Free-Style Local Perforator Flaps

Sir: We read with great interest the article entitled “Free-Style Local Perforator Flaps: Versatility of the V-Y Design to Reconstruct Soft-Tissue Defects in Skin Cancer,”1 by Brunetti et al. We congratulate the authors on their article, and we would like to share our experience with this type of local flap for skin cancer. We have had a similar experience with the perforator-based V-Y flap, and consider this procedure as now absolutely essential in our daily practice, whether for the treatment of skin tumors (such as in posttraumatic defects) or for other losses of substance. With a few exceptions, we always look for a perforator vessel in all skin flaps that we perform, to design the draw of our skin paddle: “the free-style perforator flap way of life.” Are we at the dawn of the disappearance of random flaps? We use as a unique tool for the detection of perforator vessels a portable acoustic Doppler ultrasound device (8 MHz). As authors, we currently have in our series a 7 percent error detection (false-positive) rate. That is why, when we perform the propeller flap, we always take care to identify several perforator vessels nearby. We systematically begin by performing an incision of a few centimeters on one edge of the flap, close to the selected perforator vessel, to confirm its location. If the perforator is not where it was detected, or is simply absent, we successfully transform (in almost 75 percent of cases) the propeller flap into the perforator-based V-Y advancement or rotation flap. An undeniable advantage of the V-Y flap is that it is possible to keep more than one perforator in the flap and thus secure our skin paddle. This last point is particularly interesting, especially among frail people (diabetics, elderly patients, or those with arteritis) in whom the propeller flap often suffers distally. In the same perspective, we have performed 30 perforator-based “Pac-Man” flaps for skin cancer ablation (eight in the trunk, 12 in the upper extremity, and 10 in the lower extremity).2,3 This flap, so named by Akan et al.4 in 2001 and then by Aoki and Hyakusoku2 in 2007, had indeed already been described as the “fish-mouth V-Y modification” by Niranjan et al. in 2000.5 On average, we have been able to close larger defects than those closed with our perforator-based V-Y flap (Figs. 1 and 2). In our series, the mean defect size was 5.5 × 4.1 cm (7.2 ± 4 × 5 ± 2.3 cm). We noticed only two moderate venous insufficiencies with distal partial necrosis. We found one perforator in 12 flaps and two perforators in 18 flaps.Fig. 1: Melanoma excision (6.3 × 5.9 cm) in a 93-year-old patient. In this case, multidisciplinary staff decided to use a one-stage procedure. (Above) Two perforators (arrows) originated from the posterior radial collateral artery. (Below) Note the whitish appearance at the lower jaw of the flap a few minutes postoperatively.Fig. 2: Appearance of the flap 15 days postoperatively. Note the good integration of the flap.In fact, this flap, when it is performed randomly, can be fragile and suffer at these two distal portions, which is of particular interest in being based on identified perforator vessels for its vascular reliability. Finally, to add to the words of Brunetti et al., we believe that V-Y advancement perforator flaps have a special place in skin cancer, because they do not have mechanisms of rotation or translation that will modify the initial localization of the skin cancer excision. This is crucial, particularly in the case of one-stage reconstruction, when there is persistent residual tumor for which we have to perform a second resection, but also in cases of local recurrence. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Benoit Chaput, M.D. Ignacio Garrido, M.D., Ph.D. Isabelle Pluvy, M.D. Jean Louis Grolleau, M.D. Department of Plastic and Reconstructive Surgery Faculty of Medicine University of Toulouse Rangueil Toulouse, France Ali Mojallal, M.D., Ph.D. Department of Plastic, Aesthetic, and Reconstructive Surgery Edouard Herriot Hospital University of Lyon Lyon, France