Dear Sir, We read the article by Leonard CG et al. with interest. Like the authors, we have needed to use large ALT flaps and whilst peripheral necrosis is almost unheard of, even with single perforators, it is always preferable to have more vessels supplying the flap. In some cases, there may only be a single sizeable perforator arising from the descending branch of the lateral circumflex artery (DB-LCFA); according to studies these mostly perforate the fascia within 3 cm of the midpoint of a line joining the ASIS and the superolateral patella. More proximally however, there is often a substantial perforator that arises from the transverse branch of the lateral circumflex artery (TB-LCFA) that lies on or pierces the tensor fascia lata. When large skin islands are needed, using both the DB-LCFA and the TB-LCFA in a single set of micro-anastomoses requires significant dissection to trace the vessels proximally and requires the conjoint vessel to be divided close to the profunda. The first author has approached such scenarios by 'perforator transfer'; the proximal perforator is traced proximally until it is a reasonable size and it is then cut and anastomosed to the DB-LCFA system. There are several potential recipient sites - (1) the side branches of the proximal DB-LCFA, particularly those entering the deep muscle bed, or a branch to the rectus femoris, or (2) the distal end of the DB-LCFA. In essence, two arterial territories are combined into one. The latter is a particularly useful technique to 'elongate' a pedicle whilst 'augmenting' the vascularity of an ALT flap.
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