Angular artery perforator flap for reconstruction of nasal sidewall and medial canthal defects

A case series: 3-dimensional computed tomographic study of the superior orbital vessels: Superior orbital arcades and their relationships with the supratrochlear artery and supraorbital artery

BACKGROUND

Vascular complications from periorbital intravascular filler injection are major safety concerns.

OBJECTIVE

To thoroughly describe the superior orbital vessels near the orbital rim and propose considerations for upper eyelid and forehead injections.

METHODS

Fifty-one cadaver heads were infused with lead oxide contrast media through the external carotid artery, internal carotid artery, and facial and superficial temporal arteries. Computed tomography (CT) images were obtained after contrast agent injection, and 3-dimensional CT scans were reconstructed by using a validated algorithm.

RESULTS

Eighty-six qualified hemifaces clearly showed the origin, depth, and anastomoses of the superior orbital vessels, which consistently deployed 2 distinctive layers: deep and superficial. Of all hemifaces, 59.3% had deep superior orbital vessels near the orbital rim, including 44.2% with deep superior orbital arcades and 15.1% with deep superior orbital arteries, which originated from the ophthalmic artery. Additionally, 97.7% of the hemifaces had superficial superior orbital arcades, for which 4 origins were identified: ophthalmic artery, superior medial palpebral artery, angular artery, and anastomosis between the angular and ophthalmic arteries.

LIMITATIONS

The arterial depth estimated from 3-dimensional CT needs to be confirmed by standard cadaver dissection.

CONCLUSION

This study elucidated novel arterial systems and proposed considerations for upper eyelid and forehead injections.

Bipaddle chimaeric forehead flap: A new technique for simultaneous lining and cutaneous reconstruction in case of full thickness defects of the nose

INTRODUCTION

Many techniques have been described to treat full thickness nasal defects. The authors introduce the bipaddle chimaeric forehead flap (BCFF), a new alternative technique to achieve simultaneous lining and cutaneous reconstruction in case of full thickness hemi-nasal defects, presenting surgical details and applications for its clinical use.

PATIENTS AND METHODS

From June 2015 to April 2017, 10 patients presenting with oncological full thickness defects involving nasal sidewall and/or nasal ala were reconstructed with the BCFF technique. Mean age was 69.4 years. The chimaeric flap was composed of 2 paddles (cutaneous and periosteal), nourished by a single supratrochlear pedicle, which were used to independently reconstruct the deficient cutaneous and mucosal layers of the nose. Cartilage grafts were used in 8/10 patients.

RESULTS

Mean surgical time was 114 minutes. An intermediate thinning operation was performed in 3 out of 10 patients. All the flaps survived with no partial necrosis or cartilage exposure observed. Viability and mucosalization of the periosteal paddle was documented both intra-operatively (during the 2nd stage of the operation) and postoperatively (with fiberoptic rhinoscopy performed 3 months after the procedure). Clinical follow-up period ranged from 4 to 24 months postoperatively. The final result was judged sufficient, good and excellent in 1, 5, and 4 cases, respectively.

CONCLUSIONS

The BCFF technique may be a new alternative approach to address full thickness hemi-nasal defects with no extra donor site morbidity, allowing primary placement of structural cartilage grafts and immediate definition of the nasal subunits to be reconstructed.

Nasolabial propeller perforator flap: Anatomical study and case series

PURPOSE

The previous cadaveric studies of facial artery perforators have frequently reported high variability, and those results remain to be validated in the Colombian population. Thus, we aimed to describe the vascular anatomy of the lateral nasal artery cutaneous branches and their clinical applications using Colombian cadavers.

MATERIALS AND METHODS

Nine hemifaces from six fresh cadavers were included in the study. Terminal branches of the facial artery and cutaneous perforators of the lateral nasal artery were dissected. The quality, number, and distribution of the perforators were assessed. In addition, we present results of seven clinical cases for nasal alar reconstruction.

RESULTS

Cutaneous perforators were found in all hemifaces, and zone 2 was the most common location. In our clinical case series, all flaps used to reconstruct the nasal alar defects survived. There were two cases of venous congestion but no additional procedures were needed.

CONCLUSIONS

Although nasal alar reconstruction continues to be a challenging plastic surgery procedure, the nasolabial propeller perforator flap is an excellent choice for such because it allows a precise skin island design, is less bulky, has a wide arc of rotation, and facilitates one-staged reconstruction without increasing the rate of complications.

Superficial temporal artery perforator flap: Anatomic study of number and reliability of distal branches of the superficial temporal artery and clinical applications in three cases

BACKGROUND

Limited information is available about the anatomical feasibility and clinical applications of flaps based on distal divisions of the superficial temporal artery (STA). The aim of this study was to investigate the anatomy of the STA, focusing on the number and reliability of distal branches and to show representative cases for the use of such flaps for zygomatic, parieto-frontal and occipital reconstructions.

METHODS

Fifty volunteers were examined bilaterally by Doppler to investigate the presence and variability of the distal divisions of STA branches. Dissection was performed on 14 temporal regions of 7 fresh cadavers. Three cases of reconstruction following skin cancer in the zygomatic (7 × 5 cm defect), parieto-frontal (4 × 4 cm defect) and occipital areas (4 × 2 cm defect) are presented. All the flaps were pedicled and based on a single vessel.

RESULTS

In all the 50 volunteers, the parietal branch split into 2 ± 0 branches (anterior and posterior), bilaterally, while an average of 2.84 ± 0.46 and 2.82 ± 0.48 branches originated from the frontal vessel on the right and left side, respectively. 2 ± 0 parietal and 3 ± 0 frontal (superior, central, and inferior) cutaneous perforator branches were identified in all cadaveric specimens. Flaps (4 × 10 cm, 5 × 7 cm, and 2 × 5 cm, respectively, width × length) healed uneventfully providing stable coverage.

CONCLUSIONS

STA distal perforator branches proved to be anatomically constant in both the cadaveric and clinical settings. Although a larger series of cases is needed, island flaps based on such vessels may represent a versatile surgical option, allowing a wide range of reconstructions in the different facial subunits.

Lateral Nasal Artery Perforator Flaps: Anatomic Study and Clinical Applications

Background

Previous studies have investigated facial artery perforators, but have reported inconsistent results regarding lateral nasal artery (LNA) perforators. Although several authors have described the use of LNA perforators for ala nasi and nasal sidewall reconstruction, the literature contains little information regarding the cadaveric dissection of LNA perforators, and most previously published studies have focused on facial artery perforators.

Methods

Sixteen hemifaces from eight fresh cadavers were dissected to study the LNA perforators. After the dissection was performed, the total length and diameter of the LNA and its perforators were measured. The quantity and the distribution of the LNA perforators supplying the overlying skin were then assessed. LNA perforator flaps were used for reconstruction in 10 nasal and perinasal defects.

Results

The mean total lengths of the LNA and its perforators were 49.37 mm and 16.06 mm, respectively. The mean diameters of the LNA and its perforators were 2.08 mm and 0.91 mm, respectively. Based on our findings, we mapped the face to indicate zones with a higher probability of finding perforators. No infection, hematoma, or complete flap necrosis were observed after the procedures.

Conclusions

Nasal reconstruction is a challenging procedure, and LNA propeller/V-Y perforator flaps are an excellent reconstructive option in certain cases. Based on our cadaveric study, we were able to identify an area in the upper third of the nasolabial groove with a high density of perforators.

Morphometrical aspect on angular branch of facial artery

Anatomic variability and anastomosis of the angular artery of the facial artery with the other arteries are important for both anatomists and surgeons. In particular, the angular artery is a significant landmark in dacryocystorhinostomy. Because of variations on anatomy of the angular artery, there are limited numbers of anatomic studies on the flaps of facial region. Hence, the aim of the cadaveric study was to evaluate the anatomic features of the angular artery in detail to help surgical procedures.The artery was represented under ×4 loop magnification in 32 sides of 16 formalin-fixed adult cadavers. The angular artery's position, diameter, and branch patterns relevant to the nose arterial supply were evaluated. The facial artery ended symmetrically in 10 (62.5%) of the cadavers. The facial artery was terminated as angular artery in all of the cases. The types of the angular artery were as follows: classical angular type in 8 cases (25.0%), nasal type in 15 cases (46.9%), alar type in 4 cases (12.5%), and labial type in 5 cases (15.6%) on the facial halves. We studied the topographic anatomic features of the angular artery for increasing reliability of the flaps on the region. The angular arterial anatomic details are critical and essential for surgical cosmetic and functional results.

Facial Artery Perforator and Depressor Anguli Oris Muscle Chimeric Flap: A New Design of an Old Flap

BACKGROUND

The aim of this study was to investigate the reliability and outcomes of the facial artery perforator and separately elevated depressor anguli oris (DAO) muscle chimeric flap for the reconstruction of partial or total lower lip defects.

METHODS

Eleven patients with malignant skin tumors located at the lower lip were operated between 2013 and 2015. After the excision of the tumor with adequate clear margins using margin controlled excision technique, an appropriate flap fitting to the resultant defect based on the perforators of the facial artery and DAO muscle was prepared and placed into the defect. The DAO muscle activity was tested with electromyography in the postoperative first year examination.

RESULTS

Besides 1 patient with transient venous insufficiency, all the flaps healed well without a partial or total flap loss. The mean follow-up period was 10 months. No new primary tumor or recurrence was observed. Although in 1 patient, transient asymmetric smiling and mild drooling was observed, the overall oral competence results were found to be quite satisfactory. The electromyography evaluation of DAO muscle of 5 patients who reached the postoperative first year examination showed action potential results in normal limits with a slight decrease. All patients were satisfied with the final esthetic and functional result.

CONCLUSIONS

The facial artery perforator and depressor angel oris muscle chimeric flap is a valuable option for reconstruction of lower lip defects providing esthetically and functionally good results.

The anatomical origin and course of the angular artery regarding its clinical implications

BACKGROUND

The purposes of this study were to determine the morphological features and conceptualize the anatomical definition of the angular artery (AA) as an aid to practical operations in the clinical field.

MATERIALS AND METHODS

Thirty-one hemifaces from 17 Korean cadavers and 26 hemifaces from 13 Thai cadavers were dissected.

RESULTS

The topography of the AA was classified into 4 types according to its course: Type I (persistent pattern), in which the AA traverses the lateral side of the nose (11%); Type II (detouring pattern), in which the AA traverses the cheek and tear trough area (18%); Type III (alternative pattern), in which the AA traverses the medial canthal area through a branch of the ophthalmic artery (22.8%); and Type IV (latent pattern), in which the AA is absent (26.3%).

CONCLUSION

The findings of this study will contribute toward improved outcomes for cosmetic surgery involving the injection of facial filler by enhancing the understanding of AA anatomy.

Reconstruction of the zygomatic cheek defects using a flap based on the pretragal perforator of the superficial temporal artery

BACKGROUND

The aim of this study was to create a new flap based method for zygomatic cheek defect reconstruction using the pretragal perforator from the superficial temporal artery.

METHODS

Ten fresh cadavers were dissected after vascular injection to study pretragal perforator distribution, length, and diameter. Twelve clinical cases of zygomatic cheek defects were reconstructed using pretragal perforator flaps. According to the location of the perforator that was preoperatively probed using an ultrasound Doppler blood flow detector and the zygomatic cheek defect condition, size, and distance from the distal border to the tragus and the flabby surrounding skin, we designed a spindle-shaped longitudinal flap in the preauricular region based on the pretragus. The flap was raised superficially to the superficial musculoaponeurotic system from the caudal border incised primarily to the cephalic border to create the perforator flap. The flap was sutured to the defect and the donor site was closed.

RESULTS

Cadaver dissection showed a quite constant perforator given off by the superficial temporal artery or its auricular branches with an appearance rate of 85% anterior to the tragus. The average perforator length was 18.3 mm (range, 11.2-24.2 mm). The average perforator diameter was 0.65 mm (range, 0.4-1.15 mm). A total of 12 clinical cases were available for 6-12 month postoperative follow-up. Favorable survival, primary closure, and esthetic results were achieved without any complications.

CONCLUSIONS

Zygomatic cheek defect reconstruction using the above-mentioned flap can achieve satisfactory esthetic and functional results and boasts a simple design, convenient procedure, reliable blood supply, and concealed donor site incision.