Where do perforator flaps fit in our armamentarium?

The Facial Artery Perforator Flap for Reconstruction of Facial Defects: Surgical Pearls and Clinical Series

BACKGROUND

Based on the knowledge of facial vascularity, facial artery perforator flaps could be used as potent tools for facial defect reconstruction. However, lack of experience and misconception of this technique limits the broad application in the clinical background. Here, we discussed surgical techniques based on our previous experience with facial artery perforator (FAP)-based facial defect reconstruction.

METHODS

A retrospective review of 12 patients undergoing facial defect reconstruction using an FAP flap was performed, including 8 defects in the mid-facial part and 4 defects in the nasal area generally resulted from basal cell carcinoma (8 patients), squamous cell carcinoma (3 patients), and actinic keratosis (one patient).

RESULTS

All patients received one-stage FAP flap reconstruction. The overall follow-up period was 6 to 12 months. All reconstructions were successful with satisfactory patient-reported outcome and no local recurrence. No significant complications were observed in most cases, except for one instance of partial flap loss.

CONCLUSIONS

Overall, taking advantage of FAP flaps will contribute to a good functional and esthetic outcome of facial defect reconstructions.

Current status and evolution of microsurgical tongue reconstructions, part I

Reconstructive surgery in the management of head and neck cancer has evolved to include structure-specific approaches in which organ-specific treatment algorithms help optimize outcomes. Tongue cancer management and reconstruction are surgical challenges for which well-executed reconstructive plans should be completed promptly to avoid delaying any subsequently planned oncologic treatment. Crucial considerations in tongue cancer resection are the significant functional morbidity associated with surgical defects, particularly in terms of speech and swallowing, and the consequent negative impact on patients' quality of life. With the evolution of microsurgical techniques and the development of the perforator flap concept, flap options can be tailored to the characteristics of various tongue defects. This has allowed the implementation of pliable flaps that can help restore tongue mobility and yield subsequent functional outcomes. Using an evolutional framework, we present this series of reviews related to tongue reconstruction. The first part of the review summarizes flap options and flap-related factors, such as volume and tissue characteristics. Related functional aspects are also presented, including tongue mobility, speech, and swallowing, as well as ways to evaluate and optimize these outcomes.

Surgical defect reconstructions in knee, lower leg, and foot with flaps: a retrospective analysis

Background

The first description of local fascio-cutaneous flaps used for the coverage of soft tissue defects of the limbs originates from the 1980s. Over the years, this technique has advanced, and in the meantime, a sub-group of flaps named perforator-based propeller flaps has gained increased attention. In our study, we aimed to demonstrate our experience of operating surgeries with perforator-based propeller flaps and to compare this technique with other flap techniques, which are to reconstruct tissue defects of the knee, lower leg, and foot.

Methods

A systematic retrospective search for flap procedures for defect reconstructions in the knee, lower leg, and foot from our database was performed. All data between January 2010 and August 2018 were considered. We identified 56 procedures performed on 14 female and 42 male patients with the mean age of 54.13 years. Reconstruction procedures consisted of 34 free flaps, 14 perforator-based propeller flaps, and eight other perforator-based flaps. Compared to free flaps, the perforator-based propeller flaps had shorter surgery duration by 46.6% (p < 0.0001) and the complication rate in the cases of perforator-based propeller flaps was reduced by 31.14% (p = 0.0315). Furthermore, the operations carried out with perforator-based propeller flaps resulted in a significantly lower rate of revisions by 36.03% (p = 0.0204), compared to those with free flaps. The majority of the donor sites of free flaps were self-closing with the direct suture (p = 0.004).

Conclusions

Based on our findings, we can propose the applicability of perforator-based flaps in treating defects of the knee, lower leg, and foot. With a correct indication, perforator-based propeller flap represents a promising alternative to free flaps, with its significantly shorter surgery duration, lower complications rate, and lower revision rate. However, both techniques of the free flap transfer and the transfer of local pedicle-based flap possess their advantages and disadvantages. Therefore, it is hard to define which microsurgical technique is exclusive in treating lower leg defects.

Level of evidence: Level IV, therapeutic study.

Perforator Flap versus Conventional Flap

The introduction of perforator flaps represented a significant advance in microsurgical reconstruction. However, confusion has developed due to the erroneous belief that perforator flaps are different from conventional flaps. The concept of the perforator is not new, but is an idea that evolved from the conventional flap. In fact, some of the flaps used by microsurgeons were perforator flaps. The only difference is the anatomical level of the blood vessels involved; the perforator concept is focused on the distal circulation, so-called 'perforator'. Therefore, thinner sections of tissue can be taken from the conventional donor sites of myocutaneous flaps. With the use of perforators, there are no longer "flap of choice" for specific reconstructions, because conventional donor sites have become universal donor sites, enabling the harvesting of a variety of flaps. Moreover, depending on the surgeon's ability, any flap can be utilized as a perforator-based island flap whose source vessel has been completely preserved. Therefore, tissues can be efficiently customized and tailored into any configuration required for reconstruction. The application of perforator flap technique enables more precise dissection, and allows more selective harvesting of thinner flaps, which will expand options in reconstructive surgery. No doubt the technique will continue to evolve.

The freestyle pedicle perforator flap: a new favorite for the reconstruction of moderate-sized defects of the torso and extremities

BACKGROUND

Perforating vessels are a consistent anatomical finding and well described in the current literature. Any skin flap can be raised on a subcutaneous pedicle as long as it contains at least one supplying perforator. Perforator flaps have been interlinked with microsurgery and generally not widely performed by the general plastic surgeons. The aim of this paper is to present the simplicity of pedicled perforator flap reconstruction of moderate-sized defects of the extremities and torso.

METHODS

We retrospectively reviewed the charts of 34 patients reconstructed using 34 freestyle pedicled perforator flaps for moderate-sized defects of the truncus and extremities. We registered indications, flap size and localization, success rate, and complications. Most importantly, we describe a simple approach to the design of freestyle pedicled perforator flaps and elaborate on technical aspects in the context of current literature.

RESULTS

The reconstructive goals were achieved in all cases without any total flap loss or major complications. Minor complications occurred in 7/34 (21 %) cases consisting of venous congestion leading to distal tip necrosis or epidermolysis; partial flap loss was significant in 4 cases, however never more than 10 % of the total flap size. Reconstruction was performed on the lower limb in 13 cases, upper limb in 12, and 9 cases were on the truncus. The angle of rotation was 90° in 21 cases and 180° in 13 cases. The most common indication was reconstruction of oncological skin defects; melanoma 19, BCC 6, SCC 2, other 7. The flap size varied from 1.5×3 cm to 12×22 cm. The perforator identification was done by intraoperative exploration in 17 cases and by color Doppler ultrasonography in 17 cases.

CONCLUSIONS

Moderate-sized defects of the torso and extremities can be successfully reconstructed by pedicled perforator flaps. The flap dissection is simple, and the complication rates comparable to other reconstructive options. Level of evidence IV, therapeutic study.

Flap reconstruction of the elbow and forearm: a case-based approach

Elbow and forearm wounds have distinct reconstructive requirements, but both require a durable and pliable solution. Pedicle, free fasciocutaneous and muscle, and distant (2-stage) flaps have a role in wound reconstruction in these unique areas. This article presents practical surgical cases as a guide to soft tissue reconstruction of the elbow and forearm.

Scrotal and perineal reconstruction

The scrotal and perineal area serves a special function. It is the pelvic outlet for the gastrointestinal tract, urinary system, and sexual function. In the male, the scrotum allows testicular mobility to reduce trauma and allow optimal thermal regulation for spermatogenesis. Trauma, infection, and cancer resection create defects that require reconstruction. The reconstructive goal here is to obtain durable coverage, function, and lastly aesthetic outcome. Pedicled local and regional flaps are the mainstay for this area. Due to the special function and appearance of the scrotum, reconstructive options for total scrotal defect always fall far short of the native scrotum. On the other hand, perineal reconstruction is overall satisfactory.