A prospective clinical study including a group of 30 patients, whose mean age was 58.33 ± 12.47, were chosen to undergo perforator-based flap surgery at the Plastic and Reconstructive Surgery Department, University Hospital, and other non-governmental hospitals. The patients had small to moderate size facial defects (5–6 cm) resulting from post-tumor resection.

Operative technique

All the operations were performed in the operating room, 27 cases were performed under general anesthesia and 3 cases under local anesthesia.

Existing skin tumors were excised with wide surgical margins (Fig. 1).

Fig. 1

Tumor excision with wide local resection

Eight MHZ handheld doppler was used to identify all the perforators surrounding the defect, and several perforators were marked.

Exploration of the chosen perforator was done before raising the flap to make sure that it was suitable for the vascular supply of the flap and for its proposed movement into the defect. Then, the final perforator was selected by the reliability of the caliber and length among the identified perforators.

A flap was designed adjacent to a defect based on the amount of tissue that remained for reconstruction. The skin paddle was designed slightly larger than the defect size to enable insetting with minimal tension. The flaps were elevated and dissected meticulously using loupe magnification × 3.5 and inset into the defect areas along the axis of the perforator by rotation, transposition, or advancement. If a flap needed rotation for insetting, the perforator artery was dissected more meticulously. Whether the perforator would be skeletonized (Fig. 2) or not, would be governed by the needed movement of the flap to be in set without any compromise of its blood supply. If advancement was sufficient, perforator skeletonization was unnecessary.

Fig. 2

Perforator skeletonization

The donor site was closed directly in two layers (Fig. 3), the dermis, and the skin, with minimal undermining. The flap was sutured in two layers in a tension-free manner, after which a slightly compressive dressing was applied. The skin was sutured in two layers with a 5.0 resorbable monofilament suture in the dermis and a monofilament 5.0 prolene in the skin. In the first three patients, the subcutaneous drain was placed underneath the flap for drainage, but we found that this was not necessary and was abandoned in the successive flaps. Paper tape and a light dressing were placed on the scar and suture removal was planned in 7 days at the clinic.

Fig. 3

In the setting of the flap

Post-operative follow-up

A histopathological examination was done for the excised lesions. The patient stayed in the hospital for 48 h and was given antibiotics, antiedematous, analgesics, and proper fluids. Patients were followed up in the outpatient clinic after 1 week for suture removal and then checked in on a monthly, quarterly, and annually thereafter, depending on the pathology involved. Four cases showed complications including congestion, wound dehiscence, inadequate excision, and recurrence.

Flap assessment

Through clinical assessment as color, warmth, tension on the flap, and blood flow (by capillary filling test).

Statistical analysis

Data was analyzed using the Statistical Package for Social Sciences (SPSS)version 24. A p value < 0.05 was considered significant.

Methods of evaluation

Aesthetic and function aspects were evaluated by both patients measured by the “Likert scale” instrument and a group of 3 independent consultants utilized a visual analog scale (scores 1–10).

Aesthetic aspect (contour, color match, scar) Post-operative subjective satisfaction for surgeons

Utilizing a visual analog scale (scores 1–10) with pre-and post-operative photos during outpatient consultations 3 and 6 months following surgery, independent consultants were asked to rate the post-operative look on a visual analog scale ranging from 1 to 10 as regards contour, color match, and score.

Post-operative patient satisfaction

Was measured by the Likert scale instrument, translated into Arabic to evaluate patient satisfaction using visual analog.

Functional aspect Independent surgeons

Evaluation was done regarding the motor affection of both donor and recipient and the compatibility of the flap with the vital function of the recipient site.

Patients

Were asked during outpatient consultations 3- and 6 months following surgery if they complained of any disability or lack of function in both donor and recipient sites following the operation.