The auriculomastoid fasciocutaneous island flap: A new flap for orofacial reconstruction

568

DISCUSSION

J Oral Maxillofac 54:566, 1996

Surg

Discussion The Auriculomastoid Fasciocutaneous Flap: A New Flap for Orofacial Reconstruction

Island

Joseph I. Helman, DMD University

of Michigan,

Ann Arbor,

Michigan

The aim of reconstruction of the hard and soft tissues of the facial area has been a continuous challenge for the surgical specialties involved in the restoration of tissue volume and continuity. This retrospective study presented is a welcome contribution to our field. In 1947, Macomber and Berkeley’ gave the following reasons in support of the use of local flaps in facial reconstruction: Better color and texture match, production of minimal defect in the donor area, ideal thickness, proximity of tissue to be transferred, and greater vascularity. The auriculomastoid fascia-cutaneous island flap (AMFC) described in this article has each one of the advantages, with the addition of: 1) having a reasonably long pedicle, 2) being a one-stage tunneled flap, and 3) having the potential to be used with multiple pedicles with attached bone, cartilage, or skin with hair bearing areas. It is fascinating to follow the progress that led to the development of the AMFC by looking at the literature associated with this procedure during the past 70 years and identifying how each additional contribution in the literature significantly improves the design and versality of this flap. 1. This flap was first described as a tubed postauricular skin flap by Hunt’ in 1926. 2. The flap was presented as a two-stage vascularized pedicled retroauricular-temporal flap by Washio” in 1969, based on the posterior branch of the superficial temporal artery. 3. The skin pedicle was extended to include the skin covering the mastoid, published by Maillard and Montandon in 1982.4 4. The flap was modified as a postauricular one-stage tunneled island flap by Guyuron’ in 1985. 5. This current article combines the extended skin paddle used by Maillard and Montandon4 with the one-stage island flap design by Guyuron.5 The innovations introduced by Choung include an extended incision between the parietal branch of the superficial temporal and the posterior auricular vessels. This enables the surgeon to access more distal sites, and the potential for a composite flap combined with an additional pedicle. The neurosensory recovery observed in the area of the recipient site gives this method of reconstruction a significant advantage for intraoral reconstruction by allowing sensory perception. This enables the patient to identify and mobilize food particles, therefore improving the effectiveness of mastication. This excellent contribution contains three controversial issues for discussion. First, Chuong mentions that insuffi-

cient venous drainage was overcome by hyperbaric oxygenation (HBO). I recognize that HBO is a valuable method of treatment for hypoxic tissues in selected cases and significantly improves angiogenesis. However, I do not believe that clinical or experimental evidence supports its use in the treatment of acute venous congestion. Second, in Figure 2C there is a suggestion that the AMFC could be used as an island flap with contralateral feeding vessels. In the past Galvao6 described a stage contralateral full thickness flap with an extremely wide pedicle. Galvao also delayed his flap by ligating the ipsilateral occipital and posterior auricular vessels 10 days before flap elevation. Because of the significant differences between Galvao’s design and the AMFC, it is not possible to assume that a contralatera1 blood supply will provide a viable skin paddle. Data published by Har Shai7et aI in 1992 that evaluates the potential extension of the galeal flap in the interparietal area supports this concept. Their study showed “that an ipsilateral superficial temporal artery that supplies the galeal flap does not cross the midline or anastomose with the contralateral superficial temporal artery but insures the survival of a flap extended up to 1 cm proximal to the sagittal suture line.” Reinforcement of this concept is also provided by Byrd’ and Marty et al: who described partial distal necrosis of extended galeal flaps. The final controversial statement made by Choung is in regard to the vascular supply to the AMFC. The flap contains the parietal branches of the superficial temporal vessels and the distal branches of the posterior auricular and/or the occipital vessels. However, the axial blood supply is based solely on the superficial temporal vessels. To conclude, I congratulate the author for his creative flap design and for this valuable contribution to the armamentarium for facial reconstmcReferences 1. Macomber

WB, Berkeley WT: Use of neck pedicles in recondefects of the face. Plast Reconstr Surg 2585,

structions of

1947 2. Hunt HL: Plastic Surgery of the Head, Face, and Neck. Philadelphia, PA, Lea and Febiger, 1926 3. Washio H: Retroamicular-temporal flap. Plast Reconstr Surg 43:162, 1969 4. Maillard GF, Montandon D: Washio temporo-retroauricular flan: its use in 20 aatients Plast Reconstr Sum 70:550, 1982 5. Guy&m B: Retroau&ular island flap for eye socket reconstruction. Plast Reconstr Surg 76527, 1985 6. Galvao MSL: A postauricular flap based on the contralateral superficial temporal vessels. Plast Reconstr Surg 68:891, 1981 7. Har Shai Y, Fukuta K, Collares MV: The vascular anatomy of the galeal flap in the interparietal and midline regions. Plast Recontr Surg 89:64, 1992 8. Byrd HS: Temporoparietal (superficial temporal artery) fascial flau. In Stauch B.. Vasconez LO. and Hall-Findlav EJ, (Eds), Grabb’s Encyclopedia of Flaps; vol 1. Boston, MA, Little, Brown, 1990, p27 9. Marty F, Montadon D, Gumerer R: Subcutaneous tissue in the scalp: Anatomical, physiological and clinical study. Ann Plast Surg 16:368, 1986