BOOK REVIEW

Perforator Flaps-Anatomy, Technique, and Clinical Applications. Phillip N. Blondeel, Steven F. Morris, Geoffrey G. Hallock, and Peter C. Neligan Quality Medical Publisher Inc., St. Louis, MO, 2006, 1096 pgs, $495.00.

It has been almost half a century since microvascular surgical technique have been clinically applied. In the initial period of the 1960s, successful replantations of the upper extremities were reported in the United States and China; and the optic equipment, suture materials, and instruments for microvascular surgery were quickly developed. There were limited series of free skin flaps and free toe transfers subsequently carried out.

In the ‘70s and ‘80s of the last century, in addition to free toe transfers and free skin flaps, revascularized muscle, bone, and nerve grafts, as well as composite tissue transfers, were developed, and many of the useful donor sites were discovered, based on anatomic investigations and clinical trials. Applications in reconstructive microsurgery were maturing and became popularized and more effective in patient management.

More recently, in the middle of the ‘90s of the last century, there appeared a new concept of perforator flaps for refinement of some musculocutaneous flaps, which leave the muscles intact by isolating the musculocutaneous perforator to its main trunk, so that the flaps are less bulky and the donor sites have less morbidity postoperatively. In addition, by intramuscular dissection, the length of the vascular pedicle can be increased for 3 to 6 cm, which helps to facilitate microvascular anastomoses and to extend the indications for more applications. The technique of perforator flaps was truly the most outstanding achievement in refinement of some donor sites, by which musculocutaneous flaps could be altered to be merely cutaneous. Among those, the deep inferior epigastric perforator (DIEP) flap, the superior and inferior gluteal artery perforator (S-GAP) flaps, the anterolateral thigh (ALT) perforator flap and thoracodorsal artery perforator (TAP) flap are most commonly employed in clinical use.

I am very pleased to see the publication of this two-volume work which, I believe, many microsurgeons should have for their clinical practices. It is my fortune and honor to read it early and to provide a book review.

The work, with 51 contributors from 14 countries, has a magnificent foreword by an honorable pioneer in microsurgery, Dr. G. Ian Taylor. It consists of four parts. The first is a general introduction, which includes the history, anatomic investigation, physiology, terminology, and operative management for skin flap surgery. The second part is the substantive core of the work: it presents the anatomy and surgical technique for 33 cutaneous perforator flaps in four body regions-head and neck, upper extremity, trunk, and lower extremity. The third part discusses clinical applications, which include reconstructions of each body part in the four regions, and for reconstructions of the breast, back, pelvic, and perineogenital regions, as well as use in pediatric surgery. The fourth part presents controversies and future directions, and provides space in which the contributors can freely present their different opinions and experiences in the development of perforator flaps.

This is a comprehensive and detailed textbook of skin flap transfers vascularized by their perforators and the main trunk vessels below. It is absolutely valuable for surgeons engaged in microsurgery, hand surgery, plastic surgery, and orthopedics. The work contains a large number of anatomic photographs of cadaver specimens and angiograms of the integument, enhanced with colorful drawings and detailed text descriptions. Based on anatomic knowledge and clinical experiences, the surgical techniques are revealed from designing to actual procedures with proper descriptions, some with color pictures taken during surgery and some with drawings, so that readers can easily follow and use these techniques in their own clinical practices.

These two volumes also include a DVD, which gives technical demonstrations of the deep inferior epigastric artery perforator flap, the thoracodorsal artery perforator flap, and the lateral circumflex femoral artery perforator flap. This is a valuable reference work for readers who want to use these flaps in their clinical practices.

Controversially, this book categorizes vascularized skin flaps entirely to be “perforator flaps.” In the nomenclature of microsurgical skin flap transfers, I understand the idea that the “perforator flap” is utilized everywhere, because these flaps are anatomically based on either direct or indirect (septocutaneous or musculocutaneous) perforators; in accordance with the terminology, the vascularized tissue transfer can be named by its arterial system. However, as we know, the concept of the perforator flap was evolved from the musculocutaneous flap, in order to avoid or eliminate its bulkiness and postoperative morbidity at the donor site.

The logo of the work on the cover and on the first page of each chapter, in which an isolated perforator penetrates a separated muscle to supply a skin flap, represents the essence of the perforator flap. Of 33 cutaneous flaps described, most are based on the septocutaneous or direct perforators, and their nomenclature in other classical textbooks, such as radial or ulnar forearm flap, scapular flap, lateral arm flap, and others, here becomes the general category “perforator flaps”-radial or utnar artery perforator flap, circumflex scapular artery perforator flap, lateral arm perforator flap, and so on. This nomenclature may make readers somewhat confused. However, from the viewpoint of clinical significance, the perforator flap nomenclature may serve to remind surgeons that it is especially necessary to do preoperative Doppler detection and intramuscular dissection during surgery.

The advantages and significance of the perforator flap in the development of reconstructive microsurgery are recognized because of the discovery of DIEP, S-GAP, I-GAP, TAP flaps, and others, which seem to be somewhat submerged and neglected in this work. In my opinion, I would prefer to limit the term “perforator flap” to those flaps based on the musculocutaneous perforator.

This controversy over nomenclature does not lessen the value of this work. Overall, this is an excellent and comprehensive textbook for vascularized skin flap transfer, and the authors have successfully accomplished their mission in introducing the concept and techniques of perforator flaps. These two volumes can be valuable additions in the library of the reconstructive microsurgeon.