Freestyle facial perforator flaps—a safe reconstructive option for moderate-sized facial defects

We have performed a single-stage reconstruction of moderate-sized defects using 21 perforator-based flaps in 19 patients; see Table 1. In all cases, the intended reconstruction was successfully achieved with a high self-reported patient satisfaction.

The nasolabial flap, and glabellar and forhead flaps are well described as axial pattern flaps on a narrow pedicle or as island flaps [1]. Since then, the knowledge of a perforator-based design evolved from the angiosomal concept introduced by Taylor and Palmer in 1987 [4]. In the year 2000, Dr. Taylor’s team published a study on the facial angiosomes, which is the basis of the flap design which we have used in this series of flaps [5]. The facial artery perforator flap, which we used in 16/ 21 flaps, was first described by Hofer et al. in 2005 including an anatomical dissection to indicate the location of perforators [6]. D‘arpa et al. published a series of nasolabial perforator flaps for alar reconstruction in 2009 [7]. In 2012, Qassemyar et al. published a series of 20 cadaver dissections establishing further the perforosomes of the facial artery perforators [8] already described by Taylor et al. [5]and confirming the results found by Hofer and colleagues [6]. There is no in vitro knowledge of how big a perforosome a perforator can supply. We found that the perforators are consistently located where they have previously been described, and a reliable skin island can be perfused based on any one of those perforators. Flap size varies and has in the more recent cases become bigger and extends well beyond usual random flap design without any surprises in terms of perfusion. Studies with facial transplantation have shown that, due to a rich vascularity and interconnections of perforosomes of the face an extensive area, a whole face, in fact, can survive on a single facial artery anastomosis [9]. With increased understanding of facial perforators and perforosomes, the perforator flaps have become a useful tool for the reconstructive surgeon. We attained a desired anatomical subunit replacement with the chosen flap design and an aesthetically pleasing result with high patient satisfaction in all cases. This seems to indicate that reconstruction of the aesthetic units are best attained by the mobility of the perforator flap and limited only by the donor site, preferably primarily closed within the boundaries of anatomical skin lines.

V-Y flaps are well published in the literature; however, we found in this small series, that a better understanding of their perforator origin has made them a safer choice and better reconstructive option. The supratrochlear flap is well known and has been used as an axial flap at least since the description of Sushruta Samhita, most often referred to as a forehead flap. The interconnection of the angular and supratrochlear artery indicates that a forehead flap could be based on either of the arteries increasing the freedom of rotation [10]. Forehead flaps often suffer from a venous congestion due to a compression, as was the case in our first propeller version which was probably due to a tight-fitting design causing tension on the distal part of the flap. The modeolus is the safest and most consistent perforator location [6, 8], and this has been the base of some of our biggest flaps and most satisfactory reconstructions of FAP flaps. The alar reconstruction in one stage has been published [7], since we started using it, and more recently, the supratrochlear flap was described by the same team [11]. This leaves only the zygomatic and modified Trepier periorbital flap remaining to be published.