Perforator flap breast reconstruction remains the “gold standard” for autologous breast reconstruction because of the ability to preserve the underlying muscular units.  In the process of preserving the muscle we find we are limited to a single perforator for GAP flaps and a medial or lateral row perforator(s) for DIEP flaps.  This dissection results in definitive vascular zones of perfusion.  There is little concern of adequate vascular perfusion in those flaps with medium to large perforators and/or no need for peripheral zone inclusion. However, in those flaps with smaller perforators or those reconstructions which require reliance on the peripheral zones for needed volume, the vascular inflow is a concern.  To overcome this uncertainty, nearby (secondary) perforators were dissected just through the muscle and anastomosed to the primary system after flap harvest.  The improved perfusion of adjacent zones has allowed us to more reliably include them in the reconstruction.          

Top pictures:Left- reveals the primary (right) and secondary (left) perforators dissected         on a GAP flap.

            Right- corresponding surface points of entry of perforators dissected

Bottom pictures: Left- deep surface of the GAP flap showing location of the perforators

Right- the secondary perforator has been anastomosed to the primary