Advances in Plastic & Reconstructive Surgery © All rights are reserved by Dr. Sharanabasav Hiremath, et al.

*Address for Correspondence: Dr. Sharan Hiremath’s, Plastic Surgeon, Adora Cosmetic surgery and Trauma Centre, Solapur, Maharashtra, India., E-mail: drsharanmh@gmail.com

Received: April 24, 2020; Date Accepted: June 05, 2020, Date Published: June 06, 2020.

Sharanabasav Hiremath, Somashekhar Gejje, Snehalata HiremathAdora Cosmetic surgery and Trauma Centre, Solapur, Maharashtra, India. lastic Surgery, Vitalis Clinic.

useful characterization of serotonin receptor subtypes in the treatment of

Technique ISSN: 2572-6684

Dr Sharan Hiremath’s Preauricular flag flap for temple and lateral forehead defects

subcutaneous tissue of the flap. the flap is incised lateral and medial side on the marking. With careful dissection flap is elevated with incorporating superficial temporal artery. The artery has frontal and temporal branches1. The frontal branch anastomose with the supra-trochlear and supraorbital vessels. The vascularity of the flap is depe-ndent on the anastomosis between the frontal branch of STA and supraorbital and supratrochlear vessels [1, 2].

The parietal branch is cut and cauterized while incising the flap superolaterally hence I have never incorporated the parietal branch in the flap. The dissection of the pedicle is advanced cranially .when temperoparietal fascia around superficial temporal vessels is undermi-ned, with the help of NMS450 nerve mapping locator, temporal branches of facial nerve [3-5] is identified and confirmed by direct stimulation intraoperatively. The dissection is continued till the flap can be transferred to the defect without tension and torsion. The flap is transferred to the defect by incising the bridge of the defect and then sutured with 4-0 Ethilon (synthetic nonabsorbable nylon suture). The donor site is closed primarily with 3-0 monocryl suture. Drain was not put in any of the cases. Loose circumferential padded dressing was done over the flap with window kept open for monitoring of the flap. Donor site dressing was done separately. The average time taken for the procedure was around 80-90 min.

Results

We performed this flap in three cases. On an average the size of the defect was 5X4cm in size. The donor site is closed primarily.

The postoperative course was uneventful. Distal tip necrosis was seen in third case measuring approximately 2x2cm. The results were favourable cosmetically and donor site scar was inconspicuous. One of the drawback is dog ear at the base of flap which can be revised after three months under local anesthesia which gives better cosmetic results.

Case reportsCase1

The procedure is performed under General Anesthesia. Incision is taken in the distal end of the flap. Skin and subcutaneous tissue isA 23-year-old female met with RTA, and sustained injury to face. Onexamination there was complete loss of skin and periosteum on thelateral aspect of forehead. Under general anesthesia after debridement,the defect was measuring around 5X4 cm in size with exposed frontalbone around 3X2 cm in size [figure 2a]. Flap is elevated from preauri-cular region and rotated and covered the frontal bone [figure 2b]. Restarea is covered with FTG. The postoperative course was uneventfuland donor area scar was inconspicuous. [Figure 2c and 2d].

Introduction Local flaps have an ideal colour and texture match, so it could be the technique of choice for the reconstruction of small-sized defects on the lateral forehead [1]. These flaps are desirable with minimal donor-site morbidity and inconspicuous donor-site scars.

Technique The planning of the surgery includes identification and palpation

of the superficial temporal artery [Figure 1]. The course of the artery is marked with the help of hand held arterial Doppler ultrasound with frequency of 2MHz-3MHZ. After measurement of the size of the defect the flap is planned in the hairless preauricular region.

Figure 1: Anatomy of superficial temporal artery and its branches.

The procedure is performed under General Anesthesia. Incision is taken in the distal end of the flap. Skin and subcutaneous tissue is incised. STA is identified and ligated. The ligated end is fixed to the

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Sharanabasav H, Somashekhar G, Snehalata H. Semi-open rhinoplasty: Getting together the best of both, open and closed rhinoplasty. Adv Plast Reconstr Surg, 2020; 4(2): 332-333.

Case 2 A 55year old lady was having swelling over lateral aspect of forehead since 2 years [figure 3a]. Biopsy was taken. It was diagnosed as soft tissue sarcoma. After wide local excision the defect was measuring around 4x5cm in size. Flap was designed in preauricular region. As lady was old lot of laxity was there so a wider flap than regular size. Flap was elevated with STA till the anastomosis with supratrochlear vessels(figure3b). Flap is rotated and sutured to the defect.

a b

c d

Case 3 A six-year-old girl, fell down from height, sustaining injury to lateral aspect of forehead on right side. After debridement the defect was measuring approximately 5x3x2cm in size. Flap was marked over preauricular area, STA artery was ligated and cut. Flap was elevated along with STA and then rotated, covered over the defect and suturing done without tension and torsion.

Donor site was closed. After two days the distal end of the flap was dusky as the flap was taken little longer distal to the artery with 2x2cm random flap. Later on, it healed by secondary intension.

Discussion

The reverse STA flap from the preauricular region was reported in 1976 by Bostwick et al., [4] and Yamauchi et al [1] in which they treated

the case of a forehead skin defect using this flap based on both the frontal and parietal branch of the STA. In our cases the flap was based on frontal branch of superficial temporal artery and the anastomosis between frontal STA and ipsilateral supratrochlear and supraorbital vessels. The vascularity of the flap was good and reliable, in one case the distal part of the flap got necrosed4 as the distal end of the flap was beyond 2 cm of the ear lobe. and in other two cases result was excellent.

After identifying the superficial temporal vessels, the flap is elevated [4, 5] with the skin and their vessels alone. This is easier to perform and produces a thin flap without the reddish skin colour peculiar to the postauricular region [5]. In addition, this has reliable blood circulation and application as both the pedicled and free flaps. The donor site does not leave a conspicuous scar or ear deformity even if it sutures primarily. The Yamauchi et al1 study reverse superficial temporal artery flap is used mainly either islanded or free flap, in our study the flap is mainly pedicled, based on anastomosis between frontal branch of superficial temporal artery and supra trochlear and supraorbital branches. These types of defects can also be covered by free radial artery forearm flaps, scapular flaps, lateral arm flap, dorsalis pedis flap and suprafacial anterolateral thigh flaps [6]. These flaps are time consuming, aesthetically less appreciable as some are bulky, hairy and chances of flap failure.

Conclusion

Dr Sharan Hiremath’s preauricular flag is one of the ideal flap for coverage of lateral forehead defects. These defects are commonly due to trauma or malignancy. Small to medium sized are covered by this flap. This flap is harvested from non hairy area and it will match the colour of forehead. Cosmetically gives better result. Donor area is hidden and scar mark is incospicous. We can avoid free flap which are time consuming and tedious. This flap is very reliable because of its rich vascularity.

References

1. Yamauchi M, Yotsuyanagi T, Yamashita K, Ikeda K, Urushidate S, Mikami M .The reverse superficial temporal artery flap from the preauricular region, for the small facial defects J plast Reconstr Surg 2012; 65(2):149-55. [Crossref]

2. Yotsuyanagi T, Watanabe Y, Yamashita K, Urushidate S, Yokoi K. SawadaY.Retroauricular flap: its clinical application and safety. Br J Plast Surg 2001; 54(1):12-9. [Crossref]

3. Park C, Chung S. Reverse-flow postauricular arterial flap for auricularreconstruction. Ann Plast Surg 1989; 23:369-74. [Crossref]

4. Bostwick J, Briedis J, Jurkiewicz MJ. The reverse flowtemporal artery island flap.Clin Plast Surg 1976; 3:441-5. [Crossref]

5. Yamauchi M, Yotsuyanagi T, Ezoe K, Saito T, Ikeda K, Arai K. Reverse facial arteryflap from the submental region.JPlast Reconstr Aesthet Surg 2010; 63:583-8.[Crossref]

6. Yamamoto Y1, Minakawa H, Sugihara T, Shintomi Y, Nohira K, Yoshida T, Igawa H, Ohura T. Facial reconstruction with free-tissue transfer.Plast Reconstr Surg. 1994Sep; 94(3): 483-9. [Crossref]

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