DISCUSSION. Irrigation and Drainage ... cutaneous system.18 The frontal skin does not. Volume ... belong to a musculocut
RECONSTRUCTIVE Frontal Reconstruction with Frontal Musculocutaneous V-Y Island Flap Lorenzo S. Rocha, M.D., Ph.D. Geruza R. Paiva, M.D., M.S. Luiz C. de Oliveira, M.D. Joel Veiga Filho, M.D., M.S. Ivan D. A. O. Santos, M.D., Ph.D. Jorge M. Andrews, M.D., Ph.D. Porto Velho, Minas Gerais, and Sa˜o Paulo, Brazil
Background: Defects of the frontal region are mostly caused by the ablation of tumors. When the treatment of such a defect cannot be achieved by the approximation of its margins, some of the solutions may alter the form or the continuity of the frontal aesthetic unit. Methods: With the intent of reconstructing frontal defects with proper skin, a musculocutaneous island flap of the frontal belly of the occipitofrontalis muscle based on the supratrochlearis or the supraorbitalis vessels was planned for a V-Y application in a single procedure. It was used in 31 patients. Results: The treated frontal defects ranged from 1.5 per 1.5 cm to 4.5 per 5.5 cm and, depending on the depth of the resection, exposed periosteum, bone, or dura mater. All the vessels were identified and preserved and the flaps were viable and sufficient for the defects. Three cases presented 1 cm2 of superficial skin necrosis with spontaneous healing that caused hypochromic scars. In eight patients the extirpation of the tumor compromised the rami temporales of the nervus facialis and caused postoperative asymmetry of the facial mimicking. All the followed patients presented normal sensitivity to touch stimuli on the flap skin and presented loss of sensitivity on the scalp distally to the flap and to the donor site. Conclusion: The frontal musculocutaneous island V-Y flap based on the supratrochlearis or the supraorbitalis vessels is safe and permits frontal reconstruction in a single procedure with proper maintenance of the aesthetic unit. (Plast. Reconstr. Surg. 120: 631, 2007.)
A
lthough having been widely used as a donor site for reconstruction of facial defects for many years, the difficulty in the treatment of frontal defects has been referred to by many surgeons.1–9 Defects of the frontal skin, such as wide scars from secondary healing and nonmatching color or texture from grafts, used to cause dissatisfaction to both patients and surgeons.1,3,5,9,10 The frontal region may seriously denote loss of function resulting from the absence of muscle.8 The more complex the defect, as occurs after removal of periosteum or frontal bone, the more From the Surgery Division, Department of Medicine, Federal University of Rondoˆnia; Center Pla´stica Clinic; Plastic Surgery Division, Department of Surgery, University of Pouso Alegre; and Plastic Surgery Division, Department of Surgery, Federal University of Sa˜o Paulo. Received for publication July 31, 2005; accepted June 27, 2006. Presented in part as a thesis for the doctoral degree in public defense at the Federal University of Sa˜o Paulo on December 1, 1997. Copyright ©2007 by the American Society of Plastic Surgeons DOI: 10.1097/01.prs.0000270294.76440.d1
complex the reconstruction. Such reconstructions require large scalp flaps that bring, even temporarily, hair to the aesthetic unit of the frontal region, tissue expanders, or free flap transfer.1,5–7,11 Considering the anatomy and the modern concepts concerning cutaneous and musculocutaneous flaps, the authors studied an axial pattern flap that could carry specialized frontal skin with sensitivity, improved in thickness by the presence of functional muscle, and that could permit primary closure of the donor site.3,5,8,10,12–18
PATIENTS AND METHODS This project was evaluated by the ethics in research committee and approved. To be included in this protocol, patients were required to carry a frontal defect resulting from ablation of a malignant neoplasm, the surgical margins of which were considered to be free of tumor. The defect should not allow direct primary closure, the attempt of which would cause either eyebrow or hairline deformity (Figs. 1, above, 2, center, and 3, above). All of the patients signed an informed consent form including authorization for the use of the
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Fig. 1. (Above, left) A 5 ⫻ 3-cm defect after removal of a basal cell carcinoma. (Above, right) Planning the skin island; arrows by the left side of the defect indicate the appropriate placement of the curved incisions considering that the skin island will not slide to the defect as in a traditional subcutaneous pedicle but will rotate at the extremity of the divided muscle, and a third arrow indicates the distant right margin to be reached. (Center, left) The skin superficial to the muscular pedicle is freed from the proximal portion of the muscle and raised. The arrow indicates the fat tissue level of the dissection. (Center, right) The muscle is divided distally at the distal margin of the skin island. The flap carrying the desired amount of skin is raised and the supratrochlearis and the supraorbitalis vessels are identified. The supraorbitalis vessels were sacrificed in a “back-cut.” The arrow indicates the left supratrochlearis vessels. (Below, left) The skin island is transferred by rotation of the muscle. (Below, right) At 6 months postoperatively, the eyebrows are symmetrical and the defect has been treated with frontal skin.
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Volume 120, Number 3 • Frontal Reconstruction
Fig. 2. (Above, left) A solid basal cell carcinoma. (Above, right) A 4 ⫻ 3-cm defect exposing bone and dura mater. (Center, left) The flap carrying the desired amount of skin and periosteum is raised to permit identification of the supratrochlearis vessels indicated by the arrows. (Center, right) The flap is sutured without tension. The lower margin was enlarged above the right eyebrow and sutured primarily. (Below) At 6 months postoperatively, the eyebrows were not deformed.
photographs in scientific publications and presentations. The studied flap consists of a triangular portion of frontal skin, isled on the frontal belly of one of the occipitofrontalis muscles, harvested from the neighborhood of the defect in such a way to have one of its margins in common with the defect.
Ink marks outline an unconventional curved V to allow transference of the isle to the defect by means of rotation of the pedicle (Fig. 1, above, right). The skin superficial to the muscular pedicle is divided at the proximal margin of the skin island, freed from the proximal portion of the mus-
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Fig. 3. (Above, left) A multicentric basal cell carcinoma. (Above, right) A 5.5 ⫻ 4.4-cm defect exposing bone and dura mater. (Center, left) The skin superficial to the muscular pedicle is freed from the proximal portion of the muscle and raised. (Center, right) The muscle is divided distally at the distal margin of the skin island. The flap carrying the desired amount of skin and periosteum is raised and identification of the supratrochlearis vessels is indicated by the arrows. (Below, left) The rotation of the muscles transports the skin and periosteumislandtothedefectwithouttension,andtheflapissutured.(Below,right)At6monthspostoperatively,aparietalbonewas grafted between the periosteum and the dura mater. The hairline presented irregularities but the eyebrows are symmetrical.
cle, and raised at the fat tissue level, exposing the muscle at the pedicle (Figs. 1, center, left, and 3, center, left). The muscle is divided distally at the distal margin of the skin island. The flap is then freed from the
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skull, carrying the desired amount of periosteum, and raised to permit identification of the supratrochlearis and supraorbitalis vessels (Figs. 1, center, right, 2, center, left, and 3, center, right).
Volume 120, Number 3 • Frontal Reconstruction Depending on the necessary arch of rotation, preservation of both vessels is not possible, and one of the pedicles might be sacrificed. The flap is transferred to the neighbor defect and held by deep stitches in the muscular plane (Fig. 1, below, left). The skin is sutured in a curved Y shape, simultaneously closing the original wound and the donor site (Figs. 2, center, right, and 3, below, left). Care is taken when suturing the proximal margin of the skin island not to loop the stitches too deep to preserve the vessels, in particular the veins, which become superficial in the upper forehead. In each case, the donor site was chosen according to the disposition of the defect. When the defect was central at the forehead or medial to the frontal belly of the occipitofrontalis muscles, any muscle was used (Fig. 1, above, left). When the defect was lateral, at the temporal area, the preference was to use the muscle of the same side or on a bilateral pedicle for the rotation of both frontal muscular bellies to the same side (Figs. 2, above, right, and 3, above, right). For wide defects, the skin island included skin beyond the limits of the muscle. For deep defects that compromised bone, an island of periosteum was included underneath the muscle, in the depth of the flap, to face the exposed dura mater or to better cover a bone graft (Figs. 2, center, left, and 3, center, right).
noma that invaded the dura mater and presented an exposed graft of bovine pericardium. By the time of death, the flap was viable and the sutures had already been removed. In three patients, areas of superficial skin necrosis measuring approximately 1 cm2 were observed. One, in the center of the flap, had no further complication. A second at the distal margin of the flap and a third at the donor site suture caused dehiscence. All healed spontaneously before 4 months but presented hypochromia at the 6-month follow-up. Patients whose defect was central at the forehead or medial to the frontal belly of the occipitofrontalis muscles had their forehead symmetry preserved by mobilization of the flap within its innervated muscle. In eight patients whose extirpation of the tumor compromised the rami temporales of the nervus facialis, postoperative asymmetry of facial mimicking occurred. Patients whose flap mobilization caused transference of some amount of hair at the extremity of the flap presented irregularities at the postoperative hairline. All of the followed patients presented normal sensitivity to touch stimuli on the flap skin and presented loss of sensitivity on the scalp distal to the flap and to the donor site.
RESULTS
Irrigation and Drainage All of the consulted publications made reference to the constancy of the supratrochlearis artery,3,10,12,15,17,18 but Salmon mentioned that the supraorbitalis artery was not always present in his studies.12 Although not the subject of the study, these vessels were identified in all the authors’ dissections. The cutaneous branches of the supratrochlearis and supraorbitalis arteries are considered sufficient for the entire frontal region, and their anastomosis lay in a more superficial position.15 This special consideration justifies the viability of the portions of the skin island that are not within the limits of the muscle in the studied flap. Studies made evident the situation with the supratrochlearis artery: (1) deep to the occipitofrontalis muscles beneath the orbital margin and in the lower third of the frontal region, (2) in the muscle in the middle third of the frontal region, and (3) superficial in the upper third near the hairline.17 This aspect was confirmed by the authors and permitted the deep situation of the pedicle in all of the flaps. The frontal flap has been described as an axial pattern flap of the direct cutaneous system.18 The frontal skin does not
Thirty-one patients, all white, 22 of whom were male and nine of whom were female, with ages varying from 30 to 88 years, underwent surgical ablation of a malignant tumor at the forehead skin, and the specimen’s histopathologic examination presented margins free of tumor. The resultant frontal defects ranged from 1.5 per 1.5 cm to 4.5 per 5.5 cm and, depending on the depth of the resection, exposed periosteum, bone, or dura mater. Flaps were planned and executed according to the proposed method and suited for each defect. The chosen vessels, either the supratrochlearis or the supraorbitalis, were identified and preserved in all cases. All of the defects were closed with such a tension that 4-0 and 5-0 nylon sutures were sufficient. All of the patients were followed for a minimum of 6 months (Figs. 1, below, right, 2, below, and 3, below, right), except for the second patient, an 84-year-old patient who died as a result of pulmonary embolism on postoperative day 17. This patient had undergone, by the neurosurgery team, a wide surgical excision of a squamous cell carci-
DISCUSSION
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Plastic and Reconstructive Surgery • September 1, 2007 belong to a musculocutaneous system, but when isled in the flap it is nourished by the anastomosis with the muscular branches. The term “musculocutaneous” becomes proper for the flap’s composition.18 Taylor et al. affirmed that the skin veins of the frontal region have no valves and present a wide drainage net.16 Two of the patients who were operated on presented some flap abnormality caused by the lowering of the drainage but did not need a secondary repair. Nerve Supply Fatah showed that the motor rami temporales of the facial nerve may be damaged in resections when close to the lateral margin of the frontal belly of the occipitofrontalis muscles and to the orbicularis oculi muscle.8 This anatomical condition explains the cases of muscular function loss previously observed with tumor removal and the maintenance of muscle function when the tumor resection did not involve the rami temporales of the facial nerve. In some cases, the function of the frontal belly of the occipitofrontalis muscles did not exist or was almost undetectable before the operation and was then disregarded after the operation. These nerves were not the subject of investigation during the studied surgical dissections; however, the procedures did not cause nerve damage, because the contraction of the muscle was preserved. The ramus temporales of the nervus facialis was not identified in any of the dissections, and careful back-cuts at the base of the muscle pedicle were often necessary. The risk of nerve lesion during the course of the dissection must be considered. As in the cases reported by Hallock and Trevaskis,4 all the patients studied presented anesthesia in the areas distal to the flaps or to the donor sites as well. Nevertheless, the axiality of the frontal branches of the supratrochlearis and supraorbitalis nerves explains the persistence of the sensitivity of the flaps and of the undermined frontal skin.
Technique Tissue expansion in the reconstruction of the frontal region is recommended, but at least two surgical procedures become necessary.7 Local flaps may be the preference of other authors, even when necessitating two procedures in a temporary pedicle tissue transfer.3,4,6 The V-Y frontal musculocutaneous island flap based on the supratrochlearis or the supraorbitalis vessels can be performed in a single procedure. V-Y island flaps,2 elliptical flaps,13 lenticular flaps,19 and triangular flaps14 were all proposed for the frontal region, but when based on the subcutaneous fat tissue, as initially described, cannot be advanced enough because of short pedicle. When based on the frontal branch of the superficial temporal artery, the flap may carry muscle and preserve a proper bulky characteristic for the frontal region, but it slides up or down9 and does not permit the reconstruction of large defects such as those presented in this study because of the wide transposition of the skin and the periosteum island provided by the rotation of the muscle branches of the supratrochlearis or the supraorbitalis pedicle.
CONCLUSION The frontal musculocutaneous island V-Y flap based on the supratrochlearis or the supraorbitalis vessels is safe and permits frontal reconstruction in a single procedure with proper maintenance of the aesthetic unit. Lorenzo S. Rocha, M.D., Ph.D. Department of Medicine Federal University of Rondoˆnia Hospital do Caˆncer de Rio Branco Acre 69900-970, Brazil
[email protected]
DISCLOSURE None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this article. REFERENCES
Aesthetic Unit The presence of hair in the frontal region after reconstruction has been reported as inconvenient by others.1 When the dimensions of the defect exceeded the upper limits of the aesthetic unit, the skin island included some hair and deformed the hairline. The transverse scars from the V-Y procedure in this study were appropriate for the frontal region.5,11
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1. Gillies, H. D. Note on scalp closure. Lancet 2: 310, 1944. 2. Barron, J. N., and Emmett, A. J. J. Subcutaneous pedicle flaps. Br. J. Plast. Surg. 18: 51, 1965. 3. Burget, G. C., and Menick, F. J. Aesthetic Reconstruction of the Nose. St. Louis: Mosby, 1984. Pp. 57–65. 4. Hallock, G. G., and Trevaskis, A. E. Refinements of subcutaneous pedicle flap for closure of forehead and scalp defects. Plast. Reconstr. Surg. 75: 903, 1985. 5. Millard, D. R. Principlization of Plastic Surgery. Boston: Little, Brown, 1986. Pp. 315–318. 6. Sakai, S., Soeda, S., and Terayama, I. Subcutaneous pedicle flaps for scalp defects. Br. J. Plast. Surg. 41: 255, 1988.
Volume 120, Number 3 • Frontal Reconstruction 7. Antonyshyn, O., Gruss, J. S., Zuker, R., et al. Tissue expansion in head and neck reconstruction. Plast. Reconstr. Surg. 82: 58, 1988. 8. Fatah, M. F. Innervation and functional reconstruction of the forehead. Br. J. Plast. Surg. 44: 351, 1991. 9. Guerrerosantos, J. Frontalis musculocutaneus island flap for coverage of forehead defect. Plast. Reconstr. Surg. 101: 18, 2000. 10. Bozola, A. R., Kurimori, N. S., and Chaem, L. H. T. Retalho frontal. In J. Hochberg (Ed.), Manual de Retalhos Miocutaˆneos. Porto Alegre: Associac¸a˜o Me´dica do Rio Grande do Sul, 1984. Pp. 25–41. 11. Iwahira, Y., and Maruyama, Y. Expanded unilateral forehead flap (sail flap) for coverage of opposite forehead defect. Plast. Reconstr. Surg. 92: 1052, 1993. 12. Salmon, M. T. Arte`res de La Peau. Paris: Masson, 1936. Pp. 104–116. 13. Trevaskis, A. E., Rempel, J., Okunski, W., et al. Sliding subcutaneous-pedicle flaps to close a circular defect. Plast. Reconstr. Surg. 46: 155, 1970.
14. Emmett, A. J. J. The closure of defects by using adjacent triangular flaps with subcutaneous pedicle. Plast. Reconstr. Surg. 59: 45, 1977. 15. Lebeau, J., Antoine, P., and Rafael, B. Introduction ange´iologique a` la chirugie du scalp. Ann. Chir. Plast. Esthe´t. 31: 321, 1986. 16. Taylor, I. G., Palmer, J. H., and Mc Manamny, D. The vascular territories of the body (angiosomes) and their clinical applications. In J. G. McCarthy (Ed.), Plastic Surgery, Vol. 1. Philadelphia: Saunders, 1990. Pp. 329–378. 17. Shumrick, K. A., and Smith, T. L. The anatomic basis for the design of forehead flaps in nasal reconstruction. Arch. Otolaryngol. Head Neck Surg. 118: 373, 1992. 18. Cormack, G. C., and Lamberty, B. G. H. The Arterial Anatomy of Skin Flaps, 2nd Ed. Edinburgh: Churchill Livingstone, 1994. Pp. 132–148. 19. Jobe, R. When an “ellipse” is not an ellipse. Plast. Reconstr. Surg. 46: 295, 1970.
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