Pedicle perforator flaps and keystone perforator island flaps are additional tools for reconstructive surgeons. Advances in understanding of vascular anatomy, the dynamic nature of perforator perfusion, inter-perforator flow and the hot-spot principle have led to reconstructive techniques that allow innovative autologous tissue transfer while limiting donor site morbidity. Further modifications of the pedicle perforator flap have led to a multitude of freestyle pedicle perforator flap options, as well as freestyle free flaps for soft tissue reconstruction. Modifications in the keystone perforator island flap have increased the degrees of freedom for soft tissue coverage of large defects, with reliable and aesthetically pleasing results.
The increase in knowledge of vascular anatomy, including the concept of the perforasome theory and perforator hot-spot versus cold-spot anatomy, has led to significant advances in reconstructive options.
Pedicle perforator flap (PPF)–based reconstruction benefits patients by using autologous tissue for reconstruction and decreases operative morbidity by limiting transfer of tissue on perforators.
Freestyle PPF allows greater degrees of freedom in operative planning, because flaps can be based on any dominant perforator.
Keystone perforator island flap is a multiperforator advancement flap based on musculocutaneous or fasciocutaneous perforators with high rates of flap survival, decreased donor site morbidity and pain, and quick patient recovery.