ARTÍCULO CLÍNICO

 

Reconstruction of defects in the genian region with flaps and muscle suspension

Reconstrucción de defectos de la región geniana mediante colgajos y suspensiones musculares

 

 

S. Gallana Álvarez¹, A. Rollón Mayordomo¹, R. del Rosario Regalado², T. Creo Martinez³, J.M. Pérez Sánchez⁴

1 Médico Adjunto.
2 Residente 5º año.
3 Residente 4º año.
4 Jefe de Servicio.
Servicio de Cirugía Oral y Maxilofacial. Hospital Universitario Virgen Macarena. Sevilla, España

Correspondence

 

 

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ABSTRACT

We present three patients whose genian complex defects were reconstructed with several cutaneous flaps and dynamic suspension of the temporal muscle.
Complex genian defects are those that involve major skin and facial muscle loss, which can also include genian mucous or not.
Two cases involved a nodular lesion in the genian region with biopsy reports that indicated dermatofibrosarcoma protuberans, without previous treatment; the other patient had an epidermoide carcinoma, which had been operated twice, and she had received radiotherapy. For the cutaneous reconstruction a composite free radial forearm flap, a cervicofacial flap and a temporal muscle flap were used. Primary healing with no complications was achieved in all patients together with good aesthetic and functional results.

Key words: Free radial forearm flap; Palmaris longus tendon; Facial suspension; Temporal muscle; Facial paralysis; Coronoid process.

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RESUMEN

Presentamos tres pacientes con defectos genianos complejos, que fueron reconstruidos mediante tres combinaciones diferentes de colgajos cutáneos y suspensiones dinámicas de músculo temporal.
Los defectos comprendían amplias pérdidas de piel y musculatura facial, pudiendo incluir o no la mucosa geniana.
En dos de los casos se trataba de una lesión indurada a nivel geniano con histología compatible con dermatofibrosarcoma protuberans, que no habían recibido ningún tratamiento previo. En el otro paciente se trataba de un carcinoma epidermoide, intervenido en dos ocasiones y que había recibido radioterapia.
Para la reconstrucción del defecto cutáneo usamos el colgajo libre compuesto radial, un colgajo de rotación cervicofacial y un colgajo de músculo temporal.
Todos los pacientes curaron sin complicaciones y los resultados estéticos y funcionales fueron buenos.

Palabras clave: Colgajo libre radial; Tendón palmar mayor; Supensión facial; Musculo temporal; Paralisis facial; apófisis coronoides.

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Introduction

Complex genian defects are those defects that include extensive loss of skin and facial muscle, and which may or may not include genian mucosa.

The objectives when reconstructing these defects are cutaneous coverage with tissue of a similar appearance and disposition to that of the original, the conservation of the function of the facial muscles and closure of the mucosal defect.

The reconstruction can be carried out with local, pedicled or free flaps. The reconstruction of the neuromuscular function can be carried out by using suspension techniques for remaining tissues or by using a neuromuscular free flaps.^1,2

The material used for carrying out the suspension can be alloplastic (Gore-Tex, silastic, etc.) homologous (lyophilized fascia lata) or autologous (autologous fascia lata, temporal fascia, the temporalis muscle itself, etc). If the traction system is fixed over structures with no mobility such as temporal fascia or the periosteum of the zygomatic arch, we would refer to static suspension, and dynamic if the suspension is carried out with functioning masticatory muscles (masseter or temporal) that on contracting traction the suspended tissue in the desired direction.

Three patients are presented with complex cheek defects that were reconstructed by means of three different combinations of cutaneous flaps and dynamic suspension of the temporalis muscle.

 

Material and methods

Patient 1

Female, 42 years old, with a nodular lesion in the left genian area that had been evolving for several months. The facial CT scan showed asymmetry and fat density increase that was infiltrating the subcutaneous cellular tissue, skin and muscle. The image showed a rounded morphology and there was minimum enhancement with IV contrast material. The biopsy indicated dermatofibro- sarcoma protuberans. The treatment consisted in a wide surgical excision, which included the skin in the genian area, part of the upper lip, genian mucosa and the vestibular and buccal branch of the facial nerve (Fig. 1). The reconstruction was carried out with a radial forearm fasciocutaneous free flap that included a segment of palmaris longus tendon for the suspension of the upper lip and commissure of the mouth (Fig. 2). The flap was turned down which permitted the closure of the skin and mucosal defect and the two ends of the tendon were attached to the commissure, after crossing the temporal muscle tendon and the previously osteotomized coronoid process in the form of a strip. Six months later the flap had adapted correctly, as had the elevation of the lip commissure (Figs. 3 and 4).

Patient 2

Male, 76 years old, with a history of ischemic cardiopathy attended our department as a result of a nodular lesion in the left genian region. A facial CT scan was carried out that showed an infiltration with rounded morphology of the skin and cellular subcutaneous tissue. An incisional biopsy was carried out that indicated dermatofibro-sarcoma protuberans. The treatment consisted of the excision of the lesion with margins that included the skin and muscle group in the left genian region (Fig. 5). The defect was reconstructed by filling it with a Bichat’s fat pad so as to provide volume, and a cervicofacial rotation flap was used for skin coverage. Traction of the commissure of the mouth was achieved by means of an autologous fascia lata graft. Its ends were fixed to the upper lip and to the modiolus, which crossed the tendon of the temporalis muscle and the coronoid process in the form of a strip, and once the coronoid process had been separated from the mandible by means of an osteotomy of its base (Fig. 6). Five months into the postoperative period, the patient could elevate the lip commissure and an acceptable aesthetic result could also be observed. (Fig. 7 and 8).

Patient 3

Female, 84 years old, was referred because of epidermoid carcinoma in the right preauricular region. She had been treated previously with surgery and RT (Fig. 9). The facial CAT scan showed a mass in the right preauricular region that extended towards the soft areas of the malar region, and which was connected with the masseter muscle and the parotid gland. The surgical treatment consisted in the removal of the lesion including the right external area of the ear, EAC and a radical total parotidectomy. The reconstruction was carried out with a flap of temporalis muscle that was released from the temporalis crest and pedicled to the coronoid process. It was then rotated in a caudal direction in order to cover the defect. The lower portion of deep temporalis fascia was dissected and divided into two sheets. Both ends were sutured to the commissure and muscles of the upper lip (Fig. 10). The transposed temporalis muscle was covered with a partial skin graft. Two months into the postoperative period, the patient could elevate the commissure of the mouth and an acceptable aesthetic appearance could be observed in the reconstructed area (Fig. 11 and 12).

 

Discussion

The difficulty in reconstructing these defects lies in the anatomic, histologic and functional complexity of the tissues that have been lost, which include skin, muscle and nerve structures, and oral mucosa.

An attempt should always be made to reconstruct cutaneous defects using direct closure or local flaps in order to introduce skin similar to that which has been lost and in order to obtain the best aesthetic result. Because of the extent of the defects this could not be carried out in any of our cases.

In Case 2 we opted for carrying out a cervicofacial rotation flap which has been described and used basically for covering cutaneous defects in the middle third of the face^3,4 or the lower lid area.⁵ This flap provides skin of an identical texture, color and elasticity to that which has been lost, and in addition, it is a reliable flap that can be obtained quickly and easily as it is in the same surgical field. There is little morbidity, which makes it suitable for elderly patients and those with risk factors. The main inconveniences are the limited volume of tissue provided, which we solved in this case by including underneath a Bichat’s fat pad flap, and the difficulty in reconstructing defects above the lower lid, although authors such as Cuesta-Gil,⁶ carry out a prolongation in the design of this flap reaching 4t^h-5^th intercostal space, which permits reconstructing defects that are even above the supraorbital margin.

In Case 3 the patient had been reconstructed on two previous occasions with local flaps and the defect was located in the temporal region, which made the use of a cervicofacial flap difficult and limiting. Due to this, and to the age of the patient, a temporalis muscle flap was decided on. The temporalis muscle myofascial flap was first described by Golovine with an orbital defect in 1898,7 and it is used frequently for reconstructing midface defects, particularly after a maxillectomy and in surgery of the skull base.^8,9 In this case of ours, the indication was based on the proximity of the defect, the need for providing volume and the age of the patient, which limits the use of more complex techniques such as free flaps. The muscle was released from the temporal crest and rotated downwards and forwards to cover the soft tissue defect, which was then covered with a partial thickness skin graft.

At the same time we carried out partial separation and advancement of the deep temporalis fascia that, once fixed to the commissure and to the upper lip muscles, enabled carrying out dynamic suspension, as described by authors such as McCarthy.¹⁰ The inconveniences of this flap are the depression at the donor site, which in women is counterbalanced as it can be hidden by hair, and in this case of ours, a partial thickness skin graft had to be used in order to cover the muscle.

In Case 1 the defect was more extensive and deep, and the skin and mucosa were affected, which limited the use of a cervicofacial flap. A radial forearm fasciocutaneous free flap was used, which was long enough to fold down.¹¹ Both defects could be reconstructed and the palmaris longus tendon was included so that suspension of the oral commissure could be carried out.

The advantages of the radial forearm free flap are: abundance of fine and adaptable skin available for reconstruction of complex defects (cutaneous and mucosal),^11,12 with a vascular pedicle that permits carrying out anastomosis reliably and safely, and with the possibility of including branches of the radial or medial cutaneous nerve and the palmaris longus tendon. The incorporation of this tendon to the radial forearm flap was first described by Reid and Moss in 1983,¹³ for the reconstruction of complex defects of the hand. It was later used for the reconstruction of complex defects of the lower lip and chin^14,15 where the tendon was used for maintaining the continuity of the orbicular muscles and to support soft tissue.

With regard to the inclusion of nerve branches in the flap, the incorporation of medial cutaneous or lateral antebrachial branches +means sensation can be re-established on carrying out anastomosis to cervicofacial sensory branches. ¹⁶ Moreover, the use of a segment and the terminal branches of the radial cutaneous nerve has been described as a vascularized nerve graft for reconstructing the continuity of the facial nerve trunk together with the cutaneous defect.¹⁷

The main inconvenience of the radial forearm free flap lies in the need for a partial skin graft for closing the donor area, which results in aesthetic deformity and a delay in healing, although muscle flaps and tissue expanders can be used in order to avoid this.^18,19

Other free flaps that could be used for skin reconstruction for these defects are the lateral arm free flap and the myocutaneous flaps such as the rectus abdominis or the lateral thigh with the inconvenience of excess volume due to the muscular mass, unless raised as perforating flaps.

The loss of the muscles around the top lip and the corresponding motor branches of the defect is a difficult problem to solve. In these cases dynamic facial suspension is a simple and fast technique with low morbidity. This will stop the lip commissure from falling while maintaining certain mobility as a result of the contraction of the muscle used.

In 1934 Gillies²⁰ used the temporalis muscle flap as a technique for facial reanimation, by means of the transposition and advancement of the deep temporalis fascia in order to fix it to the lip muscles as in Case 3.

The temporalis muscle tendon is freed by the osteotomized coronoid process over which suspension of the soft tissue is carried out, as first described by McLaughlin in 1953,²¹ who separated the apophysis from the maxilla at its base, and added strips of fascia lata which are sutured to the lip commissure. In this way the muscle is lengthened and on maintaining its orientation, it will traction in a cranial and lateral direction, and the loss of the muscles of the upper lip will be compensated by a certain mobility of the commissure and the upper lip on contracting. Releasing the coronoid process has the advantage over the transposition of the muscle as there is no aesthetic defect in the temporal area and the muscle will maintain its orientation on contracting.²²

In Case 1, the strip which crosses the coronoid process and the tendon of the muscle, and that tractions the soft tissue, was carried out with autologous fascia lata and in Case 1 with the palmaris longus tendon embedded in the flap. The palmaris longus tendon has been used separately as a free graft for frontalis suspension of upper eye ptosis^23,24 where, by means of several incisions around the eye, strips of tendon are fixed to the upper eyelid. According to the literature reviewed, this is the first case describing the use of a radial forearm flap and palmaris tendon for the suspension of the top lip from the coronoid process.

This technique is inconvenient in that mobility of the commissure is carried out through the mandibular nerve that contracts the temporalis muscle, and there is no facial expression as a result of the contraction produced by the facial nerve, and we consider that it should be used for partial defects.

For more extensive defects, the use of nerve grafts is not indicated because of the lack of muscle, and transferring muscle flaps using neurovascular microsurgery would be necessary, such as with the gracilis, wide dorsal, rectus or serratus muscle²⁵ which gives the face new vascularized muscle, which can be pulled in various directions according to the orientation and, if anastomosis is carried out of the facial nerve, animation and a more natural expression can be achieved.

 

Conclusions

The difficulty in reconstructing complex genian defects lies in the different tissues affected and in the considerable functional repercussions involved. We believe that:

• The reconstruction of skin defects should be carried out with local flaps among which the cervicofacial flap stands out. If this is not possible it should be carried out with free flaps of fine pliable skin such as the radial forearm flap.

• The function of the top lip muscles can be reconstructed by means of dynamic suspension of the temporalis muscle using autologous fascia lata that will pull the lip through the osteotomized coronoid process.

• Of the free flaps, the radial forearm flap has the advantage of being able to include the palmaris longus tendon, which can be used for the suspension of the upper lip.

• The reconstruction with the transposed temporalis muscle flap is indicated for high-risk patients in cases in which a free flap is contraindicated. It is also indicated in defects of the orbitotemporal region, which would permit the simultaneous reconstruction of the defect with traction.

 

 

Correspondence:
Silvia Gallana Alvarez
C/ Isbilia 10
41907 Valencina de la Concepción, Sevilla, España
E-mail: sgallana@hotmail.com

Recibido: 21.01.06
Aceptado: 06.10.06

 

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