An Overview of Pre-expanded Perforator Flaps

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

  • Along with the development of the flap and comprehension of the vascular anatomy, pre-expanded perforator flaps are a versatile option for reconstructive surgery.

  • 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.

  • Several principles should be recognized and adhered to in order to ensure the success of the procedure when performing the pre-expanded perforator flap.

  • 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 .

Table 1
Comparison of different flap selections for cervicofacial resurfacing
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
  • 1.

    The descending branch of the lateral circumflex femoral artery is dissected to anastomose to the superior thyroid artery or the facial artery and their venae comitantes as a vascular carrier.

  • 2.

    The vascular carrier is inset into the pocket created in the cervicothoracic region.

  • 3.

    Tissue expander is placed beneath the vascular carrier.

  • 4.

    Tissue overexpansion assisted by stem cells.

  • 5.

    Several cosmetic surgeries are needed.

  • 6.

    Post care: airway nursing care and enteral nutrition are needed.

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.
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Nov 21, 2017 | Posted by in Dental Materials | Comments Off on An Overview of Pre-expanded Perforator Flaps
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