“Image-Guided” Perforator Flaps versus “Free-Style” Perforator Flaps

Abstract

Sir:FigureWe read with great interest the article on pedicled perforator flaps by Rozen et al., in which the authors report their experience with preoperative imaging of the perforator course in the subcutaneous plane using computed tomographic angiography.1 Based on their experience of “over 1000 image-guided perforator flaps,” the authors have classified perforators into those with unidirectional or stellate subcutaneous courses. The authors suggest that placing the suprafascial portion of the perforator along the “axis” of the flap will ensure complete flap survival. We would like to comment on certain aspects of the authors' proposal. First, the concept of axial flaps propounded by McGregor and Morgan states that an axial flap is “a single pedicled flap which has an anatomically recognized arterio-venous system running along its long axis” in the subcutaneous plane.2 The authors do not elaborate on how a stellate pattern perforator may be placed along an axis of a flap, unlike a unidirectional perforator. Moreover, the dimensions of an “axial pattern” perforator flap with respect to dimensions of the selected perforator have not been elucidated completely. The capture of the adjacent perforasome territory (“random” territory) by an “axial pattern” perforator by means of linking vessels may increase flap dimensions.3 Second, a randomized controlled trial using objective endpoint measures would be required to prove the added advantage gained from use of image-guidance during perforator flap harvest. The simplicity of flap design and the surgeon's stress level during perforator dissection in patients undergoing an image-guided perforator flap versus a free-style perforator flap harvest may be studied using an objective scoring system. The surgeon's stress level may be graded from 1 through 4 (none, mild, moderate, and severe levels), with more difficult dissections being assigned a higher score. The simplicity of flap design can also be graded 1 through 4, with more complex designs, depending on perforator suitability, being assigned a higher score. Third, using image guidance for perforator flap harvest is expensive and requires advanced equipment and personnel trained in perforator imaging. In conclusion, “image-guided” perforator flaps may have certain advantages, but the evidence toward the same is inconclusive.4 Further randomized controlled studies (using objective scoring systems) need to be performed before the supremacy of image-guided perforator flaps is established over free-style perforator flaps. Adhish Basu, M.Ch.(Plast.Surg.) Ramesh K. Sharma, M.Ch.(Plast.Surg.) Department of Plastic Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. No outside funding was received.