Disclosure Ocular Adnexal Reconstruction I have no financial - - PowerPoint PPT Presentation

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Paramedian Forehead Flap for Ocular Adnexal Reconstruction

• M. Reza Vagefi, M.D.

Oculofacial Plastic Surgery Associate Professor of Ophthalmology University of California, San Francisco UCSF Ophthalmology Update December 2, 2016

Disclosure

I have no financial interests or relationships to disclose.

Case Presentation

CC: Blast injury of right peri-ocular area HPI: 47 year-old male presents 9 days after

ruptured globe repair OD for further evaluation and treatment. He reports working

• n a hydraulic pipe used in the machinery to

crate fruit when it exploded in his face. He denies the use of eye protection.

PMH: None Social Hx: 1 PPD smoker

Exam

Eye Exam External Exam Right Eye Left Eye

VA LP w/o projection 20/20 IOP Unable 13 Pupils + Reverse APD 4 2 mm EOM Globally restricted Full CVF

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How should this be repaired?

Options

Wound

Primary Closure Primary Closure

Tissue Graft Tissue Graft

2ndary Intention 2ndary Intention

Tissue Flap Tissue Flap

Normally…

Dutton JJ. Atlas of Clinical and Surgical Orbital Anatomy. W.B Saunders Co. Philadelphia, PA. 1994

Back to our dilemma

Loss of lids Moderate defect Active smoker Normal skin elasticity Aesthetics

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What does the BCSC book say?

Classification and Management of Eyelid Disorders. Orbit, Eyelids, and Lacrimal

• System. San Francisco, CA: American Academy of Ophthalmology; 2003.

The Ancient Texts

The Sushruta Samita

(~700 BC)

Surgery was performed

by the Koomas.

The need for the

• peration arose from

the common practice of amputating the tip of the nose.

What is a Paramedian Flap?

A forehead flap that takes

advantage of the vascular supply of the supratrochlear artery.

A useful flap because of the

axial design, narrower base, and greater effective length.

They are the reconstructive

mainstay for nasal defects.

A Little More History

Antonio Branca

15th Century Italy 18th Century UK

• J. C. Carpue

19th Century Prussia/B avaria

John Mason Warren

19th Century USA

Varaztad H. Kazanjian

Baker SR. Interpolated Paramedian Forehead Flap. In: Baker SR, ed. Local Flaps in Facial Reconstruction. 3rd ed. Philadelphia: Elsevier, 2014: 268-316.

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It is estimated that 5.4 million

cases of non-melanoma skin cancer, including basal cell carcinoma and squamous cell carcinoma, were diagnosed in the U.S. in 2012.

The Sun has Replaced the Sword

Current estimates are that one

in five Americans will develop skin cancer in their lifetime.

The annual cost of treating non-

melanoma skin cancer in the U.S. is estimated at $4.8 billion.

Paramedian Flap

Flap design Flap mobilization Flap secured Forehead closure Pedicle division

& inset

Paramedian in Oculoplastics

First introduced in our

literature in 1981.

In 2004, Bartley and

Garrity presented a series

• f 18 patients utilizing the

flap for intermediate sized periorbital defects.

The flap can be split to

allow simultaneous reconstruction of the upper and lower lid.

Anterior Lamellar Reconstruction

Pre-Resection Post-Resection Cervico-facial Flap Paramedian Flap Post-reconstruction Post-operative Week 1 Pedicle Division Week 4 Post-operative Month 4 Post-operative Year 2

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Nasal and Medial Canthal Reconstruction

Pre-resection Post-resection Post-reconstruction Flap Design Post-operative Week 3 Post-pedicle Division Post-operative Month 6 Post-operative Year 1.5

Socket Reconstruction

Pre-reconstruction Post-debridement & Anterior Exenteration Post-reconstruction Flap Thinning Year 1 Pedicle Division Follow-up Year 1.5

Conclusions

The paramedian forehead flap is a versatile

alternative for ocular adnexal and socket reconstruction.

This is especially true in cases of moderate

to large, complex defects or tissue loss that preclude smaller advancement flaps or skin grafting.

It can be employed especially when local

blood flow may be compromised by trauma, radiotherapy and/or smoking history.

Thanks