Broadening options of recipient vessels in microsurgical facial reconstruction: Moving toward distal

Authors: Yoo K-E, Lee M K, Chung J E, Lee K-T

Affiliation: Dept. of Plastic Surgery, Samsung Medical Center; Dept. of Plastic Surgery, Ewha Womans University, Seoul, South Korea

Journal: Journal of Plastic, Reconstructive & Aesthetic Surgery (JPRAS). 2025

PMID: 40779991

Key takeaways

• In 109 facial free flaps, distal recipient vessels performed comparably to main trunk (superficial temporal/facial) with no increase in perfusion‑related complications.

• Adoption of distal vessels rose from 20.0% to 70.6% over time (p = 0.002), reflecting a deliberate practice shift.

• Distal vessel use enabled shorter pedicles (67.9 vs 79.3 mm) and tighter flap‑to‑defect sizing (ratio 1.09 vs 1.26), without longer OR time.

• Multivariable analysis: distal vessel choice not associated with adverse events; diabetes and active smoking were significant risk factors.

• Post hoc power was low (≤8.5%) for primary endpoints; type 2 error risk is high.

Background

Superficial temporal vessels (STV) and facial vessels (FV) are reliable facial recipients but may be distant from defects, necessitating long pedicles, vein grafts, and larger flaps. Distal facial branches could reduce morbidity and expand flap choices if outcomes are equivalent.

Objective

Compare perioperative characteristics and outcomes of distal recipient vessels versus main trunk STV/FV in microsurgical facial soft‑tissue reconstruction.

Methods

• Design/setting/LOE: Retrospective cohort, single surgeon at a high‑volume tertiary cancer center; 2017–2023.

• n enrolled/analyzed: 109 patients (119 cases screened; 10 excluded). Mean age 64.2 ± 16.6 years; BMI 25.1 ± 4.3 kg/m²; 62.4% male.

• Inclusion/exclusion: Included facial soft‑tissue free flap reconstructions. Excluded neck reconstructions, pedicled/local flaps, and flow‑through cases using another flap’s pedicle as recipient. Single‑surgeon cases only. IRB approved.

• Groups: Main trunk (STV/FV) n = 53 vs Distal vessel branches/small vessels n = 56.

  • Main trunk vessels included the superficial temporal vessel (STV) or the facial vessel (FV)

  • Distal recipients included branches off aforementioned main trunk vessels and were located more proximal to the defect. 

  • Recipient selection was based on intraoperative identification and judged “reliable,” regardless of size.

• Recipient details (distal): Parietal branch STV (n=31); others included occipital (n=7), angular (n=5), inferior labial (n=5), supratrochlear (n=4), plus isolated cases (infraorbital, dorsal/lateral nasal, transverse facial).

• Flaps used: ALT most common overall; distal group favored SCIP/TDAP/other perforator flaps; main trunk group used more ALT/RFF.

• Endpoints: Primary—perfusion‑related complications (total/partial loss; threatened flap). Secondary—overall flap‑site complications, reoperation, hospital LOS, operative metrics.

• Statistics: χ²/Fisher’s for categorical; t‑test/Mann–Whitney for continuous; univariable and multivariable logistic regression for independent associations; temporal trend across quartiles; post hoc power for primary endpoints; α = 0.05.

Results

• Temporal adoption: Distal recipients increased from 20.0% → 70.6% across quartiles (p = 0.002).

• Operative characteristics: Distal group had shorter pedicles (67.9 ± 31.2 vs 79.3 ± 28.3 mm; p = 0.045) and smaller flap‑to‑defect ratios (1.09 ± 0.11 vs 1.26 ± 0.30; p < 0.001). Total OR time and ischemia time: no significant differences.

• Complications: Overall flap‑site complications 14.7% (9/53 main trunk vs 7/56 distal; p = 0.509). Perfusion‑related: 7.3% (4/53 vs 4/56; p = 0.936). Total flap loss: 3/109 (2.8%) (1 vs 2; p = 0.591). Reoperation for flap‑site issues: 11.9% (7 vs 6; p = 0.688).

• Length of stay: Trend toward shorter LOS in distal group (10.3 ± 5.5 vs 13.0 ± 9.7 days; p = 0.079).

• Vein availability: In 10 cases, distal artery suitable but no vein—used main‑trunk vein with interposition grafts. Outcomes similar with/without conversion.

• Regression: Distal vessel use not independently associated with perfusion‑related complications; diabetes and active smoking were significant predictors.

• Power: Post hoc power for detecting group differences: flap failure 8.5%; perfusion‑related complications 5.1%.

Conclusion

For facial free‑flap reconstruction distant from STV/FV, using nearby distal recipient vessels is feasible and safe in experienced hands, without higher perfusion‑related complication rates and with advantages in tissue economy and flap selection.

Strengths: Largest cohort to date evaluating distal facial recipients; single‑surgeon technical consistency; clear definitions; multivariable adjustment; meaningful operational metrics (pedicle length, sizing).

Limitations: Retrospective, single‑surgeon/single‑center (external validity); nonrandom allocation with high potential for selection bias; small numbers per specific distal vessel; low statistical power for rare events; lack of routine preop vascular imaging; no standardized vein diameter data.

Clinical Relevance

This report presents the refinement of a distal recipient‑vessel approach for head and neck free flap reconstruction, not a robust analytical study. In experienced hands, distal branches are feasible and does not markedly raise flap complications. They allow shorter pedicles, smaller flaps and presumably less surgical trauma, which can improve outcomes. Although underpowered for statistics, this series encourages surgeons to consider distal recipient options.