Abstract
Severe coloboma of ocular malignant neoplasms post‐resection poses a reconstructive challenge to surgeons. To compare the practicability, manipulability and outcomes of temporal (myocutaneous) flaps (TFs), forehead (supratrochlear artery/supraorbital artery) flaps (FFs) and buccal (facial artery) flaps (BFs) for periorbital defects reconstruction, a retrospective case series was conducted and evaluated between March 2014 and March 2021. Patient demographics and clinical parameters including age, gender, pathological diagnosis, operative methods, flap selection, operation time, aesthetic satisfaction and follow‐up period were collected. The differences in complications were compared and assessed of the three flaps, including flap survival, venous congestion and donor site healing. Totally, 68 patients who underwent periorbital reconstructive operations because of common ocular malignant tumours were reviewed in this study. As for aesthetic satisfaction, a score more than “moderately dissatisfied” was obtained in 21 patients with TFs (95.5%), and of which the scores in FFs group were 12 cases (60%) and 16 cases with BFs reconstruction (61.5%) (P < .05). Severe microvascular complications underwent re‐exploration operation occurred in one patient with FFs (1.5%) (P > .05). Notable flap necrosis was observed in two patients with BFs repair (2.9%) and in one case with FFs repair (1.5%), with no statistical difference between the three flap selections (P > .05). Moderate venous congestion occurred in one patient with TFs (1.5%), which was fully meliorated non‐surgically. The three familiar facial island flaps are considered as minor trauma and time‐saving process for reconstructing the extensive periorbital defects with comparable ranks of complications.
Keywords: island flap, ocular malignancy, periorbital defect, reconstruction, soft tissue injury
Abbreviations
- TFs
temporal (myocutaneous) flaps
- FFs
forehead (supratrochlear artery/supraorbital artery) flaps
- BFs
buccal (facial artery) flaps
- TWIS
treatment write‐in scale
1. INTRODUCTION
Over 1 million patients were diagnosed with skin cancer, the most common malignancy per year in the United States, and nearly 10% of the cases violated the periorbital regions and eyelids. 1 , 2 The operations including full‐thickness excision of the eyelid, enucleation of eyeball or even orbital exenteration on the side of the lesion ought to be routinely performed for malignancies invading the eyelid and eyeball, inevitably creating more perplexing cavitary defects because of the particularity of eye anatomy. 3 , 4 Although various repair methods including autologous skin grafts, local advancement and rotation flaps or free flaps have been used to purposively reconstruct the pretty uneven wounds, insufficiencies still exist because of their limited principal indications. 5 , 6 Skin grafts cannot be placed on a flat surface of the uneven wounds, which would generate dead space or effusion under the grafts. Local advancement or rotation flaps have their limited repair coverage as the invariable perfusion of the blood supply. Although the free‐flap reconstruction for secondary wounds poses adopted operating mode currently, this time‐consuming surgery with a certain additional trauma at the donor site, long recovery time or underlying risk of embolism brings about negative elements for the reconstruction outcomes, leaving uncertain issues to clinicians. 3 , 7
The island flaps of the facial artery branches (e.g., superficial temporal artery, supratrochlear artery/supraorbital artery, facial artery and the blood supply diagram, as shown in Figure 1A–C, respectively), designed by retaining vascular pedicle and dissociating into island shape, are characterised by stable blood supply, flexible stretch and relative acceptable appearance because of the similarity appearance with facial skin. 8 Meanwhile, based on the medical characteristics, on the one hand, age pigment or nevus in elderly patients were more prone to deteriorate into periorbital malignancy, and on the other hand, cutis laxa senilis could enhance the availability and utilisation of the facial flaps, which would pose advantages over the young. 1 , 4 , 9 However, to date, to the best of our knowledge, there is still a lack of valuable reports to introduce and compare three familiar facial island flaps (TFs, FFs and BFs) in reconstructing periorbital defects. In the present study, we reviewed the outcomes of interest and aesthetic acceptability of three facial island flaps for repairing serious orbital coloboma after resection surgeries in ocular malignancies cases.
FIGURE 1.
The blood supply diagram of the three island flaps of the facial artery branches. (A) The branches of the superficial temporal artery. (B) The branches of the supratrochlear artery/supraorbital artery. (C) The branches of the facial artery
2. METHODS
2.1. Patients selection
A retrospective review of 68 patients, diagnosed with periorbital malignancies, who underwent single‐stage periorbital region reconstruction with TFs, FFs and BFs from March 2014 to March 2021 at Xijing Hospital (Xi'an, China). All patients or their representatives signed the informed consent form before surgery. This study was retrospective in accordance with the tenets of the Declaration of Helsinki and approved by the Institutional Review Board of the Xijing Hospital of Air Force Medical University. All patients gave their informed written consent including their consent to publish the identifiable photographs.
This is a retrospective case series analysis on consecutive patients with traceable data, and the whole research processes do not violate ethical requirements. The detailed clinical demographics and main outcomes of the reconstructions are shown in Table 1 and Table 2. For the outcomes of interests, types of facial island flaps were compared to determine any difference in the occurrence ratio and severity in venous congestion, effusion, infection, marginal necrosis or complete necrosis. The aesthetic satisfaction results were recorded at least 6 months after surgery with scores 1 (completely dissatisfied), 2 (dissatisfied), 3 (moderately dissatisfied), 4 (satisfied) or 5 (completely satisfied).
TABLE 1.
Clinical demographics of patients undergoing flap reconstruction
| TFs | FFs | BFs | |
|---|---|---|---|
| Characteristics | n = 22 | n = 20 | n = 26 |
| Age, y, mean (range) | 63.63 (32–84) | 60.46 (34–86) | 59.67 (35–76) |
| Female, No (%) | 12 (54.5) | 12 (60) | 14 (53.8) |
| Male, No (%) | 10 (45.5) | 8 (40) | 12 (46.2) |
| Pathological diagnosis | |||
| Basal cell carcinoma | 8 (36.4) | 7 (35) | 7 (26.9) |
| Squamous cell carcinoma | 6 (27.3) | 6 (30) | 6 (23.1) |
| Malignant melanoma | 2 (9.1) | 3 (15) | 3 (11.5) |
| Sebaceous carcinoma | 4 (18.2) | 2 (10) | 6 (23.1) |
| Spindle cell sarcoma | 2 (9.1) | 2 (10) | 4 (15.4) |
| Operation time (hours) | 2.91 (2.74–3.08) | 3.15 (2.93–3.37) | 2.79 (2.48–3.1) |
| Follow‐up period (months) | 29.7 (6.9–79.2) | 28.5 (6.2–74.8) | 31.2 (6.5–80.7) |
| Donor site healing (days) | 9.7 (7.4–11.2) | 9.5 (8.1–10.8) | 10.2 (8.5–11.7) |
Note: Values of sex and pathological diagnosis are numbers (percentage) of patients. Values of age, operation time, follow‐up period and donor site healing are in number (range).
Abbreviation: BFs, buccal (facial artery) flaps FFs, forehead (supratrochlear artery/supraorbital artery) flaps; TFs, temporal (myocutaneous) flaps.
TABLE 2.
General outcomes of interests and flap‐related complications
| Variables | TFs (n = 22) | FFs (n = 20) | BFs (n = 26) | P Value |
|---|---|---|---|---|
| Flaps complications | ||||
| Complete survival | 19 (86.4) | 17 (85) | 23 (88.5) | .325 |
| Venous congestion | 1 (4.5) | 0 (0) | 0 (0) | .235 |
| Effusion | 0 (0) | 1 (5) | 0 (0) | .592 |
| Infection | 1 (4.5) | 0 (0) | 0 (0) | .383 |
| Marginal necrosis | 0 (0) | 2 (10) | 1 (3.8) | .564 |
| Complete necrosis | 1 (4.5) | 0 (0) | 2 (7.7) | .491 |
| Aesthetic satisfaction | ||||
| Completely dissatisfied | 0 (0) | 2 (10) | 3 (11.5) | <.05 |
| Dissatisfied | 1 (4.5) | 6 (30) | 7 (26.9) | |
| Moderately dissatisfied | 2 (9) | 6 (30) | 9 (31) | |
| Satisfied | 4 (18) | 4 (20) | 2 (7.7) | |
| Completely satisfied | 15 (68.2) | 2 (10) | 5 (19.2) | |
Note: Values are presented as number (percentage).
Abbreviation: BFs, buccal (facial artery) flaps; FFs, forehead (supratrochlear artery/supraorbital artery) flaps; TFs, temporal (myocutaneous) flaps.
The inclusion criteria were as follows: (1) all patients met the diagnostic criteria for periorbital skin malignancies; (2) all met the indications for surgical resection and reconstructed with single‐stage TFs, FFs or BFs operations; (3) patients had no mental disorder or psychiatric illness; (4) follow‐up >6 months.
The exclusion criteria were as follows: (1) combined with other malignant tumours; (2) excessive tumour invasion reconstructed with other treatment methods; (3) patients with mental illnesses or psychiatric conditions; (4) follow‐up <6 months.
2.2. Preoperative assessment and resection procedure
The physical examination results of binocular vision and pain on eye movement, together with binocular MRI measurements, were recorded in all patients. The degree, size and shape of periorbital defects were estimated as far as precisely according to the outcomes of preoperative imaging and physical examination of the extent and size of tumour invasion. Extended tumour resection or enucleation of orbital contents was performed with tumour resection range of normal tissue more than 5 mm around the tumour. Intraoperative rapid freezing pathology and routine pathology were both executed.
2.3. Reconstruction procedure
To compare the practicability and manipulability of TFs, FFs and BFs for periorbital reconstruction, the key points of the three facial island flaps are as follows.
2.4. Temporal (myocutaneous) flaps (TFs)
In short, we determined the scope of the temporalis muscle area and designed the required vascular pedicle length. The size and shape of the temporalis muscle flap were conducted according to the defect area and distance. A T‐shaped skin incision was made, following the exposure of skin flap, superficial temporal fascia, deep temporal fascia and temporalis muscle, temporalis muscle and the skin between the defect area and the pedicle were incised.
2.5. Forehead (supratrochlear artery/supraorbital artery) flaps (FFs)
Briefly, we followed the principle of retrograde design according to the defect area, and a frontal myocutaneous flap with the ipsilateral or contralateral supraorbital artery and supratrochlear artery as the pedicle was designed. The contour of the flap was drawn on the forehead. The distal end was first incised and dissected under the galeal aponeurosis, or forming frontalis muscle to a myocutaneous flap with a narrow pedicle.
2.6. Buccal (facial artery) flaps (BFs)
In brief, the skin flap was designed according to the wound surface defect, followed by subcutaneous tissue and platysma in sequence. The submandibular border was separated to the front and back of the digastric muscle. We made sure that the periosteum at the lower edge of the mandible cannot be separated from the flap. We dissect the submandibular gland and the proximal end of the facial artery. The facial artery flap was rotated retrogradely to cover the defects.
2.7. Postoperative management
The patients stayed in a semi‐recumbent position, and the flap area was kept warm after surgery. Skin temperature, skin colour, degree of swelling and capillary flow of flaps were intimately observed. We regularly used anticoagulants, antispasmodics and vasodilators. The blood supply was observed every 2 h using ultrasound Doppler on the third day after surgery. The dressing change and suture removal were based on wound recovery.
2.8. Statistical analysis
Statistical analysis was performed using SPSS 24.0 software. Measurement data were expressed as mean ± standard error of mean (S.E.M). The comparison of count data between groups was analysed using the x 2 test. ANOVA test was used to compare multiple groups. P < .05 was considered a statistically significant difference.
3. RESULTS
A total of 68 patients with common ocular malignancies (median, 61.2 y; range, 32–86 y) underwent periorbital reconstruction surgeries with TFs, FFs and BFs (22 [32.4%], 20 [29.4%] and 26 [38.2%] separately) and were recorded in this retrospective study. Among the 68 patients, 39 cases accepted extended tumour resection with eye‐preserving (57.4%) and 29 patients received enucleation of orbital contents (42.6%). Pathological findings are tumours containing basal cell carcinoma (22 [32.4%]), squamous cell carcinoma (18 [26.5%]), malignant melanoma (8 [11.8%]), sebaceous carcinoma (12 [17.6%]) and spindle cell sarcoma (8 [11.8%]). The mean operation time of TFs, FFs and BFs was 2.91 (range, 2.74–3.08), 3.15 (range, 2.93–3.37) and 2.79 (range, 2.48–3.1) hours, with an average follow‐up period of 29.7 (range, 6.9–79.2), 28.5 (range, 6.2–74.8) and 31.2 months (range, 6.5–80.7), and a mean donor site healing time of 9.7 (7.4–11.2), 9.5 (8.1–10.8) and 10.2 (8.5–11.7) days, respectively. The detailed demographic data are shown in Table 1.
Complete flap necrosis was observed in two patients with BFs repair (2.9%) and one patient with FFs repair (1.5%), with no statistical difference in the three flap selections (P > .05). Moderate venous congestion occurred in one patient with TFs (1.5%), which was fully meliorated non‐surgically. Although there were also some minor complications of the three island facial flaps (ie, effusion, dehiscence, marginal necrosis or infections), no statistical difference was observed among the three flaps. The outcomes of aesthetic satisfaction were recorded that the evaluation scores over the “moderately dissatisfied” category were acquired in 21 patients in the TFs group (95.5%); meanwhile, for the same indicator, the scores in FFs group were 12 cases (60%) and 16 cases in BFs group (61.5%) (P < .05) (Table 2).
3.1. Typical case of TFs
A 62‐year‐old male patient was admitted to hospital with 6‐month diplopia, 3‐month right eye movement disorder and 1‐week visual loss (Figure 2A). Binocular MRI examination suggested that the tumour was located in the right eyeball (red arrow, Figure 2B). Extended tumour resection and orbital exenteration were implemented with a pathological evidence of squamous cell carcinoma, leaving a 3.5 × 2.0 cm defect with exposed orbital bone, which could not be implanted with a prosthesis (Figure 2C). A 4.5 × 2.5 cm temporal fascial flap was designed for the right temporoparietal into the right orbital cavity via the subcutaneous tunnel. The superficial temporal fascia was stuffed into the orbital cavity (Figure 2D), followed by a layered suture of the subcutaneous tissue and skin (Figure 2E). An 18‐month follow‐up of the case showed that the patient acquired acceptable appearance without any other complications (Figure 2F).
FIGURE 2.
Typical case of the periorbital region reconstruction with TFs. (A) A patient with right eye movement disorder. (B) The binocular MRI examination suggested that the tumour was located in the right eyeball (red arrow). (C) Extended tumour resection and orbital exenteration, leaving a 3.5 × 2.0 cm defect with exposed orbital bone. (D) A 4.5 × 2.5 cm temporal fascial flap was designed for the right temporoparietal into the right orbital cavity. (E) The layered suture of the subcutaneous tissue and skin was performed. (F) An 18‐month follow‐up of the case, showing that the patient acquired an acceptable appearance without any other complications
3.2. Typical case of FFs
A 65‐year‐old woman was sent to the hospital with 4‐month diplopia and 2‐month mild eye movement disorder (Figure 3A). Binocular MRI found the right eyeball a tumour (red arrow, Figure 3B). Extended tumour resection was executed with a pathological finding of spindle cell sarcoma, leaving behind a 6.0 × 2.5 cm defect with partial exposure of maxillae (Figure 3C). A 7.0 × 3.0 cm forehead myocutaneous flap was dressed and displaced in a counterclockwise rotation to cover the orbital cavity through the surface channel (Figure 3D) with a layered suture of the subcutaneous tissue and skin subsequently (Figure 3E). A 14‐month period of follow‐up showed a conspicuous forehead scar, which was undesirable for some patients (Figure 3F).
FIGURE 3.
Typical case of the periorbital region reconstruction with FFs. (A) A patient with mild eye movement disorder. (B) The binocular MRI found the right eyeball a tumour (red arrow). (C) Extended tumour resection was executed, leaving behind a 6.0 × 2.5 cm defect with partial exposure of maxillae. (D) A 7.0 × 3.0 cm forehead myocutaneous flap was dressed and displaced in a counterclockwise rotation to cover the orbital cavity. (E) The layered suture of the subcutaneous tissue and skin was performed. (F) A 14‐month period of follow‐up showed a conspicuous forehead scar, which was undesirable for some patients
3.3. Typical case of BFs
This is an 82‐year‐old hospitalised female who suffered 8‐month local tumour on the left eyeball, progressive malaise symptom, 1‐week surface erosion with secretion and 3‐day haemorrhage (Figure 4A). The MRI results showed a mass occupying the left orbit with an eyeball mass (red arrow, Figure 4B). Extended tumour resection and orbital exenteration were operated with the pathological examination of meibomian gland carcinoma, giving rise to a 7.0 × 4.5 cm defect with bony exposure, with lack of blood supply (Figure 4C). Confirming the facial artery at the anterior edge of the masseter muscle aside the mandibular border, a 9.0 × 6.0 cm skin flap was arranged with this point as the centre (Figure 4D). Briefly, we dissected the skin flap at the deep fascia layer, cut the upper edge of the skin flap, and transferred the skin flap to the recipient area through the subcutaneous tunnel (Figure 4E). With a follow‐up of 8 months, a striking crooked of the corner of the mouth was observed caused by the incision scar traction (Figure 4F).
FIGURE 4.
Typical case of the periorbital region reconstruction with BFs. (A) A patient with surface erosion with secretion and haemorrhage of the left eyeball. (B) The MRI results showed a mass occupying the left orbit with an eyeball mass (red arrow). (C) Extended tumour resection and orbital exenteration were operated, giving rise to a 7.0 × 4.5 cm defect with bony exposure. (D) A 9.0 × 6.0 cm skin flap was arranged with this point as the centre. (E) The layered suture of the subcutaneous tissue and skin was performed. (F) A follow‐up of 8 months showed striking crooked of the corner of the mouth caused by the incision scar traction
4. DISCUSSION
Uneven defects of the orbital region caused by surgical excision of periorbital malignancies can leave an exceptional challenge for reconstructive therapeutists because of their close association with unanticipated complications and vexatious cosmetic outcomes. 5 , 10 Various therapies including skin grafting, local advancement/regional flaps or free flaps were attempted to reconstruct these challenging wounds. Particularly, although skin grafting is accessible to numerous surgeons, this method cannot pack into the cavity, which would pose undesirable complications like dead space, effusion or infections, leaving a long‐term noticeable deformity. In addition, the local advancement or rotation flaps are commonly applied to cover the defects adjacent not only because of their operative simplicity, but also the similarity of donor site with regard to the thickness, colour and texture with the recipient site. Surrounding tissues are prone to be invaded by malignant tumours, as a result, local or rotation flaps are limited by their less tissue availability and specific functional requirements to cover severe defects because of orbital exenteration. Furthermore, even if free‐flap transfer via vascular anastomosis has been privileged for complex defective wounds, this lengthy surgical procedure brings additional issues to clinicians and patients including the increase of complication risk, hospitalisation and expense. 3 , 7 , 11 In the case series reviewed by Richardson et al, the hospital admission in the intensive care unit after free‐flap reconstruction was elongated for at least 24 to 48 h for close observation. 12 In this article, the reconstructive operations performed with three facial island flaps (TFs, FFs and BFs) for the reconstruction of periorbital defects should and could be accomplished after the malignant neoplasms excision procedures, which is consistent with the viewpoints of other studies in the literature. 7 , 13
4.1. Technical considerations
This retrospective case series is focused on the feasibility, comparability and cosmetic results among three facial island flaps including the temporal (myocutaneous) flaps, forehead (supratrochlear artery/supraorbital artery) flaps and buccal (facial artery) flaps abbreviated as TFs, FFs and BFs respectively for reconstructing periorbital defects after ocular malignancies resection. 9 , 12 , 13 , 14 , 15 To date, as far as we know, there is a lack of valuable summary of clinical outcomes of comparing facial island flaps in the reconstruction of periorbital defects.
In this study, TFs, FFs and BFs are commonly recognised as minor trauma, low cost and time‐consuming procedure in repairing severe periorbital defects with acceptable complications. Furthermore, TFs method is considered as a priority with a higher degree of satisfaction for patients with more aesthetic requirements. In terms of expansion of TFs, FFs and BFs, they are characterised by stable blood supply and tissue availability. Direct suture is conducted for the closure of the island flaps donor site in our study, neither required split‐thickness skin grafting nor other local or regional flaps. 11 , 13 , 15
Specifically, compared with other flaps, there is a minimal anatomical variation of TFs vascular structure, which has been proven to be clinically beneficial for operation. Apart from this, there is an additional advantage of TFs in that the concealed incision is in the temporal region, which avoided noticeable facial scar. Although concomitant outcomes of bulky flaps and hair growth in donor sites unpleasantly bothered patients, several laser therapy and flap revisions, thankfully, made significant positive results. 11 , 13 , 14
The FFs option is another alternative surgery for restoring orbital region defects with several advantages that merit consideration. On the one hand, except for the facilitation of rotation as an adjacent flap, FFs can also be valued owing to matches in thickness, texture and colour with periorbital skin. On the other hand, the supraorbital nerve and supratrochlear nerve of FFs carrying, bring about good results of the reconstructed eyelid sensation or regio orbitalis functions. However, the eyebrows and hair displacement are caused by the pulling of visible forehead incision scars, which causes undesirable outcomes, making some patients uncomfortable. 11 , 12 , 15
Of note, compared with TFs and FFs as discussed above, the use of BFs has showed major merits because of the buccal muscles and mucous membranes, including an adequate blood supply, the suitable stuffing effect to infill the cavity, flexible transfer and enhanced friction tolerance to the artificial eye by reconstruction of the island buccal mucosal flap. While the potential striking crooked the corner of the mouth by the incision scar traction and the facial nerve injury, especially the buccal branch cannot be ignored. 13 , 15
Above all, in this article, the selection of TFs, FFs and BFs, as single‐stage operations, is considered as minor trauma and time‐saving process for reconstructing the extensive periorbital defects with comparable ranks of complications and acceptable cosmetic results. However, there are still some limitations in our article: (1) in this article, we only focused on the feasibility, comparability and outcomes of the three island flaps and overlooked the treatment write‐in scale (TWIS) for reconstructing the periorbital defects post‐resection of the malignancies; (2) there is a lack of the detailed data on the long‐term quality of life and the survival rate.
5. CONCLUSION
The three familiar facial island flaps could be considered as banausic and reliable reconstructive options, which bring less complications and provide acceptable cosmetic appearance for reconstructing the serious orbital coloboma after the resection surgeries of ocular malignancies.
AUTHOR CONTRIBUTIONS
Juntao Han designed the operation and acted as operator. Zhuoqun Fang, Yujie Wu, Jun Li and Kejia Wang worked as assistants in the operation. Zhuoqun Fang, Jun Li and Kejia Wang collected all the information and written contents from the patients. Jun Li and Xuekang Yang performed the statistical analysis. Hongtao Wang and Honglei Liu contributed to the pathological analysis. Juntao Han revised the manuscript and approved the final submission. All authors discussed the results and reviewed the manuscript. All of the protocols were approved by the Ethics Committee of Xijing Hospital, affiliated with Air Force Medical University (China).
CONFLICT OF INTEREST
The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article.
Fang Z, Wu Y, Li J, et al. Feasibility, comparability and outcomes of three acquainted facial island flaps for periorbital defects reconstruction. Int Wound J. 2023;20(6):1849‐1856. doi: 10.1111/iwj.14042
Zhuoqun Fang and Yujie Wu contributed equally to this work.
Contributor Information
Honglei Liu, Email: liuhongleipro@163.com.
Juntao Han, Email: 13572103890@163.com.
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are avaliable request from the corresponding author.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are avaliable request from the corresponding author.