Advancing Pure-Skin-Perforator Flap Application: Microscope-Free Harvesting, Versatile Donor Sites, and Clinical Outcomes

BACKGROUND: Reconstruction of shallow but complicated defects with exposed critical structures often requires vascularized tissue with skin-like thinness, which pure-skin-perforator flaps can provide. Despite their benefits, pure-skin-perforator flaps are underutilized due to remained uncertainties surrounding their application. This study reviews our experience with free pure-skin-perforator flap reconstruction, focusing on the elevation process, donor site selection, and clinical outcomes. METHODS: Patients who underwent microsurgical reconstruction using pure-skin-perforator flaps between April 2021 and January 2024 were reviewed. All flaps were elevated using loupe magnification through distal-to-proximal dissection. Donor sites were selected based on the defect: superficial circumflex iliac perforator (SCIP) flaps for finger/toe defects, and anterolateral thigh (ALT) or thoracodorsal artery perforator (TDAP) flaps for longer pedicles generally. The development of complications and associated risk factors were investigated. RESULTS: Seventy-one cases were analyzed, with a mean body mass index of 24.2 kg/m², including 55 SCIP, 10 ALT, and six TDAP flaps. No conversions to microscope-assisted elevation were needed. The mean skin paddle size was 26.3 cm² with a thickness of 3.5 mm; TDAP flaps were thickest, and SCIP flaps were thinnest. The average pedicle length was 4.8 cm, with TDAP flaps having the longest. Flap elevation took 37.0 minutes averagely, consistent across flap types. Flap complications occurred in 18 cases, including two total flap losses and four partial losses, associated with chronic wounds, and larger flap sizes. CONCLUSIONS: Pure-skin-perforator flaps might be a valuable reconstructive option for shallow, but complicated defects, offering easy harvesting of microscope-free, versatile donor selection, and reliable outcomes.