Skip to main content
NCBI home page
Plastic and Reconstructive Surgery Global Open logoLink to Plastic and Reconstructive Surgery Global Open
. 2026 Feb 26;14(2):e7453. doi: 10.1097/GOX.0000000000007453

Why Is the Perforator Flap Opaque? Consideration From the Perspective of Tissue Composition Based on a New Skin Flap Classification

Hideo Nakajima *, Yoshiaki Sakamoto †,✉, Nobuaki Imanishi ‡, Toshiharu Minabe §, Hak Chang , Satoshi Fukuzumi ∥, Kazuo Kishi †
PMCID: PMC12944133  PMID: 41767579

Summary:

Despite the clinical importance of perforator flaps in the field of flap surgery, ambiguity still surrounds the terminology and definition. This study aimed to resolve this ambiguity through a logical analysis of perforator flaps. In this study, we present a new classification system for skin flaps with various tissue compositions based on the vascular plexus we have previously clarified and examine whether perforator flaps constitute an independent category from the perspective of tissue composition. Through anatomical and physiological analyses, we identified 7 distinct skin flap types: full-thickness, split-thickness, thin (including the super-thin and pure skin subtypes), dermis, adipofascial, protective adipofascial, and lubricant adipofascial flaps. All perforator flaps except for the pure skin perforator flap do not exhibit tissue compositions exclusive to their type and, therefore, cannot be considered a distinct category based solely on tissue structure. We discussed the need for rethinking the classification not only in terms of the surgical technique, but also based on objective anatomical features such as tissue composition and vascular connectivity. By focusing on these criteria, this new classification system further clarifies and homogenizes the terminology and conceptual framework of skin flap surgery.

Takeaways.

Question: What is the reason for a perforator flap being termed a perforator flap? Focusing on tissue composition, specific elements of the perforator flap were examined.

Findings: The total number of possible skin flap combinations according to the vascular plexus was 10. The perforator flaps reported so far have been from one of these 10 forms, and no specific elements were found.

Meaning: The term perforator flap is already widely used, and its clinical usefulness is unquestionable. However, from a “flapology” point of view, it is difficult to consider the perforator flap as an independent category in terms of tissue composition.

INTRODUCTION

The perforator flap was developed approximately one-third of a century ago, and its use expanded rapidly; however, the term “perforator flap” caused confusion. Therefore, in the early part of this century, pioneers reached a consensus on the terminology and definition of the perforator flap at the Gent1 and Taipei meetings.2 However, the reason for using the term “perforator flap” remained unclear, because there is still no answer to the question: “What is the reason for a perforator flap being a perforator flap?”

The perforator flap was developed based on the assumption that the main vessel of the musculocutaneous (MC) flap may pass through the muscle and nourish the skin tissue above the muscle.3,4 In 1986, axialized fasciocutaneous flaps with vascular pedicles were developed in various regions of the body, identifying 6 distinct types of deep fascia-piercing vessels.5 Among the 6 types, a vessel that branched off into the muscle and perforated the deep fascia was termed the perforating cutaneous branch of the muscular vessels. Previous research demonstrated the cervicodorsal flap and lateral femoral flap as clinical cases (Fig. 1).5,6 These axialized fasciocutaneous flaps had a skin paddle of the same size as the MC flap (Fig. 2). Three years later, Koshima and Soeda7 described a deep inferior epigastric perforator flap, in which the perforator corresponded to the perforating cutaneous branch of the muscular vessel, similar to other studies.8,9

Fig. 1.

Fig. 1.

Open in a new tab

Cervicodorsal flap. A, Epifascial vascular network of a cervicodorsal flap. B, Rotation arc of the island cervicodorsal flap. S, cutaneous branch of the superficial cervical artery; PIC, posterior intercostal artery. Reprinted from Nakajima and Fujino.6.

Fig. 2.

Fig. 2.

Open in a new tab

Island fasciocutaneous flaps using various cutaneous vessels in the dorsal trunk. Reprinted from Nakajima and Fujino.6 A, Cervicodorsal flap. B, Scapular flap. C, Parascapular flap. D, Infrascapular flap. E, Subcostal flap. F, Lumbogluteal flap.

Therefore, the question remains whether axial island fasciocutaneous flaps can be considered perforator flaps. Herein, we examine whether perforator flaps constitute a distinct category among skin flaps. For the future development of skin flaps, although the search for clinically viable flaps with finer vascular pedicles is important, we believe that a comprehensive understanding and anatomical classification of flaps is also crucial for advancing theoretical flap development. According to the definition of taxonomy, for a category to be recognized as a new category, it must possess common characteristics in the elements that determine its nature.

Hallock10 proposed a group of factors to define and classify skin flaps, known as the 6C. The mandatory requirements are the constituents (tissue composition) and circulation (blood perfusion system), which are closely related to each other.10 We believe that blood circulation in the skin flap consists of an intrinsic perfusion system (IPS) within the skin flap tissue and an extrinsic perfusion system (EPS), which provides blood circulation to the IPS (Fig. 3). The IPS is determined by the vertical pile of the vascular plexus in each layer within the integument, and the tissue composition of the skin flap is determined spontaneously. The EPS is determined by the type of perforator and the configuration of the vascular pedicle. If any of the 3 elements (tissue composition, type of perforator, and configuration of the vascular pedicle) contains a unique element common to the perforator flap, then the perforator flap can be classified into a new category of skin flaps. In this study, we examined whether perforator flaps have their own category based on the tissue compositions of the skin flaps.

Fig. 3.

Fig. 3.

Open in a new tab

The blood circulation of the skin flap. The IPS refers to the circulation within the tissue of the skin flap. The EPS provides blood circulation to the IPS.

CLASSIFICATION OF SKIN FLAPS BASED ON THE TISSUE COMPOSITION AND PLEXUS

In this study, a skin flap is defined as a flap composed entirely or partially of the integument. Therefore, the deep fascia and periosteum were excluded from this classification.

In our previous study,11 the vascular plexus between the epidermis and deep fascia was classified as the dermal plexus, subdermal plexus, and fasciocutaneous plexus. The fasciocutaneous plexus is subclassified into the protective adipofascial system (PAFS) plexus and the lubricant adipofascial system (LAFS) plexus according to the 2-layer structure of the subcutaneous tissue. We refer to the superficial layer of the subcutaneous tissue as the PAFS, which exhibits a cushioning structure, and the deep layer as the LAFS, characterized by a lubricating structure.12 However, in areas where the subcutaneous tissue consists of a single layer of PAFS, such as the buttocks, posterior thigh, palms, and soles of the feet, only the PAFS plexus is present.

The dermal plexus includes the subpapillary plexus and the plexus formed by the dermal twigs. The subdermal plexus is anastomosed with the dermal plexus and the PAFS plexus, running up and down like a wave between the shallow PAFS, just below the dermis and the deep dermis. Therefore, the deep dermis and shallow PAFS layers were considered in the tissue composition for integument classification (Figs. 4, 5).

Fig. 4.

Fig. 4.

Open in a new tab

Schematic view of the arborization of the perforator and vascular plexuses in the skin with PAFS and LAFS. 1, The main trunk of a perforator; 2, adipocutaneous branch; 3, adipofascial branch; 4, linear twig; 5, dermal twig; 6, surrounding twig; 7, MC twig; 8, linking twig; 9, descending twig.

Fig. 5.

Fig. 5.

Open in a new tab

Enlarged view of the dotted-line area in Figure 4. The subdermal plexus straddles the border between the dermis and the PAFS and is named the deep dermis and the shallow PAFS layers, respectively.

Considering possible skin flaps based on combinations of the 4 vascular plexuses inherent in the integument, their tissue composition is spontaneously determined (Table 1). If a perforator flap dominates a category of skin flaps, that perforator flap can be recognized as a new, independent skin flap. The details of our classification of skin flaps in the 2-layer subcutaneous tissue region are as follows.

Table 1.

Classification of Skin Flaps Based on the Plexus and Tissue Compositions

Plexus Tissue Composition* Name of the Skin Flap†
Dermal, subdermal, PAFS, LAFS Epidermis, dermis, LAFS, PAFS FTSF
Dermal, subdermal, PAFS Epidermis, dermis, PAFS STSF
Dermal, subdermal Epidermis, dermis, the shallow layer of PAFS Thin thickness skin flap (thin flap)
Dermal Epidermis, dermis without deep dermis Dermis flap
Subdermal, PAFS, LAFS Deep part of dermis, PAFS, LAFS Denuded FTSF
Subdermal, PAFS Deep part of dermis, PAFS Denuded STSF
Subdermal Deep dermal of dermis, shallow layer of PAFS Denuded thin flap
PAFS, LAFS LAFS with whole/ partial PAFS Adipofascial flap
PAFS Whole/partial PAFS Protective adipofascial flap
LAFS Whole/partial LAFS Lubricant adipofascial flap
Open in a new tab
*

Tissue composition refers to the tissue that receives blood circulation mainly from the plexus and does not necessarily indicate the location of the plexus.

†

The name of the skin flap is logically derived from the composition of the plexus. The denuded skin flap here refers to the epidermis and the dermal reticular layer, from which parts of the dermis have been removed.

Full-thickness Skin Flap

A full-thickness skin flap (FTSF) is a skin flap of the entire integument, in which all 4 plexuses are included as IPS (Figs. 6, 7). Because we consider the suprafascial plexus on the deep fascia to be nothing more than the LAFS plexus, the fasciocutaneous flap and FTSF are the same as in the IPS. However, as the deep fascia is not included in the integument, the fasciocutaneous flap is not included in a skin flap. Additionally, considering donor site morbidity, it is recommended to preserve the deep fascia.13 The terminal part of the EPS is the perforator to the deep fascia. In clinical practice, a skin flap is commonly raised to this thickness without much awareness, as seen with flaps such as the deltopectoral flap,14 scapular flaps,15 parascapular flap,16,17 or deep inferior epigastric perforator flap,7 which are categorized as FTSFs.

Fig. 6.

Fig. 6.

Open in a new tab

Tissue composition of the FTSF (1), STSF (2), thin flap (3), dermis flap (4), adipofascial flap (5), PAFS flap (6), and LAFS flap (7).

Fig. 7.

Fig. 7.

Open in a new tab

Full-thickness skin flap.

Split-thickness Skin Flap

A split-thickness skin flap (STSF) consists of the epidermis, dermis, and all or part of the PAFS layers. The IPS includes the dermal plexus, subdermal plexus, and PAFS plexus up to the point of hemodynamic equilibrium, where retrograde blood circulation is established by linking twigs (Figs. 6, 8). The terminal part of the EPS is the adipocutaneous branch of the perforator and the adipofascial branch of the PAFS layer.

Fig. 8.

Fig. 8.

Open in a new tab

Split-thickness skin flap.

The STSF has been traditionally described as a conventional cutaneous or subcutaneous (adipofascial) pedicled skin flap without specific reference to the vessels supplying the skin flap. Once the details of the arborization of the perforator are anatomically well known,11,18–20 it is possible to isolate the adipocutaneous branch of the perforator as a vascular pedicle and adjust the subcutaneous fat layer to achieve any thickness.21

Horizontal circulation in the PAFS plexus is poor and primarily depends on vertical circulation from the subdermal and LAFS plexuses. Comparing blood circulation between the shallow and deep PAFS layers of the STSF, the shallow PAFS layer was dependent on the antegrade blood flow of descending twigs and linking twigs. However, blood circulation in the deep PAFS becomes retrograde blood flow in the linking twigs. In other words, the angiosome “zone”22 is different between the shallow PAFS and deep PAFS, and the hemodynamics of blood circulation in the deep PAFS are unstable in an STSF. This is why deep PAFS layer necrosis precedes distal necrosis of the skin flap.

Thin Skin Flap

The thin skin flap consists of the epidermis, dermis, and the shallow PAFS. The IPS is the dermal and subdermal plexus, and the terminal part of the EPS is the adipocutaneous branch of the perforator (Figs. 6, 9). The shallow PAFS can be thinned to the range of influence of hemodynamics by descending twigs.

Fig. 9.

Fig. 9.

Open in a new tab

Thin skin flap.

The concept of a pedicled thin skin flap, in which the subcutaneous fat is intentionally thinned to focus on the strong vascularity of the subdermal plexus, was described by Thomas23 as a thin flap. In 1988, Nakajima24 was the first to convert such a pedicled thin flap into an island or free thin flap and reported a thin extended latissimus dorsi MC flap (Fig. 10). Thin forearm flaps were continuously developed, and thin skin flaps were subsequently reported.25–27 When the adipocutaneous branch of the perforator is confirmed just below or above the superficial fascia layer, and the subcutaneous fat layer is isolated by debulking to the shallow PAFS layer, then the thin flaps can be raised by all types of perforators.

Fig. 10.

Fig. 10.

Open in a new tab

Thin extended latissimus dorsi MC flap. A, The actual flap that was elevated. B, Cross-sectional schema along the green line in A. C, Cross-sectional schema along the blue line in A.

Subtype I: Super-thin Flap

Kimura et al28 reported a super-thin flap with just a little bit of adipose tissue in a worm-eating procedure performed under a microscope to preserve the subdermal plexus just below the dermis (Fig. 11).

Fig. 11.

Fig. 11.

Open in a new tab

Super-thin flap. Note that adipose tissue is depicted in green to clarify its location.

Subtype II: Pure Skin Flap

The concept of a skin flap with only the epidermis and dermis was first described by Cronin29 in 1951 as a cross-finger flap. However, the flap was small in size, and it was unclear whether it survived as a skin flap or as a skin graft. Subsequently, there have been reports of small skin flaps containing only the epidermis and dermis in umbilical reconstruction.30 In 2011, Narushima et al31 reported the first free perforator flap consisting only of the epidermis and dermis using the superficial circumflex iliac artery, as the pure skin perforator flap. Cronin29 referred to a skin flap consisting of only of the epidermis and dermis as an FTSF according to the classification of skin grafts; however, we consider it practical and valuable to unify the terminology as a pure skin flap to avoid confusion. The perfusion system of the pure skin flap was defined as IPS for the subdermal plexus within the deep dermis and dermal plexus, and the terminal part of the EPS was a pure skin perforator, which was an adipocutaneous branch that perforated just below the dermis (Figs. 6, 12). In our understanding, the difference between a pure skin flap and a super-thin flap may be the number of fat lobules left behind in the shallow PAFS layer.

Fig. 12.

Fig. 12.

Open in a new tab

Pure skin flap. Note that adipose tissue is depicted in green to clarify its location.

Dermis Flap

The dermis flap is a skin flap in which the dermal plexus is the IPS, and the dermal twig is the terminal part of the EPS (Fig. 13). In 2018, Narushima et al32 described the concept of an STSF. In 2019, Yoshimatsu et al33 reported a clinical case of a dermis flap; however, the authors did not isolate the perforator (ie, dermal twig) from the dermal plexus, and the difference in the thickness of the dermis flap and pure skin flap was not clear. In our theoretical classification, the dermis flap is possible; therefore, it is defined as a distinct category but does not yet exist in clinical practice.

Fig. 13.

Fig. 13.

Open in a new tab

Dermis flap.

Adipofascial Flap

The adipofascial flap is a skin flap consisting of the LAFS and all or part of the PAFS layers, with the LAFS plexus and PAFS plexus as the IPS and the perforator to the deep fascia as the terminal part of the EPS (Figs. 6, 14). Regarding the IPS, the adipofascial branches of the PAFS and LAFS plexus are the main vessels, and the PAFS receives supplemental blood supply through the linking twig from the linear twigs. In 1986, Nakajima et al5 first reported a clinical case of an adipofascial flap and their skin flap classification.

Fig. 14.

Fig. 14.

Open in a new tab

Adipofascial flap.

Protective Adipofascial Flap

The IPS is the PAFS plexus, and the terminus of the EPS is the adipocutaneous or adipofascial branch to the PAFS (Figs. 6, 15). Because the PAFS plexus has a weak horizontal vascular network, a narrow PAFS tissue flap in the axial territory of the adipofascial branches of the PAFS layer is possible. Thus, its versatility is limited. However, adipofascial flaps with large territories, such as the Scarpa adipofascial flap and the superficial temporal fascial flap, have been reported.34,35

Fig. 15.

Fig. 15.

Open in a new tab

Protective adipofascial flap.

Lubricant Adipofascial Flap

The IPS is the LAFS plexus, and the terminal part of the EPS is the perforator to the deep fascia (Figs. 6, 16). The adipofascial branches of the LAFS plexus are in direct anastomosis with the adjacent next territory,20,36 and the vascular network of the linear twig has dense horizontal continuity,11 enabling the elevation of a large LAFS flap. This flap is characterized by a sliding structure that allows the tissue to slide easily, making it suitable for covering exposed tendons without causing skin defects at the donor site.

Fig. 16.

Fig. 16.

Open in a new tab

Lubricant adipofascial flap.

Clinical examples include the dorsal thoracic fascia flap,37 serratus fascia flap,38 and anterolateral thigh adipofascial flap.39 The subgaleal areolar tissue of the pericranial flap corresponds to the LAFS35; however, the pericranium is included in the flap as a supporting tissue. Therefore, pericranial flaps are excluded from this category.

DISCUSSION

Flap surgery originated approximately in the year 600 BC and has since evolved through intuitive methods rooted in experience and serendipity. Approximately 50 years ago, particularly with the introduction of the concept of random and axial pattern flaps, the theory of the hemodynamic mechanism of skin flaps made remarkable progress because of the innovative ideas of Fujino,40 Milton,41 McGregor and Morgan,42 Daniel and Kerrigan,43 Taylor and Palmer,44 Hallock,45 Blondeel et al,1 Kim and Kim,46 and Saint-Cyr et al.20

However, questions remain regarding the novelty of perforator flaps as a new concept in skin flaps. This fundamental question—namely, “What exactly is a perforator flap?”—should be examined based on the science of “flapology”, which is grounded in the anatomy of the tissues and vessels that constitute the flap and the hemodynamics of the flap.

A similar skin flap classification has already been reported.47,48 However, these previous classifications are based on the thickness of the skin flap layers elevated for clinical use, with the vascular plexus as the blood supply being considered an afterthought. Therefore, the course of these vessels beneath the skin differs from the findings we have obtained through anatomical research. In contrast, a new classification of skin flaps based on tissue compositions derived from vascular plexuses is proposed. This classification encompasses the tissue composition of all clinically feasible skin flaps. Furthermore, it delineates the relationship between the plexus (IPS) that should be preserved during skin flap elevation and the perforator (EPS) that serves as the vascular pedicle supplying it. This is considered useful when selecting skin flaps in clinical practice.

Based on our classification, out of tissue composition, type of perforator, and the configuration of the vascular pedicle, we focused on tissue composition and examined whether the perforator flaps identified in PubMed had any specific characteristics that would allow them to form a distinct category of skin flaps. However, in the tissue compositions of skin flaps, there were no novel or unique characteristics regarding the perforator flap. Provided that the type of skin flap is limited to free skin flaps, only the pure skin perforator flap would fall under the category of the pure skin flap. Thus, it is appropriate to use the term “perforator flap” only for the pure skin perforator flap. However, because many flaps with various tissue compositions have been developed and reported as perforator flaps, many plastic surgeons would not agree with assigning the term “perforator flap” only to the pure skin perforator flap. In the next study, we would like to consider the perforator flap from the standpoint of the type of perforator and the configuration of the vascular pedicle.

CONCLUSIONS

The term “perforator flap” is commonly used, and its clinical significance is indisputable; however, a clear definition of this term is still lacking. For the progress of flap surgery without confusion, it is important to discuss flapology using a common language based on objectivity, systematization, reproducibility, critical thinking, and empiricism.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

Footnotes

Published online 26 February 2026.

Disclosure statements are at the end of this article, following the correspondence information.

REFERENCES

  • 1.Blondeel PN, Van Landuyt KH, Monstrey SJ, et al. The “Gent” consensus on perforator flap terminology: preliminary definitions. Plast Reconstr Surg. 2003;112:1378–1383; quiz 1383, 1516; discussion 1384. [DOI] [PubMed] [Google Scholar]
  • 2.Blondeel PN, Van Landuyt K, Hamdi M, et al. Perforator flap terminology: update 2002. Clin Plast Surg. 2003;30:343–346, v. [DOI] [PubMed] [Google Scholar]
  • 3.Maxwell GP. Iginio Tansini and the origin of the latissimus dorsi musculocutaneous flap. Plast Reconstr Surg. 1980;65:686–692. [DOI] [PubMed] [Google Scholar]
  • 4.McCraw JB, Dibbell DG. Experimental definition of independent myocutaneous vascular territories. Plast Reconstr Surg. 1977;60:212–220. [DOI] [PubMed] [Google Scholar]
  • 5.Nakajima H, Fujino T, Adachi S. A new concept of vascular supply to the skin and classification of skin flaps according to their vascularization. Ann Plast Surg. 1986;16:1–19. [DOI] [PubMed] [Google Scholar]
  • 6.Nakajima H, Fujino T. Island fasciocutaneous flaps of dorsal trunk and their application to myocutaneous flap. Keio J Med. 1984;33:59–82. [DOI] [PubMed] [Google Scholar]
  • 7.Koshima I, Soeda S. Inferior epigastric artery skin flaps without rectus abdominis muscle. Br J Plast Surg. 1989;42:645–648. [DOI] [PubMed] [Google Scholar]
  • 8.Wei FC, Jain V, Suominen S, et al. Confusion among perforator flaps: what is a true perforator flap? Plast Reconstr Surg. 2001;107:874–876. [DOI] [PubMed] [Google Scholar]
  • 9.Geddes CR, Morris SF, Neligan PC. Perforator flaps: evolution, classification, and applications. Ann Plast Surg. 2003;50:90–99. [DOI] [PubMed] [Google Scholar]
  • 10.Hallock GG. The complete classification of flaps. Microsurgery. 2004;24:157–161. [DOI] [PubMed] [Google Scholar]
  • 11.Sakamoto Y, Nakajima H, Imanishi N, et al. Arborization of musculocutaneous perforators in the skin and subcutaneous tissue. Plast Reconstr Surg Glob Open. 2025;13:e6683. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Nakajima H, Imanishi N, Minabe T, et al. Anatomical study of subcutaneous adipofascial tissue: a concept of the protective adipofascial system (PAFS) and lubricant adipofascial system (LAFS). Scand J Plast Reconstr Surg Hand Surg. 2004;38:261–266. [DOI] [PubMed] [Google Scholar]
  • 13.Saint-Cyr M, Schaverien M, Wong C, et al. The extended anterolateral thigh flap: anatomical basis and clinical experience. Plast Reconstr Surg. 2009;123:1245–1255. [DOI] [PubMed] [Google Scholar]
  • 14.Bakamjian VY. Total reconstruction of pharynx with medially based deltopectoral skin flap. N Y State J Med. 1968;68:2771–2778. [PubMed] [Google Scholar]
  • 15.dos Santos LF. The vascular anatomy and dissection of the free scapular flap. Plast Reconstr Surg. 1984;73:599–604. [DOI] [PubMed] [Google Scholar]
  • 16.Nassif TM, Vidal L, Bovet JL, et al. The parascapular flap: a new cutaneous microsurgical free flap. Plast Reconstr Surg. 1982;69:591–600. [DOI] [PubMed] [Google Scholar]
  • 17.Upton J, Albin RE, Mulliken JB, et al. The use of scapular and parascapular flaps for cheek reconstruction. Plast Reconstr Surg. 1992;90:959–971. [DOI] [PubMed] [Google Scholar]
  • 18.Kimura N, Saitoh M, Okamura T, et al. Concept and anatomical basis of microdissected tailoring method for free flap transfer. Plast Reconstr Surg. 2009;123:152–162. [DOI] [PubMed] [Google Scholar]
  • 19.Nakajima H, Minabe T, Imanishi N. Three-dimensional analysis and classification of arteries in the skin and subcutaneous adipofascial tissue by computer graphics imaging. Plast Reconstr Surg. 1998;102:748–760. [DOI] [PubMed] [Google Scholar]
  • 20.Saint-Cyr M, Wong C, Schaverien M, et al. The perforasome theory: vascular anatomy and clinical implications. Plast Reconstr Surg. 2009;124:1529–1544. [DOI] [PubMed] [Google Scholar]
  • 21.Imaizumi A, Kadota H. Perforator branch flaps. J Plast Reconstr Aesthet Surg. 2020;73:1255–1262. [DOI] [PubMed] [Google Scholar]
  • 22.Rozen WM, Ashton MW, Le Roux CM, et al. The perforator angiosome: a new concept in the design of deep inferior epigastric artery perforator flaps for breast reconstruction. Microsurgery. 2010;30:1–7. [DOI] [PubMed] [Google Scholar]
  • 23.Thomas CV. Thin flaps. Plast Reconstr Surg. 1980;65:747–752. [DOI] [PubMed] [Google Scholar]
  • 24.Nakajima H. Thin extended latissimus dorsi musculocutaneous flap. Presented at: The 9th Meeting of International Society of Reconstructive Microsurgery, April 17–22, 1988; Tokyo. [Google Scholar]
  • 25.Kimura N, Satoh K. Consideration of a thin flap as an entity and clinical applications of the thin anterolateral thigh flap. Plast Reconstr Surg. 1996;97:985–992. [DOI] [PubMed] [Google Scholar]
  • 26.Kim JT, Koo BS, Kim SK. The thin latissimus dorsi perforator-based free flap for resurfacing. Plast Reconstr Surg. 2001;107:374–382. [DOI] [PubMed] [Google Scholar]
  • 27.Kimura N. A microdissected thin tensor fasciae latae perforator flap. Plast Reconstr Surg. 2002;109:69–77; discussion 78–80. [DOI] [PubMed] [Google Scholar]
  • 28.Kimura N, Satoh K, Hosaka Y. Microdissected thin perforator flaps: 46 cases. Plast Reconstr Surg. 2003;112:1875–1885. [DOI] [PubMed] [Google Scholar]
  • 29.Cronin TD. The cross finger flap: a new method of repair. Am Surg. 1951;17:419–425. [PubMed] [Google Scholar]
  • 30.Watanabe K, Kiyokawa K, Yamauchi T, et al. New umbilicoplasty procedure for postoperative umbilical defect using a rabbit head-shaped scar flap with bilateral subcutaneous pedicles. Plast Reconstr Surg. 2009;123:1724–1728. [DOI] [PubMed] [Google Scholar]
  • 31.Narushima M, Yamasoba T, Iida T, et al. Pure skin perforator flap for microtia and congenital aural atresia using supermicrosurgical techniques. J Plast Reconstr Aesthet Surg. 2011;64:1580–1584. [DOI] [PubMed] [Google Scholar]
  • 32.Narushima M, Yamasoba T, Iida T, et al. Pure skin perforator flaps: the anatomical vascularity of the super-thin flap. Plast Reconstr Surg. 2018;142:351e–360e. [DOI] [PubMed] [Google Scholar]
  • 33.Yoshimatsu H, Hayashi A, Yamamoto T, et al. Visualization of the “intradermal plexus” using ultrasonography in the dermis flap: a step beyond perforator flaps. Plast Reconstr Surg Glob Open. 2019;7:e2411. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 34.Koshima I, Inagawa K, Jitsuiki Y, et al. Scarpa’s adipofascial flap for repair of wide scalp defects. Ann Plast Surg. 1996;36:88–92. [DOI] [PubMed] [Google Scholar]
  • 35.Nakajima H, Imanishi N, Minabe T. The arterial anatomy of the temporal region and the vascular basis of various temporal flaps. Br J Plast Surg. 1995;48:439–450. [DOI] [PubMed] [Google Scholar]
  • 36.Taylor GI, Corlett RJ, Dhar SC, et al. The anatomical (angiosome) and clinical territories of cutaneous perforating arteries: development of the concept and designing safe flaps. Plast Reconstr Surg. 2011;127:1447–1459. [DOI] [PubMed] [Google Scholar]
  • 37.Kim PS, Gottlieb JR, Harris GD, et al. The dorsal thoracic fascia: anatomic significance with clinical applications in reconstructive microsurgery. Plast Reconstr Surg. 1987;79:72–80. [PubMed] [Google Scholar]
  • 38.Schwabegger AH, Hussl H, Rainer C, et al. Clinical experience and indications of the free serratus fascia flap: a report of 21 cases. Plast Reconstr Surg. 1998;102:1939–1946. [DOI] [PubMed] [Google Scholar]
  • 39.Hsieh CH, Yang CC, Kuo YR, et al. Free anterolateral thigh adipofascial perforator flap. Plast Reconstr Surg. 2003;112:976–982. [DOI] [PubMed] [Google Scholar]
  • 40.Fujino T. Contribution of the axial and perforator vasculature to circulation in flaps. Plast Reconstr Surg. 1967;39:125–137. [DOI] [PubMed] [Google Scholar]
  • 41.Milton SH. Pedicled skin-flaps: the fallacy of the length: width ratio. Br J Surg. 1970;57:502–508. [DOI] [PubMed] [Google Scholar]
  • 42.McGregor IA, Morgan G. Axial and random pattern flaps. Br J Plast Surg. 1973;26:202–213. [DOI] [PubMed] [Google Scholar]
  • 43.Daniel RK, Kerrigan CL. Skin flaps: an anatomical and hemodynamic approach. Clin Plast Surg. 1979;6:181–200. [PubMed] [Google Scholar]
  • 44.Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental study and clinical applications. Br J Plast Surg. 1987;40:113–141. [DOI] [PubMed] [Google Scholar]
  • 45.Hallock GG. Direct and indirect perforator flaps: the history and the controversy. Plast Reconstr Surg. 2003;111:855–865; quiz 866. [DOI] [PubMed] [Google Scholar]
  • 46.Kim TK, Kim SW. Perforator flap versus conventional flap. J Korean Med Sci. 2015;30:514–522. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 47.Rios S, Falguera-Uceda MI, Dean A, et al. Suprafascial free flaps: classification and comprehensive review of the literature. Craniomaxillofac Trauma Reconstr Open. 2021;6. [Google Scholar]
  • 48.Kwon JG, Brown E, Suh HP, et al. Planes for perforator/skin flap elevation-definition, classification, and techniques. J Reconstr Microsurg. 2023;39:179–186. [DOI] [PubMed] [Google Scholar]

Articles from Plastic and Reconstructive Surgery Global Open are provided here courtesy of Wolters Kluwer Health

RESOURCES