Perforator-based Flap Research Articles

A New Flap Alternative for Trochanteric Pressure Sore Coverage

Management of long-term bedridden patients experiencing pressure sores still represents a surgical challenge due to limited flap alternatives and high recurrence rates after the treatment. Fasciocutaneous, musculocutaneous, local perforator-based flaps, and free flaps have all been used for treatment of trochanteric pressure sores. This study presents a new use of distal gluteus maximus (GM) muscle as an advancement musculocutaneous flap for coverage of trochanteric pressure sores in 7 patients. The technique involves design of a long V-shaped skin island over the distal fibers of the GM muscle, beginning from the inferoposterior wound edge and extending inferomedially, almost parallel to the gluteal crease. After its harvest as an island flap on the distal fibers of the GM muscle, the skin paddle can be advanced onto the trochanteric defect, whereas the muscle itself is rotated after severing its insertion to femur. If a second triangular skin island is designed on the proximal fibers of GM muscle to cover an associated sacral defect, 2 coexisting pressure sores can be reconstructed concomitantly with 2 skin paddles on a single muscle belly at 1 surgical setting. Of the 7 patients, 3 had 3 (bilateral trochanteric and sacral), 2 had 2 (sacral and trochanteric), and 2 had 1 (only trochanteric) pressure sores. All ulcers were closed successfully and all of the flaps survived totally without any complication except the one in which we experienced minimal wound dehiscence in the early postoperative period. Conclusively, our current surgical method provided a reliable coverage for trochanteric pressure sores although it was technically straightforward and fast. Additionally, it offers simultaneous closure of 2 pressure ulcers with 2 skin islands on a single muscle flap.

Lateral calcaneal artery perforator-based skin flaps for coverage of lower-posterior heel defects

Perforator-based flaps have been explored across almost all of the lower leg except in the Achilles tendon area. This paper introduced a perforator flap sourced from this area with regard to its anatomic basis and clinical applications. Twenty-four adult cadaver legs were dissected to investigate the perforators emerging along the lateral edge of the Achilles tendon in terms of number and location relative to the tip of the lateral malleolus, and distribution. Based on the anatomic findings, perforator flaps, based on the perforator(s) of the lateral calcaneal artery (LCA) alone or in concert with the perforator of the peroneal artery (PA), were used for reconstruction of lower-posterior heel defects in eight cases. Postoperatively, subjective assessment and Semmes-Weinstein filament test were performed to evaluate the sensibility of the sural nerve-innerved area. The PA ended into the anterior perforating branch and LCA at the level of 6.0 ± 1.4 cm (range 3.3-9.4 cm) above the tip of the lateral malleolus. Both PA and LCA, especially the LCA, gave rise to perforators to contribute to the integument overlying the Achilles tendon. Of eight flaps, six were based on perforator(s) of the LCA and two were on perforators of the PA and LCA. Follow-up lasted for 6-28 months (mean 13.8 months), during which total flap loss and nerve injury were not found. Functional and esthetic outcomes were good in all patients. The integument overlying the Achilles tendon gets its blood supply through the perforators of the LCA primarily and that of through the PA secondarily. The LCA perforator(s)-based and the LCA plus PA perforators-based stepladder flap is a reliable, sensate flap, and should be thought of as a valuable procedure of choice for coverage of lower-posterior heel defects in selected patients.

Lower limb reconstruction using propeller flaps

Background: The islanded pedicled perforator-based propeller design flap is a versatile local flap for reconstruction of defects of lower limbs from knee to leg to ankle to foot. Patients and Methods: All patients with small-and moderate-sized defects in lower limbs which required a flap cover are included in the study. Between October 2014 and September 2015, prospective study of patients undergoing perforator-based propeller flap procedure was performed. Patients were evaluated for defect size, defect location, procedure done, and donor site cover. Results and complications of the propeller flap were also analyzed. Atotal of eight flaps were done to cover defects of lower limbs. Results: Out of the eight flaps, seven were islanded on posterior tibial artery, one on the lateral geniculate artery perforator. Four flaps were used to cover lower one-third leg, three for middle one-third leg, and one for knee. The flap dimensions ranged from 3 cm×7 cm to 7 cm×19 cm. The median angle of rotation was 160°(ranging from 60° to 180°). Sixty-three percent of patients had associated fractures. Seven flaps survived completely and one flap had partial necrosis, which was managed with secondary split skin grafting. Conclusion: The islanded propeller design pedicled perforator flaps provides reliable coverage for small-to medium-sized defects for lower limbs, particularly lower one-third leg defects. This flap can provide an esthetically acceptable result as well.

The use of perforator radial fascial forearm flap in the management of recurrent carpal tunnel syndrome

Background Management of recurrent carpal tunnel syndrome is considered a challenge for hand surgeons. We treated this clinical entity using a novel technique involving pedicled tissue transfer using a perforator-based radial-sided fascial forearm flap. Patients and methods The procedure was performed in six patients, all of whom had undergone previous failed surgery to release the median nerve and a period of initial relief not less than 3 months. Results At an average of 24 months following the procedure, all patients reported symptomatic improvement with complete resolution of night-time symptoms. No patient reported worsening of symptoms postoperatively; however, subjective paresthesias persisted in three of the six patients. Objective assessment revealed complete resolution of Tinel's sign in half of the patients and significant improvement in the other half. The average two-point discrimination improved from 10 mm preoperatively to 6 mm postoperatively, and the average postoperative grip strength improved from 11 to 20 kg. Conclusion The radial perforator-based fascial forearm flap is a useful option in the management of selected patients with recurrent carpal tunnel syndrome.

Reconstruction of soft tissue defects in the distal third of the leg, ankle, and foot: A meta-analysis

Management of soft tissue defects in the distal third of the leg, ankle and foot has evolved over time despite its challenges. No option of coverage is universally recommended for defects in this region of the body. Our objectives were to review and analyze outcomes of reported options of reconstruction of soft tissue defects in this region. We conducted a search of PUBMED and HINARI databases from 2000-2014 to identify reported options of reconstruction of soft tissue defects of the leg, ankle, and foot. Pooled data from suitable articles were analyzed and the success and complication rates as well as the relative risks for failure and complications were computed. One thousand and thirty two articles were retrieved out of which thirty three met the inclusion criteria for analysis. All the 33 articles were uncontrolled cohort and descriptive studies. There were 14 reports on sural artery flap, 6 on perforator-based flaps, and 5 on free flaps. Cross leg flaps, adipofascial, peroneus brevis, and hemisoleus muscle flaps were reported in two studies each while medial plantar, supramalleolar, and skin grafts were reported in one study each. Flap failure was the commonest complication with free flaps while reconstruction with skin grafts had the lowest failure rate. Free flaps were, however, versatile for reconstruction of complex defect. Conclusively, meticulous planning is required in the reconstruction of defects of the lower third of the distal third of the leg, ankle, and foot in order to use the most appropriate method for best outcomes.

Free Tissue Harvest from the Thigh

BACKGROUND: The thigh offers a myriad of reconstructive options, from fasciocutaneous perforator flaps, to free functional muscle and composite tissue constructs. The surgeon should be familiar with the advantages and disadvantages specific to each flap in order to tailor the reconstructive plan to the needs of each patient. The authors reviewed the relevant donor-site morbidities associated with more commonly utilized thigh-based flaps. METHODS: A systematic review of the MEDLINE and Cochrane databases from 1994 to 2014 was conducted to identify all reports of “anterolateral thigh,” “anteromedial thigh,” “transverse upper gracillis,” tensor fascia lata,” “gracillis,” “rectus femoris,” and “vastus lateralis” flaps. Only studies that investigated donor-site outcomes related to pain, parasthesia, wound dehiscence, infection, hematoma, seroma, contour deformity, and/or objective functional performance were included. Case series or anecdotal reports with fewer than 5 flaps, as well as non-English and animal studies were excluded. RESULTS: From the initial 2,425 citations, 121 articles met criteria and were manually reviewed by two authors (Figure 1). A total of 4,276 flaps were analyzed, including 2,727 ALT, 102 AMT, 436 TUG, 193 TFL, 527 Gracilis, 164 RF, and 127 VL flaps. Of these, 3,458 (80.8%) were perforator-based flaps. The most frequently sited donor-site complication was parasthesia (n=496), followed by wound dehiscence (n=144), musculoskeletal dysfunction (n=69), infection (n=66), and pain (n=47). The frequency of donor-site skin grafting was highest among AMT flaps (22.5%), as were pain (4.9%) and parasthesia (19.6%). Donor-site dehiscence occurred over 3 times as often with the TUG flap when compared to other flap types (8.03% vs 2.2%). Despite mixed results regarding functional performance, there were no clinically significant reductions in strength, daily activities, or quality of life specific to any donor-site. Compared to perforator-flaps, muscle-flap reconstructions were associated with increased pain (2.1% vs 0.9%), infection, (2.2% vs 1.4%), and contour deformity (3.1% vs 0.6%). Rates of musculoskeletal dysfunction however, were similar in both (0.9% vs 1.8%) (Table 1).Figure 1: Trial-Flow Diagram.Table 1: Donor-Site Morbidity for Given Flap Type.CONCLUSION: Donor-site morbidity for commonly used thigh-flaps is minimal and appears to be well tolerated by most of patients. However, flap selection is highly individualized, and patients must be informed of potential complications and morbidities specific to each flap. We have established the most current review of donor-site morbidity for thigh-based flaps to aid the surgeon in this important discussion.

The Dorsal Metatarsal Artery Perforator Flap

Few options exist for the resurfacing of web-space and small soft tissue defects of the dorsum of the distal foot. The study examines the anatomy of the second to fourth dorsal metatarsal arteries in 16 fresh frozen cadavers to determine if the anatomy correlates to that in the hand, permitting the design of local flaps based on perforators of these vessels. A clinical case is also presented, illustrating the efficacy of such a perforator-based flap.Sixteen Asian cadaveric lower limbs were used for this study. The specimens were prepared with latex dye injection. Dissection under loupe magnification was carried out to determine the position and caliber of the cutaneous perforators from the dorsal metatarsal arteries, and the spread of the latex dye in the skin from these cutaneous perforators. One clinical case illustration of this perforator-based flap for distal foot defect resurfacing is presented.In our cadaveric study, each second to fourth dorsal metatarsal artery had between 2 and 5 cutaneous perforators with calibers of 0.5 to 0.7 mm in diameter. The most distal cutaneous perforator was present consistently, always arising between the heads of the respective metatarsals.In conclusion, the vascular anatomy of the second to fourth dorsal metatarsal arteries is similar to that in the hand, thus allowing for the design of reliable perforator-based flaps for distal foot resurfacing.

Reconstruction of the Achilles Tendon and Overlying Skin Defect

Although various reconstruction surgery techniques are available to repair posterior heel defects, the compound defects reconstruction is an ongoing surgical challenge. Complex, free tissue flaps are often clinically used in this repair operation but the techniques have some disadvantages, including intraoperative tedious dissections, vascular anastomosis, and postoperative thrombogenesis. Here, we present a single-stage procedure for Achilles tendon and its overlying skin defects repair with a complex posterior tibial artery perforator-based tissue flap on 3 patients. This method can repair the Achilles tendon and the soft tissue defects simultaneously in a relatively short operative time. The prognosis of the 3 operative patients described here was great for participating in exercise and daily work unassisted 18 to 26 months after operation. Clinical results indicate that our operative method can be effective in repair of Achilles tendon and its overlying skin defects without major complications.

The keystone-design perforator-based flap for leg defects: a synthesis of philosophies

Aim: The classical keystone-design flap, although elegantly employed for various trunk defects, has limited movement on the leg. This study aims to modify the keystone-design flaps for leg defects. Methods: A keystone-design flap, in which perforators are identified and dissected, is described specifically for elliptical defects overlying the tibia. Results: It retains the unique advantages of both the perforator island flap concept as well as the keystone-design philosophy. Conclusion: The technique as well as the possibilities of raising such flaps over various areas of the leg is outlined.

Comparison of outcomes of pressure sore reconstructions among perforator flaps, perforator‐based rotation fasciocutaneous flaps, and musculocutaneous flaps

Pressure sore reconstruction remains a significant challenge for plastic surgeons due to its high postoperative complication and recurrence rates. Free-style perforator flap, fasciocutaeous flap, and musculocutaneous flap are the most common options in pressure sore reconstructions. Our study compared the postoperative complications among these three flaps at Kaohsiung Chang Gung Memorial Hospital. From 2003 to 2012, 99 patients (54 men and 45 women) with grade III or IV pressure sores received regional flap reconstruction, consisting of three cohorts: group A, 35 free-style perforator-based flaps; group B, 37 gluteal rotation fasciocutaneous flaps; and group C, 27 musculocutaneous or muscle combined with fasciocutaneous flap. Wound complications such as wound infection, dehiscence, seroma formation of the donor site, partial or complete flap loss, and recurrence were reviewed. The mean follow-up period for group A was 24.2 months, 20.8 months in group B, and 19.0 months for group C. The overall complication rate was 22.9%, 32.4%, and 22.2% in groups A, B, and C, respectively. The flap necrosis rate was 11.4%, 13.5%, and 0% in groups A, B, and C, respectively. There was no statistical significance regarding complication rate and flap necrosis rate among different groups. In our study, the differences of complication rates and flap necrosis rate between these groups were not statistically significant. Further investigations should be conducted.

Pre-expanded Thoracodorsal Artery Perforator-Based Flaps for Repair of Severe Scarring in Cervicofacial Regions

Reconstruction of cervicofacial scarring continues to present challenges for surgical treatment. Here we present our clinical experience in repairing cervicofacial scarring using pre-expanded thoracodorsal artery perforator flaps. From January 2007 to December 2012, 15 patients were treated for severe cervicofacial scarring. In the first surgical stage, expanders were implanted subcutaneously in the zone nourished by thoracodorsal artery perforators. The expansion generally took 3 to 6 months. In the second surgical stage, the cervicofacial cicatricial contracture was released and the secondary defect was covered with local flaps. The remaining wound was covered by the free thoracodorsal artery perforator expanded flap, which was anastomosed to the facial vascular bundle. The donor site was closed directly in all the patients. The postoperative follow-up time ranged from 1 to 5 years. The deformities were corrected, all flaps survived completely and none were bulky. The maximum length of the flaps was 32 cm (mean, 22.4 ± 4.2 cm), and the maximum width was 17 cm (mean, 14.4 ± 2.2 cm). All patients exhibited recovery of neck movement, and there was no recurrence of neck contracture. The pre-expanded thoracodorsal artery perforator flap is an ideal method for reconstruction of severe cervicofacial cicatricial contracture.

Peroneal artery perforator‐based flaps for reconstruction of middle and lower third post‐traumatic defects of the leg

Grade IIIb open tibial fractures require local or free flaps for cover of the fracture site. Perforator flap surgery is an innovative method for wound cover in this setting. The anatomy of perforating vessels of the peroneal artery is well described. All patients who underwent peroneal artery perforator-based flap cover for acute Grade IIIb fracture tibia between December 2011 and March 2013 were prospectively studied. The wounds were located either in middle or in lower third of the tibia. Flaps were performed under loupe magnification after identifying perforators preoperatively with handheld Doppler. All flaps were of a hockey stick or J design, incorporating the peroneal skin territory and completely islanded. Patients were followed up until all wounds were epithelialized. Eleven patients were identified. Eleven flaps were performed, out of which 10 survived entirely and served the purpose of stable wound cover. One patient sustained partial flap necrosis, which was debrided, and another local flap was performed. More than one perforator could be identified and retained in six of these 11 patients. The peroneal artery perforator-based flap is reliable and reproducible in an acute post-traumatic setting. It should be considered as a suitable alternative for reconstruction for limited defects with exposed fractured tibia over the middle and lower third of the leg.

Comparing the Effects of Pedicle Torsion on Axial or Perforator Flaps; Improving the Perforator Flap Resistance to Pedicle Torsion with Delay Phenomenon

The torsion of the flap's pedicle is one of the most common conditions causing vascular compromise. We aimed to compare the resistance to torsion of axial flap pedicle and perforator pedicle patterns. In the second part of the study, we investigated whether the delay phenomenon is an effective method for improving perforator flap resistance to pedicle torsion. In the first phase, 90 male Wistar rats were randomly divided into two groups: perforator and axial. Bilateral groin flaps were elevated in the axial group and bilateral posterior thigh perforator-based flaps were elevated in the perforator group. Viable flap areas were compared at 90, 180, 270, 360, and 720 degrees of pedicle rotation. Microangiographic and histopathological studies were performed. As a result, necrosis was seen following earlier rotation in the perforator group and viable flap areas were also lower. In the second phase, after delay procedure, the perforator flaps were exposed to 270, 360, and 720 degrees of pedicle rotation. With the delay procedure, no significant difference in viable flap areas was observed. In conclusion, the resistance to torsion of the axial flap pedicle pattern was greater than that of the perforator pedicle pattern, and the delay procedure was not an effective method for improving flap resistance to torsion.

Free-Style Dual Plane Recycling Tensor Fascia Lata Musculocutaneous Perforator Flap for Reconstruction of Recurrent Trochanteric Defects

Sequential flap coverage might be required for recurrent defects, but reusing a flap as a donor site has seldom been reported. The concept of a "free-style flap" has been developed, and it allows reconstructive surgeons to raise flaps with various designs reliably, even at sites of previous flap surgery. This article presents the concept of free-style recycling of a tensor fascia lata flap into a perforator-based flap separated in 2 planes in a patient with a recurrent bilateral trochanteric defect. If a reliable perforator is preserved and identified within the tissues by computed tomography angiography or a Doppler device, a new perforator flap can be designed and raised at the previous flap site.

Using the proximal perforator-based anterolateral thigh flap from the same donor site to salvage the reconstruction after failure of the distal perforator-based anterolateral thigh flap

We presented a patient who experienced the anterolateral thigh (ALT) flap failure but the reconstruction was successfully salvaged by harvesting a second ALT flap from the same donor site 2 days after the first reconstruction. A 47-year-old man received cancer ablation for right mouth floor squamous cell carcinoma. The resultant defect was planned to be reconstructed with the ALT flap. During the flap dissection, we identified three proximal cutaneous perforators originating from the transverse branch of the lateral circumflex femoral artery (t-LCFA) and two distal cutaneous perforators originating from the descending branch (d-LCFA). We harvested a skin flap based on the distal two perforators and divided the d-LCFA just distal to the bifurcation of the d-LCFA and the t-LCFA. Unfortunately, the ALT flap showed venous congestion on postoperative day 2 and eventually failed. We harvested a second ALT flap from the same donor site based on the previously preserved perforators. The recovery course was smooth thereafter. We believe that the harvest of a second ALT flap from the same donor site may be an option, to avoid other donor site violation, in some patients who experienced the first flap loss. © 2014 Wiley Periodicals, Inc. Microsurgery 34:409-412, 2014.

Ten-year experience of superior gluteal artery perforator flap for reconstruction of sacral defects in Tri-Service General Hospital

Background: Despite advances in reconstruction techniques, sacral sores continue to present a challenge to the plastic surgeon. The superior gluteal artery perforator (SGAP) flap is a reliable flap that preserves the entire contralateral side as a future donor site. On the ipsilateral side, the gluteal muscle itself is preserved and all flaps based on the inferior gluteal artery are still possible. However, the dissection of the perforator is tedious and carries a risk of compromising the perforator vessels. Patients and Methods: During the period between April 2003 and March 2013, 30 patients presented to our section with sacral wounds causing by pressure sores or infected pilonidal cysts. Of a total of 30 patients, 13 were female and 17 were male. Their ages ranged from 22 to 92 years old (mean 79.8 years old). Surgical intervention was performed electively with immediate or delayed reconstruction using a SGAP flap. The characteristics of patients' age, and sex, and cause of sacral defect, co-morbidities, wound culture, flap size, perforator number, hospital stay, and outcome were reviewed. Results: For all operations, the length of the pedicle dissection will not exceed 1 cm because of the vascular anatomy of the SGAP, which lies adjacent to the sacral region. Due to short pedicle dissection, all SGAP flap were elevated around an hour. All flaps survived except two, which had partial flap necrosis and were finally treated by contralateral V-Y advancement flaps coverage. The mean follow-up period was 14.8 months (range 3-24). No flap surgery-related mortality was found. Conclusion: Perforator-based flaps have become popular in modern reconstructive surgery because of low donor site morbidity and good preservation of muscle. Our study shows that deep pedicle dissection is unnecessary when the surgery involves an accurate indicating perforator, adequate flap size design, and correct selection of flap utilization between tunnel and rotation. The advantages of this modification include a faster operation, less bleeding, and less trauma of the pedicle, which make the SGAP flaps an alternative choice for sacral sores coverage.

A perforator-based dorsal flap's experimental research in the rat

To develop a new experimental animal model of different a single perforating vessel as its pedicle, and to investigate this vessel can captures how many adjacent angiosomes in different directions. Thirty-six Sprague-Dawly rats of both sexes were used. The rats were divided into group A, group B and group C. Group A: the unilateral deep circumflex iliac perforator artery- based flap. Group B: the unilateral posterior intercostal perforator artery-based flap. Group C: the unilateral lateral thoracic perforator artery-based flap. An extended dorsal perforator flap measuring up to 13 cm x 6 cm was designed in 36 rats to assess the viability of the flap. The upper margin was located at the level of the tip of the scapula and the lower margin at a level 1 cm below the iliac crest. All flaps were observed for 7 days postoperatively, 72 hours after flap elevation, observe flap dyeing conditions through the vivo fluorescein injection, the surviving flap area was calculated as a percentage of total flap dimensions and the angiosome's structure of the flap was displayed by radiopaque microangiography. No fluorescence was visible in the distal flap of groups A and C, the whole flap show bright fluorescence in group B. Survival rate of C, A, B were improved in order. Statistic difference is significant (P < 0.01) between group and group. In group A, lead oxide-gelatin angiography shows the cephalic flap necrosis occurred in the bilateral lateral thoracic territories, and the vascular architecture partly disappeared in the necrotic area. In group B, the vascular architecture of flap is unbroken. In group C, the caudal flap necrosis occurred in the bilateral deep circumflex iliac perforator artery territories, and the vascular architecture partly disappeared and disordered in the necrotic area. The perforator flap is based centrally on a single perforator, this vessel can capture multiple the second vascular territory. In a direction, the longest distance that the blood supply can reach is the point of the third perforator vessel puncture into skin, which can provide certain theoretical guidance for designing of perforator flap.

A New Facial Artery Free-Style Perforator Flap and Conchal Cartilage Graft for One-Step Reconstruction of the Alar Defects

The nose is the most commonly affected area by basal and squamous skin carcinomas of the head and neck area (D'Arpa et al. J Plast Reconstr Aesthet Surg. 2009, 62:36-42). The nasolabial flap is a very well known local flap that provides excellent color and texture matches. However, its major drawback is that it requires a 2-stage procedure to restore an adequate nasal cheek groove (Karsidag et al. J Craniofac Surg. 2010;21:1887-1889). In the perforator flaps, there are numerous studies that describe flaps whose vascular supply depend on perforators from the fascial artery.We planned to harvest a perforator flap around the medial cheek area, which included one cutaneous perforator from the facial artery. Free-style facial artery perforator flaps and auricular conchal cartilage framework were performed in 9 patients who have alar defect due to malignancies.From September 2010 to December 2011, the free-style facial perforator artery flap was performed in 9 patients at the Plastic and Reconstructive Surgery Department of the Ankara Numune Training and Research Hospital, Turkey. The whole flap was used to reconstruct the whole alar unit, which includes cartilaginous tissues.Our aim is to define a one-stage reconstruction technique with a perforator-based flap. Our flap is supplied by a perforating branch of the facial artery. We develop this method because of its reliable vascularization, that is, the possibility of performing one-stage technique with sensation preservation.In conclusion, we strongly recommend one-stage reconstruction in any kind of alar region defect with this versatile facial perforator flap.

Reconstruction of Various Perinasal Defects Using Facial Artery Perforator-Based Nasolabial Island Flaps

BackgroundClassical flaps for perinasal defect reconstruction, such as forehead or nasolabial flaps, have some disadvantages involving limitations of the arc of rotation and two stages of surgery. However, a perforator-based flap is more versatile and allows freedom in flap design. We introduced our experience with reconstruction using a facial artery perforator-based propeller flap on the perinasal area. We describe the surgical differences between different defect subtypes.MethodsBetween December 2005 and August 2013, 10 patients underwent perinasal reconstruction in which a facial artery perforator-based flap was used. We divided the perinasal defects into types A and B, according to location. The operative results, including flap size, arc of rotation, complications, and characteristics of the perforator were evaluated by retrospective chart review and photographic evaluation.ResultsEight patients were male and 2 patients were female. Their mean age was 61 years (range, 35-75 years). The size of the flap ranged from 1 cm×1.5 cm to 3 cm×6 cm. Eight patients healed uneventfully, but 2 patients presented with mild flap congestion. However, these 2 patients healed by conservative management without any additional surgery. All of the flaps survived completely with aesthetically pleasing results.ConclusionsThe facial artery perforator-based flap allowed for versatile customized flaps, and the donor site scar was concealed using the natural nasolabial fold.

A Basosquamous Cell Carcinoma of the Periorbital Region Arising From a Chronic Wound Created by Laser Ablation of a Basal Cell Carcinoma

Basosquamous cell carcinomas (BSCs) are very rare and behave aggressively, with features of both basal cell carcinoma and squamous cell carcinoma. The diagnosis of BSC includes a spectrum of histologic definitions, ranging from coexistence of basal cell carcinoma and squamous cell carcinoma with or without a transition zone, to any basal cell carcinoma with evidence of keratinization.A 63-year-old man presented with a BSC within a chronic periorbital wound, which was confirmed through a postoperative histologic examination. The wound was created from a previous laser ablation of a diagnosed basal cell carcinoma. The BSC was excised without causing any deformity, and coverage of the defect was obtained using a local perforator-based flap. No recurrence was observed during a 5-month follow-up.