The thin profunda femoral artery perforator flap for tongue reconstruction

Customized Soft Tissue Free Flaps in Head and Neck Reconstruction

The integration of imaging technologies such as computed tomography angiography and color Doppler ultrasonography are transforming soft tissue free flap reconstruction. The search for thinner and more refined flaps has expanded indications for flaps harvested from donor sites that were not commonly used in head and neck reconstruction. This article explores how these tools and techniques facilitate precise flap selection, thickness, and design customization based on detailed patient preoperative perforator anatomy and vascular configuration mapping. Optimizing outcomes with tailored flap designs improves surgical accuracy and patient-specific results in soft tissue reconstruction.

The Role of Computed Tomography Angiography in Perforator Flap Planning

Preoperative computed tomography angiography (CTA) for perforator free flaps is accurate, precise, and reliable in mapping perforator anatomy that can be used in the intraoperative domain. CTA holds important clinical value as a tool in surgical decision making and surgical innovation, enabling reconstructive surgeons to tailor complex flap designs for extensive defects. Integration into existing infrastructure for virtual surgical planning is feasible, and future efforts to characterize the association of preoperative CTA with postoperative outcomes and cost-analyses for perforator flaps are warranted.

Profunda Artery Perforator Flaps in Head and Neck Reconstruction: Anatomy, Surgical Techniques, and Evolving Applications

Reconstructive surgeons navigate a plethora of options when choosing a soft-tissue flap donor site for head and neck reconstruction, each with its distinct pros and cons. This review delves into the profunda artery perforator flap and provides expert recommendations for its use in head and neck reconstruction.

Contralateral facial artery myomucosal island flap for the reconstruction of T2-T3 oncologic oral defects

Objectives

To avoid the oncologic risks of ipsilateral regional flaps, this study aimed to explore the feasibility and clinical outcomes of the contralateral-based facial artery myomucosal island flap (C-FAMMIF) for oral T2-T3 oncologic defects reconstruction.

Methods

A study of flap anatomy was conducted on 7 cadaver samples and a cohort of 24 patients who received C-FAMMIF reconstruction after malignancy resection were retrospectively researched. A balanced anterolateral thigh flap (ALT) group of 47 patients was extracted as control group using propensity score matching method. Progression-free survival (PFS), functional outcomes, and donor site complications were assessed.

Results

Consistent blood supply and drainage through facial artery and vein with median maximum pedicle length of 106 mm supported contralateral reconstruction. The superficial vein drainage pattern indicated safer flap harvest at contralateral neck under circumstances of ipsilateral neck dissections. The pedicle and marginal facial nerve formed three anatomical patterns. The surgical management of each was described. Patients with ipsilateral pN+ neck accounted for 41.7% and 40.4% in the C-FAMMIF and ALT group, respectively. The 2-year PFS rate between the C-FAMMIF and ALT groups was not significantly different (88.2% in C-FAMMIF group and 84.6% in ALT group, respectively, p = 0.6358). Promising recoveries were observed for swallowing function and tactile sensation. The donor sites healed upon primary closure without trismus or permanent facial palsy.

Conclusion

Our findings suggested that C-FAMMIF is feasible and safe for T2-T3 oral oncologic defect reconstruction in patients with ipsilateral cN+ neck.

Thin Profunda Artery Perforator Flap for Hand and Upper Extremity Coverage

The profunda artery perforator (PAP) flap provides a good option for hand and upper extremity reconstruction. The reliable quality, caliber, and number of perforators in the posteromedial thigh support large flaps with long pedicles. The PAP flap has been widely used for breast reconstruction, although its use in the extremities has been slower to catch on due to the bulk and thickness of the subcutaneous tissue. The authors discuss evolution of thin flaps and our application of the thin and superthin PAP flap for upper extremity reconstruction.

Aesthetic Considerations of Simultaneous Reconstruction With Free Flap for Local Advanced Hypopharyngeal Combined With Cervical Esophageal Cancer

BACKGROUND AND OBJECTIVE

Patients with local advanced hypopharyngeal combined with esophageal cancer often require total laryngectomy and cervical esophagectomy, which result in big-sized upper aerodigestive tract defects and neck deformities. Although free flap is widely used to reconstruct aerodigestive defects, the aesthetic results especially that of neck contour have not brought to the forefront or discussed extensively. This article aims to report the preliminary aesthetic results of free flap reconstruction for local advanced hypopharyngeal cancer combined with cervical esophageal cancer defects, highlighting the thickness of subcutaneous fat of the flap.

METHODS

A retrospective study of 21 patients with local advanced hypopharyngeal combined with cervical esophageal cancer from July 2010 to August 2022 was conducted. After completing total laryngectomy, bilateral neck dissection, and removal of the tumor with safe margin, a free thigh flap of subcutaneous fat greater than 1 cm in thickness was used to reconstruct the hypopharyngeal and cervical esophageal defects. In addition to general demographic, oncological, and reconstructive data, preoperative and postoperative neck circumferences were recorded and compared. A subjective questionnaire survey was conducted on patients' satisfaction with postoperative neck contour. The patients were followed up from 3 to 10 years, with an average of 3 years.

RESULTS

There were 2 cases (2/21) of free flap loss because of flap necrosis and secondary repair with a pedicled pectoralis major flap. Nineteen flaps (19/21) survived. Three cases (3/21) developed a pharyngeal fistula and one case (1/21) experienced salivary fistula, all of the fistulae healed after drainage and dressing change. There was a relatively high satisfaction rate among patients (16/21) with the postoperative neck contour. A paired sample t test showed no statistically significant difference between the preoperative and postoperative values ( t = 2.002, P > 0.05). Patients with a thicker subcutaneous fat flap (≥1.5 cm) had a more symmetrical and fuller neck contour during long-term postoperative follow-up.

CONCLUSIONS

The application of a fat-rich subcutaneous free thigh flap to reconstruct the defect of local advanced hypopharyngeal combined with cervical esophageal cancer can achieve better neck aesthetic contour.

Use of free flaps with supermicrosurgery for oncological reconstruction of the maxillofacial region

Supermicrosurgery involves the dissection and anastomosis of vessels<0.8 mm in diameter with minimal donor site morbidity. This study evaluated the feasibility and outcomes of free flaps using supermicrosurgery to repair oncological defects in the maxillofacial region. Forty-two patients were treated with supermicrosurgery to repair oncological defects in the maxillofacial region between December 2015 and February 2021. The supermicrosurgery technique was used for different types of free flap, including 24 superficial circumflex iliac artery perforator flaps, seven anterolateral thigh flaps, three peroneal artery perforator flaps, five medial femoral condyle osteo-adipofascial flaps, and three profunda artery perforator flaps. An artery-to-artery approach was used in 38 patients; venous grafts for anastomosis were used in four patients to resolve an arterial discrepancy. Forty-one flaps (97.6%) survived. Thirty-six patients (85.7%) healed without any complications; three flaps required revision surgery including one lost, one demonstrated wound dehiscence, and two demonstrated wound infection. Supermicrosurgery is a useful complement to conventional microsurgery in head and neck reconstruction.

Profunda Artery Perforator Flaps From the Posteromedial Region of the Thigh for Head and Neck Reconstruction

OBJECTIVE

Profunda femoris artery perforator flaps (PAPFs) have not been widely used in head and neck reconstructions. The feasibility and outcomes of PAPFs for various head and neck reconstructions need to be investigated.

STUDY DESIGN

Retrospective analysis.

SETTING

A single-institution review.

METHODS

PAPFs were utilized in head and neck reconstructions from 2019 to 2021. Local anatomy, surgical technique, and complications were discussed. Chimeric PAPF applications with muscle components were described for coverage of extensive multiunit defects. Additionally, aesthetic and functional outcomes were compared with anterolateral thigh perforator flaps.

RESULTS

A total of 33 cases were included. The average age was 54.2 years (range, 30-74). The most common underlying pathology was oral squamous cell carcinoma (n = 26, 78.8%), while the mean ± SD body mass index was 25.4 ± 2.8 kg/m² . Middle perforators (n = 14, 42.4%) were the most commonly utilized ones. The perforator-based chimeric/composite applications were used in 9 (27.3%), with the muscular components consisting of gracilis (n = 3, 9.1%), adductor magnus (n = 5, 15.2%), or semimembranosus muscles (n = 1, 3.0%). Venous thromboses of the PAPFs were found in 2 (6.1%), though salvaged. The occurrence of postoperative 90-day morbidity (complication) was related to mandibulectomy/maxillectomy (P = .020). Postoperative validated questionnaires showed a trend of intermediate to high scores, indicating noninferior outcomes in several categories, when compared with the anterolateral thigh perforator flap counterparts.

CONCLUSION

PAPFs are a good reconstructive alternative for intermediate to large head and neck reconstructions. Besides, PAPFs can provide sufficient tissue volume and versatility of potentially incorporating adjacent muscle components.

The profunda artery perforator flap for upper limb reconstruction: A case report and literature review on the flap applications in reconstruction

The profunda femoris artery perforator (PAP) flap has been recently popularized as an alternative option for microsurgical reconstruction. The use of PAP flap has never been reported and described for reconstruction of the upper extremities, in particular the forearm. The purpose of this case report is to describe a case suggesting the PAP flap as a further reconstructive option in the upper limb. A 16-year-old girl who sustained a traumatic injury to her right dominant forearm resulting in subtotal circumferential tissue loss following a road traffic accident was referred to the authors' department 2 years post-trauma. The disabling fibrotic sequelae on her volar forearm (15 × 10 cm) resulted in a nonfunctional hand. She was unable to perform any active movement of her wrist or digits. Passive movements in the finger joints were preserved. Following debridement and reconstruction of nerves and tendons, soft tissues were resurfaced with a PAP flap. The transverse skin paddle, 12 × 7 cm, was placed distally with the adipofascial portion positioned proximally above the muscle bellies and anastomoses site. A small raw area (4 × 3 cm) was covered with an acellular dermal matrix (ADM). The postoperative course was uneventful. At 9 months postoperatively, the patient demonstrated active flexion and extension of the fingers with independent function. The patient reported satisfaction with the flap donor site and forearm resurfacing. The PAP flap can be a further option for areas requiring soft tissue coverage in patients refusing visible scars. This flap had both the advantage of reducing the morbidity and visibility of the donor site, as well as the ability to resurface a large recipient site with soft and pliable tissue, covering exposed nerves and tendons.

Imaging for thinned perforator flap harvest: current status and future perspectives

With advances in anatomical knowledge and technology, increased interest has been directed towards reconstruction with enhanced aesthetic and functional outcomes. A myriad of thinned perforator flap harvest approaches have been developed for this purpose; however, concerns about jeopardizing their vascularity remain. To ensure optimum reconstructive outcome without hampering the flap's microcirculation, it is important to make good use of the existing advanced imaging modalities that can provide clear visualization of perforator branches, particularly in the adipose layer, and an accurate assessment of flap perfusion. Therefore, this review will highlight the imaging modalities that have been utilized for harvesting a thinned perforator flap from these two perspectives, along with future insights into creating both functionally and aesthetically satisfying, yet simultaneously safe, thinned perforator flaps for the best reconstructive outcomes for patients.

The profunda artery perforator free flap for lower extremity reconstruction

BACKGROUND

The profunda artery perforator (PAP) flap has been reported in several types of reconstructions. This report aims to evaluate the usefulness and the clinical outcome of patients who underwent the PAP free flap for lower limb reconstruction.

METHODS

Between February 2018 and February 2020, nine patients with injury at lower third of the leg, foot dorsum or foot plant (eight acute injuries and one chronic ulcer) were selected. Mean wound size was 12.5 × 6.3 cm (9 × 5-14.5 × 6.5). Inclusion criteria consisted in patient's request to hide the donor site scar and the absence of previous traumas or surgery in the donor site. Patients considered unable to bear prolonged surgery were excluded. Patients underwent preoperative CT angiography and peri-operative Doopler, for perforator selection. All flaps were designed with pinch test, in elliptical shape. Microvascular anastomosis was performed to the tibialis anterior/posterior or medial plantar vessels. Outcomes were evaluated in terms of wound coverage success and patient's quality of life through Lower Extremity Functional Scale (LEFS) questionnaire.

RESULTS

The mean size of the harvested skin paddle was 13.5 × 7.4 cm (9 × 6-15 × 8) and mean pedicle length was 8.5 cm. Mean flap harvest time was 43.5 min (35-55). Flap survival rate was 100%, with one re-exploration with minimal partial flap loss. Mean follow-up was 13.5 months . Reconstructive results were successful in wound coverage and function. All patients reported satisfaction with their result by LEFS questionnaire (score:64.7).

CONCLUSION

With proper patient selection, there was 100% flap survival rate with no major complication. According to our data, the PAP free flap could be a valuable option for lower extremity reconstruction.

Chimeric profunda artery perforator - gracilis flap: A computed tomographic angiography study and case report

BACKGROUND

The possibility of harvesting the profunda artery perforator (PAP) flap in a chimeric configuration together with the innervated gracilis muscle may be a good option for dynamic reconstruction following total glossectomies. In this paper, we present a retrospective radiological study, which evaluates the presence and characteristics of the anatomical variation of the chimeric PAP - gracilis flap.

METHODS

The study sample comprised 66 patients (132 legs), 38 men, and 28 women with an average age of 56 ± 2 years old, who underwent head and neck reconstruction with a free flap. Preoperative computed tomographic angiography (CTA) was used for morphologic analysis. We present a case report of a patient with a total glossectomy reconstructed with this flap.

RESULTS

A perforator in the PAP area joining with the main pedicle of the gracilis muscle was found in 38 legs (28.8%). Mean length of the pedicle from the profunda femoral artery to the point where the perforator in the PAP area and the pedicle of the gracilis joined was 3.0 ± 0.3 cm. Differences in the existence of this vascular configuration were not significant comparing groups by sex, BMI, height, side or source vessel. Motion of the new tongue was documented clinically and with electromyography. The patient achieved an intelligible speech and normal diet.

CONCLUSIONS

Preoperative evaluation is necessary to assess the existence of a perforator in the PAP area joining with the main pedicle of the gracilis muscle. This chimeric flap has been demonstrated useful for dynamic reconstruction of a patient with a total glossectomy.