|Year : 1986 | Volume
| Issue : 1 | Page : 57-60
"The red flap" (Arterial pedicle flaps a way out for large lid defects)
Premi Pillai, PO Watts, IS Jain
Department of Ophthalmology, Post Graduate Institute of Medical Education and Research Chandigarh, India
Department of Ophthalmology, Post Graduate Institute of Medical Education and Research Chandigarh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Pillai P, Watts P O, Jain I S. "The red flap" (Arterial pedicle flaps a way out for large lid defects). Indian J Ophthalmol 1986;34:57-60
|How to cite this URL:|
Pillai P, Watts P O, Jain I S. "The red flap" (Arterial pedicle flaps a way out for large lid defects). Indian J Ophthalmol [serial online] 1986 [cited 2020 Feb 27];34:57-60. Available from: http://www.ijo.in/text.asp?1986/34/1/57/26345
In the case presented, the extent of the tumors necessitated wide surgical excisions and repair with pedicle flaps mandatory. The flaps carried with them the security of an excellent blood supply, provided parity as regards skin colour, and allowed themselves to be carved into the conformity of the defect.
| Case report|| |
Case 1. MR a 55-year-old male had a localised 2.5 cm X 2 cm, lobulated, yellowish tumor of the left upper eyelid which showed superficial vascularization, was firm in consistency and involved the tarsal plate with extension through the palpebral conjunctiva as a fungating mass [Figure l]a. Wedge biopsy returned a histopathological diagnosis of meibomian cell carcinoma. Under general anaesthesis the total mass with 0.5 cms of normal tissue margin was excised leaving a large rectangular defect which included the lid margin. It extended medially 0.2 cm from the upper punctum at the lid margin vertically upto the eye brow, laterally from the lateral canthus with an oblique tilt to the lateral margin of the brow and superioly upto the inferior border of the brow the palpebral conjunctiva was excised upto the upper fornix. A Composite graft prepared from the right nostril comprising nasal mucosa (3.5 cms X 3 cms) and septal cartilage (1.5 cms X 1 cm) was fashioned to replace the excised conjunctiva and tarsal
plate. The mucosa was sutured with 5.0 interrupted chromic catgut sutures on three sides to the free edges of the conjunctiva, leaving the lower border free a few slips of orbicularis oculi were attached to the nasal septal cartilage. A Fr ickle flap based at the left temple and extending upto the forehead, incorporating the superficial temporal artery and measuring 6.5 cm X 2.5 cm was raised from its bed. It was rotated anti-clockwise, hinged at the base and sutured to the skin defect with 5,0 interrupted silk sutures. The bed of the pedicle was closed after careful undermining to the edges which allowed adequate apposition of the wound Post-operatively the graft appeared well taken [Figure - 2] but 72 hours after surgery, showed a superficial grey zone of demarcation at the medial third. This eventually healed seven days later, the epithelium of this area was shed exposing viable pink epithelium. The pedicle was divided at the base at the end of 3 weeks and sutured back to the borders of the raw area in the shape of a triangle, the redundant skin being excised [Figure - 3]. Post operative results were satisfactory. Adequate closure of eyelids was possible there was no exposure of the cornea and the cosmetic appearance was good. No tumor recurrence after 1 year follow up.
S. K., a 70 year-old female had as ulcerated at the left medial canthus, extending horizontally along the entire lower lid upto the lateral canthus, and including one centimetre of the medial part of upper lid. It measured 4 cms horizontally and 2-5 cms vertically., Its lower limit was the orbital margin. The floor of the ulcer was filled with irregular fungating tissue, the base was free from the underlying bone and the edge was everted [Figure 4]. The biopsy report read basal cell carcinoma.
Under general anaesthesia the tumor mass with 0.5 cms of surrounding normal tissue was excised, the area included, 1.5 cm of medial part of upper lid, the entire medial canthus region and the total lower lid including a part beyond the lateral canthus. A dacrocystectomy was carried out. A forehead flap (6 cm X 3.0 cm) in the supratrochear arterial territory was fashioned. based on the glabella and hinged downwards. The flap was designed so as to fit both the upper and lower lid defects plus the medial canthus, in the shape of a two unequal pronged fork with the short prong for the upper lid and the longer one for the lower [Figure 5]. The conjunctiva of the lower fornix and part of the spared palpebral conjunctiva of both lids were sufficient to line the raw surface of the graft. No rigid support was required for the lower eyelid as the forehead skin made good for a tarsal plate. The forehead defect was closed by undermining the edges and apposing them. Forty eight hours post-operatively the wound was inspected; it showed some oedema at the site but with a good viable graft. The pedicle was cut at the base at the end of the 3rd week, the redundant part excised, the base fashioned in the form of a triangle and sutured back to the defect on the forehead. After suture removal, the result was cosmetically acceptable, No recurrence of the lesion was observed during a 2J years follow-up.
D. F. a 40-year-old male first presented to us in March 1982 with a mass on the lateral canthus of the left eye which had been in completely excised previouly. On examination, the growth in the lateral canthus showed scarred and puckered skin (the result of previous incomplete excision) the mass was deep, firm in consistency with no bony involvement [Figure 6]. Histopathological diagnosis was meibomian gland carcinoma. The whole tumor with its deeper extension was excised The defect left, included the entire lateral rectus muscle and the lateral halves of both eyelids.
A temporal pedicle flap measuring 6.58 cms X 3.5 cms and icorporating the superficial temporal artery was fashioned and rotated down and sutured over the defect with interupted 5-0 silk sutures [Figure 7].
Mobilized conjunctival flap from the supierior and inferior fornix were sutured to the posterior surface of the pedicle. Division of the pedicle was done three weeks post operative.
The palpebral aperture was lengthened and reconstructed at a second sitting. The final results were satisfactory [Figure 8] and no recurrences noted during a two year follow up.
| Discussion|| |
In all our cases, the edges of widely excised tumors showed no evidence of malignancy. There was a 100% take of the pedicle grafts in all cases.
The patients received a cosmetically acceptable reconstructed lid or lids in terms of colour of skin, movement of lids and an adequate palpebral aperture. The composite graft in case I took in spite if a free lower margin. The pedicle flaps in case II and II had the unique advantage that it could be so fashioned as to cover the complicated defects in the canthal region and lids.
In all three cases the pedicle flaps used were local, single, open compound and of rotation type incorporating in the first and third cases, the superficial temporal as arteriovenous systems and in the second, the supratrochlear arterio-venous complex. Only in the first case was a composite graft (mucosa with cartitoge) given with the skin pedicle.
The length width ratios worked out for pedicles are 2½ to 3:1. Ibis depends on (1) the vessel in the pedicle (2) the vascularity of the area (3) the age of the patient. The pedicle to be transferred to the defect is measured to be slightly larger than the defect with a measure tape. In our cases, flaps were fachioned from the temporal and forehead area in ratios ranging from 2.6:1 in the first patient 2 : 1 in the second and 1.8:1 in the third. In this area, however, due to the rich vascularity, lengths and width of the flaps can be latered with scare impunity, as Milton has strongly emphasised that pedicle flaps survival does not support a clearly defined relatiorsbip between length and width.
Division of the pedicle has been carried out as early as the seventh day or upto the fifteenth day. In all our cases pedicles were divided on the 3rd post-operatively given good results.
| Summary|| |
Three cases of localized lid malignancies after surgical resection left large lid and canthal defects. One had a 90% loss of upper lid upto the eyebrow; the other had a larger defect involving the entire medial canthus, total lower lid margin and medial third of upper lid, and the third had extensive lateral canthal involvement, Surgical reconstruction mobilizing local compound pedicle flaps, incorporating well defined 100% take with acceptable cosmestic appearances and no recurrence of the malignancies.
| References|| |
Hoopes. J.E., 1976, Pedicle Flaps an overviewSymposium on Basic Science in Plastic Surgery Vol. 15. Saint Louis C.V. Mosby. 1976.jPg. 241-256.
Milton, S.H., 1970, Br. J. Surg. 57: 502.
[Figure - 1], [Figure - 2], [Figure - 3]