The combined profunda artery perforator‐gracilis flap for immediate facial reanimation and resurfacing of the radical parotidectomy defect

Abstract

Background A radical parotidectomy with facial nerve sacrifice results in facial nerve paralysis as well as a volume and often cutaneous defect. Prior experience with nerve grafting and static suspension has yielded suboptimal results. The present report aims to examine the feasibility and outcomes of a combined free gracilis and profunda artery perforator (PAP) flap from a single donor site can reconstruct these extensive defects and potentially restore dynamic facial reanimation even in the setting of adjuvant radiation. Patients and Methods A retrospective review of 10 patients (6 males and 4 females) was performed from 2016 to 2020 that underwent a combined PAP‐gracilis reconstruction of a radical parotidectomy defect. All patients (mean age: 71.3 years; range: 52–83 years) received adjuvant radiation. A chimeric PAP‐gracilis flap requiring a single microvascular anastomosis was performed in three patients while the remaining patients underwent a double free flap reconstruction. Results The gracilis flap was innervated using the facial nerve stump, spinal accessory and massecteric nerve in three patients each. One patient's gracilis was innervated using the hypoglossal nerve. Three patients also underwent nerve grafting of the facial nerve. One patient was taken back to the operating room for a hematoma in the recipient site and there were not flap losses of either the PAP or gracilis flap. Two patients had delayed wound healing of the donor site that healed with conservative management. Average follow‐up was 11.1 months (range: 8.1–19.5 months). Six patients were able to achieve dynamic animation while the others obtained a static reconstruction and did not have issues with drooling, eating, or speaking. Conclusions Immediate functional muscle transfer can potentially restore dynamic facial reanimation even following radiation. Combining reconstruction using a PAP‐gracilis flap addresses the soft tissue deficit and facial paralysis using a single donor site in a single operation.

Volumetric Analysis of a Novel Chimeric Gracilis and Profunda Artery Perforator Flap

“…Clinical utility of this flap has been demonstrated by both Heredero et al 3 and Yao et al 4 in large-volume head and neck reconstruction. 3,4 Despite the utility of the combined flap, the identification, dissection, and microsurgical anastomosis (if used as a free flap) of two distinct pedicles represents a significant disadvantage of prolonged operative time, greater risk of anastomotic complications, and resources. As we have previously demonstrated feasibility of a chimeric flap harvest in cadaveric models 2 , pre-operative mapping through CTA could allow for identification of a common arterial pedicle and improve pre-operative planning and resource utilization.…”

“…1,2 Due to its chimeric design, this flap may potentially offer greater soft tissue volume than either a singular gracilis or PAP flap, providing flexibility for reconstruction, especially in scenarios featuring a large defect. Clinical utility of this flap has been demonstrated by both Heredero et al 3 and Yao et al 4 in large-volume head and neck reconstruction as well as in perineal reconstruction. [5][6][7] Despite the utility of the combined flap, the identification, dissection, and microsurgical anastomosis (if used as a free flap) of two distinct pedicles represents a significant disadvantage of prolonged operative time, greater risk of anastomotic complications, and resources.…”

“…1 2 Due to its chimeric design, this flap may potentially offer greater soft tissue volume than either a singular gracilis or PAP flap, providing flexibility for reconstruction, especially in scenarios featuring a large defect. Clinical utility of this flap has been demonstrated by both Heredero et al 3 and Yao et al 4 in large-volume head and neck reconstruction as well as in perineal reconstruction. 5 6 7…”

Expanding the Armamentarium of Donor Sites in Microvascular Head and Neck Reconstruction

“…The perforator anatomy again has proven to be remarkably reliable and likely more reliable than the ALT, which can have tremendous variation and in some circumstances may not have any suitable perforators at all. For many head and neck patients who suffer from weight loss due to the extensive tumor burden, pain, trismus, or the sequelae of previous radiation, the PAP can provide tissue that is thicker than the ALT ( Figure 5 and Figure 6 ) [ 24 , 25 , 26 ]. The length of the flap can be tailored to the size of the defect, but the width that can be harvested is variable from patient to patient and is dependent on the laxity in the donor site.…”

Innovative Strategies in Microvascular Head and Neck Reconstruction

“…While these factors were considered relative contraindications to dynamic reconstruction in the past, we have confirmed that patients undergoing immediate functional gracilis transfer were able to achieve volitional control. When using a single donor site from the medial thigh, a profunda artery perforator (PAP) flap can be harvested with the gracilis muscle allowing the reconstructive microsurgeon to address the volume deficit using the PAP flap and restore dynamic facial movement using the gracilis muscle [ 66 ]. A simultaneous harvest of the PAP and gracilis can be performed in the supine position.…”