Split Lateral Forehead Flap for Reconstruction of Upper and Lower Eyelids

Background: Eyelids reconstruction after tumor resection has be one of the most challenging procedures in reconstructive plastic surgery. Small defects may be closed by primary suture or covered by small local flaps or skin graft. But in large eyelids defects, we need to find a bigger source of color and texture matching tissue that will ensure functional and aesthetical outcomes. Many techniques have been described, but in this case, the author suggest a split lateral forehead flap designed to cover upper and lower eyelids. Patient and Operation Techniques: A Male 51 years-old-patient, presented himself in our clinic with a basal cell carcinoma involving the right upper and lower eyelids. The tumor had a history of 7 years, without any pain or vision disorders involved. Tumor was widely excised, leaving a full thickness on upper and lower eyelids. The inner lining palpebral was replaced by composite auricular graft following by lateral cantophexy. A lateral forehead flap raised with a right temporal pedicle, and the distal part of flap was split in half, and inset into the upper and lower eyelids defect. The donor region was closed with an STSG from Femur Dextra. After 14 days the flap was divided, the functional result was excellent. Discussion: At first, surgeons were worried of raising forehead flaps beyond the midline, fearing that by splitting the distal flap would cause its compropmise. However, rich anastomostic plexus exists between the major forehead angiosomes lined by the smaller calibre “choke” vessels. Conclusions: Periorbital Basal cell carcinoma resection may leave great defect to the underlying tissue. The need to provide adequate support to this structure requires complex techniques with minimum two flaps. In our case, we performed a split lateral forehead flap with a good functional and cosmetic outcome.

asal cell carcinoma (BCC) has a predilection for the periorbital region, which is a special, prominent, cosmetic, functional area to protect the eyeball. For squamous cell carcinoma and melanoma, extensive resection with reconstruction is performed. In contrast, for BCC, resection is often confined to a small to medium-sized area, necessitating higherquality reconstructive surgery (Kakudo, 2009). These tumors are usually diagnosed by incisional biopsy. Following tumor removal in the periocular region, reconstruction of the defect requires understanding of the differences and uses of soft tissue flaps and skin grafts (Hayano, 2012). Many techniques have been described and its can be classified considering the anatomical area requiring treatment: superior eyelid, inferior eyelid, and inner or external canthus (Actis, 2011). Flaps are usually preferred over grafts because homogeneity of skin color and texture more likely leads to better unification with surrounding tissue (Fogagnolo, 2012). The ultimate goal of every eyelid reconstruction is to create a stable eyelid margin, to ensure the eyelid has proper dimensions and tension when open and closed, to obtain eyelid symmetry with no rough or uneven internal surfaces, and to optimize aesthetics (Hayano, 2012).
Case Report 51-years-old male was presented with chronic wound since 7 years ago on his right upper and lower eye lid. At first it appears as a nodule which grows slowly, and hardened with a blackened appearance. The computed tomographic scan showed lesions size 1.17x3.11x0.81 cm in the soft tissue of the right periorbital region of the lateral side which infiltrate up to Musculus Orbicularis Oculi and extends to the right palpebra soft tissue. The patological examination confirm it was Basal Cell Carcinoma.

Technique
Tumor was widely excised, leaving a full thickness on upper and lower eyelids. A lateral forehead flap raised with based on the right temporal artery transversely across the forehead. Upon elevation, the flap design encompass the whole forehad area just below the hairline up to the upper edge of eyebrows, from one pedicle reaching the full contralateral forehead. This is done in order to leave a donor defect which suits the forehead aesthethic unit. The flap is elevated just above the pericranium layer, then shaped as necessary into the dimensions needed to cover the primary defect. In this case, the distal part of flap was split in half, and inset into the upper and lower eyelids defect.
Inner lining palpebra superior and inferior was replaced by composite auricular graft then following by lateral cantophexy. The donor region was closed with an STSG from Femur Dextra. Fixation sutures was done pericranial base serves as a rigid and immobile graft bed. To maintain pressure, tieover dressing applied, allow 5 days before the first dressing change. By 24 hour monitoring, it has been showed the survival of flap without any bleeding or ischemic part. After 14 days the flap was divided, the functional result was excellent.   Inner lining palpebra superior and inferior was replaced by composite auricular graft then following by lateral cantophexy. The donor region was closed with an STSG from Femur Dextra. Fixation sutures was done pericranial base serves as a rigid and immobile graft bed. To maintain pressure, tieover dressing applied, allow 5 days before the first dressing change. By 24 hour monitoring, it has been showed the survival of flap without any bleeding or ischemic part. After 14 days the flap was divided, the functional result was excellent.

Discussion
There are fundamental guidelines that should be followed with every reconstruction effort. First, the surgeon should assess the defect. This patient had large defect involves right upper and lower eyelids due to wide excision of tumor. There exists no singular flap that can address all full-thickness upper and lower eyelid and medial canthus defects. Thus, a minimum of two flaps is required for these types of combined defects (Motomura et al., 2006). But in this case the surgeon suggest using split lateral forehead flap rather than use multi techniques.
The forehead flap is acknowledged as the ideal donor for midface reconstruction due to its color and texture match, vascularity, and ability to resurface all or part of the reconstructed area (Thorne, 2014). Its supplied by superficial temporal arteries, and opthalmic arteries each consisting of the supraorbital and supratrochlear arteries (Houseman, 2000). At first, surgeons were worried of raising forehead flaps beyond the midline, fearing that by splitting the distal flap would cause its compromise. However, a vascular study using micropaque injections on the superfacial temporal artery in cadavers shows that rich anastomotic plexus exists between the major forehead angiosomes linked by the smaller caliber "choke" vessels (Mangold, 1980). Fortunately, at 24 hour post operative evaluation, the vascular status of flap was excellent which monitored by observation of color and has no tendencies to bleeding or ischaemia on flap site. After 14 days the flap was divided, the functional result was excellent.

Conclusion
Periorbital Basal cell carcinoma resection may leave great defect to the underlying tissue. The need to provide adequate support to this structure requires complex techniques with minimum two flaps. In our case, we performed a split lateral forehead flap with a good functional and cosmetic outcome.