Perforator-based Flap Research Articles

Closure of excisional defects of pilonidal sinus surgery using a perforator-based island flap

Background and Aim of the Work: Pilonidal sinus disease is a common condition in the young adults, which carries significant patient discomfort. There is no consensus regarding the best surgical technique for the treatment of this disease. A controversy is present about the various options for closure of the wound following resection of the affected tissue. In this study, the perforator-based island flap was successfully used for closing the defect left after excising the pilonidal sinus. Methods: Twenty-three patients with a primary complex pilonidal sinus disease were operated upon and followed up in the period from October 2014 to October 2018 at the General Organization of Teaching Hospitals and Institutes hospitals. After wide excision of the pilonidal sinuses, the defects were reconstructed with perforator-based flaps, which were designed with an axis of 45°–90° angle to the vertical axis of the defects. Results: Of the 23 patients included in this study, only three patients developed minor complications (one case of mild seroma and two cases of minor wound infections), and they were treated conservatively. Mean time of hospital stay was <2 days. Mean time to return to normal daily activities was 5 days (range: 3–7). Mean time to complete healing of the wound was 12 days (range: 10–15). Mean time off-work days was14 days (range 12–17). All the patients did not show recurrences during the period of follow-up which continued for at least 9 months postoperatively with a mean time of 10 months (range: 9–15). Conclusions: This study shows that closure of postexcisional defect of pilonidal sinus using a perforator-based island flap is a reliable option for the treatment that fulfill the principles and criteria required to achieve complete cure of the condition in a short period of time.

Coverage of exposed pericardium with a lateral thoracic artery perforator flap

Electricity is an indispensable part of the society that we live in, depending on it from household appliances to farms and industries. Electrical burn injuries, although form a small proportion of the total burn cases, pose significant challenges in their management due to their varied manifestations and the high associated morbidity and mortality. Most high voltage electrical injuries are work related. The entry wounds are most commonly seen over the upper extremities, whereas the exit wounds are seen over the lower extremities. The thorax presents an uncommon site for an entry wound. In this case report, the authors present one such case of electrical injury with an entry wound over the thorax presenting as a left parasternal defect that was debrided and covered successfully with a lateral thoracic artery perforator-based flap from the lateral chest wall.

Thoracodorsal artery perforator flap in immediate breast reconstruction: a series of twenty cases

Background: The management of breast cancer has shown a progressive change, from radical ablative surgery, to breast conserving techniques. Traditionally, the mini latissimus dorsi flap has been used for reconstruction; which is associated with donor site morbidity. Vascular research has now allowed the use of perforator-based flaps for reconstruction, which reduce donor site morbidity.Methods: Twenty thoracodorsal perforator flaps in twenty early breast cancer patients were studied between January 2018 and December 2018. Parameters studied were adequacy of volume, ease and time taken for flap elevation, and final aesthetic outcome.Results: Flap volume was adequate to fill defect. One of twenty cases had flap loss due to venous congestion secondary to pedicle kinking. Average time taken for flap elevation was 70.45 minutes. All patients were satisfied with cosmetic outcome.Conclusions: The TDAP flap is a safe and reliable flap which provides adequate volume for partial breast reconstruction.

Anatomical Basis and Clinical Application of the First Metatarsal Proximal Perforator-Based Neurocutaneous Vascular Flap.

Forefoot defects caused by accidents are very common, but their reconstruction remains a substantial challenge for plastic surgeons. The purpose of this study is to determine the anatomical structure of the first metatarsal proximal perforator-based flap and to propose its clinical application. The study was divided into two parts: an anatomical study and a clinical application. Thirty preserved lower limbs injected with red latex were chosen for observation, and the following were recorded: the course and distribution of the medialis dorsalis pedis cutaneous nerve; the origin, course, branching and distribution of the first metatarsal proximal perforator; and the communication of the perforator and the dorsal medial vessels. Clinically, six cases of forefoot skin defects were reconstructed with the first metatarsal proximal perforator-based neurocutaneous vascular flap. The medialis dorsalis pedis cutaneous nerve mainly arose from the medial branch of the superficial peroneal nerve and proceeded forward for a distance of 2.5 ± 0.4 cm under the surface of the inferior extensor retinaculum; then, the nerve divided into the medial dorsal branch and the first and second dorsal metatarsal branches. The first metatarsal proximal perforator-based neurocutaneous vessels were multisegmented and multisourced, and the first branch was closely related to the operative procedure. In terms of the clinical application, all flaps of the six cases survived completely with good appearance, texture and elasticity. The first metatarsal proximal perforators present as constant. The first metatarsal proximal perforator-based neurocutaneous vascular flap may become a useful supplemental material for the reconstruction of forefoot defects. Clin. Anat., 33:653-660, 2020. © 2019 Wiley Periodicals, Inc.

Imaging and printing in plastic and reconstructive surgery part 2: emerging techniques

Background: In the second of a two-part series, we evaluate emerging three-dimensional (3D) imaging and printing techniques based on computed tomography angiography (CT) and magnetic resonance angiography (MRA) for use in plastic and reconstructive surgery. Method: A review of the published English literature dating from 1950 to 2017 was taken using databases such as PubMed, MEDLINE®, Web of Science and EMBASE. Results: Image-guided navigation systems using fiducial markers have demonstrated utility in numerous surgical disciplines, including perforator-based flap surgery. However, these systems have largely been superseded by augmented reality (AR) and virtual reality (VR) technologies with superior convenience and speed. With the added benefit of tactile feedback, holograms also appear promising but have yet to be developed beyond the prototypic stage. Aided by a growing volume of digitalised clinical data, machine learning (ML) poses significant benefits for future image-based decision-making processes. Conclusion: Most studies of image-guided navigation systems, AR, VR, holograms and ML have been presented in small case series and they remain to be analysed using outcomes-based validation studies. However, together they illustrate an exciting future where clinicians will be armed with intuitive technologies for surgical planning and guidance.

Septocutaneous perforator mapping and clinical applications of the medial arm flap

The medial arm flap has a long history but remains underused despite providing multiple advantages. We reviewed our experience with using the medial arm flap to clarify the distribution of septocutaneous perforators and its relationship with pedicled flap design. This retrospective study included 36 consecutive patients who underwent reconstructive surgery with a medial arm flap (42 arms). Septocutaneous perforator mapping was conducted using a refined coordinate system originating at the medial epicondyle, with the y-axis running to the axillary apex. At least three perforators were identified along the medial intermuscular septum of the arm, located densely at 88 ± 8%, 49 ± 9%, and 20 ± 6% of the distance between the medial epicondyle and axillary apex (i.e., arm length), with a prevalence of 95.2%, 100%, and 85.7%, respectively. All arms had at least one medium- or large-sized perforator, and 90.5% of arms had at least two such perforators. Twenty-nine flaps were transferred as pedicled distant flaps for head and neck reconstruction or hand reconstruction, while the remaining 13 were transferred as perforator-based propeller flaps for axillary, elbow, or chest wall reconstruction. Thirty-six flaps underwent pre-transfer expansion. The average flap size was 157.9 ± 64.5cm2 (range: 40-330cm2). All flaps were successful, except for one perforator-based flap, which was replaced due to partial loss. Donor site morbidity was minimal. Given its rich septocutaneous perforator distribution, the medial arm flap can be harvested reliably with versatile design and minimal donor site morbidity, thus deserving more attention in reconstructive surgery.

Anatomical and clinical evaluation of perforator-based flaps of lower limb

Background: Wound of lower leg have a poor and delayed healing due to paucity of blood supply. Coverage of defects of leg and foot has always posed a problem for reconstructive surgeon. The objective of this study was to evaluate anatomical basis of various perforator-based flaps in lower limb and their clinical outcome and usefulness.Methods: All patients with post traumatic defects with exposed bones/tendons in the leg and ankle region presenting in MLN Medical college, Allahabad from August 2011 to July 2012 were included in the study.Results: A total 12 patients were included in study. Majority of cases are of compound fracture following accidents involving lower one third of leg. Majority of flaps were based on peroneal artery (5) and posterior tibial artery (5), only 2 flaps were based on anterior tibial artery. Maximum flap length was 21cm and maximum flap rotation was 180º. Complications occurred more in cases having maximum rotation. Result were good in 11 patients and satisfactory in 1 patient with coverage of the defect leading to healing of the wound. More time gap between injury and flap reconstruction leads to more complications and longer hospital stay. Graft site complication occur in 5 cases include partial flap necrosis, infection and venous congestion. There was no complication at the donor site.Conclusions: Perforator based flaps can be used for all large lower leg defects provided there is correct measurement and anatomical knowledge of various perforators, with good functional and cosmetic results.

Surgical Algorithmic Approach to Facilitate Primary Closure of the Anterolateral Thigh Flap Donor Site in Head and Neck Reconstruction.

Use of the anterolateral thigh (ALT) flap has gained popularity in head and neck reconstruction. However, donor sites that cannot achieve primary closure are reported to have poorer functional and aesthetic outcomes. Therefore, we propose an algorithm to facilitate primary closure of the donor site. Since May 2013, when an attempt at donor site direct closure failed, we have used a VY advancement flap or a propeller flap for primary closure of the donor site, using the remnant lateral thigh perforator or nearby medial thigh perforator. Otherwise, a skin graft was used. A total of 91 patients were enrolled in this algorithmic approach. We retrospectively reviewed patients with head and neck cancer who underwent cancer ablation and immediate ALT flap reconstruction since August 2010. The patients were then categorized into a "before" group and an "after" group according to the application time of the algorithm. Their demographics, intraoperative findings, and postoperative outcomes were analyzed. A total of 321 patients (309 men, 12 women) were enrolled, with 230 patients in the before group and 91 patients in the after group, with a mean age of 52.9 years. The mean size of the flap was 130 cm, with a mean width of 8.1 cm. No statistical difference existed between the groups. The donor site was directly closed in 82 patients (35.7%) in the before group. Using the perforator-based flap in 21 patients (23.1%), the donor site was closed primarily in 72 patients (79.1%) in the after group, contributing to a significantly higher donor site closure rate (P < 0.001). The average operative time was 348.7 minutes. The overall flap survival rate was 97.2%, donor-site complication rate was 6.9%, and hospitalization length was 23.5 days. None showed statistical differences between the groups. The proposed algorithm may considerably increase the primary closure rate of the ALT flap donor site.

Perforator pedicled propeller flap: A reliable coverage of wounds around ankle

Background: This study aimed to determine the reliability of perforator pedicled propeller flap for coverage of wounds around the ankle. Materials and Methods: This was a prospective study undertaken between September 2017 and November 2018 in the Division of Plastic and Reconstructive Surgery of our institution. Patients with soft-tissue defect of the ankle referred from the Division of Orthopedic Surgery were included. Those with a scarring in the region of calf in the area of proposed flap were excluded. A detailed history and examination were recorded. A complete blood count, kidney and liver function tests, coagulation profile, and hepatitis B and C and human immunodeficiency viral marker testing were performed following informed consent. Anteroposterior and lateral radiographs of the ankle were taken in all cases. Perforator pedicled propeller flaps were raised in all patients for coverage of soft-tissue defects around the ankle. All patients were followed up regularly. Results: Ten patients with soft-tissue defect around the ankle were referred to our division from the Division of Orthopedic Surgery or admitted through the outpatient department of the Division of Plastic and Reconstructive Surgery of our institution. Eight patients were male and two were female, with the age ranging from 10 to 50 years. The mean operation time was 58 min. Size of the flap varied from 21 cm × 8 cm (168 cm2) to 8 cm × 5 cm (40 cm2). Flaps were rotated through 110°–180°. Out of ten flaps, eight flaps survived completely without any complications. Partial flap loss was found in one patient (10%), marginal flap necrosis in one patient (10%), and none of the flap was lost completely. Thus, the overall success rate of perforator pedicled propeller flap in our study observed was 80%. Conclusion: The perforator-based propeller flap is a versatile and reliable flap for the coverage of soft-tissue defects around the ankle because its vascularity is predictable.

Distribution of internal thoracic artery perforators: A clincal anatomy study

There are various modifications of the transverse rectus abdominis musculocutaneous flap and deep inferior epigastric perforator flap to reduce the morbidity of the donor site or to augment the vascularity of the flap. For microanastomosis of multiple pedicles, multiple recipient vessels or an intervening vein graft should be provided. In addition, alternative perforator-based flaps used in breast reconstruction have small caliber pedicles. Therefore, small recipient vessels such as internal thoracic artery perforators are more suitable for appropriate microanastomosis. Therefore, it is important to acquaint the distribution and anatomical characteristics of internal thoracic artery perforators. We researched the perforators running in the intercostal spaces under the pectoralis major muscle to provide an overview of the anatomical distribution and characteristics of the perforators in patients who underwent immediate subpectoral implant-based breast reconstructions. In our study, the major perforators (diameter > 1.5 mm) were easily found 2-7 cm medially between the third and fourth intercostal space and were sparse in the lateral area from the midline of the breast (usually 8-9 cm lateral to the midsternal line) and above the third rib. In each side of the breast, the average number of perforators greater than 1.5 mm was 1.6, and the average number of perforators between 1 mm and 1.5 mm in diameter was 3.2. Our results provide information about perforators in the anterior chest wall related to the breast area. Clin. Anat. 32:471-475, 2019. © 2018 Wiley Periodicals, Inc.

Posterior tibial perforator-based flaps for leg and foot defects: Indications, limitations, and technical considerations

BackgroundCovering defects at the lower leg and foot is a common challenge in reconstructive surgery. A flap is often required, and free flaps are widely used. The posterior tibial perforator-based flap constitutes a valuable option in this situation. The objectives of this study were to evaluate the reliability of the posterior tibial perforator-based flap, report any complications, and describe the outcomes, with the goal of defining the indications of this flap in the treatment of lower limb defects. HypothesisThe posterior tibial perforator-based flap is a useful and reliable option for soft-tissue defect reconstruction at the leg and foot. Material and methodPatients managed using a posterior tibial perforator-based flap to cover soft-tissue defects of the leg and foot were reviewed retrospectively. A physical examination was performed and radiographs obtained at the last postoperative follow-up visit. ResultsThirteen patients with a mean age of 46.9 years (range: 25–73 years) were reviewed after a mean follow-up of 19.5 months (range: 16–63 months). The tissue defects were due to compound fractures in 10 patients and to postoperative complications in 3 patients. Mean flap size was 12.3cm by 6.2cm. The donor site was covered by a skin graft in 12 patients and closed primarily in 1 patient. The procedure was successful in 11 (85%) patients. DiscussionThe posterior tibial perforator-based flap is a method of choice for covering soft-tissue defects at the leg and foot. Careful patient selection and flawless technique contribute to minimise the failure rate. Level of evidenceIV, retrospective study.

Optimizing Perforator Selection: A Multivariable Analysis of Predictors for Fat Necrosis and Abdominal Morbidity in DIEP Flap Breast Reconstruction.

This study aims to elucidate the important predicting factors for fat necrosis and abdominal morbidity in the patient undergoing deep inferior epigastric artery perforator flap reconstruction. The authors conducted a retrospective review of 866 free-flap breast reconstructions performed at one institution from 2010 to 2016. Twenty-eight potential predictors were included in multivariable analyses to control for possible confounding interactions. Four hundred nine total deep inferior epigastric artery perforator flaps were included in the statistical analysis. Of these, 14.4 percent had flap fat necrosis, 21.3 percent had an abdominal wound or complication, and 6 percent had an abdominal bulge or hernia. Analysis showed an increase in the odds of fat necrosis with increasing flap weight (OR, 1.002 per 1-g increase; p = 0.0002). A decrease in the odds of fat necrosis was seen with lateral row (OR, 0.29; p = 0.001) and both medial and lateral row perforator flaps (OR, 0.21; p = 0.001), if indocyanine green angiography was used (OR, 0.46; p = 0.04), and with increasing total flow rate of the flap (OR, 0.62 per 1-mm/second increase; p = 0.05). Increased odds of abdominal bulge or hernia were seen with lateral row or both medial and lateral row perforators (OR, 3.21; p = 0.05) versus medial row perforator-based flaps, and with patients who had an abdominal wound postoperatively (OR, 2.59; p = 0.05). The authors' results suggest that using larger caliber perforators and perforators from the lateral row alone, or in addition to medial row perforators, can decrease fat necrosis more than simply harvesting more perforators alone. However, lateral and both medial and lateral row perforator flaps come at the cost of increasing abdominal bulge rates. Risk, III.

Applied anatomy of the first metatarsal proximal perforator-based neurocutaneous vascular flap

Objective To explore the anatomical characteristics of mediate dorsal pedal cutaneous nerve and its nutritional vessels to provide anatomical basis of the perforator pedicle flap based on the medial dorsal pedal neurocutaneous vessels for repairing the forefoot soft-tissue defects. Methods From December, 2016 to April, 2017, the following contents were investigated in 30 adult feet specimens perfused with red latex: ①The course, branches and distribution of the medial dorsal pedal cutaneous nerve. ②The origin, course, branches and distribution of the nutrient vessels of the medial dorsal pedal neurocutaneous vessels. Mimic operation was performed on 1 fresh specimen. Results ①The mediate dorsal pedal cutaneous nerve mainly arose from the medial branch of the superficial peroneal nerve and processed forward for a distance of (2.5±0.4) cm under the surface of the inferior extensor retinaculum, and then divided into the mediate dorsal branch, the 1st and 2nd dorsal metatarsal branch over part of the dorsal pedal and digital skin. ②The medial dorsal pedal neurocutaneous vessels were multiple segmental and polyphyletic, mainly include dorsalis pedis artery proximal perforator, the first metatarsal proximal perforator, the tibial proper plantar digital artery of the great toe and the perforater of the second toe web artery, of which the first metatarsal proximal perforator was most associated with operating methods. The first metatarsal proximal perforator perforate through the deep fascia to the subcutaneous area within the range of 1.0-2.0 cm near the proximal first plantar gap, the piercing point of which on deep fascia was constant,and the anatomical plane of the first metatarsal proximal perforator was higher than that of both the perforator of the toe web artery and the tibial proper plantar digital artery of the great toe. The first metatarsal proximal perforator divide into a large number of branches, which closely anastomose with adjacent perforators and other medial dorsal pedal neurocutaneous vessels. ③Simulated surgery showed that the first metatarsal proximal perforation pedicle flap to meet the forefoot soft tissue defect repair. Conclusion The first metatarsal proximal perforator is constant in piercing point and reliable in blood supply, and it have a higher anatomical plane than that of both the perforator of the toe web artery and the tibial proper plantar digital artery of the great toe. The first metatarsal proximal perforator-based medial dorsal pedal neurocutaneous vascular flap can be transferred to repair the soft-tissue defects of forefoot. Key words: First metatarsal proximal perforator; Medical dorsal pedal cutaneous nerve; Surgical flaps; Applied anatomy

Experimental remodeling of vascular bed tissue for combined expanded perforator-based flaps obtaining

The aim — to study the effect of expansion on the vascular bed tissues remodeling to obtain the combined perforator­based flaps and to determine their survival in the experiment.Materials and methods. Experimental studies were carried out on 35 rats, which underwent the skin flaps modelling supplied with skin perforators of the thoracic artery and superior gluteal artery. In the main group (n = 20), the expanded combined flaps with vascular networks of the posterior and middle muscle perforators of VII—X intercostal and I — II lumbar arteries and lateral artery of the chest were formed. The comparison group included 15 rats, in whom flaps with different power sources were formed on one side of the trunk. A comparative analysis of flap survival for different flap formation methods, including tissue expansion, was held.Results and discussion. The possibility of vascular bed remodeling, which allows the large expanded flaps formation which unite up to 5 perforasome skin areas supplied by single key vessel, is shown. Today, there is no universal method to improve the survival of the skin flaps, so tissue expansion with the inclusion of the neighboring 5 vascular sources perforators will help to obtain more plastic material with better survival potential.Conclusions. Tissue expansion facilitates the inclusion of additional vascular networks into the flaps, the vascular bed remodeling, allows to increase the flaps square in 1.9 times, improves their survival in 2.4 times and reduces the necrosis square in 2.8 times.

Defektdeckung durch Gluteuslappen

Gluteal skin, fasciocutaneous and myocutaneous flaps can be used to cover decubitus ulcers in the sacral and ischiocrural area. Decubitus ulcers in the sacral or ischial area that do not heal after exhausted conservative therapy. Moribund patients who are very likely to suffer a life-threatening complication. Non-cooperative patients who cannot follow the postoperative recommendations. The presence of extensive scars after previous operations in the donor area or irradiation of the donor area which may compromise the flap perfusion. A distinction is made between local skin flaps, perforator-based fasciocutaneous flaps and the myocutaneous gluteus maximus flap. By partial or complete elevation of the gluteus maximus muscle based on the superior and inferior gluteal vessels, this flap is useful for larger and deep defects in the sacral and ischial region. For more superficial defects, fasciocutaneous perforator flaps might be used. Smaller ulcers can be treated with local skin flaps. The donor site should be closed primarily. Consistent, postoperative relief by prone and lateral positioning of the patient, avoiding new decubitus ulcers. Drainage for at least 5-7 days. Antibiotic therapy is indicated only with appropriate detection of pathogens and in case of persistent infection. With distinct anatomical and improved technical knowledge, the use of fasciocutaneous and myocutaneous flaps in the gluteal region is now an established procedure and can be used for reliable coverage of sacral and ischiocrural decubitus ulcers.

Smartphone-based thermography for perforator localisation in microvascular breast reconstruction

Thermography permits non-invasive examination and presentation of cutaneous temperature differences. When planning microvascular flaps, thermography may illustrate these differences and may portray patterns of blood circulation near to perforators. As an additional tool, thermography may enhance quality and diversity in free flaps. In this prospective study, we examined 10 patients with 13 free DIEP-flaps for breast reconstruction. With smartphone-based thermography, we analysed preoperative abdominal "hot spots" of skin circulation (entrance of perforators). The results were compared with preoperative computed tomographic angiography (CTA) and intraoperative anatomical findings. Thermography was succesfully performed on all patients. Areas of perfusion were reliably shown in the raised area ("hot spot"). Each perforator selected by thermography was also selected for the DIEP free flap on the basis of intraoperative findings. Moreover, the identified main perforators were identical to perforators found at the CTA. Smartphone-based thermography provides an easy, rapid and non-invasive method to present cutaneous differences in temperature. "Hot spots" can reliably illustrate the entrance of perforators. When selecting a suitable perforator, thermography provides additional information for imaging perforator-based flaps.

A novel application of the lotus petal flap in high-risk perineal urethrostomy: principles and outcomes

Introduction: Perineal urethrostomy is a valuable technique in the management of complex anterior urethral strictures, as well as following penectomy or urethrectomy. Traditional techniques that employ perineal or scrotal skin flaps have documented failure rates of up to 30 per cent. Current techniques for salvage have only modest success, leaving patients few options other than permanent suprapubic catheter or cystectomy and ileal conduit formation. Results: We present a new method of perineal urethrostomy using perforator-based lotus petal flaps in cases which were high risk or unsuitable for traditional perineal urethrostomy techniques, or where traditional strategies had failed. All patients demonstrated continent voiding at a minimum of 22 months follow-up, with patency confirmed by flexible cystoscopy. No complications were encountered.**Conclusion**: Utilisation of lotus petal flaps in high-risk cases of perineal urethrostomy will lead to significant improvements in patient outcomes. The availability of larger amounts of soft tissue coverage will obviate the need for compromise on either resection of involved urethra, or calibre and inset of urethrostomy. This will subsequently minimise the rates of failure, reduce the requirement for urinary diversion procedures and lead to improved quality of life.

Orthoplastic extremity reconstruction – From replantation to transplantation

For more than a half century, the use of the operating microscope for extremity surgery has led to remarkable advances in the management of orthopaedic trauma, tumours, infections and congenital differences. The microsurgical reconstructive ladder ascends from basic microsurgical procedures such as digital artery or nerve repair, to more complex procedures such as autologous tissue transplantation (free tissue transfer). Tissue transfers have also become more sophisticated with the evolution from simple myocutaneous flaps to perforator-based flaps. Functional muscle transfers, toe-to-hand transfers, and recently vascularised composite allotransplantation make up the highest rungs on this ladder. The development of the orthoplastic approach simultaneously integrates principles and practices of both orthopaedic surgery and plastic surgery for optimal care of extremities based heavily on the application of microsurgical techniques. We will describe our contributions and innovations in orthopaedic clinical practice using microsurgical techniques as well as highlight our clinical, anatomic and basic science research in reconstructive microsurgery that have led to improvements in limb salvage, reconstruction and restoration during the last 25 years.

Evaluation of facial artery perforator-based flaps in reconstruction of facial defects.

Introduction:Several flaps have been described for reconstructing facial or oral defects. Flaps such as forehead and pectoralis major are often too bulky for small-to-moderate-sized defects, for which nasolabial flaps are often ideal. However, nasolabial flaps have limited mobility and reach and may need two stages, particularly for intraoral defects. According to recent literatures, facial artery provides numerous small cutaneous perforators, based on which skin flaps can be islanded, with greater mobility and reach for reconstruction of small-to-moderate-sized intraoral and facial defects in one stage. Our study aims to evaluate the reliability and versatility of facial artery perforator-based flaps in the reconstruction of such defects.Materials and Methods:A ethical committee-approved retrospective study was conducted on data of the patients attending our outpatient department between February 2014 and October 2015 with small-to-moderate-sized facial/oral lesions. The total sample size was 23. We studied the relation of flap survival with size of flap, route of inset and neck dissection, functional and aesthetic outcomes and feasibility of adjuvant therapy in cases of malignancies.Results and Analysis:A wide range of facial defects, especially intraoral defects, could be reconstructed in one stage using facial artery perforator-based flaps. The flaps were reliable. Complications included only partial skin loss of the flaps in a few cases. Complications were directly related to the length of the flaps and the route of inset. Functional and aesthetic outcomes were satisfactory and none of the flaps showed any significant post-radiotherapy changes.Conclusions:We concluded that facial artery perforator flap can be a simple, safe, versatile and one-stage alternative to the traditional flaps in the reconstruction of small-to-moderate-sized facial defects. Neck dissection can be safely done in the same sitting.

A Wise Surgical Approach for Reconstruction of Postburn Axillary Contractures and Versatility of Perforator Flaps.

Postburn axillary adduction contractures should essentially be released for adequate shoulder function. Many methods have been described for this purpose. However, use of perforator flaps prevents harm to the underlying muscle and provides thin, pliable skin flaps. Despite the major advantages offered by perforator flaps, certain shortcomings of perforator flap surgery restrict their widespread use by inexperienced surgeons, including anatomic variations of perforator vessels. In order to rule out these shortcomings, we devised a new surgical approach with an initial incision that provides access to possible perforator systems on the dorsolateral thoracic area. The approach can easily be converted to a fasciocutaneous transposition flap when attempts for identification of a proper perforator fail. Nevertheless, a proper perforator can easily be reached through the exposure provided by this initial incision. With the intention of using perforator-based flap for reconstruction, we used this surgical approach for coverage in 14 cases of postburn axillary contractures. In 3 cases, conversions of the initial incision to local transposition flap (parascapular flap) were required. There was only 2 tip necrosis observed, which healed with secondary intention. Our current surgical approach may offer taking the advantages of using a true perforator flap for reconstruction while avoiding a second stress on the patient when an operative plan for perforator flap harvest fails.