European Journal of Plastic Surgery

, Volume 41, Issue 3, pp 345–350 | Cite as

Expanded version pedicled free-style perforator flaps in clinical practice: a need for a more comprehensive classification system

  • Ruben Y. Kannan
  • J. Hardwicke
Original Paper



The evolution of the angiosome concept into the perforasome theory as we increasingly move towards the distal end of the microvascular tree for reconstructive options has allowed us to design ad hoc perforator flaps.


In a retrospective sample of more than 60 pedicled perforator flaps over a 36-month period, a variety of defects in all regions of the body were reconstructed. Pre-operative planning was based on either Doppler vascular studies or CT angiography.


The overall complete flap survival rate was 89%, with a tip necrosis rate of 8.1% and a partial flap necrosis rate of 3.3%. The risk factors identified were smoking, nicotine patches, vasopressor use and pro-thrombotic states.


It is feasible to perform the many variations of perforator flaps provided; the microsurgical anatomy of the area is well defined, aided by imaging studies as necessary. Risk stratification also needs to be taken into account when planning these flaps. Based on our results and observations, an alternative pedicled perforator flap classification is put forward.

Level of Evidence: Level IV, therapeutic study.


Classification of perforator flaps Free-styled flaps Ad hoc flaps 


Compliance with ethical standards



Conflict of interest

Ruben Yap Kannan, J. Hardwicke declare that they have no conflict of interest.

Ethical approval

For this kind of retrospective study formal consent from a local ethics committee is not required.

Informed consent

Patient provided written consent before their inclusion in this study.


  1. 1.
    Kannan RY, Mathur BS (2013) Perforator flaps of the facial artery angiosome. J Plast Reconst Aesthet Surg 66(4):483–488CrossRefGoogle Scholar
  2. 2.
    Saint-Cyr M, Wong C, Schavarien M, Mojallal A, Rohrich RJ (2009) The perforasome theory: vascular anatomy and clinical applications. Plast Reconstr Surg 124:1529–1544CrossRefPubMedGoogle Scholar
  3. 3.
    McGregor IA, Morgan G (1973) Axial and random pattern flaps. Br J Plast Surg 26:202–213CrossRefPubMedGoogle Scholar
  4. 4.
    Milton SH (1969) Pedicled skin flaps: the fallacy of the length: width ratio. Br J Plast Surg 56:381Google Scholar
  5. 5.
    Asko-Selvajaara S (1983) Free-style free flaps. Paper presented at: Seventh congress of the international congress of the international society of reconstructive microsurgery, June 19–30, New York, NYGoogle Scholar
  6. 6.
    Wei FC, Mardini S (2004) Free-style free flaps. Plast Reconstr Surg 114:910–916CrossRefPubMedGoogle Scholar
  7. 7.
    Wallace CG, Kao HK, Jeng SF, Wei FC (2009) Free-style flap: a further step forward for perforator flap surgery. Plast Reconstr Surg 124(6 Suppl):e419–e426CrossRefPubMedGoogle Scholar
  8. 8.
    Lecours C, Saint-Cyr M, Wong C, Bernier C, Mailhot E, Tardif M, Choilet A (2010) Freestyle pedicle perforator flaps: clinical results and vascular anatomy. Plast Reconstr Surg 126(5):1589–1603CrossRefPubMedGoogle Scholar
  9. 9.
    Erdmann MW, Court-Brown CM, Quaba AA (1997) A five year review of islanded distally based fasciocutaneous flaps on the lower limb. Br J Plast Surg 50(6):421–427CrossRefPubMedGoogle Scholar
  10. 10.
    Waterstone SW, Quaba O, Quaba AA (2008) The ad hoc perforator flap for contracture release. J Plast Reconstr Aesthet Surg 61(1):55–60CrossRefGoogle Scholar
  11. 11.
    Saint-Cyr M, Schaverien M, Arbique G et al (2008) Three- and four-dimensional computed tomographic angiography and venography for the investigation of the vascular anatomy and perfusion of perforator flaps. Plast Reconst Surg 121:772–780CrossRefPubMedGoogle Scholar
  12. 12.
    Mardini S, Tsai FC, Wei FC (2003) The thigh as a model for free-style free flaps. Clin Plast Surg 30:473–480CrossRefPubMedGoogle Scholar
  13. 13.
    Schaverien M, Saint-Cyr M, Arbique G et al (2008) Arterial and venous anatomies of the deep inferior epigastric perforator and superficial inferior epigastric artery flaps. Plast Reconstr Surg 121:1909–1919CrossRefPubMedGoogle Scholar
  14. 14.
    Mehrotra S (2010) Perforator plus flaps: optimizing results while preserving function and esthesis. Indian J Plast Surg 43(2):141–148CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Kannan RY (2014) The reconstructive pyramid: redefining our yardsticks. Plast Reconstr Surg 133(5):733e–743ePubMedGoogle Scholar
  16. 16.
    Bravo FG, Schwarze HP (2009) Free-style local perforator flaps: concept and classification system. J Plast Reconstr Aesthet Surg 62:602–609CrossRefPubMedGoogle Scholar
  17. 17.
    Javaid RH, Chamadi E, Hardwicke JT, Kannan RY (2015) Elbow defect coverage using a capillary perforator flap rising from the vasa nervorum of the ulnar nerve. J Plast Reconstr Aesthet Surg 68(4):592–594CrossRefPubMedGoogle Scholar
  18. 18.
    Terzis JK, Anesti K (2013) Novel use of platysma for oral sphincter substitution or countering excessive pull of a free muscle. J Plast Reconstr Aesthet Surg 66(8):1045–1057CrossRefPubMedGoogle Scholar
  19. 19.
    Kannan RY, Mathur BS, Tzafetta K (2013) Single flap reconstruction of complex orofacial defects with the chimeric free fibular flap and its variants. J Plast Reconstr Aesthet Surg 66(3):358–363CrossRefPubMedGoogle Scholar
  20. 20.
    Innocenti M, Cardin-Langlois E, Menichini G, Baldirighi C (2014) Gastrocnemius-propeller extended myocutaneous flap: a new chimeric flap for soft tissue reconstruction of the knee. J Plast Reconstr Aesthet Surg 67(2):244–251CrossRefPubMedGoogle Scholar
  21. 21.
    Wong C, Saint-Cyr M, Rasko Y, Mojallal A, Bailey S, Myers S, Rohrich RJ (2009) Three- and four-dimensional arterial and venous perforasomes of the internal mammary artery perforator flap. Plast Reconstr Surg 124(6):1759–1769CrossRefPubMedGoogle Scholar
  22. 22.
    Kannan RY (2016) The internal mammary artery perforator flap and its subtypes in the reconstruction of median sternotomy wounds. J Thorac Cardiovasc Surg 152(1):264–268CrossRefPubMedGoogle Scholar
  23. 23.
    Gunnarsson GL, Jackson IT, Westvik TS, Thomsen JB (2015) The freestyle pedicle perforator flap: a new favourite for the reconstruction of moderate-sized defects of the torso and extremities. Eur J Plast Surg 38:31–36CrossRefPubMedGoogle Scholar
  24. 24.
    Gunnarsson GL, Jackson IT, Thomsen JB (2014) Freestyle facial perforator flaps—a safe reconstructive option for moderate-sized facial defects. Eur J Plast Surg 37:315–318CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany 2017

Authors and Affiliations

  1. 1.Department of Plastic SurgeryQueen Victoria HospitalEast GrinsteadUK
  2. 2.Department of Plastic SurgeryUniversity Hospitals Coventry and WarwickshireCoventryUK

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