Importance: The strategic option between vascular supercharge and flap prefabrication in the fabrication of multipedicle flaps for difficult head and neck reconstruction has not been reported. Objectives: To summarize our 13-year experience in the design of multipedicle pre-expanded perforator flaps for extensive head and neck defect reconstruction, with vascular supercharge and flap prefabrication, either solely or in combination. To discuss the strategy for judicious selection between these techniques in the design of multipedicle flaps at different donor sites. Design, Setting, and Participants: A retrospective study was performed in patients with severe head and neck deformities and treated with multipedicle pre-expanded perforator flaps between May 2005 and May 2018. Intraoperative indocyanine green angiography was utilized for visualization of flap perfusion and analysis of the hemodynamics of pre-existing perforator and prefabricated vessels. Main Outcomes and Measures: The main outcomes measured were (1) features of deformities, (2) multipedicle flap designs, and (3) postoperative complications and long-term functional and aesthetic outcomes. Results: Seventy-five multipedicle pre-expanded perforator flaps were harvested, including 44 supercharged, 26 prefabricated, and 5 tripedicle, combining both techniques, with sizes ranging from 22 × 12 to 45 × 27 cm2. Hemodynamic analysis demonstrated slower arterial inflow (0.60 ± 0.29 U/s vs. 2.65 ± 1.29 U/s, p < 0.05) and venous outflow (0.10 U/s vs. 0.23 ± 0.11 U/s) in prefabricated vessels, compared to the pre-existing perforator, namely the internal mammary arterial perforator. Partial necroses were observed in three patients with only one requiring skin grafting. The aesthetic and functional outcomes were satisfying after reconstruction. Conclusions and Relevance: Multipedicle pre-expanded perforator flaps fabricated by vascular supercharge and flap prefabrication, either solely or in combination in various donor sites, are powerful reconstructive tools for extensive head and neck defects. For a more reliable design, vascular supercharging should be considered a priority strategy, and flap prefabrication an alternative when suitable supercharging vessels are unavailable.
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