Journal of Plastic, Reconstructive & Aesthetic Surgery (2006) 59, 747751

A combined ap reconstruction for full-thickness defects of the medial canthal region

Hisashi Motomura*, Toshiko Taniguchi, Teruichi Harada, Michinari Muraoka
Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Osaka City University, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
Received 6 January 2005; accepted 17 November 2005

KEYWORDS
Combined ap; Reconstructive surgery; Medial canthus; Nose; Eyelid

Summary The medial canthus is an aesthetically and functionally important area. Adequate consideration of the local anatomy is essential when reconstructing this area. We developed a combined ap technique with a simple combination of standard aps for the treatment of extensive defects of the nose and upper and lower eyelids, including full-thickness medial canthus defect. In our technique, a median forehead island ap is used for the nasal region, the anterior surface of the eyelid is reconstructed along aesthetic unit, and the posterior surface is reconstructed with a palatal mucoperiosteal graft. A cheek ap is then used for the reconstruction of the lower eyelid. When reconstructing a small defect of the upper eyelid, the upper eyelid is advanced, while a VY advancement ap within the upper eyelid is used for a large defect. To reconstruct the acute angle of the medial canthus, a 0.3 mm titanium wire was passed through the tip of the tarsal plate of the upper and lower eyelids to be reconstructed and was xed in the perforated nasal bone on the affected side. Using this technique, the acute angle of the medial canthus is well preserved after surgery, and is located symmetrically with its counterpart on the intact side. Our technique provides good reconstructive results and should serve as a valid alternative for the reconstruction of this area. q 2006 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved.

We developed a combined ap technique for the treatment of extensive defects of the nose and upper and lower eyelids (including full-thickness medial canthus defects), which is a simple combination standard aps, convenient, reproducible and
* Corresponding author. Tel.: C81 6 6645 3892; fax: C81 6 6646 6059. E-mail address: motomura@med.osaka-cu.ac.jp (H. Motomura).

does not require secondary revision. We report the details of this simple combination which achieves excellent reconstructive results.

Patients and methods

Patients
We report three patients with full-thickness defects of the medial canthal region who attended the

S0007-1226/$ - see front matter q 2006 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2005.11.017

748 Osaka City University Medical School Hospital between October 2002 and April 2004, and underwent reconstruction using our combined ap technique. All three were males, ranging in age from 62 to 86 years (mean, 72 years). The extensive defects in the nose and upper and lower eyelids, including full-thickness defects of the medial canthus, were the direct results of surgical resection of basal cell carcinoma.

H. Motomura et al. cheek rotation ap was employed for reconstruction of the cheek and lower eyelid, and the upper eyelid was advanced. In the median forehead ap, the contralateral supratrochlear artery and vein, which had been conrmed preoperatively with a Doppler blood ow meter, served as the pedicle. An extra triangular ap, on the median forehead ap, may help reconstruction of the upper eyelid in some cases. The ap was raise and transferred through a subcutaneous tunnel as an island. The cheek ap was used for anterior surface reconstruction of the defect of the lower eyelid. The upper eyelid defect was treated by full-thickness advancement of the upper eyelid skin. In cases where the skin was under high tension, a VY advancement ap was created within the upper eyelid. The lateral tarsal plate was moved medially, together with the tip of the cheek ap and upper eyelid.

Surgical procedure
For full-thickness defects of the medial canthus (including the lacrimal duct and medial eyelid ligament) and full-thickness defects of the neighbouring upper and lower eyelids, reconstruction with a combined ap was performed (Fig. 1). A median forehead island ap was used for reconstruction of the lateral nasal region, a

Figure 1 Schematic representation of the reconstruction technique using the combined ap. (A) A median forehead ap was used for reconstruction of the nose (medial to the position of the medial canthal ligament [!]), a cheek ap was employed for reconstruction of the lower eyelid (inferiolateral to the position of the medial canthal ligament [!]), and an advancement ap of the upper eyelid was used for the upper eyelid (superiolateral to the position of the medial canthal ligament [!]). In the caudal region, a triangular ap for the upper eyelid was also designed. (B) The median forehead ap was raised and moved as an island ap. A cheek ap was created for anterior lobe reconstruction of the defect of the lower eyelid. The upper eyelid defect was treated by full-thickness advancement of the upper eyelid skin. The lateral tarsal plate was moved medially, together with the tip of cheek ap. (C) When reconstructing the medial canthus, a 0.3 mm titanium wire was passed through the tip of the tarsal plate of the upper and lower eyelids to be reconstructed, and xed to the perforated nasal bone on the affected side. The lateral tarsal plate was moved medially, together with the tip of cheek and upper eyelid ap. The defect, which was newly created on the lateral side of the posterior lobe, was lled with a palatal mucoperiosteal graft. (D) In the medial canthus, the skin of the already xed upper and lower eyelids is xed by loosely suturing the median forehead ap to the skin. Simple suture application was performed on the frontal donor site. Immediately after surgery, considerable tension remains in the operated region, making it difcult to open the eyelids smoothly. (E) In cases where the skin was intensely tensioned, a VY advancement ap was created within the upper eyelid.

A combined ap for medial canthal reconstruction The defect that had been newly created on the lateral side of the posterior surface was lled with a palatal mucoperiosteal graft. When reconstructing the medial canthus, a 0.3 mm titanium wire was passed through the edge of the tarsal plate of the upper and lower eyelids to be reconstructed, and was xed in the nasal bone on the affected side (Fig. 2). The tarsal plate serves as an adequate support for wiring if the full thickness of the plate is moved medially together with the upper and lower eyelid extended ap. Application of the loop of wire to the upper and lower tarsal plates allows placement of the upper eyelid in contact with the lower eyelid. This unit is then fastened with the wire to a position of slightly excessive correction as compared to the location of the medical canthal ligament on the intact side. Immediately after surgery, considerable tension remains in the operated region, making it difcult to open the eyelids smoothly. However, the eyelids become less tensioned over time. During this process, it is important to reposition the reconstructed eyelids in the correct position to prevent lateral drift. In the medial canthus, the skin of the already xed upper and lower eyelids was xed by loosely suturing the median

749 forehead ap to the skin. When suturing the median forehead ap to the nasal area, it is important to free the intact skin adequately to provide a sufcient margin for suturing, so that differences in skin thickness can be overcome, and a gap-free appearance is produced. Primary closure was performed on the frontal donor site. The management of the lacrimal duct was determined in individual cases.

Results
The postoperative observation period ranged from 12 to 25 months (average, 20 months), and no tumour recurrence was observed. We performed reconstruction of the lacrimal duct in only one case, with adequate drainage provided by a conjuctivorhinotomy using a Jones tube. None of the patients developed complications (e.g. disturbances of opening/closure of eyelids, lagophthalmos) after surgery. Minimal epiphora was noted in the two patients who did not undergo lacrimal duct reconstruction, but they complained of epiphora only when excess tears were produced, such as with crying or wind irritation. The acute angle of the medial canthus was retained well after surgery, and the location of the medial canthus was symmetrical with the counterpart on the intact side (Fig. 3).

Discussion
The goals of reconstruction of this area are reproduction of the acute angle of the medial canthus, maintenance of the tension of the lower eyelid, matching the colour and texture in the aesthetic unit, and a minimum sacrice of the donor site. Numerous techniques have been proposed for the reconstruction of the medial canthus and eyelids involving the use of healing by secondary intension,14 local skin ap,58 and orbicularis oculi myocutaneous ap.9,10 If the defect is extensive as in our cases, it becomes necessary to combine two or more techniques. The technique of a forehead muscle ap combined with septal chondro-mucosal graft, oral mucosa and skin grafts11 appears successful, but has certain disadvantages such as the need for a donor site, patchy take, and poor colour. Several groups have described attempts to reconstruct the medial canthus using combined aps.12,13 Few of these reports, describe the method of full-thickness reconstruction including

Figure 2 When reconstructing the medial canthus, a 0.3 mm titanium wire was passed through the tip of the tarsal plate of the upper and lower eyelids to be reconstructed, and xed in the perforated nasal bone on the affected side (arrow). The lateral tarsal plate was moved medially together with the tip of cheek ap (arrowhead). The defect that was newly created on the lateral side of the posterior lobe was lled with a palatal mucoperiosteal graft (*).

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Figure 3 The acute angle of the medial canthus is retained well after surgery, and is approximately symmetrical with its counterpart on the intact side as shown by the three patients. Top row: Patient 1. (A) Preoperative ndings. (B) Intraoperative ndings. (C) Twenty ve months after surgery. Frontal view. (D) Full closure of the eyelids was achieved. Middle row: Patient 2. (A) Preoperative ndings. (B) Intraoperative ndings. (C) Twenty three months after surgery. Frontal view. (D) Full closure of the eyelids was achieved. Bottom row: Patient 3. (A) Preoperative ndings. (B) Intraoperative ndings. (C) Twelve months after surgery. Frontal view. (D) Full closure of the eyelids was achieved.

the medial canthal ligament. Gruss14 used a combined ap for full-thickness reconstruction including the medial eyelid ligament. In that report, it was recommended that reconstruction be performed in separate aesthetic units, and the reconstructive technique was considered highly successful. However, the described technique has some disadvantages: (1) disgurement in the pedicle of the forehead ap and the necessity of a second revision, and (2) expertise is required when selecting the reconstruction and operative procedure. We developed a combined ap technique for the treatment of extensive defects of the nose and upper and lower eyelids, including full-thickness medial canthus. We transferred the median forehead ap as an island ap to the nasal defect through a subcutaneous tunnel in the glabella to avoid secondary disgurement. This technique is combined with a simple cheek ap for the lower eyelid and advancement of the upper eyelid, and thus no esoteric expertise is necessary. Titanium wire is used because the precise adjustment of the location of medial canthal ligament is difcult with a nylon suture; and the safety of titanium has been established. Image quality on computerised tomography and magnetic

resonance images is also excellent.15 Patients need to be closely followed after this operation to check for infection and exposure. Our procedure is appropriate and suitable for extensive defects (including full-thickness defects of the medial canthus).

References
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