Hartrampf’s Zones of Perfusion

Hartrampf's Zones of Perfusion refers to the subdivision of the lower abdominal flap into 4 equal zones based on their level of perfusion and viability. This article examines the history, clinical significant and current concepts.
Hartrampf’s Zones of Perfusion


Hartrampf’s Zones of Perfusion refers to the subdivision of the lower abdominal flap into 4 equal zones based on their level of perfusion and viability.

Hartrampf's Zones of Perfusion

Zones I-IV

Identifying the zones

  1. Divide lower abdominal flap at midline to form 2 hemi-abdomens.
  2. Zone I always correlates to the zone of selected perforator.
  3. Zone II is adjacent to zone I on the contralateral hemi-abdomen.
  4. Zone III is lateral to zone I
  5. Zone IV is lateral to zone II

Clinical Significance

  • Zone I: most perfused and is the most reliable for flap reconstruction.
  • Zone IV: most distant one, least perfused and unlikely to be viable.
Holm's Zones of Perfusion


The Origin of Zones of Perfusion

Whilst initially described by Scheflan and Dinner for a unipedicled TRAM flap, Hartrampf’s name has been associated with the zones after his paper on TRAM flap for breast reconstruction.

Holm’s Modification

Further studies have casted a shadow on the strictness of Hartrampf’s Zones of Perfusion.

1 year after Hartrampf’s paper, Dinner’s study suggested zones II and III should be switched. This was later confirmed by Holm et al in a fluorescent perfusion study.

Saint-Cyr’s Modification

There is often confusion regarding which is more accurate, Hartrampf’s or Holm’s Zones.

Saint-Cyr et al clarified zones of perfusion with 3D and 4D CTA studies. The zones depend on the row position of the perforator harvested.

  • Medial row of perforators have a more centralised perfusion, therefore Hartrampf’s classification is valid.
  • Lateral row of perforators have a more lateral perfusion, therefore Holm’s classification is valid.

Saint-Cyr et al also introduced the perforasome concept and the perforasome Zone’s of perfusion.


  1. Dinner MI, Dowden RV, Scheflan M. Refinements in the use of the transverse abdominal island flap for postmastectomy reconstruction. Ann Plast Surg. 1983 Nov;11(5):362-72.
  2. C. R. Hartrampf’s Jr., B. J. Michelow. Hartrampf’s Breast Reconstruction with Living Tissue. (New York, Raven Press, 1990)
  3. Holm C et al. Perfusion zones of the DIEP flap revisited: a clinical study. Plast Reconstr Surg. 2006 Jan;117(1):37-43.
  4. Saint-Cyr M. Assessing perforator architecture. Clin Plast Surg. 2011 Apr;38(2):175-202. doi: 10.1016/j.cps.2011.03.015.
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