Discussion: The complete nomenclature for combined perforator flaps.

N and classification of compound perforator flaps can be as complex and convoluted as the vascular anatomy of these multicomponent flaps. The article “The Complete Nomenclature for Combined Perforator Flaps”1 presents the author’s proposed classification and standardized nomenclature for combined perforator flaps. I believe that the author’s classification of compound perforator flaps as either composite or combined, and subclassification of combined perforator flaps as chimeric or conjoined (Siamese), may prove useful academically and scientifically to aid in the study or creation of algorithms for use of these types of perforator flaps. I believe, however, that this classification and nomenclature scheme, although very detailed, does not describe the relevant vascular anatomy precisely enough to be useful for describing specific individual flaps in clinical situations. For example, Figure 3 shows a skin and subcutaneous tissue flap with two perforators arising from a common source pedicle. In the author’s classification, this flap is termed a “common form of indigenous conjoined perforator flap.” Although this may be a useful classification, it does not sufficiently describe the flap for clinical discussion and communication. The donor site of this flap is not specified, but if this were an anterolateral thigh flap, it would simply be named a double-perforator anterolateral thigh flap. If this flap were from the lower abdominal wall, it would simply be named a double-perforator deep inferior epigastric perforator (DIEP) flap. With either of these common names, we know immediately that the flap is conjoined (has a single contiguous skin paddle), that it is indigenous (does not have a fabricated intraflap microvascular anastomosis), and that it is common (meaning that both perforators arise from the same source pedicle vessel). Similarly, Figures 4 through 6 show an “independent,” “indigenous conjoined” DIEP flap, which is a longer name that I do not think is more precise than “bipedicled DIEP flap.” In either case, one still needs to describe whether each of the two pedicles is pedicled or free, and to which recipient vessels each pedicle is anastomosed. Likewise, Figures 17 through 19 show a “sequential fabricated chimeric perforator free flap.” This name, however, does not sufficiently describe the vascular anatomy, except to state that it is fabricated (that there is an intraflap vascular anastomosis) and is not superior to the traditional descriptive term “sequential anterolateral thigh free flaps in series.” Either name requires further description to specify that the first anterolateral thigh flap “flows through” to the second anterolateral thigh flap. This complex and detailed classification and naming scheme for combined perforator flaps is well explained, and a number of examples are shown. Evidence of the utility of this naming and classification scheme, however, is not provided, and advantages over the existing naming convention are not demonstrated. I imagine that this naming and classification scheme may prove useful for scientific purposes, but there are no data in this article to support that contention.