Reconstruction of the inner canthus region with a forehead muscle flap: a report on three cases

Glabellar superciliary bilobed flap for reconstruction of large medial canthus region defect

The aim of this study was to describe a series of patients who have undergone a medial canthal reconstruction with a glabellar superciliary bilobed flap. A series of 30 patients were included with medial canthal defects after excision of medial canthal tumour who underwent reconstruction using a glabellar-superciliary bilobed flap of adjoining skin and subcutaneous tissue. Eighteen procedures were performed under local anaesthesia. The remaining 12 cases were combined with major lid reconstruction and performed under general anaesthesia. Complete closure of the defect, aesthetic outcome, complications, and re-operations were all used as outcome measures. Primary closure of the donor site was achieved in all cases without wound dehiscence. In all cases, the cosmetic appearance was highly satisfactory to the surgeons and patients and there were no intraoperative complications. The glabellar superciliary bilobed flap is an effective, quick, simple, and single-stage technique for medial canthal region reconstruction. It provides excellent cosmesis and is associated with minimal complications. It can be modified according to the nature of the periorbital skin, location, size, and depth of the defect.

Single-staged Tunneled Forehead Flap for Medial Canthal and Eyelid Reconstruction

Purpose:

The paramedian forehead flap, while initially used for reconstruction of nasal defects, has been adapted for repair of anatomical subunits in the medial canthal and eyelid area. A significant obstacle for utilizing the flap has been the bulky, unsightly vascular pedicle that is maintained between surgical stages. We describe our surgical experience using the tunneled variation in a single stage procedure.

Methods:

A retrospective chart review was performed of three surgeons’ charts over a 5-year period. All patients who underwent the tunneled paramedian forehead flap variation were selected. Outcomes measured included underlying pathology, Mohs defect area and depth, and canalicular involvement.

Results:

A total of 20 tunneled flaps were performed after successful Mohs excision of cutaneous malignancies. The average Mohs defect surface area was 13.57 cm² with depth down to periosteum (n = 13), bone (n = 5), or orbital fat (n = 2). Five patients had full-thickness eyelid defects (25%), and nine (45%) had canalicular defects. The overall complication rate for this study was low with no flap failure. Two patients (10%) desired thinning of the subcutaneous flap for improved cosmesis, and one patient (5%) required further eyelid revision due to the complexity of the initial Mohs defect. The remaining 17 patients required no further surgical procedures.

Conclusion:

The tunneled paramedian forehead flap is a useful technique for medial canthal and eyelid reconstruction. This technique allows reconstruction of a challenging area. Complication rates are low, and this tunneled variation provides a single stage variation to the traditional multistage forehead pedicle flap.

"Pickaxe" double flap: a useful "tool" for reconstruction of deep large medial canthal defects-5-year experience and brief literature review

OBJECTIVE

Reconstruction of large, deep medial canthal defects presents a challenge to reconstructive surgeons, since both safe oncologic excision and aesthetically pleasant results should be met. We report our 5-year experience with the use of a double flap technique, which looks like a "pickaxe", in reconstruction of the aforementioned kind of defects.

METHODS

The technique is based on the simultaneous use a glabellar and a nasolabial flap designed and raised on either side of the medial canthal defect. The complex of the defect with the flaps looks like a pickaxe. The technique was applied in 17 patients during the last 5 years.

RESULTS

No tumour relapses were recorded in our series (mean follow-up period of 24.8 months). Also neither disfiguring scar contractures nor trapdoor deformities were noticed because of the ample tissue provided and the w-plasty outline of the resulting surgical scar. All patients were satisfied with the aesthetic outcome.

CONCLUSION

The suggested technique is simple, reliable and provides very good aesthetic results without disfiguring deformities. Most importantly, consistent long-term results with high patient satisfaction and no tumour relapses were achieved.

LEVEL OF EVIDENCE V

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The application of axial superficial temporal artery island flap for repairing the defect secondary to the removal of the lower eyelid basal cell carcinoma

Our aim was to investigate the repair of the defect that follows excision of a basal cell carcinoma (BCC) of the lower eyelid. Skin projections of the superficial temporal artery and its frontal branches were marked using Doppler ultrasonography. The lesion was excised with 0.5-1.5cm margins. Frozen sections were taken to clarify the diagnosis. The frontal flap was designed according to the preoperative labelling, and was 0.5cm larger than the defect. The pedicle was 1.0-1.5cm longer than the distance between the pedicle and the defect, and the width of the pedicle was 3cm. If the lesion affected the full thickness of the lower eyelid, a conjunctival flap was sutured with the flap. A skin graft was applied when the defect was large. Such defects have been repaired successfully in 10 patients. There was no secondary defect or ectropion postoperatively. The superficial temporal artery frontal branch island flap is a satisfactory method for the repair of a defect secondary to a BCC of the lower eyelid.

The tunneled forehead flap in medial canthal and eyelid reconstruction

BACKGROUND

The midline forehead flap is used in the reconstruction of large, deep defects of the medial canthal area and lower eyelid. Drawbacks are a cosmetically unfavorable skin bulge at the nasal bridge and obliteration of the natural medial canthal concavity, requiring correction in a second stage.

OBJECTIVE

We adopted a modification of the technique to avoid these drawbacks.

METHODS

We reviewed the medical records and photographs of patients who received the tunneled midline forehead flap procedure in the repair of medial canthal defects and in the anterior lamellar repair of eyelid defects. The forehead flap was elevated in the subdermal plane, and the pedicle was de-epithelialized and transferred through a subgaleal tunnel from the pivot point of the flap into the primary defect.

RESULTS

Nine patients had defects of the medial canthal area, medial part of the eyelids, or both after surgical removal of malignant tumors. Follow-up ranged from 5 months to 6.1 years (mean 2.1 years, median 11 months). In all cases, flap viability was maintained, globe protection was achieved, and the concave architecture of the medial canthus was preserved.

CONCLUSION

The tunneled midline forehead flap can be an advantageous single-stage technique in medial canthal and medial eyelid repair.

A reliable surface landmark for localizing supratrochlear artery: Medial canthus

OBJECTIVE: To determine the reliability of medial canthus as a surface landmark to locate supratrochlear vascular pedicle.

STUDY DESIGN AND SETTING: The distance from medial canthal line to supratrochlear vascular pedicle was measured in 57 healthy volunteers (Doppler imaging study) and also in 15 fresh cadavers.

RESULTS: In the Doppler study, the pedicle was found at most 3 mm lateral or medial to medial canthus (mean ± SD, 0.8 ± 0.7 mm). SVP mark tended to be medial to the medial canthus mark in females (males, 6; females, 42), whereas it was lateral to it in males (males, 20; females, 5). In the cadaver study, the pedicle was found 0.7 mm away from medial canthus on average.

CONCLUSION: Medial canthus can be used as a reliable landmark for paramedian forehead flaps. When Doppler examination fails, pedicle may be found at most 3 mm away from medial canthus. SVP is more commonly located lateral to medial canthus in males and medial to it in females.

Supraorbital Artery Island Flap for Periorbital Defects

The forehead skin has the same color and texture as the periorbital region as well as the other parts of the face. The forehead is a local flap donor area for the reconstruction of full-thickness periorbital defects. This report presents eight cases in which full-thickness defects resulting from tumor resection have been repaired with supraorbital artery island flaps. Of eight patients, one was female and the rest were male with a mean age of 72.8 years (range, 64-88 years). Defects were located in the medial canthal region, lateral canthal region, glabella, and lateral part of the orbita. The flaps ranged from 2 x 3 cm to 6 x 7 cm in size. The patients were followed for 7 to 18 months. No complications occurred, except for decreased sensation on the forehead, and trapdoor deformity was seen in one case. The outcome was functionally and aesthetically satisfactory in all cases and all patients were happy with the outcome. The supraorbital artery island flap is a good alternative for the repair of defects around the orbita in that the color and texture of this flap match up with the orbital region and that it is pliable, simple, safe, and sensorial and requires only a single-session procedure.

Forehead anatomy: arterial variations and venous link of the midline forehead flap

The largest prospective cadaver study done over a 3-year period to investigate the arterial variations of the forehead is presented. The primary goal was to find anatomical support for various forehead flaps previously designed. Thirty cadaver foreheads (60 hemi-foreheads) were dissected from deep to superficial to identify arterial variations. The arteries were filled with a latex solution prior to dissection. The results show that the supratrochlear and dorsal nasal arteries have a relatively constant origin. Vertical (VB), oblique (OB), medial (MB) and lateral branches (LB) of the supraorbital artery were identified. The frontal branch of the superficial temporal artery (FBSTA) was found to continue in the direction of the scalp at the lateral orbital rim vertical line and gave off a transverse branch, the transverse frontal artery (TFA), to supply the forehead. The oblique branch of the supraorbital artery (OBSOA) most often anastomosed with either the transverse frontal artery or the frontal branch of the superficial temporal artery at the lateral orbital rim vertical line. A central artery (CA) was consistently found originating from the dorsal nasal artery usually 5mm from its origin. The central artery had a constant anastomosis with the opposite central artery in the inferior transverse third of the forehead. The central artery was not easily identifiable in the superior third of the forehead. The angular artery (AA) was found to have a variable termination. The angular artery could communicate with the supratrochlear artery (STrA) at the supraorbital rim (SOR) or it could continue up into the forehead medial to the STrA. This artery was called the paracentral artery (PCA). The central artery, paracentral artery and supratrochlear artery have an important relationship with the most prominent central vein that is relevant to flap construction. The significance of the central artery and vein favours the median forehead flap as anatomically superior and the prominent central vein is a constant landmark on which to select the side of the pedicle. Clear landmarks for defining the pedicle base for the median forehead flap are provided.

Arterial features of inner canthus region: confirming the safety for the flap design

The medial canthus represents a fixed-point fulcrum that is necessary for eyelid function. The aim of the study was to investigate the arterial distribution of the inner canthus. The origin, calibration, and branches of the inner canthus arteries and their topographical relations were examined by dissecting 19 cadavers, injecting red latex to their corresponding 38 nasal sections before the dissection. The distance from the dorsal nasal artery to the inner canthus was found to be 7.2 +/- 0.3 mm. In this study, the average diameter of the dorsal nasal artery was 0.74 mm on the right side and 0.88 mm on the left. Concerning the course of dorsal nasal artery on the lateral side of the nose, 4 types were observed. In most of the examples (44.7%), dorsal nasal artery anastomosed with angular artery via thick branch and gave off supplying branches to the medial canthus and to the lateral side of the nose. Dorsal nasal artery is a vessel of satisfactory size and is potentially a good vascular source for a thin free flap. It may be an ideal flap to reconstruct the eyelid defect for texture and color similarity of the inner canthus skin. A better understanding of the inner canthus vascularity should allow modification of reconstructive techniques and reduce postoperative complications.

Medial Canthal Reconstruction by a Modified Glabellar Flap

AIMS

To present a modified technique for the preparation of glabellar skin flaps to reconstruct medial canthal defects.

METHODS

Ten consecutively treated patients were included who had skin defects after resection of skin tumours like basal cell carcinomas in the medial canthal area of a medium vertical diameter of 2.5 cm. The defects were closed by preparation of a modified glabellar flap. The pedicle of the flap was guided through a skin tunnel prepared diagonally at the root of the nose. The pedicle was resected 4 weeks after the initial surgery.

RESULTS

In all 10 cases, the procedure was adequate for reconstruction of the defect. There were no flap necroses and the cosmetic results were favourable in all cases. The resection of the pedicle could be performed easily in an out-patient procedure 4 weeks after the operation.

CONCLUSION

Glabellar flaps are established procedures to reconstruct medium to large defects of the medial canthus. Skin distortion in the area of the flap pedicle leading to a skin bulge and visible scars at the root of the nose and medial transposition of the eye brows can be reduced by a modification of the surgical technique preparing a skin tunnel for the flap pedicle. In our hands, the cosmetic results are better with the modified technique in comparison to the original procedure.

A combined flap reconstruction for full-thickness defects of the medial canthal region

The medial canthus is an aesthetically and functionally important area. Adequate consideration of the local anatomy is essential when reconstructing this area. We developed a combined flap technique with a simple combination of standard flaps for the treatment of extensive defects of the nose and upper and lower eyelids, including full-thickness medial canthus defect. In our technique, a median forehead island flap is used for the nasal region, the anterior surface of the eyelid is reconstructed along aesthetic unit, and the posterior surface is reconstructed with a palatal mucoperiosteal graft. A cheek flap is then used for the reconstruction of the lower eyelid. When reconstructing a small defect of the upper eyelid, the upper eyelid is advanced, while a V-Y advancement flap within the upper eyelid is used for a large defect. To reconstruct the acute angle of the medial canthus, a 0.3 mm titanium wire was passed through the tip of the tarsal plate of the upper and lower eyelids to be reconstructed and was fixed in the perforated nasal bone on the affected side. Using this technique, the acute angle of the medial canthus is well preserved after surgery, and is located symmetrically with its counterpart on the intact side. Our technique provides good reconstructive results and should serve as a valid alternative for the reconstruction of this area.

[Reconstruction of complex tissue loss of the medial canthus]

The medial canthus is an anatomic and surgical entity. Reconstruction after cancerological resection is complex. The purpose of this article is to report a reconstruction technique for massive loss of tissue of the medial canthus which was applied in 2 patients with 2 years follow-up. Anatomic reconstruction was achieved. Each element of the canthus was restored: skin using Mustardé temporojugal and frontal flaps, conjunctive using a palatine mucosal graft, lacrimal canal using conjuctivo-rhinostomy, the medial canthal ligament using a fascia lata graft and transnasal canthopexia. Both patients developed an ectropion which required revision surgery. At 2 years, the functional outcome is good. Reconstruction allowed adapted social life and the cancer was controlled successfully.