Over a period of 5 years, 12 patients (4 females and 8 males) were included in this study. Four patients experienced chemical burns, and 8 patients experienced thermal burns. All patients presented with the same criteria for periorbital reconstruction using a BSTIF to reconstruct their eyebrows and to release ectropion in their upper and lower eyelids. Two patients underwent bilateral flap reconstruction, and 10 patients underwent unilateral reconstruction; there were no flap failures and no postoperative infections. Two eyebrows of patients underwent surgical refinement, with one receiving scar revision 9 months after surgery and the other having the flap advanced for better positioning and symmetry 6 months after surgery. Laser hair removal was performed for 9 cases to design the new eyebrow to mimic the normal side. Ideal position of the eyelid was observed in 10 cases; however, in 2 cases, a postoperative residual scleral a range of 1 to 2 mm was observed, although neither of the upper or lower eyelids required a secondary release after the operation. No complications were noted, apart from one case in which the loss of hair density in the parietal flap was observed combined with the loss of the distal 5 mm of the frontal flap. We administered a questionnaire to assess patient satisfaction within this group; the points included the degree of patient satisfaction, the density and orientation of hairs, the symmetry with the other side, and the skin color match of the nonhairy flap. The results of the questionnaire are summarized in Table 2 (Figs. 6, 7).
A burned face is the single most important anatomical structure a burn surgeon is called upon to reconstruct. The periorbital area serves an important function in the identification of the individual and contains the organs of sight and personal identity. Distortion of this region can potentially cause functional impairment and deformities that lead to the withdrawal of the victim from society.14 The complex shape and form of the periorbital area renders reconstruction difficult, and the exposed position of the face allows only limited camouflage with clothing and makeup.9
The problems encountered in burned periorbital areas include alopecia in the eyebrows and ectropion in the upper and lower eyelids with lagophthalmos.
The goals of reconstruction should be to preserve, restore, and maintain function and appearance so that the cornea is protected from ulcers and painful conditions and the patient can function in society.15 To accomplish these goals, it is essential that the surgeon have an organized approach to the reconstruction of the burned periorbital area, including contracture release with replacement using the uncontracted option and restoration of the hair in the eyebrows.16
The eyebrows function as an essential part of facial expression, conveying a spectrum of emotions including anger, sadness, and surprise. Their shape, proportion, angulation, symmetry, and size play a significant role in the perception of the face.17 The eyebrows are a unique area among hair-bearing areas in the body because of the notable thinness of the hair and the complicated pattern of hair direction. The orientation of the hairs varies according to their location within the eyebrow. Although hairs in the medial and lower eyebrows grow in the superolateral direction, those in the lateral and superior regions grow in the inferolateral direction. At the individual level, eyebrow hairs are short in length, small in diameter, and slow growing; all these characteristics are unique to the eyebrow.18
Eyebrow reconstruction works particularly well for those with extensive burn scarring of the face. The presence of hair can make the facial appearance more aesthetically pleasing by breaking up the uninterrupted area of scars. Options available for eyebrow reconstruction include micrografting,19,20 hair-bearing full-thickness skin grafts,21 and using vascularized island flaps based on the superficial temporal artery. However, cases of diffusely scarred and stiff recipient sites caused by burned or irradiated tissue represent the most difficult sites for successful transplantation.22,23
In cases where the recipient bed is not well vascularized because of burns or prior irradiation, pedicled vascularized scalp flaps based on the superficial temporal artery, either tunneled or tubed, may be used. This is typically a better reconstructive site technique, especially for men, because the thicker nature of male eyebrows is more appropriately matched by pedicled scalp flaps, which often cannot be thinned safely in a single operation to the extent appropriate for female patients, who typically possess a narrower eyebrow width.8 In fact, although the problems encountered with the use of the flap include the density and direction of hair, we typically find that the flaps yield better hair density than either grafts or hair transplantation and that the direction of the hair is more natural with a flap than in other options, as well.
In our cases, the reconstructed eye brow was refined to nearly normal by continuous toweling or laser hair ablation to achieve a finalized eyebrow shape according to patient preference. In some patients, the eyebrow may need to be advanced medially, which can be done under local anesthesia.
The most common periorbital problems are related to unopposed contraction of the scar tissue on the mobile lid margin, leading to ectropion.24 To correct this issue, the upper eyelid is released at the level of the supratarsal fold and is frequently reconstructed using a thick split-thickness skin graft because the skin of this area is more mobile. However, recurrence in the graft is common.2,3 Therefore, our solution for using the maximum available scarred tissue is to release the upper eyelid and occupy the defect with the temporal flap to resist recontracture and provide tissue for the future eyebrow.
The lower lid is released at the subciliary margin and is then managed using an full-thickness skin graft or local flaps, such as a laterally based myocutaneous upper eyelid flap or a superiorly based nasolabial flap, both of which are useful for lower lid ectropion.25 However, the use of skin grafts may lead to recurrent contracture, and the surrounding local flaps may not be available because of severe scarring, in addition to the added facial scarring.2,3 Therefore, the island superficial temporal artery flap provides an excellent and optimum solution for lower lid reconstruction with hidden scars. In some cases, the flap may be hairy, but the patient can undergo laser hair ablation to correct this issue.
Kajikawa and Ueda26 described unilateral extended superficial temporal artery flap surgery with 2 scalp paddles for the reconstruction of 2 eyebrows in their study. Bozkurt et al27 described the use of a medusa flap to reconstruct the periorbital area, although the authors actually used only a single skin paddle, not 2 skin paddles. In addition, they mentioned only 1 case in their report. Cöloğlu et al28 reported the use of an axial bilobed superficial temporal artery island flap (tulip flap) for the reconstruction of combined defects of the lateral canthus, including the lower and upper eyelids in 5 cases, although the author described only a single tailored island flap, not a chimeric flap. However, in the literature, no previous attempts have been made to use 2 paddles based on a single superficial temporal artery to reconstruct the eyebrow, upper eyelid, and lower eyelid simultaneously.
Limitations of usage of the flap include scarring of the temporal area or the previous use of temporoparietal fascia flap.
We consider this technique an innovative method for solving problems associated with periorbital burns and for helping patients reintegrate into society.
BSTIF is an innovative flap for reconstructing both burned eyebrows and eyelids. It is a new idea that reconstructs 3 different unique aesthetic facial units with a 1-stage island flap.
Patients provided written consent for the use of their images.
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Copyright © 2016 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons. All rights reserved.
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