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Revista Española de Cirugía Oral y Maxilofacial

versión On-line ISSN 2173-9161versión impresa ISSN 1130-0558

Rev Esp Cirug Oral y Maxilofac vol.42 no.1 Madrid ene./mar. 2020  Epub 04-Mayo-2020

http://dx.doi.org/10.20986/recom.2020.1062/2019 

CASE REPORTS

Medial canthal and eyelid reconstruction using the split paramedian forehead flap: a case report

Reconstrucción del canto interno con un colgajo frontal: presentación de un caso

Marta María Pampín Martínez1  *  , José Luis del Castillo Pardo de Vera1 

1Department of Oral and Maxillofacial Surgery, Hospital Universitario La Paz. Madrid, Spain.

ABSTRACT

Medial eyelid/canthal defects are difficult to reconstruct. This region has both functional an cosmetic importance in facial esthetics. The lacrimal apparatus drains in the medial canthal area and both eyelids protect the eye from dryness and exposure, so damage to this organs may have severe ophthalmic consequences. Furthermore, the medial canthal area owns a complex concave surface difficult to replace satisfactorily. Poor reconstruction techniques may have undesirable cosmetic outcomes, which may be easily noticeable.

The paramedian forehead flap is a mainly used in nasal reconstruction. It has a reliable vascu­larity and allows a wide arc of rotation. Plus, trimming and recontouring of the flap may be done to offer the best results. Several modifications of the flap have been purposed in the literature. The paramedian forehead flap may be a good choice for medial canthal/eyelid reconstruction as well, given the characteristics aforementioned. We present a case of an 88 year old woman who presented with a medial eyelid/canthal defect following resection of a squamous cell carcinoma. Reconstruction with a contralateral split paramedian forehead flap was achieved.

We conclude that the paramedian forehead flap may represent a safe and simple alternative in medial eyelid/canthal reconstruction, preserving eyelid function and offering acceptable cosmetic results with minor donor site morbidity.

Keywords: Paramedian forehead flap; medial canthal reconstruction; eyelid reconstruction

RESUMEN

Los defectos que comprometen el canto interno son difíciles de reconstruir. Esta región tiene importancia funcional y estética en la armonía facial. El aparato lagrimal drena en el área del canto interno y ambos párpados protegen el ojo de la sequedad y la exposición, de tal forma que el dañar estas estructuras puede tener consecuencias oftalmológicas severas. Además, el canto medial es un área con una superficie cóncava y compleja, difícil de reconstruir de manera satisfactoria. Es importante realizar una buena técnica de reconstrucción para evitar resultados cosméticos indeseables. El colgajo frontal se utiliza principalmente en la reconstrucción nasal. Tiene una buena vascularización y permite un amplio arco de rotación. Además, se puede remodelar y adelgazar de manera que ofrezca mejores resultados estéticos. Se han descrito diferentes modificaciones en la literatura. El colgajo frontal puede ser una buena opción para la reconstrucción del área del canto medial dadas las características mencionadas previamente. Presentamos el caso de una paciente de 88 años de edad que presentó un defecto del área del canto medial tras la resección de un carcinoma escamoso. Se realizó la reconstrucción con un colgajo frontal contralateral.

Concluimos que el colgajo frontal puede ser una opción segura y sencilla como alternativa en la reconstrucción del canto medial. Permite preservar la función del párpado y ofrece resultados estéticos aceptables con mínima morbilidad de la zona donante.

Palabras clave: Colgajo frontal; reconstrucción canto medial; reconstrucción párpado

INTRODUCTION

The medial eyelid/canthal area comprises an important anatomical region given its esthetical relevance and its intimate relationship with the eye and lacrimal apparatus. One major cause of medial canthal/eyelid defects are malignant skin cancers. The main goal in the reconstruction of any eyelid/canthal defect is to provide a good esthetic and functional outcome, ensuring integrity of the lacrimal apparatus and corneal protection.

A wide variety of local flaps can be used, as well as distant flaps in case of larger defects. Skin grafting is not advisable given the poor cosmetic outcomes.

In this article we describe the case of an 88 years old woman who suffered from a squamous cell carcinoma of the medial canthal region which was excised and repair using a contralateral split paramedian forehead flap.

CASE REPORT

We report the case of an 88 years old woman who presented with a medial canthal lesion affecting both superior and inferior medial eyelids of her left eye (Figure 1). Patient's informed consent was obtained. Incisional biopsy confirmed a squamous cell carcinoma moderately differentiated.

Figure 1. Pre-operative photographs. A medial canthal lesion affecting both upper and lower medial eyelids 

Preoperative CT showed a poorly defined lesion located in the medial canthal area of the left eye, in intimate proximity with the left nasal bone and periorbital fat (Figure 2). No pathological nodes were found.

Figure 2. Pre-operative CT images 

A conservative approach was decided in order to preserve her left eye, given the diminished visual acuity in her right eye due to a previous ophthalmic artery embolism. Surgical resection was performed including the left nasal bone, the medial canthal tendon, the lacrimal punctum and the upper portion of the lacrimal sac and both upper and lower eyelids in their most medial region including the conjuntiva. A right supratrochlear artery-based split paramedian forehead flap was designed, providing two axially perfused flaps for simultaneous repair of both upper and lower eyelids (Figure 3). The flap was elevated, rotated, passed over the nasal dorsum and then trimmed to fit the defect. A canthopexy with wires was performed, fixed to the contralateral nasal bone. Reconstruction of the conjunctiva was not performed. A silicone tube was placed in the left nasolacrimal duct for three weeks to maintain drainage. The donor site was closed primarily.

Figure 3. Surgical resection performed, contralateral split paramedian forehead flap designed 

Histopathological analysis confirmed the previous biopsy: infiltrating squamous cell carcinoma with a maximum thickness of 10 mm. Perineural invasion was found. The lachrymal glands were found free of disease.

A follow up photograph is shown (Figure 4). Adjuvant radiotherapy was considered. Satisfactory esthetic outcomes were achieved. No revision surgery was considered. The patient remained free of disease during the 2 year follow-up.

Figure 4. Post-operative photograph 

DISCUSSION

Skin cancer is a major cause of medial eyelid/canthal region defects, being basal cell carcinoma the most frequent type (80 %). 1 followed by squamous cell carcinoma.

Reconstruction of medial eyelid/canthal defects is technically challenging because of the remarkable important function and esthetics of the lids2. Difficulties arise from the necessity to restore different type of tissues at the same time: skin, tarsus, muscle, conjunctiva, etc. 3. Sometimes a canthopexy may be needed.

Defects larger than one-third of the length of the eyelid require the use of flaps. 4. Microvascular flaps can be used when larger defects are found. However, local flaps are to be the workhorse in this type of defects.

Paramedian forehead flaps and their following modifications have been widely used to repair nasal defects, as well as medial canthal areas. It offers a large portion of donor tissue for large, complex defects5 of the medial eyelid/canthal area. It is an axial patterned flap based on the supratrochlear artery6. Blood supply is so reliable that a narrow pedicle can nourish a relatively large flap7. The main disadvantage is the thickness of the flap, so that debulking and thinning may be necessary, which implies a risk of jeopardizing the vascularity and subsequent flap failure.

One modification of the paramedian forehead flap is the split paramedian forehead flap, presented in this article. Its main advantage is its suitability to repair both eyelids simultaneously.

We want to highlight the importance of performing a canthopexy to achieve optimal esthetical results, enhancing the medial canthal contour and reducing medial canthal webbing.

In conclusion, the paramedian forehead flap is a versatile and reliable that should be considered when a defect in the medial eyelid/canthal area is found. Its ease to harvest and minimum donor-site morbidity make the paramedian forehead flap a simple yet satisfactory flap in medial canthal repair.

REFERENCES

1. Hyung Kim J, Min Kim J, Wan Park J, Ha Hwang J, Seog Kim K, Yong Lee S. Reconstruction of the medial canthus using an ipsilateral parwamedian forehead flap. Arch Plast Surg. 2013;40(6):742-7. DOI: 10.5999/aps.2013.40.6.742. [ Links ]

2. Onara Z, Yazici I, Karakaya E, Cavusoglu T. Simultnaoeus Reconstruction of medial canthal area and both eyelids with a single transverse split forehead island flap. J Craniofac Surg. 2011;22(1):363-5. DOI: 10.1097/SCS.0b013e3181f8148f. [ Links ]

3. Chiarelli A, Forcignano R, Boatto D, Zuliani F, Bisazza S. Reconstruction of the inner canthus region with a forehead muscle flap: a report on three a cases. Br J Plast Surg. 2001;54(3):248-52. DOI: 10.1054/bjps.2000.3529. [ Links ]

4. Mathijssen IMJ, Van der Meulen JC. Guidelines for reconsruction of the eyelids and cantha regions. J Plast Reconstr Aesthet Surg. 2010;63(9):1420-33. DOI: 10.1016/j.bjps.2009.05.035. [ Links ]

5. Lu GN, Pelton RW, Humphrey CD, Kriet JD. Defects of the Eyelids. Facial Plast Surg Clin North Am. 2017;25(3):377-92. DOI: 10.1016/j.fsc.2017.03.009. [ Links ]

6. McCarthy JG, Lorenc ZP, Cutting C, Rachesky M. The median forehead flap revisited: the blood supply. Plast Reconstr Surg. 1985;76(6):866-9. DOI: 10.1097/00006534-198512000-00012. [ Links ]

7. Mombaerts I, Gillis A. The tunneled forehead flap in a medial canthal and eyelid reconstruction. Dermatol Surg. 2010;36(7): 1118-25. DOI: 10.1111/j.1524-4725.2010.01593.x. [ Links ]

Received: April 18, 2019; Accepted: July 27, 2019

* Autor para correspondencia: Correo electrónico: Marta María Pampín Martínez mpampin@ucm.es

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