Strategies to Achieve Nontattooed Flap Transfer Where Decorative Tattoos Are Found at Workhorse Donor Sites

Tattooing in the general population has become increasingly popular in recent years. Tattoo ink may contain carcinogenic chemicals, and long-term health risks remain a concern. When any proposed surgical intervention violates a tattooed area, such as where a tattoo is located in a planned donor site of a workhorse flap, the physical, cosmetic, and psychological effects of both recipient and donor sites on a patient must always be considered.

In this study, we aimed to develop alternative options for microsurgeons when faced with planned donor sites for workhorse flaps covered with tattoos. Our objective was to avoid tattooed flap transfer to head and neck defects while preserving patients' personal tattoos as a patient-centered concept.

We retrospectively reviewed 12 patients between January 2020 and December 2024. All the patients were males with an average age of 51.4 years (11 patients with oral cancer and 1 patient with trauma). All the patients had tattoo at donor sites of workhorse flaps. When we faced such conditions, our strategies included the following: option 1, selecting different flaps that have no tattoo area; and option 2, selecting flaps that would not violate a tattoo, using the concept of freestyle flaps as alternative options for preserving a tattoo in a tattooed donor site.

We transferred nontattooed flaps to a recipient area in all the patients. Nine free flap transfers were performed, including 2 free superficial circumflex iliac artery flaps, 4 anterolateral thigh flap, 1 fibula osteocutaneous flap, 1 anteromedial thigh flap, and 1 medial sural artery perforator flap. Three locoregional flaps were 2 distally based sural flaps and 1 pectoralis major myocutaneous flap. All the flaps were designed to preserve the tattoos. All the transferred flaps were successful. Donor-site defects were primarily closed in 8 patients, whereas the other 4 required skin grafts.

When surgeons face donor sites of usual workhorse flaps covered with tattoos, strategies include selecting flaps from different donor sites without tattoos or using the concept of freestyle flaps as alternative options for preserving the tattoo to achieve a better result for the patient.