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The Concepts of Propeller, Perforator, Keystone, and Other Local Flaps and Their Role in the Evolution of Reconstruction

Mohan, Anita T. M.R.C.S.; Sur, Yoo Joon M.D., Ph.D.; Zhu, Lin M.D.; Morsy, Mohamed M.B.B.Ch., M.Sc.; Wu, Peter S. M.D., M.S.; Moran, Steven L. M.D.; Mardini, Samir M.D.; Saint-Cyr, Michel M.D.

Plastic and Reconstructive Surgery: October 2016 - Volume 138 - Issue 4 - p 710e-729e
doi: 10.1097/PRS.0000000000002610
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Learning Objectives: After studying this article, the participant should be able to: 1. Understand the history and physiology of perforator flaps. 2. Understand the concept of “free-style” perforator flaps and principles in design and harvest. 3. Understand the uses of perforator flaps in reconstruction and applications in new settings. 4. Understand new principles in single and multiple perforator flap harvest and adjunct techniques that can be used in perforator flaps. 5. Highlight pertinent anatomy and techniques for selected perforator flaps described.

Summary: Extended knowledge of vascular anatomy has propagated the development of perforator flaps, which preserve muscle function and reduce morbidity. This has been achieved through the exemplary works of Manchot, Salmon, Milton, Taylor, and many others. With over 350 clinically relevant perforators in the body, this has created new flap options and a sense of creative freedom for reconstruction tailored toward a specific defect, without constraints of specific landmarks and using a “free-style” approach. Dominant perforators may be found in zones of high perforator density or “hot spots,” which can help to conceptualize local flap options and aid flap design. This article aims to outline the history, physiology, and principles of flap design and harvest, and highlight traditional and evolving concepts and modifications of contemporary and traditional flaps that are changing reconstructive practice. This is a broad overview focusing on clinical applications, highlighting key concepts in a selection of new or evolving flaps being used in clinical practice and providing source references to acquire detailed flap descriptions.

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Rochester, Minn.; Middlesex and Cambridge, United Kingdom; Seoul, Republic of Korea; and Assiut, Egypt

From the Division of Plastic Surgery, Mayo Clinic; Restoration of Appearance and Function Charitable Trust; Department of Surgery, University of Cambridge; Department of Orthopedic Surgery, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea; and the Department of Orthopedics, Assiut University.

Received for publication September 17, 2015; accepted May 31, 2016.

Disclosure:None of the authors has any commercial associations that might pose or create a conflict of interest with information presented in this article. Dr. Saint-Cyr is a consultant for Pacira.

Related Video content is available for this article. The videos can be found under the “Related Videos” section of the full-text article, or, for Ovid users, using the URL citations published in the article.

Michel Saint-Cyr, M.D., Division of Plastic Surgery, Scott & White, 2401 South 31st Street, Temple, Texas 76508,

Copyright © 2016 by the American Society of Plastic Surgeons