**Region:** Head and Neck # Facial Artery Perforator Flap ## Anatomy - Pedicle: single facial artery perforator arising from the facial artery; small-caliber perforators (reported caliber range 0.6–1.8 mm, average 1.2 mm) with accompanying venous plexus/venae comitantes when identifiable (Hofer & Payne). Perforator length from facial artery to skin reported range 13–51 mm (average 25.2 mm). Average of 5.7 facial artery perforators (FAPs) found between mandible and nasal alar rim (Hofer & Payne). - Course: perforators originate from the facial artery as it ascends from the antegonial notch toward the nasolabial/alar region and medial canthus. On Doppler the course is felt as a string of “crescendos” along the facial artery; individual perforators are typically encountered along this course (Neligan). - Perforator pattern: multiple small perforators along the facial artery; flaps may safely include the territory of two adjacent perforators (two‑perforator principle) to increase reliability (Neligan). Perforators are predominantly intramuscular/septocutaneous as they traverse buccal muscles and subcutaneous tissue to the skin. - Nerves: - Supratrochlear nerve accompanies supratrochlear vessels in the paramedian forehead context (used as anatomic analogy for forehead perforators) and may be encountered when using flaps that extend to the glabellar region (Hanasono; supratrochlear chapter). - Facial branch motor nerves (buccal/facial mimetic branches): identified and preserved during FAP dissection in the perioral/jowl region—avoid deep dissection that risks motor branches (Hofer & Payne; FAMM chapter describes muscular relationships and the need to respect mimetic muscles). - No requirement to include a named sensory nerve with cutaneous facial artery perforator flaps in the classic descriptions; when sensate reconstruction is needed, alternative sensate flap options should be considered (Neligan). - Included tissues: - Cutaneous island: skin and subcutaneous tissue are the typical tissue elements; a small cuff of surrounding fat is recommended around the perforator to protect the venous plexus (Hofer & Payne; Shokrollahi). - When raised as V‑Y advancement flaps, the flap commonly incorporates more than one perforator and is essentially a cutaneous/subcutaneous flap (Neligan). - FAMM (for comparison/combined techniques): mucosa, submucosa and a strip of buccinator muscle with the facial artery lie deep in the cheek and will be included if intraoral musculomucosal transfer is used (Hanasono). - Thickness/arc: facial perforator islands are thin relative to regional pedicled flaps but thickness depends on included subcutaneous fat; average reported flap thicknesses for axial mucosal flaps (FAMM) ≈ 1 cm. Maximum reliable cutaneous flap size (direct donor closure) reported ≈ 2.5 × 5 cm when using jowl/perioral donor tissue (Hofer & Payne). - Common variants/anomalies: - Perforators are highly variable in size and presence; some perforators may be too small or absent (Neligan). If the facial artery is small, perforators are often even smaller. - Prior ligation of the facial artery (eg, during neck dissection) eliminates option for inferiorly based axial/inferior pedicled flaps that rely on antegrade flow (FAMM chapter). - Donor‑site anatomic variability and prior trauma/surgery may render perforators unreliable (supratrochlear/supraorbital chapters address forehead variability in analogous fashion). ## Dissection Steps 1. Positioning, markings, landmarks. - Patient supine with head turned to expose operative side; nasotracheal tube preferred for perinasal/oromaxillary access (Hofer & Payne; supratrochlear chapter for forehead procedures). - Use handheld Doppler to map the facial artery along its course (from antegonial notch toward the nasolabial fold and alar base). Mark crescendo points (probable perforators) and plan flap such that chosen perforator is at or near the flap edge when propeller rotation is required (Neligan; Hofer & Payne). - Plan donor blade in the jowl/nasolabial region (excess skin zone) and respect facial aesthetic units; for intraoral FAMM mark from retromolar trigone to labial sulcus (Hanasono). 2. Plane (suprafascial/subfascial), perforator identification (handheld/IO Doppler). - Begin with exploratory skin incision or incision at wound edge over a marked perforator. Identify the perforator by visual inspection and Doppler signal; pulsatility of the perforator indicates adequacy (Neligan). - Elevation plane: raise the skin/subcutaneous island. Protect the perforator by preserving a cuff of adjacent fatty tissue (Hofer & Payne; Shokrollahi). When elevating forehead perforator flaps (supratrochlear/supraorbital analogues), dissect in subfascial/subgaleal plane until vessels are encountered and then proceed carefully with loupe magnification (supratrochlear chapter). 3. Pedicle dissection: exposure, control, division; transfer/inset; perfusion checks. - If V‑Y advancement (no propeller rotation), extensive individual perforator dissection is not required; gently tease and mobilize tissue to achieve advancement—these often include more than one perforator (Neligan). - For propeller flaps: - Make an incision adjacent to the chosen perforator; identify and visually inspect the perforator. If no pulsation or an isolated vein only, abort and choose another perforator (Neligan). - Dissect the perforator down toward the source vessel (facial artery) to gain length sufficient for rotation—common error is insufficient pedicle length causing strangulation/kinking on rotation (Neligan). - Preserve a small cuff of surrounding fat to protect venous plexus; ligate and divide side branches as needed (Hofer & Payne). - Test rotation in both clockwise and counterclockwise directions under Doppler monitoring; ensure Doppler signal remains similar to baseline and the color/bleeding of the flap is acceptable. If Doppler signal is lost after rotation, release and extend dissection or change rotation direction (Neligan). - Insetting: rotate/transposition to defect; inset in layers (deep absorbable sutures for muscle/deeper tissues, fine nonabsorbable for skin as needed). For intraoral FAMM flaps inset mucosa with absorbable sutures. - If tunneling is used, ensure tunnel is wide enough to avoid pedicle compression; otherwise transfer via open route. - Perfusion checks: - Continuous intraoperative Doppler during dissection. Observe color, capillary refill and marginal bleeding. - For staged pedicled flaps (eg paramedian forehead variants): allow 2–3 weeks (FAMM pedicle division) or 3–4 weeks (paramedian forehead) for neovascularization before pedicle division; temporarily occlude pedicle (vessel loop) to test flap perfusion prior to division (Hanasono; supratrochlear chapter). 4. Donor-site closure techniques. - Jowl/perioral donor sites: design to allow direct closure; maximum flap sizes that permit direct closure reported ≈ 2.5 × 5 cm. Wide undermining of adjacent tissues helps closure (Hofer & Payne). - If closure under tension: score galea (forehead analog) or perform additional undermining; consider delayed tissue expansion pretransfer for larger defects (supratrochlear chapter). - If primary closure impossible, small areas may be allowed to heal secondarily or covered with a skin graft—expect cosmetic tradeoffs and consider delayed revision/excision after healing (Hanasono; supratrochlear chapter). - Intraoral donor sites (FAMM): two‑layer closure approximating buccinator muscle and mucosa with absorbable sutures; drains typically not required (Hanasono). ## Indications and Contraindications - Indications: - Small to modest-sized cutaneous facial defects in the perioral, nasolabial, alar base, suborbital and cheek regions that lie within reach of a perforator-based jowl/nasolabial donor (Neligan; Hofer & Payne). - V‑Y advancement for local coverage of alar/cheek defects; propeller FAP flap for small rotational closure or to transfer territory of two adjacent perforators (Neligan). - FAMM flap indications (adjacent/intraoral): wet/vermilion lip reconstruction, intraoral lining (gingiva, floor of mouth, palate), nasal lining (Hanasono). - Forehead supratrochlear/supraorbital perforator flaps (related anatomic option): nasal and periorbital reconstruction as single‑stage or expanded single-stage option (supratrochlear chapter). - Size limits / tissue characteristics: - Direct donor closure typically feasible for cutaneous FAP donor of up to approximately 2.5 × 5 cm (Hofer & Payne). - For FAMM: flap width limited to 2.5–3 cm (commonly 1–2 cm) to permit primary intraoral closure; axial FAMM length up to 7–8 cm reported; average thickness ≈ 1 cm (Hanasono). - Contraindications: - Absence or inadequacy of perforator on Doppler or visual inspection (Neligan). - Prior ligation of the facial artery (eg after neck dissection) precludes inferiorly based FAMM or reliance on antegrade facial artery flow (Hanasono). - Prior surgery, trauma, scarring or prior radiation to the planned donor site that has disrupted the perforator network makes the flap unreliable (supratrochlear and FAP texts). - Severe peripheral vascular disease compromising small perforator flow is a relative contraindication (Neligan). ## Postoperative Care - Monitoring schedule/method: - Clinical monitoring of flap color, temperature, capillary refill and bleeding characteristics is standard; perform frequent checks in the immediate 24–72 hours (supratrochlear chapter; Hofer & Payne). - Intraoperative and immediate postoperative Doppler checks are useful; loss of Doppler signal postoperatively should prompt urgent evaluation (Neligan). - Indocyanine green angiography may be used in preexpanded forehead flaps to visualize arterial and venous flow (supratrochlear chapter) — technique specific to forehead expansion cases. - Warming/antithrombotic practice: - No specific anticoagulation protocols mandated in the cited texts; observe standard institutional perioperative DVT prophylaxis. Maintain normothermia and avoid vasospasm; topical measures are not specified. - Positioning/splinting: - Head elevation as tolerated; avoid compression of pedicle or tunnel. For intraoral flaps, keep mouth open with retraction as needed early postop. - Drains, mobilization, diet/analgesia: - Drains typically not required for FAMM flaps; if used (forehead expanded flaps), remove when output < 5 mL to reduce hematoma risk (supratrochlear chapter). - Early mobilization per general postoperative protocols; soft diet for intraoral reconstructions as instructed (FAMM). - Return-to-OR thresholds and time windows: - Immediate return to OR indicated for sudden loss of flap Doppler signal, rapidly progressive pallor, hard ischemic suggestion or tense hematoma under the flap. Neligan emphasizes re-exploration if Doppler signal disappears intraoperatively/early postoperatively and soft tissue strangulation is suspected. - For staged pedicled flaps: test pedicle occlusion at planned division time (FAMM 2–3 weeks; paramedian forehead 3–4 weeks) and delay division if flap appears pale or congested. ## Complications (rates & management) - Rates: specific numeric complication rates are not provided in the supplied texts for the FAP flap series. Reported physiologic observations include: - Early postoperative slight venous congestion common in FAP flaps during first 24–48 hours (Hofer & Payne). - No explicit percentages for failure, partial necrosis, infection or donor complications in the provided chapters. - Typical complications and management principles: - Venous congestion / partial distal congestion: - Expect mild congestion early (24–48 h). Observe; if progressive or persistent with poor capillary refill, consider release of tight sutures, remove compressive dressings, consider leech therapy only if venous outflow is inadequate and team experienced (not specifically detailed in source texts). - If congestion correlates with pedicle kinking or compression (eg through a tight tunnel), return to OR to release tunnel and lengthen pedicle or transpose open. - Arterial insufficiency / loss of Doppler signal: - If Doppler disappears intraoperatively or early postoperatively and flap rapidly becomes pale, return to OR urgently for exploration—look for pedicle twist, undue compression, hematoma, or pedicle traction; extend perforator dissection to source vessel to relieve tension (Neligan). - Partial flap necrosis / tip loss: - Small distal losses may be managed expectantly with secondary intention or local revision; in setting of mucosal flaps (FAMM) manage with local wound care and staged revision if needed. - Infection: manage with antibiotics and drainage if abscess develops—no specific rates reported. - Donor-site issues: - Jowl donor: contour irregularity, scar; direct closure usually possible up to ~2.5 × 5 cm. If skin graft used (forehead analog), expect poorer cosmetic outcome (supratrochlear; Hanasono). - Intraoral donor (FAMM): avoid parotid (Stensen) duct injury; two‑layer closure reduces fistula/contour problems. - Management algorithms (re-exploration, thrombolysis, leeching): - Re-exploration: indicated for acute loss of perfusion or hematoma; primary remedy is to release compression/untwist pedicle and lengthen dissection to source vessel (Neligan; supratrochlear chapter). - Thrombolysis, systemic thrombolytics or microvascular salvage approaches are not described in these chapters and are not recommended without vascular surgery/microvascular expertise. - Leeching is not specifically discussed in the supplied FAP literature; standard microvascular/venous congestion algorithms apply if venous outflow cannot be restored. ## Key Clinical Pearls - Always map the facial artery and candidate perforators with a handheld Doppler preoperatively; mark crescendos and plan flap so the perforator lies at or just inside the flap edge for propeller rotation (Neligan; Hofer & Payne). - Two‑perforator territory safety: when based on a single perforator, designing the flap to include the territory of the adjacent perforator improves reliability—avoid asking a single small perforator to perfuse an excessively large random territory (Neligan). - Preserve a cuff of surrounding fat around the perforator to protect the venous plexus—this is critical because a discrete vein is not always visible and venous drainage often relies on surrounding plexus (Hofer & Payne; Shokrollahi). - Ensure adequate pedicle length: dissect perforator toward the source facial artery to avoid an acute twist and strangulation during rotation; test both clockwise and counterclockwise rotation intraoperatively under Doppler (Neligan). - Size constraints: plan for direct donor closure—perioral/jowl FAP donor closure typically feasible up to ≈ 2.5 × 5 cm (Hofer & Payne). For larger defects, consider pretransfer expansion or alternative flaps. - For intraoral FAMM flaps: limit width to 2.5–3 cm (commonly 1–2 cm) and keep anterior border ≥ 1 cm posterior to oral commissure; include a thin strip of buccinator and the facial artery within the deep layer (Hanasono). - Pedicle division timing: staged pedicled flaps—test temporary occlusion before division. FAMM delayed pedicle base division commonly at ≈ 2–3 weeks; paramedian forehead pedicle division commonly at ≈ 3–4 weeks (Hanasono). - Expect mild early congestion (first 24–48 hours) in cutaneous FAP flaps; distinguish expected transient congestion from progressive venous compromise that requires early return to OR (Hofer & Payne).