Hotspots of facial artery perforators and perforasomes for easier flap guidance: An anatomical study

Background: The facial artery perforator flap is a valuable alternative for reconstruction of small to medium defects in the central midface and provide pleasing cosmetic results, allowing reconstruction in a one-stage procedure. Since Doppler ultrasound is not applicable to distinguish perforator from source artery, anatomical studies are needed to identify perforator areas along the course of the facial artery. Methods: Twenty facial arteries of 10 fresh anatomical head specimens were dissected. All perforators with an outer diameter of at least 0.50 mm were identified and injected with dye to color their respective vascular territories. Size and location of colored skin territories as well as the location of its perforators were documented and statistically analyzed. Results: In total, 89 perforators were identified. The average number of perforators per facial artery was 4.45 +/- 1.15. The mean outer diameter of the perforator at the origin of the facial artery was 0,65 +/- 0.14 mm. The mean size of the colored skin territories was 577.57 +/- 488.81 mm2. Perforator diameters were significantly associated with the size of its resulting perforasomes. Furthermore, perforators mostly originated in two specific areas: 3.5 cm lateral and caudal and 4.5 cm lateral and 5.5 cm caudal of the anterior nasal spine. Conclusion: This study provides evidence of two predominant locations of emergence of facial artery perforators. Additionally, the significant correlation between perforator size and its appendant perforasomes as well as their location with reference to the anterior nasal spine as relevant osseous landmarks helps surgeons in decision making for flap design and surgery.