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Background: Perforator flap nomenclature continues to evolve, with many classification schemes reported. Each of them focuses on the fascial penetration pattern of perforators, which has no impact on flap perfusion. With the advent of advanced imaging technologies, the subcutaneous course of perforators can be highlighted for the first time, offering new insight into flap design., Methods: The current study presents the authors' technique for imaging local perforator flaps with computed tomographic angiography, utilizing a standard technique for perforator imaging with computed tomographic angiogram, regardless of whether the flap is a local or free flap, and regardless of body region. This technique has been used in more than 1000 image-guided perforator flaps, with the current study highlighting three such cases in different body regions., Results: With the use of preoperative imaging, flap design can be based on the subcutaneous ramification of individual perforators. Several ramification patterns are presented and potential improvements to nomenclature schemes suggested., Conclusion: : With the use of preoperative imaging, "image-guided" perforator flaps that are truly axial-pattern in terms of their arterial supply can be designed., Clinical Question/level of Evidence: Diagnostic: V.

Background: Effective postoperative monitoring of the vascular pedicle to a free flap can potentiate rapid return to the operating room in the setting of compromise, allowing for the potential to salvage the flap. The only ubiquitous method for postoperative monitoring of free flaps is clinical bedside monitoring, but although the use of clinical monitoring may be inferred in large reported series of free flaps, there has been little discussed in the literature of specific clinical outcome measures., Methods: The authors present their experience with 1140 consecutive cases of free tissue transfer and the use of clinical monitoring as a sole method of monitoring, and subgroup analysis of different recipient sites., Results: There were 94 take-backs, four of which had no pedicle compromise (false-positives) and there were four false-negatives. The overall flap salvage rate was 62.8 percent and the false-positive rate was 0.4 percent. Subgroup analyses demonstrated statistically significant differences between recipient sites for the false-positive rates: fewer false-positives with breast reconstruction cases (p < 0.05) and significantly more false-positives in the extremity group (p < 0.05). There was an improved flap salvage rate in cases of venous compromise compared with arterial compromise (69 percent versus 51 percent, p = 0.015)., Conclusions: This largest reported series to date provides an outcome-based analysis of postoperative monitoring for free flaps, providing a benchmark standard against which adjunctive monitoring techniques can be compared. Future studies need to be assessed in the context of individual recipient sites, with significant differences in monitoring outcomes between sites.

Background: The anterolateral thigh flap is a popular reconstructive option, with a major advantage being its low donor-site morbidity. However, donor-site morbidity following anterolateral thigh flap harvest does occur, with postulated causes including damage to muscle, deep fascia, and the motor nerves to the vastus lateralis. No anatomical studies have yet described the relationship of these motor nerves to the vascular pedicle of the anterolateral thigh flap., Methods: Thirty-six human cadaveric thighs underwent dissection studies, and the innervation of the vastus lateralis and the relationship of the nerves to the descending branch of the lateral circumflex femoral artery were documented. Variations were recorded., Results: The nerve to the vastus lateralis branches extensively before entering the muscle, with four to seven nerves identified per thigh. Two particular variations of the nerve anatomy are uniquely susceptible to damage: where the motor nerve passes through the vascular pedicle itself or passes between perforators supplying the flap. At least one unfavorable variation was present in 28 percent of cases., Conclusions: The nerves innervating the vastus lateralis are intimately related to the vascular pedicle of the anterolateral thigh flap. These nerves may be damaged during flap harvest and may contribute to donor-site morbidity after anterolateral thigh flap surgery.

Background: The lumbar region has been scarcely explored as a donor site for free tissue transfer or as a free flap recipient site. The lumbar integument provides a versatile prospective flap site, with a potentially well-concealed scar. Similarly, defects of this region can require recipient vessels that may be difficult to identify. Although lumbar artery perforators have been described, the reliability of perforators in this region remains questionable., Methods: An anatomical study was undertaken combining both cadaveric and in vivo analysis of the lumbar vessels. The cadaveric component comprised both dissection and angiographic studies in fresh and embalmed cadavers (36 lumbar regions in 18 cadavers), and the clinical study comprised a computed tomographic angiographic study (44 sides in 22 patients) and an operative case report., Results: Perforators were shown to arise from all eight lumbar arteries to enter the lumbar integument, with their size, location, and course described. Lower lumbar perforators were more often septocutaneous and of larger caliber. A case in which the fourth lumbar artery and concomitant vein were used as free flap recipient vessels is described, the first such reported case in the literature., Conclusions: Improving the incidence of identifying lumbar perforators of large caliber and with a septocutaneous course can be achieved by selecting lower lumbar vessels, or with the use of preoperative computed tomographic angiography. Computed tomographic angiography can successfully identify the location, size, and course of lumbar artery perforators and can aid flap design. Lumbar artery perforators are highly useful for both donor and recipient vessels in free flap surgery.

Background: The deep inferior epigastric artery perforator (DIEP) flap aims to reduce donor-site morbidity by minimizing rectus muscle damage; however, damage to motor nerves during perforator dissection may denervate rectus muscle. Although cadaveric research has demonstrated that individual nerves do not arise from single spinal cord segments and are not distributed segmentally, the functional distribution of individual nerves remains unknown. Using intraoperative nerve stimulation, the current study describes the motor distribution of individual nerves supplying the rectus abdominis, providing a guide to nerve dissection during DIEP flap harvest., Methods: Twenty rectus abdominis muscles in 17 patients undergoing reconstructive surgery involving rectus abdominis (DIEP, transverse rectus abdominis musculocutaneous, or vertical rectus abdominis musculocutaneous flaps) underwent intraoperative stimulation of nerves innervating the infraumbilical segment of the rectus. Nerve course and extent of rectus muscle contraction were recorded., Results: In each case, three to seven nerves entered the infraumbilical segment of the rectus abdominis. Small nerves (type 1) innervated small longitudinal strips of rectus muscle, rather than transverse strips as previously described. There was significant overlap between adjacent type 1 nerves. In 18 of 20 cases, a single large nerve (type 2) at the level of the arcuate line supplied the entire width and length of rectus muscle., Conclusions: Nerves innervating the rectus abdominis are at risk during DIEP flap harvest. Small, type 1 nerves have overlapping innervation from adjacent nerves and may be sacrificed without functional detriment. However, large type 2 nerves at the level of the arcuate line innervate the entire width of rectus muscle without adjacent overlap and may contribute to donor-site morbidity if sacrificed.

Background: The deep inferior epigastric artery perforator flap is increasingly used for autologous breast reconstruction, with low donor-site morbidity cited as a major advantage of this operation. Preoperative imaging of the donor-site vasculature is frequently used as a further means of improving operative outcome. Computed tomographic angiography has been increasingly described as a preferred imaging modality; however, its formal evaluation has not been described in a clinical setting., Methods: A prospective, single-blind, cohort study was undertaken on 60 consecutive patients for whom deep inferior epigastric artery perforator flap surgery had been planned. Patients who did not undergo the procedure during the study period were excluded, with 42 patients ultimately included in the study. All computed tomographic angiography scans were obtained at a single institution. Perforators were mapped both on angiography and intraoperatively using a grid of 4-mm squares centered on the umbilicus. Only perforators larger than 1 mm were included in the study. All imaging findings were recorded by a single operator, and all intraoperative findings were recorded by the operating surgeon., Results: Computed tomographic angiography identified 280 major perforators in 42 patients. It was highly accurate, demonstrating 279 perforators recorded accurately, with one false-positive and one false-negative. Its sensitivity for mapping perforators was thus 99.6 percent, with a positive predictive value of 99.6 percent., Conclusions: Computed tomographic angiography is highly accurate in identifying and mapping the perforators of the deep inferior epigastric artery. Its accuracy is superior to that of the previous modalities used in this role and suggests the usefulness of this technique before deep inferior epigastric artery perforator flap surgery for breast reconstruction.