British _%foernal ofPlastic Surgery (1977), 30, 14-16
A FREE GROIN FLAP RECONSTRUCTION IN PROGRESSIVE FACIAL HEMIATROPHY By TAKAOHARASHINA, M.D., TATSUONAKAJIMA,M.D. and YOKOYOSHIMURA, M.D. Department of Plastic and Reconstructive Surgery, Keio University Hospital, 35 Shinanomachi Shinjukuku, Tokyo, Japan 160
THE treatment of progressive facial hemiatrophy (Romberg’s disease) has long been unsatisfactory; bulky free grafts take badly while pedicled flaps are time consuming and scar producing. Tissue transfer by microvascular anastomoses would seem to offer greater possibilities of success and already Fujino et al. (1975) have used a free deltopectoral flap and Dr Seiichi Ohmori (personal communication) has used omentum to replace the lost subcutaneous tissue. But the former leaves unacceptable scars on a woman and the latter involves opening the abdomen. In the case presented we decided
Fig. FIG. 2.
I. Facial
herniatrophy
in a z8-year-old
woman.
The dotted line is the proposed incision, the solid lines the extent of the undermining. arrows indicate the position of the facial vessels. 14
The
FREE
GROIN
FLAP
FIG. 3.
FIG. 4. FIG. 5.
RECONSTRUCTION
Immediately
IN
PROGRESSIVE
FACIAL
HEMIATROPHY
15
after the groin flap had been sutured in place.
The flap survived completely
Two months after the second operation
and the deformity
when the remaining removed.
has been over-corrected. groin skin and excess fat had been
16
BRITISH JOURNAL OF PLASTIC SURGERY
to use a free groin flap to avoid these problems. later, a z-stage procedure was planned.
For reasons which will be discussed
CASE REPORT A z&year-old woman first noticed the progressive atrophy of the left side of her face when she was 24. She had been referred to us 18 months previously but the disease was still progressing and operation was postponed until the condition seemed stable (Fig. I). At operation the facial skin was raised over the depressed area through a long submandibular incision and the facial artery and vein were dissected free (Fig. 2). A groin flap 6 x 18 cm was raised and the nutrient vessels anastomosed to the facial vessels. The upper half of the groin flap was denuded of its epidermis and placed subcutaneously; the skin covering the remainder was sutured into the submandibular wound (Fig. 3). The bulk of the flap was such that the deformity was over-corrected. The flap survived completely (Fig. 4). The second operation was carried out when the oedema had subsided. The remaining flap skin and the excess fat were resected (Fig. 5). The resected tissues were macroscopically and histologically normal. DISCUSSION There are several advantages in making this a 2-stage procedure and-leaving part of the flap skin in the submandibular wound at the first operation. The flap may be readily monitored during its early postoperative course. The facial skin in Romberg’s disease is shrunken and, if the submandibular wound were to be closed immediately over the bulky flap, the increased skin tension might well kill the flap. A planned second stage enables the defect to be over-corrected at the first stage and the excess fat removed when the size and shape have become stable. It is dangerous to trim fat from a free flap primarily. In extreme cases of facial skin deficiency some of the groin flap skin might be retained at the second stage, but in this patient and probably in most, the colour match was unsatisfactory. REFERENCE FUJINO, T., TANINO, R. and SUGIMOTO,C. (1975). Microvascular transfer of free deltopectoral dermal-fat flap. Plastic and Reconstructive Surgery, 55, 428.
A FREE GROIN FLAP RECONSTRUCTION IN PROGRESSIVE FACIAL HEMIATROPHY By TAKAOHARASHINA, M.D., TATSUONAKAJIMA,M.D. and YOKOYOSHIMURA, M.D. Department of Plastic and Reconstructive Surgery, Keio University Hospital, 35 Shinanomachi Shinjukuku, Tokyo, Japan 160
THE treatment of progressive facial hemiatrophy (Romberg’s disease) has long been unsatisfactory; bulky free grafts take badly while pedicled flaps are time consuming and scar producing. Tissue transfer by microvascular anastomoses would seem to offer greater possibilities of success and already Fujino et al. (1975) have used a free deltopectoral flap and Dr Seiichi Ohmori (personal communication) has used omentum to replace the lost subcutaneous tissue. But the former leaves unacceptable scars on a woman and the latter involves opening the abdomen. In the case presented we decided
Fig. FIG. 2.
I. Facial
herniatrophy
in a z8-year-old
woman.
The dotted line is the proposed incision, the solid lines the extent of the undermining. arrows indicate the position of the facial vessels. 14
The
FREE
GROIN
FLAP
FIG. 3.
FIG. 4. FIG. 5.
RECONSTRUCTION
Immediately
IN
PROGRESSIVE
FACIAL
HEMIATROPHY
15
after the groin flap had been sutured in place.
The flap survived completely
Two months after the second operation
and the deformity
when the remaining removed.
has been over-corrected. groin skin and excess fat had been
16
BRITISH JOURNAL OF PLASTIC SURGERY
to use a free groin flap to avoid these problems. later, a z-stage procedure was planned.
For reasons which will be discussed
CASE REPORT A z&year-old woman first noticed the progressive atrophy of the left side of her face when she was 24. She had been referred to us 18 months previously but the disease was still progressing and operation was postponed until the condition seemed stable (Fig. I). At operation the facial skin was raised over the depressed area through a long submandibular incision and the facial artery and vein were dissected free (Fig. 2). A groin flap 6 x 18 cm was raised and the nutrient vessels anastomosed to the facial vessels. The upper half of the groin flap was denuded of its epidermis and placed subcutaneously; the skin covering the remainder was sutured into the submandibular wound (Fig. 3). The bulk of the flap was such that the deformity was over-corrected. The flap survived completely (Fig. 4). The second operation was carried out when the oedema had subsided. The remaining flap skin and the excess fat were resected (Fig. 5). The resected tissues were macroscopically and histologically normal. DISCUSSION There are several advantages in making this a 2-stage procedure and-leaving part of the flap skin in the submandibular wound at the first operation. The flap may be readily monitored during its early postoperative course. The facial skin in Romberg’s disease is shrunken and, if the submandibular wound were to be closed immediately over the bulky flap, the increased skin tension might well kill the flap. A planned second stage enables the defect to be over-corrected at the first stage and the excess fat removed when the size and shape have become stable. It is dangerous to trim fat from a free flap primarily. In extreme cases of facial skin deficiency some of the groin flap skin might be retained at the second stage, but in this patient and probably in most, the colour match was unsatisfactory. REFERENCE FUJINO, T., TANINO, R. and SUGIMOTO,C. (1975). Microvascular transfer of free deltopectoral dermal-fat flap. Plastic and Reconstructive Surgery, 55, 428.
