General discussion The era of perforator flaps started in 1989 with Koshima1 followed by Allen2 in 1994 opening the doors, from an anatomical and clinical point of view, to new studies and research. The knowledge of the topographical anatomy of perforator vessels is essential and the basis for the development of new techniques. With the discovery of perforator flap surgery it became clear that the skin could be harvested without sacrifying the underlying muscle. As our understanding of the vascular anatomy of perforators advanced we understood that any skin flap could be harvested, as long as a perforator vessel was incorporated that could be dissected. As a consequence our point of view radically changed bringing us, in some situations, first of all to choose the best donor site for a reconstruction and then to identify the nourishing perforator for that tissue. This knowledge brought Wei in 2004 to the con- cept of “free style perforator flaps”: he described the possibility to harvest a flap based only on the preoperative knowledge of the Doppler signal of a perforator in a specific region. Between June 2002 and September 2003 he performed successfully 13 free style flaps: the average size of the flaps was 108 cm2 and the average length of their pedicle was 10 cm3. The “propeller flap” concept, actually introduced in 1991 by Hyakusoku, was a variant of a free style perforator flap as the flap was based on a “off-center” perforator: by rotating the flap at the perforator pivot point, a transposition of the skin island in the defect was achieved. The anatomy of perforators is variable, in some areas more than other ones, but, in most of the cases, their origin is from well known and more constant bigger vessels. As a consequence very often patterns of their presence can be recognized and possible landmarks to standardise the design of a flap are identified. Usually 1 or 2 veins are accompanying an artery and, as a consequence, no separated landmarks for the artery and the veins are needed. We analyzed in this PhD the pattern of perforators of the antero- lateral thigh flap (one of the most variable regions for perforators) in chapter 2, the medial sural artery perforator flap in chapter 3, the superior gluteal artery flap in chapter 4, 5 and 6 and the septocutaneous tensor fasciae latae perforator flap in chapter 8. In the first 2 studies of this PhD (chapter 2 and 3) only the anatomical dissection was taken into consideration to analyse the anatomy and variability of perforators. Nowadays we have tools to help us, in the research setting as well as clinically, to identify perforators, making the dissection more reliable and easier (we introduced some of them in this thesis). The hand-held Doppler (HHD), 166
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