Reconstruction of the medial canthus using an ipsilateral paramedian forehead flap

Development and validation of a decision algorithm for eyelid reconstruction following oncological resection

BACKGROUND

Eyelid reconstruction is an intricate process, addressing both aesthetic and functional aspects post-trauma or oncological surgery. Aesthetic concerns and oncological radicality guide personalized approaches. The complex anatomy, involving anterior and posterior lamellae, requires tailored reconstruction for optimal functionality.

AIM

To formulate an eyelid reconstruction algorithm through an extensive literature review and to validate it by juxtaposing surgical outcomes from Cattinara Hospital with established findings.

METHODS

The algorithm was formulated by analyzing 1538 articles, which were subsequently refined to 113 according to quality standards, and then implemented in surgical cases at Cattinara Hospital. Complication rates were examined for validity.

RESULTS

The decision algorithm was employed to apply reconstructive techniques customized to the characteristics of the eyelid defect, including its depth and location. The results exhibited a minimal complication rate, consistent with established guidelines. Validation confirmed the algorithm’s efficacy in reducing post-operative problems.

CONCLUSION

This algorithm functions as an essential decision-making instrument for eyelid reconstruction, enhancing outcomes by minimizing complications in clinical practice.

Reconstruction of Full-thickness Lower Eyelid Defects After Basal Cell Carcinoma Excision Using a Modified Hughes Procedure

Background

Basal cell carcinoma (BCC) is the most common malignant tumor of the eyelid. These cancers often necessitate eyelid reconstruction in ophthalmic plastic surgery, which poses significant challenges. This study describes the use of a tarsoconjunctival flap from the orbicularis oculi muscle of the upper eyelid for reconstructing full-thickness lower eyelid defects following BCC resection.

Methods

Four consecutive patients with full-thickness lower eyelid BCC underwent radical resection with 3-mm margins, followed by reconstruction using a tarsoconjunctival flap from the upper eyelid. Digital photographs were taken at baseline and at 1, 3, and 6 months postsurgery to evaluate clinical outcomes. Histological examination confirmed complete tumor excision in all cases.

Results

The modified Hughes procedure resulted in a high rate of functional and aesthetic success, with no recurrences observed over an average follow-up of 12 months. None of the patients experienced temporary forced eyelid closure, and both aesthetic and functional results were satisfactory.

Conclusions

The tarsoconjunctival flap from the upper eyelid is an effective method for reconstructing extensive full-thickness lower eyelid defects, providing excellent functional and aesthetic outcomes.

Comparison of local flaps versus skin grafts as reconstruction methods for defects in the medial canthal region

BACKGROUND

The medial canthal region features a complex three-dimensional and internal anatomical structure. When reconstructing a defect in this area, it is crucial to consider both functional and aesthetic aspects, which presents significant challenges. Generally, local flaps are preferred for reconstruction; however, skin grafts can be used when local flaps are not feasible. Therefore, we conducted a comparative analysis of surgical outcomes skin grafts when local flaps were not feasible, to determine which surgical method is more effective for medial canthal region reconstruction.

METHODS

Twenty-five patients who underwent medial canthal region reconstruction using skin grafts or local flaps from 2002 to 2021 were enrolled. Patient information was obtained from medical records. Five plastic surgeons evaluated the surgical outcomes based on general appearance, color, contour, and symmetry.

RESULTS

Skin grafts were used in eight patients and local flaps were used in 13. Combined reconstructions were employed in four cases. Minor complications arose in four cases but improved with conservative treatment. No major complications were reported. Recurrence of the skin cancer was noted in two cases. All categories showed higher scores for the local flap compared to both skin graft and combined reconstruction; however, the differences were not statistically significant respectively.

CONCLUSION

The choice of appropriate surgical methods for reconstructing defects in the medial canthal region depends on various factors, including the patient's overall health, the size and depth of the defect, and the degree of involvement of surrounding structures. When a local flap is not feasible, a skin graft may provide favorable surgical outcomes. Therefore, a skin graft can serve as a viable alternative for reconstructing the medial canthal region.

Functional and Symmetry Outcomes After Forehead Flap Reconstruction of Medial Peri-Ocular Defects

BACKGROUND

Orbital defects have a profound impact on orbital function and symmetry of the face and are difficult to reconstruct given the complexity of this area. The paramedian forehead flap (PMFF) has not been well studied in reconstruction of orbital defects.

METHODS

Retrospective review of patients who underwent reconstruction of periorbital defects with PMFF between 2016 and 2021. Variables were ocular adnexal asymmetry, functional outcomes, and orbital complications.

RESULTS

Eighteen patients met inclusion criteria. Mean defect size was 11.1 ± 7.5 cm. The most common subsite involved was medial canthus in 88.9% of patients. There was no statistically significant difference between mean medial canthus to midline ratio and mean medial brow to midline ratio when compared to the assumed normal of 1. The medial canthus to pupil ratio and medial canthus to lateral canthus ratio had a statistically significant mean difference from 1.0 (p = 0.003 for both). In 22.2% of patients, the orbit was functional with impairment; the remaining had no impairment. Surgical sequelae occurred in 12/18 (66.7%) of patients, most commonly epiphora in 9/18 (50%) of patients, and ectropion in 5/18 (27.7%).

CONCLUSION

The PMFF is feasible for medial periorbital reconstruction with acceptable functional and symmetrical outcomes and low morbidity.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:2584-2589, 2023.

The use of the paramedian forehead flap alone or in combination with other techniques in the reconstruction of periocular defects and orbital exenterations

PURPOSE

The paramedian forehead flap (PMFF) is a reconstructive option for large eyelid defects and orbital exenterations. We report a series of cases where PMFF reconstruction was carried out at various institutions in Australia.

METHODS

This study was a multi-centre, retrospective, non-comparative case series investigating the clinical outcomes of the PMFF for reconstructing periocular defects and orbital exenterations.

RESULTS

This case series describes twenty-seven patients (Female = 15, Male = 12), operated between 1991 to 2019, with a median age of 81 years (range: 45-93 years). Defect locations involved combinations of the medial canthus (16/27, 59.3%), upper eyelids (7/27, 25.9%), lower eyelid (4/27, 14.8%), both upper and lower eyelids (5/27, 18.5%), and orbital (7/27, 25.9%). There were no cases of flap necrosis. Minor post-operative complications were observed in ten patients with the most common being lagophthalmos. Median duration of follow-up was 17months (Range: 2months- 23years).

CONCLUSIONS

The PMFF is a versatile reconstructive tool for a range of periocular defects and orbital exenterations with minor post-operative complications.

Holding back the tears: is there a role for marsupialisation?

Objective

Medial eyelid tumours may result in the loss of the proximal lacrimal system during staged excision and delayed reconstruction, to achieve tumour margin clearance. The remnant canaliculus was marsupialised during reconstruction. The aim was to understand how many patients experienced symptomatic epiphora as a consequence of this.

Methods and analysis

A retrospective study including patients over a 15-year period with medial eyelid tumours, where the proximal lacrimal system was sacrificed to achieve tumour margin clearance. Included were all who had marsupialisation of the remnant distal stump as part of their delayed reconstruction. All who had pre-existing epiphora were excluded. The primary objective was the rate of epiphora following the procedure. A systematic literature review of postoperative epiphora occurring in patients with lid tumours requiring lacrimal system injury/sacrifice during tumour excision.

Results

There were 22 eyes (22 patients). All were basal cell carcinomas except for 1 (4.5%) tarsal conjunctival squamous cell carcinoma. All cases involved the lower lid. There were two (9.1%) patients who developed epiphora. One patient underwent a superior three-snip punctoplasty, botulinum toxin to the lacrimal gland and conjunctivodacryocystorhinostomy with Lester Jones tube insertion. The other patient was not overly troubled and did not require further treatment. The literature review showed the median postoperative rate of epiphora in these patients was 12.5% (range 0%–100%).

Conclusion

Marsupialisation of the remnant canaliculus during delayed reconstruction is a straightforward and effective surgical option, which may help prevent postreconstruction epiphora when the proximal lacrimal system is sacrificed for tumour margin clearance.

Trial registration number

10391.

Medial Canthus Reconstruction with the Paramedian Forehead Flap

Background:

The medial canthus represents the medial confluence of the upper and lower eyelid margins and plays an integral role in the lacrimal duct system. Various flaps have been utilized for the reconstruction of the lower eyelid in the medial canthal region. Our institution primarily utilizes the paramedian forehead flap for the reconstruction of medial canthus defects. Our study looked to evaluate the work of a single plastic surgeon and identify their postoperative outcomes.

Methods:

A retrospective chart review was conducted at Beaumont Health System, Royal Oak, for patients who underwent medial canthal repair by the lead surgeon between the years 2014 and 2018. Demographic data, operative details, complications, medical comorbidities, and patient outcomes were retrospectively gathered and analyzed.

Results:

A total of five patients were isolated. Patients underwent paramedian forehead flap medial canthal repair by the lead surgeon and were found to tolerate the procedure well. All patients had clinically viable flaps with aesthetically pleasing results.

Conclusions:

Utilization of the paramedian forehead flap leads to successful medial canthal repair with adequate coverage. Although the paramedian forehead flap requires three stages to complete, the procedure leaves patients with aesthetically pleasing results. In addition, the paramedian forehead flap has limited cases of ectropion. With the right expertise and patient population, the paramedian forehead flap can be highly successful in the repair of medial canthal defects.

Single-staged Tunneled Forehead Flap for Medial Canthal and Eyelid Reconstruction

Purpose:

The paramedian forehead flap, while initially used for reconstruction of nasal defects, has been adapted for repair of anatomical subunits in the medial canthal and eyelid area. A significant obstacle for utilizing the flap has been the bulky, unsightly vascular pedicle that is maintained between surgical stages. We describe our surgical experience using the tunneled variation in a single stage procedure.

Methods:

A retrospective chart review was performed of three surgeons’ charts over a 5-year period. All patients who underwent the tunneled paramedian forehead flap variation were selected. Outcomes measured included underlying pathology, Mohs defect area and depth, and canalicular involvement.

Results:

A total of 20 tunneled flaps were performed after successful Mohs excision of cutaneous malignancies. The average Mohs defect surface area was 13.57 cm² with depth down to periosteum (n = 13), bone (n = 5), or orbital fat (n = 2). Five patients had full-thickness eyelid defects (25%), and nine (45%) had canalicular defects. The overall complication rate for this study was low with no flap failure. Two patients (10%) desired thinning of the subcutaneous flap for improved cosmesis, and one patient (5%) required further eyelid revision due to the complexity of the initial Mohs defect. The remaining 17 patients required no further surgical procedures.

Conclusion:

The tunneled paramedian forehead flap is a useful technique for medial canthal and eyelid reconstruction. This technique allows reconstruction of a challenging area. Complication rates are low, and this tunneled variation provides a single stage variation to the traditional multistage forehead pedicle flap.

Reconstruction of Medial Canthal Defects by Local/Loco-Regional Flaps

AIM

To describe a series of medial canthal defect reconstruction by local/loco-regional flaps following excision of basal cell carcinoma.

MATERIAL AND METHODS

A series of 35 medial canthal defects following excision of basal cell carcinoma was reconstructed by local/loco-regional flaps. For smaller defects, glabellar lateral advancement flap or Limberg's flap from the nasolabial area were used to resurface the defects. For larger defects extending to the upper and lower eyelid or to the nose, a combination of flaps, that is, forehead and cheek rotation flaps or glabellar and cheek rotation flaps were used.

RESULT

In all the cases, the aesthetic and functional results were highly satisfactory except in one, where punctum and lower canaliculi were also excised with the tumor for clearance. This patient complained of watering from the affected eye. Two patients had developed webbing after the operation. It was corrected by Z plasty after 6 months.

CONCLUSION

Medial canthal defects are best managed by local/loco-regional flaps. For smaller defects in the upper part, the glabellar flap is the choice of the flap and in the lower part, flaps from the nasolabial region give the best result. For larger defects not amenable to single flap, a combination of flaps (glabellar/forehead flap and cheek rotation flap) can close the defects with the good aesthetic and functional results.

Reconstruction of Extensive Periorbital Defects With Pericranial Flap

ABSTRACT

Wide excision of recurrent malignant tumors of periorbital region leaves deep and large composite defects, requiring a reconstruction to restore both the form and function of the eyelids. In this study, a pericranial flap was utilized in the reconstruction of large, complex defects of periorbital region.This study included 5 patients who underwent wide excision of recurrent large medial canthus and supraorbital rim malignant tumors. All defects involved the medial parts of eyelids including medial canthal ligaments, nasal walls, periosteum, and medial orbital walls. Defects were reconstructed via a pericranial flap, which was facilitated by the natural concavity and the acute angled nature of the medial canthus.The pericranial flap is not only a versatile alternative to the local or regional flaps in the reconstruction of periorbital defects, but also has the advantages of availability of abundant amount of flap tissue.

Transnasal or transglabellar semicircular flap for medial canthal reconstruction

PURPOSE

To review the results of medial canthal reconstruction with the medial (transnasal or transglabellar) semicircular flap.

METHODS

Medical charts of 38 patients who underwent the described procedure were reviewed. After tumor excision, a semicircular flap created along the nasal bridge or glabella was advanced to the canthal defect; if necessary, this flap was combined with other reconstructive methods.

RESULTS

The patients (19 male, 19 female; mean age, 66 years) had basal cell (n = 36) or squamous cell (n = 2) carcinomas. The mean tumor diameter was 9.2 mm (range, 3-21 mm). Tumor epicenters were in the midcanthal area in 21 patients (55%) and in the infra- or supracanthal areas in 17 patients (45%). After excision, 22 patients had only canthal defects, and 16 had an associated upper and/or lower eyelid defect. To cover the defect, the medial semicircular flap alone was used in 19 patients (50%) and in association with other flaps in 19 patients (50%). The excisional defect was primarily closed in 37 patients (97%). Flap necrosis or infection did not occur. During follow-up (range, 1-91 months; median, 19 months), 10 patients (26%) developed a total of 17 complications. Three patients (8%) required secondary surgery for eyelid reconstruction-related complications.

CONCLUSIONS

Transnasal or transglabellar semicircular flap may be a good alternative for medial canthal reconstruction. For large or complex defects, the medial semicircular flap can be combined with other periocular flaps. In the latter case, postoperative complications requiring secondary surgery may develop.

Broadening applications and insights into the cross-paramedian forehead flap over a 19-year period

BACKGROUND

Forehead flap reconstruction of large nasal defects can be challenging. The senior author has used a paramedian forehead flap modification using the supratrochlear artery on the contralateral side of the defect.

METHODS

A 9-year retrospective review (2008-2016) was performed for patients undergoing nasal reconstruction with the cross-paramedian forehead flap. Outcomes were analyzed by comparing our previous reviews, which allows us to analyze patient outcomes for over 19 years.

RESULTS

Fifty-three patients were identified. The aasal defect was most frequently due to basal cell carcinoma (n = 37, 69.8%). Twenty-three (43%) patients were smokers, and nine (17%) had diabetes. The mean defect size was 12.9 cm², involving an average of 2.6 nasal subunits. One-third of the patients had cartilage defects (n = 18) and mucosal lining defects (n = 19). Periorbital involvement was present in five patients. Complications included partial flap loss (n = 6), donor site dehiscence (n = 4), flap dehiscence (n = 2), and postoperative infection (n = 1). Only two of the partial flap losses were considered significant, as they required additional reconstructive procedures for soft tissue coverage. Complications were 12 times as likely as those in diabetes (OR = 11.97, p = 0.007, 95% CI 1.94-72.44), six times as likely as those in cartilage defects (OR = 6.4, p = 0.007, 95% CI 1.64-24.92), and nearly five times as likely as those in mucosal lining defects (OR = 4.8, p = 1.27-18.09, 95% CI 1.27-18.09). Thirty-one patients required revisions most commonly for flap debulking (n = 16).

CONCLUSION

The cross-paramedian forehead flap is a reliable option in the armamentarium of the reconstructive surgeon for large and complex defects in addition to those with periorbital extension.

SUMMARY

Coverage of distal nasal defects after tumor extirpation remains a challenge to the reconstructive surgeon. Our institution uses the cross-paramedian forehead flap for these defects. This flap is based on the supratrochlear artery on the contralateral side of the defect and is oriented obliquely across the forehead for additional length and an improved donor site scar at the level of the eyebrow. The technique and outcomes were published in 2009, and this manuscript serves as an update on outcomes and applications during the past 9 years. By including all our data, we can analyze outcomes for over 19 years. During the past 9 years, 53 patients underwent the cross-paramedian forehead flap technique between 2008 and 2016. These patients were found to have an average defect size of 12.9 cm² and an average loss of 2.6 nasal subunits. Cartilage defects were present in 34.6% (n = 18) and mucosal defects were present in 36.5% (n = 19) of patients. Five patients had periorbital reconstruction with the forehead flap, of which three patients underwent a single-stage islandized forehead flap reconstruction. Given the large defect size, additional local flaps were frequently used, including nasolabial flaps (n = 16) and cheek rearrangement (n = 11). Complications included partial flap loss (n = 6), donor site dehiscence (n = 4), and postoperative infection (n = 1). Only two of these partial flap losses were considered significant, as they required additional reconstructive procedures to address areas of soft tissue loss. Increased rates of complications were associated with the presence of diabetes and defect characteristics, which reflects increased complexity including mucosal and cartilage loss. When comparing with our prior review of this technique, the more recent population have had increasing complexity of the nasal defects with a large surface area involvement. Overall, the cross-paramedian forehead flap is a reliable option in the armamentarium of the reconstructive surgeon for large and distal nasal defects.

Medial canthal reconstruction with multiple local flaps

Background

It is often difficult to reconstruct comparatively large defects in the medial canthal region. The authors have performed reconstruction with multiple local flaps in 4 medial canthal defects after resection of malignant skin tumors.

Method

The defects exceeded the medial canthal region, extending to the upper eyelid and the lower eyelid. The medial canthal defect was covered by transposition of a glabellar flap, the upper eyelid defect was covered by an upper eyelid myocutaneous advancement flap, and the lower eyelid defect was covered by a cheek rotation flap. Then the donor site of the glabellar flap was covered by a Rintala flap.

Results

There was no recurrence in any of the cases, and good results were obtained. One case showed mild linear contracture, but the patient did not want corrective surgery.

Conclusion

This method is somewhat complicated compared to reconstruction with a single flap, but it is a combination of standard local flaps and is a simple reconstructive procedure. By adding additional resection, the suture line is consistent with the border of the facial unit, so postoperative scarring is inconspicuous. This technique is aesthetically useful because of the continuity of colour and texture resulting from the use of adjacent flaps.

The Versatility of Cheek Rotation Flaps

Background

The cheek rotation flap has sufficient blood flow and large flap size and it is also flexible and easy to manipulate. It has been used for reconstruction of defects on cheek, lower eyelid, or medial and lateral canthus. For the large defects on central nose, paramedian forehead flap has been used, but patients were reluctant despite the remaining same skin tone on damaged area because of remaining scars on forehead. However, the cheek flap is cosmetically superior as it uses the adjacent large flap. Thus, the study aims to demonstrate its versatility with clinical practices.

Methods

This is retrospective case study on 38 patients who removed facial masses and reconstructed by the cheek rotation flap from 2008 to 2015. It consists of defects on cheek (16), lower eyelid (12), nose (3), medial canthus (3), lateral canthus (2), and preauricle (2). Buccal mucosa was used for the reconstruction of eyelid conjunctiva, and skin graft was processed for nasal mucosa reconstruction.

Results

The average defect size was 6.4 cm², and the average flap size was 47.3 cm². Every flap recovered without complications such as abnormal slant, entropion or ectropion in lower eyelid, but revision surgery required in three cases of nasal side wall reconstruction due to the occurrence of dog ear on nasolabial sulcus.

Conclusion

The cheek rotation flap can be applicable instead of paramedian forehead flap for the large nasal sidewall defect reconstruction as well as former medial and lateral canthal defect reconstruction.

Median forehead flap - beyond classic indication

Introduction. The paramedian forehead flap is one of the best options for reconstruction of the median upper two-thirds of the face due to its vascularity, color, texture match and ability to resurface all or part of the reconstructed area. The forehead flap is the gold standard for nasal soft tissue reconstruction and the flap of choice for larger cutaneous nasal defects having a robust pedicle and large amount of tissue. Materials and Methods. We are reporting a clinical series of cutaneous tumors involving the nose, medial canthus, upper and lower eyelid through a retrospective review of 6 patients who underwent surgical excision of the lesion and primary reconstruction using a paramedian forehead flap. Results. The forehead flap was used for total nose reconstruction, eyelids and medial canthal reconstruction. All flaps survived completely and no tumor recurrence was seen in any of the patients. Cosmetic and functional results were favorable. Conclusions. The forehead flap continues to be one of the best options for nose reconstruction and for closure of surgical defects of the nose larger than 2 cm. Even though is not a gold standard, median forehead flap can be an advantageous technique in periorbital defects reconstruction.

Expanded forehead flaps for reconstruction of different faciocervical units: selection of flap types based on 143 cases

BACKGROUND

Forehead flaps have been used in the reconstruction of one particular faciocervical region, such as the nose and periorbital unit. The aims of the present study were to determine whether all the unit/multiunits of the face and neck could be aesthetically reconstructed by using expanded forehead flaps and to propose a strategy for flap selection for the reconstruction of different faciocervical units.

METHODS

The authors systematically reviewed the application of expanded forehead flaps for cervicofacial rehabilitation in their center from 2000 to 2013.

RESULTS

Four types of expanded forehead flaps were used for the faciocervical reconstruction of 143 patients. Type I was a pre-expanded local flap used for repairing defects of the partial forehead unit, subunits of the periorbital unit, or partial involvement of the two adjacent units. Type II was an expanded paramedian forehead flap used for resurfacing the nose, orbital unit, upper cheek unit, and partial involvement of these adjacent units. Type III was a bilateral pedicled expanded forehead flap for the reconstruction of the lower face and anterior neck. Type IV was a unilateral pedicled expanded forehead flap, based on the superficial temporal vessels, used to reconstruct the ipsilateral part of the middle face.

CONCLUSIONS

The four types of expanded forehead flap can be used for the reconstruction of different faciocervical units. Based on the location and size of the defect or lesion, the selection of these flaps can be planned preoperatively.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Medial and lateral canthal reconstruction with an orbicularis oculi myocutaneous island flap

BACKGROUND

The eyelid and canthal areas are common locations for cutaneous tumors. The medial canthus includes, among many other apparatuses, the canthal tendon and lacrimal canaliculi, and its characteristic thin and supple skin is hard to mimic and restore using tissue from other regions. Accordingly, reconstruction of the canthal area can prove challenging for surgeons. Although various methods, such as skin grafts and local flaps from adjacent regions, have been utilized for reconstructive purposes, they present known disadvantages. However, we were able to successfully reconstruct both lateral and medial canthal area defects by using orbicularis oculi myocutaneous island flaps.

METHODS

Our study included seven patients who underwent medial or lateral canthal region reconstruction, using orbicularis oculi myocutaneous island flaps, between 2011 and 2014, following either cutaneous tumor excision or traumatic avulsion injury.

RESULTS

Five patients had basal cell carcinoma, one had squamous cell carcinoma of the eyelid, and one had sustained a traumatic avulsion injury of the eyelid and canthal area. Entire flap loss was not observed in any patient, but one-a heavy smoker-showed partial flap loss, which healed with secondary intention and yielded acceptable results. Donor site morbidity was not observed, and all patients were satisfied with their surgical outcomes.

CONCLUSIONS

The canthal regions can be successfully reconstructed with orbicularis oculi myocutaneous island flaps. These flaps offer several key advantages, including similarity in texture, color, and thickness to the recipient site and a negligible incidence of donor site morbidity.