Reliable Perforator Research Articles

The ulnar digital artery perforator flap for little finger defects: Using the abductor digiti minimi as a landmark – Surgical technique

This surgical technique article outlines the planning and harvesting methods for the ulnar digital artery perforator (UDAP) flap, using the abductor digiti minimi as a landmark for flap elevation. This approach demonstrates a reliable perforator and offers a wide range of coverage for little finger reconstruction, both on the palmar and dorsal sides. The UDAP flap is technically straightforward and easily accessible and results in minimal donor site morbidity, making it a highly viable option for little finger defects. The technique’s simplicity and effectiveness represent a significant advancement in reconstructive surgery for the little finger.

Perforator-based local flaps for cutaneous facial reconstruction

BackgroundDespite the advancement of reconstructive surgical techniques, facial defect reconstruction has been always very challenging, aesthetic satisfaction has often been difficult to achieve due to the unique characteristics and complexity of the facial tissue. There have been various options regarding reconstruction and compensation of soft tissue loss all over the body rather than the face. Regardless of whether skin grafts, local flaps, and free flaps were used in the reconstruction process, each of them has its limitations. Beginning with skin grafts results could not always be satisfactory due to contracture, color, and lack of texture Additionally, local flaps have limitations due to mobility and the availability of overlapping skin and tissue, as well as the bulkiness of the pedicle which may need a second staged surgery and lately the difficulty of the free flaps and being a major surgery.ResultsPatients ages ranged between 23 and 77 years old, with a mean age of 58.33 ± 12.47. As regards the patients’ sex, 63.3% of our patients were males and 36.7% were females. Co-morbidities were found in 60% of cases (DM 23.3%, HTN 20%, HCV 3.3%, cardiac 3.3%).Most flaps were facial artery perforator flaps 53.3%, then transverse facial artery 26.7%, superficial temporal artery 10%, angular artery 6.7%, and supra-trochlear artery 3.3%.Twenty-ix cases representing 86.7% of cases went uneventful, while complications showed in 4 cases representing 13.3% of cases, 1 case (3.3%) showed venous congestion that was relieved within 24 h after 2 suture releases, another case (3.3%) showed wound dehiscence that was improved after 2 days with regular dressings, the third patient (3.3%) had recurrence after 4 months that was treated by excision and grafting, while last patient (3.3%) had inadequate excision that was treated by radiotherapy. No bleeding or infection occurred. Also, we observed no correlation between flap length and complications. As regards the functional point of view, all patients showed no functional impairment at the donor site, and only one case showed functional impairment at the recipient site.As regards patient satisfaction, all 30 patients achieved positive satisfaction scores using the Likert scale, 18 cases were satisfied, and 12 cases were very satisfied.ConclusionThe use of perforator-based flaps can provide a more effective and aesthetically pleasing solution for the reconstruction of small to moderate facial defects, provided that a reliable Perforator is accurately identified and executed by an experienced surgeon.

Clinical Applications of the Intercostal Artery Perforator Flap for Trunk Reconstruction

Background Trunk defects can occur because of surgical site infections after spinal surgery, resection of malignant tumors, or trauma. Herein, we present our experience of using intercostal artery perforator (ICAP) flaps to reconstruct trunk defects without noteworthy complications. Fourteen patients underwent reconstruction with ICAP flaps between March 2015 and March 2019. Methods Patients' data, including age, sex, the cause of the defect, defect size, perforator location, flap size, complications, and follow-up period, were retrospectively reviewed. The mean age of the patients was 56.5 years (range, 19-80 years). All operations were performed after the results of bacterial culture from the wound showed no microbial growth. We found reliable perforators around the defect using Doppler ultrasonography. The perforator flaps were elevated with a pulsatile perforator and rotated in a propeller fashion to the defects. We performed five dorsal and two lateral ICAP flaps. The mean flap dimensions were 12 × 5.5 cm 2 (range, 6 × 5 to 18 × 8 cm 2 ). Results Primary closure of the donor site was performed. Marginal congestion was observed as a complication in one case, but it healed with no need for revision. The mean follow-up period was 8 months. All patients were satisfied with the surgical outcomes. Conclusion ICAP flaps can be easily mobilized, thereby reducing donor site morbidity without sacrificing the underlying muscles for trunk reconstruction. Therefore, these flaps are useful options for the reconstruction of trunk defects.

LICAP Versus TDAP for the Reconstruction of Partial Breast Defects.

Perforator flaps are the latest development in reconstructive surgery. Pedicled chest wall perforator flaps can be utilized in many cases of partial breast reconstruction. This research compares the outcome and technique of thoracodorsal artery perforator flap (TDAP) and the lateral intercostal artery perforator flap (LICAP) in the reconstruction of partial breast defects. Patient records were reviewed for the time period between 2011 and 2019 at the Breast Unit of the National Cancer Institute of Cairo University. Eighty three patients were accessible for the study. (46 cases of TDAP flap and 37 cases of LICAP flap). Relevant clinical data were extracted from patients' records. A special visit was organized for all 83 patients, where a digital photograph was taken in an antroposterior view. The photographs were later processed via BCCT.core software to obtain an objective cosmetic outcome assessment. Complication rates and cosmetic outcome were comparable for both techniques. TDAP flap proved to require more tedious dissection and preoperative Doppler mapping to localize perforator vessels. On the other hand, LICAP was technically easier with more consistent perforators. Pedicled chest wall perforator flaps constitute an excellent reconstructive option in partial breast defects. TDAP flap and LICAP are two reliable perforator flaps which can reconstruct outer breast defects with acceptable outcome.

A Simple Method of Intraoperative Identification of a Reliable Perforator while Dissecting an Anterolateral Thigh Flap.

A Simple Method of Intraoperative Identification of a Reliable Perforator while Dissecting an Anterolateral Thigh Flap.

A randomized trial of use of a modified reverse sural neurofasciocutaneous flap to extend the reconstruction range.

BackgroundWhen a reverse sural neurofasciocutaneous flap is used to reconstruct a forefoot defect, usually, the transverse length of the flap is increased or the pivot point is lowered to ensure the reconstruction range. Therefore, proximal partial necrosis leading to surgery failure is sometimes caused by insufficient arterial supply if the flap is too long or the pivot point is too low and has no a reliable perforator in the pedicle. Herein, we describe a new method for extending the reconstruction range of the reverse sural neurofasciocutaneous flap that can provide a higher survival rate.MethodsBetween July 2010 and July 2014, 24 patients with forefoot defect were randomly assigned into two groups. In the research group, 12 modified reverse sural neurofasciocutaneous flaps with extended reconstruction range were used to reconstruct forefoot defect. We dissected the septum along the last perforator to locate the main trunk of the peroneal artery, disconnected the proximal end of the peroneal artery at the root of the perforator, and separated the peroneal artery more distally to obtain a lower rotation point to extend the reconstruction range. The last perforator and a section of the peroneal artery were contained in the pedicle. In the control group, 12 traditional reverse sural neurofasciocutaneous flap procedures were performed.ResultsIn the research group, 11 flaps survived with good quality and esthetic contours. Partial distal necrosis occurred in 1 flap. In the control group, 7 flaps survived. Partial necrosis occurred in the other 5 flaps. Compared with control group, the survival rate in the research group was significantly higher while the healing time was significantly shorter. All patients were satisfied with the therapeutic outcome in the research group.ConclusionsOur modified method proved efficacious in extending the reconstruction range of the reverse sural neurofasciocutaneous flap. Meanwhile, partial necrosis was avoided because the length of the flap was shortened, and a reliable perforator was preserved in the artery pedicle.Trial RegistrationChictr.org Identifier: ChiCTR2100046323.

The Long-Term Stability of Fat-Graft Myringoplasty in the Closure of Tympanic Membrane Perforations and Hearing Restoration

Background/Aims: This study was conducted to evaluate the long-term stability of fat-graft myringoplasty (FGM) for chronic tympanic membrane perforations, analyzing the perforation closure rate and re-gained hearing outcome with respect to the size and location of the perforations. Methods: Between August 2007 and June 2018, a total of 193 patients who underwent FGM due to chronic tympanic membrane perforation at a tertiary referral center were enrolled and analyzed. Results: The mean follow-up was 14.6 months (range 6–39). The complete perforation closure rate after FGM was 89.6%, with no statistical difference among the perforation size groups. The mean postoperative air-bone gap (ABG) was 11.0 dB and mean ABG improvement was 4.9 dB. Conclusion: Our FGM technique had a favorable tympanic closure rate for small to large perforations, and yielded relatively good hearing improvement in the mid-size perforation cases over long-term follow-up periods. According to the topographic evaluation of FGM, this procedure resulted in a reliable perforation closure rate and audiological results regardless of the perforation site.

The Feasibility of Harvesting an Innervated Profunda Artery Perforator Flap for Breast Reconstruction

Summary:The profunda artery perforator (PAP) flap has become an alternative option for breast reconstruction. Reliable perforators arise through the adductor magnus muscle, and dissection of the perforator is straightforward. Recently, we have found that the PAP flap with the sensory nerves can be harvested as an innervated flap. We discuss the feasibility of PAP flap neurotization. We reviewed 13 patients for whom innervated PAP flap harvesting was considered. The average age was 50.7 years. There are 3 different patterns of innervated PAP flap harvesting, Type 1: including a sensory nerve that can be found in the adipose tissue around the PAP flap, Type 2: including a sensory nerve that runs along the medial femoral circumflex system, and Type 3: including a sensory nerve that runs along the profunda artery perforators. The average flap harvest time was 2:11 ± 0:31, and a sensory nerve was identified in 10 of 13 cases (77%). No sensory nerves were found in the other 3 cases. The length of the included sensory nerve was 5.5 ± 1.6 mm on average. Types 1 and 2 were found in 3 patients (30%), Type 3 was found in 2 patients (20%), and combined Types 1 and 3, 2 and 3 were found in one patient each (10%). As sensory nerves run around the PAP flap or close to the perforators, it is easy to perform flap neurotization with the PAP flap. We believe that the PAP flap could be an alternative option to achieve sensate breast reconstruction.

Reliability of propeller flaps in post-traumatic reconstruction of wrist and hand defects.

This is a purely observational study with a literature comparison to assess the effectiveness of radial and ulnar arteries propeller perforator-based flaps in post-traumatic soft tissue reconstruction and identify the risk factors for complications. Sixteen patients were involved with post-traumatic wrist and hand soft tissue defects not exceeding 5 × 20cm. Defects were covered with propeller radial and ulnar arteries perforator-based flaps. Patient demographics, soft tissue defects, complications and clinical outcomes were recorded. Assessment of patients' satisfaction for donor site morbidity and aesthetic outcome of the flap were performed. Radial artery propeller perforator flap was performed in seven cases, and ulnar artery propeller perforator flap was done in nine cases. The size of the skin paddle ranged from 2.5 × 5cm to 4.5 × 10.5cm. Primary closure of the donor site was performed in all cases. One flap was lost, while superficial epidermolysis occurred in seven cases (45%). Edge necrosis ranging between 3 and 7 mm occurred in nine cases (60%). Patients' factors, mode of injury, associated injuries and interval between trauma and coverage were all correlated with complication incidence. The patients' satisfaction for donor site morbidity was very good and good in 80% of patients, while satisfaction for aesthetic outcome of the flap was very good and good in only 40%. Radial and ulnar arteries have reliable perforators for flap elevation, which produce reliable outcome for small- and medium-sized soft tissue reconstruction. Effectiveness decreases in post-traumatic reconstructions. Complications are more frequent in crushing injuries especially if associated with bony fractures. Most complications in trauma cases were attributed to venous congestion, for which supercharging with a vein if accessible to the surgeon is recommended.

The Medial Sural Artery Perforator Flap: Lessons Learned from 200 Consecutive Cases

The medial sural artery perforator flap is a versatile option in reconstructive microsurgery. However, most reports of this flap have been limited by sample size. This study reviews the experience of a single large-volume center using the medial sural artery perforator flap and its variants for a variety of reconstructive purposes. A retrospective review of all patients who received the medial sural artery perforator flap reconstruction between March of 2006 and July of 2014 was performed. Two-hundred medial sural artery perforator flaps were used at three anatomical regions: head and neck (n = 129), upper extremity (n = 47), and lower extremity (n = 24). Flaps were transferred as free (n = 189) and pedicled (n = 11). Overall flap survival was 96 percent. Flap variants used included chimeric flap (n = 11) and dual skin paddle (n = 2). Plantaris tendon and saphenous/sural nerve graft were harvested in conjunction in 20 and seven patients, respectively. In 5 percent of the cases harvested in the conventional manner, a reliable perforator could not be found. The medial sural artery perforator flap is a reliable, alternative workhorse flap for nearly any small- to medium-size defect. It can be harvested as free or pedicled and the option to include multiple tissue components further expands its versatility. Therapeutic, IV.

Imaging in Propeller Flap Surgery.

Since propeller flaps are elevated as island flaps and most often nourished by a single perforator nearby the defect, it is challenging to change the flap design intraoperatively when a reliable perforator cannot be found where expected to exist. Thus, accurate preoperative mapping of perforators is essential in the safe planning of propeller flaps. Various methods have been reported so far: (1) handheld acoustic Doppler sonography (ADS), (2) color duplex sonography (CDS), (3) perforator computed tomographic angiography (P-CTA), and (4) magnetic resonance angiography (MRA). To facilitate the preoperative perforator assessment, P-CTA is currently considered as the gold standard imaging tool in revealing the three-dimensional anatomical details of perforators precisely. Nevertheless, ADS remains the most widely used tool due to its low cost, faster learning, and ease of use despite an undesirable number of false-positive results. CDS can provide hemodynamic characteristics of the perforator and is a valid and safer alternative particularly in patients in whom ionizing radiation and/or contrast exposure should be limited. Although MRA is less accurate in detecting smaller perforators of caliber less than 1.0 mm and the intramuscular course of perforators at the present time, MRA is expected to improve in the future due to the recent developments in technology, making it as accurate as P-CTA. Moreover, it provides the advantage of being radiation-free with fewer contrast reactions.

Perforator-Pedicled Propeller Flaps for Lower Extremity Reconstruction.

Reconstruction of the lower extremity is considered a major challenge due to frequent bone exposure and the absence of local tissue redundancy, as well as often due to the presence of vascular insufficiency. Many surgeons have preferred free flaps especially for reconstructing the more distal lower limb defects until the evolution of pedicled perforator flaps and propeller flaps in particular provided a like-with-like reconstruction of the lower extremity without affecting the main vessels of the limb or the underlying muscles, and without the risk of any microanastomosis especially in patients with multiple comorbidities. Perforator-pedicled propeller flaps as local flaps in the lower extremity are best suited for small- and medium-sized defects with minimal donor-site morbidity, regardless of the cause of the defect. Any of the three source vessels of the leg can provide reliable perforators for propeller flap coverage of the distal leg and foot. The three main risk factors that are relative contraindications may be advanced age, diabetes mellitus, and atherosclerotic peripheral vascular disease.

An ulnar parametacarpal perforator flap for volar digital soft tissue reconstruction.

We present outcomes of using a perforator-based ulnar parametacarpal flap in 25 patients for digital pulp defects. These included 17 free transfers to the thumb, index, middle and ring fingers and eight reverse pedicled transfers to the little fingers. This flap includes a dorsal sensory branch of the ulnar nerve, which was sutured to the digital nerve in all transfers. Each flap had one to three reliable perforators (mean 0.44 mm diameter) to the ulnar parametacarpal region and contained at least one perforator within 2 cm proximal to the palmar digital crease. All the 25 flaps survived completely. Twenty-two patients were followed for 15 months (range 12 to 24), and three were lost to follow-up. The mean static and moving two-point discrimination of the flap was 7 mm and 5 mm, respectively. At the donor site, sensory reinnervation was acceptable. We conclude that ulnar parametacarpal perforator flaps offer sensate, thick and glabrous skin for finger pulp repair, all in a single operative field.Level of evidence: IV.

Reconstructive microsurgery in upper limb reconstruction: 30 years’ experience of a single surgeon

The reconstruction of compound tissue defects in upper extremity injuries often represents a challenge. The goal of reconstruction is to obtain not only a good cosmetic result, but also the best possible function. Microsurgery highly contributes to the management of upper limb simple or complex defects by offering a large number of surgical possibilities. Due to advances in understanding of blood supply to tissues and microsurgical techniques in the last 50years, microsurgeons have renounced more and more to the use of traditional flaps in favour of the more reliable perforator flaps. This article presents the experience of a single surgeon performing post-traumatic upper limb reconstructive microsurgery over the last 30years.

Utility of the lateral arm free flap in oral cavity reconstruction: a single-centre experience with Chinese patients

The lateral arm flap (LAF) may offer an alternative option for oral cavity repair. Twenty-five Chinese patients with oral cavity defects were reconstructed with a LAF. The anatomical characteristics of the flap, the donor site complications, and the functional and aesthetic assessments of recipient site were reviewed. The overall flap survival was 96.0% (24/25patients). The average pedicle length was 7.07±1.09cm when it was cut off at the insert of the deltoid, with an average arterial diameter of 1.30±0.37mm and vein diameter of 2.06±0.48mm. The average flap length was 7.06±1.01cm, and the average flap breadth was 5.28±0.66cm, with the average flap size ranging from 18 to 42cm2. One to three reliable perforators supplied the flap, with the proximal, middle, and distal perforators being located at 9.9±1.1cm, 8.6±1.4cm, and 5.7±1.2cm from the lateral epicondyle, respectively. The donor defect was closed primarily and healed uneventfully. A longitudinal scar was the most common morbidity of the donor site. The function and shape of the reconstructed tissues were well restored. The LAF provides a reliable choice for reconstructing medium-sized oral cavity defects, with minimal donor-site morbidity and ideally functional and aesthetic rehabilitation of the recipient site.

Perforator artery response to tissue expansion: An experimental study in rabbits.

The reconstruction of defects is a major area of interest in plastic surgery. Tissues are expanded to extend the tissue surface area and to prepare more reliable perforator flaps. Because expanded perforator flaps have become more popular, the aim of this study is to determine the response of the perforator artery to tissue expansion. We used a rabbit S1 perforator (first perforator branch of the thoracodorsal arteries) flap model. In 12 New Zealand White rabbits, left flaps were used as the experimental group (n = 12) and right flaps were used as the control group (n = 12). Both flaps were constructed in the dorsal skin. The experimental group was further divided into 3 subgroups according to expansion volume: 150 mL (n = 4), 200 mL (n = 4) and 250 mL (n = 4). We evaluated the responses of the perforator arteries to tissue expansion using the resistivity index (RI), the pulsatility index (PI), vessel diameter (D), histopathological examinations, and angiography. After 3 weeks of expansion, the perforator artery diameter had increased (p = 0.002) and the RI had decreased (p = 0.031) in the experimental group. The perforator artery diameter (p = 0.006) and RI had increased (p = 0.003) in the control group. No significant changes were observed in the PI in either group (p > 0.05) and no significant differences in post-expansion measurements were observed between experimental subgroups (p > 0.05). Suprafascial expansion of a perforator flap leads to an increase in diameter and a decrease in the RI of the perforator artery. The decrease in RI may indicate increased flap perfusion.

Expanding the use of internal mammary artery perforators as a recipient vessel in free tissue transfer: An anatomical analysis by computed tomography angiography in breast cancer patients

The internal mammary artery (IMA) perforator has assumed recent prominence as recipient vessels in free autologous breast reconstruction. However, anatomical understanding is unclear, due to limited cadaver and clinical studies. We evaluated the usability of these vessels by evaluating perforator size, dominance, laterality, interspace location, and relationship with breast volume. A retrospective review assessed 197 female patients with breast cancer who had undergone computed tomography angiography (CTA) of the chest wall. The average age and body mass index (BMI) of patients was 49.0 ± 6.5 years and 24.2 ± 5 .8 kg/m2 , respectively. The average volume of breasts was 437 ± 190 mL. Our analysis focused on the anatomy of IMA perforator and its relationship to volume and BMI. A total of 377 hemi-chest evaluations were performed. Most patients (95.5%) had sizeable perforating artery identified on CTA. Among all sizeable perforators identified, the mean diameter of the most dominant arterial perforator was 1.8 ± 0 .8 mm. The right hemi-chest had significantly larger perforators than the left (1.9 ± 0 .9 mm vs. 1.7 ± 0 .7 mm, p = 0.002). The first intercostal space (ICS) had a slightly greater of perforators than second ICS (34.6% vs. 29.8%, p = 0.172). However, second ICS had a greater number of most dominant perforators compared to first ICS (38.9% vs. 34.7%, p = 0.357). Perforators from first ICS emerge medial to the sternal edge and breast footprint. When dividing groups with 0-1 versus 2-3 reliable perforators, breast volume was significantly higher in the later (422.0 mL vs. 461.2 mL, p = 0.019). These results are expected to encourage microsurgeons to use the IMA perforator by providing a clear anatomical roadmap.

Inferior pole breast reconstruction by TDAP flap in post-burn breast contracture

Post-burn breast deformities are not an uncommon condition after severe second-degree or third-degree burn and present as severe asymmetry of the breast as compared to the opposite side, displacement of nipple-areola complex, obliteration of inframammary fold, and reduced breast projection. Based on deformities especially for lower pole breast contracture, we propose a new classification to describe breast contracture. There is no tailor-made approach described to deal such deformities. Various options are available ranging from skin graft to different flaps. We present reconstruction by TDAP flap after the release of breast contracture grades I and II. This study aimed to classify the lower pole breast contracture according to its severity and to evaluate the outcome of TDAP flap reconstruction and augmentation of the lower pole of the breast in terms of symmetry and aesthesis. This is a descriptive retrospective study of 10 patients with 15 post-burn contracted breast affecting the inferior pole of the breast and inframammary fold within a period of January 2012 to March 2016 in Kasralainy hospital, Cairo. All cases were evaluated according to flap vascularity, donor site morbidity, symmetry, and esthetic outcome. All flaps survived completely. Flap dimension ranged from 18 × 10 to 22 × 12 cm. The muscle sparing design had been used in three patients due to lack of reliable perforators. Patients were evaluated for their satisfaction, and all of them were satisfied. It is essential to classify the grade of post-burn lower pole breast contracture according to the proposed classification. TDAP is a valuable option in case of grade I and II deformities only. For severe grade III breast contracture, more volume restoring procedure is advisable. Level of Evidence: Level IV, therapeutic study.

The Use of Magnetic Resonance Imaging in Planning a Pedicled Perforator Flap for Pressure Sores in the Gluteal Region.

Pedicled perforator flaps (PPFs) have been widely used to treat pressure sores in the gluteal region. Selection of a reliable perforator is crucial for successful surgical treatment of pressure sores using PPFs. In this study, we evaluate the role of magnetic resonance imaging (MRI) in planning PPF reconstruction of pressure sores in the gluteal region. A retrospective chart review was performed in patients who had undergone these PPF reconstructions and who had received preoperative MRI. Preoperatively, the extent of infection and necrotic tissue was evaluated using MRI, and a reliable perforator was identified, considering the perforator location in relation to the defect, perforator size, and perforator courses. Intraoperatively, the targeted perforator was marked on the skin at the locations measured on the MRI images, and the marked location was confirmed using intraoperative handheld Doppler. Superior gluteal artery, inferior gluteal artery, or parasacral perforators were used for the PPFs. Surgical outcomes were evaluated. A total of 12 PPFs were performed in 12 patients. Superior gluteal artery perforator flaps were performed in 7 patients, inferior gluteal artery perforator flaps were performed in 3 patients, and parasacral perforator flaps were performed in 2 patients. We could identify a reliable perforator on MRI, and it was found at the predicted locations in all cases. There was only one case of partial flap necrosis. There was no recurrence of the pressure sores during the mean follow-up period of 6.7 months (range = 3-15 months). In selected patients with gluteal pressure sores, MRI is a suitable means for not only providing information about disease extent and comorbidities but also for evaluating perforators for PPF reconstructions.

Re-introducing the delto-acromial perforator flap: Clinical experience and cadaver dissection

Although perforator flaps from the pectoral branch of the thoraco-acromial (TA) axis have been well-described, there are few reports of perforator flaps based on the delto-acromial (DA) branches. We have found a reliable perforator coming off the DA branch of the TA axis, and have named a flap based on this vessel the delto-acromial perforator (DAP) flap. We describe our experience with the DAP flap together with a fresh cadaver anatomical study. A retrospective review of all DAP flaps performed between December 2012 and January 2015 at our institution, with analysis of operative details, flap characteristics and surgical outcomes. We performed fresh cadaver dissection on 5 hemi-chest walls. The main cutaneous perforator from the deltoid and/or acromial branches is found at the delto-pectoral groove, 8 cm lateral to the TA axis and 8 cm inferior to the acromio-clavicular joint. Five patients underwent DAP flap reconstruction. Three were pedicled and 2 were free flaps. Average pedicle length from the origin of the DA branch was 8 cm, with an arterial diameter of at least 1 mm and vein diameter 1.5 mm. All flaps survived completely. Cadaver dissection showed a consistent perforator arising from the common delto-acromial branch in 4 cadavers, and from the deltoid branch in 1 cadaver. The DAP flap is a good addition to the armamentarium of reconstructive surgeons when a relatively thin fasciocutaneous flap with minimal hair is desired. It may be used for free tissue or locoregional transfer.