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Total lower eyelid reconstruction with free posterior auricular chondrocutaneous flap
Journal of Plastic, Reconstructive & Aesthetic Surgery (2010) 63, e384ee386
CASE REPORT
Total lower eyelid reconstruction with free posterior auricular chondrocutaneous flap Antonio Rampazzo*, Bahar Bassiri Gharb, Hung Chi Chen Department of Plastic Surgery, E-Da hospital, I-Shou University, Kaohsiung, Taiwan Received 12 July 2009; received in revised form 4 October 2009; accepted 13 October 2009
KEYWORDS Free posterior auricular flap; Eyelid; Free flap; Microsurgery
Summary Lower eyelid is characterised by a thin musculocutaneous anterior lamella and a posterior lamella composed of tarsus and conjunctiva. Several techniques have been reported for total lower eyelid reconstruction suitable especially for the elderly patients with skin laxity. We report a total lower eyelid reconstruction with a free posterior auricular chondrocutaneous flap with a good functional and aesthetic outcome in a young patient. This technique can be taken into consideration for complex soft-tissue defects of the eyelids. ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Case report Three months prior to the consultation, a 28-year-old Asian male sustained multiple lacerations to the face and full-thickness loss of the right lower eyelid in a road traffic accident (Figures 1 and 2). The main problems were exposure and keratinisation of the conjunctiva and epiphora. After discussion of the possible options, he accepted to undergo reconstruction of the lower eyelid with a free posterior auricular flap. On the day of the surgery, a 6 3 cm skin paddle centred over the posterior auricular sulcus was marked. The course of a superficial vein and the posterior auricular artery were detected with a hand-held 8 Megahertz
* Corresponding author. Via Pigafetta 27, 36040 Grisignano (Vicenza), Italy. Tel.: þ39 44 07887556811. E-mail address: [email protected] (A. Rampazzo).
Doppler (Multi Dopplex II, Territory Surgical Supplies, Australia) (Figure 3). Dissection started in the proximal part of the flap with the identification of a superficial vein, which showed a sizable calibre. The flap was then raised from distal to proximal. The artery was identified in the retroauricular sulcus close to the periosteum. The branches to the conchal cartilage were preserved. A small strip of the conchal cartilage measuring 0.5 4 cm was harvested with the flap for the reconstruction of the tarsus (Figures 4 and 5). The superficial temporal artery and vein were dissected from the pre-auricular area to the lateral eyebrow within the hairline to avoid visible scars and used as recipient vessels. The conjunctiva was separated from the skin, the remnants of the medial and lateral canthal ligaments were identified and tagged to anchor the flap later. A small pocket at the orbitopalpebral groove level was created for the inset of the flap. A subcutaneous tunnel was dissected between the preauricular area and the new eyelid position. An end-to-end anastomosis was performed with 10/0 nylon (Johnson &
1748-6815/$ - see front matter ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2009.10.010
Total lower eyelid reconstruction with free posterior auricular chondrocutaneous flap
e385
Figure 3 Marking of the flap and of the superficial vein and the posterior auricular artery.
Figure 1 The patient sustained multiple lacerations to the face and total loss of the right lower eyelid with permanent exposure of cornea and conjunctiva.
(Figure 6). The postoperative course was uneventful and, after 10 days, a full-thickness mucosal graft was taken from the hard palate for the reconstruction of the conjunctiva. At the same time, the flap was debulked (Figure 7). Six months after the operation, part of the previous scars of the face sustained during the accident and the newly reconstructed eyelid were revised under local anaesthesia. The new eyelid maintained its position against the globe and protected the eyeball from exposure keratopathy. Epiphora did not occur, therefore the lower canalicus was not reconstructed. Fifteen months after the operation, the patient was satisfied with the functional and aesthetic result (Figure 8).
Discussion Several techniques have been reported in the past for the reconstruction of the lower eyelid. Mustarde ` flap, Tripier and Fricke flaps, forehead flap or flaps taken from the nasojugal sulcus are the most commonly used for reconstruction of the outer lamella.1 In young patients there is no skin laxity, and it is therefore more difficult to select a local flap, providing adequate coverage without leaving noticeable scars. The posterior lamella is usually reconstructed with a chondromucosal graft from the septum. The take of such a composite graft relies on the vascularity of the anterior lamella flap with possible partial or complete loss or absorption of the graft with support deficit. Figure 2 The patient sustained multiple lacerations to the face and total loss of the right lower eyelid with permanent exposure of cornea and conjunctiva.
Johnson Medical, Taipei, Taiwan) between the frontal branch of the superficial temporal artery and the posterior auricular artery. After the clamps were released, a good venous return was present from the comitant veins and the superficial vein. An end-to-end anastomosis was then performed with 10/0 nylon (Johnson & Johnson Medical, Taipei, Taiwan) between the superficial vein and the frontal branch of the superficial temporal vein. The flap was then passed under the tunnel and both medial and lateral canthal ligaments were sutured to the cartilage of the neo-tarsus with 4/ 0 prolene (Johnson & Johnson Medical, Taipei, Taiwan)
Figure 4
The flap after dissection.
e386
Figure 5
A. Rampazzo et al.
The conchal cartilage will create the new tarsus.
Figure 8
Figure 6 After the anastomosis the flap was tunnelled under the skin and inset to create the new eyelid.
Follow up at 15 months after revision of the scars.
described based on the superficial temporal vessels; although easier to dissect, the shape of the root of the helix is not suitable for defects of the eyelid.5 This is the first report of a full-thickness lower eyelid reconstruction with a free posterior auricular chondrocutaneous flap. Advantages of using this flap are good colour and texture match with the facial skin, association of vascularised cartilage that creates a new tarsus where the canthal ligaments can be fixed, less donor-site morbidity with a well-hidden scar and absence of further scars to the face. Disadvantages are necessity of microsurgical skills and instrumentation. We preferred to combine the neoconjunctiva reconstruction with debulking of the flap in a second stage. However, as the cartilage is covered with vascularised perichondrium, grafting can be performed in the first stage. In conclusion, free posterior auricular chondrocutaneous flap can be taken into consideration for difficult reconstructions of the eyelids in young patients.
Conflict of interest None.
Funding None.
References Figure 7 The flap was debulked and a mucosal graft from the palate was applied over the vascularised conchal cartilage and the deep raw area to reconstruct the posterior lamella of the eyelid (10 days after the initial transfer of the flap).
Retro-auricular tissue has always been considered a good substitute for the reconstruction of facial defects because of similar colour and texture. In 1976, Fujimo for the first time reported the use of a free posterior auricular free flap.2 Park et al. studied the anatomy of the flap and used the flap for reconstruction of nasal and orbital rim defects showing the reliability of this flap.3,4 Other chondrocutaneous flaps were
1. Mustarde JC. Repair and reconstruction in the orbital region: practical guide. London: Churchill Livingstone; 1980. 2. Fujino T, Harashina T, Nakajima T. Free skin flap from the retroauricular region to the nose. Plast Reconstr Surg 1976;57:338e41. 3. Park C, Shin KS, Kang HS, et al. A new arterial flap from the postauricular surface: its anatomic basis and clinical application. Plast Reconstr Surg 1988;82:498e505. 4. Park C. The chondrocutaneous postauricular free flap. Plast Reconstr Surg 1989;84:761e71. 5. Zhang YX, Yang J, Wang D. Extended applications of vascularized preauricular and helical rim flaps in reconstruction of nasal defects. Plast Reconstr Surg 2008;121:1589e97.
CASE REPORT
Total lower eyelid reconstruction with free posterior auricular chondrocutaneous flap Antonio Rampazzo*, Bahar Bassiri Gharb, Hung Chi Chen Department of Plastic Surgery, E-Da hospital, I-Shou University, Kaohsiung, Taiwan Received 12 July 2009; received in revised form 4 October 2009; accepted 13 October 2009
KEYWORDS Free posterior auricular flap; Eyelid; Free flap; Microsurgery
Summary Lower eyelid is characterised by a thin musculocutaneous anterior lamella and a posterior lamella composed of tarsus and conjunctiva. Several techniques have been reported for total lower eyelid reconstruction suitable especially for the elderly patients with skin laxity. We report a total lower eyelid reconstruction with a free posterior auricular chondrocutaneous flap with a good functional and aesthetic outcome in a young patient. This technique can be taken into consideration for complex soft-tissue defects of the eyelids. ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Case report Three months prior to the consultation, a 28-year-old Asian male sustained multiple lacerations to the face and full-thickness loss of the right lower eyelid in a road traffic accident (Figures 1 and 2). The main problems were exposure and keratinisation of the conjunctiva and epiphora. After discussion of the possible options, he accepted to undergo reconstruction of the lower eyelid with a free posterior auricular flap. On the day of the surgery, a 6 3 cm skin paddle centred over the posterior auricular sulcus was marked. The course of a superficial vein and the posterior auricular artery were detected with a hand-held 8 Megahertz
* Corresponding author. Via Pigafetta 27, 36040 Grisignano (Vicenza), Italy. Tel.: þ39 44 07887556811. E-mail address: [email protected] (A. Rampazzo).
Doppler (Multi Dopplex II, Territory Surgical Supplies, Australia) (Figure 3). Dissection started in the proximal part of the flap with the identification of a superficial vein, which showed a sizable calibre. The flap was then raised from distal to proximal. The artery was identified in the retroauricular sulcus close to the periosteum. The branches to the conchal cartilage were preserved. A small strip of the conchal cartilage measuring 0.5 4 cm was harvested with the flap for the reconstruction of the tarsus (Figures 4 and 5). The superficial temporal artery and vein were dissected from the pre-auricular area to the lateral eyebrow within the hairline to avoid visible scars and used as recipient vessels. The conjunctiva was separated from the skin, the remnants of the medial and lateral canthal ligaments were identified and tagged to anchor the flap later. A small pocket at the orbitopalpebral groove level was created for the inset of the flap. A subcutaneous tunnel was dissected between the preauricular area and the new eyelid position. An end-to-end anastomosis was performed with 10/0 nylon (Johnson &
1748-6815/$ - see front matter ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2009.10.010
Total lower eyelid reconstruction with free posterior auricular chondrocutaneous flap
e385
Figure 3 Marking of the flap and of the superficial vein and the posterior auricular artery.
Figure 1 The patient sustained multiple lacerations to the face and total loss of the right lower eyelid with permanent exposure of cornea and conjunctiva.
(Figure 6). The postoperative course was uneventful and, after 10 days, a full-thickness mucosal graft was taken from the hard palate for the reconstruction of the conjunctiva. At the same time, the flap was debulked (Figure 7). Six months after the operation, part of the previous scars of the face sustained during the accident and the newly reconstructed eyelid were revised under local anaesthesia. The new eyelid maintained its position against the globe and protected the eyeball from exposure keratopathy. Epiphora did not occur, therefore the lower canalicus was not reconstructed. Fifteen months after the operation, the patient was satisfied with the functional and aesthetic result (Figure 8).
Discussion Several techniques have been reported in the past for the reconstruction of the lower eyelid. Mustarde ` flap, Tripier and Fricke flaps, forehead flap or flaps taken from the nasojugal sulcus are the most commonly used for reconstruction of the outer lamella.1 In young patients there is no skin laxity, and it is therefore more difficult to select a local flap, providing adequate coverage without leaving noticeable scars. The posterior lamella is usually reconstructed with a chondromucosal graft from the septum. The take of such a composite graft relies on the vascularity of the anterior lamella flap with possible partial or complete loss or absorption of the graft with support deficit. Figure 2 The patient sustained multiple lacerations to the face and total loss of the right lower eyelid with permanent exposure of cornea and conjunctiva.
Johnson Medical, Taipei, Taiwan) between the frontal branch of the superficial temporal artery and the posterior auricular artery. After the clamps were released, a good venous return was present from the comitant veins and the superficial vein. An end-to-end anastomosis was then performed with 10/0 nylon (Johnson & Johnson Medical, Taipei, Taiwan) between the superficial vein and the frontal branch of the superficial temporal vein. The flap was then passed under the tunnel and both medial and lateral canthal ligaments were sutured to the cartilage of the neo-tarsus with 4/ 0 prolene (Johnson & Johnson Medical, Taipei, Taiwan)
Figure 4
The flap after dissection.
e386
Figure 5
A. Rampazzo et al.
The conchal cartilage will create the new tarsus.
Figure 8
Figure 6 After the anastomosis the flap was tunnelled under the skin and inset to create the new eyelid.
Follow up at 15 months after revision of the scars.
described based on the superficial temporal vessels; although easier to dissect, the shape of the root of the helix is not suitable for defects of the eyelid.5 This is the first report of a full-thickness lower eyelid reconstruction with a free posterior auricular chondrocutaneous flap. Advantages of using this flap are good colour and texture match with the facial skin, association of vascularised cartilage that creates a new tarsus where the canthal ligaments can be fixed, less donor-site morbidity with a well-hidden scar and absence of further scars to the face. Disadvantages are necessity of microsurgical skills and instrumentation. We preferred to combine the neoconjunctiva reconstruction with debulking of the flap in a second stage. However, as the cartilage is covered with vascularised perichondrium, grafting can be performed in the first stage. In conclusion, free posterior auricular chondrocutaneous flap can be taken into consideration for difficult reconstructions of the eyelids in young patients.
Conflict of interest None.
Funding None.
References Figure 7 The flap was debulked and a mucosal graft from the palate was applied over the vascularised conchal cartilage and the deep raw area to reconstruct the posterior lamella of the eyelid (10 days after the initial transfer of the flap).
Retro-auricular tissue has always been considered a good substitute for the reconstruction of facial defects because of similar colour and texture. In 1976, Fujimo for the first time reported the use of a free posterior auricular free flap.2 Park et al. studied the anatomy of the flap and used the flap for reconstruction of nasal and orbital rim defects showing the reliability of this flap.3,4 Other chondrocutaneous flaps were
1. Mustarde JC. Repair and reconstruction in the orbital region: practical guide. London: Churchill Livingstone; 1980. 2. Fujino T, Harashina T, Nakajima T. Free skin flap from the retroauricular region to the nose. Plast Reconstr Surg 1976;57:338e41. 3. Park C, Shin KS, Kang HS, et al. A new arterial flap from the postauricular surface: its anatomic basis and clinical application. Plast Reconstr Surg 1988;82:498e505. 4. Park C. The chondrocutaneous postauricular free flap. Plast Reconstr Surg 1989;84:761e71. 5. Zhang YX, Yang J, Wang D. Extended applications of vascularized preauricular and helical rim flaps in reconstruction of nasal defects. Plast Reconstr Surg 2008;121:1589e97.