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Median forehead flaps for eyelid reconstruction
Median forehead flaps for eyelid reconstruction
733 to optimise vision, or to irrigate the joint. This technique releases the assistant to perform these tasks. Yours faithfully,
C, Bernardis BSc, MBBS, FRCS, Specialist Registrar H. J, C. R. Belcher MB, MS, FRCS(Plast), Consultant Plastic Surgeon Department of Plastic Surgery, The Queen Victoria Hospital, Holtye Road, East Grinstead, West Sussex RH 19 3DZ, UK.
References 1. Swanson AB, Maupin BK, Gajjar NV, de Grout Swanson G. Flexible implant arthroplasty in the proximal interphalangeal joint of the hand. J Hand Surg 1985; 10A: 796-805. 2. Erdmann MWH, Sach RE Dorsal chevron flap for exposure of the proximal interphalangeal joint. J Hand Surg 1998; 23B: 673-5. 3. Fahmy NR, Lavender A, Brew C. A conservative approach for proximal interphalangeal joint arthroplasty. J Hand Surg 2001; 26B: 235-7. 4. Adamson GJ, Gellman H, Brumfield RH, Kuschner SH, Lawler JW. Flexible implant resection arthroplasty of the proximal interphalangeal joint in patients with systemic inflammatory arthritis. J Hand Surg 1994; 19A: 378-84. 5. Ostgaard SE, Weilby A. Resection arthroplasty of the proximal interphalangeal joint. J Hand Surg 1993; 18B: 613-15. 6. Lipscomb PR. Synovectomy of the distal two joints of the thumb and fingers in rheumatoid arthritis. J Bone Joint Surg 1967; 49A: 1135-40. 7. Lin HH, Wyrick JD, Stern PJ. Proximal interphalangeal joint silicone replacement arthroplasty: clinical results using an anterior approach. J Hand Surg 1995; 20A: 123-32.
doi:10.1054/bjps.2001.3698
Median forehead flaps for reconstruction
Figure 1--(A) The retraction suture is inserted' from the dermal side of one of the flaps, (B) passed around the digit and (C) introduced into the other skin flap from the epidermal side; (D) the suture is then tied on the opposite side of the digit, (E) exposing the joint. The retraction-suture technique is simple to perform and aids exposure of the PIP joint via dorsal or lateral approaches. This technique is gentler to the tissues than the use of retractors, which may be adjusted repeatedly. Surgery to the joint is demanding, and assistance is often required to control position,
eyelid
Sir, The recent article in this journal describing reconstruction of the inner canthus region using a forehead muscle flap based on the supraorbital and supratrochlear vessels was of interest. J The supratrochlear and supraorbital (median forehead) flaps are versatile flaps for eyelid reconstruction. The flap will extend to the outer canthus, and provides sufficient skin cover for the upper and lower lids simultaneously. We recently used this flap to reconstruct a defect at the outer canthus. A 90-year-old woman presented with a cicatrising basal cell carcinoma involving the lateral aspects of the upper and lower right eyelids (Fig. 1). Previous excision of a basal cell carcinoma in the right malar area, and the presence of a squamous cell carcinoma on the right cheek limited the reconstructive options. Excision created a 25% anterior and posterior lamella defect of the lateral margin of the lower eyelid, in continuity with a 50% anterior lamella defect of the upper eyelid including a fullthickness loss of the lateral one-third of the upper lid. Medial canthotomy of the anterior fibres of the suspensory ligament and a lateral canthoplasty were undertaken, with a flap of periosteum raised from the lateral aspect of the orbit. The remaining defect was resurfaced using a shaped tunnelled supratrochlear (paramedian) island flap with primary closure of the donor site. Whilst a supratrochlear flap can be bulky and leaves a secondary scar deformity, the result in this case was very satisfactory (Fig. 2).
734
British Journal of Plastic Surgery
Reference 1. Chiarelli A, Forcignanb R, Boatto D, Zuliani F, Bisazza S. Reconstruction of the inner canthus region with a forehead muscle flap: a report on three cases. BrJ Plast Surg 2001; 54: 248-52.
doi:10.1054/bjps.2001.3699
Multistage type III venous flap or 'pre-arterialisation of an arterialised venous flap'
Figure 1--Preoperative appearance. A: cicattising basal cell carcinoma involving the upper and lower eyelids; B: squamous cell carcinoma; C: old scar from previous excision of a basal cell carcinoma.
Figure 2--Postoperative appearance. A: median forehead flap; B: fullthickness skin graft following excision of a squamous cell carcinoma.
Sir, I read with great interest the article titled 'Pre-arterialisation of an arterialised venous flap: clinical cases' by Wungcharoen et al in this journal. 1 The authors mention Nakayama et al as the first to report preformed arteriovenous fistulae for venous flaps in experimental animals, 2 and then go on to describe their clinical cases, giving the reader the impression that no clinical cases have been previously reported. In 1995, in the Annals of Plastic Surgery, 3 we reported a clinical case of a type III venous flap performed as a multistage procedure involving planning an arterialised venous flap a technique that is similar to what Wungcharoen et al term 'pre-arterialisation of an arterialised venous flap'. The patient had a defect on the dorsum of the foot for which we performed an ipsilateral end-to-side anastomosis between the long saphenous vein and the anterior tibial artery. A week later a flap measuring 6.2 • 9.8 cm based on the arterialised vein was transferred to the defect, together with an end-to-end anastomosis of the cephalad draining end of the vein with the short saphenous vein, without termination of the arteriovenous shunt. Though the flap remained oedematous and congested for a week, it settled and successfully covered the defect. The advantage of this multistage procedure was that it combined the benefits of prearterialisation with a reduction in the possibility of anastomotic failure because only a venous-end anastomosis was needed at the second stage. Patients in whom this ipsilateral procedure may not be possible will benefit from a free transfer as described by Wungcharoen et al. 1 The early ischaemic and congested appearance seen in all these venous flaps probably indicates that a longer period of pre-arterialisation, along with a delay of venous outflow channels, is required in order for the flap to readjust to a new pattern of circulation. Yours faithfully,
The use of the supratrochlear flap for reconstruction of the medial canthal region is well reported, but this versatile flap can also be used for eyelid reconstruction in the lateral canthal region. Yours faithfully,
Simon P. H. Bennett FDS, FRCS, Senior House Officer in Plastic Surgery Bruce M. Richard MD, FRCS, Specialist Registrar in Plastic Surgery Kenneth E. G r a h a m FRCS(Plast), Consultant Plastic Surgeon Mersey Regional Burns and Plastic Surgery Unit, Whiston Hospital, Warrington Road, Prescot, Merseyside L35 5DR, UK.
George Alexander MBBS, MS, MCh, Plastic Surgeon A1-Babtain Centre for Burns and Plastic Surgery, Ward 1 & 2, Ibn Sina Hospital, PO Box 25427, Safat 13115, Kuwait.
References 1. Wungcharoen B, Santidhananon Y, Chongchet V. Pre-arterialisation of an arterialised venous flap: clinical cases. Br J Hast Surg 2001; 54: 112-16. 2. Nakayama Y, Soeda S, Kasai Y. Flaps nourished by arterial inflow through the venous system: an experimental investigation. Plast Reconstr Surg 1981; 67: 328-34. 3. Alexander G, Thatte MR, Govilkar PS. Use of type III venous flaps: single- and multistaged procedures. Ann Plast Surg 1995; 35: 214-19.
733 to optimise vision, or to irrigate the joint. This technique releases the assistant to perform these tasks. Yours faithfully,
C, Bernardis BSc, MBBS, FRCS, Specialist Registrar H. J, C. R. Belcher MB, MS, FRCS(Plast), Consultant Plastic Surgeon Department of Plastic Surgery, The Queen Victoria Hospital, Holtye Road, East Grinstead, West Sussex RH 19 3DZ, UK.
References 1. Swanson AB, Maupin BK, Gajjar NV, de Grout Swanson G. Flexible implant arthroplasty in the proximal interphalangeal joint of the hand. J Hand Surg 1985; 10A: 796-805. 2. Erdmann MWH, Sach RE Dorsal chevron flap for exposure of the proximal interphalangeal joint. J Hand Surg 1998; 23B: 673-5. 3. Fahmy NR, Lavender A, Brew C. A conservative approach for proximal interphalangeal joint arthroplasty. J Hand Surg 2001; 26B: 235-7. 4. Adamson GJ, Gellman H, Brumfield RH, Kuschner SH, Lawler JW. Flexible implant resection arthroplasty of the proximal interphalangeal joint in patients with systemic inflammatory arthritis. J Hand Surg 1994; 19A: 378-84. 5. Ostgaard SE, Weilby A. Resection arthroplasty of the proximal interphalangeal joint. J Hand Surg 1993; 18B: 613-15. 6. Lipscomb PR. Synovectomy of the distal two joints of the thumb and fingers in rheumatoid arthritis. J Bone Joint Surg 1967; 49A: 1135-40. 7. Lin HH, Wyrick JD, Stern PJ. Proximal interphalangeal joint silicone replacement arthroplasty: clinical results using an anterior approach. J Hand Surg 1995; 20A: 123-32.
doi:10.1054/bjps.2001.3698
Median forehead flaps for reconstruction
Figure 1--(A) The retraction suture is inserted' from the dermal side of one of the flaps, (B) passed around the digit and (C) introduced into the other skin flap from the epidermal side; (D) the suture is then tied on the opposite side of the digit, (E) exposing the joint. The retraction-suture technique is simple to perform and aids exposure of the PIP joint via dorsal or lateral approaches. This technique is gentler to the tissues than the use of retractors, which may be adjusted repeatedly. Surgery to the joint is demanding, and assistance is often required to control position,
eyelid
Sir, The recent article in this journal describing reconstruction of the inner canthus region using a forehead muscle flap based on the supraorbital and supratrochlear vessels was of interest. J The supratrochlear and supraorbital (median forehead) flaps are versatile flaps for eyelid reconstruction. The flap will extend to the outer canthus, and provides sufficient skin cover for the upper and lower lids simultaneously. We recently used this flap to reconstruct a defect at the outer canthus. A 90-year-old woman presented with a cicatrising basal cell carcinoma involving the lateral aspects of the upper and lower right eyelids (Fig. 1). Previous excision of a basal cell carcinoma in the right malar area, and the presence of a squamous cell carcinoma on the right cheek limited the reconstructive options. Excision created a 25% anterior and posterior lamella defect of the lateral margin of the lower eyelid, in continuity with a 50% anterior lamella defect of the upper eyelid including a fullthickness loss of the lateral one-third of the upper lid. Medial canthotomy of the anterior fibres of the suspensory ligament and a lateral canthoplasty were undertaken, with a flap of periosteum raised from the lateral aspect of the orbit. The remaining defect was resurfaced using a shaped tunnelled supratrochlear (paramedian) island flap with primary closure of the donor site. Whilst a supratrochlear flap can be bulky and leaves a secondary scar deformity, the result in this case was very satisfactory (Fig. 2).
734
British Journal of Plastic Surgery
Reference 1. Chiarelli A, Forcignanb R, Boatto D, Zuliani F, Bisazza S. Reconstruction of the inner canthus region with a forehead muscle flap: a report on three cases. BrJ Plast Surg 2001; 54: 248-52.
doi:10.1054/bjps.2001.3699
Multistage type III venous flap or 'pre-arterialisation of an arterialised venous flap'
Figure 1--Preoperative appearance. A: cicattising basal cell carcinoma involving the upper and lower eyelids; B: squamous cell carcinoma; C: old scar from previous excision of a basal cell carcinoma.
Figure 2--Postoperative appearance. A: median forehead flap; B: fullthickness skin graft following excision of a squamous cell carcinoma.
Sir, I read with great interest the article titled 'Pre-arterialisation of an arterialised venous flap: clinical cases' by Wungcharoen et al in this journal. 1 The authors mention Nakayama et al as the first to report preformed arteriovenous fistulae for venous flaps in experimental animals, 2 and then go on to describe their clinical cases, giving the reader the impression that no clinical cases have been previously reported. In 1995, in the Annals of Plastic Surgery, 3 we reported a clinical case of a type III venous flap performed as a multistage procedure involving planning an arterialised venous flap a technique that is similar to what Wungcharoen et al term 'pre-arterialisation of an arterialised venous flap'. The patient had a defect on the dorsum of the foot for which we performed an ipsilateral end-to-side anastomosis between the long saphenous vein and the anterior tibial artery. A week later a flap measuring 6.2 • 9.8 cm based on the arterialised vein was transferred to the defect, together with an end-to-end anastomosis of the cephalad draining end of the vein with the short saphenous vein, without termination of the arteriovenous shunt. Though the flap remained oedematous and congested for a week, it settled and successfully covered the defect. The advantage of this multistage procedure was that it combined the benefits of prearterialisation with a reduction in the possibility of anastomotic failure because only a venous-end anastomosis was needed at the second stage. Patients in whom this ipsilateral procedure may not be possible will benefit from a free transfer as described by Wungcharoen et al. 1 The early ischaemic and congested appearance seen in all these venous flaps probably indicates that a longer period of pre-arterialisation, along with a delay of venous outflow channels, is required in order for the flap to readjust to a new pattern of circulation. Yours faithfully,
The use of the supratrochlear flap for reconstruction of the medial canthal region is well reported, but this versatile flap can also be used for eyelid reconstruction in the lateral canthal region. Yours faithfully,
Simon P. H. Bennett FDS, FRCS, Senior House Officer in Plastic Surgery Bruce M. Richard MD, FRCS, Specialist Registrar in Plastic Surgery Kenneth E. G r a h a m FRCS(Plast), Consultant Plastic Surgeon Mersey Regional Burns and Plastic Surgery Unit, Whiston Hospital, Warrington Road, Prescot, Merseyside L35 5DR, UK.
George Alexander MBBS, MS, MCh, Plastic Surgeon A1-Babtain Centre for Burns and Plastic Surgery, Ward 1 & 2, Ibn Sina Hospital, PO Box 25427, Safat 13115, Kuwait.
References 1. Wungcharoen B, Santidhananon Y, Chongchet V. Pre-arterialisation of an arterialised venous flap: clinical cases. Br J Hast Surg 2001; 54: 112-16. 2. Nakayama Y, Soeda S, Kasai Y. Flaps nourished by arterial inflow through the venous system: an experimental investigation. Plast Reconstr Surg 1981; 67: 328-34. 3. Alexander G, Thatte MR, Govilkar PS. Use of type III venous flaps: single- and multistaged procedures. Ann Plast Surg 1995; 35: 214-19.