Change of Concept in Head and Neck Reconstruction by Various Perforator Flaps

With the introduction of the perforator concept, flap selection in head and neck reconstruction has expanded. Instead of the radial forearm flap, a thin perforator flap can be considered as a good alternative for intraoral reconstruction without a noticeable donor scar. With a branched pedicle, such a thin perforator flap from the flank or thigh is more useful. In this study, several characteristics of perforator flaps were compared with the fixed idea of conventional flap selection in head and neck reconstruction.

Latissimus dorsi or thoracodorsal perforator flaps were designed for resurfacing, with required thinness for intraoral reconstruction, and could be used as in a chimeric pattern for three-dimensional reconstruction. Anterolateral thigh perforator flaps could be designed in a folded pattern for inner and outer resurfacing, or in a chimeric pattern by using the descending branch of the pedicle. Submental island flaps and a reversed pattern were used for facial resurfacing and nose reconstruction after the surgery for facial skin cancer.

Thirty-one cases were reconstructed based on the perforator concept with no failure as; free perforator flaps (22) and perforator-based island flaps (9). In the free flaps, various applications were available, depending on the individual case: chimeric pattern, folded pattern, resurfacing tool, dermoadiposal pattern, or 3-D pattern. They were effectively available, especially in tongue and floor-of-mouth reconstructions, with good contour or proper resurfacing. The latissimus dorsi perforator flap was the most popular flap (12), and the thoracodorsal perforator flap and anterolateral thigh perforator flap were used in descending order. The p-perforator-based island flaps selected were all submental perforator flaps, including three cases in reversed pattern. Compared to conventional flaps, such the radial forearm flap, the results were quite satisfactory from the aspect of contour, function, and donor scar.

The thin character and long pedicle of perforator flaps are fundamental requirements for head and neck reconstruction. The proximal branching systems of the vascular pedicle in the subscapular artery and lateral circumflex femoral artery make it possible to reconstruct three-dimensional composite defects with a combined chimeric pattern. Regional perforator-based island flaps can provide one more option for flap selection in facial reconstruction. As described, the perforator concept provides more extensive options in flap selection for head and neck reconstruction.