INTRODUCTION
Malignant tumors involving the eyelids represent
5 to 10% of all skin cancers [1]. Tumor excision
results in challenging periocular defects to reconstructive
surgeons owing to the requirement of
achieving better function and cosmoses. The available
options for its reconstruction include; skin
grafting, local flaps and may be free flaps [2-5].
Spinelli and Jelks, 1993 were the first to make
classification of eye lid defects into zones; zone I
(upper eye lid), zone II (lower eye lid), zone III
(medial canthus) and zone IV(lateral canthus) [2].
Anatomical basis of the flap:
Nearly at the level of zygomatic arch, superficial
temporal artery divides into two terminal divisions
which are the frontal or the anterior and the parietal
or the posterior. The frontal is wider in diameter,
longer in length and more constant than the parietal
423
one [6-8]. The frontal division courses anterosuperior
then in most cases it is divides into two branches
superior (posterior) and inferior (anterior) one.
However sometimes a third branch called central
may be also present (Fig. 1a,b) [9,10]. Use of an
island flap based on superficial temporal artery
itself or on its frontal division has been described
in literature for coverage of facial defects [11,12].
In this study we present a new technique using an
island bifid flap based on the branches of the frontal
division of superficial temporal artery for coverage
of defects involving zones I, II and IV of eyelids
together. To our knowledge, this technique was
not described before, so it could be considered a
novel one.
PATIENTS AND METHODS
Over 31 month's period, from April 2015 to
November 2017, 11 cases of periocular defects (8
males and 3 females) were reconstructed using
bifid frontal superficial temporal artery island flap
in Plastic Surgery Unit, Zagazig University Hospitals.
All defects resulted after excision of basal
cell carcinomas, 8 of them were recurrent. They
were affecting the lateral canthus as well as both
upper and lower eyelids (zones I, II and IV according
to Spinelli and Jelks classification) [2]. The
patient's demographics, lesions description, defect
sizes, flap dimensions, complications and additional
procedures are summarized in Table (1).
Operative technique:
Before starting the operation, the superficial
temporal, frontal division and its branches were
identified using hand held 8MHz Doppler. All
procedures were done under general anesthesia.
All patients received one dose of 1gm cefotaxim
one hour before surgery and continued twice daily
postoperatively for one week in addition to local
chloramphenicol eye drops. During operation, the
basal cell carcinoma was excised with 10mm safety
margin (Fig. 2). Safety margins were confirmed
to be free of malignancy after frozen section biopsy
examination. In all cases, full thickness excision
of the outer part of both eyelids together with the
outer canthus was done. However, the bulbar conjunctiva
was intact in all cases (Fig. 3). The flap
dimensions were designed to be slightly larger
than the resulting defects and the pedicle to be
slightly longer than its distance from the defect to
help its safe rotation (Fig. 3).
The island skin paddle was first dissected ovoid
in shape including branches of the frontal division
of superficial temporal artery. A longitudinal incision
within the hairy area over the vessel (frontal
division of superficial temporal) course was then
done. The dissection of the pedicle was then started
sub-dermal with only thin layer of fat was left
attached to the skin to avoid its necrosis and all
subcutaneous tissues was kept with the flap pedicle.
The dissection was continued from distal to proximal
till the origin of frontal division from the
superficial temporal artery with each time testing
the adequacy to reach the defect (Fig. 4). When
dissection completed and heamostasis was secured,
a wide tunnel was then created to allow the flap
to reach the defect (Fig. 5). The flap was then bifid
with the help of transillumination to highlight the
branches of the frontal division. Two branches
were seen in most cases with exception of one,
which showed a third central branch that was
included with the lower part. The flap was then
in-setted to reconstruct the upper and lower eyelids
as well as the lateral canthal missing defects.
Palpebral conjunctiva was reconstructed by buccal
mucosal graft that lined the undersurface of the
flap facing the globe (Fig. 6). All donor site defects
except in one patient were closed using thick split
thickness skin grafting.
424 Vol. 42, No. 2 /Bifid Frontal Superficial Temporal Artery Island Flap
The patients were discharged on the third postoperative
day. Suture removal was done on the 7th
day. Then, repeated dressing of the donor site was
done till the graft healed well. A programmed
followed-up regimen after 2 weeks, 2 months, 6
months, one year and 1.5 years was done. Patient's
satisfaction was assessed using a questionnaire
made of 4 items. The items included; good color
match, symmetry with opposite side, ability to
feely open and close eyelids, suggest same procedure
to others. Item response were scored using
five point scale (strong agree=4, agree=3, not
sure=2, not agree=1, strong not agree=0). The
summation of the points (ranged from 16 points
which mean very satisfied to zero which mean not
satisfied) dichotomized the result into three groups;
we consider 16 response very satisfied, 12 to 15
response satisfied and any response else is not
satisfied.
RESULTS
The size of the flaps ranged from 3.4 x 6.5 to
4 x 8.6. The postoperative period was uneventful
except some postoperative congestion in 8 flaps
(Fig. 7) which was relieved spontaneously within
one week. All flaps survived completely without
complications except one (1/11) where a distal
necrosis affected its lower part. Debridement and
re-insetting was done. After that, it healed well.
Histopathologic examination of the excised specimens
showed basal cell carcinoma with clear
surgical margins in all patients. We did not notice
recurrences during the follow-up period. Results
of patient's satisfaction questionnaire study are
summarized in Table (2). Postoperative appearance
of the patient is illustrated in (Fig. 8).
Table (1): Patient's demographics, lesions description, defect sizes, flaps size, complications and additional procedures.
1
2
3
4
5
6
7
8
9
10
11
Patient No.
M/74
M/68
F/72
M/63
F/58
M/70
F/65
M/62
F/73
M/67
F/60
Age/Sex Side
Left
Right
Right
Left
Left
Right
Right
Left
Right
Left
Left
1.5 x 2
1.4 x 2
1.4 x 2
1.3 x 2.1
1.7 x 2.2
1.6 x 2
1.4 x 1.8
1.8 x 2.2
1.5 x 2
1.8 x 2.1
1.3 x 1.8
Upper eyelid
defect in cm
1.4 x 2.1
1.3 x 1.8
1.5 x 1.7
1.6 x 2
1.4 x 1.7
1.5 x 2.1
1.8 x 2.2
1.6 x 2
1.7 x 2.3
1.7 x 2
1.6 x 2.1
Lower eyelid
defect in cm
Lateral canthus
defect in cm
2.5 x 3.2
2.4 x 3.5
2.5 x 3.5
2.7 x 3.2
2.8 x 3.5
3 x 4
3.2 x 3.4
3.2 x 4
3.1 x 4
3.1 x 4.1
2.4 x 3.5
Flap
dimensions
in cm
3.3 x 8
3.2 x 8.5
3.5 x 7.6
3.4 x 6.5
3.5 x 7.5
3.7 x 8.2
3.5 x 7.8
3.8 x 8.5
3.6 x 8.5
4 x 8.6
3.4 x 8
Complications
Congestion
Congestion
Congestion
Distal necrosis
None
Congestion
None
Congestion
Congestion
Congestion
Congestion
Additional
Procedures
None
None
None
Debridement
& reinsetting
None
None
None
None
None
None
None
Egypt, J. Plast. Reconstr. Surg., July 2018 425
Table (2): Results of patient's satisfaction questionnaire of all studied patients.
Patient N./character
Color match
Symmetry
Eyelid movement
Suggest procedure to others
Total Score
Degree of satisfaction
1
4
4
4
4
16
VS
2
4
3
4
3
14
S
3
4
4
4
4
16
VS
4
4
2
3
3
12
S
5
4
4
4
4
16
VS
6
4
3
4
4
15
S
7
4
4
4
4
16
VS
8
4
2
3
4
13
S
9
4
4
4
4
16
VS
10
4
4
4
4
16
VS
11
4
2
4
2
12
S
Fig. (1): Digital subtraction angiography (A) and cadaveric dissection (B) show the superficial temporal artery dividing
into frontal and parietal divisions and the branching of the frontal one into anterior and posterior branches [9].
Fig. (2): Basal cell carcinoma involving zones 1,2 & 4 of left
periocular region and the limits of resection.
Fig. (3): The resulting defect after resection and the design
of the flap.
S = Satisfied. VS = Very satisified.
(A) (B)
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Fig. (8): The late postopeartive appearance with accepted eye opening (A), closure (B).
Fig. (4): The flap totally harveseted as an island attached
only to the frontal division of superficial temporal
vessles (yellow arrow) with tunnel created (white
arrow).
Fig. (5): The flap reached the defect without tension after passing
through the created wide subcutaneous tunnel.
Fig.(6): The flap bifid and insetted to reconstruct both upper
and lower lids with adequate palpebral fissure and
lined with buccal mucosal graft to reconstruct the
palpebral conjunctiva.
Fig. (7): Mild postoperative congestion of the flap.
(A) (B)
Egypt, J. Plast. Reconstr. Surg., July 2018 427
DISCUSSION
Of all skin tumors about 5-10% are affecting
the eyelids [1]. Basal cell carcinoma is the most
common skin cancer affecting the periocular area
[13].
Periocular area is a special one owing to both
functional and personal identity identification. It
has a complex shape and composition rendering
its reconstruction a great challenge to plastic surgeons.
The goals of eyelid reconstructive surgery
are achieving a good function, color match, smooth
surfaces of both the margins and inner aspects,
provides corneal protection, all these should be in
side to side with optimum cosmoses. Several reconstructive
options have been reported for its
reconstruction [2-4].
Superficial temporal artery island flap was
described in literature. Its drawbacks are presence
of hair, sacrifice of its two main divisions and the
two stages if prefabricated [12,14]. Bifurcated superficial
temporal island flap utilizing both frontal
and parietal divisions was also previously reported
for periocular defect reconstruction [15-17]. However,
the parietal branch territory is hairy so frequently
a hair ablation method is required, and the
resulting Y shaped scar is another disadvantage.
Frontal artery is the larger of the two terminal
divisions of the superficial temporal artery. It
supplies a hairless wide area with good color match
and texture comparable to eyelids skin [18]. Bhattacharyla
et al., 2006 described frontal island flap
of superficial temporal artery for perioral reconstruction
[11].
Cadaveric dissection studies [10,19] as well as
Studies utilizing either digital subtraction angiography
or three-dimensional computerized tomographic
angiography [20,21] demonstrated that the
frontal division is more constant and less liable to
anatomical variations than the parietal one. It is
wider in diameter (1.4mm versus 1.3mm), longer
in length (106mm versus 99mm). So, either it or
its branches could be used as a pedicle for microvascular
transfer.
Omari et al., 2012 reported a case of island flap
based on anterior branch of frontal division of
superficial temporal for contracted socket with a
successful result [22].
Depending on the previous anatomical and
clinical studies, we added a new island flap. It
depends on the two branches of the frontal division
of the superficial temporal artery. Preoperative
Doppler studies and intra-operative trans–illumination
help to define their course, which proved
constant in all cases of the study. It is almost
hairless flap that gives good color match and texture
to both eyelids. The flap harvesting is easy and the
planes of dissection are clear.
In spite of the wide tunnel created to deliver
the flap to the defect, early postoperative mild
congestion developed in 8/11 cases. The cause is
unclear. There may be a relative higher arterial
inflow than the capacity of the venous drainage in
the early postoperative period that improves by
time. All cases of the study passed a smooth postoperative
course. Only one case (1/11) developed
partial distal flap necrosis and it healed well after
debridement and resuturing.
The functional outcome was excellent regarding
smooth opening and closure of eyelids. The only
drawback was the need for split thickness skin
grafting for donor site closure in most cases. Regarding
patient's satisfaction, 6/11 (55%) of them
were very satisfied and 4/11 (45%) were satisfied
while no patients were unsatisfied. This adds to
the merits of this flap.
Conclusion:
Bifid frontal superficial temporal artery island
flap is easily dissected due to distinct anatomical
landmarks. It provides adequate hairless coverage,
with good color and texture match for complex
eyelid defects involving zones zones I, II and IV.
It is a single stage procedure and it preserves the
parietal division for use in any other future defects.
All patients were satisfied functionally and aesthetically.
The only disadvantage is the skin grafting
of the donor site. The flap is considered an innovation
one for covering these challenging defects.
