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

This study evaluates the feasibility of using smaller, more distal vessels as alternatives to the superficial temporal vessel (STV) or facial vessel (FV), which have long been the representative recipients, for microsurgical facial reconstruction. Patients who underwent facial soft tissue reconstruction using free flaps from 2017 to 2023 were retrospectively reviewed. With a gradual shift from using STV or FV main trunks to distal branches and other minor vessels, patients were divided into the main trunk group and the distal vessel group. Outcomes, including perfusion-related complication rates, were compared. A total of 109 patients were analyzed, with 53 in the main trunk group and 56 in the distal vessel group, where the parietal branch of the STV was most commonly used, followed by the occipital, angular, inferior labial, and supratrochlear vessels. The use of distal vessels increased over time, from 20% in the first quartile to 70.6% in the last. The distal vessel group had a significantly lower flap-to-defect dimension ratio, shorter pedicle length, and distinct flap type distributions compared to the main trunk group. Perfusion-related complications occurred in eight cases, with no significant differences in overall or specific complication rates. Multivariable analysis showed no significant association between distal vessel use and adverse outcomes. Our results suggest that a smooth transition from using the main trunks of the STV or FV to smaller distal vessels, when feasible, does not increase the risk of perfusion-related complications, while improving tissue economy and enhancing flexibility in flap selection.