Perforator Peroneal Artery Flap for Tongue Reconstruction

Abstract

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 ...

Analysis of Survival Quality of Peroneal Artery Perforator Flap in Immediate Repairment and Reconstruction of Oral and Maxillofacial Malignancies

“…Anatomical research has found that the peroneal artery is composed of ~4 to 6 clinical blood vessels which helps to formulate a relatively constant anatomy position. 14 Further, these vessels are interconnected across the skin, bones, and muscles, providing ideal conditions for the application of artery flaps, including one- paddle artery flap, multi-artery flaps, and chimeric flaps. Such features empower peroneal artery perforator flaps not only to repair the defect of soft tissues, but also to reconstruct the oral and maxillofacial structure after oral cancer ablation with the assistance of fibula to create chimeric flap.…”

Modification of the anterior‐posterior tongue rotation flap for oral tongue reconstruction

“…In practical terms, free flaps are usually required for glossectomy defects approaching half the tongue and larger. 18,19 However, patients frequently appeal to surgeons to operate intraorally with minimal secondary sacrifice. Although some studies advocate one flap over another, Engel et al have pointed out that the specific defect should determine flap selection.…”

“…Tongue defects are among the most challenging for the reconstructive surgeon because of the intimate relationship between form and function in this anatomical area. In practical terms, free flaps are usually required for glossectomy defects approaching half the tongue and larger 18,19 . However, patients frequently appeal to surgeons to operate intraorally with minimal secondary sacrifice.…”

Value of a smartphone‐compatible thermal imaging camera in the detection of peroneal artery perforators: Comparative study with computed tomography angiography

“…Recently, PAP flaps have been applied for intraoral reconstruction due to its thin and palpable nature. It has a long pedicle with large size caliber, and the donor site morbidity is low . Reliable cutaneous flaps should be based on suitable PAPs.…”

“…It has a long pedicle with large size caliber, and the donor site morbidity is low. [9][10][11][12][13][14] Reliable cutaneous flaps should be based on suitable PAPs. However, the variable anatomy of the vasculature makes this challenging.…”