Flaps and Grafts
E. Sabet Jason-Peyman, MD
DISEASE DESCRIPTION
Periocular defects resulting from surgical excision of carcinoma or traumatic injuries may need to be repaired using a variety of flap or graft techniques. These techniques are used to minimize vertical tension on the eyelids that could cause eyelid retraction and clinically significant exposure of the ocular surface. Scar tissue from prior trauma or surgeries may require flaps and/or grafts to relieve tension on the eyelid.
MANAGEMENT OPTIONS
Management is dictated by the location, size, and depth of the defect. Superficial, small defects can be managed with direct closure if the skin edges can be approximated with minimal tension. If this is not possible, advancement flaps can be used to transfer adjacent tissue into the defect site. Reconstruction choice will be determined by the depth of the defect, availability of a vascularized recipient bed, eyelid structures affected, and donor site suitability. Tensionless closure is essential to maintaining tissue perfusion; generally, we keep the length of the flap less than 2.5 to 3 times its width. The most common flaps used in the periocular region include advancement flaps, pivotal flaps, composite flaps, and Z-plasties. Often, multiple suitable options exist and several strategies might be combined to close a defect. Full-thickness skin grafting is also useful in cases where flaps may not work.
Advancement flaps (eg, Tenzel, O-to-T, O-to-H, island-pedicle flaps, V-to-Y, Y-to-V)
One flap edge adjoins the defect and the flap is moved linearly into the defect. These flaps can successfully be used to close a variety of periocular defects, as long as the advancement minimizes vertical traction on the eyelid.
For larger defects, a double advancement can be performed from opposite sides of the defect. These flaps work well for defects of the pretarsal and preseptal aspects of the eyelids, as well as for the brow region.
Rotational and transposition flaps (eg, Mustardé, bilobed, rhombic, bucket-handle)
A rotational flap adjoins the defect and is rotated directly into the defect.
A transposition flaps adjoins the defect, but the flap is lifted over a span of normal tissue to reach the defect.
These flaps work well in regions where local lid tension can be redistributed, by rotation, to adjacent zones with more soft-tissue extensibility, such as the medial and lateral canthi, lateral cheek, and temple.
Composite and interpolated flaps (eg, Hughes, Cutler-Beard, paramedian forehead)
A composite flap contains more than one type of tissue (eg, tarsoconjunctival, myocutaneous).
An interpolated flap recruits distant or nonadjoining tissue to cover the defect by moving over a span of normal tissue.
These can be used to reconstruct tissue that serves a specialized function (eg, tarsus, canthal tendon). These involve transfer or bridging of tissue from more distant sites, such as the ipsilateral upper eyelid or forehead.
Z-plasty flap
Z-plasty can be particularly useful for elongating tissue or relieving tension along a particular meridian, such as for a scar causing eyelid retraction.
Skin grafts
Preferred in situations where a flap may not be possible, are difficult to perform, or cause more scarring.
The best match for periocular skin defects, in terms of thickness and skin texture, is usually the upper eyelid skin.
Another good source of skin is the retroauricular area.
In some cases, non-hair-bearing preauricular or supraclavicular skin may be appropriate if other areas are not suitable.
INDICATIONS FOR SURGERY
For any defect larger than a few millimeters around the eye, if left to granulate, there is a risk of eyelid retraction and unsatisfactory cosmetic result. Therefore, most defects larger than several millimeters or involving the posterior lamella of the eyelids should be closed by one or more of the strategies outlined here.
SURGICAL DESCRIPTION
Advancement Flap
Outline the flap along relaxed skin tension lines (RSTLs), such that the flap extends at least two times the length of the defect. A Burow’s triangle can be marked at each side of the base to prevent buckling when the tissue is advanced (Figure 23.1).
FIGURE 23.1. Construction of an advancement flap. A, Cut along the blue dotted lines and undermine within the black dotted circle. B, The myocutaneous flap is advanced to fill the defect without tension. Burow’s triangles are excised on each side, if needed.
Make an incision through the skin and raise the flap. Within the confines of the orbital rim, the plane should be suborbicularis (preseptal). In the cheek and forehead, the plane should be subcutaneous or in the subcutaneous fat. Applying gentle countertraction on the epidermal surface at the base of the flap will help maintain flap thickness. Undermine the area surrounding the defect to help close the defect without tension. Maintain hemostasis with judicious monopolar or bipolar cautery. Avoid excessive cautery at the base of the flap.
Advance the flap into the defect and close in layers. Close the deeper subcutaneous/dermal layers with buried interrupted polyglactin of appropriate diameter, typically 5-0. Close the superficial layer with running or interrupted monofilament, such as 6-0 polypropylene.
The same procedure can be performed on the opposite side of the defect (“O-to-H”) if it is larger and needs a double advancement flap to close without tension.
Maintaining small subcutaneous fat lobules on both the raised and donor bed aspects of a skin flap will help preserve the subdermal and dermal vascular plexuses. Perfusion pressure, which is reduced by tension on a flap’s closure, must exceed arterial critical closing pressure to avoid flap ischemia.
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