Perforator flaps: the next step in the reconstructive ladder?

YBJOM-4562; No. of Pages 9

ARTICLE IN PRESS Available online at www.sciencedirect.com

British Journal of Oral and Maxillofacial Surgery xxx (2015) xxx–xxx

Review

Perforator flaps: the next step in the reconstructive ladder? K.-D. Wolff ∗ Department of Oral and Maxillofacial Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675 München, Germany Accepted 25 March 2015

Abstract Perforator flaps are claimed to be a sign of major progress in head and neck reconstruction, but are they a further step up the reconstructive ladder? In this paper I provide a short summary of the development and current clinical use of perforator flaps in the head and neck, which is based on a presentation to the annual meeting of the British Association of Oral and Maxillofacial Surgeons in 2014. I will describe 4 flaps from the lower leg, which are useful specifically for covering intraoral defects, as examples. When we consider the spectrum of new donor sites, and the precision of flap design that is offered by perforator flaps, it becomes evident that the potential of this new technique has not yet been reached. © 2015 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: Perforator flaps; Head and neck reconstruction; Donor sites at the lower leg; Peroneal; Medial sural; Lateral sural; Soleus

Introduction Since the first microvascular tissue transfers in humans by Seidenberg et al.,1 Mc Lean and Buncke,2 and Daniel and Taylor,3 this technique has spread worldwide. For at least 2 decades it has become the reconstructive procedure of choice for complex defects in all parts of the body, with success rates of about 95%. Efforts continue to evolve these techniques to improve aesthetic and functional results and reduce morbidity at donor sites. As a result of the comprehensive work by Taylor,4 who described the angiosomes of the human body, a basic anatomical concept was developed to allow new approaches to raising soft tissue flaps that rely solely on a single terminal vessel to nourish the skin. Unlike conventional lipocutaneous flaps such as those from the groin, with skin perfusion by many unnamed small branches of direct cutaneous vessels, the blood supply of the “new generation” of skin flaps is reduced to a single, small artery (usually 0.7-1.5 mm in diameter) that enters the anastomotic vascular plexus of the dermis. Using the rich anastomotic network, ∗

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and because of opening choke vessels, the vascular territory of such small terminal arteries is surprisingly large and always sufficient to cover any defect in the oral cavity. These small arteries have to perforate deep fascia before they enter the skin, which has given rise to the term “perforators”, and their dependent flaps have been named “perforator flaps”. In nearly all cases, the raising of a perforator flap needs intramuscular dissection. This is painstaking and at times tedious. Hypothetically, these flaps can be raised in any region of the body if the perforators are sizeable enough to be detected and for direct anastomosis (“free style flaps”). These could be interpreted as “true” perforator flaps. Alternatively, the perforator can be traced to a source vessel, which then serves as the pedicle. Many commonly used early perforator flaps such as the anterolateral thigh (ALT) and deep inferior epigastric perforator (DIEP) are in fact anastomosed on large, long, named vessels not the short, small, unnamed, dispensable perforator. Definition We follow the simplified classification of Hallock,5 and name perforator flaps according to the course of the vessel that

http://dx.doi.org/10.1016/j.bjoms.2015.03.020 0266-4356/© 2015 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Wolff K-D. Perforator flaps: the next step in the reconstructive ladder? Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2015.03.020


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ARTICLE IN PRESS K.-D. Wolff / British Journal of Oral and Maxillofacial Surgery xxx (2015) xxx–xxx

Because this technique theoretically opens up new possibilities, perforator flaps are considered to provide important improvements for our patients. It might therefore be asked whether perforator flaps may be the next step on the reconstructive ladder. To answer this question, we reviewed relevant published reports by searching MEDLINE, the Cochrane Collaboration, and Embase for “perforator flaps in head and neck reconstruction”. Current clinical applications

Fig. 1. Lipocutaneous deep inferior epigastric perforator flap with complete preservation of the muscles of the abdominal wall.

penetrates the deep fascia. Direct perforator flaps are perfused by a vessel that travels directly from the source artery to the deep fascia, whereas in indirect perforator flaps, the perforator courses through muscle or along intermuscular septa. In 2003, the “Gent consensus conference” provided a terminology which stipulated not only the definition of perforator vessels and perforator flaps but also the correct nomenclature of perforator flaps.6 The individual perforator flap is then specified according to the name of the source vessel (DIEP flap) or according to the muscle which has to be separated (vastus lateralis perforator flap). Since the anastomosis of a perforator flap can either be made without loss of the source vessel at the perforating vessel itself (short pedicle with small calibre) or at the source vessel (long pedicle with large calibre), the structure of the vascular pedicle should be mentioned as a further characteristic of the flap (soleus perforator only flap, vastus lateralis long pedicle perforator flap). The term “perforator-based” should further define those flaps harvested without loss of the proximal vessels.7 The main difference from conventional flaps, therefore, is that to raise a perforator flap, a specific skin vessel (the location of which can be variable) must be exposed and followed to the source vessel by incision of the deep fascia and, depending on its course, septa or muscle tissue. This technique allows for preservation of structures not needed to cover the defect, particularly muscles including their motor innervation. This, for example, is important to protect the integrity of the muscular abdominal wall (Fig. 1). Perforator flaps therefore combine the reliable blood supply of musculocutaneous flaps with the reduced donor site morbidity of a skin flap.8,9 Apart from the individual design of the skin flap, which can be tailored to fit the defect exactly, an advantage of perforator flaps is their minimal donor site morbidity. However, for a successful reconstruction, it is essential to master the subtle dissection that is required to raise a flap, to have exact knowledge of the vascular anatomy and its possible variations, and to be able to suture vessels reliably with a diameter of 1 mm or less.10

The review uncovered 244 articles that described perforator flaps used in reconstructions of the head and neck. When we analysed whether the technique had led to new donor sites or obvious improvement in the results of reconstruction in clinical practice, they were inconsistent. The first description of a perforator flap without the source vessel was given by Koshima and Soeda of the thinned paraumbilical perforator flap in 1989.8 Many others followed that described numerous donor sites throughout the body. Although about 400 cutaneous perforators can be found that reach the integument,11 only a few donor sites have made an appreciable impact on raising perforator flaps in routine clinical practice. In general, donor sites such as the lower abdomen (DIEP flap, paraumbilical perforator flap), thigh (ALT and vastus lateralis perforator flap) and the gluteal region (superior and inferior gluteal perforator flaps) are the most attractive and commonly used perforator flaps. Flaps from the thoracodorsal and circumflex iliac artery have proved their usefulness for reconstructive purposes all over the body,12 but when we focus on free perforator flaps for reconstruction of the head and neck it becomes evident that the range of perforator flaps that are used is still quite limited. As the review of previous reports showed, most of the free perforator flaps come from the thigh, which is extremely well-suited for raising flaps in the predominantly slim populations of the Asian countries.13–15 Despite the option to shape (Fig. 2) or thin out these flaps (Figs. 3 and 4), the thigh is a less attractive site for us, as the thickness of the subcutaneous fatty tissue is greater in Northern European and North

Fig. 2. Tailored, de-epithelialised, anterolateral thigh flap for augmentation of the contour.




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Fig. 3. Raising of an anterolateral thigh perforator flap. Inset shows level of thinning of the flap and remaining muscle/fat cuff.

Fig. 4. Primarily thinned anterolateral thigh flap.

American people with a different body habitus. Although it has been shown that radical thinning can be considered safe and reliable, 16,17 surgeons still seem to have concerns about the procedure because they are anxious about jeopardising the perforator or somehow reducing the vascular supply of the flap.18 Reports of the raising of perforator flaps from the ALT with intramuscular dissection and primary radical thinning of the flap in the predominantly overweight Western population to cover defects in the head and neck are still therefore relatively rare. This is particularly true for intraoral reconstruction, where small, thin flaps are needed. Those thin flaps cannot easily be obtained from an adipose thigh because the residual bulk created by the protective cuff of fatty tissue around the perforator is still relatively large. When you focus on the specific requirements for intraoral reconstruction, the technique of raising a perforator flap



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does not create a revolutionary change in clinical practice. To convert a standard latissimus dorsi or rectus abdominis flap into a thin skin flap which perfectly meets the criteria needed for intraoral lining, for example, is far from clinically routine, although such a procedure is regularly pointed out as a new option when the benefits of perforator flaps are being highlighted. For some donor sites one might argue that only the name of the flap has been changed, and the technique for modifying the raising of the flap is the same (ALT, submental artery perforator flap), and often the term “septocutaneous flap” has simply been replaced by the modern term “perforator flap”. When you analyse the papers that describe perforator flaps in the head and neck, few substantial new donor sites can be discovered compared with those already known from conventional “non-perforator” flaps. One exception is the lower leg, which provides thin and pliable skin without the need for primary thinning. Although this anatomical region has already been described as a source for free flaps in reconstruction of the head and neck before the era of the perforator flap,19–21 these flaps have not often been used because the morbidity created by sacrificing one of the major arteries seemed to be unjustified.

The lower leg as a donor site for perforator flaps Preoperative planning Unlike conventional flaps in which the anatomy is reliable, and allowing for a standardised step-by-step procedure to raise the flap, the success of a perforator flap depends decisively on the integrity of the perforator vessel. As the exact position of the perforator varies, and can never be predicted precisely by clinical experience or expectation, objective preoperative measures are recommended. To speed up raising the flap and facilitate planning of the initial skin incision with which to expose the perforator, techniques such as computed tomography (CT) or magnetic resonance (MR) angiography (Habib A, et al. The role of preoperative perforator mapping using CT angiography compared with conventional Doppler in the successful harvest of antero-lateral thigh flaps: a comparative prospective study. Paper presented at the annual meeting of the British Association of Oral and Maxillofacial Surgeons, 2011),22,23 near infrared spectroscopy24 or colourcoded Duplex sonography25 have been suggested. These methods have been proved to detect perforators in at least 95% of cases. From our own experience, a handheld Doppler can give similar precision if the signal is focused on a single spot, is loud, and is obtained from a region where perforators are expected. The position of the initial skin incision is of even greater importance if small flaps are planned, and one should aim to have the perforator in the centre. One of the main aims of perforator flaps (minimising donor site morbidity) can be reached only if superfluous surgical manoeuvres to expose a suitable perforator or to give the flap its definitive

shape are reduced to an absolute minimum. The initial cut through the skin should therefore ideally be one definitive border of the flap. The following 4 flaps have been chosen because they fulfil the criteria for raising a perforator flap, and show that this new technique can definitely expand the range of donor sites. Their reconstructive properties for intraoral defects completely match those of the gold standard radial forearm flap, and therefore meet the requirement of reducing morbidity as long as the donor site is closed primarily. Peroneal perforator flap The anatomy of the lateral lower leg has been well-known since the introduction of the osteocutaneous fibular flap by Hidalgo in 1989,26 but before that, Yoshimura et al had described the possibility of raising skin flaps pedicled on the peroneal artery.27 Without the term “perforator flap” being used, this flap was first used to cover defects in the extremities, and later for intraoral lining.28 To gain a pedicle as long as possible, a preferred donor site was the supramalleolar area, where a suitable septocutaneous perforator could usually be found, but the need to cover this donor site with a skin graft was a disadvantage. When the flap is raised from the middle or upper third of the lower leg, it can be closed directly as long as the width of the flap does not exceed 5-6 cm. After preoperative Doppler mapping along the posterior intermuscular septum, the skin is incised 2-3 cm anterior to the preferred perforator, which is exposed and traced to the peroneal vessels by leaving a cuff of deep fascia, soleus, and flexor hallucis longus muscle around it. In keeping with any perforator flap, the vessel is accompanied by 2 veins. To protect these fine vessels, they must not be completely peeled out of the muscle but only deroofed, which allows the surgeon to identify their course to the main vessels precisely. Because this flap is a long pedicle perforator flap, the peroneal vessels are included by opening the deep flexor space and dissecting them proximally as far as is needed for a tension-free anastomosis. Finally, the skin paddle is raised by accurately shaping it according to the dimensions of the defect. The perforator is positioned in the centre of the skin flap. Immediate haemostasis and control of the perforator pulse is possible only when the flap is raised without a tourniquet. Another precondition for raising a flap is the integrity of all the vessels of the lower leg which should be checked in the same way as a fibular donor site, by MR angiography (Figs. 5–8). Soleus perforator flap The soleus perforator flap is raised from a donor site similar to that of the peroneal perforator flap, but without including the main vessels. The pedicle therefore consists of the perforator itself, making it a short-pedicle (4-7 cm), narrow-calibre flap with minimal donor site morbidity. For successful anastomosis of this flap there must be a sizeable perforator present with




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Fig. 5. Distally-based donor site of peroneal perforator flap.

Fig. 6. Long pedicled peroneal perforator flap.

a strong pulse and a diameter of at least 1 mm. The anatomy of the lower leg perforators was thoroughly investigated in the early 90s when the reliability of the fibular skin paddle was described.29 The peroneal vessels give off about 3-4 perforators, predominantly with a myocutaneous course in the proximal, and a septocutaneous course in the distal, half of the lower leg. According to a recent overview, the most reliable perforator is located at the transition of the middle and distal thirds.30 Nevertheless variations are always possible, which makes the inclusion of the peroneal vessels necessary if the calibre of the perforators seems too small for a direct anastomosis. After its first description for intraoral reconstruction,31 this flap has also been used for covering other defects in the head and neck,32,33 and success rates of at least 90% are regularly achieved. To create the least possible donor site

Fig. 7. Primary result after partial reconstruction of the tongue.

Fig. 8. Tension-free direct closure of the donor site.

morbidity (a short pedicle flap with direct closure), there must be adequate recipient vessels, and the size of the defect must allow direct closure. The thin and pliable soleus perforator flap is therefore ideally suited for intraoral lining, if suitable recipient vessels can be preserved during dissection of the neck (Figs. 9-10). Medial sural perforator flap Although the region above the gastrocnemius muscle was described as a potential donor site for free skin flaps in 1975,34 it took another 2 decades until its first clinical application as a regional (Montegut WJ et al. Sural artery perforator flap as an alternative for the gastrocnemius myocutaneous flap. Paper presented at the Ninetieth Annual Scientific Meeting of the Southern Medical Association, Baltimore, 1996) or free35 flap. Chen et al36 and Kao et al37 were the first to use the medial sural perforator flap to cover defects in the oral cavity. In a prospective study, this flap was found to have the same success rate and reconstructive quality as the radial forearm flap, but with lower donor site morbidity.38 The pedicle of the flap is the medial sural artery, which has a calibre of up to 3 mm at its origin from the popliteal artery. Typically the main perforators pierce the medial head of the gastrocnemius muscle 8 and 15 cm distal to the flexor crease of the knee joint, respectively. Whereas the perforators



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Fig. 11. Vascular pedicles of medial and lateral superficial sural artery perforator flap.

greater saphenous vein can also be used for drainage.39 If a strong signal can be obtained from the distal perforator, a long pedicle can be dissected, always sufficient for a tension-free anastomosis to the neck vessels. The dimensions of the flap can be as much as 6 x 15 cm, with the central axis of the flap positioned parallel and dorsal

Fig. 9. Donor site with septomyocutaneous perforator of the soleus perforator flap.

of the peroneal vessels mostly need only intramuscular dissection along a short segment, the whole pedicle of the medial sural artery flap runs within the muscle and must be carefully separated from the muscle fibres along almost its entire length. The artery is usually accompanied by 2 veins, which allow for a safe anastomosis (2 – 4 mm). Additionally, the

Fig. 10. Short pedicled soleus perforator flap without thinning.

Fig. 12. Medial sural artery perforator flap.




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Fig. 14. Donor site of a lateral superficial sural artery perforator flap.

Fig. 13. Appearance of the donor site of a medial sural artery perforator flap at day 10.

to the tibia. As with all perforator flaps, definitively outlining the flap margins is possible only after exposure of the perforator. Because of its high calibre and relatively long pedicle, the medial sural artery perforator flap is ideally suited to be an alternative to the radial forearm flap (Figs. 11–13). Superficial lateral sural artery perforator flap Another (currently rarely used) option for raising a perforator flap is the vascular territory of the lateral sural artery. The superficial branch gives off direct feeding vessels to the skin, all of which perforate the deep crural fascia. Because this vessel mostly courses directly underneath the fascia, raising of the flap does not need intramuscular dissection. An anatomical study showed that the superficial branch of the lateral sural artery was present in 31 out of 42 lower legs, with a calibre of at least 1 mm.40 The vessel has its origin from the lateral sural artery close to the peroneal vessels and is accompanied by 2 veins, one of which is the lesser saphenous vein or a branch parallel to it. The perforators to the skin are located within an area 3 -10 cm distal to the fibular head and about 3 cm from the posterior midline, so all perforators are located dorsal to the posterior intermuscular septum. Anastomotic vessels can be found to the peroneal perforators

in every case, building an overlapping vascular territory with the peroneal or soleus perforator flap. This is advantageous as, in patients with an insufficient or missing superficial sural artery, a perforator flap from the peroneal vascular system can be raised instead. The initial skin incision is therefore made 1-2 cm dorsal to the septum, in either the anterior margin of the soleus or the posterior border of the sural flap. In a series of 20 flaps raised at the lateral lower leg, the artery could not be used in 8 patients because of absence (n=2) or insufficient calibre. In these cases, the posterior intermuscular septum was included, and a soleus flap was raised successfully. In the remaining 12 cases, the thin and extremely pliable superficial sural artery flaps had pedicles about 8 cm long and were well-suited for intraoral lining (Figs. 14–17).

Fig. 15. Raised lateral superficial sural artery flap with large saphenous vein and small artery.



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Fig. 16. Hemiglossectomy reconstruction using a lateral superficial sural artery perforator flap.

Perspective To evaluate the benefits from new developments in head and neck reconstruction we first have to analyse the remaining problems, which we encounter daily during our work. Given regularly quoted success rates of at least 95%, and in the light of the fact that nearly all defects can be reconstructed with the full scope of standard flaps, we have to ask whether

perforator flaps are necessary at all. Almost all intraoral defects can be managed with a radial forearm flap, which is extremely reliable and easy to raise. For more extensive defects, many myocutaneous flaps are available. Facial bones can be replaced with 3 different osseous flaps, all of them well-recognised and with good reconstructive qualities. Why should we look for new flaps or other donor sites if we have the ideal soft tissue flap, as suggested by Wei et al? 13 Surely the answer to these questions is: because we must. Developments and improvements can be achieved only if new ideas are born, tested, and finally implemented into clinical practice. Perforator flaps are an excellent example of such progress. Although they are not necessarily needed, any reconstructive surgeon understands the considerable advantages they can have compared with the standard flaps, particularly in relation to minimising donor site morbidity. There can be no doubt that, where appropriate, this technique will steadily replace flaps with more donor site morbidity. It is also clear that further input is necessary until we can offer a perfect reconstructive option to any patient, without subjecting them to the degree of donor site morbidity that we do now. Conclusion Obtaining optimal results by primary thinning, individual shaping, and minimising donor site morbidity are our aims when we raise a perforator flap. If we keep these aims in mind and compare them with our routine reconstructive work it becomes more than evident that the potential of perforator flaps has not yet been exhausted. Perforator flaps are undoubtedly an important evolution of a proved technique. As long as we still debulk flaps secondarily, as long as we have to repair failed wounds at the forearm donor site, and as long as patients complain about muscular weakness postoperatively, we have not reached the next step of the reconstructive ladder. Conflict of Interest I have no conflict of interest. Ethics statement/confirmation of patient permission The work was done according to the Declaration of Helsinki, and was approved by the Ethics Committee.

References

Fig. 17. Appearance of the donor site of a lateral superficial sural flap on day 20.

1. Seidenberg B, Rosenak SS, Hurwitt ES, et al. Immediate reconstruction of the cervical esophagus by a revascularized isolated jejunal segment. Ann Surg 1959;149:162–71.




2. McLean DH, Buncke Jr HJ. Autotransplant of omentum to a large scalp defect, with microsurgical revascularization. Plast Reconstr Surg 1972;49:268–74. 3. Daniel RK, Taylor GI. Distant transfer of an island flap by microvascular anastomoses. A clinical technique. Plast Reconstr Surg 1973;52:111–7. 4. Taylor GI. The angiosomes of the body and their supply to perforator flaps. Clin Plast Surg 2003;30:331–42. 5. Hallock GG. Direct and indirect perforator flaps: The history and the controversy. Plast Reconstr Surg 2003;11:855–66. 6. Blondeel PN, van Landuyt KH, Monstrey SJ, et al. The “Gent” consensus on perforator flap terminology: preliminary definitions. Plast Reconstr Surg 2003;112:1378–82. 7. Kim JT. New nomenclature concept of perforator flap. Br J Plast Surg 2005;58:431–40. 8. Koshima I, Soeda S. Inferior epigastric artery skin flaps without rectus abdominis muscle. Br J Plast Surg 1989;42:645–8. 9. Kroll SS, Rosenfield L. Perforator-based flaps for low posterior midline defects. Plast Reconstr Surg 1988;81:561–8. 10. Wolff KD, Hölzle F. Raising of microvascular flaps: a systematic approach. 2nd ed. Berlin: Springer; 2011. 11. Morris SF, Tang M, Almutairi K, et al. The anatomic basis of perforator flaps. Ann Plast Surg 2010;37:553–70. 12. Blondeel PN, Hallock GG, Morris SF, editors. Perforator flaps: anatomy, technique & clinical applications. St. Louis: Quality Medical Publishing; 2005. 13. Wei FC, Jain V, Celik N, et al. Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps. Plast Reconstr Surg 2002;109:2219–30. 14. Chana JS, Odili J. Perforator flaps in head and neck reconstruction. Semin Plast Surg 2010;24:237–54. 15. Lyons AJ. Perforator flaps in head and neck surgery. Int J Oral Maxillofac Surg 2006;35:199–207. 16. Kimura N, Satoh K. Consideration of a thin flap as an entity and clinical applications of the thin anterolateral thigh flap. Plast Reconstr Surg 1996;97:985–92. 17. Wolff KD, Plath T, Hoffmeister B. Primary thinning of the myocutaneous vastus lateralis flap. Int J Oral Maxillofac Surg 2000;29:272–6. 18. Alkureishi LW, Shaw-Dunn J, Ross GL. Effects of thinning the anterolateral thigh flap on the blood supply to the skin. Br J Plast Surg 2003;56:401–8. 19. Morrison WA, Shen TY. Anterior tibial artery flap: anatomy and case report. Br J Plast Surg 1987;40:230–5. 20. Zhang SC. Clinical applications of the medial skin flap of leg – analysis of 9 cases (in Chinese). Zhonghua wai ke za zhi 1983;21:743–9. 21. Wee JT. Reconstruction of the lower leg and foot with the reverse-pedicled anterior tibial flap: Preliminary report of a new fasciocutaneous flap. Br J Plast Surg 1986;39:327–37. 22. Chen SY, Lin WC, Deng SC, et al. Assessment of the perforators of the anterolateral thigh flaps using 64-section multidetector computed tomographic angiography in head and neck cancer reconstruction. Eur J Surg Oncol 2010;36:1004–11.

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23. Wolff KD, Bauer F, Dobritz M, et al. Further experience with the free soleus perforator flaps using CT-angiography as a planning tool – a preliminary study. J Craniomaxillofac Surg 2012;40:e253–7. 24. Sacks JM, Nguyen AT, Broyles JM, et al. Near-infrared laser-assisted indocyanine green imaging for optimizing the designing of the anterolateral thigh flap. Eplasty 2012;12:e30. 25. Ensat F, Babl M, Conz C, et al. The efficacy of color duplex sonography in preoperative assessment of anterolateral thigh flap. Microsurgery 2012;32:605–10. 26. Hidalgo DA. Fibula free flap: a new method of mandible reconstruction. Plast Reconstr Surg 1989;84:71–9. 27. Yoshimura M, Imura S, Shimamura K, et al. Peroneal flap for reconstruction in the extremity: preliminary report. Plast Reconstr Surg 1984;74:402–9. 28. Wolff KD. The supramalleolar flap based on septocutaneous perforators from the peroneal vessels for intraoral soft tissue replacement. Br J Plast Surg 1993;46:151–5. 29. Schusterman MA, Reece GP, Miller MJ, et al. The osteocutaneous free fibula flap: is the skin paddle reliable? Plast Reconstr Surg 1992;90:787–98. 30. Iorio ML, Cheerharan M, Olding M. A systematic review and pooled analysis of peroneal artery perforators for fibula osteocutaneous and perforator flaps. Plast Reconstr Surg 2012;130:600–7. 31. Wolff KD, Holzle F, Nolte D. Perforator flaps from the lateral lower leg for intraoral reconstruction. Plast Reconstr Surg 2004;113: 107–13. 32. Chang CC, Huang WC, Lin JY, et al. Perforator flap from proximal lateral leg for head and neck reconstruction. J Reconstr Microsurg 2013;29:263–70. 33. Hsu H, Chen PR, Chien SH, et al. Application of proximal lateral leg perforator flaps for head and neck reconstructions. Otolaryngol Head Neck Surg 2014;151:791–6. 34. Taylor GI, Daniel RK. The anatomy of several free flap donor sites. Plast Reconstr Surg 1975;56:243–53. 35. Cavadas PC, Sanz-Gimenez-Rico JR, Gutierrez-de la Camara A, et al. The medial sural artery perforator free flap. Plast Reconstr Surg 2001;108:1609–17. 36. Chen SL, Yu CC, Chang MC, et al. Medial sural artery perforator flap for intraoral reconstruction following cancer ablation. Ann Plast Surg 2008;61:274–9. 37. Kao HK, Chang KP, Chen YA, et al. Anatomical basis and versatile application of the free medial sural artery perforator flap for head and neck reconstruction. Plast Reconstr Surg 2010;125:1135–45. 38. Kao HK, Chang KP, Wei FC, et al. Comparison of the medial sural artery perforator flap with the radial forearm flap for head and neck reconstructions. Plast Reconstr Surg 2009;124:1125–32. 39. Hallock GG. Anatomic basis for the gastrocnemius perforator-based flap. Ann Plast Surg 2001;47:517–22. 40. Wolff KD, Bauer F, Kunz S, et al. Superficial lateral sural artery flap for intraoral reconstruction: anatomic study and clinical implications. Head Neck 2012;34:1218–24.


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