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Facial reconstruction using the visor scalp flap
Burns 28 (2002) 679–683
Facial reconstruction using the visor scalp flap Farhad Hafezi∗ , Bjjan Naghibzadeh, AmirHossein Nouhi Department of Plastic Surgery, Motahary Burn and Reconstructive centre, Iran University of Medical Sciences, Tehran, Iran Accepted 15 May 2002
Abstract In male burn victims, scar may cause grotesque disfigurement to the upper lip and lower face. There are many ways to address the problem, for simple skin grafting to complex flaps. Bipedicle scalp flaps are used sporadically for reconstruction of the upper lip. In this article, the use of bitemporal artery hair-bearing flap for reconstruction of the moustache and beard area in nine cases as a substitute for facial deformed skin is described. The results indicate that the scalp flap is one of the best-matched flaps for reconstruction of the mid and lower part of the male face. As a result of choosing the proper size of the flap, use of the tissue expander is omitted, the donor site may be closed primarily and early return of the patient to normal life is guaranteed. Although, the width of the flap is not sufficient enough to cover the whole lower face and the cheeks, it is enough to imitate a normal face and give a pleasant appearance. © 2002 Elsevier Science Ltd and ISBI. All rights reserved. Keywords: Scalp; Flap; Reconstruction; Moustache; Beard
1. Introduction
2. Technique
The face is the first most visible part of the human anatomy, so the aesthetic surgeon must pay special attention to devising any plan for the restitution of the face. In male burn victims, burn scars may cause grotesque facial disfigurement to the beard and moustache. Conventional methods of reconstruction of the upper lip and cheeks, by the use of skin grafts or local flaps are timeconsuming and can leave poor cosmetic results, with visible scarring and, especially, lack of hair growth [1,2]. There are very few cases of moustache and beard reconstruction described in the recent medical literature [3–12]. This paper explains the use of the bitemporal artery hair-bearing flap in the reconstruction of the moustache and beard, in nine male patients with burn injuries to the upper lip and lower face. The superficial temporal artery system is a terminal branch of the external carotid artery that supplies blood for the flap and lies down in the temporoparietal fascia [1,2]. The temporoparietal fascial flap is a thin, pliable layer of richly vascularized tissue that may be transferred either pedicled or free and alone or as a carrier of subjacent bone or overlying skin and scalp [11]. The quality of the tissue may be enhanced, and a successful color and texture match may be achieved [10].
Before the operation, a history is taken on the male baldness pattern in the patient’s family pedigree, especially on the father and maternal grandfather, because they can transfer the baldness genes to the offspring. The surgical plan is discussed with the patient and the result of surgery is shown either by photos or visiting postoperative patients, so the patient will be aware of the outcome. The deformed non-hair-bearing scarred skin is removed from the upper lip or lower face. Using Doppler ultrasound or light touch palpation, the location of the superficial temporal arteries are marked on both sides of temple (Fig. 1A). The width of the donor site should be chosen in a way for it to be closed primarily without tension, and then a 1–1.5 cm. anterior and posterior to the palpable artery is determined (Fig. 1B). The width of 2–3 cm usually gives enough tissue for reconstruction and this omits the use of the tissue expander. Avoiding tension gives better hair growth at the donor area. The incision is made deep to the galea and the flap is undermined at the galea-periostium space. Connecting two sides together, the scalp edges are approximated together with skin staplers. Based on these vessels, the bipedicled flap is then raised and turned over the face for reconstruction of the moustache (Fig. 1C) or beard (Fig. 1D). For reconstruction of the beard, the anesthetist should disconnect the endotracheal tube to allow the flap to pass over the naso-oral region and
∗
Corresponding author. Tel.: +98-21-225-0623; fax: +98-21-227-3233. E-mail address: [email protected] (F. Hafezi).
0305-4179/02/$22.00 © 2002 Elsevier Science Ltd and ISBI. All rights reserved. PII: S 0 3 0 5 - 4 1 7 9 ( 0 2 ) 0 0 1 1 2 - 2
680
F. Hafezi et al. / Burns 28 (2002) 679–683
Table 1 Patients summary Cases
Age (years)
Number of operations
Total time period (weeks)
Reconstruction area
1 2 3 4 5 6 7 8 9
25 24 18 26 22 32 23 27 25
2 3 2 2 4 3 2 3 2
3 6 3 3 12 6 3 6 6
Beard Moustache (single pedicle) Beard Beard Moustache and beard Moustache Beard Moustache and beard Moustache
3. Discussion
Fig. 1. Anatomy of the superficial temporal artery (A); donor site selection (B); transfer of the flap to the recipient site (C and D).
fit the lower face area. The flap is then placed into a new position. As a temporary dressing, the temporal donor area is covered with split thickness skin graft. Three weeks later, the flap bases are divided and excess segments are turned back to replace the skin graft over the temporal areas. The donor site suture line will heal and is not visible after the scar matures. 2.1. Cases Due to burn sequelae of the upper lip and or lower hair-bearing facial skin, nine patients underwent surgery for the moustache and beard reconstruction. The cases were operated on from 1994 to 2001. All cases were operated upon by same surgeon at a University affiliated hospital, in Tehran, Iran. We did beard reconstruction in five patients, moustache on two, both beard and moustache on two others (See Table 1). No flap necrosis or hair loss was observed in the patients (Fig. 2).
Severe post-bum scarring of lower face in adult male may cause loss of hair-bearing skin in addition to other complications resulting boyish appearance [7]. Several methods have been described for upper lip and lower face reconstruction [1–12]. A hairy skin flap is used in order to reconstruct the upper and lower face in a man who requests more natural, soft and pliable tissue. Scalp is a good source since it is in the vicinity of the face and the donor site scar could be camouflaged. The visor flap (visor: the front part of a helmet, protecting the face) was described by Duformental in 1919 (r&r). Vallis [4] reported a patient in whom hair was transplanted to the upper lip to create a moustache (1974). Walton and Bunkis [5] reported a free occipital hair-bearing flap for reconstruction of upper lip (1983). Lyon et al. [6] used the free superficial temporal artery hair-bearing flap for upper lip reconstruction (1989). Kumar [7] reported L-shape scalp flap for moustache reconstruction (1996). De Haro and Giraldo [13] used bipedicled fronto-occipital flap for reconstruction of postoncologic defects of the lateral scalp (2001). More recently Agrawal and Panda [12] emphasized the reliability of the midline forehead flap for nasal defect and moustache reconstruction. However, it is a multistage procedure and hence causes prolonged morbidity. Inigo et al. [10] used a frontotemporal fasciocutaneous island flap successfully for facial aesthetic subunit reconstruction. Our experience reveals that using island flap increases the risk and complexity of post-operative care and less tissue can be transferred simultaneously for both sides of the face. Kim et al. [11] explained the benefits and versatility of hair-bearing flap for upper lips and scalp defects, but did not mention use of this flap for lower parts of the face such as the lower lip, chin and neck. Although this flap preserves its donor site characteristics i.e. may lose hairs in their middle ages, but the results are pliable and non-contracting good quality skin. In the above techniques we limit the frequency of operations by choosing the proper width of the flap to fit the closing of the donor site primarily, resulting in an earlier return of the patient to normal life with less economic and social losses. The flap is safe to perform with adequate
F. Hafezi et al. / Burns 28 (2002) 679–683
681
Fig. 2. Upper row pre and lower row are the postoperative view of four patient photos. Case 1: neck burn scar, corrected by using bilateral epaulet and bipedicle scalp flap. Case 2: 22-year-old man with burn scars of the left cheek, upper lip and lateral part of the left eye brow. Case 3: hypertrophic neck scar following use of tissue expander, covered by scalp flap. Case 4: 25-year-old patient with grafted lower facial scar. Beard reconstructed.
682
F. Hafezi et al. / Burns 28 (2002) 679–683
Fig. 2. (Continued).
F. Hafezi et al. / Burns 28 (2002) 679–683
blood supply and achieves the goal of the operation, which is the restoration of more natural and masculine appearance [7]. We believe that the bipedicled superficial temporal artery flap is an excellent method for upper lip and cheek reconstruction, and gives an acceptable appearance both to donor and recipient area. The problems that may be encountered in this type of operation is temporary include occasional hair loss at high tension temporal areas, and also there would be different hair growth directions if there is any remnant of the normal hair growing skin on the face.
References [1] Jurkiewicz MJ, Krizek TJ, Matles SJ, Ariyan, S. Plastic surgery principles and practice by the c.v. Mosby Company; 1990. p. 419–39. [2] McCarthy JG, May JW, William Littler, J. Plastic Surg. London: Saunders; 1990. p. 614–22. [3] Kazanjian VH, Converse JM. Surgical treatment of facial injuries. Baltimore: William and Wilkins, 1974.
683
[4] Vallis CP. Hair transplantation to the upper lip to create a moustache: case report. Plas Reconstr Surg 1974;54:606–8. [5] Walton RL, Bunkis J. A free occipital hair-bearing flap for reconstruction of upper lip. Br J Plast Surg 1983;36:168–70. [6] Lyons GB, Milory BC, Lendvay PG, Teston LM. Upper lip reconstruction: use of the free superficial temporal artery hair-bearing flap. Br J Plast Surg 1989;42:333–6. [7] Kumar P. L-shaped scalp flap for moustache reconstruction in a patient with an acid burn of the face. Burns 1996;22:413–6. [8] Datubo-Brown DD, Khalid NK, Paul LL. Tissue-expanded visor flap in burn surgery. Ann Plat Surg 1994;32:205–8. [9] Kitazawa T, Harashina T, Tiara H, Takamatso A. Bipedicled sub mental island flap for upper lip reconstruction. Ann Plast Surg 1999;42:83–6. [10] Inigo F, Jimenez-Murat Y, Rojo P, Ysunza A. Frontotemporal fasciocutaneous island flap for facial aesthetic subunit reconstruction. J Craniofac Surg 1999;10(4):330–6. [11] Kim JC, Hadlock T, Varvares MA, Cheney ML. Hair-bearing temporoparietal fascial flap reconstruction of upper lip and scalp defects. Arch Facial Plast Surg 2001;3(3):170–7. [12] Agrawal K, Panda KN. Moustache reconstruction using an extended midline forehead flap. Br J Plast Surg 2001;54(2):159–61. [13] De Haro F, Giraldo F. Bipedicled fronto-occipital flap for reconstruction of postoncologic defects of the lateral scalp. Plast Reconstr Surg 2001;107(2):506–10.
Facial reconstruction using the visor scalp flap Farhad Hafezi∗ , Bjjan Naghibzadeh, AmirHossein Nouhi Department of Plastic Surgery, Motahary Burn and Reconstructive centre, Iran University of Medical Sciences, Tehran, Iran Accepted 15 May 2002
Abstract In male burn victims, scar may cause grotesque disfigurement to the upper lip and lower face. There are many ways to address the problem, for simple skin grafting to complex flaps. Bipedicle scalp flaps are used sporadically for reconstruction of the upper lip. In this article, the use of bitemporal artery hair-bearing flap for reconstruction of the moustache and beard area in nine cases as a substitute for facial deformed skin is described. The results indicate that the scalp flap is one of the best-matched flaps for reconstruction of the mid and lower part of the male face. As a result of choosing the proper size of the flap, use of the tissue expander is omitted, the donor site may be closed primarily and early return of the patient to normal life is guaranteed. Although, the width of the flap is not sufficient enough to cover the whole lower face and the cheeks, it is enough to imitate a normal face and give a pleasant appearance. © 2002 Elsevier Science Ltd and ISBI. All rights reserved. Keywords: Scalp; Flap; Reconstruction; Moustache; Beard
1. Introduction
2. Technique
The face is the first most visible part of the human anatomy, so the aesthetic surgeon must pay special attention to devising any plan for the restitution of the face. In male burn victims, burn scars may cause grotesque facial disfigurement to the beard and moustache. Conventional methods of reconstruction of the upper lip and cheeks, by the use of skin grafts or local flaps are timeconsuming and can leave poor cosmetic results, with visible scarring and, especially, lack of hair growth [1,2]. There are very few cases of moustache and beard reconstruction described in the recent medical literature [3–12]. This paper explains the use of the bitemporal artery hair-bearing flap in the reconstruction of the moustache and beard, in nine male patients with burn injuries to the upper lip and lower face. The superficial temporal artery system is a terminal branch of the external carotid artery that supplies blood for the flap and lies down in the temporoparietal fascia [1,2]. The temporoparietal fascial flap is a thin, pliable layer of richly vascularized tissue that may be transferred either pedicled or free and alone or as a carrier of subjacent bone or overlying skin and scalp [11]. The quality of the tissue may be enhanced, and a successful color and texture match may be achieved [10].
Before the operation, a history is taken on the male baldness pattern in the patient’s family pedigree, especially on the father and maternal grandfather, because they can transfer the baldness genes to the offspring. The surgical plan is discussed with the patient and the result of surgery is shown either by photos or visiting postoperative patients, so the patient will be aware of the outcome. The deformed non-hair-bearing scarred skin is removed from the upper lip or lower face. Using Doppler ultrasound or light touch palpation, the location of the superficial temporal arteries are marked on both sides of temple (Fig. 1A). The width of the donor site should be chosen in a way for it to be closed primarily without tension, and then a 1–1.5 cm. anterior and posterior to the palpable artery is determined (Fig. 1B). The width of 2–3 cm usually gives enough tissue for reconstruction and this omits the use of the tissue expander. Avoiding tension gives better hair growth at the donor area. The incision is made deep to the galea and the flap is undermined at the galea-periostium space. Connecting two sides together, the scalp edges are approximated together with skin staplers. Based on these vessels, the bipedicled flap is then raised and turned over the face for reconstruction of the moustache (Fig. 1C) or beard (Fig. 1D). For reconstruction of the beard, the anesthetist should disconnect the endotracheal tube to allow the flap to pass over the naso-oral region and
∗
Corresponding author. Tel.: +98-21-225-0623; fax: +98-21-227-3233. E-mail address: [email protected] (F. Hafezi).
0305-4179/02/$22.00 © 2002 Elsevier Science Ltd and ISBI. All rights reserved. PII: S 0 3 0 5 - 4 1 7 9 ( 0 2 ) 0 0 1 1 2 - 2
680
F. Hafezi et al. / Burns 28 (2002) 679–683
Table 1 Patients summary Cases
Age (years)
Number of operations
Total time period (weeks)
Reconstruction area
1 2 3 4 5 6 7 8 9
25 24 18 26 22 32 23 27 25
2 3 2 2 4 3 2 3 2
3 6 3 3 12 6 3 6 6
Beard Moustache (single pedicle) Beard Beard Moustache and beard Moustache Beard Moustache and beard Moustache
3. Discussion
Fig. 1. Anatomy of the superficial temporal artery (A); donor site selection (B); transfer of the flap to the recipient site (C and D).
fit the lower face area. The flap is then placed into a new position. As a temporary dressing, the temporal donor area is covered with split thickness skin graft. Three weeks later, the flap bases are divided and excess segments are turned back to replace the skin graft over the temporal areas. The donor site suture line will heal and is not visible after the scar matures. 2.1. Cases Due to burn sequelae of the upper lip and or lower hair-bearing facial skin, nine patients underwent surgery for the moustache and beard reconstruction. The cases were operated on from 1994 to 2001. All cases were operated upon by same surgeon at a University affiliated hospital, in Tehran, Iran. We did beard reconstruction in five patients, moustache on two, both beard and moustache on two others (See Table 1). No flap necrosis or hair loss was observed in the patients (Fig. 2).
Severe post-bum scarring of lower face in adult male may cause loss of hair-bearing skin in addition to other complications resulting boyish appearance [7]. Several methods have been described for upper lip and lower face reconstruction [1–12]. A hairy skin flap is used in order to reconstruct the upper and lower face in a man who requests more natural, soft and pliable tissue. Scalp is a good source since it is in the vicinity of the face and the donor site scar could be camouflaged. The visor flap (visor: the front part of a helmet, protecting the face) was described by Duformental in 1919 (r&r). Vallis [4] reported a patient in whom hair was transplanted to the upper lip to create a moustache (1974). Walton and Bunkis [5] reported a free occipital hair-bearing flap for reconstruction of upper lip (1983). Lyon et al. [6] used the free superficial temporal artery hair-bearing flap for upper lip reconstruction (1989). Kumar [7] reported L-shape scalp flap for moustache reconstruction (1996). De Haro and Giraldo [13] used bipedicled fronto-occipital flap for reconstruction of postoncologic defects of the lateral scalp (2001). More recently Agrawal and Panda [12] emphasized the reliability of the midline forehead flap for nasal defect and moustache reconstruction. However, it is a multistage procedure and hence causes prolonged morbidity. Inigo et al. [10] used a frontotemporal fasciocutaneous island flap successfully for facial aesthetic subunit reconstruction. Our experience reveals that using island flap increases the risk and complexity of post-operative care and less tissue can be transferred simultaneously for both sides of the face. Kim et al. [11] explained the benefits and versatility of hair-bearing flap for upper lips and scalp defects, but did not mention use of this flap for lower parts of the face such as the lower lip, chin and neck. Although this flap preserves its donor site characteristics i.e. may lose hairs in their middle ages, but the results are pliable and non-contracting good quality skin. In the above techniques we limit the frequency of operations by choosing the proper width of the flap to fit the closing of the donor site primarily, resulting in an earlier return of the patient to normal life with less economic and social losses. The flap is safe to perform with adequate
F. Hafezi et al. / Burns 28 (2002) 679–683
681
Fig. 2. Upper row pre and lower row are the postoperative view of four patient photos. Case 1: neck burn scar, corrected by using bilateral epaulet and bipedicle scalp flap. Case 2: 22-year-old man with burn scars of the left cheek, upper lip and lateral part of the left eye brow. Case 3: hypertrophic neck scar following use of tissue expander, covered by scalp flap. Case 4: 25-year-old patient with grafted lower facial scar. Beard reconstructed.
682
F. Hafezi et al. / Burns 28 (2002) 679–683
Fig. 2. (Continued).
F. Hafezi et al. / Burns 28 (2002) 679–683
blood supply and achieves the goal of the operation, which is the restoration of more natural and masculine appearance [7]. We believe that the bipedicled superficial temporal artery flap is an excellent method for upper lip and cheek reconstruction, and gives an acceptable appearance both to donor and recipient area. The problems that may be encountered in this type of operation is temporary include occasional hair loss at high tension temporal areas, and also there would be different hair growth directions if there is any remnant of the normal hair growing skin on the face.
References [1] Jurkiewicz MJ, Krizek TJ, Matles SJ, Ariyan, S. Plastic surgery principles and practice by the c.v. Mosby Company; 1990. p. 419–39. [2] McCarthy JG, May JW, William Littler, J. Plastic Surg. London: Saunders; 1990. p. 614–22. [3] Kazanjian VH, Converse JM. Surgical treatment of facial injuries. Baltimore: William and Wilkins, 1974.
683
[4] Vallis CP. Hair transplantation to the upper lip to create a moustache: case report. Plas Reconstr Surg 1974;54:606–8. [5] Walton RL, Bunkis J. A free occipital hair-bearing flap for reconstruction of upper lip. Br J Plast Surg 1983;36:168–70. [6] Lyons GB, Milory BC, Lendvay PG, Teston LM. Upper lip reconstruction: use of the free superficial temporal artery hair-bearing flap. Br J Plast Surg 1989;42:333–6. [7] Kumar P. L-shaped scalp flap for moustache reconstruction in a patient with an acid burn of the face. Burns 1996;22:413–6. [8] Datubo-Brown DD, Khalid NK, Paul LL. Tissue-expanded visor flap in burn surgery. Ann Plat Surg 1994;32:205–8. [9] Kitazawa T, Harashina T, Tiara H, Takamatso A. Bipedicled sub mental island flap for upper lip reconstruction. Ann Plast Surg 1999;42:83–6. [10] Inigo F, Jimenez-Murat Y, Rojo P, Ysunza A. Frontotemporal fasciocutaneous island flap for facial aesthetic subunit reconstruction. J Craniofac Surg 1999;10(4):330–6. [11] Kim JC, Hadlock T, Varvares MA, Cheney ML. Hair-bearing temporoparietal fascial flap reconstruction of upper lip and scalp defects. Arch Facial Plast Surg 2001;3(3):170–7. [12] Agrawal K, Panda KN. Moustache reconstruction using an extended midline forehead flap. Br J Plast Surg 2001;54(2):159–61. [13] De Haro F, Giraldo F. Bipedicled fronto-occipital flap for reconstruction of postoncologic defects of the lateral scalp. Plast Reconstr Surg 2001;107(2):506–10.