Perforator flaps have become standard fare for the reconstructive surgeon performing free TRAM, gluteal, and other free flaps. Advantages have included less donor-site morbidity, increased pedicle lengths, and more reconstructive options. These flaps have also brought new challenges. The most obvious to those used to muscle-inclusive free TRAMs is the lack of fascia and muscle for insetting and supporting flaps, and the loss of stability of the perforator pedicle. Now freed from its muscular constraints, the perforator pedicle is easily kinked and compressed by surrounding tissue. Perhaps the most difficult inset is the SIEP flap, as the pedicle is superficial in the flap and often must make a 90- or 180-degree turn in order to properly inset the flap and still give good breast projection. The author's technique of inset, which maintains lower pole fullness and delivers the pedicle in proper orientation was presented.
