|Year : 2020 | Volume
| Issue : 3 | Page : 135-139
The use of free helical rim flaps for the reconstruction of the ala nasi and lower eyelid
Zulfikar Ulas Bali1, Alper Aksoy2, Levent Yoleri1
1 Department of Plastic and Reconstructive Surgery, Manisa Celal Bayar University, Izmir, Turkey
2 Department of Plastic Aesthetic and Reconstructive Surgery, Konur Hospital, Bursa, Turkey
|Date of Submission||16-May-2019|
|Date of Acceptance||21-Jul-2019|
|Date of Web Publication||26-May-2020|
Dr. Alper Aksoy
Department of Plastic Aesthetic and Reconstructive Surgery, Konur Hastanesi, Zübeyde Hanim Caddesi, Çekirge, Osmangazi, Bursa
Source of Support: None, Conflict of Interest: None
Aims and Objectives: The aim of this study was to present our experience using free flaps harvested from the helix in the reconstruction of the nose and lower eyelid. Materials and Methods: Between 2016 and 2019, 5 male and 2 female patients treated surgically with free helical flaps were included in the study. All defects had occurred due to tumor excision. Results: A total of two lower eyelid defects and five ala nasi defects were reconstructed using free helical rim flaps. Seven helical flaps based on the superficial temporal vessels were obtained and used for reconstruction. No recurrence was detected in any of the patients within the followup period. The only remarkable complication reported was dehiscence development, which was attributed to partial venous congestion in one patient. Free helical rim flaps are similar to the ala nasi and lower eyelids in terms of concave shape, tissue, and color. Conclusion: The results have shown that free helical rim flaps are a suitable option for use in the repair of appropriately sized fullthickness defects of the ala nasi and lower eyelid.
Keywords: Eyelid reconstruction, free helical flap, nose reconstruction
|How to cite this article:|
Bali ZU, Aksoy A, Yoleri L. The use of free helical rim flaps for the reconstruction of the ala nasi and lower eyelid. Turk J Plast Surg 2020;28:135-9
| Introduction|| |
The nose and eyelids have various important characteristics that are similar. They are esthetically important structures because they are among the primary landmarks of the face. Histologically, both are comprised the skin, cartilage, and mucosa tissues; therefore, their reconstruction is significantly more difficult than other tissues. The outcome of reconstruction is not only important for esthetic reasons but also due to the functional roles of the nose and eyes. Unsuccessful reconstruction of the eyelids may cause the development of conjunctivitis, keratitis, and other complications which could lead to visual impairment. In regard to the nose, unsuccessful reconstruction of the ala nasi may result in breathing difficulties, which could lead to numerous secondary problems.
Many techniques have been put forth for the partial or complete reconstruction of these two critical structures. However, the skin and the cartilage of each of these regions form very important functional units. Thus, appropriate reconstruction of these regions requires the use of thin and pliable tissues with cartilage. In addition, the use of such tissues is critical to achieve acceptable esthetic and functional outcomes. Fortunately, the helical rim is similar to these regions with its tissue composition, shape, and color.
The use of free composite auricular flaps based on the superficial temporal (ST) artery was first described in 1984. These flaps became popular in the following years, and various modifications to the procedures were made. In 2018, Lassus et al. were the first to report the use of a flap obtained from the ear for the reconstruction of the eyelid temporal artery posterior auricular skin (TAPAS flap).
In this study, we report the surgical technique and follow-up of 2 lower eyelid and 5 ala nasi reconstructions, which were performed with helical rim flaps between 2016 and 2019.
| Materials and Methods|| |
A total of 5 male and 2 female patients treated surgically with free helical rim flaps between July 2016 and January 2019, for 5 ala nasi and 2 lower eyelid defects were included in the study. The mean age was 59 years, with an age range of 50–65 years. The etiology of all defects was tumor ablation.
Descriptive data, duration of follow-up, comorbidities, complications, and recurrence were recorded together with an assessment of the size of the surgical defect [Table 1].
Preoperative Color Duplex Doppler ultrasonography examination (Philips Ultrasound, Andover, MA, USA) with a 12-3 MHz linear transducer probe was routinely performed for the identification of the exact localization of the temporal superficial vessels and recipient's vessels.
The planning of the flaps was performed after the extent of each defect was fully determined. Flap sizes were designed to be a few millimeters larger than the actual size of the defect.
Operations were performed under general anesthesia with the patients in the supine position. First, all 7 patients underwent total tumor excision with regard to frozen pathology results. Subsequently, full-thickness defects, including three different tissue types developed in all 7 patients [Figure 1]. The ipsilateral ear was used as the flap source, and we planned to include the root of the helix and adjacent periauricular skin in the flaps [Figure 2]. The flap area was visualized by drawing and the size of each flap was designed to be a few millimeters larger than the defect. Before advancing to the dissection of the flap, recipient vessels were prepared and the decision for anterograde or reverse pedicle placement was decided based on the distance between the defect and recipient vessels. The first choice recipient vessels were identified as the angular vessels, and they were dissected after Doppler examination. In two patients, the angular vessels were deemed insufficient. In these two patients, recipient vessels were determined as the facial artery and vein which were then appropriately prepared. In order to avoid the requirement of a graft to reach the facial artery and vein, we obtained a long pedicle by following the temporal superficial vessel to the major temporal bifurcation, as reported elsewhere [Figure 3].
|Figure 1: Basal cell carcinoma was excised, the resultant full-thickness right alar defect and distance to facial vessels|
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The procedure was begun with an incision from the upper pole to the ear lobe. The ST vein (STV) was dissected until its maxillary branches and then, the dissection was continued toward the cranial. The ear-supplying anterior STV branches within the flap area were tied. All structures between the flap and the STV remained untouched; therefore, the anterior artery and vein of the ear were preserved. Finally, the skin and cartilage incisions of the flap were performed according to prior tracing, and the flap was obtained. In patients where a longer pedicle was required, the dissection was continued toward the frontal area as necessary, and a reverse-flow flap was obtained after the STV was tied at the caudal side of the flap. In patients where the recipient vessel was the facial vessel (s), a tunnel was opened between the defect area and recipient vessels through blunt dissection. In the final step, the vessels of the flap were carried to the recipient vessels with the help of a silicone catheter, and a Penrose drain was placed at the site. The donor site was closed through rotation and advancement [Figure 4] and [Figure 5].
During the surgery, patients received 5000 units of heparin as the anastomosis was begun. A total of 100 mg of enteric coated aspirin was started in all patients at postoperative day 1. The condition of the flap was monitored with direct inspection of the color and Doppler imaging. Patients were discharged after an average of 5 days of follow-up as inpatients. Head elevation was ordered for 2 weeks, and aspirin was continued for 3 weeks.
| Results|| |
A total of seven free helical flap reconstructions were performed for 2 lower eyelid and 5 ala nasi defects. Flap dimensions ranged from 3.5 cm × 2.5 cm to 2.2 cm × 1.5 cm. The mean surgery duration was 4 h.
In the two patients with lower eyelid reconstruction, [Figure 6], [Figure 7], [Figure 8] flaps were anterograde, and the angular artery and vein were used as recipient vessels. Among the 5 patients with ala nasi reconstruction, recipient vessels were angular in 3 and facial in 2. In the latter 2 patients, venous congestion was observed on postoperative day 1 and continued for 3–4 days; however, Doppler examination showed the presence of venous flow; thus, the intervention was deemed unnecessary. The color of the flap returned to normal after the 4th day in all patients.
|Figure 6: Excised lesion with a 2.4 cm × 1.5 cm full-thickness lower eyelid defect|
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One of the patients who received alar rim reconstruction developed minimal dehiscence, but secondary recovery was observed. No other complications were determined in the early postoperative period. Total follow-up durations ranged from 5 to 30 months, and no recurrence was found in any of the patients.
Among the two patients who underwent lower eyelid reconstruction, 1 described a stinging sensation at the flap region. In the second patient, the conjunctiva was repaired with an oral mucosa graft. In addition, the helical rim flap was removed without including the skin to the inferior and was placed on top of the mucosa. The patient had no complaints during the early and late period. One patient was unhappy with the deformity at the donor site (ear), this complaint was addressed with the application of two Mustarde stitches to the donor site at postoperative 3 months.
Apart from the aforementioned complications and complaints, no other problems were observed or reported. The esthetic and functional results of all patients were satisfactory.
| Discussion|| |
Skin cancers are frequently seen on the nose and around the eye as these areas are exposed to direct sunlight. In addition, esthetic and functional losses in these areas may develop due to causes such as trauma and burns.
The ala nasi and the eyelids are among the most challenging structures in terms of reconstruction. Their three-dimensional anatomy makes reconstruction a complex task, especially in the presence of full-thickness defects. Esthetically speaking, surgeons aim to achieve minimal donor site morbidity and acceptable shape in the reconstruction of the nose and eyelid. However, the characteristics of these structures warrant reconstruction with like-for-like tissue to achieve esthetic success. Usually, local flaps are the only tissues that can meet these demands; but the advantages of this approach are undercut by visible donor site scarring, and moreover, local flaps may not be available or feasible.
Various techniques have been described for the reconstruction of full-thickness ala nasi and eyelid defects. In regard to nasal defects, various local and pedicled flaps have been described such as the bilobed flap, nasolabial flap, cranial-based nasolabial flap, forehead flap (with modifications), reverse auricular flaps, and ST fascia island flap. However, these local flaps do not contain all anatomic layers. Furthermore, interpolation flaps generally necessitate two or three operations with an evident donor site scar. Reconstructions with various free flaps, such as radial forearm flaps, foot dorsum flaps, and postauricular flaps, have also been described; however, they are disadvantaged by often requiring multiple operations, having large volume, not including all three anatomical layers, and also their differences from the original tissue in terms of color, texture, and shape.
In the reconstruction of lower eyelid defects, acceptable results have been achieved for the repair of the anterior and posterior lamella with various local options and single or multiple local flaps used with regard to defect size. As a general principle, eyelid reconstruction is described based on the size of the defect: lateral cantholysis, primary repair without cantholysis in cases with <50% tissue loss, tarsoconjunctival flap and graft in cases with tissue loss in excess of 50%, and composite nasal chondromucosal grafts with cheek flaps in defects with >75% defects. There are various potential complications of lower eyelid reconstruction, such as ectropion, flap bulkiness, and wound contraction. Ectropion has been reported as being the most common problem, seen in 2.5%–7% of cases. Furthermore, local flaps cause significant donor site scarring which is an important problem.
The chondrocutaneous graft of the helical rim is similar to the ala nasi and lower eyelid in terms of shape, structure, and color. The reconstruction is also made easier due to the capability to reshape the flexible periauricular tissues as required. Despite these significant advantages, helical rim grafts have the disadvantage of not having sufficient vascular supply. Thus, these grafts are used in defects with a maximum size of 1 cm × 1.5 cm. In the presence of larger defects, helical rim tissue is used in the form of flaps, including the ST vessels. In this study, we used free helical rim flaps in the reconstruction of full-thickness nose defects larger than 1.5 cm, and lower eyelid defects larger than 1.5 cm which could not be treated through cantholysis + primary closure (>50% tissue loss).
The first description of a free composite auricular flap including the ST artery was in 1984. Several advances were then made based on this initial description, one being the reverse-flow variation described by Lin et al. These techniques and various modifications received widespread adoption and were used in other structures and procedures. In 2002, successful reconstruction of a 3.0 cm × 2.0 cm wide nasal columella defect with a chondrocutaneous microsurgical free flap from the root of the auricular helix, was presented by Ozek et al. Furthermore, the use of a reverse pedicle flap with increased pedicle length and facial vessel anastomosis was reported by Duygu et al. in 2012 and Castello et al. in 2014., The lack of valves in the STV was shown in a study by Zhang et al. Thus confirming that reversed harvest would avoid the requirements for any grafts when performing anastomosis to recipient vessels.
In the current study, we also used the facial vessels as recipients through lengthening the pedicle in two patients whose angular vessels were deemed insufficient. This was attributed to the possibility that the angular arteries were branched from the ophthalmic or infraorbital arteries; as suggested by to two prior studies: Loukas et al. detected that the facial artery terminated as the angular artery in 51.4% of their cases (284 hemi-faces), while others ended as the superior labial or lateral nasal artery or as a simple rudimentary branch. Hou et al. examined 22 hemi faces and found that the angular artery was consistently present in their specimens; however, it originated from the ophthalmic or infraorbital artery in about 64% of the specimens.
In 2018, Jeong et al. described the use of the helix-supplying perforator of the temporal superficial artery and its accompanying vein as pedicles to which end-to-side anastomosis was performed to angular vessels. With this approach, they achieved a technique that provided less scarring with shorter pedicles.
In our series, we performed 7 helical rim flaps: 5 for ala nasi and 2 for lower eyelid reconstruction. We used the temporal superficial vessels as pedicles in all patients. In 2018, Lassus et al. described a new auricular flap for lower eyelid reconstruction. They used the TAPAS flap, which is based on the same ST vascular axis. This flap was harvested from the retroauricular region. To our knowledge, our study is the first to describe the use of helical flaps in lower eyelid reconstruction.
One of the patients receiving eyelid reconstruction described a stinging sensation around the flap, which did not regress during the early postoperative follow-up. In the second patient, the conjunctiva was repaired with an oral mucosa graft and the helical rim flap, which was removed without including the skin to the inferior, was placed on top of the mucosa. Esthetic and functional results were deemed to be almost ideal in the two lower eyelid reconstruction, and no significant complaints were noted during the early and late period. The results of the ala nasi procedures were also acceptable, both esthetically and functionally. None of the patients had retractions in excess of what was expected (we designed the flaps a few millimeters larger than the defect size).
Despite its advantages, this technique has some limitations. The procedure takes longer time compared to local techniques, it requires the use of microsurgical instruments, and the surgeon must have significant experience in microsurgery to achieve good results.
| Conclusion|| |
Reconstruction is challenging in tissues such as the nose and eyelid due to their tissue composition. Functional outcome and its direct relationship with the reconstruction are factors that pose a risk and increase the importance of the surgical procedure and approach. Free helical rim flaps are structurally similar to these regions in terms of composition, shape, and color. We believe this technique is an important addition to the literature for the reconstruction of full-thickness >1.5 cm nose defects, and lower eyelid defects which could not be treated through cantholysis + primary closure (>50% tissue loss).
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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