Primary and secondary perforator-based flap-in-flap reconstructions of postexcisional head and neck soft tissue defects

INTRODUCTION: Perforator-based flap-in-flap (PBFIF) refers to the construct of one flap within another based on a perforator. Primary flap-in-flap is the simultaneous construct of two flaps, one within the other. It is particularly useful in cases where despite perfect planning, the flap does not fit congruently into recesses of the defect. It facilitates tension-free flap inset without the need for secondary movement from adjacent areas. Secondary flap-in-flap is the construction of a flap within a previously transferred settled flap. It is particularly useful in cases of wound dehiscence and partial necrosis, which results in a defect-warranting flap cover, when other flap options are either not feasible or other options have been exhausted. AIM: To assess the outcome and define the biogeometry of primary and secondary PBFIFs, which were used in postexcisional head and neck soft tissue defects. MATERIALS AND METHODS: Eight patients who underwent flap-in-flap head and neck reconstruction from January 2014 to January 2016 (four cases of primary PBFIF with nasolabial flaps, and four cases of secondary PBFIF with pectoralis major myocutaneous flaps) were retrospectively studied. All were nonsmokers with no associated comorbidities. At the end of the follow-up period, two independent observers and the patient assessed the outcome based on the Institutional Reconstruction Assessment Score (IRAS). RESULTS: All flaps settled well with a mean follow-up of 16.75 months. All flaps were used for the reconstruction of postexcisional defects only. None of the patients had any loco regional recurrences. The mean IRAS obtained in 8 patients was 3.5 (primary PBFIF=3.87 and secondary PBFIF= 3.12). None of the flaps resulted in the late distortion of adjacent anatomical landmarks by hypertrophy or contracture of scars. CONCLUSION: Flap-in-flap reconstruction (whether primary or secondary) is a useful technique to cover defects where reconstruction without anatomical distortion is required (e.g., face). It is a useful option for a tension-free flap inset. Flap-in-flap reconstruction is a relatively easy adjunct in the salvage reconstructive armamentarium of plastic surgeons.