Application of Posterior Thigh Three-Dimensional Profunda Artery Perforator Perforasomes in Refining Next-Generation Flap Designs: Transverse, Vertical, and S-Shaped Profunda Artery Perforator Flaps

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We read the article by Mohan et al. with interest.1 The posterior medial thigh is gaining renewed popularity among reconstructive surgeons, and the authors give an important contribution to further define its vascular boundaries. However, we would like to make a few comments. Our group has extensively used the posteromedial thigh as a donor site for free perforator flaps, in vertical, transverse, and compound designs, for distant defects such as in head and neck2 and breast surgery.3 We have also appreciated its versatility in its pedicled form for locoregional defects,4 although rarely (approximately 5 percent of the sizable perforators) we found that the perforator to the area of interest (the skin roughly centered on the adductor magnus) originated from the medial circumflex femoral artery and not from the profunda femoris artery. As illustrated in our studies, these perforators from the medial circumflex femoral artery had a septocutaneous course, between the gracilis and adductor magnus. These findings, in which the same skin territory can be irrigated by perforators from different source vessels, have raised some doubts with regard to the name given to this flap. According to the Gent consensus,5 a perforator flap should be named after the source artery (i.e., medial circumflex femoral artery or profunda femoris artery perforator). However, the exact origin of the perforator can be defined confidently only by imaging studies or by direct visualization of the source vessel. Both of these steps are often omitted. Many surgeons perform a retrograde dissection “from foliage to the root,” and there is often no need to reach the source vessel (which thus remains unidentified). Furthermore, although the profunda femoris artery perforators are widely distributed throughout the thigh, each of them being a potential profunda femoris artery perforator flap, the most attractive characteristics as a donor site that the surgeon is looking for (e.g., long sizable perforator, redundant skin, concealed scars) are centered in the medial portion of the posterior thigh. For the aforementioned reasons, we prefer to name this flap the posteromedial thigh flap and not the profunda artery perforator flap.
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