12/2/2016 Paramedian Forehead Flap for Disclosure Ocular Adnexal Reconstruction I have no financial interests or M. Reza Vagefi, M.D. relationships to disclose. Oculofacial Plastic Surgery Associate Professor of Ophthalmology University of California, San Francisco UCSF Ophthalmology Update December 2, 2016 Case Presentation Exam � CC : Blast injury of right peri-ocular area Right Eye Left Eye � HPI : 47 year-old male presents 9 days after VA LP w/o projection 20/20 ruptured globe repair OD for further Eye IOP Unable 13 evaluation and treatment. He reports working Exam Pupils + Reverse APD 4 � 2 mm on a hydraulic pipe used in the machinery to EOM Globally restricted Full crate fruit when it exploded in his face. He External CVF denies the use of eye protection. Exam � PMH : None � Social Hx : 1 PPD smoker 1
12/2/2016 Options Primary Primary Closure Closure How should this be repaired? Tissue Tissue Tissue Tissue Wound Flap Flap Graft Graft 2ndary 2ndary Intention Intention Normally… Back to our dilemma � Loss of lids � Moderate defect � Active smoker � Normal skin elasticity Dutton JJ. Atlas of Clinical and Surgical Orbital Anatomy . � Aesthetics W.B Saunders Co. Philadelphia, PA. 1994 2
12/2/2016 What does the BCSC book say? The Ancient Texts � The Sushruta Samita (~700 BC) � Surgery was performed by the Koomas. � The need for the operation arose from the common practice of amputating the tip of the nose. Classification and Management of Eyelid Disorders. Orbit, Eyelids, and Lacrimal System. San Francisco, CA: American Academy of Ophthalmology; 2003. What is a Paramedian Flap? A Little More History 15 th � A forehead flap that takes Century Italy advantage of the vascular supply of the supratrochlear 18 th artery. Century UK � A useful flap because of the 19 th axial design, narrower Century Prussia/B base, and greater effective avaria length. 19 th Antonio Branca Varaztad H. Kazanjian John Mason Warren � They are the reconstructive Century USA Baker SR. Interpolated Paramedian Forehead Flap. J. C. Carpue mainstay for nasal defects. In: Baker SR, ed. Local Flaps in Facial Reconstruction. 3rd ed. Philadelphia: Elsevier, 2014: 268-316. 3
12/2/2016 The Sun has Replaced the Sword Paramedian Flap � Current estimates are that one � Flap design in five Americans will develop skin cancer in their lifetime. � Flap mobilization � It is estimated that 5.4 million cases of non-melanoma skin � Flap secured cancer, including basal cell carcinoma and squamous cell � Forehead closure carcinoma, were diagnosed in the U.S. in 2012. � Pedicle division � The annual cost of treating non- & inset melanoma skin cancer in the U.S. is estimated at $4.8 billion. Anterior Lamellar Paramedian in Oculoplastics Reconstruction � First introduced in our literature in 1981. � In 2004, Bartley and Pre-Resection Garrity presented a series Post-operative Month 4 Post-operative Week 1 Paramedian Flap of 18 patients utilizing the flap for intermediate sized Cervico-facial Flap periorbital defects. � The flap can be split to allow simultaneous reconstruction of the Post-operative Year 2 Pedicle Division Week 4 upper and lower lid. Post-Resection Post-reconstruction 4
12/2/2016 Nasal and Medial Canthal Socket Reconstruction Reconstruction Pre-reconstruction Pre-resection Post-operative Month 6 Post-reconstruction Flap Thinning Year 1 Post-operative Week 3 Flap Design Post-debridement & Anterior Exenteration Follow-up Year 1.5 Pedicle Division Post-operative Year 1.5 Post-resection Post-pedicle Division Post-reconstruction Conclusions Thanks � 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. 5
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