Evaluation of Flap Reliability and Usefulness
Patients’ records were searched for the following outcome variables: width and length of the flap, width and length of the hair-bearing region, occurrence of any circulatory problems, flap survival, growth pattern of the transplanted hair, patient satisfaction with the cosmetic outcome, and occurrence of any complications. In 1 patient, we observed blood circulation of the flap during the surgery by intravenously injecting 1 mL (1.7 mg/mL) of indocyanine green (ICG).
Flaps were 1.7–3.5 cm (mean, 2.7 cm) in width and 3.0–5.1 cm (mean, 4.1 cm) in length. The hair regions within the flaps were 1.2–1.8 cm (mean, 1.4 cm) in width and 0.5–1.3 cm (mean, 0.9 cm) in length (Table 1). No circulatory problems were encountered in the flaps, and all flaps survived completely. Hair growth was confirmed in the flap apex in all patients (Figs. 4–6). The hair on the flap was directed slightly upward 1 or 2 months after the surgery. However, it turned downward as time went by. Furthermore, the hair grew long, and all patients cut it about once a month. All patients were satisfied with the results of the flap transplantation, and no revision was necessary for any patient. The scar at the donor site was not noticeable because it followed the wrinkles of the lateral eyelid, and no postoperative complication, such as facial paralysis, hematoma, and infection, occurred. In the case in which we performed the ICG test, blood reached the distal side of the flap, though not immediately; the entire flap stained with ICG (See Video 1, Supplemental Digital Content 1, which displays circulatory dynamics of the flap observed with a near infrared camera. The video shows the condition before and after ICG administration, http://links.lww.com/PRSGO/A23).
The lateral orbital flap contains a thick vascular network.14–16 Although Ogawa et al8 stated that the orbicularis oculi muscle is not always necessary for the lateral orbital flap, some authors have elevated such flaps based on the orbicularis oculi muscle.10–12,15 We think that attachment of the orbicularis oculi muscle containing the zygomatic facial artery ensures blood supply to the extended hair-bearing lateral orbital flap. When the flap is elevated solely on the muscle, the pedicle can be made narrow, facilitating rotation of the flap. We think that the use of the muscle does not endanger the temporal branch because the branch exists on the lateral side of the muscle. Survival of our flap, hair growth on the distal part, and the ICG confirmation suggest that blood flow to the hair-bearing region of this flap is stable. The length-to-width ratio of the flaps in our patient series was in the range of 1.2–2.2:1. Ogawa et al8 note that the usual lateral orbital flap is designed at a ratio of approximately 2:1. In our patient series, this flap was limited in terms of its width because the donor site required closure. Generally, the width of the flap is no more than 3–3.5 cm.
Attention should be paid to the deep layer of the flap because the temporal branch of the facial nerve is present there. This nerve exists under a reference line drawn from about 0.5 cm below the tragus to the upper part of lateral end of the eyebrow9,17,18 and passes through the region approximately 3–4 cm lateral to the lateral orbital rim at the level of the upper margin of the zygoma. We marked the distribution of the temporal branch on the skin and avoided deep dissection of the subcutaneous fat layer in the marked region. Use of the nerve stimulator was also helpful.
Eyebrow reconstruction methods fall roughly into 3 categories: free hair graft transfer, free skin graft with hair transfer, and flap transfer. For the free hair graft, there are 2 methods: transplantation of a single hair and transplantation of a bundle of 3–4 hairs.3 Tunnel scalp grafting4 and use of the postauricular hairline2 have been reported for the free skin graft. For flap transfer, hair transplantation with a superficial temporal artery-pedicle flap,1 a subcutaneous pedicle flap from the affected eyebrow,5 and an orbicularis oculi myocutaneous flap6 have been reported. The main characteristic of our procedure is the simultaneous reconstruction of a part of the eyebrow and the upper eyelid. Because the hair-bearing region of this flap is the sideburn with sparse hair, it fits well with the lateral eyebrow. In the reconstructed eyebrow, new hairs grow upward at the root but after some growth hang downward due to gravity. This is aesthetically pleasing. It is difficult to design the flap so that it precisely fits the defect in terms of the amount of hair needed and the direction of hair growth. The flap is oriented in the horizontal direction on the face, and this cannot be changed. We do our best to adjust the length and width of harvested sideburn on the flap to match those of the eyebrow defect. However, the direction of hair growth cannot be corrected.
The extended hair-bearing lateral orbital flap has 4 main advantages: The eyebrow and upper eyelid can be reconstructed in 1 stage with a single flap, the flap is thin and does not require revision, the flap elevation is relatively safe and easy, and the donor site scar is acceptable. Disadvantages are that the direction of hair growth in the reconstructed eyebrow can be upward and the hair grows long. However, the 1-stage simultaneous reconstruction of the upper eyelid and eyebrow reduces the number of surgeries required, which is sensible for elderly patients with skin cancer.
Patients provided written consent for the use of their images.
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Supplemental Digital Content
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