Vol 11-R2- Eyelid

SRPS • Volume 11 • Issue R2 • 2010
flap incision extended below the orbital rim to
gain additional flap length. According to Baker,
Labat re-designed the median forehead flap to be
centered around a unilateral supratrochlear artery
and Millard and Menick then modified the flap
by shifting the entire vertical axis to a paramedian
position and showed that the flap would survive
without the central glabellar skin. The modification
allowed for a narrower flap with greater freedom of
tissue movement. Baker reported that in the 1980s,
Burget and Menick extended the paramedian flap
below the bony orbital rim, which allowed the flap
to exclude hair-bearing scalp tissue.
Baker 139 described, in great detail, the
paramedian forehead flap based on a single
supratrochlear artery. A Doppler probe often is
used to assist in locating the supratrochlear artery,
although Baker noted that it is not necessary.
The vertical axis of the supratrochlear artery is
located approximately 2 cm lateral to the midline,
corresponding to the medial border of the brow,
and the width of the flap is designed to be 1.5 cm
and not flared. In recent Doppler studies of healthy
volunteers, the supratrochlear vascular pedicle was
found, at most, to be 3 mm lateral (more common
in men) or medial (more common in women) to
the medial canthus. 150 Kelley et al. 151 showed that
within the paranasal and medial canthal region,
an anastomotic connection exists between the
supratrochlear, infraorbital, and branches of the
facial arteries and branches from the contralateral
side, producing a rich vascular arcade. This
relationship allows a median forehead flap to be
narrowly based at the level of the medial canthus.
The upper border of the flap typically is the
frontal hairline unless the patient has a receding
hairline or frontal balding. It is crucial to carefully
measure the size of the defect and correlate it to
the size of the flap that is raised. Once measured
and marked, an incision is created and the flap is
elevated from the underlying periosteum. To close
the donor site, it is necessary to undermine the
wound in a subfacial plane from one temporalis
muscle to the other. Galea and frontalis muscles are
completely removed from the distal tip of the flap,
38
as is a majority of the subcutaneous fat. The flap is
sutured at the recipient site with vertical mattress
sutures, and the forehead donor site is closed
in layers. 139
A frontal hairline flap, as described by
Karşdağ et al., 152 can be used in a single-stage
alternative to closing a medial canthus defect with
an accompanying dorsal nasal defect. In 10 patients
who were status post surgical tumor resection,
Karşdağ et al. fashioned an elliptically shaped
frontal island flap at the level of the frontal hairline.
The flap was vascularized by the supraorbital and
supratrochlear arteries. The lateral points of the
pedicle were in alignment with the vertical lines
crossing the medial canthus and pupillary midline,
respectively. Dissection of the pedicle was confined
between the lines, and a subcutaneous tunnel was
formed between the defect and the flap recipient
area. The island flap was transposed to the recipient
area through the subcutaneous tunnel. The hairline
incision was sutured intracuticularly. No major
vascular damage was observed during dissection,
and arterial insufficiency was not reported. Venous
insufficiency and trapdoor deformity occurred in
two patients and healed spontaneously. They authors
stated that the venous insufficiency might have
occurred secondary to the kinking of the pedicle or
the inadequately narrow tunnel.
A pericranial flap composed of periosteum
and subgaleal fascia is a very versatile flap
used extensively in craniofacial surgery. Its
use for repairing medial canthus defects is
fairly new. Leatherbarrow et al. 153 conducted a
retrospective review of consecutive cases requiring
reconstruction of medial canthal defects involving
loss of periosteum or bone by a median forehead
pericranial flap and full-thickness skin grafting. The
authors described two different techniques of flap
harvest. One is an open technique that includes
a midline forehead incision, and the other is an
endoscopic technique that includes two incisions
behind the hairline.
With the open technique, a vertical midline
incision of approximately 3 to 4 cm is made,
extending superiorly from the glabella with a