Drs. Basu and Sharma make some interesting points in relation to the anatomy and planning of perforator flaps and in terms of studies exploring their incorporation into clinical practice.1 We recently reported our experience with the use of preoperative imaging to plan locoregional perforator flaps, and highlighted the benefits we subjectively obtained with this planning.2
In the past, we have undertaken such flaps without imaging, basing the central location of the flaps on the fascial penetration pattern of perforators alone and basing flap dimensions on long-held concepts of length-to-width ratios. We have since found that the use of new imaging technologies that can map subcutaneous branching patterns can improve the survival of the tips of the flaps by converting “random” intrinsic vasculature into “axial” intrinsic vasculature. It is unclear from the letter by Drs. Basu and Sharma whether this was made clear to the authors in our original article. We feel that axial pattern and random pattern extensions of the perforator flap concept can facilitate improved design for improved survival. To answer the first point of the authors, a stellate pattern perforator planned in this fashion can have a design that extends from the central perforator in multiple directions—which can enable a flap to be designed in a range of single directions, a bilobed pattern along two branches, or any number of patterns along the course of such branches.
The authors also suggest randomized trials or higher level studies to improve the evidence attributable to such techniques. Although this is true, and evident throughout research in surgery, we made it clear from the outset that this was a cohort study and designated the study a “Diagnostic III” level study, according to the guidelines of all Plastic and Reconstructive Surgery submissions. Lastly, although the suggestion that preoperative imaging is expensive is relatively true, we feel that cost alone should not preclude the use of such advances in surgery from use either clinically or in research. Individual surgeons and institutions can then incorporate such techniques into their practice according to their resources.
Warren M. Rozen, M.B.B.S., M.D., Ph.D.
Alenka M. Paddle, M.B.B.S.
Daniel Chubb, M.B.B.S.
Jeremy Wilson, M.B.B.S.
Damien Grinsell, M.B.B.S.
Mark W. Ashton, M.B.B.S., M.D.
Jack Brockhoff Reconstructive Plastic Surgery Research Unit, Department of Anatomy and Cell Biology, University of Melbourne, Parkville, Victoria, Australia
The authors have no financial interest to declare in relation to the content of this communication.
1. Basu A, Sharma AK. “Image-guided” perforator flaps versus “free-style” perforator flaps: Where is the evidence? Plast Reconstr Surg. 2013;131:444e–445e.
2. Rozen WM, Paddle AM, Chubb D, Wilson J, Grinsell D, Ashton MW. Guiding local perforator flaps with preoperative imaging: Revealing perforator anatomy to improve flap design. Plast Reconstr Surg. 2012;130:130–134.
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