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Reconstruction after wide excision in medial canthal region: The extended bilobed glabellar-palpebral flap
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MODEL
Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) xx, 1e2
CORRESPONDENCE AND COMMUNICATION Reconstruction after wide excision in medial canthal region: The extended bilobed glabellarpalpebral flap
Dear Sir, Reconstruction after excision of non-melanoma skin cancer involving the medial canthal region is a functional and aesthetic challenge. Several important anatomical structures (the lacrimal duct, the medial canthal ligaments and the superior and inferior eyelids with anterior and posterior lamellae) that the surgeon must preserve or has to reconstruct may be involved in the excision. Several techniques for reconstructing this region have been described in the literature but all of them present several limits. Full thickness skin grafts are useful in cases of high risk of recurrence or with superficial defects but can often cause cicatricial ectropion/entropion that require corrective procedures. Moreover they are not suitable for treatment of full thickness defects.1,2 Local flaps from the superior palpebral crease or from the glabella are often well vascularized, but they are not suitable for irregular defects involving the medial canthus and the inferior lid at the same time; in case of the glabellar flap, this is often too bulky and leads to poor results.3,4 Chao et al. proposed the “Combined glabellar and orbicularis oculi myocutaneous advancement flaps”, in which a small portion of the orbicularis oculi muscle is used to reconstruct the defect, and the glabellar flap to close the donor site.5 This flap is useful in case of irregular-shaped defects, but can only cover the medium size ones. Further, it is not clear neither which portion of the orbicularis muscle need to be taken (preseptal or pretarsal), nor whether the flap is suitable for the defects involving the medial part of the inferior eyelid. We designed an “extended bilobed glabellar-palpebral flap” consisting of a myocutaneous flap from the upper eyelid to cover the defect in the medial canthus, and of a glabellar flap transposed to close the medial part of the donor site in the upper eyelid.
After verifying on frozen section the negativity of the margins and bottom of the excision for presence of tumour cells, we first mark the palpebral part of the flap in the superior palpebral crease matching the size of the defect and securing that the width of the flap’s base be at least 1/ 3 of the flap’s length. This is followed by marking of the glabellar part of the flap, the length and width of which have to match the length and width of the donor site defect in its medial part. The flap is raised with the cutaneous and muscle components in the subseptal plane, which is followed by a deeper (gentle) dissection near the base of the flap and near the radix of the nose, where the vascular pedicle lies just above the periosteum (Figure 1). Then, the septal-myocutaneous flap is transposed into the defect. The donor site in the superior lid is closed by suturing the redundant skin of the palpebral crease in the lateral/central part and by transposition of the glabellar flap into the medial part. The donor site in the glabella is closed primarily. Furthermore before closure of the glabellar region, we harvest a strip of aponeurotic galea, which will be used as a graft for reconstruction of the posterior lamella. From 2011 to 2014 we used this flap on 6 patients with basocellular carcinoma involving the medial canthal region, the medial third of the inferior eyelid and the superior/ inferior medial canthal ligament. The average size of the defect was 6 cm2 (range 2e4 2e3 cm). All our flaps survived completely. We observed venous congestion and oedema during the immediate postoperative period in 4 patients, which resolved spontaneously in two days. We did not experience any problem at the donor site in terms of loss of sensitivity or motility. We did not see any cicatricial ectropion/entropion or recurrence (Figure 2). The extended bilobed glabellar-palpebral flap can be the technique of choice in cases of large and irregularshaped defects that involve the medial canthal region, medial tendon, and both lamellae of medial third of lower eyelid. In our hands this technique provides good cosmetic and functional results, since it does not alter the specific anatomy of the area and can also be used in young patients with no redundant skin on the upper eyelid. Another advantage is the possibility to harvest a strip of galea, for reconstruction of the posterior lamella, without any additional scar or a second donor site.
http://dx.doi.org/10.1016/j.bjps.2014.08.072 1748-6815/ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Panizzo N, et al., Reconstruction after wide excision in medial canthal region: The extended bilobed glabellar-palpebral flap, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/j.bjps.2014.08.072
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MODEL
2
Correspondence and communication
Figure 1 Left: Pre-op markings. In the superior lid, the design of the flap is the same of blepharoplasty. It is important to maintain a length/width ratio of 3:1 in the palpebral flap, in order to ensure its viability. Center: Dissection of the myocutaneous palpebral flap begins laterally, in the palpebral crease, where the flap is raised in the subseptal plane, and goes deeper medially, where it reaches the periosteum of nasal wall (white arrow). In this way we preserve the vascularization of the orbicularis flap. Right: Insetting of the flap. Myocutaneous flap can be trimmed in order to better fit in the defect. Donor site in the glabella and lateral upper eyelid are closed without tension.
Conflicts of interest None declared.
References 1. Alghoul M, Pacella S, Codner MA. Eyelid reconstruction. Plast Reconstr Surg 2013;132:288e. 2. Leibovitch I, Huilgol SC, Hsuan JD. Incidence of host site complications in periocular full thickness skin grafts. Br J Ophthalmol 2005;89:219e22. 3. Anderson RL, Edwards JJ. Reconstruction by myocutaneous eyelid flaps. Arch Ophtalmol 1979;97:2358. 4. Tirone L, Schonauer F, Sposato G, Molea G. Reconstruction of lower eyelid and periorbital district: an orbicularis oculi myocutaneous flap. J Plast Reconstr Aesthet Surg 2009;62: 1384ee1388. 5. Chao Y, Xin X, Jiangping C. Medial canthal reconstruction with combined glabellar and orbicularis oculi myocutaneous advancement flaps. J Plast Reconstr Aesthet Surg 2010;63: 1624ee1628.
Figure 2 Above: Pre-op. 76 y-o patient with BCC in the medial canthal region. Below: 6 months post-op. No sign of recurrence, no epiphora or cicatricial entropion/ectropion.
This flap can be used also in case of full thickness defects with medium/high risk of recurrence, where skin grafts would offer poor results (both functional and cosmetic). In fact, the site of the excision is covered by the very thin and pliable palpebral skin and, thus, any recurrence can be detected easily.
Ethical approval Not required.
Funding
N. Panizzo G. Colavitti G. Papa V. Ramella Department of Plastic and Reconstructive Surgery, Trieste, Italy D. Tognetto Department of Ophthalmology, Trieste, Italy Z.M. Arnez Department of Plastic and Reconstructive Surgery, Trieste, Italy E-mail addresses: [email protected], [email protected] 24 June 2014
None.
Please cite this article in press as: Panizzo N, et al., Reconstruction after wide excision in medial canthal region: The extended bilobed glabellar-palpebral flap, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/j.bjps.2014.08.072
MODEL
Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) xx, 1e2
CORRESPONDENCE AND COMMUNICATION Reconstruction after wide excision in medial canthal region: The extended bilobed glabellarpalpebral flap
Dear Sir, Reconstruction after excision of non-melanoma skin cancer involving the medial canthal region is a functional and aesthetic challenge. Several important anatomical structures (the lacrimal duct, the medial canthal ligaments and the superior and inferior eyelids with anterior and posterior lamellae) that the surgeon must preserve or has to reconstruct may be involved in the excision. Several techniques for reconstructing this region have been described in the literature but all of them present several limits. Full thickness skin grafts are useful in cases of high risk of recurrence or with superficial defects but can often cause cicatricial ectropion/entropion that require corrective procedures. Moreover they are not suitable for treatment of full thickness defects.1,2 Local flaps from the superior palpebral crease or from the glabella are often well vascularized, but they are not suitable for irregular defects involving the medial canthus and the inferior lid at the same time; in case of the glabellar flap, this is often too bulky and leads to poor results.3,4 Chao et al. proposed the “Combined glabellar and orbicularis oculi myocutaneous advancement flaps”, in which a small portion of the orbicularis oculi muscle is used to reconstruct the defect, and the glabellar flap to close the donor site.5 This flap is useful in case of irregular-shaped defects, but can only cover the medium size ones. Further, it is not clear neither which portion of the orbicularis muscle need to be taken (preseptal or pretarsal), nor whether the flap is suitable for the defects involving the medial part of the inferior eyelid. We designed an “extended bilobed glabellar-palpebral flap” consisting of a myocutaneous flap from the upper eyelid to cover the defect in the medial canthus, and of a glabellar flap transposed to close the medial part of the donor site in the upper eyelid.
After verifying on frozen section the negativity of the margins and bottom of the excision for presence of tumour cells, we first mark the palpebral part of the flap in the superior palpebral crease matching the size of the defect and securing that the width of the flap’s base be at least 1/ 3 of the flap’s length. This is followed by marking of the glabellar part of the flap, the length and width of which have to match the length and width of the donor site defect in its medial part. The flap is raised with the cutaneous and muscle components in the subseptal plane, which is followed by a deeper (gentle) dissection near the base of the flap and near the radix of the nose, where the vascular pedicle lies just above the periosteum (Figure 1). Then, the septal-myocutaneous flap is transposed into the defect. The donor site in the superior lid is closed by suturing the redundant skin of the palpebral crease in the lateral/central part and by transposition of the glabellar flap into the medial part. The donor site in the glabella is closed primarily. Furthermore before closure of the glabellar region, we harvest a strip of aponeurotic galea, which will be used as a graft for reconstruction of the posterior lamella. From 2011 to 2014 we used this flap on 6 patients with basocellular carcinoma involving the medial canthal region, the medial third of the inferior eyelid and the superior/ inferior medial canthal ligament. The average size of the defect was 6 cm2 (range 2e4 2e3 cm). All our flaps survived completely. We observed venous congestion and oedema during the immediate postoperative period in 4 patients, which resolved spontaneously in two days. We did not experience any problem at the donor site in terms of loss of sensitivity or motility. We did not see any cicatricial ectropion/entropion or recurrence (Figure 2). The extended bilobed glabellar-palpebral flap can be the technique of choice in cases of large and irregularshaped defects that involve the medial canthal region, medial tendon, and both lamellae of medial third of lower eyelid. In our hands this technique provides good cosmetic and functional results, since it does not alter the specific anatomy of the area and can also be used in young patients with no redundant skin on the upper eyelid. Another advantage is the possibility to harvest a strip of galea, for reconstruction of the posterior lamella, without any additional scar or a second donor site.
http://dx.doi.org/10.1016/j.bjps.2014.08.072 1748-6815/ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Panizzo N, et al., Reconstruction after wide excision in medial canthal region: The extended bilobed glabellar-palpebral flap, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/j.bjps.2014.08.072
+
MODEL
2
Correspondence and communication
Figure 1 Left: Pre-op markings. In the superior lid, the design of the flap is the same of blepharoplasty. It is important to maintain a length/width ratio of 3:1 in the palpebral flap, in order to ensure its viability. Center: Dissection of the myocutaneous palpebral flap begins laterally, in the palpebral crease, where the flap is raised in the subseptal plane, and goes deeper medially, where it reaches the periosteum of nasal wall (white arrow). In this way we preserve the vascularization of the orbicularis flap. Right: Insetting of the flap. Myocutaneous flap can be trimmed in order to better fit in the defect. Donor site in the glabella and lateral upper eyelid are closed without tension.
Conflicts of interest None declared.
References 1. Alghoul M, Pacella S, Codner MA. Eyelid reconstruction. Plast Reconstr Surg 2013;132:288e. 2. Leibovitch I, Huilgol SC, Hsuan JD. Incidence of host site complications in periocular full thickness skin grafts. Br J Ophthalmol 2005;89:219e22. 3. Anderson RL, Edwards JJ. Reconstruction by myocutaneous eyelid flaps. Arch Ophtalmol 1979;97:2358. 4. Tirone L, Schonauer F, Sposato G, Molea G. Reconstruction of lower eyelid and periorbital district: an orbicularis oculi myocutaneous flap. J Plast Reconstr Aesthet Surg 2009;62: 1384ee1388. 5. Chao Y, Xin X, Jiangping C. Medial canthal reconstruction with combined glabellar and orbicularis oculi myocutaneous advancement flaps. J Plast Reconstr Aesthet Surg 2010;63: 1624ee1628.
Figure 2 Above: Pre-op. 76 y-o patient with BCC in the medial canthal region. Below: 6 months post-op. No sign of recurrence, no epiphora or cicatricial entropion/ectropion.
This flap can be used also in case of full thickness defects with medium/high risk of recurrence, where skin grafts would offer poor results (both functional and cosmetic). In fact, the site of the excision is covered by the very thin and pliable palpebral skin and, thus, any recurrence can be detected easily.
Ethical approval Not required.
Funding
N. Panizzo G. Colavitti G. Papa V. Ramella Department of Plastic and Reconstructive Surgery, Trieste, Italy D. Tognetto Department of Ophthalmology, Trieste, Italy Z.M. Arnez Department of Plastic and Reconstructive Surgery, Trieste, Italy E-mail addresses: [email protected], [email protected] 24 June 2014
None.
Please cite this article in press as: Panizzo N, et al., Reconstruction after wide excision in medial canthal region: The extended bilobed glabellar-palpebral flap, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/j.bjps.2014.08.072