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Paramedian Forehead Flap for Ocular Adnexal Reconstruction

M. Reza Vagefi, M.D.Oculofacial Plastic SurgeryAssociate Professor of OphthalmologyUniversity of California, San Francisco

UCSF Ophthalmology Update December 2, 2016

DisclosureI have no financial interests or relationships to disclose.

Case Presentation� CC: Blast injury of right peri-ocular area� HPI: 47 year-old male presents 9 days after ruptured globe repair OD for further evaluation and treatment. He reports working on a hydraulic pipe used in the machinery to crate fruit when it exploded in his face. He denies the use of eye protection.� PMH: None� Social Hx: 1 PPD smoker

Exam

Eye Exam

External Exam

Right Eye Left EyeVA LP w/o projection 20/20IOP Unable 13

Pupils + Reverse APD 4 � 2 mmEOM Globally restricted FullCVF

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How should this be repaired?

Options

Wound

Primary ClosurePrimary Closure

Tissue GraftTissue Graft

2ndary Intention2ndary Intention

Tissue FlapTissue Flap

Normally…

Dutton JJ. Atlas of Clinical and Surgical Orbital Anatomy. W.B Saunders Co. Philadelphia, PA. 1994

Back to our dilemma

� Loss of lids� Moderate defect� Active smoker� Normal skin elasticity� Aesthetics

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What does the BCSC book say?

Classification and Management of Eyelid Disorders. Orbit, Eyelids, and Lacrimal System. San Francisco, CA: American Academy of Ophthalmology; 2003.

The Ancient Texts� The Sushruta Samita(~700 BC)� Surgery was performed by the Koomas.� The need for the operation arose from the common practice of amputating the tip of the nose.

What is a Paramedian Flap?� A forehead flap that takes advantage of the vascular supply of the supratrochlearartery.� A useful flap because of the axial design, narrower base, and greater effective length.� They are the reconstructive mainstay for nasal defects.

A Little More History

Antonio Branca

15th

CenturyItaly

18th

CenturyUK

J. C. Carpue

19th

CenturyPrussia/Bavaria

John Mason Warren19th

CenturyUSA

Varaztad H. KazanjianBaker SR. Interpolated Paramedian Forehead Flap. In: Baker SR, ed. Local Flaps in Facial Reconstruction. 3rd ed. Philadelphia: Elsevier, 2014: 268-316.

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� It is estimated that 5.4 million cases of non-melanoma skin cancer, including basal cell carcinoma and squamous cell carcinoma, were diagnosed in the U.S. in 2012.

The Sun has Replaced the Sword� Current estimates are that one

in five Americans will develop skin cancer in their lifetime.

� The annual cost of treating non-melanoma skin cancer in the U.S. is estimated at $4.8 billion.

Paramedian Flap

� Flap design� Flap mobilization� Flap secured� Forehead closure� Pedicle division& inset

Paramedian in Oculoplastics� First introduced in our

literature in 1981.� In 2004, Bartley and

Garrity presented a series of 18 patients utilizing the flap for intermediate sized periorbital defects.

� The flap can be split to allow simultaneous reconstruction of the upper and lower lid.

Anterior Lamellar Reconstruction

Pre-Resection

Post-Resection

Cervico-facial FlapParamedian Flap

Post-reconstruction

Post-operative Week 1

Pedicle Division Week 4

Post-operative Month 4

Post-operative Year 2

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Nasal and Medial CanthalReconstruction

Pre-resection

Post-resection Post-reconstruction

Flap DesignPost-operative Week 3

Post-pedicle Division

Post-operative Month 6

Post-operative Year 1.5

Socket Reconstruction

Pre-reconstruction

Post-debridement & Anterior Exenteration

Post-reconstructionFlap Thinning Year 1

Pedicle DivisionFollow-up Year 1.5

Conclusions� The paramedian forehead flap is a versatile alternative for ocular adnexal and socket reconstruction. � This is especially true in cases of moderate to large, complex defects or tissue loss that preclude smaller advancement flaps or skin grafting. � It can be employed especially when local blood flow may be compromised by trauma, radiotherapy and/or smoking history.

Thanks