Use of Perforator Flaps in Head and Neck Reconstruction

Since first conceived by Koshima in the 1980s, perforator flaps have become more and more a part of our regular armamentarium. They offer the advantages of minimizing donor-site morbidity, as well as optimizing flap design. Their role in head and neck reconstruction is still evolving, but already several of these flaps have found a place in this region.

Floor of Mouth Reconstruction: The anterolateral thigh flap has significant advantage in this region. The donor site is excellent and can generally be closed directly. Flap dimensions are easily adjusted. While the flap can be thick in some populations, it is also amenable to thinning.

Pharyngoesophageal Reconstruction: While the jejunum is still the preferred flap for pharyngoesophageal reconstruction in many parts of the world, the author has moved toward use of the anterolateral thigh flap in this region. It provides a relatively rigid tube that facilitates swallowing, but produces better voice than the jejunum with traceo-esophageal puncture.

Reconstruction of the Subtotal Glossectomy: The DIEP flap has replaced the rectus abdominis flap in the author's practice for reconstruction of the subtotal glossectomy defect. It provides a flap with predictable bulk and a long pedicle. It withstands radiation well and appears to maintain its bulk predictably.

Soft Tissue Reconstruction in the Head and Neck: Many of the perforator flaps have been used to reconstruct soft tissue defects in the forehead, cheek, and neck. These include the anterolateral thigh, the thoracodorsal perforator (TAP) flap, the DIEP, as well as the submental flap. More recently, that author has started to use the internal mammary artery perforator (IMAP) flap to resurface neck defects as a pedicled flap. All of these flaps increase versatility. Recently described by Hofer, the facial artery perforators increase versatility even more, and provide small local flaps of exactly the type of tissue that has been resected. This has opened a new and exciting chapter in the area of local flaps in the head and neck.