Reconstruction of a Large Oncologic Defect Involving Lower Eyelid and Infraorbital Cheek Using MSTAFI Flap

Abstract

An oncologic defect that includes both the lower eyelid and the infraorbital cheek often results in complex reconstructive problems because its reconstruction involves 2 distinct tissue types and cosmetic subunits. Herein, we first present a novel combination of modified supratrochlear artery forehead island flap and advancement rotation cheek flap enables reconstructing a large oncologic defect of lower eyelid and infraorbital cheek. Although discoid lupus erythematosus affects the skin, the patient had achieved a satisfying color match and an acceptable aesthetic restoration without tumor recurrence. This novel flap has shown to be feasible, reliable, and advantageous alternative to the repair of such defects.

An oncologic defect that includes both the lower eyelid and the infraorbital cheek often results in complex reconstructive problems because its reconstruction involves 2 distinct tissue types and cosmetic subunits. ¹ A relatively indistinct although important boundary exists between the lower eyelid and cheek that overlies the orbital bone. Achieving both aesthetic and functional restoration after tumor resection, one-stage reconstruction is certainly the optimal solution. However, seeking a reliable and suitable flap for one-stage restoration remains a great challenge for plastic surgeons.

A 51-year-old woman was admitted to our department with a history of untreated facial lesions present for over 20 years, developed an ulcer in one of the preexisting discoid lupus erythematosus (DLE) lesions on her right cheek (Figure 1A and B). Biopsies revealed the ulcerating lesion to be squamous cell carcinoma. Deep surgical excision was performed, with a final defect consisting of a suborbicular full-thickness skin defect measuring 7 × 6 cm on the whole length of the right lower eyelid and infraorbital cheek (Figure 2A).

Figure 1.

Photomontage showing (A) a 15 × 7 cm hypopigmented, atrophic, slightly erythematous patch involving the bilateral cheeks and nasal “butterfly” areas (B) A 4 × 3 cm portion of the right cheek was involved with an ulcerating, fungating hyperkeratotic lesion.

Figure 2.

Photomontage showing (A) deep incision in the right lower eyelid and infraorbital malar cheek, (B) a large advancement rotation cheek flap covering nearly 75% of the initial defect, (C) design of a tunneled transverse-median supratrochlear artery forehead island flap, and (D) the defect closed with fine interrupted sutures.

In our present case, given her systemic lupus erythematosus (SLE), a more secure and minimally invasive flap was required to avoid the risk of necrosis and ectropion. ² To repair large defects involving lower eyelid and infraorbital cheek at single stage, several options could be considered. Side-to-side closure would not completely reconstruct this wound. The superior area of the wound involves the lower eyelid, while the inferior area involves infraorbital cheek. The inferior area tends to supply an abundance of loose skin on the cheeks, which offers an ideal situation for side-to-side closure. However, side-to-side closure of such a large defect in the lower eyelid will result in ectropion. Local flap reconstruction is a traditional alternative to consider. An advancement and rotation flap might allow closure of the defect. However, if local flap reconstruction is performed here, repair of the superior area of the defect with its proximity to the lower eyelid margin and lateral canthus may result in persistent ectropion. Use of a full-thickness skin graft to patch the entire defect is another alternative to consider. Although grafting decreases wound contraction and the risk of ectropion, one major drawback is the difference in color, texture, and thickness that the donor tissue has in comparison to the tissue surrounding the recipient site. Therefore, the ultimate cosmetic result would not be optimal.

In 1963, Converse and Wood-Smith were the first to describe supratrochlear artery forehead island (STAFI) flap for one-stage reconstruction of nasal dorsum defects. ³ Since then, STAFI flap has been widely utilized to repairing nasal defects caused by congenital malformation, trauma, and tumor resection. However, rarely research reported the application of STAFI flap for one-stage reconstruction of lower eyelid defects. ⁴ Due to the limited reach, STAFI flap is not suitable to reconstruct the lower eyelid defects. ⁵ Furthermore, STAFI flap also has certain drawbacks such as distorted eyebrows and requiring correction in a second stage. To address these issues, we modify a tunneled design for one-stage reconstruction. To distinguish the traditional STAFI flap, this modified supratrochlear artery forehead flap was named modified STAFI (MSTAFI) flap. Several authors have proposed that the combination of different flaps can be useful in the closure of large defects that involve several cosmetic units. ⁶ Herein, we first describe a novel combination of MSTAFI flap and advancement rotation cheek flap to close large defects involving lower eyelid and infraorbital cheek.

The surgical technique consists of the following. The donor skin adjacent to the defect was outlined, locating the incision along the lateral border of the cheek. A deep incision was made at the lateral border of the cheek, continuing the dissection through the subdermal plane by undermining the skin occupied by the flap. Once the flap was properly dissected, it was advanced to close as much of the defect area as possible (Figures 2B). After this advancement rotation cheek flap, nearly 75% of the initial defect area had been covered. To close the rest of the defect, a MSTAFI flap was designed. The supratrochlear artery is identified by means of a Doppler probe and marked on the skin. Full thickness of skin is incised around the inverted pattern of the defect outlining the skin portion of the island flap. A transverse leaf-shaped island flap is excised superficially from the median forehead area. The skin of the forehead is then undermined downward over the glabella and inner canthus as far as the right lower eyelid defect (Figure 2C). The undermining of the skin is extended laterally toward the vascular pedicle in the supratrochlear region on the appropriate side. The island flap and subcutaneous pedicle are now mobilized and rotated 180° through the subcutaneous channel to the defect. The skin edges of the island flap are then sutured to the edges of the defect with fine interrupted sutures (Figure 2D). At 5-month follow-up visit after operation, the patient had achieved a satisfying color match and an acceptable aesthetic restoration without tumor recurrence (Figure 3).

Figure 3.

Clinical outcome after 5 months of follow-up.

This MSTAFI flap offers several advantages. First, the tunneled transverse island flap has advantage of greater mobility and longer turning radius; thus, it is more suitable to cover the further lower eyelid or cheek area. Second, due to a median leaf-shaped design, distorted eyebrows were avoided. Third, the island flap is raised and immediately placed into the defect, the secondary defect is closed, and the operative procedure is completed at the one stage.

Our flap also has several limitations that require consideration. The principle disadvantage encountered with the island flap is the protrusion produced in the region of the root of the nose by the subcutaneous pedicle. This protrusion may require secondary excision, although we have noted a marked tendency to regression after about 3 months. Another disadvantage is possible flap ischemic necrosis due to pedicle torsion and trapdoor deformation. The marked degree of venous congestion was observed in the flap during the first 2 days after transplantation. The clinical changes undergone by the flap resemble in part those displayed by a composite graft. It’s worth noting that alopecia is common finding in the majority of individuals with SLE and the lupus-specific forms of alopecia often exhibit an erythematous or violaceous tone. ⁷ As shown in Figure 3, at 5-month follow-up visit after surgery, the patient presented with alopecia areata and drug-induced effluvium of her scalp.

In our previous study, we had created the first successful paradigm for one-stage reconstruction of nasal defects using MSTAFI flap. ⁸ Herein, we first present a novel combination of MSTAFI flap and advancement rotation cheek flap enables reconstructing a large oncologic defect of lower eyelid and infraorbital cheek. Although DLE affects the skin, the patient had achieved a satisfying color match and an acceptable aesthetic restoration without tumor recurrence. This novel flap has shown to be feasible, reliable, and advantageous alternative to the repair of such defects. However, given the complexity of the procedure, the surgeon’s experience and familiarity with MSTAFI flap is especially important.