- Email: [email protected]
Reconstruction of the inner canthus region with a forehead muscle flap: a report on three cases
248
British Journal of Plastic Surgery
BritishJournalofPlasticSurgery(2001),54 9 2001The BritishAssociationof PlasticSurgeons doi:10.1054/bjps.2000.3529
Reconstruction of the inner canthus region with a forehead muscle flap: a report on three cases A. Chiarelli, R. Forcignanb, D. Boatto, E Zuliani and S. Bisazza
Institute of Plastic Surgery and Burn Unit, University of Padua, Padova, Italy SUMMARY. We report our experience of using a forehead flap to repair the defect left by the excision of skin tumours in the medial canthal region involving both eyelids in three patients. Both eyelids and the inner canthus were reconstructed using a myofascial flap taken from the forehead, combined with septal chondro-mucosal grafts, oral mucosa and skin grafts. After a careful anatomical study of the vascularisation of the frontal region, we used only the frontal myofascial portion, a part of the forehead muscle vascularised by the deep branch of the supraorbital artery and by the supratroclear artery; the skin left behind is adequately nourished by the fine mesh of anastomoses in the area between the two supratroclear arteries, the supraorbital artery and the terminal vessels of the superficial temporal artery. The particularly thin, elastic and resistant features of this flap enabled us to repair a loss of substance in a difficult area with a successful outcome in terms of morphology, function and cosmetic appearance. 9 2001 The British Association of Plastic Surgeons Keywords: eyelid reconstruction, inner canthus, skin tumour, forehead flap. Skin tumours in the medial canthal area often involve both eyelids and thus make it necessary to reconstruct these structures. Full-thickness repair of the eyelids and inner canthus is often difficult due to the need to restore structurally different tissues including conjunctival mucosa, tarsal fibrous connective tissue, orbicularis muscle and skin. This paper describes a new surgical procedure used in three patients to repair defects of the inner canthus and near-total defects of both eyelids after the excision of skin tumours. Both eyelids were reconstructed using a myofascial flap from the forehead without the overlying skin, combined with composite chondro-mucosal grafts from the septum, oral mucosa and skin grafts.
supply to the grafts. A vertical paramedian incision was made on the forehead, and a 4 x 3.5cm trapeze-shaped myofascial flap, 2.5 cm wide at the base, was raised from the subcutaneous frontal region and rotated through 180~ to cover the defect (Fig. 3). This flap was covered with a split-skin graft (SSG) taken from the medial aspect of the right arm and reinforced with a sheet of auricular cartilage. The opening of the inferior lacrimal ducts was maintained by inserting a drainage tube. Tarsorrhaphy of the reconstructed eyelids was performed. In the immediate postoperative period, moderately severe oedema of the upper eyelid developed, regressing within about 3 weeks. On removal of the dressing 5 days postoperatively, the skin graft appeared to have only partially taken, presumably as a
Case reports
Case 1 A 79-year-old patient presented with a 2 year history of an ulcerated, solid cystic basal cell carcinoma (BCC) originating from the inner canthus of the right eye. The neoplasm extended from the orbito-palpebral region of the right inner canthus to include one-third of the upper eyelid and two-thirds of the lower eyelid (Fig. 1). The excisional defect consisted of the loss of skin and soft tissue from the inner canthus, the total loss of the lower eyelid and of one-third of the full thickness of the upper eyelid (Fig. 2); the lacrimal canaliculi were sacrificed. Reconstruction was performed in a single procedure under general anaesthesia. For the repair of the tarsal portion of the lower eyelid, a chondromucosal graft taken from the septum was used, after suitably weakening its cartilaginous component by means of radial incisions. Mucosa taken from the lower lip was used as a graft for reconstruction of the palpebral conjunctiva. A myofascial flap from the forehead was used to cover and provide a valid blood
Presented at the 47th National Congress of the Italian Society of Plastic, Aesthetic and ReconstructiveSurgery, Palermo, Italy, September 1998.
Figure 1--Case 1. Preoperative lesion extending from the orbitopalpebral region of the right inner canthus to involve one-third of the upper eyelid and two-thirds of the lower eyelid.
Forehead flap for reconstruction of the inner canthus
Figure 2---Case 1. The excision defect consisted of the loss of skin and soft tissue from the inner canthus, the total loss of the lower eyelid and the loss of one-third of the full thickness of the upper eyelid.
Figure 3--Case 1. A 4 • 3.5 cm trapeze-shaped myofascial flap, 2.5 cm wide at the base, was sculpted in the subcutaneous frontal region and rotated through 180~ to cover the defect.
result of the oedema of the flap induced by venous stasis. On the 12th postoperative day the skin graft was necrotic in places and on the 25th day the patient underwent a second operation to regraft the non-epithelialised area under local anaesthesia. The patient was followed up every 6 months. Two years after the operation there were no signs of any recurrent disease and the reconstruction of the defect was satisfactory (Fig. 4). Case 2
An 82-year-old patient presented with a 1.5 x 2 cm solid cystic BCC of the inner canthus of the right eye involving the medial parts of the upper and lower eyelids (Fig. 5). The excisional
249
Figure 4 ~ C a s e 1. Result 2 years postoperatively.
Figure 5--Case 2. Solid cystic BCC of the inner canthus of the right eye, involving only part of the upper and lower eyelids.
defect consisted of loss of the inner canthus and full-thickness defects of parts of both the upper and the lower eyelid. In a single surgical procedure under general anaesthesia, the lower eyelid was reconstructed with a chondro-mucosal graft taken from the septum, restoring the conjunctiva using mucosa from the oral cavity and inserting a cannula into the residual lacrimal channels to keep them open. The composite graft was covered with a 3.5 x 2.5cm trapeze-shaped myofascial flap from the forehead, using the same procedure as in case 1. This flap was coated with a SSG from the supraclavicular region. Despite signs of initial graft distress, the postoperative course was uneventful. The patient was followed up every 6 months. Two years after the operation there were no signs of recurrence and the reconstruction of the defect was satisfactory (Fig. 6).
250
British Journal of Plastic Surgery
Figure 6--Case
2. Result 2 years postoperatively.
Figure 8--Case
Figure 7--Case
3. Recurrent neoplasm of the inner canthus and lower
Figure 9--Case
left eyelid.
Case 3
A 66-year-old patient presented with a recurrent BCC of the inner canthus and lower left eyelid (Fig. 7). A C T scan revealed no invasion of the ocular structures or bone tissues and excision left a cutaneous and subcutaneous defect of the inner canthus and full-thickness defects of parts of the upper and lower eyelids. Reconstruction was achieved using a chondro-mucosal graft from the septum to reconstruct the tarsus (Fig. 8) and grafting of oral mucosa for the conjunctiva, covered with a 3.5 • 2.5 cm myofascial flap from the forehead (Fig. 9), using the previously described procedure. Once again, there were signs of flap oedema due to venous stasis, which delayed the heating of the graft taken from the left retroauricular region. The graft had taken completely by the 20th postoperative day. A naso-lacrimal drain was used for 3 weeks to ensure lacrimal discharge.
3. Reconstruction of the tarsus with a chondro-mucosal graft taken from the septum.
3. Myofascial flap from the forehead used to cover the
defect. The patient was followed up every 6 months. Two years after the operation there were no signs of recurrence and the reconstruction of the defect was satisfactory (Fig. 10).
Discussion Reconstruction o f full-thickness defects of the eyelids is complex, especially if it is done in a single surgical procedure. The difficulty arises from the need to reconstruct different supporting and covering structures, i.e. the conjunctiva, tarsus, orbicularis muscle, canthal ligaments and skin. Numerous techniques have been proposed for the reconstruction o f the inner canthus and eyelids involving the use of local skin flaps or flaps o f superficial temporal fascia. 1-11 If the defect is particularly extensive, it becomes
Forehead flap for reconstruction of the inner canthus
251
subcutaneous protection, the pedicle can easily become twisted and this can lead, in some cases, to swelling of the flap due to insufficient venous drainage. However, this problem regressed spontaneously in our cases. It is also important to take care over the cartilaginous graft used for the tarsal reconstruction, which must be thin and carefully shaped because excess thickness and poor positioning make the graft obvious and unsatisfactory. We nonetheless believe that, in selected cases, this flap is worth considering as an alternative to the conventional methods for repairing the inner canthal region with associated palpebral defects.
References
Figure l ~ - C a s e
3. Result 2 years postoperatively.
necessary to combine two or more techniques, the results of which, in terms of appearance and function, are often unsatisfactory. Moreover, the skin of the regions surrounding the eye (forehead, cheek bone, naso-genial region and cheek) is generally too thick to be suitable for the orbitopalpebral areas and is also difficult to model because of its relative inelasticity and softness. A flap of superficial temporal fascia is often used to repair the orbital region, but may not be sufficient to cover the inner canthus. 2'x2 In order to overcome such difficulties we adopted an alternative solution using a portion of frontal muscle with its deep fascia but without the overlying skin. The traditional forehead flap, with the median and paramedian variants, is well known for reconstructing the dorsum of the nose. 13'14 After a reassessment based on anatomical studies of the blood supply to the frontal region, 15-21 we used a thin myofascial flap from the forehead, without the skin. The frontal muscle is vascularised by the deep branch of the supraorbital artery and the supratrochlear artery, and the overlying skin can be left in place because it is adequately vascularised by the fine network of anastomoses between the two supratrochlear arteries, the supraorbital artery and the terminal vessels of the superficial temporal artery. The delayed healing and partial necrosis of the graft used to cover the muscle flap may be attributable to a venous vascular deficiency, probably due to kinking at the base of the flap, which is mechanically weaker when this technique is used because of the lack of any cutaneous support. It is worth emphasising the importance of accurate preparation of the flap, carefully respecting the anatomical planes in order to avoid damaging the delicate vascular structures. The particularly thin and elastic features of this flap enabled us to repair a loss of substance at a site that is not easy to reconstruct satisfactorily in terms of morphology, function and appearance. To ensure success, it is essential to pay particular attention to certain risks associated with this procedure. For instance, because of the lack of cutaneous and
1. Chiarelli A, Baldelli A, Di Vincenzo A, Martini G. Utilization of the superficial temporoparietal fascia in reconstructive plastic surgery: a clinical case. Ophthal Plast Reconstr Surg 1989; 5: 274-6. 2. Ellis DS, Toth BA, Stewart WB. Temporoparietal fascial flap for orbital and eyelid reconstruction. Plast Reconstr Surg 1992; 89: 606--12. 3. McGregor IA. Eyelid reconstruction following subtotal resection of upper or lower lid. Br J Plast Surg 1973; 26: 346-54. 4. Millard DR Jr. Eyelid repairs with a chondromucosal graft. Plast Reconstr Surg 1962; 30: 267. 5. Millard DR Jr. Repair of a severe medial canthal defect. Br J Plast Surg 1966; 19: 90-3. 6. Mustard6 JC. The use of flaps in the orbital region. Plast Reconstr Surg 1970; 45: 146-50. 7. Carraway JH. Reconstruction of the eyelids and correction of ptosis of the eyelid. In Aston SJ, Beasley RW, Throne CHM, eds. Grabb and Smith's Plastic Surgery. 5th ed. Philadelphia: Lippincott-Raven, 1997. 8. Scuderi N, Rubino C. Island chondro-mucosal flap and skin graft: a new technique in eyelid reconstruction. Br J Plast Surg 1994; 47: 57-9. 9. Uchinuma E, Sakurai H, Shioya N. Anterofrontal superficial temporal artery island flap for full-thickness eyelid reconstruction. Ann Plast Surg 1989; 23: 433-6. 10. Yoshimura Y, Nakajima T, Yoneda K. Reconstruction of the entire upper eyelid area with a subcutaneous pedicle flap based on the orbicularis oculi muscle. Plast Reconstr Surg 1991; 88: 136-9. 11. Testut L, Jacob R, eds. Anatomia Topografica. Torino: UTET, 1926: 35-46. 12. Rose EH, Norris MS. The versatile temporoparietal fascial flap: adaptability to a variety of composite defects. Plast Reconstr Surg 1990; 85: 224-32. 13. Converse JM, ed. Chirurgia Plastica Ricostruttiva: principi e tecniche nella correzione ricostruzione e trapianti. Padova: Piccin, 1991: 737. 14. McCarthy JG, Lorenc ZP, Cutting C, Rachesky M. The median forehead flap revisited: the blood supply. Plast Reconstr Surg 1985; 76: 866-9. 15. Abul-Hassan HS, von Drasek Ascher G, Acland RD. Surgical anatomy and blood supply of the fascial layers of the temporal region. Plast Reconstr Surg 1986; 77: 17-28. 16. Blanco-D~vila F, Arrendondo G, De La Garza O, Montemayor R, Gregori OU, Vttsconez HC. Anatomical study of the blood supply to the skin in rhytidectomy. Aesthetic Plast Surg 1995; 19: 175-81. 17. Corso PF. Variations of the arterial, venous and capillary circulation of the soft tissues of the head by decades as demonstrated by the methyl methacrolate injection technique, and their application to the construction of flaps and pedicles. Plast Reconstr Surg 1961; 27: 160. 18. McGregor IA, Morgan G. Axial and random flaps. Br J Plast Surg 1973; 26: 202-13. 19. Ricbourg B, Mitz V, Lassau J-P. Art~re temporale superficielle: etude anatomique et dtductions pratiques. Ann Chit Plast 1975; 20: 197-213.
252 20. Whetzel TP, Mathes SJ. Arterial anatomy of the face: an analysis of vascular territories and perforating cutaneous vessels. Plast Reconstr Surg 1992; 89: 591-603. 21. Williams PL, Warwich R, Dyson M, Bannister LH, eds. Anatomia del Gray, vol. 2.2nd ed. Bologna: ZanicheUi, 1985: 1043.
The Authors Angelo Chiarelli MD, Contract Professor Roberto Forcignanb MD Danilo Boatto MD, Resident
British Journal of Plastic Surgery Francesca Zuliani MD, Resident Stefano Bisazza MD, Resident Institute of Plastic Surgery and Burn Unit, University of Padua, Padova, Italy. Correspondence to Dr Angelo Chiarelli MD, Istituto di Chimrgia Plastica, Monoblocco Ospedaliero, Via Giustiniani 2, 35128 Padova, Italy. Paper received 17 April 2000. Accepted 13 November 2000, after revision.
British Journal of Plastic Surgery (2001), 54
9 2001 The BritishAssociationof PlasticSurgeons doi:10.1054/bjps.2000.3543
Argyria caused by an earring P. Sugden, S. Azad and M. Erdmann
Department of Plastic Surgery, Shotley Bridge Hospital, Consett, UK SUMMARY. The staining of skin by silver is termed argyria and is grey-blue in colour. This may be caused by a number of mechanisms such as ingestion and direct implantation. We report an unusual case, caused by an impacted earring, where the skin discoloration was not entirely typical of argyria. This may have been due to copper impurities present in the earring. The literature on the subject is also reviewed. 9 2001 The British Association of Plastic Surgeons Keywords: impacted earring, argyria, cuprinosis.
Case report A 24-year-old woman was referred to us by her general practitioner with discoloration of her right ear lobe. Nine years previously the stud from a silver earring had become stuck in her ear lobe; she had attended the accident and emergency department at that time but no action was taken. For the last 5 years she had had green-blue discoloration on the anterior and posterior surfaces of the ear lobe. Both these areas were progressively increasing in size and becoming darker. She had no history of contact dermatitis in response to any chemicals or jewellery and was otherwise well. There was no history suggestive of local infection. On examination, there was a green-blue oval macule measuring 0.5 cm in diameter behind her right ear lobe (Fig. 1). There was a similar, but more faintly pigmented, area on the anterior aspect of the ear lobe. Palpation of this area revealed a firm nodule just below the skin. The area was explored under local anaesthetic and the remnant of an earring was removed (Fig. 2). The defect was sutured directly, and healed without complications.
Discussion The use of earrings as adornments can cause many problems in medical practice. The most commonly encountered complications are keloid scars and split ear lobes. Additionally, earrings can result in allergic reactions, sepsis, embedded studs and cysts.1 The discoloration of skin by silver is a well-recognised phenomenon termed argyria. Normal skin is impervious to the metal but it may pass through mucous membranes or damaged skin or be directly implanted. 2 The metal may be present as metallic silver, an oxide or a sulphide. 2 Silver binds to the basement membrane of sweat glands, small blood vessels and elastin fibres causing a blue-grey
Figure 1--Back of the ear lobe showing skin discoloration.
discoloration of the skin. Silver in an implanted object may be partially dissolved by inflammation secondary to infection, so increasing the amount that seeps into the skin) Localised argyria has been reported as a complication of wound dressings, the use of acupuncture needles 4 and following surgical orthodontic treatment. 5 Though many metals, and in particular nickel, frequently cause contact dermatitis, silver has not been reported to do so. 6
British Journal of Plastic Surgery
BritishJournalofPlasticSurgery(2001),54 9 2001The BritishAssociationof PlasticSurgeons doi:10.1054/bjps.2000.3529
Reconstruction of the inner canthus region with a forehead muscle flap: a report on three cases A. Chiarelli, R. Forcignanb, D. Boatto, E Zuliani and S. Bisazza
Institute of Plastic Surgery and Burn Unit, University of Padua, Padova, Italy SUMMARY. We report our experience of using a forehead flap to repair the defect left by the excision of skin tumours in the medial canthal region involving both eyelids in three patients. Both eyelids and the inner canthus were reconstructed using a myofascial flap taken from the forehead, combined with septal chondro-mucosal grafts, oral mucosa and skin grafts. After a careful anatomical study of the vascularisation of the frontal region, we used only the frontal myofascial portion, a part of the forehead muscle vascularised by the deep branch of the supraorbital artery and by the supratroclear artery; the skin left behind is adequately nourished by the fine mesh of anastomoses in the area between the two supratroclear arteries, the supraorbital artery and the terminal vessels of the superficial temporal artery. The particularly thin, elastic and resistant features of this flap enabled us to repair a loss of substance in a difficult area with a successful outcome in terms of morphology, function and cosmetic appearance. 9 2001 The British Association of Plastic Surgeons Keywords: eyelid reconstruction, inner canthus, skin tumour, forehead flap. Skin tumours in the medial canthal area often involve both eyelids and thus make it necessary to reconstruct these structures. Full-thickness repair of the eyelids and inner canthus is often difficult due to the need to restore structurally different tissues including conjunctival mucosa, tarsal fibrous connective tissue, orbicularis muscle and skin. This paper describes a new surgical procedure used in three patients to repair defects of the inner canthus and near-total defects of both eyelids after the excision of skin tumours. Both eyelids were reconstructed using a myofascial flap from the forehead without the overlying skin, combined with composite chondro-mucosal grafts from the septum, oral mucosa and skin grafts.
supply to the grafts. A vertical paramedian incision was made on the forehead, and a 4 x 3.5cm trapeze-shaped myofascial flap, 2.5 cm wide at the base, was raised from the subcutaneous frontal region and rotated through 180~ to cover the defect (Fig. 3). This flap was covered with a split-skin graft (SSG) taken from the medial aspect of the right arm and reinforced with a sheet of auricular cartilage. The opening of the inferior lacrimal ducts was maintained by inserting a drainage tube. Tarsorrhaphy of the reconstructed eyelids was performed. In the immediate postoperative period, moderately severe oedema of the upper eyelid developed, regressing within about 3 weeks. On removal of the dressing 5 days postoperatively, the skin graft appeared to have only partially taken, presumably as a
Case reports
Case 1 A 79-year-old patient presented with a 2 year history of an ulcerated, solid cystic basal cell carcinoma (BCC) originating from the inner canthus of the right eye. The neoplasm extended from the orbito-palpebral region of the right inner canthus to include one-third of the upper eyelid and two-thirds of the lower eyelid (Fig. 1). The excisional defect consisted of the loss of skin and soft tissue from the inner canthus, the total loss of the lower eyelid and of one-third of the full thickness of the upper eyelid (Fig. 2); the lacrimal canaliculi were sacrificed. Reconstruction was performed in a single procedure under general anaesthesia. For the repair of the tarsal portion of the lower eyelid, a chondromucosal graft taken from the septum was used, after suitably weakening its cartilaginous component by means of radial incisions. Mucosa taken from the lower lip was used as a graft for reconstruction of the palpebral conjunctiva. A myofascial flap from the forehead was used to cover and provide a valid blood
Presented at the 47th National Congress of the Italian Society of Plastic, Aesthetic and ReconstructiveSurgery, Palermo, Italy, September 1998.
Figure 1--Case 1. Preoperative lesion extending from the orbitopalpebral region of the right inner canthus to involve one-third of the upper eyelid and two-thirds of the lower eyelid.
Forehead flap for reconstruction of the inner canthus
Figure 2---Case 1. The excision defect consisted of the loss of skin and soft tissue from the inner canthus, the total loss of the lower eyelid and the loss of one-third of the full thickness of the upper eyelid.
Figure 3--Case 1. A 4 • 3.5 cm trapeze-shaped myofascial flap, 2.5 cm wide at the base, was sculpted in the subcutaneous frontal region and rotated through 180~ to cover the defect.
result of the oedema of the flap induced by venous stasis. On the 12th postoperative day the skin graft was necrotic in places and on the 25th day the patient underwent a second operation to regraft the non-epithelialised area under local anaesthesia. The patient was followed up every 6 months. Two years after the operation there were no signs of any recurrent disease and the reconstruction of the defect was satisfactory (Fig. 4). Case 2
An 82-year-old patient presented with a 1.5 x 2 cm solid cystic BCC of the inner canthus of the right eye involving the medial parts of the upper and lower eyelids (Fig. 5). The excisional
249
Figure 4 ~ C a s e 1. Result 2 years postoperatively.
Figure 5--Case 2. Solid cystic BCC of the inner canthus of the right eye, involving only part of the upper and lower eyelids.
defect consisted of loss of the inner canthus and full-thickness defects of parts of both the upper and the lower eyelid. In a single surgical procedure under general anaesthesia, the lower eyelid was reconstructed with a chondro-mucosal graft taken from the septum, restoring the conjunctiva using mucosa from the oral cavity and inserting a cannula into the residual lacrimal channels to keep them open. The composite graft was covered with a 3.5 x 2.5cm trapeze-shaped myofascial flap from the forehead, using the same procedure as in case 1. This flap was coated with a SSG from the supraclavicular region. Despite signs of initial graft distress, the postoperative course was uneventful. The patient was followed up every 6 months. Two years after the operation there were no signs of recurrence and the reconstruction of the defect was satisfactory (Fig. 6).
250
British Journal of Plastic Surgery
Figure 6--Case
2. Result 2 years postoperatively.
Figure 8--Case
Figure 7--Case
3. Recurrent neoplasm of the inner canthus and lower
Figure 9--Case
left eyelid.
Case 3
A 66-year-old patient presented with a recurrent BCC of the inner canthus and lower left eyelid (Fig. 7). A C T scan revealed no invasion of the ocular structures or bone tissues and excision left a cutaneous and subcutaneous defect of the inner canthus and full-thickness defects of parts of the upper and lower eyelids. Reconstruction was achieved using a chondro-mucosal graft from the septum to reconstruct the tarsus (Fig. 8) and grafting of oral mucosa for the conjunctiva, covered with a 3.5 • 2.5 cm myofascial flap from the forehead (Fig. 9), using the previously described procedure. Once again, there were signs of flap oedema due to venous stasis, which delayed the heating of the graft taken from the left retroauricular region. The graft had taken completely by the 20th postoperative day. A naso-lacrimal drain was used for 3 weeks to ensure lacrimal discharge.
3. Reconstruction of the tarsus with a chondro-mucosal graft taken from the septum.
3. Myofascial flap from the forehead used to cover the
defect. The patient was followed up every 6 months. Two years after the operation there were no signs of recurrence and the reconstruction of the defect was satisfactory (Fig. 10).
Discussion Reconstruction o f full-thickness defects of the eyelids is complex, especially if it is done in a single surgical procedure. The difficulty arises from the need to reconstruct different supporting and covering structures, i.e. the conjunctiva, tarsus, orbicularis muscle, canthal ligaments and skin. Numerous techniques have been proposed for the reconstruction o f the inner canthus and eyelids involving the use of local skin flaps or flaps o f superficial temporal fascia. 1-11 If the defect is particularly extensive, it becomes
Forehead flap for reconstruction of the inner canthus
251
subcutaneous protection, the pedicle can easily become twisted and this can lead, in some cases, to swelling of the flap due to insufficient venous drainage. However, this problem regressed spontaneously in our cases. It is also important to take care over the cartilaginous graft used for the tarsal reconstruction, which must be thin and carefully shaped because excess thickness and poor positioning make the graft obvious and unsatisfactory. We nonetheless believe that, in selected cases, this flap is worth considering as an alternative to the conventional methods for repairing the inner canthal region with associated palpebral defects.
References
Figure l ~ - C a s e
3. Result 2 years postoperatively.
necessary to combine two or more techniques, the results of which, in terms of appearance and function, are often unsatisfactory. Moreover, the skin of the regions surrounding the eye (forehead, cheek bone, naso-genial region and cheek) is generally too thick to be suitable for the orbitopalpebral areas and is also difficult to model because of its relative inelasticity and softness. A flap of superficial temporal fascia is often used to repair the orbital region, but may not be sufficient to cover the inner canthus. 2'x2 In order to overcome such difficulties we adopted an alternative solution using a portion of frontal muscle with its deep fascia but without the overlying skin. The traditional forehead flap, with the median and paramedian variants, is well known for reconstructing the dorsum of the nose. 13'14 After a reassessment based on anatomical studies of the blood supply to the frontal region, 15-21 we used a thin myofascial flap from the forehead, without the skin. The frontal muscle is vascularised by the deep branch of the supraorbital artery and the supratrochlear artery, and the overlying skin can be left in place because it is adequately vascularised by the fine network of anastomoses between the two supratrochlear arteries, the supraorbital artery and the terminal vessels of the superficial temporal artery. The delayed healing and partial necrosis of the graft used to cover the muscle flap may be attributable to a venous vascular deficiency, probably due to kinking at the base of the flap, which is mechanically weaker when this technique is used because of the lack of any cutaneous support. It is worth emphasising the importance of accurate preparation of the flap, carefully respecting the anatomical planes in order to avoid damaging the delicate vascular structures. The particularly thin and elastic features of this flap enabled us to repair a loss of substance at a site that is not easy to reconstruct satisfactorily in terms of morphology, function and appearance. To ensure success, it is essential to pay particular attention to certain risks associated with this procedure. For instance, because of the lack of cutaneous and
1. Chiarelli A, Baldelli A, Di Vincenzo A, Martini G. Utilization of the superficial temporoparietal fascia in reconstructive plastic surgery: a clinical case. Ophthal Plast Reconstr Surg 1989; 5: 274-6. 2. Ellis DS, Toth BA, Stewart WB. Temporoparietal fascial flap for orbital and eyelid reconstruction. Plast Reconstr Surg 1992; 89: 606--12. 3. McGregor IA. Eyelid reconstruction following subtotal resection of upper or lower lid. Br J Plast Surg 1973; 26: 346-54. 4. Millard DR Jr. Eyelid repairs with a chondromucosal graft. Plast Reconstr Surg 1962; 30: 267. 5. Millard DR Jr. Repair of a severe medial canthal defect. Br J Plast Surg 1966; 19: 90-3. 6. Mustard6 JC. The use of flaps in the orbital region. Plast Reconstr Surg 1970; 45: 146-50. 7. Carraway JH. Reconstruction of the eyelids and correction of ptosis of the eyelid. In Aston SJ, Beasley RW, Throne CHM, eds. Grabb and Smith's Plastic Surgery. 5th ed. Philadelphia: Lippincott-Raven, 1997. 8. Scuderi N, Rubino C. Island chondro-mucosal flap and skin graft: a new technique in eyelid reconstruction. Br J Plast Surg 1994; 47: 57-9. 9. Uchinuma E, Sakurai H, Shioya N. Anterofrontal superficial temporal artery island flap for full-thickness eyelid reconstruction. Ann Plast Surg 1989; 23: 433-6. 10. Yoshimura Y, Nakajima T, Yoneda K. Reconstruction of the entire upper eyelid area with a subcutaneous pedicle flap based on the orbicularis oculi muscle. Plast Reconstr Surg 1991; 88: 136-9. 11. Testut L, Jacob R, eds. Anatomia Topografica. Torino: UTET, 1926: 35-46. 12. Rose EH, Norris MS. The versatile temporoparietal fascial flap: adaptability to a variety of composite defects. Plast Reconstr Surg 1990; 85: 224-32. 13. Converse JM, ed. Chirurgia Plastica Ricostruttiva: principi e tecniche nella correzione ricostruzione e trapianti. Padova: Piccin, 1991: 737. 14. McCarthy JG, Lorenc ZP, Cutting C, Rachesky M. The median forehead flap revisited: the blood supply. Plast Reconstr Surg 1985; 76: 866-9. 15. Abul-Hassan HS, von Drasek Ascher G, Acland RD. Surgical anatomy and blood supply of the fascial layers of the temporal region. Plast Reconstr Surg 1986; 77: 17-28. 16. Blanco-D~vila F, Arrendondo G, De La Garza O, Montemayor R, Gregori OU, Vttsconez HC. Anatomical study of the blood supply to the skin in rhytidectomy. Aesthetic Plast Surg 1995; 19: 175-81. 17. Corso PF. Variations of the arterial, venous and capillary circulation of the soft tissues of the head by decades as demonstrated by the methyl methacrolate injection technique, and their application to the construction of flaps and pedicles. Plast Reconstr Surg 1961; 27: 160. 18. McGregor IA, Morgan G. Axial and random flaps. Br J Plast Surg 1973; 26: 202-13. 19. Ricbourg B, Mitz V, Lassau J-P. Art~re temporale superficielle: etude anatomique et dtductions pratiques. Ann Chit Plast 1975; 20: 197-213.
252 20. Whetzel TP, Mathes SJ. Arterial anatomy of the face: an analysis of vascular territories and perforating cutaneous vessels. Plast Reconstr Surg 1992; 89: 591-603. 21. Williams PL, Warwich R, Dyson M, Bannister LH, eds. Anatomia del Gray, vol. 2.2nd ed. Bologna: ZanicheUi, 1985: 1043.
The Authors Angelo Chiarelli MD, Contract Professor Roberto Forcignanb MD Danilo Boatto MD, Resident
British Journal of Plastic Surgery Francesca Zuliani MD, Resident Stefano Bisazza MD, Resident Institute of Plastic Surgery and Burn Unit, University of Padua, Padova, Italy. Correspondence to Dr Angelo Chiarelli MD, Istituto di Chimrgia Plastica, Monoblocco Ospedaliero, Via Giustiniani 2, 35128 Padova, Italy. Paper received 17 April 2000. Accepted 13 November 2000, after revision.
British Journal of Plastic Surgery (2001), 54
9 2001 The BritishAssociationof PlasticSurgeons doi:10.1054/bjps.2000.3543
Argyria caused by an earring P. Sugden, S. Azad and M. Erdmann
Department of Plastic Surgery, Shotley Bridge Hospital, Consett, UK SUMMARY. The staining of skin by silver is termed argyria and is grey-blue in colour. This may be caused by a number of mechanisms such as ingestion and direct implantation. We report an unusual case, caused by an impacted earring, where the skin discoloration was not entirely typical of argyria. This may have been due to copper impurities present in the earring. The literature on the subject is also reviewed. 9 2001 The British Association of Plastic Surgeons Keywords: impacted earring, argyria, cuprinosis.
Case report A 24-year-old woman was referred to us by her general practitioner with discoloration of her right ear lobe. Nine years previously the stud from a silver earring had become stuck in her ear lobe; she had attended the accident and emergency department at that time but no action was taken. For the last 5 years she had had green-blue discoloration on the anterior and posterior surfaces of the ear lobe. Both these areas were progressively increasing in size and becoming darker. She had no history of contact dermatitis in response to any chemicals or jewellery and was otherwise well. There was no history suggestive of local infection. On examination, there was a green-blue oval macule measuring 0.5 cm in diameter behind her right ear lobe (Fig. 1). There was a similar, but more faintly pigmented, area on the anterior aspect of the ear lobe. Palpation of this area revealed a firm nodule just below the skin. The area was explored under local anaesthetic and the remnant of an earring was removed (Fig. 2). The defect was sutured directly, and healed without complications.
Discussion The use of earrings as adornments can cause many problems in medical practice. The most commonly encountered complications are keloid scars and split ear lobes. Additionally, earrings can result in allergic reactions, sepsis, embedded studs and cysts.1 The discoloration of skin by silver is a well-recognised phenomenon termed argyria. Normal skin is impervious to the metal but it may pass through mucous membranes or damaged skin or be directly implanted. 2 The metal may be present as metallic silver, an oxide or a sulphide. 2 Silver binds to the basement membrane of sweat glands, small blood vessels and elastin fibres causing a blue-grey
Figure 1--Back of the ear lobe showing skin discoloration.
discoloration of the skin. Silver in an implanted object may be partially dissolved by inflammation secondary to infection, so increasing the amount that seeps into the skin) Localised argyria has been reported as a complication of wound dressings, the use of acupuncture needles 4 and following surgical orthodontic treatment. 5 Though many metals, and in particular nickel, frequently cause contact dermatitis, silver has not been reported to do so. 6