Sir:
Reconstruction of defects in the paranasal region is a challenging procedure. Apart from the use of skin grafts, numerous flaps from the upper lid, glabella, or cheek have been reported to resolve this problem.1–3 Nevertheless, these reconstructive procedures frequently result in deformities such as an epicanthal fold, bulky pedicles, asymmetry, and unfavorable donor-site scars, so that the ideal flap is still waiting for discovery.
Vessels qualifying for reconstruction with axial flaps in the paranasal region are the angular1,2 and supratrochlear arteries.2,3 The vascular anatomy of these arteries has been studied extensively. In particular, an anastomosis between the internal carotid–supplied angular and the external carotid–supplied supratrochlear artery has been shown to be highly consistent.4 Furthermore, anatomical and angiographic studies demonstrate a high density of perforators in the range of the nasal root. A small perforator, arising from the confluence of the angular and the supratrochlear arteries and perforating the procerus muscle, is depicted in numerous angiographic and anatomical figures4,5; nevertheless, so far it has remained nameless and is disregarded.
We present a novel flap from the nasal root pedicled on this perforator. The flap is circumcised (resulting in an island flap in a horizontal shape), rotated, tunneled, and inserted into the defect, resulting in a propeller perforator flap (Fig. 1, left).
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Fig. 1: (Left) Intraoperative view of defect closure in the paranasal region using a procerus perforator flap. The procerus perforator is identified and dissected, and the flap is circumcised and rotated in the form of a propeller flap and pulled through into the defect. The donor site is closed and the flap is stitched in. (Right) The patient in the outpatient control on postoperative day 10 with the flap perfectly healed.
Eight subsequent patients with defects in the paranasal region were included in this trial, and all operations were performed by the first author (S.R.) within the past 12 months. In all cases, the defect resulted from an excision of nonmelanotic skin cancer. All tumors were excised with clear margins, with a mean defect size of 18.8 mm.
The operation was uneventful in all patients. In each case, an adequate procerus perforator was identified and dissected, and the flap was elevated and pulled through into the defect and stitched tension-free. The postoperative course was uneventful in seven patients; in one patient, an epitheliolysis had to be recorded after the patient had neglected the nicotine proscription. However, all flaps healed perfectly, resulting in a favorable reconstructive result, including an inconspicuous donor-site scar (Fig. 1, right).
Admittedly, the preparation of the tenuous perforator vessels in the nasal root fold demands some microsurgical skills. Nevertheless, in all cases, a 2.5× magnification loupe and the conventional tools sufficed. In contrast to upper lid flaps, the procerus perforator flap is pedicled on only tenuous vessels; therefore, the pedicle is far from being bulky, and we observed no epicanthal folds. Furthermore, the flap features an ideal donor site, as it is taken from excess tissue of the nasal root, forming the anger crease. In contrast to upper lid flaps, the donor site does not cause any asymmetry. We present a novel flap for paranasal reconstruction that yields excellent results, with perfect match regarding color and skin texture, and with a low complication rate.
Stefan Riml, M.D.
Department for Plastic, Aesthetic, and Reconstructive Surgery, Academic Hospital Feldkirch, Feldkirch, Austria
Lorenz Larcher, M.D.
Section of Plastic, Aesthetic, and Reconstructive Surgery, General Hospital Linz, Linz, Austria
Martin Grohmann, M.D.
Peter Kompatscher, M.D.
Department for Plastic, Aesthetic, and Reconstructive Surgery, Academic Hospital Feldkirch, Feldkirch, Austria
DISCLOSURE
The authors have no financial interest to declare in relation to the content of this article.
PATIENT CONSENT
The patient provided written consent for the use of his images.
ACKNOWLEDGMENT
The authors thank A. Piontke for excellent photodocumentation.
REFERENCES
1. Seo YJ, Hwang C, Choi S, Oh SH. Midface reconstruction with various flaps based on the angular artery. J Oral Maxillofac Surg. 2009;67:1226–1233.
2. Furnas DW, Furnas H. Angular artery flap for total reconstruction of the lower eyelid. Ann Plast Surg. 1983;10:322–325.
3. Onishi K, Maruyama Y, Okada E, Ogino A. Medial canthal reconstruction with glabellar combined Rintala flaps. Plast Reconstr Surg. 2007;119:537–541.
4. Kelly CP, Yavuzer R, Keskin M, Bradford M, Govila L, Jackson IT. Functional anastomotic relationship between the supratrochlear and facial arteries: An anatomical study. Plast Reconstr Surg. 2008;121:458–465.
5. Houseman ND, Taylor GI, Pan WR. The angiosomes of the head and neck: Anatomic study and clinical applications. Plast Reconstr Surg. 2000;105:2287–2313.
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