Perforator flaps from the lower leg for intraoral reconstruction: Experience of 131 flaps

Background: During the last decade, perforator flaps have become popular for defect cover in the head and neck because they increase the choice of reconstructive possibilities and can lead to minimal donor site morbidity. In particular, the lower leg is considered a suitable option, as it provides thin and pliable skin for intraoral lining. Having gained experience with 131 flaps raised from four different donor sites at the lower leg, the aim of this paper is to evaluate success rates and patient satisfaction, but also difficulties and pitfalls during flap transfer. Methods: In a retrospective study, all perforator flaps from the lower leg that have been raised between January 2002 and December 2016 were evaluated according to flap type, indications, size, vascular anatomy, complications, success rates, and donor site morbidities. For this, the patient's charts including photographic documentation were analysed with particular respect to difficulties during raising and transferring the flaps and wound healing disturbances. The patient's ability to speak and swallow and the aesthetic and functional results at the donor sites were assessed by clinical examination during the first postoperative year. Results: During the 14-year period, 53 soleus perforator flaps (I), 47 peroneal- (II), 18 medial sural- (III) and 13 lateral superficial sural artery perforator flaps (IV) have been used for intraoral reconstruction. Defects were located at all regions of the oral cavity, mostly the floor of the mouth (67), tongue (31), buccal mucosa (19) and others (14). The size of the flaps ranged from 2 × 4 cm to 6 × 9 cm with an average of 4 × 6 cm. Success rates were 93.6% (II), 90.5% (I), 88.8% (III) and 84.6% (IV) with an overall success rate of 90.8%. Intraoperative complications occurred in 22.1% and were related to small perforator arteries (11), spasm of perforator (8), perforator transection (2) or difficulties to carry out anastomoses directly to the perforating vessels (7). After successful transfer, the functional outcome was favourable with no need for secondary thinning, and most of the patients were satisfied with the donor site appearance. There was no functional limitation associated with the harvest of any of the four flap types. Conclusions: Perforator flaps from the lower leg show higher complication rates than conventional flaps but can be useful for small or medium sized defects if a hidden donor site without functional limitations is required. The vascular architecture and anatomic variations of perforators seem to make success rates of 95% or more difficult.