Journal of Plastic, Reconstructive & Aesthetic Surgery (2015) 68, 1235e1241
Combined flaps based on the superficial temporal vascular system for reconstruction of facial defects Renpeng Zhou, Chen Wang, Yunliang Qian*, Danru Wang* Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, School of Medicine, Shanghai JiaoTong University, 639 Zhi Zao Ju Road, Shanghai 200011, PR China Received 20 December 2014; accepted 26 April 2015
KEYWORDS Combined flaps; Superficial temporal vascular system; Facial defect; Multicomponent deficiencies
Summary Background: Facial defects are multicomponent deficiencies rather than simple soft-tissue defects. Based on different branches of the superficial temporal vascular system, various tissue components can be obtained to reconstruct facial defects individually. Methods: From January 2004 to December 2013, 31 patients underwent reconstruction of facial defects with composite flaps based on the superficial temporal vascular system. Results: Twenty cases of nasal defects were repaired with skin and cartilage components, six cases of facial defects were treated with double island flaps of the skin and fascia, three patients underwent eyebrow and lower eyelid reconstruction with hairy and hairless flaps simultaneously, and two patients underwent soft-tissue repair with auricular combined flaps and cranial bone grafts. All flaps survived completely. Donor-site morbidity is minimal, closed primarily. Donor areas healed with acceptable cosmetic results. The final outcome was satisfactory. Conclusion: Combined flaps based on the superficial temporal vascular system are a useful and versatile option in facial soft-tissue reconstruction. ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Introduction Facial bone and soft-tissue defects are always accompanied with facial trauma, tumor, malformation correction, or
* Corresponding authors. E - m a i l a d d r e s s e s : q i a n y u n l i a n g @ 1 2 6 . c o m ( Y. Q i a n ) , [email protected] (D. Wang).
burns. Facial defects represent a unique challenge as its unique anatomic layers are associated with facial aesthetic units. The peripheral units include the forehead, cheek, and mentum, and the central units consist of the nose, eye, and lip. Furthermore, each unit has its own subunit as well as anatomical structure, and different unit’s color, thickness, texture, and shape. Most of these defects can be reconstructed with various types of local flaps. Optimal tissue should meet both the
http://dx.doi.org/10.1016/j.bjps.2015.04.022 1748-6815/ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
1236
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aesthetic and structural characteristics. Full-thickness facial defects may involve cutaneous, fascial, cartilaginous, or bony tissue simultaneously. Combined flaps should be considered for multicomponent deficiency, whereas local flaps need a combination of several flaps harvested at several donor sites. Various combined flaps1 can be designed based on the superficial temporal vascular system for the superficial temporal artery network can provide both various individual flaps and different tissue components such as calvarial bone,2 helical cartilage,3 fascia,4 and skin with or without hair.5 These tissues can be elevated as either a composite or a chimeric flap. Here, we report our experience with the combined flaps based on the superficial temporal vascular system for the reconstruction of facial defects in 31 patients over a 10year period.
Materials and methods Anatomy With the increasing use of the temporal flap, a number of anatomical studies of the superficial temporal vascular system6,7 have been documented. Though the anatomical observation and statistics differ in detail, the analysis indicated that the temporal vascular system is relatively constant. The superficial temporal artery is a terminal branch of the external carotid artery. Ascending between the tragus and the posterior root of the zygomatic arch, the superficial temporal artery nourishes the widespread territory including the frontal, temporal, parietal, and auricular regions. It gives off a middle temporal artery and a superior auricular branch in front of the auricle; then, it bifurcates into the frontal and parietal branches at the level superior to the zygomatic arch. The frontal branch further divides into the anterofrontal, centrofrontal, as well as posterofrontal branches (Figure 1). In anatomical layers, the superficial temporal artery lies in the superficial temporal fascia at the level of superficial musculoaponeurotic system (SMAS), and it runs into the deep temporal fascia at the
Figure 1
level superior to the temporal line; then, it gives off multiple perforators to the periosteum and the outer layer of calvaria. The skin and superficial temporal fascia are mainly supplied by the superficial temporal artery, whereas the middle temporal artery is mainly distributed at the deep temporal fascia.
Patients Thirty-one patients with various facial tissue defects received the combined flaps based on the superficial temporal vascular system as primary reconstruction.
Surgical method Double island flaps Double fasciocutaneous flaps are raised in the subfascial plane based on the anterofrontal and centrofrontal branches, respectively. Then, the double island flaps are transferred to the recipient sites through the subcutaneous tunnel. The donor site is closed primarily if the width of the flap is less than approximately 4 cm, and it is covered with skin grafts in the patients with a larger defect. Auricular combined flaps The elevated auricular combined flaps include the preauricular area and the helical rim with blood supplied by the branch of the superficial temporal artery in a retrograde fashion. The helical-rim flap including is designed according to the defect size and unit principle. The defect of donor site is repaired with an advancement flap of the remaining helical rim. The superficial temporal fascial flap can be designed with the helical-rim flap to fill the subcutaneous tissue deficiency. Then, the combined flaps are transferred to restore the defect. Hairy and non-hairy chimeric flaps Hair-bearing skin island flaps based on the posterofrontal branch or the parietal branch, depending on the defect size, can be designed around the posterofrontal branch or the parietal branch of the ipsilateral superficial temporal artery. The direction of the hair growth is considered
The anatomy of the branches of the superficial temporal artery in patients (A) and fresh cadavers (B).
Reconstruction of facial defects acceptable, and the vascular pedicle is confirmed adequate to transfer to the recipient site such as the eyebrow or the mustache. Another hairless fasciocutaneous flap is elevated to cover the adjacent defect. The chimeric flap is then transferred to the recipient sites through the subcutaneous tunnel. The pedicles of the flap are divided secondarily 3 weeks later. Combined auricular composite with temporoparietal osteofascial flap With the incision made at the subfollicular layer, the galea and fascia are incised larger than the edge of the designed bony component. Using a bur and curved osteotomes, the outer layer of the calvaria and superior periosteum and galea are harvested. The osteofascial flap can be transferred into the defect of maxilla, zygoma, or mandible. Another auricular composite flap is designed as the chondrocutaneous flap mentioned earlier. Then, the combined flap are passed through the tunnel or transferred as free flap.
1237
Case reports Case 1 A 38-year-old man was admitted to our department with postburn deformity. He lost the right eye and an eyebrow (Figure 2A). A hairy skin flap based on the parietal branch and a hairless skin flap based on the frontal branch were designed. The ipsilateral fasciocutaneous flap based on the parietal branch was used to reconstruct the defect of the eyebrow, whereas the fasciocutaneous flap based on the frontal branch was used to restore the lower eyelid (Figure 2B and C). An ocular prosthesis was encased in the eye socket. With 6 months of follow-up, the flaps and reconstructed eyebrow were in good shape, with no ulcers and scar contracture (Figure 2D). Case 2 A 40-year-old man was admitted to our department with posttraumatic facial deformity, present at the right nasal alar deformity and a step deformity and bony concave at
Figure 2 Case 1: (A) Patient with postburn defects. (B) Design of a chimeric flap. (C) The ipsilateral fasciocutaneous flap was used to reconstruct the defect of the eyebrow; the fasciocutaneous flap restores the lower eyelid. (D) A view at 6 months post operatively; the eye prosthesis fits well in the new eye socket.
Figure 3 Case 2: (A and B) The patient has deformity of the right nasal alar and inferior orbital wall by motor vehicle collision. (C and D) Dissection of the local recipient angular vessels. (E and F) Design of the contralateral auricular composite flap and temporoparietal osteofascial flap for nasal alar and orbital wall, respectively. (G and H) The bony step of the orbital region was restored (15 months) postoperatively.
Reconstruction of facial defects the infraorbital margin of the maxilla (Figure 3A and B). On the affected side, the angular artery and vein were dissected as recipient vessels (Figure 3C and D). A contralateral auricular composite flap and temporoparietal osteofascial flap were designed and elevated, and then transferred as a free flap (Figure 3E and F). The nasal alar deformity was corrected by an auricular composite flap. The osteofascial flap, measuring about 4 5 cm in size, was used to reconstruct the orbital wall of the maxilla. With 15 months of follow-up, the flaps were in good shape, with no pigmentation and scar contracture (Figure 3G and H). Case 3 A 18-year-old girl was admitted to our department with congenital left heminasal hypoplasia associated with Tessier facial clefts (Figure 4A). The operation was performed; nasal defect was constructed by a contralateral auricular combined flap as described above. The donor site was closed primarily, and the flap survived (Figure 4B and C). With 6 months of follow-up, although ectropion and
1239 epiphora of the left lower eyelid still exist, the appearance of the nose is relatively normal, and good color match and shape were obtained (Figure 4D).
Results All flaps survived completely. Thirty-one patients were followed up for 3e9 months. Donor sites healed with acceptable appearance. Aesthetically and functionally satisfied outcomes were achieved in all the patients.
Discussion The facial defect required the delicate restoration of the aesthetic units and anatomic layer rather than “fill the hole.” The nose, eyelids, and lips are relatively more prominent units in the face, and each unit has its own unique subunits. The nasal unit is divided into subunits, consisting of the tip, dorsum, columella, a pair of sidewalls,
Figure 4 Case 3: (A) A patient with Tessier facial clefts. (B) Design of the auricular combined flaps for defect. (C) A contralateral helical-rim flap was harvested to reconstruct the alar deformity; the superficial temporal fascia was used for the insertion underneath the sidewall. (D) Postoperative appearance (6 months) with natural nasal contour.
1240 soft triangles, and alar lobule. And the periocular surgical zones8 can be divided into the upper eyelid, lower eyelid, medial canthal region, lateral canthal region, and outside (majorly consisting of eyebrows). In the anatomic structure, the nose is composed of skin, cartilage, bony support, and lining, whereas the full-thickness eyelid defects involve the skin, muscle, tarsal plate, and conjunctiva; sometimes, the medial or lateral canthal ligament is also included. The use of various local and distant flaps has been reported for the reconstruction of the facial defects. The bilobed flap is appropriate for the reconstruction of the soft-tissue defects of the face,9 especially nasal defects.10 The nasolabial flap is also widely used in facial defects due to its good match in texture and good contour.11 The median or paramedian forehead flap is useful in resurfacing large soft-tissue defects.12,13 However, as a transposition flap, the bilobed flap is limited in motion of the point of rotation. The forehead flap is transferred in two stages traditionally.14 In addition, all of these flaps are not sufficient for a full-thickness nasal defect. The distant flap always appears as a mismatched patch within the residual surrounding facial skin.15 Local or perforator flaps based on the superficial temporal vascular system16,17 have been used for the reconstruction of facial small-sized defects for its color and texture match. Relatively, the versatile combined flaps based on the superficial temporal vascular system are superior in several aspects. First, the combined flaps can be designed as simultaneously multiple types of tissues. Components including the calvarial bone and the conchal cartilage framework can provide support as a platform and a cartilaginous structure. Shape and contour can be modified independently with the fascia and skin flaps. Second, the multiple tissue components are supplied by the single major superficial temporal artery. In the case of a fullthickness or wide-range defect, compared with multiple donor sites as other local or distant flaps, all the components can be elevated from a single donor site. In addition, the color of the temporal skin matches the adjacent facial skin. The hairy parietal and non-hairy frontal flaps are useful to restore facial defects, which may include hairy flaps such as eyebrows or mustache and hairless skin. The frontal branch runs to the front of the head, and it lies in the temporoparietal fascia, which courses close to the frontal branch of the facial nerve. When dissecting in the superficial fascial layer, it is notable to preserve the nerve branch in case of eyebrow ptosis. The superficial temporal vein is thin, and it lies on the surface of the temporoparietal fascia. It divides into one, two, or three major branches, and the venous distribution sometimes is independent of the superficial temporal artery.7 When pedicled flaps are harvested, the long axis of the flap should be designed along the course of the superficial temporal artery and vein whenever possible to keep the venous drainage. Drainage can also be improved by including a sufficient length of the flap and width of the tunnel. Confronted with the independence of the superficial temporal vein from the superficial temporal artery, the width of the fascia pedicle should be preserved 1.5e2 cm approximately to reserve the vena comitans around the branch of the superficial temporal artery. When raising the temporoparietal fascia flap, a dissecting plane should be
R. Zhou et al. just beneath the hair follicles to separate from the overlying cutaneous and subcutaneous layers. It should be performed carefully to avoid complications such as postoperative eyebrow ptosis, venous congestion, or alopecia.
Conclusions The combined flaps based on the superficial temporal vascular system are a valuable choice for facial reconstructive surgery. The benefits of the combined flaps include the multiple types of donor tissues for the complex facial defect. And all the components are harvested from a single donor site. The combined flaps are also suitable for its color and texture match. The results also demonstrate that the versatility of the combined flaps based on the superficial temporal vascular system could meet the aesthetic and structural characteristics for the facial defects.
Conflicts of interest None.
Funding None.
Ethical approval Not required.
Acknowledgments None.
References 1. Tan O, Atik B, Ergen D. Temporal flap variations for craniofacial reconstruction. Plast Reconstr Surg 2007;119(7). 152ee63e. 2. Parhiscar A, Har-El G, Turk JB, Abramson DL. Temporoparietal osteofascial flap for head and neck reconstruction. J oral Maxillofac Surg Official J Am Assoc Oral Maxillofac Surg 2002; 60(6):619e22. 3. Pribaz JJ, Falco N. Nasal reconstruction with auricular microvascular transplant. Ann Plast Surg 1993;31(4):289e97. 4. Collar RM, Zopf D, Brown D, Fung K, Kim J. The versatility of the temporoparietal fascia flap in head and neck reconstruction. J Plast Reconstr Aesthet Surg 2012;65(2):141e8. 5. Kalantar-Hormozi A, Loghmani S, Motamed S. Using hairy and non-hairy retroauricular-temporal composite flap in facial reconstruction. Arch Iran Med 2009;12(6):566e9. 6. Pinar YA, Govsa F. Anatomy of the superficial temporal artery and its branches: its importance for surgery. Surg Radiologic Anat SRA 2006;28(3):248e53. 7. Imanishi N, Nakajima H, Minabe T, Chang H, Aiso S. Venous drainage architecture of the temporal and parietal regions: anatomy of the superficial temporal artery and vein. Plast Reconstr Surg 2002;109(7):2197e203. 8. Spinelli HM, Jelks GW. Periocular reconstruction: a systematic approach. Plast Reconstr Surg 1993;91(6):1017e24. discussion 25e6.
Reconstruction of facial defects 9. Chu EA, Byrne PJ. Local flaps I: bilobed, rhombic, and cervicofacial. Facial Plast Surg Clin North Am 2009;17(3):349e60. 10. Xue CY, et al. The bilobed flap for reconstruction of distal nasal defect in Asians. Aesthetic Plast Surg 2009;33(4):600e4. 11. Kerem H, et al. The cranially based contralateral nasolabial flap for reconstruction of paranasal and periorbital surgical defects. J Plast Reconstr Aesthet Surg 2014;67(5):655e61. 12. de Pochat VD, et al. Nasal reconstruction with the paramedian forehead flap using the aesthetic subunits principle. J Craniofac Surg 2014;25(6):2070e3. 13. Choi JW, et al. Total nose reconstruction using superselective embolisation and a forehead flap: overlooked in recurrent massive vascular malformations of the nose. J Plast Reconstr Aesthet Surg 2010;63(3):423e30.
1241 14. Menick FJ. A 10-year experience in nasal reconstruction with the three-stage forehead flap. Plast Reconstr Surg 2002; 109(6):1839e55. discussion 1856e61. 15. Muresan C, et al. Forehead reconstruction with microvascular flaps: utility of aesthetic subunits. J Reconstr Microsurg 2012; 28(5):319e26. 16. Yamauchi M, Yotsuyanagi T, Yamashita K, Ikeda K, Urushidate S, Mikami M. The reverse superficial temporal artery flap from the preauricular region, for the small facial defects. J Plast Reconstr Aesthet Surg 2012;65(2):149e55. 17. Xu M, Yang C, Li JH, Lu WL, Xing X. Reconstruction of the zygomatic cheek defects using a flap based on the pretragal perforator of the superficial temporal artery. J Plast Reconstr Aesthet Surg 2014;67(11):1508e14.
Combined flaps based on the superficial temporal vascular system for reconstruction of facial defects Renpeng Zhou, Chen Wang, Yunliang Qian*, Danru Wang* Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, School of Medicine, Shanghai JiaoTong University, 639 Zhi Zao Ju Road, Shanghai 200011, PR China Received 20 December 2014; accepted 26 April 2015
KEYWORDS Combined flaps; Superficial temporal vascular system; Facial defect; Multicomponent deficiencies
Summary Background: Facial defects are multicomponent deficiencies rather than simple soft-tissue defects. Based on different branches of the superficial temporal vascular system, various tissue components can be obtained to reconstruct facial defects individually. Methods: From January 2004 to December 2013, 31 patients underwent reconstruction of facial defects with composite flaps based on the superficial temporal vascular system. Results: Twenty cases of nasal defects were repaired with skin and cartilage components, six cases of facial defects were treated with double island flaps of the skin and fascia, three patients underwent eyebrow and lower eyelid reconstruction with hairy and hairless flaps simultaneously, and two patients underwent soft-tissue repair with auricular combined flaps and cranial bone grafts. All flaps survived completely. Donor-site morbidity is minimal, closed primarily. Donor areas healed with acceptable cosmetic results. The final outcome was satisfactory. Conclusion: Combined flaps based on the superficial temporal vascular system are a useful and versatile option in facial soft-tissue reconstruction. ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Introduction Facial bone and soft-tissue defects are always accompanied with facial trauma, tumor, malformation correction, or
* Corresponding authors. E - m a i l a d d r e s s e s : q i a n y u n l i a n g @ 1 2 6 . c o m ( Y. Q i a n ) , [email protected] (D. Wang).
burns. Facial defects represent a unique challenge as its unique anatomic layers are associated with facial aesthetic units. The peripheral units include the forehead, cheek, and mentum, and the central units consist of the nose, eye, and lip. Furthermore, each unit has its own subunit as well as anatomical structure, and different unit’s color, thickness, texture, and shape. Most of these defects can be reconstructed with various types of local flaps. Optimal tissue should meet both the
http://dx.doi.org/10.1016/j.bjps.2015.04.022 1748-6815/ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
1236
R. Zhou et al.
aesthetic and structural characteristics. Full-thickness facial defects may involve cutaneous, fascial, cartilaginous, or bony tissue simultaneously. Combined flaps should be considered for multicomponent deficiency, whereas local flaps need a combination of several flaps harvested at several donor sites. Various combined flaps1 can be designed based on the superficial temporal vascular system for the superficial temporal artery network can provide both various individual flaps and different tissue components such as calvarial bone,2 helical cartilage,3 fascia,4 and skin with or without hair.5 These tissues can be elevated as either a composite or a chimeric flap. Here, we report our experience with the combined flaps based on the superficial temporal vascular system for the reconstruction of facial defects in 31 patients over a 10year period.
Materials and methods Anatomy With the increasing use of the temporal flap, a number of anatomical studies of the superficial temporal vascular system6,7 have been documented. Though the anatomical observation and statistics differ in detail, the analysis indicated that the temporal vascular system is relatively constant. The superficial temporal artery is a terminal branch of the external carotid artery. Ascending between the tragus and the posterior root of the zygomatic arch, the superficial temporal artery nourishes the widespread territory including the frontal, temporal, parietal, and auricular regions. It gives off a middle temporal artery and a superior auricular branch in front of the auricle; then, it bifurcates into the frontal and parietal branches at the level superior to the zygomatic arch. The frontal branch further divides into the anterofrontal, centrofrontal, as well as posterofrontal branches (Figure 1). In anatomical layers, the superficial temporal artery lies in the superficial temporal fascia at the level of superficial musculoaponeurotic system (SMAS), and it runs into the deep temporal fascia at the
Figure 1
level superior to the temporal line; then, it gives off multiple perforators to the periosteum and the outer layer of calvaria. The skin and superficial temporal fascia are mainly supplied by the superficial temporal artery, whereas the middle temporal artery is mainly distributed at the deep temporal fascia.
Patients Thirty-one patients with various facial tissue defects received the combined flaps based on the superficial temporal vascular system as primary reconstruction.
Surgical method Double island flaps Double fasciocutaneous flaps are raised in the subfascial plane based on the anterofrontal and centrofrontal branches, respectively. Then, the double island flaps are transferred to the recipient sites through the subcutaneous tunnel. The donor site is closed primarily if the width of the flap is less than approximately 4 cm, and it is covered with skin grafts in the patients with a larger defect. Auricular combined flaps The elevated auricular combined flaps include the preauricular area and the helical rim with blood supplied by the branch of the superficial temporal artery in a retrograde fashion. The helical-rim flap including is designed according to the defect size and unit principle. The defect of donor site is repaired with an advancement flap of the remaining helical rim. The superficial temporal fascial flap can be designed with the helical-rim flap to fill the subcutaneous tissue deficiency. Then, the combined flaps are transferred to restore the defect. Hairy and non-hairy chimeric flaps Hair-bearing skin island flaps based on the posterofrontal branch or the parietal branch, depending on the defect size, can be designed around the posterofrontal branch or the parietal branch of the ipsilateral superficial temporal artery. The direction of the hair growth is considered
The anatomy of the branches of the superficial temporal artery in patients (A) and fresh cadavers (B).
Reconstruction of facial defects acceptable, and the vascular pedicle is confirmed adequate to transfer to the recipient site such as the eyebrow or the mustache. Another hairless fasciocutaneous flap is elevated to cover the adjacent defect. The chimeric flap is then transferred to the recipient sites through the subcutaneous tunnel. The pedicles of the flap are divided secondarily 3 weeks later. Combined auricular composite with temporoparietal osteofascial flap With the incision made at the subfollicular layer, the galea and fascia are incised larger than the edge of the designed bony component. Using a bur and curved osteotomes, the outer layer of the calvaria and superior periosteum and galea are harvested. The osteofascial flap can be transferred into the defect of maxilla, zygoma, or mandible. Another auricular composite flap is designed as the chondrocutaneous flap mentioned earlier. Then, the combined flap are passed through the tunnel or transferred as free flap.
1237
Case reports Case 1 A 38-year-old man was admitted to our department with postburn deformity. He lost the right eye and an eyebrow (Figure 2A). A hairy skin flap based on the parietal branch and a hairless skin flap based on the frontal branch were designed. The ipsilateral fasciocutaneous flap based on the parietal branch was used to reconstruct the defect of the eyebrow, whereas the fasciocutaneous flap based on the frontal branch was used to restore the lower eyelid (Figure 2B and C). An ocular prosthesis was encased in the eye socket. With 6 months of follow-up, the flaps and reconstructed eyebrow were in good shape, with no ulcers and scar contracture (Figure 2D). Case 2 A 40-year-old man was admitted to our department with posttraumatic facial deformity, present at the right nasal alar deformity and a step deformity and bony concave at
Figure 2 Case 1: (A) Patient with postburn defects. (B) Design of a chimeric flap. (C) The ipsilateral fasciocutaneous flap was used to reconstruct the defect of the eyebrow; the fasciocutaneous flap restores the lower eyelid. (D) A view at 6 months post operatively; the eye prosthesis fits well in the new eye socket.
Figure 3 Case 2: (A and B) The patient has deformity of the right nasal alar and inferior orbital wall by motor vehicle collision. (C and D) Dissection of the local recipient angular vessels. (E and F) Design of the contralateral auricular composite flap and temporoparietal osteofascial flap for nasal alar and orbital wall, respectively. (G and H) The bony step of the orbital region was restored (15 months) postoperatively.
Reconstruction of facial defects the infraorbital margin of the maxilla (Figure 3A and B). On the affected side, the angular artery and vein were dissected as recipient vessels (Figure 3C and D). A contralateral auricular composite flap and temporoparietal osteofascial flap were designed and elevated, and then transferred as a free flap (Figure 3E and F). The nasal alar deformity was corrected by an auricular composite flap. The osteofascial flap, measuring about 4 5 cm in size, was used to reconstruct the orbital wall of the maxilla. With 15 months of follow-up, the flaps were in good shape, with no pigmentation and scar contracture (Figure 3G and H). Case 3 A 18-year-old girl was admitted to our department with congenital left heminasal hypoplasia associated with Tessier facial clefts (Figure 4A). The operation was performed; nasal defect was constructed by a contralateral auricular combined flap as described above. The donor site was closed primarily, and the flap survived (Figure 4B and C). With 6 months of follow-up, although ectropion and
1239 epiphora of the left lower eyelid still exist, the appearance of the nose is relatively normal, and good color match and shape were obtained (Figure 4D).
Results All flaps survived completely. Thirty-one patients were followed up for 3e9 months. Donor sites healed with acceptable appearance. Aesthetically and functionally satisfied outcomes were achieved in all the patients.
Discussion The facial defect required the delicate restoration of the aesthetic units and anatomic layer rather than “fill the hole.” The nose, eyelids, and lips are relatively more prominent units in the face, and each unit has its own unique subunits. The nasal unit is divided into subunits, consisting of the tip, dorsum, columella, a pair of sidewalls,
Figure 4 Case 3: (A) A patient with Tessier facial clefts. (B) Design of the auricular combined flaps for defect. (C) A contralateral helical-rim flap was harvested to reconstruct the alar deformity; the superficial temporal fascia was used for the insertion underneath the sidewall. (D) Postoperative appearance (6 months) with natural nasal contour.
1240 soft triangles, and alar lobule. And the periocular surgical zones8 can be divided into the upper eyelid, lower eyelid, medial canthal region, lateral canthal region, and outside (majorly consisting of eyebrows). In the anatomic structure, the nose is composed of skin, cartilage, bony support, and lining, whereas the full-thickness eyelid defects involve the skin, muscle, tarsal plate, and conjunctiva; sometimes, the medial or lateral canthal ligament is also included. The use of various local and distant flaps has been reported for the reconstruction of the facial defects. The bilobed flap is appropriate for the reconstruction of the soft-tissue defects of the face,9 especially nasal defects.10 The nasolabial flap is also widely used in facial defects due to its good match in texture and good contour.11 The median or paramedian forehead flap is useful in resurfacing large soft-tissue defects.12,13 However, as a transposition flap, the bilobed flap is limited in motion of the point of rotation. The forehead flap is transferred in two stages traditionally.14 In addition, all of these flaps are not sufficient for a full-thickness nasal defect. The distant flap always appears as a mismatched patch within the residual surrounding facial skin.15 Local or perforator flaps based on the superficial temporal vascular system16,17 have been used for the reconstruction of facial small-sized defects for its color and texture match. Relatively, the versatile combined flaps based on the superficial temporal vascular system are superior in several aspects. First, the combined flaps can be designed as simultaneously multiple types of tissues. Components including the calvarial bone and the conchal cartilage framework can provide support as a platform and a cartilaginous structure. Shape and contour can be modified independently with the fascia and skin flaps. Second, the multiple tissue components are supplied by the single major superficial temporal artery. In the case of a fullthickness or wide-range defect, compared with multiple donor sites as other local or distant flaps, all the components can be elevated from a single donor site. In addition, the color of the temporal skin matches the adjacent facial skin. The hairy parietal and non-hairy frontal flaps are useful to restore facial defects, which may include hairy flaps such as eyebrows or mustache and hairless skin. The frontal branch runs to the front of the head, and it lies in the temporoparietal fascia, which courses close to the frontal branch of the facial nerve. When dissecting in the superficial fascial layer, it is notable to preserve the nerve branch in case of eyebrow ptosis. The superficial temporal vein is thin, and it lies on the surface of the temporoparietal fascia. It divides into one, two, or three major branches, and the venous distribution sometimes is independent of the superficial temporal artery.7 When pedicled flaps are harvested, the long axis of the flap should be designed along the course of the superficial temporal artery and vein whenever possible to keep the venous drainage. Drainage can also be improved by including a sufficient length of the flap and width of the tunnel. Confronted with the independence of the superficial temporal vein from the superficial temporal artery, the width of the fascia pedicle should be preserved 1.5e2 cm approximately to reserve the vena comitans around the branch of the superficial temporal artery. When raising the temporoparietal fascia flap, a dissecting plane should be
R. Zhou et al. just beneath the hair follicles to separate from the overlying cutaneous and subcutaneous layers. It should be performed carefully to avoid complications such as postoperative eyebrow ptosis, venous congestion, or alopecia.
Conclusions The combined flaps based on the superficial temporal vascular system are a valuable choice for facial reconstructive surgery. The benefits of the combined flaps include the multiple types of donor tissues for the complex facial defect. And all the components are harvested from a single donor site. The combined flaps are also suitable for its color and texture match. The results also demonstrate that the versatility of the combined flaps based on the superficial temporal vascular system could meet the aesthetic and structural characteristics for the facial defects.
Conflicts of interest None.
Funding None.
Ethical approval Not required.
Acknowledgments None.
References 1. Tan O, Atik B, Ergen D. Temporal flap variations for craniofacial reconstruction. Plast Reconstr Surg 2007;119(7). 152ee63e. 2. Parhiscar A, Har-El G, Turk JB, Abramson DL. Temporoparietal osteofascial flap for head and neck reconstruction. J oral Maxillofac Surg Official J Am Assoc Oral Maxillofac Surg 2002; 60(6):619e22. 3. Pribaz JJ, Falco N. Nasal reconstruction with auricular microvascular transplant. Ann Plast Surg 1993;31(4):289e97. 4. Collar RM, Zopf D, Brown D, Fung K, Kim J. The versatility of the temporoparietal fascia flap in head and neck reconstruction. J Plast Reconstr Aesthet Surg 2012;65(2):141e8. 5. Kalantar-Hormozi A, Loghmani S, Motamed S. Using hairy and non-hairy retroauricular-temporal composite flap in facial reconstruction. Arch Iran Med 2009;12(6):566e9. 6. Pinar YA, Govsa F. Anatomy of the superficial temporal artery and its branches: its importance for surgery. Surg Radiologic Anat SRA 2006;28(3):248e53. 7. Imanishi N, Nakajima H, Minabe T, Chang H, Aiso S. Venous drainage architecture of the temporal and parietal regions: anatomy of the superficial temporal artery and vein. Plast Reconstr Surg 2002;109(7):2197e203. 8. Spinelli HM, Jelks GW. Periocular reconstruction: a systematic approach. Plast Reconstr Surg 1993;91(6):1017e24. discussion 25e6.
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