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SplitLateralForeheadFlapforReconstructionofUpperandLowerEyelidsIG.A.N.WidyaPramanaa,SittiRizaliyanaa*aDepartmentofPlasticReconstructiveandAestheticSurgery,FacultyofMedicineUniversitasAirlangga*Correspondingauthor:SittiRizaliyana-DepartmentofPlasticReconstructiveandAestheticSurgery,FacultyofMedicineUniversitasAirlangga.Emailaddress:srizaliyana@gmail.comARTICLEINFO

ABSTRACT

Keywords:SplitlateralforeheadflapPeriorbitalReconstructive

Background:Eyelidsreconstructionaftertumorresectionhasbeoneof themost challenging procedures in reconstructive plastic surgery.Small defects may be closed by primary suture or covered by smalllocal flapsorskingraft.But in largeeyelidsdefects,weneedtofindabigger source of color and texture matching tissue that will ensurefunctional and aesthetical outcomes. Many techniques have beendescribed,but in this case, theauthor suggest a split lateral foreheadflapdesignedtocoverupperandlowereyelids.Patient and Operation Techniques: A Male 51 years-old-patient,presentedhimselfinourclinicwithabasalcellcarcinomainvolvingtheright upper and lower eyelids. The tumor had a history of 7 years,without any pain or vision disorders involved. Tumor was widelyexcised,leavingafullthicknessonupperandlowereyelids.Theinnerliningpalpebralwasreplacedbycompositeauriculargraftfollowingbylateralcantophexy.Alateralforeheadflapraisedwitharighttemporalpedicle, and thedistalpartof flapwassplit inhalf, and inset into theupperand lowereyelidsdefect.ThedonorregionwasclosedwithanSTSG from Femur Dextra. After 14 days the flap was divided, thefunctionalresultwasexcellent.Discussion:At first, surgeonswereworried of raising forehead flapsbeyondthemidline,fearingthatbysplittingthedistalflapwouldcauseits compropmise. However, rich anastomostic plexus exists betweenthe major forehead angiosomes lined by the smaller calibre “choke”vessels.Conclusions: Periorbital Basal cell carcinoma resection may leavegreat defect to the underlying tissue. The need to provide adequatesupport to this structure requires complex techniqueswithminimumtwoflaps.Inourcase,weperformedasplitlateralforeheadflapwithagoodfunctionalandcosmeticoutcome.

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asal cell carcinoma (BCC) has apredilectionfortheperiorbitalregion,which is a special, prominent,cosmetic, functional area to protect

theeyeball.Forsquamouscellcarcinomaandmelanoma, extensive resection withreconstruction is performed. In contrast, forBCC, resection isoftenconfined toasmall tomedium-sized area, necessitating higher-quality reconstructive surgery (Kakudo,2009).Thesetumorsareusuallydiagnosedbyincisionalbiopsy.Followingtumorremovalinthe periocular region, reconstruction of thedefect requires understanding of thedifferences and uses of soft tissue flaps andskin grafts (Hayano, 2012).Many techniqueshavebeendescribedand itscanbeclassifiedconsidering the anatomical area requiringtreatment: superior eyelid, inferior eyelid,and inner or external canthus (Actis, 2011).Flaps are usually preferred over graftsbecause homogeneity of skin color andtexturemorelikelyleadstobetterunificationwith surrounding tissue (Fogagnolo, 2012).The ultimate goal of every eyelidreconstruction is to create a stable eyelidmargin, to ensure the eyelid has properdimensions and tension when open andclosed, to obtain eyelid symmetry with norough or uneven internal surfaces, and tooptimizeaesthetics(Hayano,2012).

CaseReport51-years-old male was presented withchronicwoundsince7yearsagoonhisrightupperandlowereyelid.Atfirstitappearsasanodulewhich growsslowly,andhardenedwithablackenedappearance.Thecomputedtomographic scan showed lesions size1.17x3.11x0.81 cm in the soft tissue of theright periorbital region of the lateral sidewhich infiltrate up to Musculus OrbicularisOculiandextendsto theright palpebrasofttissue.ThepatologicalexaminationconfirmitwasBasalCellCarcinoma.

Figure1.BasalCellCarcinomaonRightEyelids

TechniqueTumor was widely excised, leaving a

full thickness on upper and lower eyelids. Alateralforeheadflapraisedwithbasedontherighttemporalarterytransverselyacrosstheforehead. Upon elevation, the flap designencompassthewholeforehadareajustbelowthehairlineuptotheupperedgeofeyebrows,from one pedicle reaching the fullcontralateral forehead. This is done in orderto leave a donor defect which suits theforeheadaesthethicunit.The flap iselevatedjustabovethepericraniumlayer,thenshapedas necessary into the dimensions needed tocover the primary defect. In this case, thedistal part of flapwas split in half, and insetintotheupperandlowereyelidsdefect.

Inner lining palpebra superior andinferiorwasreplacedbycompositeauriculargraft then following by lateral cantophexy.The donor region was closed with an STSGfrom Femur Dextra. Fixation sutures wasdone pericranial base serves as a rigid andimmobilegraftbed.Tomaintainpressure,tie-overdressingapplied,allow5daysbeforethefirstdressingchange.By24hourmonitoring,it has been showed the survival of flapwithout any bleeding or ischemic part. After14 days the flap was divided, the functionalresultwasexcellent.

Figure2.PostExcisionofTumor

B

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Figure 3. Placing composite graft onpalpebralsuperiorandsuperior

Figure4.LateralCanthopexy

Figure5.Composite

AuricularGraftInner lining palpebra superior and

inferiorwasreplacedbycompositeauriculargraft then following by lateral cantophexy.The donor region was closed with an STSGfrom Femur Dextra. Fixation sutures was

done pericranial base serves as a rigid andimmobilegraftbed.Tomaintainpressure,tie-overdressingapplied,allow5daysbeforethefirstdressingchange.By24hourmonitoring,it has been showed the survival of flapwithout any bleeding or ischemic part. After14 days the flap was divided, the functionalresultwasexcellent.

Figure 6. Elevation of Lateral ForeheadFlap

Figure 7. Defect covered by split lateralforehead flap,donorcoveredbySTSGfromFemurDextra

Figure 8. 14 days after flap placement,distalpartwasdividedfromthebase

DiscussionThere are fundamental guidelines that

shouldbefollowedwitheveryreconstructioneffort. First, the surgeon should assess the

Composite Graft Palpebra Superior

Composite Graft Palpebra Inferior

Canthopexy Lateral

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defect.Thispatienthad largedefect involvesright upper and lower eyelids due to wideexcision of tumor. There exists no singularflap that can address all full-thickness upperand lowereyelidandmedialcanthusdefects.Thus,aminimumoftwoflaps isrequiredforthese types of combined defects (Motomuraet al., 2006). But in this case the surgeonsuggestusingsplitlateralforeheadflapratherthanusemultitechniques.

The forehead flap is acknowledged asthe ideal donor for midface reconstructiondue to its color and texture match,vascularity,andabilitytoresurfaceallorpartof the reconstructedarea (Thorne,2014). Itssuppliedbysuperficialtemporalarteries,andopthalmic arteries each consisting of thesupraorbital and supratrochlear arteries(Houseman, 2000). At first, surgeons wereworriedof raising forehead flapsbeyond themidline, fearing that by splitting the distalflapwouldcauseitscompromise.However,avascular study using micropaque injectionson the superfacial temporal artery incadavers shows that rich anastomoticplexusexists between the major foreheadangiosomes linked by the smaller caliber“choke”vessels(Mangold,1980).Fortunately,at 24 hour post operative evaluation, thevascular status of flap was excellent whichmonitoredbyobservationofcolorandhasnotendencies to bleeding or ischaemia on flapsite. After 14 days the flap was divided, thefunctionalresultwasexcellent.

ConclusionPeriorbital Basal cell carcinoma

resection may leave great defect to theunderlying tissue. The need to provideadequate support to this structure requirescomplextechniqueswithminimumtwoflaps.In our case, we performed a split lateralforehead flap with a good functional andcosmeticoutcome.

References1. ActisAG,ActisG.ReconstructionoftheUpper

Eyelid with Flaps and Free Grafts afterExcision of Basal Cell Carcinoma. Case

Reports in Ophthalmology. 2011;2(3):347-353.doi:10.1159/000334674.

2. Houseman ND, Taylor GI, Pan WR. Theangiosomes of the head and neck: anatomicstudyandclinicalapplications.PlastReconstrSurg2000;105:2287-313

3. Kakudo,N.,Ogawa,Y.,Suzuki,K.,Kushida,S.,Kusumoto, K.. Clinical Outcome of SurgicalTreatment for Periorbital Basal CellCarcinoma. Ann Plast Surg 2009;63: 531–535

4. MangoldU,LierseW,PfeiferG. [Thearteriesof the forehead as the basis of nasalreconstruction with forehead flaps]. ActaAnat(Basel)1980;107:18-25.

5. Motomura, H., Taniguchi, T., Harada, T.,Muraoka, M., 2006. A combined flapreconstruction for full-thickness defects ofthemedial canthal region. J. Plast. Reconstr.Aesthet.Surg.59(7),747–751.

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8. Scott M. Hayano, Katherine M. Whipple,Bobby S. Korn, and Don O. Kikkawa,“Principles of Periocular ReconstructionfollowingExcisionofCutaneousMalignancy,”Journal of Skin Cancer, vol. 2012, Article ID438502,6pages,2012

9. ThorneCH,BeasleyRW,AstonSJ,BartlettSP,Menick FJ, Yap LH, Langstein HJ, et al, eds.Grabb and Smith ’s Plastic Surgery. 7th ed.Philadelphia, PA: Lippincott Williams &Wilkins;2014:389-96.