Free-style perforator-based hatchet flap: a novel and innovative approach for superior aesthetic outcomes in facial defect reconstruction

BACKGROUND: The face, with its distinct subunits, demands particularly high aesthetic standards for defect reconstruction. Although traditional hatchet flaps are commonly used, they are limited by a constrained rotation arc and susceptibility to dog-ear deformities, compromising aesthetic outcomes. This study introduces and investigates a novel free-style perforator-based hatchet flap technique designed to overcome these limitations and enhance aesthetic outcomes. PATIENTS AND METHODS: Patients treated at a single center between October 2020 and April 2024 were included. The key innovation involves preoperative Doppler ultrasound mapping of perforating vessels combined with a "free-style" design principle, liberating the flap from constrained rotation and reducing the risk of dog-ear deformities associated with traditional hatchet methods. This approach enables an increased rotational arc. Outcomes were evaluated at follow-up using the Visual Analog Scale (VAS), Observer Scar Assessment Scale (OSAS), and Patient Scar Assessment Scale (PSAS). RESULTS: This retrospective analysis included 65 patients (32 free-style, 33 traditional). All free-style flaps survived, whereas partial necrosis occurred in three traditional flaps. The free-style group showed improved aesthetic outcomes, including higher VAS scores, lower OSAS scores, shorter mean scar length, and lower PSAS scores, indicating greater patient satisfaction with scar appearance. CONCLUSION: The free-style perforator-based hatchet flap, facilitated by preoperative perforator mapping, was associated with better aesthetic outcomes and higher patient satisfaction compared to the traditional technique in this retrospective cohort.