Perforator flap breast reconstruction

A perforator flap consists of skin and fat harvested from a donor site nourished by myocutaneous perforators while sparing the donor muscle for function and strength. This flap type has revolutionized microvascular free tissue transfer and the technique has been successfully applied to well-established donor sites for autologous breast reconstruction namely the lower abdomen, upper and lower buttock, the upper back, and the lateral thigh. Although these flaps are technically more demanding than conventional myocutaneous free flaps, their minimal impact on the donor site muscle function significantly reduces local morbidity, postoperative pain and hospital stay. Perforator flap breast reconstruction has an increased operating time because of the meticulous dissection of the perforators, the possible anatomical variation in their location and, once these are located, the difficulty in selecting suitable perforator(s) to base the flap on. Although it has been suggested that perforator flaps may have a higher incidence of fat necrosis and partial flap loss than conventional free myocutaneous flaps, this has not been borne out by clinical results. There is, however, a learning curve and careful patient selection is important. The role of perforator flap technique in breast reconstruction is evolving. While its indications are similar to those of free TRAM and gluteal flaps, it is clearly a better alternative to these. The choice of perforator flap depends on where the patient has the most abundant donor tissue and the surgeon's experience. These flaps may in the future become the standard of care in free flap breast reconstruction.