M. W. Findlay1,2,3,4, S. Sinha2, A. Rotman2, J. Ting2, S. Fairbank1, T. Wu2, F. Behan2 1Stanford University,Division Of Plastic And Reconstructive Surgery,Palo Alto, CA, USA 2The Peter MacCallum Cancer Centre,Divison Of Surgical Oncology,East Melbourne, VIC, Australia 3The University Of Melbourne,Department Of Surgery Royal Melbourne Hospital,Parkville, VIC, Australia 4Monash University,Combined Plastic And Reconstructive Surgery Unit,Clayton, VIC, Australia
Introduction: Perforator-based locoregional flaps provide tissue reconstruction with a shorter operative time, length of stay and fewer complications than free flaps in the head and neck. However, the vascular pedicles for common locoregional flaps can be compromised by previous surgery and/or injury and outcomes data based on large case series are lacking within the literature. Our practice has evolved from ‘random’ Keystone flaps to bespoke freestyle perforator subunit-based flaps over the past 6 years and we examined the outcomes data of over 230 cases during this time to examine the outcomes from our approach relative to large published series of free flap reconstructions.
Methods: Over 230 flaps performed over a 6-year period at two clinical centres within Australia were reviewed with institutional ethics approval. The technique for perforator selection, flap design, elevation and closure are described using operative sequences along with our modifications to subunit-based reconstruction using Keystone flap principles. Prospectively collected data including patient comorbidities, pathology, defect size, flap type and perioperative complications were combined with retrospective data such as complication profile and length of follow up for the analysis.
Results:Over 230 flaps were performed in the period between 2006 and 2012 for defects ranging from 4cm2 to 121cm2. Median patient age was 76 (range 19-98 years) with an average of 2 comorbidities per patient. The median operative time was under 100 minutes (inclusive of resective time). There was one peri-operative death (Day 5 post-op), 7 major complications including one complete flap loss and 4 partial flap losses requiring operative management. Pre- or post-operative radiotherapy and/or chemotherapy were associated with increased risk of complications.
Conclusion:An analysis of the outcomes from over 230 perforator-based island flaps in the head and neck demonstrates comparable results to free flap reconstruction, but with the added benefits provided by locoregional reconstruction. Our technique has evolved from ‘random’ Keystone flaps through to bespoke flaps based on specific perforators for esthetic unit reconstruction with shorter operative times and lower morbidity than free flap reconstruction.
