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Fasciocutaneous Flap, Secondary Axial Pattern Flap, and Microvascular Free Flap in Socket Reconstruction
Fasciocutaneous Flap, Secondary Axial Pattern Flap, and Microvascular Free Flap in Socl
MD~
Abstract: Three techniques are described to rebuild a missing or recurrently contracted socket, the selection of which is based on the anatomy of the periorbital tissue and vascular supply. When the superficial temporal vessels are present, the ipsilateral fasciocutaneous postauricular flap is used. When the vessels are present but the postauricular flap has been used, a secondary axial pattern flap is used. When the superficial temporal vessels are absent or not suitable, the dorsalis pedis vascularized free flap is used. [Key words: fasciocutaneous flap, microvascular flap, secondary axial pattern flap, socket reconstruction.] Ophthalmology 91 :94-101, 1984
Reconstruction of the contracted socket is a challenging task that often puzzles the orbital surgeon. Additionally, the injurious effects of irradiation further complicate the problem and reduce the success rate significantly. Traditional procedures such as full-thickness skin, splitthickness skin, or mucosal grafting, although successful in the majority of cases, are doomed to failure in irradiated orbits. Distant flaps, which are usually performed in two or three stages, require confinement to a cumbersome position while the transferred flap is receiving blood from the recipient site. 1 Furthermore, many of these patients also suffer from atrophy or hypoplasia of the periorbital soft tissue with or without bony deficit. If this is left uncorrected, the end result will be less than ideal, reFrom the Sections of Craniofacial,* Pediatric,t and Ophthalmic Plastic and Reconstructive Surgery,t Cleveland Clinic Foundation, Cleveland, Ohio. Reprint requests to Bahman Guyuron, MD, Head, Section of Craniofacial Surgery, Mount Sinai Medical Center, University Circle, Cleveland, OH,
44106.
94
gardless of the success of the socket reconstruction. The correct diagnosis and consideration of variable factors are critical in achieving an acceptable result from socket reconstruction.
CLASSIFICATION OF PROBLEM There is a fairly constant pattern of tissue deficit related to the etiology of the an ophthalmic socket. The majority of enucleations leave the patient with adequate soft tissue and orbital bone only in need of socket expansion (Group 1). On the other hand, there are patients who have enucleation of the globe for tumor ablation at an early age, followed by irradiation causing considerable contraction of the socket and hypoplasia of the orbital bone as well as orbital and periorbital soft tissue (Group 3). The median group (Group 2) have normal periorbital bone and soft tissue development but have lost some orbital soft tissue, which, if not replaced, will detract from the pleasing results
GUYURON,
et al •
f 1,
I
l
l
I
I
l
:r.•. Fig 1. Artist's conception of design of fasciocutaneous flap.
SOCKET RECONSTRUCTION
of socket expansion. Therefore, the quality of orbital and periorbital soft tissue and bone can be categorized into three groups, which will govern the selection of the reconstructive procedure. Group 1 includes patients who have had traumatic loss of globe and socket or have had an enucleation for a tumor or other medical problem as an adult. Because there is adequate soft tissue of the orbit and surrounding bone, failure of full-thickness skin or mucosal grafting indicates some technical problem rather than physiological change in the grafted area. Therefore, in these cases, a full-thickness skin or mucosa graft is repeated before any further complicated procedure is considered. Group 2 includes patients who have lost some orbital soft tissue as well as losing socket capacity. The socket is reconstructed using a full-thickness skin graft. A rib cartilage graft is added to overcome the soft tissue deficit. If the full-thickness skin graft fails to expand the socket satisfactorily, one of the flaps described in this paper is considered. Group 3 includes patients who have lost substantial amounts of bone and soft tissue and have received radiation treatment to the orbit. If the sulcus has not been grafted previously, a single procedure of full·thickness skin or mucosal grafting is attempted. If this is successful, the missing bone and soft tissue is replaced with rib cartilage graft in a second operation. If the skin graft fails, one of the three following procedures is chosen, depending on the local and regional anatomy. If the patient has intact superficial temporal vessels, the fasciocutaneous postauricular flap is chosen. If the patient has superficial temporal vessels, but the postauricular skin has been previously sacrificed, a secondary axial pattern flap is utilized. If the superficial temporal vessels are not suitable, judged by pulse and Doppler studies, a free dorsalis pedis flap is used.
FASCIOCUTANEOUS FLAP This flap was originally designed in two stages, delaying the postauricular skin for 3 weeks and then transferring it. However, the last four flaps have been transferred in a single stage, and they all have been successful. ANATOMY
J)
Fig 2. The flap is mobilized; a cut-back is made between the vascular pedicle and the triangular portion of the flap.
This flap has three portions. The first is the cutaneous portion, which includes the nonhairbearing skin of the postauricular area leaving only a small rim of intact skin along the free margin of the ear, which usually measures 5 by 6 em. The second portion is the subcutaneous and fascial portion, which includes a triangular composite tissue of the scalp, the base of which is the superior border of the postauricular skin, and the apex is just cephalad to the posterior branch of the superficial temporal artery.
95
OPHTHALMOLOGY •
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JANUARY 1984 •
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\
\\
Fig 3. The flap is delivered through a subcutaneous tunnel to the orbit, and full-thickness skin graft is applied only on the posterior aspect of the eyelids.
VOLUME 91
•
NUMBER 1
!his corresponds to a point about 6 em from the junction •fthe most superior portion of the ear with the scalp and lirectly in a vertical relation with this point. This part •f the flap will be de-epithelialized to avoid forniation .of ubcutaneous cysts. The third portion is the fascial porion, which includes the superficial temporal artery and ·ein. This portion is rectangular in shape. Anteriorly it s designed just 3 to 5 mm anterior to the superficial emporal vessels; posteriorly it is attached to the triangular lap superiorly, extending a few mm above the posterior •ranch of the superficial temporal artery, or roughly to he length of about 7 em from the junction of the ear 1nd scalp superiorly. The inferior limit of this fascia is he zygomatic arch (Fig 1). 'ECHNIQUE
A split-thickness skin graft is harvested from the butocks with the patient in the lateral position. The patient s then turned in a supine position and face and head are •repared. The nonhairbearing skin of the postauricular area is outlined. The triangular flap is designed from the most superior-posterior point of the cutaneous flap to a point about 6 em from the point where the superior border
Fig 4. A, left, preoperative and B, right, 6 months postoperative photographs of patient following transfer of postauricular fasciocutaneous flap and cartilage graft.
96
GUYURON, et al
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SOCKET RECONSTRUCTION
Fig 5. The design of the temporalis fascial flap to be mobilized.
Fig 6. The fascia-island flap is buried under the nonhairbearing skin of the upper neck.
of the ear joins the scalp in a vertical direction. The superficial temporal vessels are palpated and the course is outlined. The incisions are then started. In the postauricular area, the skin flap is raised, including the underlying superficial fascia. Extreme care is exercised to leave the perichondrium intact. The incision along the posterior border of the triangular portion of the flap is carried through the underlying fascia also, while the incision along the anterior border of this portion of the flap is carried through the skin only, with great caution exerted to avoid injury to the superficial temporal vessels lying just beneath the skin. The incision is continued along the preauricular fold much as a face-lift incision. The superficial temporal vessels are identified and separated from the overlying skin. The temporalis fascia encompassing the superficial temporal vessels is left attached to the vessels. This fascia is incised 3 to 5 mm anteriorly to the vessels, assuring the safety of the vessels. The vessels are raised together with the fascia and the dissection continued posteriorly to meet the previous incision along the posterior border of the triangular flap. The flap is mobilized completely, and by gentle traction on the flap, the vessels are dissected proximally to the point where they enter the parotid gland. These usually tortuous vessels can be dissected to gain considerable length to the pedicle. A subcutaneous tunnel is created, with care to preserve the integrity of the temporalis branch of the facial nerve. When the dissection reaches the lateral orbital wall, it should be continued in a subperiosteal plane to preserve the lateral canthal attachments to the skin and upper portion of the periosteum. If there is any portion of the eyelid conjunctiva still intact, it is preserved on the eyelids. The triangular portion of the flap is de-epithelialized and the reach of the flap is measured. If further length to the pedicle is needed to allow the flap to reach the medial canthal region, a cut-back incision is made between the pedicle and the triangular flap starting proximally, close to the origin of the vascular pedicle. As much as an inch of the pedicle can be separated from the triangular flap safely, leaving 3.5 to 4 em of the pedicle attached to the triangular portion of the flap (Fig 2). When external measurement indicates adequate length of the pedicle with easy reach of the pedicle to the medial canthal area, the flap is delivered through the tunnel into the orbit (Fig 3). If the conjunctiva of the eyelids is adequate, the flap is sewn to the free margins of the conjunctiva and placed in position. If the conjunctiva is not adequate, the eyelids are then lined up with a full- or split-thickness skin graft, and one or two Z-plasties are done along the junction of the skin graft and the flap to avoid linear contraction. For this junction we use 6-0 chromic sutures. Although the flap always looks slightly congested, in our experience all have survived except for a small portion of the flap in our first case, which had been done in two stages with initial delay. However, there was a large hematoma under the flap, and we felt that this contributed to the flap necrosis. The flap donor area in the postauricular region
97
OPHTHALMOLOGY •
JANUARY 1984 •
VOLUME 91
•
NUMBER 1
is covered with a split-thickness skin graft, and tieover sutures are used to hold the graft in position. The disadvantages of this flap include limited nonh~rbearing skin, tediousness of the dissection, and the requirement of split-thickness skin grafting. The advantages of this flap include achievement of a functional socket in a singlestage procedure and availability of adequate skin flap as well as soft tissue bulk needed in the majority of the cases. There is practically no chance of flap-bed contraction. Finally, this procedure leaves no obvious scars (Fig 4).
SECONDARY AXIAL PATIERN FLAP
Fig 7. The flap is transferred to the orbit through a subcutaneous tunnel three weeks following the first surgery.
The concept of the secondary axial pattern flap was first originated by Erol and Spira, 2 who conducted the experimental study, and was then applied clinically by Yao. 3 This concept is based on the dependency of the skin's blood supply on underlying soft tissue. If a given soft tissue is transferred underneath a specific portion of skin, 3 weeks after implantation, that skin, along with the underlying soft tissue, can be transferred to a new position. This concept has been used in cases in which
Fig 8. A, left, preoperative and B, right, !-year postoperative photographs of patient following a secondary axial pattern flap and rib cartilage graft to the orbit.
98
GUYURON, et al
•
SOCKET RECONSTRUCTION
the postauricular skin had previously been sacrificed, yet the superficial temporal vessels were intact. ANATOMY
The superficial temporal artery is the continuation of the external carotid artery, which travels on the temporalis fascia and divides into three branches. This thin piece of fascia can be implanted under any regional skin and carry the overlying skin to any desired position. The full extent of the temporalis fascia can be implanted under the skin. TECHNIQUE
The temporal fascia is exposed through a preauricular incision, with extreme care being taken to avoid injury to the superficial temporal vessels. The portion of the fascia that would reach the orbit easily is incised to the needed proportions (Fig 5). This fascial flap, which is attached to the superficial temporal vessels, is buried under the upper cervical skin just posterior and inferior to the ear lobe (Fig 6). Three weeks later, the fascia, together with the overlying skin, is mobilized and transferred to
(
c' ( ' ~ ~ :' ~ ~~ t Fig 9. Artist's rendition of the design of the dorsalis pedis on the dorsum of the foot.
Fig 10. The flap is transferred to the face, and a microanastomosis is created between the superficial temporal or facial vessels and the flap vessels (anterior tibial vessels).
~\
('
,'
~\
t
~ ~·~~)c.
Fig 11. Cross section of the orbit illustrating the flap covering the orbit, and full-thickness graft is covering the posterior aspect of the eyelids.
99
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•
JANUARY 1984
•
VOLUME 91
•
NUMBER 1
Fig 12. A, preoperative and B, l'h years postoperative photographs of patient following free vascularized dorsalis pedis flap and rib cartilage graft
the orbit in a fashion similar to the fasciocutaneous flap (Fig 7). The donor site of the flap is closed primarily by advancing the cervical skin (Fig 8). ADVANTAGES
This technique provides an adequate supply flap of skin with no chance of bed contraction. The scars are fairly well hidden, and no cumbersome position is required for transferring this flap. The main disadvantage is the two-stage procedure.
FREE VASCULARIZED DORSALIS PEDIS FLAP This flap is chosen when the superficial temporal vessels are not suitable. ANATOMY
Almost all the skin of the dorsum of the foot can be transferred on dorsalis pedis vessels. 4 These vessels are the continuation of the anterior tibial artery and its venae comitantes. Therefore, the pedicle to the flap can include the length of these vessels from the point where they penetrate the interosseous membrane to the dorsalis pedis artery. The artery has two venae comitantes, and the diameter of the artery can range from 2 to 4 mm.
100
TECHNIQUE
Harvesting of the flap and simultaneous exposure of the superficial temporal or facial vessel reduce operation time. Although the superficial temporal vessels might not be long enough for fasciocutaneous transferring, they might be suitable for anastomosis. The pattern of the flap needed is transferred to the dorsum of the foot (Fig 9). The dorsalis pedis vessels are identified and dissected proximally and distally while they are being preserved in the cutaneous flap. The flap is dissected free. The extensor hallucis brevis must be transected during this procedure. The superficial temporal vessels are exposed if still intact; otherwise the external jugular vein and the facial artery are dissected for anastomosis. A subcutaneous tunnel is created, and the flap pedicle is transected at a level long enough to avoid a transposition vein graft. The anastomosis is done under a microscope, and the flap is delivered through the tunnel to the orbit (Fig I 0). The excess dermis and epidermis at the periphery of the flap is removed and used as a skin graft to line the upper and lower lids if needed (Fig II). The donor site of the flap is grafted with a split-thickness skin graft harvested from the buttocks (Fig 12). Advantages of this flap include provision of an adequate amount of supple skin and soft tissue in a single stage. It avoids the cumbersome position of the staged distant flaps. Donor site morbidity may occasionally be severe. This flap procedure requires the expertise of a microvascular surgeon, and the donor site scar is less than desirable.
GUYURON, et al
•
SOCKET RECONSTRUCTION
SUMMARY Three techniques are described to rebuild a missing or recurrently contracted socket. The selection of the ap" propriate technique is based on the anatomy of the periorbital tissue and vascular supply. When the superficial temporal vessels are present, the ipsilateral fasciocutaneous postauricular flap is used. When the vessels are present but the postauricular flap has been used, a secondary axial pattern flap is used. When the superficial temporal vessels are absent or not suitable, the dorsalis pedis vascularized free flap is used.
REFERENCES 1. Wexler MR, Peled I, Kaplan H. Socket reconstruction using cross· arm flaps. Plast Reconstr Surg 1981; 68:18-22. 2. Erol 00, Spira M. Utilization of a composite island flap employing omentum in organ reconstruction: an experimental investigation. Plast Reconstr Surg 1981; 68:561-70. 3. Yao ST. Vascular implantation into skin flap: experimental study and clinical application: a preliminary report. Plast Reconstr Surg 1981; 68:404-10. 4. McCraw JB, Furlow LT Jr. The dorsalis pedis arterialized flap; a clinical study. Plast Reconstr Surg 1975; 55:177-85.
101
MD~
Abstract: Three techniques are described to rebuild a missing or recurrently contracted socket, the selection of which is based on the anatomy of the periorbital tissue and vascular supply. When the superficial temporal vessels are present, the ipsilateral fasciocutaneous postauricular flap is used. When the vessels are present but the postauricular flap has been used, a secondary axial pattern flap is used. When the superficial temporal vessels are absent or not suitable, the dorsalis pedis vascularized free flap is used. [Key words: fasciocutaneous flap, microvascular flap, secondary axial pattern flap, socket reconstruction.] Ophthalmology 91 :94-101, 1984
Reconstruction of the contracted socket is a challenging task that often puzzles the orbital surgeon. Additionally, the injurious effects of irradiation further complicate the problem and reduce the success rate significantly. Traditional procedures such as full-thickness skin, splitthickness skin, or mucosal grafting, although successful in the majority of cases, are doomed to failure in irradiated orbits. Distant flaps, which are usually performed in two or three stages, require confinement to a cumbersome position while the transferred flap is receiving blood from the recipient site. 1 Furthermore, many of these patients also suffer from atrophy or hypoplasia of the periorbital soft tissue with or without bony deficit. If this is left uncorrected, the end result will be less than ideal, reFrom the Sections of Craniofacial,* Pediatric,t and Ophthalmic Plastic and Reconstructive Surgery,t Cleveland Clinic Foundation, Cleveland, Ohio. Reprint requests to Bahman Guyuron, MD, Head, Section of Craniofacial Surgery, Mount Sinai Medical Center, University Circle, Cleveland, OH,
44106.
94
gardless of the success of the socket reconstruction. The correct diagnosis and consideration of variable factors are critical in achieving an acceptable result from socket reconstruction.
CLASSIFICATION OF PROBLEM There is a fairly constant pattern of tissue deficit related to the etiology of the an ophthalmic socket. The majority of enucleations leave the patient with adequate soft tissue and orbital bone only in need of socket expansion (Group 1). On the other hand, there are patients who have enucleation of the globe for tumor ablation at an early age, followed by irradiation causing considerable contraction of the socket and hypoplasia of the orbital bone as well as orbital and periorbital soft tissue (Group 3). The median group (Group 2) have normal periorbital bone and soft tissue development but have lost some orbital soft tissue, which, if not replaced, will detract from the pleasing results
GUYURON,
et al •
f 1,
I
l
l
I
I
l
:r.•. Fig 1. Artist's conception of design of fasciocutaneous flap.
SOCKET RECONSTRUCTION
of socket expansion. Therefore, the quality of orbital and periorbital soft tissue and bone can be categorized into three groups, which will govern the selection of the reconstructive procedure. Group 1 includes patients who have had traumatic loss of globe and socket or have had an enucleation for a tumor or other medical problem as an adult. Because there is adequate soft tissue of the orbit and surrounding bone, failure of full-thickness skin or mucosal grafting indicates some technical problem rather than physiological change in the grafted area. Therefore, in these cases, a full-thickness skin or mucosa graft is repeated before any further complicated procedure is considered. Group 2 includes patients who have lost some orbital soft tissue as well as losing socket capacity. The socket is reconstructed using a full-thickness skin graft. A rib cartilage graft is added to overcome the soft tissue deficit. If the full-thickness skin graft fails to expand the socket satisfactorily, one of the flaps described in this paper is considered. Group 3 includes patients who have lost substantial amounts of bone and soft tissue and have received radiation treatment to the orbit. If the sulcus has not been grafted previously, a single procedure of full·thickness skin or mucosal grafting is attempted. If this is successful, the missing bone and soft tissue is replaced with rib cartilage graft in a second operation. If the skin graft fails, one of the three following procedures is chosen, depending on the local and regional anatomy. If the patient has intact superficial temporal vessels, the fasciocutaneous postauricular flap is chosen. If the patient has superficial temporal vessels, but the postauricular skin has been previously sacrificed, a secondary axial pattern flap is utilized. If the superficial temporal vessels are not suitable, judged by pulse and Doppler studies, a free dorsalis pedis flap is used.
FASCIOCUTANEOUS FLAP This flap was originally designed in two stages, delaying the postauricular skin for 3 weeks and then transferring it. However, the last four flaps have been transferred in a single stage, and they all have been successful. ANATOMY
J)
Fig 2. The flap is mobilized; a cut-back is made between the vascular pedicle and the triangular portion of the flap.
This flap has three portions. The first is the cutaneous portion, which includes the nonhairbearing skin of the postauricular area leaving only a small rim of intact skin along the free margin of the ear, which usually measures 5 by 6 em. The second portion is the subcutaneous and fascial portion, which includes a triangular composite tissue of the scalp, the base of which is the superior border of the postauricular skin, and the apex is just cephalad to the posterior branch of the superficial temporal artery.
95
OPHTHALMOLOGY •
I
\
JANUARY 1984 •
I
\
\\
Fig 3. The flap is delivered through a subcutaneous tunnel to the orbit, and full-thickness skin graft is applied only on the posterior aspect of the eyelids.
VOLUME 91
•
NUMBER 1
!his corresponds to a point about 6 em from the junction •fthe most superior portion of the ear with the scalp and lirectly in a vertical relation with this point. This part •f the flap will be de-epithelialized to avoid forniation .of ubcutaneous cysts. The third portion is the fascial porion, which includes the superficial temporal artery and ·ein. This portion is rectangular in shape. Anteriorly it s designed just 3 to 5 mm anterior to the superficial emporal vessels; posteriorly it is attached to the triangular lap superiorly, extending a few mm above the posterior •ranch of the superficial temporal artery, or roughly to he length of about 7 em from the junction of the ear 1nd scalp superiorly. The inferior limit of this fascia is he zygomatic arch (Fig 1). 'ECHNIQUE
A split-thickness skin graft is harvested from the butocks with the patient in the lateral position. The patient s then turned in a supine position and face and head are •repared. The nonhairbearing skin of the postauricular area is outlined. The triangular flap is designed from the most superior-posterior point of the cutaneous flap to a point about 6 em from the point where the superior border
Fig 4. A, left, preoperative and B, right, 6 months postoperative photographs of patient following transfer of postauricular fasciocutaneous flap and cartilage graft.
96
GUYURON, et al
•
SOCKET RECONSTRUCTION
Fig 5. The design of the temporalis fascial flap to be mobilized.
Fig 6. The fascia-island flap is buried under the nonhairbearing skin of the upper neck.
of the ear joins the scalp in a vertical direction. The superficial temporal vessels are palpated and the course is outlined. The incisions are then started. In the postauricular area, the skin flap is raised, including the underlying superficial fascia. Extreme care is exercised to leave the perichondrium intact. The incision along the posterior border of the triangular portion of the flap is carried through the underlying fascia also, while the incision along the anterior border of this portion of the flap is carried through the skin only, with great caution exerted to avoid injury to the superficial temporal vessels lying just beneath the skin. The incision is continued along the preauricular fold much as a face-lift incision. The superficial temporal vessels are identified and separated from the overlying skin. The temporalis fascia encompassing the superficial temporal vessels is left attached to the vessels. This fascia is incised 3 to 5 mm anteriorly to the vessels, assuring the safety of the vessels. The vessels are raised together with the fascia and the dissection continued posteriorly to meet the previous incision along the posterior border of the triangular flap. The flap is mobilized completely, and by gentle traction on the flap, the vessels are dissected proximally to the point where they enter the parotid gland. These usually tortuous vessels can be dissected to gain considerable length to the pedicle. A subcutaneous tunnel is created, with care to preserve the integrity of the temporalis branch of the facial nerve. When the dissection reaches the lateral orbital wall, it should be continued in a subperiosteal plane to preserve the lateral canthal attachments to the skin and upper portion of the periosteum. If there is any portion of the eyelid conjunctiva still intact, it is preserved on the eyelids. The triangular portion of the flap is de-epithelialized and the reach of the flap is measured. If further length to the pedicle is needed to allow the flap to reach the medial canthal region, a cut-back incision is made between the pedicle and the triangular flap starting proximally, close to the origin of the vascular pedicle. As much as an inch of the pedicle can be separated from the triangular flap safely, leaving 3.5 to 4 em of the pedicle attached to the triangular portion of the flap (Fig 2). When external measurement indicates adequate length of the pedicle with easy reach of the pedicle to the medial canthal area, the flap is delivered through the tunnel into the orbit (Fig 3). If the conjunctiva of the eyelids is adequate, the flap is sewn to the free margins of the conjunctiva and placed in position. If the conjunctiva is not adequate, the eyelids are then lined up with a full- or split-thickness skin graft, and one or two Z-plasties are done along the junction of the skin graft and the flap to avoid linear contraction. For this junction we use 6-0 chromic sutures. Although the flap always looks slightly congested, in our experience all have survived except for a small portion of the flap in our first case, which had been done in two stages with initial delay. However, there was a large hematoma under the flap, and we felt that this contributed to the flap necrosis. The flap donor area in the postauricular region
97
OPHTHALMOLOGY •
JANUARY 1984 •
VOLUME 91
•
NUMBER 1
is covered with a split-thickness skin graft, and tieover sutures are used to hold the graft in position. The disadvantages of this flap include limited nonh~rbearing skin, tediousness of the dissection, and the requirement of split-thickness skin grafting. The advantages of this flap include achievement of a functional socket in a singlestage procedure and availability of adequate skin flap as well as soft tissue bulk needed in the majority of the cases. There is practically no chance of flap-bed contraction. Finally, this procedure leaves no obvious scars (Fig 4).
SECONDARY AXIAL PATIERN FLAP
Fig 7. The flap is transferred to the orbit through a subcutaneous tunnel three weeks following the first surgery.
The concept of the secondary axial pattern flap was first originated by Erol and Spira, 2 who conducted the experimental study, and was then applied clinically by Yao. 3 This concept is based on the dependency of the skin's blood supply on underlying soft tissue. If a given soft tissue is transferred underneath a specific portion of skin, 3 weeks after implantation, that skin, along with the underlying soft tissue, can be transferred to a new position. This concept has been used in cases in which
Fig 8. A, left, preoperative and B, right, !-year postoperative photographs of patient following a secondary axial pattern flap and rib cartilage graft to the orbit.
98
GUYURON, et al
•
SOCKET RECONSTRUCTION
the postauricular skin had previously been sacrificed, yet the superficial temporal vessels were intact. ANATOMY
The superficial temporal artery is the continuation of the external carotid artery, which travels on the temporalis fascia and divides into three branches. This thin piece of fascia can be implanted under any regional skin and carry the overlying skin to any desired position. The full extent of the temporalis fascia can be implanted under the skin. TECHNIQUE
The temporal fascia is exposed through a preauricular incision, with extreme care being taken to avoid injury to the superficial temporal vessels. The portion of the fascia that would reach the orbit easily is incised to the needed proportions (Fig 5). This fascial flap, which is attached to the superficial temporal vessels, is buried under the upper cervical skin just posterior and inferior to the ear lobe (Fig 6). Three weeks later, the fascia, together with the overlying skin, is mobilized and transferred to
(
c' ( ' ~ ~ :' ~ ~~ t Fig 9. Artist's rendition of the design of the dorsalis pedis on the dorsum of the foot.
Fig 10. The flap is transferred to the face, and a microanastomosis is created between the superficial temporal or facial vessels and the flap vessels (anterior tibial vessels).
~\
('
,'
~\
t
~ ~·~~)c.
Fig 11. Cross section of the orbit illustrating the flap covering the orbit, and full-thickness graft is covering the posterior aspect of the eyelids.
99
OPHTHALMOLOGY
•
JANUARY 1984
•
VOLUME 91
•
NUMBER 1
Fig 12. A, preoperative and B, l'h years postoperative photographs of patient following free vascularized dorsalis pedis flap and rib cartilage graft
the orbit in a fashion similar to the fasciocutaneous flap (Fig 7). The donor site of the flap is closed primarily by advancing the cervical skin (Fig 8). ADVANTAGES
This technique provides an adequate supply flap of skin with no chance of bed contraction. The scars are fairly well hidden, and no cumbersome position is required for transferring this flap. The main disadvantage is the two-stage procedure.
FREE VASCULARIZED DORSALIS PEDIS FLAP This flap is chosen when the superficial temporal vessels are not suitable. ANATOMY
Almost all the skin of the dorsum of the foot can be transferred on dorsalis pedis vessels. 4 These vessels are the continuation of the anterior tibial artery and its venae comitantes. Therefore, the pedicle to the flap can include the length of these vessels from the point where they penetrate the interosseous membrane to the dorsalis pedis artery. The artery has two venae comitantes, and the diameter of the artery can range from 2 to 4 mm.
100
TECHNIQUE
Harvesting of the flap and simultaneous exposure of the superficial temporal or facial vessel reduce operation time. Although the superficial temporal vessels might not be long enough for fasciocutaneous transferring, they might be suitable for anastomosis. The pattern of the flap needed is transferred to the dorsum of the foot (Fig 9). The dorsalis pedis vessels are identified and dissected proximally and distally while they are being preserved in the cutaneous flap. The flap is dissected free. The extensor hallucis brevis must be transected during this procedure. The superficial temporal vessels are exposed if still intact; otherwise the external jugular vein and the facial artery are dissected for anastomosis. A subcutaneous tunnel is created, and the flap pedicle is transected at a level long enough to avoid a transposition vein graft. The anastomosis is done under a microscope, and the flap is delivered through the tunnel to the orbit (Fig I 0). The excess dermis and epidermis at the periphery of the flap is removed and used as a skin graft to line the upper and lower lids if needed (Fig II). The donor site of the flap is grafted with a split-thickness skin graft harvested from the buttocks (Fig 12). Advantages of this flap include provision of an adequate amount of supple skin and soft tissue in a single stage. It avoids the cumbersome position of the staged distant flaps. Donor site morbidity may occasionally be severe. This flap procedure requires the expertise of a microvascular surgeon, and the donor site scar is less than desirable.
GUYURON, et al
•
SOCKET RECONSTRUCTION
SUMMARY Three techniques are described to rebuild a missing or recurrently contracted socket. The selection of the ap" propriate technique is based on the anatomy of the periorbital tissue and vascular supply. When the superficial temporal vessels are present, the ipsilateral fasciocutaneous postauricular flap is used. When the vessels are present but the postauricular flap has been used, a secondary axial pattern flap is used. When the superficial temporal vessels are absent or not suitable, the dorsalis pedis vascularized free flap is used.
REFERENCES 1. Wexler MR, Peled I, Kaplan H. Socket reconstruction using cross· arm flaps. Plast Reconstr Surg 1981; 68:18-22. 2. Erol 00, Spira M. Utilization of a composite island flap employing omentum in organ reconstruction: an experimental investigation. Plast Reconstr Surg 1981; 68:561-70. 3. Yao ST. Vascular implantation into skin flap: experimental study and clinical application: a preliminary report. Plast Reconstr Surg 1981; 68:404-10. 4. McCraw JB, Furlow LT Jr. The dorsalis pedis arterialized flap; a clinical study. Plast Reconstr Surg 1975; 55:177-85.
101