Perforator Based Fasciocutaneous Flap Reconstruction of Extremity Skin Cancer: A First Choice

Purpose: Aggressive skin cancers disproportionately affect the upper and lower extremities (Merkel cell and melanoma, respectively). Stable wounds are a prerequisite for reconstruction in the context of aggressive skin cancer for the initiation and un-interruption of radiotherapy. We have therefore evolved to the use of perforator based fasciocutaneous flaps with closable donor sites as a first choice option in the reconstruction of these defects and we review our experience and technical nuances.

Methods: A retrospective chart review was completed at New York University Medical Center of the senior author’s extremity skin cancer reconstructions over a 5 year period.. Charts were reviewed for patient demographics, co-morbidities, etiology of wound, defect size, wound site, method of reconstruction, complications, need for re-operation, need for adjuvant therapy, follow-up period, and technique-specific factors.

Results: A total of 24 charts were reviewed. Patient’s age ranged from 23-104, with a mean of 56. 8 propeller flaps and one posterior interosseous artery flap were performed. Only one patient who had a propeller flap had a complication, small area of wound breakdown, likely attributable to the patient’s history of peripheral vascular disease. Otherwise all propeller flaps achieved a high level of function and cosmesis. All patients treated with adjuvant radiotherapy initiated their courses without delay and went to completion without interruptions or wound complications. Follow-up times ranged between 18 weeks and 18 months.  No donor site skin grafts were required, all wounds were decreased in size by 30-50% by subfascial spanning sutures which allowed for tension free flap inset and primarily closable donor sites. In one propeller flap case, the perforator signal was lost and the flap was converted to a skin graft.

Conclusions: Perforator based fasciocutaneous flaps provide an optimal and durable method of reconstruction of extremity skin cancer wounds. Additional advantages include quick recovery, minimal wound care, and resilience in the face of adjuvant radiotherapy. Moreover, our upfront focus on stable decrease of wound size allows for tension free inset (thereby minimizing flap viability issues) and primarily closable donor sites.  The latter is the only justification of propeller flaps instead of skin grafts in these wounds given the proximity of the donor site.  Finally, this technique allows for the reversion to a skin graft should flap viability be compromised.