In the age of microsurgery, regional pedicle flaps have retained an indispensable role in maxillofacial reconstruction. Two-stage pedicle flaps are primarily indicated in patients with severe comorbidities who require short operation times, salvage surgeries, or palliative treatment [4, 5]. The disadvantages of two-stage pedicle flaps are unfavorable esthetic appearance and need for a second surgery for pedicle dissection.

The results of this study indicate that impaired general health status favors non-microvascular solutions to shorten the operating time. The mean duration of surgery was 130.5 min, which is significantly lesser than that required for any microvascular procedure performed in the maxillofacial region [4, 6]. Moreover, grading the patient’s comorbidities and classifying the physical resilience before surgery revealed that the majority of patients (64.5%) were classified as ASA-PS score 3, which indicates substantial functional limitations and severe systemic disturbances caused by the condition to be treated by surgical intervention or by other pre-existing pathological condition [7, 8]. Furthermore, almost one-thirds of the patients (29.0%) were classified as ASA-PS score 2, indicating that the overall patient collective that primarily underwent a pedicle flap procedure showed a complex medical history of general and treatment-associated illnesses. Interestingly, we did not find any significant difference in the ASA-PS scores between patients who had undergone primary two-stage pedicle flap reconstructions for esthetic reasons and those who had undergone a back-up flap procedure (overall 2 [6.5%] patients with ASA-PS score 1; 9 [29.0%] patients with ASA-PS score 2; and 20 [64.5%] patients with ASA-PS score 3). This might be explained by the fact that most patients treated in a university hospital exhibit severe general health impairment, and the main indications to perform a two-stage pedicle flap surgery are often illnesses of an aging society such as cancer or osteo(radio)necrosis or congenital deformities, which lead to higher ASA-PS scores.

Hence, most cases reviewed in this article (n = 25, 69.4%) revealed the presence of highly compromised, fibrotic, irradiated, scarred, fistulated, and even chronically infected tissue with a variety of harvested flaps (Figs. 3 and 4). In 11 (30.6%) cases, the flaps were selected as the best esthetic option for defect closure of the facial skin (Figs. 5 and 6). Hence, we clearly outline two major indications, deduced from a long reconstructive tradition, for two-stage pedicle flaps, namely the heavily pre-treated patient who is unsuitable for a long microsurgical procedure and the patient collective that is in need for an ideal reconstruction of the esthetic units of the facial skin were local pedicled flaps that show major advantages compared to microvascular procedures [2, 9]. Meaning that the texture and color of the facial skin cannot be imitated by any other harvestable tissue in the human body, local flaps serve as the ideal donor to preserve the facial profile [10]. Especially in nasal defects, the forehead flap is reliable for reconstructing full-thickness resections by preserving the functional and esthetic units of the face [11]. The same holds true for complex lip reconstruction [12]. The lip components are the oral mucosa, orbicularis oris muscle, and smaller mimic muscles, while the white role marks the border between the keratinized red part of the lip and the facial skin forming the cupid bow at the vermillocutaneous intersection. Mimicking these complex esthetic and functional interactions using microsurgical reconstruction is nearly impossible, leaving local flap procedures the only surgical option to achieve satisfactory results (Figs. 5 and 6) [13].

Back-up solution, surgery situation: A 57-years-old patient with an extraoral fistula after resection of a malignant tumor, radiation therapy, pathological fracture of the lower jaw due to an osteoradionecrosis and a free flap fibula reconstruction of the mandible, now treated with a deltopectoral flap for defect closure of a chronic extraoral fistula. Published with the patient's consent

Back-up solution, follow-up situation after pedicle dissection of the deltopectoral flap with stable and completely healed wound. Published with the patient's consent

Esthetic solution: A 56-years-old patient after resection of a basal cell carcinoma of the left infranasal region and the upper lip. Published with the patient's consent

Esthetic solution: stable and completely healed wound situation of an Abbe plasty after dissection of the pedicle. Published with the patient's consent

In terms of postsurgical complications, we noted that of the 10 (27.8%) flaps with compromised wound healing, majority occurred in the back-up pedicle flap group and only two events (1 [2.8%] venous congestion and 1 [2.8%] wound dehiscence) occurred in the group that received a pedicle flap for esthetic reasons. These results are in line with those of previous studies [5, 14] that postsurgical complications in pedicled flaps are significantly fewer than those in microvascular reconstruction in a vessel-depleted neck (34.5%) [15]. This could be attributed to the more predictable blood supply of local pedicle flaps that lie outside the field of radiation and favor fewer wound revisions. In our study, except in one patient who showed a persistent intraoral fistula, all wounds healed completely.

Current studies on donor site morbidity have shown that a pectoralis major flap does not cause greater donor site morbidity than a microvascular latissimus dorsi flap [16]. Interestingly, the radial forearm flap, which is the workhorse flap in reconstructive units for versatile applications due to its thin and adaptive lining, causes the highest donor site morbidity than any other pedicle or fasciocutaneous free flap [17, 18].

In spite of the several advantages in the use of pedicle flaps, some limitations must be considered. First, the disfiguring appearance of the pedicle for flap autonomation is a disadvantage as it precludes the patient from participation in a normal social life. While the optimal time of transplant autonomy from its blood supplying pedicle is not accurately determined in the current research, it could range from weeks to months [10, 19, 20]. These results are in line with our own experience that the time for pedicle dissection ranges from 14 to 106 days. Further research is needed to avoid a compromised facial appearance and to secure flap survival at the same time.

Furthermore, pedicle flaps do not allow full bone reconstruction of the maxilla or mandible. Correspondingly, if dental rehabilitation is planned, a harvested fibula flap, scapula flap, or deep circumflex iliac artery bone flap (DCIA) with microvascular anastomosis is the reconstruction of choice.

Finally, in terms of tumor surgery, the principles of mindful reconstruction should not be abandoned, and areas of lymphatic drainage from the pedicle flaps should be spared. If possible, the transposition of a cervical pedicle flap in a metastatic neck should be avoided to prevent the spread of tumor cells.

If these basic principles are considered, carefully selected patients will benefit from reconstruction by two-stage pedicle flaps in modern reconstructive maxillofacial surgery.