Branch-Based Conjoined Perforator Flaps

Abstract

An extremely large skin flap encompassing multiple flap territories that have a common physical boundary but with each retaining its unique vascular supply would be called a conjoined flap. If the subfascial and/or axial vascular branches to each territory in turn ultimately supply a direct or indirect perforator, such a combination raised without muscle or other tissue intermediary would specifically be defined as a branch-based conjoined perforator flap. A retrospective review of 522 cutaneous flaps in the author's experience over the past 5 years identified the use of five branch-based conjoined perforator free flaps and four local rotation flaps. Unique technical considerations and the attributes of the multiple donor sites for these conjoined flaps were further scrutinized. All nine branch-based conjoined perforator flaps were successfully transferred without any major complications. The preferred donor site was equally distributed among the anterior thigh, trunk, and lower abdomen. On three occasions, the subfascial branches ultimately arose from a common "mother" vessel that required at the most only a single arterial and venous microanastomosis. Two local flaps had totally independent branches to each territory, so that a single microanastomosis to the detached pedicle essentially supercharged the flap. For all free flaps with independent branches, the branch of one territory was always anastomosed to the other according to the mosaic flap principle, so that again only a single arterial microanastomosis was required at the recipient site. Multiple direct or indirect perforator flaps from adjacent territories can be reliably combined as conjoined flaps based on sizable subfascial and/or axial vascular branches.