CORDOVA, Adriana

D'ARPA, Salvatore

MOSCHELLA, Francesco

Plastic & Reconstructive Surgery

Archivio istituzionale della ricerca - Università di Palermo

University of Southern California, Los AngelesLos Angeles, Calif.Correspondence to Dr. BurnstineEyesthetica1513 South Grand Avenue, Suite 200Los Angeles, Calif. 90015mburnsti@earthlink.netPoster presented at the Association of Research in Vision andOphthalmology 2010 Annual Meeting, in Fort Lauderdale,Florida, May 2 through 6, 2010.DISCLOSUREThe authors have no financial interest to declare in re-lation to the content of this article. No external funding wasreceived.PATIENT CONSENTPatients provided written consent for the use of their images.REFERENCES1. Gladstone GJ, Nesi FA. Management of paralytic lagophthal-mos with a modified gold-weight implantation technique.Oph-thal Plast Reconstr Surg. 1996;12:38–44.2. McCord CD, Codner MA. Eyelid and Periorbital Surgery. St.Louis: Quality Medical; 2008.3. Sobol SM, Alward PD. Early gold weight lid implant for re-habilitation of faulty eyelid closure with facial paralysis: Analternative to tarsorrhaphy. Head Neck 1990;12:149–153.4. Freeman MS, Thomas JR, Spector JG, Larrabee WF, BowmanCA. Surgical therapy of the eyelids in patients with facialparalysis. Laryngoscope 1990;100:1086–1096.5. Kelley SA, Sharpe DT. Gold eyelid weights in patients withfacial palsy: A patient review. Plast Reconstr Surg. 1992;89:436–440.A New One-Stage Method for NoseReconstruction: The Supratrochlear ArteryPerforator Propeller FlapSir:The authors propose a single-stage method for nasalreconstruction using a perforator propeller flaptermed the supratrochlear artery propeller perforatorflap.1 The supratrochlear artery propeller perforator flapis pedicled on the supratrochlear artery which, togetherwith accompanying veins and the supratrochlear nerve,emerges from the concavity of the inner canthus andFig. 2. (Above) Preoperative appearance of a patient with right facial palsy after parotid tumor removal. (Below) Postoperativeviews show the patient after right internal eyebrow elevation, bilateral upper blepharoplasty, right upper eyelid gold weightimplantation, and right lower eyelid fascia lata suspension for epiphora, eye irritation, and lagophthalmos with a poor Bellphenomenon that does not bury cornea.Volume 129, Number 3 • Viewpoints571eperforates the procerus and corrugator supercilii andnourishes the paramedian forehead skin. A propeller flapbased on a constant and conspicuous vessel such as thesupratrochlear artery is safe and reliable.The surgical technique consists of the following.Once the nasal defect is outlined, the supratrochlearartery is identified by means of a Doppler probe andmarked on the skin. The flap, centered on this mark-ing, is planned as a skin island composed of two blades,like a propeller: a superior (frontal) blade and an in-ferior (nasal) blade.The frontal blade is planned and raised like a con-ventional forehead flap. The nasal blade includes theskin between the skin marking of the supratrochlearartery and the upper margin of the defect.Dissection is supraperiosteal except for the distal 2cm of the frontal blade. Pedicle dissection is performedunder loupe magnification: the vessels are identified attheir emergence from the orbit and freed from anyattachment to the surrounding tissues that might im-pair rotation of the skin island (Fig. 1).The flap is left attached only by its pedicle. Rotation of180 degrees is simulated both clockwise and counter-clockwise, and perfusion of the skin and pedicle kinkingare checked to determine which rotational direction isbetter.2 Once the flap is rotated, the frontal blade coversthe loss of substance of the nose, and the nasal blade willpartially cover the donor site defect.The supratrochlear artery propeller perforator flap canbe folded double distally to repair the inner layer of thenose in full-thickness defects. Septal flaps or compositegrafts3 can also be used in full-thickness reconstruction.Nose reconstruction by means of a supratrochlearartery propeller perforator flap was performed on 15patients, 10 men and five women, with ages rangingfrom 62 to 94 years (mean, 75 years). All patients weresatisfied with the results (Fig. 2). All of the operationswere performed under local anesthesia. The su-pratrochlear artery propeller perforator flap is a goodoption for one-stage nose reconstruction and is simplerthan other single-stage techniques.4The nasal blade repairs the glabellar area and pre-serves the normal distance between the brows. Residualscars overlap with the glabellar grooves.The supratrochlear artery propeller perforatorflap is not ideal when an optimal cosmetic result isrequired, because only a less-than-optimal cosmeticoutcome can be achieved in one stage and becausesubunit reconstruction is necessarily less accurate.5The supratrochlear artery propeller perforator flap isnot to be considered an alternative to the conven-tional multistage forehead flap but rather a secondchoice in cases where the one surgical procedure canbe a real advantage.DOI: 10.1097/PRS.0b013e3182419bc4Adriana Cordova, M.D.Salvatore D’Arpa, M.D., Ph.D.Francesco Moschella, M.D.Chirurgia Plastica e RicostruttivaDipartimento di Discipline Chirurgiche ed OncologicheUniversita` degli Studi di PalermoPalermo, ItalyFig. 2. At 6 months after the operation, there is excellent colormatch.Fig. 1. Tip and dorsum defect after basal cell carcinoma resec-tion. The propeller is drawn around the pivot point. The higherthe defect, the shorter the nasal blade. The flap is harvested asnarrowaspossible in thepivot point to avoid anyexcess tissue inthis area.Plastic and Reconstructive Surgery • March 2012572eCorrespondence to Dr. CordovaU.O. di Chirurgia Plastica e RicostruttivaA.O.U.P. Paolo GiacconeVia del Vespro 12990127 Palermo, Italyadriana.cordova.unipa@gmail.comPresented at 21st Meeting of the European Association ofPlastic Surgeons, in Manchester, United Kingdom, May 27through 29, 2010, and the 59th Congresso SICPRE, in Siena,Italy, September 23 through 26, 2010.REFERENCES1. Geddes CR, Morris SF, Neligan PC. Perforator flaps: Evolu-tion, classification, and applications. Ann Plast Surg. 2003;50:90–99.2. Pignatti M, Ogawa R, Hallock GG, et al. The “Tokyo” con-sensus on propeller flaps. Plast Reconstr Surg. 2011;127:716–722.3. Cordova A, Di Lorenzo S, Moschella F. “Composite graft”:A simple option for nasal lining. Int J Dermatol. 2007;46:417–421.4. Park SS. The single stage forehead flap in nasal reconstruc-tion: An alternative with advantages. Arch Facial Plast Surg.2002;4:33–36.5. Menick FJ. A 10-year experience in nasal reconstruction withthe three-stage forehead flap. Plast Reconstr Surg. 2002;109:1839–1855; discussion 1856–1861.Reconstruction of Elbow Flexion by End-to-SideNeurorrhaphy in Phrenic Nerve TransferSir:Phrenic nerve transfer has been widely used in thetreatment of brachial plexus avulsion injuries and hasbeen one of the options for reconstruction of elbow flexion,with biceps strength of M3 or better at 84.6 percentrecovery.1,2 However, concerns regarding potential pulmo-nary function problems have limited its popularization.3Therefore, we considered balancing the restoration of theaffected limb and preventing denervation of the ipsilat-eral diaphragm by end-to-side neurorrhaphy.In the current study, five consecutive patients (threemale patients and two female patients) with brachialplexus avulsion injuries, aged from 6 to 36 years (mean,18.6 years), were admitted to our hospital and under-went phrenic nerve transfer with end-to-side neuror-rhaphy by neurotizing the anterior division of the up-per trunk or the musculocutaneous nerve. Theoperative delay after injury was 1 to 6 months (mean,2.5 months). In the surgical process, the distal end ofthe musculocutaneous nerve or anterior division of theupper trunk was sutured to the grafted sural nerve withend-to-end neurorrhaphy, and the other end of thegraft was sutured to the side of the phrenic nerve in“helicoid fashion” at the level of the C6 nerve root usingFig. 1. Intraoperative photograph shows “helicoid coaptation”in the end-to-side neurorrhaphy in phrenic nerve transfer. Afteran epineurialwindowwasmadeon the lateral surface of phrenicnerve (PN), the distal stumpof themusculocutaneous nervewascoapted to the lateral phrenic nerve by means of a 7-cm suralnerve (SN) graft using an8-0polypropylene suture. Theproximalend of the graft was coapted to the phrenic nerve after spirallywinding2.5cyclesalongthephrenicnervetoenlargethecontactarea (arrow).Fig. 2. Diagram shows comparison of the forced vital capacity (FVC) before and at 6, 12,18, and 24 months after surgery in the five patients.Volume 129, Number 3 • Viewpoints573e

A New One-Stage Method for Nose Reconstruction: The Supratrochlear Artery Perforator Propeller Flap

Adriana Cordova

Salvatore DʼArpa

Francesco Moschella

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A New One-Stage Method for Nose Reconstruction

https://iris.unipa.it/retrieve/handle/10447/73422/72246/A_New_One_Stage_Method_for_Nose_Reconstruction__.69%5b1%5d.pdf

A New One-Stage Method for Nose Reconstruction: The Supratrochlear Artery Perforator Propeller Flap

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