Perforator Peroneal Artery Flap for Tongue Reconstruction

Introduction

Reconstruction has evolved long way from primary closure to flaps. As time evolved, better understanding of vascularity of flap has led to the development of innovative reconstructive techniques. These flaps can be raised from various parts of the body for reconstruction and have shown least donor site morbidity. We use one such peroneal artery perforator flap for tongue reconstruction with advantage of thin pliable flap, minimal donor site morbidity and hidden scar.

Materials and Methods

Our patient 57yrs old lady underwent wide local excision with selective neck dissection. Perforators are marked about 10 and 15 cm inferiorly from the fibular head using hand held Doppler. Leg is positioned in such a way to give better exposure during dissection of the flap and flap is harvested under a tourniquet with pressure kept 350 mm Hg. The perforator is kept at the eccentric location, so as to gain length of the pedicle. Skin incison is placed over the peroneal muscle and deepened unto the deep facia, then the dissection is continued over the muscle and the perforator arising from the lateral septum. The proximal perforator about 10 cm from the fibular head is a constant perforator and bigger one, which is traced up to the peroneal vessel. We could get a 6 cm of pedicle length. Finally the flap is islanded on this perforator and the pedicle is ligated and flap harvested. Anastamosis was done to the ipsilateral side to facial vessels. The donor site is closed primarily and in the upper half one can harvest 5 cm width flap without requiring a skin graft along with a length of 8 to 12 cm.

Discussion

Various local and free flap has been used for reconstruction of partial tongue defects with its obvious donor site problems, like less pliable skin and not so adequate tissue from local flaps and sacrificing a important artery as in radial forearm flap serves as the work horse in reconstruction of partial tongue defects, Concept of super microsurgery was popularized by Japanese in 1980s and the concept of angiosome proposed by Taylor paved the way for development of new flaps. True perforator flaps are those where the source vessel is left undisturbed and overlying skin flap is raised. Yoshimura proposed cutaneous flap could be raised from peroneal artery (Br J Plast Surg 42:715–718, 1989). Wolff et al. (Plast Reconstr Surg 113:107–113, 2004) first used perforator based peroneal artery flap for oral reconstruction. Location of perforators vary, hence pre operative localisation can be done by ultrasound doppler, CT angio or MR angiography. Disadvantages over radial flap include varying anatomic location of perforators, need for imaging and difficult dissection of delicate vessels through muscles and hence a learning curve. Our patient had an arterial thrombus within few hours post-operatively which was successfully salvaged with immediate re-exploration and re-anastomosis of artery. Post-operative healing was uneventful and donor site was closed primarily without the need for graft.

Conclusions

Perforator peroneal flap serves as a useful armamentarium for reconstruction of moderate size defects of tongue, buccal mucosa and floor of mouth with advantages of thin pliable flap, minimal donor site morbidity and hidden scar.

     

Double-skin paddle perforator flap from the lateral lower leg for reconstruction of through-and-through cheek defect - a report of two cases

Extensive defects after ablative surgery of oral cancer, involving exterior skin of the cheek, demand for complex reconstruction. It often requires two free flaps, or double-skin paddle scapular-, radial forearm- or fibular-flap to reconstruct through-and-through cheek defects. The outcome is mostly described as successful and functional. Nevertheless donor site morbidity and functional impairment should not be neglected. This report describes the use of double-skin paddle perforator flaps from the lateral lower leg for combined intra and extraoral reconstruction after tumour resection. This kind of flap first avoids the need of an additional free flap, secondly it produces minimal donor site morbidity because of consequent preservation of the peroneal artery and primary wound closure. Thirdly it enables a good aesthetic outcome possible because of the primarily thin, pliable and variable skin paddles.     

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??Free flaps play key roles in reconstruction of oral soft tissue defects. Nowadays??reconstruction pays more attention to precision??function and less donor sites compromise. Upon employment of perforator flaps in recent years??more choices and less trauma to donor sites became possible. While forearm flap used to be workhorse in oral defects reconstruction??there were some drawbacks for the flap. The ALT flap has some advantages compared with forearm flap except for its bulkiness. The peroneal artery perforator flap owns the benefit of both forearm and ALT flaps in reconstruction of oral tongue??floor of mouth and buccal defects. We summarize the features of perforator flap in this article??it is a good alternative to forearm and ALT flaps in oral defects reconstruction.     

游离腹壁下深动脉穿支皮辦修复头颈肿瘤术后缺损

目的:探索供区功能损伤更小的腹壁下深动脉穿支(DIEAP)皮瓣,用于头颈部肿瘤术后缺损修复。方法:2004年1月～2006年12月,应用DIEAP皮瓣修复头颈部手术缺损患者共12例。手术缺损部位分别为全舌或近全舌缺损6例,面中部缺损3例,颊黏膜洞穿缺损2例,颅底合并头皮缺损1例。结果:11例DIEAP皮瓣修复成功(92%),1例因吻合侧的颈内静脉血栓形成导致皮瓣坏死。供区一期愈合,未发现腹壁疝和腹壁隆起等手术并发症。结论:游离DIEAP皮瓣保留了腹直肌和前鞘,将供区并发症降到最低限度,是头颈部缺损修复新的可靠技术。     

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??The ulnar forearm perforator flap has been used for reconstruction of various oral and maxillofacial-head and neck defects for about 30 years. Besides having the advantages of radial forearm perforator flap??the ulnar forearm perforator flap has some other advantages??including the possibility of direct closure of the donor defect??reduced morbidity??excellent donor site cosmesis??less hairy skin of the transplant and flexible design of the skin island??and independent skin islands may be created as required. These characteristics make it appropriate for patients to accept. Clinically??different sizes of flaps can be selected according to the size of the defected site. Because of the high survival rate and low donor-site morbidity??and its advantages in beauty and function??the ulnar forearm perforator flap plays a very important role in the repair of oral and maxillofacial-head and neck defects.     

The early use of a perforator flap of the lateral lower limb in maxillofacial reconstructive surgery

The development of perforator-based flaps led to new donor sites and enlarged the spectrum of recipient vessels using arteries and veins of very small calibres. Although these flaps, which are directly anastomosed at their terminal cutaneous branches, are becoming more and more important for reconstructions in other regions of the body, perforator-based flaps have not played an important role in maxillofacial surgery until now. This study reports the experience with 24 consecutive perforator flaps from the lateral lower limb for intra- and extraoral defect coverage. Septo- or myoseptocutaneous perforators from the peroneal artery served as the flap pedicle having a length of 4-7 cm and diameters of 1-2 mm. Indications were reconstructions of the floor of the mouth (10), soft palate (3), tongue (6), closure of perforating cheek defects (2) and reconstruction of the facial skin (3). Anastomoses were performed to the lingual, facial, temporal or thyroid superior artery. Except for 2 cases, all perforator-based flaps were healed well and the morbidity of the donor site was nearly negligible. According to the early experience in this study, perforator-based flaps from the lateral lower limb may have an indication if recipient vessels available are close to the defect and if very low donor site morbidity is important to the patient.     

腓肠内侧动脉穿支皮瓣的应用解剖及临床研究

目的: 通过对腓肠内侧动脉穿支皮瓣的解剖学研究,探讨制备腓肠内侧动脉穿支皮瓣的合理性及稳定性;并对临床上应用腓肠内侧动脉穿支皮瓣修复的患者的供区及受区术后恢复情况等进行随访,评价其在口腔颌面部缺损修复重建中的应用价值。方法: 选取 6 例中国成人下肢标本,解剖并记录腓肠内侧动脉穿支的数目、分布、部分层面血管外径及各段血管长度;同时对16 例口腔鳞癌术后缺损患者采用腓肠内侧动脉穿支皮瓣进行修复重建,皮瓣面积 3 cm×4 cm~6 cm×8 cm。术后随访12 个月,观察皮瓣存活情况,受区臃肿度,供区功能恢复,术后吞咽及语言功能情况。结果: 6 例下肢标本共测量记录到腓肠内侧动脉穿支14 条,平均 2.3 条。小腿腓肠内侧动脉穿支平均距腘皱褶下缘（9.15±4.05）cm, 距后正中线（2.82±0.91）cm,源动脉起始处外径平均为（2.11±0.17）mm。血管蒂总长度平均为（12.61±3.15）cm;16 例腓肠内侧动脉穿支皮瓣,2 例发生血管危象并部分坏死,2 例失访（术后随访 10~47 个月,平均 24 个月）。2例皮瓣移植发生血管危象伴部分坏死病例未纳入随访。腓肠内侧动脉穿支皮瓣存活率较高,供区影响小,组织量适中,受区外形不臃肿,质地、弹性良好,吞咽、语言功能均无明显影响。结论: 腓肠内侧动脉穿支皮瓣穿支数目及分布稳定,血管蒂长度及管径完全满足游离皮瓣移植要求,供区影响小,组织量适中,皮瓣受区不臃肿。结合其解剖稳定性,是口腔颌面部软组织中小型缺损修复重建的理想选择。     

Perforator flaps from the lower leg for intraoral reconstruction: Experience of 131 flaps

Background

During the last decade, perforator flaps have become popular for defect cover in the head and neck because they increase the choice of reconstructive possibilities and can lead to minimal donor site morbidity. In particular, the lower leg is considered a suitable option, as it provides thin and pliable skin for intraoral lining. Having gained experience with 131 flaps raised from four different donor sites at the lower leg, the aim of this paper is to evaluate success rates and patient satisfaction, but also difficulties and pitfalls during flap transfer.

Bipaddled radial forearm flap for the reconstruction of bilateral buccal defects in oral submucous fibrosis

Oral submucous fibrosis can result in progressive closure of the mouth. A total of 10 patients with advanced oral submucous fibrosis were surgically treated. The procedure consisted of (1) release of all the intraoral fibrotic tissue, (2) masticatory muscle myotomy and coronoidotomy, and (3) reconstruction with a bipaddled radial forearm flap. Preoperative mouth opening was 0-5mm (mean 2.3mm). The intraoperative mouth opening was 12-20mm (mean 16 mm) after submucous release, and 32-42 mm (mean 35.5mm) after further release via myotomy and coronoidotomy. The proximal flap included one perforator in four patients and two perforators in the remaining six patients. The flaps were 8-9 cm in length and 2-2.5 cm in width. Nine flaps survived uneventfully. Arterial thrombosis was noted in one flap, which was successfully salvaged. Temporomandibular joint subluxation developed in one patient. Two patients needed flap revision due to bulkiness. The postoperative mouth opening was 18-38 mm (mean 28.2mm) after a mean of 21 months' follow-up, and the mean increase was 25.9 mm. A bipaddled radial forearm flap, using a single donor site, can cover two separate buccal defects after release of oral submucosal fibrosis and obviate the need for a second free flap.     

游离腓肠内侧动脉穿支皮瓣修复头颈部缺损的初步研究

目的 探讨游离腓肠内侧动脉穿支皮瓣在头颈部缺损修复中的应用.方法 2010年4月至2011年1月16例患者头颈部肿瘤切除后拟用游离腓肠内侧动脉穿支皮瓣修复组织缺损,术前采用超声多普勒血流仪或彩色多普勒超声检测穿支血管,设计皮瓣,术中记录皮瓣大小、穿支血管的数目和血管蒂长度,术后观察游离瓣成活情况,随访记录供区愈合情况及评价术后并发症.结果 最终完成游离腓肠内侧动脉穿支皮瓣修复16例,15例皮瓣术后成活,1例术后因静脉危象手术探查后皮瓣部分存活.供区15例直接缝合,1例植皮.15例供区Ⅰ期愈合,1例因术后供区肌肉坏死行清创手术后愈合.14例术后随访3～ 12个月,所有患者供区除因瘢痕致远端皮肤触觉异常外,远期无明显功能障碍.结论 游离腓肠内侧动脉穿支皮瓣供区并发症轻微,适用头颈部中小型缺损修复.     

Clinical anatomical study and evaluation of the use of the free anteromedial thigh perforator flaps in reconstructions of the head and neck

The anteromedial thigh (AMT) perforator flap is usually thin, pliable, and nearly hairless, making it particularly suitable to repair defects of the head and neck. We studied the topography and outcomes of AMT perforator flaps in such defects after excision of tumours. We retrospectively reviewed the casenotes of 11 consecutive patients who had had reconstructions of the head and neck with the initial intent of using an AMT perforator flap from January 2010 to July 2011. For each patient we recorded the size and thickness of the flap; the length of the pedicle; and the number, external diameters, anatomical types, source vessels, and sites of the sizeable perforators. Of the 11 patients, 10 had successful reconstruction using AMT perforator flaps, but one had no AMT perforator big enough. The mean (range) number of sizeable perforators/flap was 1.3 (1–2), length of pedicle 10.6 (7–13) cm, and diameter of the artery 1.1(1.0–1.5) mm. Of the 13 sizeable perforators, 3 were direct and septocutaneous. The remaining ones were all musculocutaneous. Most of them were located in the middle third of the thigh. Primary closure of the donor site was achieved in all patients. One flap was successfully revised after compression of the perforator. All flaps survived with good functional and aesthetic outcomes. The free AMT perforator flap is suitable for reconstructions of the head and neck if a sizeable perforator can be found. The AMT flap may be used as a primary flap rather than as an alternative to the anterolateral thigh flap or a component of a chimeric flap.     

Perforator flaps in head and neck surgery

A 'perforator flap' is a flap of skin or subcutaneous tissue that is based on the dissection of a 'perforating vessel'. Over the past few years a large number of 'perforator flaps' have been devised and described. By reducing any muscle harvest and trauma to a minimum, perforator flaps aim to minimize donor site morbidity whilst providing the reconstructive surgeon with more versatility than other flap types. The principal perforator flaps are discussed, particularly those employed in head and neck reconstruction including 'free style perforator flaps'. Methods of locating perforating vessels for the use of perforator flaps are described. The technique of perforator flap harvest is illustrated as exemplified in the anterolateral thigh perforator flap. Advantages in the use of this flap for head and neck reconstruction are discussed and are compared with that of non-perforator flaps, particularly the Radial Forearm Flap. The role of the primary thinning of perforator flaps is discussed. The versatility of the anterolateral flap is discussed, which may well supersede the Radial Forearm Flap as the principal soft tissue flap used in head and neck surgery.     

股前外侧穿支皮瓣的应用解剖研究及临床应用

目的 ：通过对股前外侧穿支皮瓣的解剖学研究,探讨制备股前外侧穿支皮瓣的合理性及稳定性;并对临床上应用股前外侧穿支皮瓣的供区及受区的术后恢复情况等进行随访,评价其在口腔颌面部缺损修复重建中的应用价值。方法 ：选取6例中国成人下肢标本,解剖并记录股前外侧穿支的数目、分布、部分层面血管外径及各段血管长度;并选择9例采用股前外侧穿支皮瓣移植修复口腔颌面部缺损的病例,皮瓣面积5 cm×6 cm～6 cm×12 cm。术后随访观测皮瓣存活情况,评价受区臃肿度及供区功能恢复、术后吞咽及语言功能情况。结果 ：6例下肢标本共测量记录到股前外侧穿支21支,平均3.5支。大腿股前外侧穿支主要出现在髂前上棘至髌骨外侧缘连线中点外1 cm以下约2 cm为圆心、半径约6 cm的圆内,源动脉起始部外径平均为（2.99±0.48）mm,血管蒂总长度平均为（15.83±3.52）cm;9例股前外侧穿支皮瓣,1例发生部分组织坏死, 1例病例失访,术后随访10～47个月（平均24个月）。股前外侧穿支皮瓣存活率较高,供区并发症少,受区皮瓣臃肿程度低,吞咽功能恢复良好。结论 ：股前外侧穿支皮瓣穿支分布稳定,血管蒂较长,穿支的管径完全满足游离皮瓣的要求,临床应用中供区并发症少,受区不臃肿,组织量适中,结合其解剖稳定性,可满足临床修复口腔颌面部组织缺损的需要。     

3D打印定位导板在辅助制备股前外侧穿支皮瓣中的临床应用

目的:探讨采用3D打印固定式定位导板制取股前外侧穿支皮瓣中定位穿支血管的准确性和可行性。方法:收集2019年1月—2020年12月就诊于新疆医科大学第一附属医院/附属口腔医院口腔颌面肿瘤外科,因口腔颌面部软组织缺损需行股前外侧穿支皮瓣修复重建的患者20例。其中,实验组术前3D打印定位导板,术中定位穿支血管并辅助制取股前外侧穿支皮瓣(n=8);对照组采用常规多普勒超声定位穿支血管并辅助制取股前外侧穿支皮瓣(n=12)。比较2组在皮瓣制取时间、出血量、术后供区外形满意度、下肢功能评定量表(LEFS)评分、穿支血管定位、有无术后皮瓣并发症的差异。采用SPSS 24.0软件包对数据进行统计学分析。结果:皮瓣制取时间、出血量、术后供区外形满意度、定位穿支血管的差异有统计学意义(P<0.01);术后皮瓣并发症、LEFS评分差异无统计学意义(P>0.05)。结论:3D打印固定式定位导板为股前外侧穿支皮瓣穿支血管的定位提供了一种新方法,术中定位血管更准确,提高了手术效率以及患者对术后供区外形恢复的满意度。     

Use of free flaps with supermicrosurgery for oncological reconstruction of the maxillofacial region

Supermicrosurgery involves the dissection and anastomosis of vessels<0.8 mm in diameter with minimal donor site morbidity. This study evaluated the feasibility and outcomes of free flaps using supermicrosurgery to repair oncological defects in the maxillofacial region. Forty-two patients were treated with supermicrosurgery to repair oncological defects in the maxillofacial region between December 2015 and February 2021. The supermicrosurgery technique was used for different types of free flap, including 24 superficial circumflex iliac artery perforator flaps, seven anterolateral thigh flaps, three peroneal artery perforator flaps, five medial femoral condyle osteo-adipofascial flaps, and three profunda artery perforator flaps. An artery-to-artery approach was used in 38 patients; venous grafts for anastomosis were used in four patients to resolve an arterial discrepancy. Forty-one flaps (97.6%) survived. Thirty-six patients (85.7%) healed without any complications; three flaps required revision surgery including one lost, one demonstrated wound dehiscence, and two demonstrated wound infection. Supermicrosurgery is a useful complement to conventional microsurgery in head and neck reconstruction.     

穿支皮瓣在口腔颌面部缺损重建中的应用

穿支皮瓣是由以管径细小(0.5~0.8 mm)的穿支血管供血的,包含皮肤或者皮下组织的轴型血管皮瓣.因其具有供区损伤小及受区功能好等特点,穿支皮瓣被广泛应用于口腔颌面部缺损重建修复中.目前,关于穿支皮瓣在口腔颌面部缺损重建中的报道越来越多,但是关于皮瓣术前穿支定位以及皮瓣修复后期削薄方面的研究较少.本文就穿支皮瓣的特点、分类、解剖学基础及其在口腔颌面部缺损修复重建应用中的相关问题作一综述.     

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??The lateral femoral circumflex artery system perforator flaps include anterolateral thigh perforator flap supplied by the lateral descending branch and oblique branch of lateral femoral circumflex artery??anteromedial thigh perforator flap supplied by the medial descending branch of lateral femoral circumflex artery??and tensor fascia lata perforator flap by the ascending branch of lateral femoral circumflex artery. The advantages of these flaps include the low donor site morbidity?? the convenient donor site??the good vascular quality??the large soft tissue volume??the ability to be harvested as a chimeric flap with multiple various tissue components??and being far from the head and neck region which is fit for two-team approach. The lateral femoral circumflex artery system perforator flaps can be flexibly chosen according to the different defects??so as to obtain the best effect in oral and maxillofacial reconstruction.     

Use of medial upper arm free flap in oral cavity reconstruction: a preliminary study

The medial upper arm has previously been proposed as a potential free flap donor site, but the clinical application of such flaps in head and neck reconstruction has not been popular. The preliminary results of the clinical application of medial upper arm free flaps in oral cavity reconstruction are reported here. Five patients with oral cancer underwent surgical resection and neck dissection, with simultaneous reconstruction using a medial upper arm free flap. Functional outcomes were investigated using the University of Washington Quality of Life Questionnaire. Sensory-motor functions of the upper arm donor site were recorded before and after surgery. Four flaps were successfully transferred. One flap was abandoned during surgery because of a lack of perforators, and a forearm flap was used instead. All patients survived without loco-regional recurrence or distant metastasis. Functional outcomes, especially swallowing and speech, were satisfactory. The donor site scar was well hidden, with no functional impairment. This initial experience shows that the medial upper arm free flap represents an alternative perforator flap for oral cavity microsurgical reconstruction. The well-hidden scar and better texture match compared with other flaps make it suitable for oral cavity reconstruction.     

Further experience with the free soleus perforator flaps using CT-angiography as a planning tool – A preliminary study

IntroductionThe soleus perforator flap is a soft tissue flap with minimal donor site morbidity however is not frequently utilised due to the unpredictability of the perforating vessel to serve as the vascular pedicle. We have trialed the use of CT-angiography as a planning tool to predict location, length, course, and calibre of the pedicle to make this a more reliable choice.MethodsTwenty consecutive patients with intraoral squamous cell carcinomas were assessed with CT-angiography to examine the peroneal perforators before considering soleus flap raising. If a sizeable perforator could be visualised at the upper half of the lower leg, flap raising was carried out, and the result of the CT-angiography was compared with the intra-operative findings.ResultsCT-angiography allowed for visualisation of perforators measuring 1 mm in diameter and could predict location, length and course of the vessel. Accordingly, eight of the 20 patients had to be excluded from flap raising due to missing, too fine or too far distally located perforators. Intra-operative findings corresponded well with the results of the CT-scans.ConclusionCT-angiography is a useful tool for planning the soleus perforator flap and allows selection of the most suitable perforator making the use of this flap more reliable.     

游离胫后动脉皮瓣修复80例口腔颌面部软组织缺损效果评价

目的: 探讨胫后动脉皮瓣游离移植修复口腔颌面部软组织缺损的临床设计及效果。方法: 2017年11月—2018年8月,应用胫后动脉皮瓣修复中山大学孙逸仙纪念医院收治的80例口腔颌面部肿瘤术后缺损。术前应用计算机体层血管成像（CTA）对双侧下肢血管进行评估,明确胫后动、静脉走向及穿支数量,完成穿支体表定位。术中根据受区部位、缺损大小、形态以设计、制备皮瓣,并转移至受区进行修复。对皮瓣大小、血管蒂长度、血管直径、穿支数量、穿支长度、存活率、外形、供区和受区术后并发症等进行总结分析。结果: 80例患者中,男56例,女24例;年龄24~90（58.17±1.43）岁;皮瓣大小5 cm×6 cm~7 cm×13 cm,皮瓣厚度0.30~1.00(0.53±0.2) cm,血管蒂长度8~14(10.03±1.4) cm;供区动脉直径1.50~3.00(2.36±0.4) mm,供区静脉直径1.50~4.0(2.99±0.6) mm;穿支数量1~5(2.61±0.9)支（集中于小腿内侧中下1/3）,穿支长度0.3~6(1.70±0.7) cm。皮瓣存活率为100%,伤口愈合良好。覆盖于小腿供区缺损处的皮片2例（2.5%）完全坏死,7例（8.7%）部分坏死,但经过换药处理后恢复满意。患者对外形及功能恢复满意。结论: 应用胫后动脉皮瓣修复口腔颌面部缺损是一种较好的修复方式。胫后动脉皮瓣可携带近心端筋膜及皮下脂肪组织,用以丰满舌体形态、充填口底缺损、保护血管蒂。