Imaging of perforasome territories: the evolution of techniques

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.