Hybrid perforator flaps: Introducing a new concept in perforator flap surgery

Although perforator propeller flaps provide a safe and reliable reconstructive option, they are often limited in size, reach and degrees of freedom due to venous insufficiency. As a result, partial flap necrosis, particularly at the tip of the flap, may occur in some cases causing the loss of substance. To overcome this problem, we present a new concept of hybrid perforator flaps.

From May 2014 to October 2017, 25 Hybrid perforator flaps were performed to reconstruct a variety of defects in upper and lower extremities following the removal of soft-tissue malignancies. Hybrid flaps included 14 hybrid radial collateral artery perforator propeller (RCAP) flaps, 7 hybrid propeller anterolateral thigh perforators (ALTs), 3 hybrid medial sural perforator flaps and one hybrid saphenous perforator flap. Following the excision of malignancy, several superficial skin veins were dissected on the edge of defect to be used as potential recipient vessels for venous supercharging. Hybrid flap design included the dissection of one or two superficial veins on the edge of the flap, which was used for prophylactic supercharging. The perforator flap was then raised in a usual fashion and rotated into the defect. Microsurgical venous anastomosis was performed between the previously prepared superficial flap vein and vein on the edge of defect.

Venous stasis was encountered following flap rotation in 12 out of 25 flaps and was immediately resolved following venous anastomosis. No venous congestion was encountered perioperatively in the remaining 13 flaps. Healing was uneventful in 24 flaps with 100% flap surface area healed primarily and excellent functional/aesthetic outcome. Partial loss was found in only one single flap, with overall 96% success rate and 4% complication rate.

Hybrid perforator flaps have the advantage of improved reliability, versatility and safety. In the author's experience, technique is reliable and obviates the need for flap monitoring. By including a superficial vein in the initial flap design and resectional defect, larger flaps can be harvested more reliably. The hybrid flap concept could potentially improve outcomes of propeller flaps. Our experience shows reduced complications when this technique is utilised with success rates comparable to free flaps.