Use of ???Perforator Flaps??? in Skull Base Reconstruction after Tumor Resection:

Review of perforator flaps in head and neck cancer surgery

PURPOSE OF REVIEW

Perforator flaps are increasingly being used to reconstruct head and neck defects. They offer several advantages over nonperforator-based flaps with lower donor site morbidity and a versatile range of reconstructive options. The anterolateral thigh flap is well established in the head and neck and is a good example of a reliable perforator free flap. With the increasing use of both free and regional perforator-based flaps, it is timely to review their anatomy, clinical applications, and role in head and neck reconstruction. We also discuss increasingly popular perforator flaps such as the submental flap for the head and neck.

RECENT FINDINGS

The anterolateral thigh flap is now commonly used to reconstruct a wide variety of head and neck defects. The submental flap fills a niche role for reconstruction of intraoral defects.

SUMMARY

Perforator flaps are now mainstream reconstructive options in the head and neck surgeon's armamentarium.

Successful reconstruction of irradiated anterior skull base defect using the dual flap technique involving local pericranial flap and radial forearm free flap

Skull base reconstruction presents a challenging therapeutic problem requiring a multispecialty surgical approach and close cooperation between the neurosurgeon, head and neck surgeon, as well as plastic and reconstructive surgeon during all stages of treatment. The principal goal of skull base reconstruction is to separate the intracranial space from the nasopharyngeal and oropharyngeal cavities, creating support for the brain and providing a water-tight barrier against cerebrospinal fluid leakage and ascending infection. We present a case involving a 58-year-old man with anterior skull base defects (2.5 cm × 3 cm) secondary to the removal of olfactory neuroblastoma. The patient received conventional radiation therapy at 6000 cGy in 30 fractions approximately a month before tumor removal. The patient had radiation therapy before surgery and was planned to have postoperative radiation therapy, which would lead to a higher complication rate of reconstruction. Artificial dura was used for the packing of the dural defect, which was also suspected to increase the complication rate of reconstruction. For these reasons, we chose to apply the dual flap technique, which uses both local pericranial flap and de-epithelized radial forearm free flap for anterior skull base defect to promote wound healing. During 28 months of follow-up after coverage of the anterior skull base defect, the dual flap survived completely, as confirmed through follow-up magnetic resonance imaging. The patient was free of cerebrospinal fluid leakage, meningitis, and abscess, and there was minimal donor-site morbidity of the radial forearm free flap. Reconstruction of anterior skull base defects using the dual flap technique is safe, reliable, and associated with low morbidity, and it is ideal for irradiated wounds and low-volume defects.

Use of the lateral circumflex femoral artery perforator flap in the reconstruction of gunshot wounds to the face

PURPOSE

The reconstruction of large avulsive tissue loss in the head and neck region is one of the most difficult tasks faced by reconstructive surgeons. The advent of free tissue transfer has improved our ability to predictably reconstruct these patients. One of the most recent advances in the field of microvascular surgery is the use of perforator flaps. We have used the lateral circumflex femoral artery perforator (LCFAP) flap for reconstructions in patients who have suffered severe gunshot wounds (GSWs) to the maxillofacial area.

METHOD

A retrospective chart review was conducted of patients treated with a LCFAP flap in our division for large defects of the face resulting from GSWs between July 2005 and July 2006. The patient's age and gender, site and size of defect, and degree of bone and soft tissue loss were recorded. Flap survival and donor site morbidity were noted as outcomes of the reconstruction.

RESULTS

Four patients who met the inclusion criteria were identified. The success rate for the flaps was 100%. There was no partial necrosis of the flaps. The size of the defect ranged from 20 x 10 cm to 10 x 10 cm. None of the patients had donor site complications, and all donor sites were closed primarily.

CONCLUSIONS

Use of the LCFAP flap for the reconstruction of large defects secondary to GSWs to the face is a reliable option for the immediate reconstruction of this patient population. The lateral circumflex femoral artery perforator (LCFAP) flap is at a site not involved in the immediate resuscitation of trauma patients, thus ensuring an intact vascular system. This fact makes the LCFAP flap a reliable source for small to large soft tissues for reconstructing avulsive soft tissue losses in the head and neck.

Perforator flap entity

The perforator flap is not a new concept in microsurgery but there is still confusion. The number of centers that is using these flaps for various indications is increasing. Studies about the differences between these flaps and the conventional flaps, including donor site morbidity and long-term follow-ups, will be seen in the medical literature. Better accuracy in reconstruction, including the use of only cutaneous tissue, minimization of the morbidity, and preserving the same survival rate in free flaps are reassurances to microsurgeons to perform perforator flaps. We believe that in the near future with refinements in the techniques and instruments, perforator flaps will be the first choice flap.