Imaging of perforasome territories: the evolution of techniques

Main Article Content

Warren M Rozen
Rachael Leung
Michael P Chae
David J Hunter-Smith


computed tomographic angiography, magnetic resonance angiography, ultrasonography, Doppler, indocyanine green angiography


Background: Perforator flaps are widely used in reconstructive plastic surgery and technological advances in preoperative imaging have facilitated improvements in flap perfusion and clinical outcomes. The ‘perforasome’ concept describes the vascular territory supplied by a single arterial perforator and the imaging of these zones of perfusion has become increasingly advanced.

Methods: This paper presents a qualitative analysis of the current literature on perforasome imaging. A review of the literature was performed using PubMed and Medline. Historical and background studies were also included for completeness.

Results: The review identified an initial 858 records for assessment, with 52 studies formally reviewed. To date, there is largely level III and IV evidence for the available imaging techniques, although level II studies are emerging. There is currently no level I evidence for any imaging technique.

Conclusion: There have been significant developments in imaging techniques since the introduction of the perforasome concept nearly a decade ago. In this review we have described the evolution of these methods over time, from simple perforator location to advanced three- and four-dimensional imaging and real-time dynamic perfusion imaging. With this progression and ongoing innovation, we believe perforasome imaging has the potential to improve outcomes in perforator flap surgery.


Download data is not yet available.
Abstract 127 | PDF Downloads 39 HTML Downloads 26


1. Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental study and clinical applications. Br J Plast Surg. 1987;40(2):113–41.
2. Saint-Cyr M, Wong C, Schaverien M, Mojallal A, Rohrich RJ. The perforasome theory: vascular anatomy and clinical implications. Plast Reconstr Surg. 2009;124(5):1529–44.
3. Rozen WM, Ashton MW, Le Roux CM, Pan WR, Corlett RJ. The perforator angiosome: a new concept in the design of deep inferior epigastric artery perforator flaps for breast reconstruction. Microsurg. 2010;30(1):1–7.
4. Taylor GI, Doyle M, McCarten G. The Doppler probe for planning flaps: anatomical study and clinical applications. Br J Plast Surg. 1990;43(1):1–16.
5. Stekelenburg CM, Sonneveld PM, Bouman MB, van der Wal MB, Knol DL, de Vet HC, van Zuijlen PP. The hand held Doppler device for the detection of perforators in reconstructive surgery: what you hear is not always what you get. Burns. 2014;40(8):1702–706.
6. Khan UD, Miller JG. Reliability of handheld Doppler in planning local perforator-based flaps for extremities. Aesthetic Plast Surg. 2007;31(5):521–5.7
7. Imai R, Matsumura H, Tanaka K, Uchida R, Watanabe K. Comparison of Doppler sonography and multidetector-row computed tomography in the imaging findings of the deep inferior epigastric perforator artery. Ann Plast Surg. 2008;61(1):94–98.
8. Klasson S, Svensson H, Malm K, Wasselius J, Velander P. Preoperative CT angiography versus Doppler ultrasound mapping of abdominal perforator in DIEP breast reconstructions: A randomized prospective study. J Plast Reconstr Aesthet Surg. 2015;68(6):782–86.
9. Ono S, Hayashi H, Ohi H, Ogawa R. Imaging studies for preoperative planning of perforator flaps: an overview. Clin Plast Surg. 2017;44(1):21–30.
10. Dorfman D, Pu LL. The value of color duplex imaging for planning and performing a free anterolateral thigh perforator flap. Ann Plast Surg. 2014 Suppl 1;72:s6–8.
11. Rozen WM, Phillips TJ, Ashton MW, Stella DL, Gibson RN, Taylor GI. Preoperative imaging for DIEA perforator flaps: a comparative study of computed tomographic angiography and doppler ultrasound. Plast Reconstr Surg. 2008 Suppl 1;121:s1–8.
12. Scott JR, Liu D, Said H, Neligan PC, Mathes DW. Computed tomographic angiography in planning abdomen-based microsurgical breast reconstruction: a comparison with color duplex ultrasound. Plast Reconstr Surg. 2010;125(2):446–53.
13. Feng S, Min P, Grassetti L, Lazzeri D, Sadigh P, Nicoli F, Torresetti M, Gao W, di Benedetto G, Zhang W, Zhang YX. A prospective head-to-head comparison of color doppler ultrasound and computed tomographic angiography in the preoperative planning of lower extremity perforator flaps. Plast Reconstr Surg. 2016;137(1):335–47.
14. Su W, Lu L, Lazzeri D, Zhang YX, Wang D, Innocenti M, Qian Y, Agostini T, Levin LS, Messmer C. Contrast-enhanced ultrasound combined with three-dimensional reconstruction in preoperative perforator flap planning. Plast Reconstr Surg. 2013;131(1):80–93.
15. Gunnarsson GL, Tei T, Thomsen JB. Color Doppler ultrasonography-targeted perforator mapping and angiosome-based flap reconstruction. Ann Plast Surg. 2016;77(4):464–68.
16. Nahabedian MY. Overview of perforator imaging and flap perfusion technologies. Clin Plast Surg. 2011;38(2):165–74.
17. Rozen WM, Garcia-Tutor E, Alonso-Burgos A, Acosta R, Stillaert F, Zubieta JL, Hamdi M, Whitaker IS, Ashton MW. Planning and optimising DIEP flaps with virtual surgery: the Navarra experience. J Plast Reconstr Aesthet Surg. 2010;63(2):289–97.
18. Alonso-Burgos A, Garcia-Tutor E, Bastarrika G, Cano D, Martinez-Cuesta A, Pina LJ. Preoperative planning of deep inferior epigastric artery perforator flap reconstruction with multislice-CT angiography: imaging findings and initial experience. J Plast Reconstr Aesthet Surg. 2006;59(6):585–93.
19. Rosson GD, Williams CG, Fishman EK, Singh NK. 3D CT angiography of abdominal wall vascular perforators to plan DIEAP flaps. Microsurg. 2007;27(8):641–46.
20. Gacto-Sanchez P, Sicilia-Castro D, Gomez-Cia T, Lagares A, Collell T, Suarez C, Parra C, Leal S, Infante-Cossio P, De la Higuera JM. Computed tomographic angiography with VirSSPA three-dimensional software for perforator navigation improves perioperative outcomes in DIEP flap breast reconstruction. Plast Reconstr Surg. 2010;125(1):24–31.
21. Cina A, Barone-Adesi L, Rinaldi P, Cipriani A, Salgarello M, Masetti R, Bonomo L. Planning deep inferior epigastric perforator flaps for breast reconstruction: a comparison between multidetector computed tomography and magnetic resonance angiography. Eur Radiol. 2013;23(8):2333–343.
22. Rozen WM, Stella DL, Bowden J, Taylor GI, Ashton MW. Advances in the pre-operative planning of deep inferior epigastric artery perforator flaps: magnetic resonance angiography. Microsurg. 2009;29(2):119–23.
23. Smit JM, Dimopoulou A, Liss AG, Zeebregts CJ, Kildal M, Whitaker IS, Magnusson A, Acosta R. Preoperative CT angiography reduces surgery time in perforator flap reconstruction. J Plast Reconstr Aesthet Surg. 2009;62(9):1112–117.
24. Fitzgerald O’Connor E, Rozen WM, Chowdhry M, Band B, Ramakrishnan VV, Griffiths M. Preoperative computed tomography angiography for planning DIEP flap breast reconstruction reduces operative time and overall complications. Gland Surg. 2016;5(2):93–98.
25. Rozen WM, Ashton MW, Stella DL, Phillips TJ, Taylor GI. Stereotactic image-guided navigation in the preoperative imaging of perforators for DIEP flap breast reconstruction. Microsurg. 2008;28(6):417–23.
26. Chae MP, Hunter-Smith DJ, Rozen WM. Comparative analysis of fluorescent angiography, computed tomographic angiography and magnetic resonance angiography for planning autologous breast reconstruction. Gland Surg. 2015;4(2):164–78.
27. Vasile JV, Levine JL. Magnetic resonance angiography in perforator flap breast reconstruction. Gland Surg. 2016;5(2):197–211.
28. Chae MP, Hunter-Smith DJ, Rozen WM. Comparative study of software techniques for 3D mapping of perforators in deep inferior epigastric artery perforator flap planning. Gland Surg. 2016;5(2):99–106.
29. Gao Z, Meng D, Lu H, Yao B, Huang N, Ye Z. Utility of dual-energy spectral CT and low-iodine contrast medium in DIEP angiography. Int J Clin Pract. 2016 Suppl 9b;70:b64–71.
30. Niumsawatt V, Debrotwir AN, Rozen WM. Reducing radiation dose without compromising image quality in preoperative perforator flap imaging with CTA using ASIR technology. Int Surg. 2014;99(4):485–91.
31. Kagen AC, Hossain R, Dayan E, Maddula S, Samson W, Dayan J, Smith ML. Modern perforator flap imaging with high-resolution blood pool MR angiography. Radiographics. 2015;35(3):901–15.
32. Newman TM, Vasile J, Levine JL, Greenspun DT, Allen RJ, Chao MT, Winchester PA, Prince MR. Perforator flap magnetic resonance angiography for reconstructive breast surgery: a review of 25 deep inferior epigastric and gluteal perforator artery flap patients. J Magn Reson Imaging. 2010;31(5):1176–84.
33. Schaverien MV, Ludman CN, Neil-Dwyer J, McCulley SJ. Contrast-enhanced magnetic resonance angiography for preoperative imaging of deep inferior epigastric artery perforator flaps: advantages and disadvantages compared with computed tomography angiography: a United Kingdom perspective. Ann Plast Surg. 2011;67(6):671–74.
34. Schaverien MV, Ludman CN, Neil-Dwyer J, Perks GB, Akhtar N, Rodrigues JN, Benetatos K, Raurell A, Rasheed T, McCulley SJ. Contrast-enhanced magnetic resonance angiography for preoperative imaging in DIEP flap breast reconstruction. Plast Reconstr Surg. 2011;128(1):56–62.
35. Zou Z, Kate Lee H, Levine JL, Greenspun DT, Allen RJ, Vasile J, Rohde C, Prince MR. Gadofosveset trisodium-enhanced abdominal perforator MRA. J Magn Reson Imaging. 2012;35(3):711–16.
36. Versluis B, Tuinder S, Boetes C, Van Der Hulst R, Lataster A, Van Mulken T, Wildberger J, de Haan M, Leiner T. Equilibrium-phase high spatial resolution contrast-enhanced MR angiography at 1.5T in preoperative imaging for perforator flap breast reconstruction. PLOS ONE. 2013;8(8):e71286.
37. Mohan AT, Saint-Cyr M. Advances in imaging technologies for planning breast reconstruction. Gland Surg. 2016;5(2):242–54.
38. Yang X, Miller MJ, Friel HT, Slijepcevic A, Knopp MV. Perforator phase contrast angiography of deep inferior epigastric perforators: a better preoperative imaging tool for flap surgery than computed tomographic angiography? Invest Radiol. 2017;52(6):334–42.
39. Weum S, Mercer JB, de Weerd L. Evaluation of dynamic infrared thermography as an alternative to CT angiography for perforator mapping in breast reconstruction: a clinical study. BMC Med Imaging. 2016;16(1):43.
40. Sheena Y, Jennison T, Hardwicke JT, Titley OG. Detection of perforators using thermal imaging. Plast Reconstr Surg. 2013;132(6):1603–610.
41. Hardwicke JT, Osmani O, Skillman JM. Detection of perforators using smartphone thermal imaging. Plast Reconstr Surg. 2016;137(1):39–41.
42. Chubb DP, Taylor GI, Ashton MW. True and ‘choke’ anastomoses between perforator angiosomes: part II. dynamic thermographic identification. Plast Reconstr Surg. 2013;132(6):1457–464.
43. Chubb D, Rozen WM, Whitaker IS, Ashton MW. Images in plastic surgery: digital thermographic photography (‘thermal imaging’) for preoperative perforator mapping. Ann Plast Surg. 2011;66(4):324–25.
44. Hijjawi JB, Blondeel PN. Advancing deep inferior epigastric artery perforator flap breast reconstruction through multidetector row computed tomography: an evolution in preoperative imaging.J Reconstr Microsurg. 2010;26(1):11–20.
45. Newman MI, Samson MC. The application of laser-assisted indocyanine green fluorescent dye angiography in microsurgical breast reconstruction. J Reconstr Microsurg. 2009;25(1):21–26.
46. Komorowska-Timek E, Gurtner GC. Intraoperative perfusion mapping with laser-assisted indocyanine green imaging can predict and prevent complications in immediate breast reconstruction. Plast Reconstr Surg. 2010;125(4):1065–073.
47. Holm C, Tegeler J, Mayr M, Becker A, Pfeiffer UJ, Muhlbauer W. Monitoring free flaps using laser-induced fluorescence of indocyanine green: a preliminary experience. Microsurg. 2002;22(7):278–87.
48. Pestana IAMD, Zenn MRMD. Correlation between abdominal perforator vessels identified with preoperative ct angiography and intraoperative fluorescent angiography in the microsurgical breast reconstruction patient. Ann Plast Surg. 2014;72(6):S144–S49.
49. Burnier P, Niddam J, Bosc R, Hersant B, Meningaud JP. Indocyanine green applications in plastic surgery: A review of the literature. J Plast Reconstr Aesthet Surg. 2017;70(6):814–27.
50. Bigdeli AK, Gazyakan E, Schmidt VJ, Hernekamp FJ, Harhaus L, Henzler T, Kremer T, Kneser U, Hirche C. Indocyanine green fluorescence for free-flap perfusion imaging revisited: advanced decision making by virtual perfusion reality in visionsense fusion imaging angiography. Surg Innov. 2016;23(3):249–60.
51. Casey WJ, 3rd, Connolly KA, Nanda A, Rebecca AM, Perdikis G, Smith AA. Indocyanine green laser angiography improves deep inferior epigastric perforator flap outcomes following abdominal suction lipectomy. Plast Reconstr Surg. 2015;135(3):491e–97e.
52. Muntean MV, Muntean V, Ardelean F, Georgescu A. Dynamic perfusion assessment during perforator flap surgery: an up-to-date. Clujul Med. 2015;88(3):293–97.
53. Wu C, Kim S, Halvorson EG. Laser-assisted indocyanine green angiography: a critical appraisal. Ann Plast Surg. 2013;70(5):613–19.
54. Taylor GI, Chubb DP, Ashton MW. True and ‘choke’ anastomoses between perforator angiosomes: part I: anatomical location. Plast Reconstr Surg. 2013;132(6):1447–56.
55. Taylor GI, Corlett RJ, Ashton MW. The functional angiosome: clinical implications of the anatomical concept. Plast Reconstr Surg. 2017;140(4):721–33.
56. Lee KT, Mun GH. Perfusion of the diep flaps: A systematic review with meta-analysis. Microsurg. 2016;38(1):98–108.
57. Taylor GI, Corlett RJ, Dhar SC, Ashton MW. The anatomical (angiosome) and clinical territories of cutaneous perforating arteries: development of the concept and designing safe flaps. Plast Reconstr Surg. 2011;127(4):1447–59.
58. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ. 2009;339:b2535.