “septal ent types of perforator flaps. In analogy to the perforator flap,” and it clearly points out the recommendations of Hallock,5 perforator flaps different surgical approach during elevation. can be vascularized by direct or indirect perfo- In a further refinement of definition 4, it was rators. Direct perforators only perforate the also stated that the vessels of a muscle perfora- deep fascia and are therefore rather easy to tor flap can pierce any muscle independent of dissect. In the subgroup of indirect perfora- the donor morbidity created, independent of tors, two types of perforators need to be distin- the muscle fiber direction in relation to the guished according to the clinical relevance: course and direction of the perforator, and perforators that traverse muscle (transmuscu- also independent of the length of the pedicle. lar perforators, transepimysial perforators) and Sometimes the perforator vessel may pierce cutaneous side branches of muscular vessels several muscles of which the muscle fibers run and perforators that run through intermuscu- perpendicular to the direction of the axial ves- lar septa. sels, before emerging from the outer layer of During the dissection of a muscular perfora- the deep fascia. In these cases, some muscle tor flap, one will only take into account the fibers may have to be divided to reach the size, position, and course of the perforator ves- source vessel, as with the deep circumflex iliac sel and not whether it runs in between muscle perforator flap. This would not preclude the fibers or epimysium. In relation to the surgical use of the term “perforator flap.” Also flaps importance, we decided to only distinguish be- containing the perforator together with the tween muscle perforators and septal perfora- deeper axial vessels would still be called perfo- tors, as follows: rator flaps. Definition 2: A muscle perforator is a blood vessel that traverses through muscle to supply the overlying CLASSIFICATION skin. One of the main problems we face in the Definition 3: A septal perforator is a blood vessel literature of the last few years is that every that traverses only through septum to supply the author is coming up with his own names for overlying skin. different perforator flaps. A typical example is It is important to notice the word “only” in the perforator flap from the lower abdomen definition 3. Some perforators can have a that is called the paraumbilical perforator flap mixed septal and intramuscular course before by some and deep inferior epigastric perfora- reaching the skin. A good clinical example is tor flap by others. From an anatomical point of
Vol. 112, No. 5 / TERMINOLOGY OF PERFORATOR FLAPS 1381
view, these flaps are almost identical. Another agreed that terms such as “thin,” “perforator
example is the perforator flap from the latissi- based,” and “cutaneous island” should no
mus dorsi area, called the thoracodorsal artery longer be used together with the term “perfo-
perforator flap or the latissimus dorsi perfora- rator flap.” One is obviously free to add the
tor flap. Some call it the thoracodorsal perfo- type of transfer, either free or pedicled, to the
rator based cutaneous island flap or the thin name of a flap.
latissimus dorsi perforator based free flap.
Again, in each of these flaps, the same vessel is CONCLUSIONS
used to vascularize the skin island from the With the appearance of many new perfora-
same area. It will be important in the future to tor flaps described in the literature in the last
use corresponding names (and abbreviations) few years and the absence of any kind of stan-
to define the same flaps. For these reasons, a dardization in terminology, confusion among
standard nomenclature is very important. To reconstructive surgeons increased rapidly. It
achieve more standardization, a consensus was often occurred that, during a meeting, two
reached around the following definition: surgeons were talking about the same flap but
Definition 6: A perforator flap should be named were using different names. The lack of stan-
after the nutrient artery or vessels and not after the dardized terms has led to a lot of confusion.
underlying muscle. If there is a potential to harvest Standardization of terminology is essential
multiple perforator flaps from one vessel, the name of when surgeons are communicating with each
each flap should be based on its anatomical region or other and discussing anatomy, preoperative
muscle. planning, intraoperative surgical techniques,
A typical example of this are the lateral cir- and postoperative care.
cumflex femoris artery and vein that can be the In the human body, different types of perfo-
origin for the tensor fasciae latae perforator rators can be identified anatomically. If we
flap or the anterolateral thigh flap. These flaps would take the six definitions provided in this
will be called either by their anatomical region article very literally, any vessel that branches off
or by the underlying muscle to clarify that the the aorta and eventually reaches the skin could
skin is taken from a different location but from be called a perforator, because all of the aorta’s
the same axial vessel. Table I shows examples branches will eventually perforate the deep fas-
of correct terminology for indirect perforator cia. It is clearly not our intention to define
flaps. To avoid further confusion, it was also every flap described until now as a perforator
TABLE I
Examples of Correct Abbreviations and Terminology of Muscular and Septal Perforator Flaps
Flap/Abbreviation Flap/Full Name Nutrient Artery
Muscle perforator flaps
DIEP Deep inferior epigastric perforator Deep inferior epigastric vessels
TAP Thoracodorsal artery perforator Thoracodorsal vessels
SGAP Superior gluteal artery perforator Superior gluteal vessels
IGAP Inferior gluteal artery perforator Inferior gluteal vessels
IMAP Internal mammary artery Internal mammary vessels
perforator
ICAP Intercostal perforator Intercostal vessels
PLP Paralumbar perforator Paralumbar perforating vessels
GP Gracilis perforator Medial circumflex femoris vessels
TFLP Tensor fasciae latae perforator Transverse branch of the lateral circumflex femoris vessels
ALTP Anterolateral thigh perforator Descending branch of the lateral circumflex femoris vessels
AMTP Anteromedial thigh perforator Innominate branch of the descending branch of the lateral circumflex
femoris vessels
SAP Sural artery perforator Sural vessels
PTAP Posterior tibial artery perforator Posterior tibial vessels
ATAP Anterior tibial artery perforator Anterior tibial vessels
Septal perforator flaps
RAP Radial artery perforator Radial vessels
AP Adductor perforator Medial circumflex femoris vessels
AMTP Anteromedial thigh perforator Innominate branch of the descending branch of the lateral circumflex
femoris vessels (if perforator runs only in septum)
ALTP Anterolateral thigh perforator Descending branch of the circumflex femoris lateralis vessels (if
perforator runs only in the septum)1382 PLASTIC AND RECONSTRUCTIVE SURGERY, October 2003
flap. The terminology and the classification article are temporary and can be reviewed in a
into direct and indirect perforator flaps and later phase. The International Course on Per-
further into septal and muscle perforator flaps forator Flaps will be an annual forum to discuss
were set up to clearly identify the course of this important topic in the future.
these small terminal branches of axial vessels Phillip N. Blondeel, M.D., Ph.D.
just before they pierce the deep fascia and the Department of Plastic and Reconstructive Surgery
technical implications during the surgical pro- University Hospital Gent, 2K12C
cedure. It is evident that the dissection of a De Pintelaan 185
direct perforator flap is much easier than dis- B-9000 Gent, Belgium
section of a muscle perforator flap. In addition, phillip.blondeel@rug.ac.be
septal perforators are easier to identify and www.gentplasticsurg.com
slightly easier to dissect. REFERENCES
It still remains controversial whether skin 1. Koshima, I., and Soeda, S. Inferior epigastric artery skin
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most of the skin and/or fasciocutaneous flaps 2. Allen, R. J., and Treece, P. Deep inferior epigastric
described before, such as the groin flap (super- perforator flap for breast reconstruction. Ann. Plast.
Surg. 32: 32, 1994.
ficial circumflex iliac vessels), the superficial 3. Blondeel, P. N., and Boeckx, W. D. Refinements in free
inferior epigastric artery flap, and the scapular flap breast reconstruction: The free bilateral deep
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sels), would certainly have to be called perfo- internal mammary artery. Br. J. Plast. Surg. 47: 495,
rator flaps. Even some neurocutaneous flaps, 1994.
4. Blondeel, P. N. One hundred free DIEP flap breast
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forearm flap, dissected as such, could be called 5. Hallock, G. G. Direct and indirect perforator flaps: The
perforator flaps. For the moment, we believe it history and the controversy. Plast. Reconstr. Surg. 111:
is most logical that only skin flaps with septal or 855, 2003.
6. Nakajima, H., Fujino, T., and Adachi, S. A new concept
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flaps because of the different surgical ap- flaps according to their vascularization. Ann. Plast.
proach that is needed. This would have the Surg. 16: 1, 1986.
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geon on the anatomy of the perforator and the fusion among perforator flaps: What is a true perfo-
rator flap? Plast. Reconstr. Surg. 107: 874, 2001.
source vessel according to the angiosome prin- 8. Taylor, G. I., and Palmer, J. H. The vascular territories
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Self-Assessment Examination follows on
the next page.Self-Assessment Examination The “Gent” Consensus on Perforator Flap Terminology: Preliminary Definitions by Phillip N. Blondeel, M.D., Ph.D., Koen H. I. Van Landuyt, M.D., Stan J. M. Monstrey, M.D., Ph.D., Moustapha Hamdi, M.D., Guido E. Matton, M.D., Robert J. Allen, M.D., Charles Dupin, M.D., Axel-Mario Feller, M.D., Ph.D., Isao Koshima, M.D., Naci Kostakoglu, M.D., and Fu-Chan Wei, M.D. 1. A “SEPTAL” PERFORATOR IS A BLOOD VESSEL THAT TRAVERSES WHAT ANATOMIC STRUCTURE(S) TO SUPPLY THE OVERLYING SKIN OR SUBCUTANEOUS TISSUE? A) Intermuscular septum, muscle, and deep fascia B) Intermuscular septum and deep fascia C) Deep fascia only D) Superficial fascia only E) Intermuscular septum only 2. PERFORATORS THAT PIERCE THE DEEP FASCIA WITHOUT TRAVERSING ANY OTHER STRUCTURAL TISSUE ARE CALLED: A) Interstitial perforators B) Fascial perforators C) Direct perforators D) Axial perforators E) Indirect perforators 3. A FLAP THAT IS VASCULARIZED BY A MUSCLE PERFORATOR IS CALLED A: A) Perforator flap B) Muscle perforator flap C) Myocutaneous perforator flap D) Fasciocutaneous perforator flap E) Septal perforator flap 4. A PERFORATOR FLAP SHOULD BE NAMED AFTER WHICH OF THE FOLLOWING: A) Its anatomical region B) The underlying muscle C) The nutrient artery or vessels D) The recipient tissue E) The person who described it 5. A LOWER ABDOMINAL PERFORATOR FLAP BASED ON THE DEEP INFERIOR EPIGASTRIC VESSELS IS CALLED: A) Deep inferior epigastric perforator (DIEP) flap B) PUP flap C) TRAP flap D) Lumbar artery perforator (LAP) flap E) Transverse rectus abdominis musculocutaneous (TRAM) flap To complete the examination for CME credit, turn to page 1516 for instructions and the response form.
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