Pre-expanded perforator flaps have several advantages over their traditional counterparts owing to the thin, more pliable nature, larger size, and minimum morbidity of the donor site. Recently, plastic surgeons have begun to use pre-expanded perforator flaps to reconstruct defects of almost the entire body, including the cervicofacial region, axilla, trunk, and extremities resulting from scar, congenital melanocytic nevi, hemangiomas, and neurofibromas. Such a versatile flap is especially appropriate for face and neck resurfacing, which requires more optimal functional and cosmetic outcomes.
Key points
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Along with the development of the flap and comprehension of the vascular anatomy, pre-expanded perforator flaps are a versatile option for reconstructive surgery.
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With the advantage of offering thinner, more pliable tissue as well as the primary closure of the donor site with minimal morbidity, pre-expanded perforator flaps can be used to reconstruct defects of the whole body.
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Several principles should be recognized and adhered to in order to ensure the success of the procedure when performing the pre-expanded perforator flap.
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Guidelines for the procedural approach are summarized to assist the surgeon in better performing such a reconstruction.
Introduction
Major challenges for soft tissue reconstruction include the lack of adequate skin coverage to allow for both a functional recovery and esthetically acceptable contour. Clinicians have developed multiple variations of flaps; from random pattern flaps to axial based flaps to modification of the axial flap into perforator flaps, all in attempt to overcome such difficulties. Presently, the combination of tissue expansion with perforator flaps has now created the pre-expanded perforator flap that is becoming a better option in reconstructive surgery.
Neumann first described the tissue expansion technique in 1957. With the aid of tissue expansion, surgeons can harvest additional soft tissues to cover targeted defects. This technique became rapidly and widely applied in reconstructive surgery, as it offered a flap with similar color and texture without the morbidity at the donor site. At the same time, plastic surgeons gained progressive understanding of the superficial soft tissue vascular anatomy. In 1988, deriving from the axial pattern flap, the first perforator flap was performed clinically by Kroll and Rosenfield. As such, perforator flaps have become well known for their thinner and more pliable nature. Subsequently in 2003, Tsai used the concept of tissue expansion and perforator flaps to prefabricate a free anterolateral thigh flap for resurfacing of larger postburn cervical contractures. This was the first introduction of a pre-expanded perforator flap. Since then, pre-expanded perforator flaps have received more and more attention in the field of reconstructive surgery, especially in Asia.
Introduction
Major challenges for soft tissue reconstruction include the lack of adequate skin coverage to allow for both a functional recovery and esthetically acceptable contour. Clinicians have developed multiple variations of flaps; from random pattern flaps to axial based flaps to modification of the axial flap into perforator flaps, all in attempt to overcome such difficulties. Presently, the combination of tissue expansion with perforator flaps has now created the pre-expanded perforator flap that is becoming a better option in reconstructive surgery.
Neumann first described the tissue expansion technique in 1957. With the aid of tissue expansion, surgeons can harvest additional soft tissues to cover targeted defects. This technique became rapidly and widely applied in reconstructive surgery, as it offered a flap with similar color and texture without the morbidity at the donor site. At the same time, plastic surgeons gained progressive understanding of the superficial soft tissue vascular anatomy. In 1988, deriving from the axial pattern flap, the first perforator flap was performed clinically by Kroll and Rosenfield. As such, perforator flaps have become well known for their thinner and more pliable nature. Subsequently in 2003, Tsai used the concept of tissue expansion and perforator flaps to prefabricate a free anterolateral thigh flap for resurfacing of larger postburn cervical contractures. This was the first introduction of a pre-expanded perforator flap. Since then, pre-expanded perforator flaps have received more and more attention in the field of reconstructive surgery, especially in Asia.
Previously published works
At present, with the results of such an excellent flap, surgeons as well as patients support the benefits of pre-expanded perforator flaps to obtain improved functional and cosmetic outcomes. The pre-expanded perforator flap has been used to reconstruct defects of the face, neck, axilla, breast, trunk, and the upper and lower extremities.
The flap is able to be used for extremity resurfacing with primary closure of the donor site. Hocaoğlu and colleagues demonstrated the utilization of free pre-expanded lateral circumflex femoral artery perforator flaps in an aesthetic and functional reconstruction of severe postburn hand deformity. Pre-expanded oblique perforator-based paraumbilical flaps were described for resurfacing of the upper limb with maximal size measuring 30 × 14 cm by Zang and colleagues. Hallock applied the expansion technique and methodology of Wei and Mardini for free-style free flaps to 2 burn patients with unstable lower extremity scars and achieved adequate reconstruction as well as simultaneous primary donor site closure with avoidance of a skin graft. Wang and Wang applied an expanded thoracoacromial artery perforator flap measuring 19 × 11 cm for a 53-year-old man with upper and lower lip ectropion. Other surgeons have used this technique for axillary as well as abdominal contracture reconstruction. Kulahci and colleagues used pre-expanded pedicled thoracodorsal artery perforator flaps for postburn axillary contracture reconstruction. Cheng and Saint-Cyr applied pre-expanded pedicled right deep inferior epigastric perforator flaps in conjunction with a pre-expanded left contralateral superficial inferior epigastric artery flap, for staged reconstruction of a large abdominal scar with meshed split-thickness skin graft. Additionally, pre-expanded flaps also can be applied in perineum reconstruction. Dong and colleagues performed a pre-expanded free scapular flap to reconstruct the penis of a patient with electrical burn who had loss of his genitals.
Furthermore, pre-expanded perforator flaps can be a popular technique when it comes to cervicofacial reconstruction. There are several kinds of pre-expanded perforator flaps that have been performed by various surgeons around the globe. We compare these different flaps to show the variation among them in Table 1 .
| Type of Flap | Author | Key Points of the Procedure | Indication | Advantages | Disadvantages |
|---|---|---|---|---|---|
| Pre-expanded super-thin skin perforator flaps | Wang et al, 2016 | The tissue expander is placed between adjacent perforators and underneath the subdermal vascular plexus to prefabricate a pre-expanded super-thin skin perforator flap. A minimum amount of fat should be kept to prevent the subdermal vascular network and the perforator from injury when elevating the skin flap. | Topical use for the reconstruction of the face and neck. | Super-thin, large (skin flap). Improved functional and cosmetic outcome, No microsurgery. Easy to perform. | Cannot reconstruct stereo facial organs. |
| Pre-expanded anterior perforator of transverse cervical artery flap | Chen et al, 2016 | First procedure: the dissection is made down to the deep fascia and the expander is placed superficial to the pectoral major muscle . No need to dissect the vascular branches. Donor site closed directly or covered by split skin graft . | An option for covering large defects of the face and neck with primary closure of the donor site. | Too bulky; eliminates facial expression and contour. | |
| Pre-expanded supraclavicular artery perforator flap | Pallua & von Heimburg, 2002 | Tissue expander initially implanted under the supraclavicular flap . After expansion, the flap is elevated subfascial as an island flap or a pedicled flap with skin tube . | |||
| Pre-expanded cervico-acromial fasciocutaneous flap | Yang et al, 2014 | The expander implanted under the deep fascia of the cervico-acromion region. No vascular pedicle isolation was performed in stage 1. Skin, subcutaneous tissue, and fascia were elevated en bloc with the axial running supraclavicular vessels when flap transferred to the defect. | |||
| Pre-expanded thoracodorsal artery perforator-based flap | Wang et al, 2014 | One or 2 expanders were implanted into pockets dissected under the deep fascia through 8-cm incision . After expansion, the flap was transferred to reconstruct the neck by end-to-end anastomosis of the thoracodorsal artery and its incorporated veins to the facial artery and facial veins. | Microsurgery, time-consuming. Bulky when resurfacing the cervicofacial regions. | ||
| Pre-expanded internal mammary artery pedicle perforator flap | Saint-Cyr, et al, 2009 | The second intercostal internal mammary perforator pedicle flap was harvested in the suprafascial plane, above the pectoral fascia, without skeletonizing the pedicle. Then transposed the pedicled flap into the defect while a thoracodorsal artery perforator free flap was used to resurface the right lateral portion of the neck. | Large defects of head or neck. | Combined pedicled flap with free flap to cover relatively large defects. | Difficult techniques, involves microsurgery. |
| Pre-expanded, prefabricated monoblock perforator flap for total facial resurfacing | Li et al, 2014 |
| Total facial resurfacing and organ reconstruction. | Good aesthetic outcome with uniform coverage and delicate features. Resurfacing with a monoblock can reconstruct various components simultaneously. | Difficult technique. Multiple procedures. Complicated postprocedure care. |
As compared earlier in this article, pre-expanded perforator flaps can be used in different varieties. According to the distance between the defect and the flap, pre-expanded perforator flaps can be divided by proximity into local flaps, adjacent flaps, and distant flaps, and according to how the flap is transferred, they are divided into pedicled and free flaps. However, there remains uncertainty as to how to choose the best flap to achieve an ideal outcome. The principles of this procedure are discussed as follows.
Preoperative evaluation
How to Select the Donor Site?
One must first understand the principle “replace like with like.” Consideration must be given to the color and texture of both donor site and recipient site when designing the flap. Thus, the local flap could be the best initial choice, whereas adjacent flaps come second followed by distal flaps last.
Furthermore, it is vital to choose an appropriate perforator to supply the flap. A named and constant perforator is usually selected to be the target vessel for nourishing the flap. However, a small-caliber perforator can suffice if the dimensions of the flap are appropriately chosen to avoid excessive size. To avoid twisting or kinking of the flap pedicle, adequate dissection should be performed to ensure sufficient length of the pedicle. In addition, it is important to choose a donor site that camouflages the resultant donor site scar if possible.
How to Evaluate the Recipient Site?
According to reconstructive surgery principles, we must evaluate the size and shape of the recipient site. Usually, most reconstructions involve skin and subcutaneous tissue. If a skin defect only, the ideal flap needs to be as thin as possible, whereas if the defect includes skin, subcutaneous fat, muscle, or even nerve and bone, composite flaps play an important role in reconstructing such complicated defects.
One example is reconstruction of the face and neck. The skin overlying this region is both elastic and thin, with a compact subcutaneous fat layer adherent over the muscles of facial expression. This is what provides the countless variations and nuances behind human facial expression. In addition, this region also contains many important sensory-stereo organs, such as the eyes, nose, mouth, and ears, giving the face its own unique construction. It is important to rebuild these multiple components with an adequate flap. In this way, Li and colleagues applied an innovative pre-expanded, prefabricated monoblock perforator flap for total facial resurfacing and reconstruction of stereo organs. As to reconstructing the fine nature of facial expression with improved contouring, Wang and colleagues used a pre-expanded super-thin perforator flap to reconstruct the facial subunits to achieve improved functional and cosmetic outcome.
How to Identify and Locate the Perforator?
It is crucial to select and locate the appropriate perforators for a pre-expanded perforator flap design because of the unique vascular nature of perforators. At present, many methods including unidirectional handheld Doppler, color duplex ultrasound, and computed tomography angiography, are used to locate the perforators. Because of its accessibility, and economic and noninvasive nature, unidirectional handheld Doppler is widely used for preoperative preparation. However, with aid of multi-detector row computed tomography, (MDCT) clinicians can identify the perforators visually and more precisely in multiple dimensions, thus making it more helpful when planning expander placement.
Related posts:
An Overview of Pre-expanded Perforator Flaps
Pre-expanded Perforator Flaps
Pre-expanded Supraclavicular Artery Perforator Flap
Pre-expanded Intercostal Perforator Super-Thin Skin Flap
Pre-expanded Free Perforator Flaps
Pre-expanded, Prefabricated Monoblock Perforator Flap for Total Facial Resurfacing
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