Use of suborbicularis oculi fat flap to cover peri-orbital bone exposure

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YIJOM-3513;NoofPages4

Pleasecitethisarticleinpressas:DiA,etal.Useofsuborbicularisoculifatflaptocoverperi-orbitalboneexposure,IntJOral MaxillofacSurg(2016),http://dx.doi.org/10.1016/j.ijom.2016.09.015

Technical

Note

Reconstructive

Surgery

Use

of

suborbicularis

oculi

fat

flap

to

cover

peri-orbital

bone

exposure

A. DiMartino,P. Bonavolonta`,G. Dell’AversanaOrabona,F. Scho¨nauer:Useof

suborbicularisoculifatflaptocoverperi-orbitalboneexposure.Int.J.Oral

Maxillofac.Surg.2016;xxx:xxx–xxx.# ₂₀₁₆_{International}_Association_of_Oral_and

MaxillofacialSurgeons.PublishedbyElsevierLtd.Allrightsreserved.

A.DiMartino1_,_P._Bonavolonta`2_,

G.Dell’AversanaOrabona2_,

F.Scho¨nauer1

1_Unit_of_Plastic_Surgery,_University_of_Naples

‘‘FedericoII’’,Naples,Italy;2Departmentof MaxillofacialSurgery,UniversityofNaples ‘‘FedericoII’’,Naples,Italy

Abstract. Wideresectionofrecurrentbasalcellcarcinoma(BCC)intheperi-orbital–

infraorbital–nasal areamayincludeperiosteumresectionwithmaxillaryornasal

boneexposure.Theabsenceofvascularizedperiosteummakes thedefect

ungraftableandlocalflapsareoftenrequired.Asanalternativetoalargesingleflap

oracombinationofflaps,itispossibletoturntheungraftableportionofthedefect

intoagraftableone.Thesuborbicularisoculifat(SOOF)flapisanadvancementflap

thatisusedinaestheticsurgeryformidfacerejuvenation.TheuseoftheSOOFflap

alongwithafull-thicknessskingraft, asanalternativetotheuseofother

standardizedflapstocoverdefectsintheperi-orbital–infraorbital–nasalareawith

avascularizedtissueornoblestructureexposure,isreportedherein.Asan

immediatesingle-stagereconstruction,thisprocedureleavesotherflapoptions

intactintheeventofre-operationforarecurrenttumour.

Keywords: SOOF flap; facial reconstruction; fatflap;boneexposure;skingraft.

Acceptedforpublication16September2016

Wide resection of malignant skin tumours inthe peri-orbital–infraorbital– nasalareamayincludeperiosteal resec-tionand canresult insofttissuedefects with maxillary or nasal bone exposure (dual tissue defect). Maxillary or nasal bone exposure without periosteal cover representsanavascularizedsite.The ab-senceofvascularizationmakesit ungraf-tableandlocalflapsareoftenrequired.If alargedualtissuedefectispresent,one alternativetotheuseofalargesingleflap or a combinationof flaps is to turnthe ungraftable portion ofthe defectinto a graftableone.

Asdescribedforaestheticsurgery tech-niques inmidfacerejuvenation,1,2 where central and medial compartments ofthe suborbicularisoculifat(SOOF)havebeen usedtoresurfacetheorbitalcrease,these fat compartmentshave been used atthe authors’institutionasanadvancementflap tocovertheexposed boneportionofthe defect,makingitreadilygraftable.

Thecasesoftwopatientswithbasalcell carcinoma(BCC)ofthe peri-orbital–infra-orbital–nasalregioninfiltratingthe under-lyingperiosteum,treatedwithaSOOFflap andfull-thicknessskingraftfollowing tu-mourresection,arepresentedherein.

Casereports Case1

A71-year-oldfemalepatientwas admit-ted to the clinic with an extensive recurrent BCCof therightperi-orbital– infraorbital–nasal area. After complete ophthalmologicalexaminationtoexclude ocularinvolvement,wideresectionofthe lesion with a 1-cm tumour-freemargin was performed under local anaesthesia. The resection,in its centralportion, in-cludedtheunderlying periosteumofthe maxillary bone. Bipolar haemostasis was achieved. The result was a defect

Int.J.OralMaxillofac.Surg.2016;xxx:xxx–xxx

http://dx.doi.org/10.1016/j.ijom.2016.09.015,availableonlineathttp://www.sciencedirect.com

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measuring 3.7cm2.1cm with a por-tionofexposedmaxillarybonemeasuring 1.5cm 1.6cm(Fig.1).Intraoperative histology identified an aggressive BCC withtumour-freemargins.

Beneath the pretarsal segment of the orbicularis oculimuscle,the orbital sep-tumwasreleasedatthearcusmarginalis. Themedialandcentralfatcompartments weremobilizedinferiorlyasaslidingpad

(SOOF flap) tocover theexposed bone. Thiswas secured tothesuperficial mus-culoaponeurotic system atthezygomatic archbelowtheexposedboneareawitha few5–0Vicrylsutures(Fig.2).

A full-thickness skin graft, harvested from the pre-auricular region, was posi-tioned over the vascularized fat flap for woundclosure.Quiltingsuturesanda tie-overdressingwereusedtoguarantee

ad-herenceoftheskingrafttothedefectbed. Grafttakewasoptimalonday6 postoper-ative(Fig.3).

Definitive histology confirmed an ag-gressiveBCC,whichhadbeencompletely excised.Atthe18-monthfollow-upthere was nosign of localrecurrence and the patientwas satisfied withthe result, de-spitethepresenceofamildmedialscleral show(Fig.4).

2 DiMartinoetal.

Pleasecitethis articleinpressas:DiA,etal.Useofsuborbicularisoculifatflaptocoverperi-orbitalboneexposure,IntJOral MaxillofacSurg(2016),http://dx.doi.org/10.1016/j.ijom.2016.09.015

Fig.1. Defectresultingfromtheresectionofalong-standingbasal cellcarcinomaoftherightperi-orbital–infraorbital–nasalarea,with

partialexposureoftherightmaxillarybone. Fig.2. Suborbicularisoculifatflapadvancedtocovertheexposedright maxillarybone.

Fig.3.Skingrafttakeintheperi-orbital–infraorbital–nasalareaon day6postoperative.

Fig.4. Nosignoflocalrecurrenceat18monthsoffollow-up;amild medialscleralshowispresent.

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Case2

A68-year-oldmalepatientwasadmitted totheclinicwithaskinlesionlocatedin the nasal–peri-orbital area. He reported thatthelesionhadfirstappeared7years earlierasanoduleandhadprogressively enlarged. On examinationthe lesion ex-tended from the right nasal dorsum to therightinternal canthus,without ocular involvement, and inferiorly towards the upperlipalongthenasolabialcrease.An excisionalbiopsywasperformed.

Histology showed an aggressive micronodular BCC extensively infiltrat-ing theunderlyingdermis. Alargerand deeper excision of the primary tumour site wasperformed, includingthe nasal bone periosteum. This resulted in a 5.5cm3cm defectin the nasal–peri-orbital area with a portion of exposed nasal bone measuring 1.9cm1.1cm (Fig. 5).Intraoperativehistology identi-fied a BCC with tumour-free margins. Thereafter, reconstruction was per-formed at the samestage: a SOOFflap was harvested and advanced medially and inferiorly to cover the nasal bone exposure (Fig. 6). A full-thickness skin graftwasharvested fromthe left supra-clavicularregion andwasplacedontop of the vascularized fat for wound clo-sure. Atie-over dressing wasadded.

Therewerenopostoperative complica-tionsandthegrafttakeonday6 postop-erative was 100%. Definitive histology confirmedanaggressiveBCC;thesample marginsweretumour-free.

Atthe18-monthfollow-upthe patient presentednorecurrenceandtheresultwas

satisfactorytothepatientandtothe sur-geon(Fig.7).

Discussion

BCC is by far the most common non-melanoma skin cancer worldwide and perhaps the most common human can-cer, with a constantly increasing inci-dence of 3–10% per year.3 BCC tends to arise in sun-exposed areas of the

body, most commonly in the upper re-gion ofthe face.3

Selectingtheappropriatetechniquefor surgical incision and the restoration of facial defects has always been one of thesurgeon’sgreatestconcerns.The tech-niqueuseddependsonthenature,extent, depth,andpositionofthetissueloss,on donor site availability and morbidity, and onthe patient’sage, condition,and expectations.

SOOFflaptocoverperi-orbitalboneexposure 3

Pleasecitethisarticleinpressas:DiA,etal.Useofsuborbicularisoculifatflaptocoverperi-orbitalboneexposure,IntJOral MaxillofacSurg(2016),http://dx.doi.org/10.1016/j.ijom.2016.09.015

Fig.5. Defectresultingfromwideresectionofabasalcellcarcinoma oftherightperi-orbital–nasalarea,withexposureofaportionofthe rightnasalbone.

Fig.6. Suborbicularisoculifatflapadvancedtocovertherightnasal boneexposure.

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Inthecaseofperiostealresection and boneexposure,theuseofaskingraftisnot possible,asanavascularizedbeddoesnot allowgrafttake.Secondarygranulationon freebonesurfacescansolvetheproblem, but thisis alengthyprocess andturnsa single-stage reconstruction into a two-stage procedure.

Combined nasal–infraorbital–peri-or-bital defects with boneexposure can be restored with the use of local or loco-regionalflapsthatbringanadequate vas-cular supplyto the non-vascularized tis-sue.Varioussurgicaloptionsincludethe advancement V–Y flap, Mustarde´ cheek rotation flap, paramedian forehead flap,4 nasalsuperficialmusculoaponeurotic sys-tempedicledislandskinflap,5or orbicu-larisoculimyocutaneousflap.6

TheSOOFliesinthe lowereyelid, be-tweentheorbitalorbicularismuscleandthe maxillary periosteum.Thisfat padis pro-tected and separated anteriorly from the orbicularis muscle by the orbital septum, whichextendsfromthearcusmarginalisof theorbitalrimtothecapsulopalpebralfascia before itsinsertionontothetarsalPlates.7 TheSOOFiscomposedofthreefatregions: the medial, central, and lateral compart-ments.Anotherfatcompartmentjustabove thelateralcompartmenthasbeendescribed, andisreferredtoas‘pretarsalfat’.8

In facial rejuvenation procedures, SOOF can be removed or repositioned. Inlowerblepharoplastiesaimedat remov-ingthebulgesjustbelowtheeyelashes,the lateral and pretarsal fat compartments havetraditionallybeenremoved andany excessofthecentralandmedial compart-mentshasbeenreduced.

Loeb, and later Hamra, popularized a new techniquefor midfacerejuvenation: instead ofremovingtheexcesslowerlid fat,theystretchedthefattissuefromthe central and medial compartments of the SOOF, using it to redrape the inferior orbital crease.1,2 Loeb used it for the nasojugal groove,1andHamraaddressed theprocedure toavoidthesunkeneyelid resulting from ageing.2 With the same purposes, Goldberg describedthe use of theorbitalfatasarandom,pedicled,but pivotalflapanditsrepositioningina sub-periostealpocket.9

Infacialreconstruction,fatpadscanbe usedasfreegraftsorasflaps.TheBichat buccalfatpadisthemostfrequentlyused fat flap, especially to close maxillary defectsaftertumourexcision.10

TheuseoftheSOOFflapasarandom, pedicled,advancementfatflap,consisting ofthemedialand/orcentralcompartments ofSOOF,has notbeen describedbefore forreconstructivepurposes(Fig.8).

As stated, small-sized bone exposure can becoveredwithaSOOFflap, trans-forminganungraftablebedintoa grafta-bleone.Thelimitationsofthistechnique arethoserelatedtotheuseofaskingraft instead of a skin flap, such as colour mismatch and skin retraction. Thelatter disadvantage mustbe taken into consid-eration,especiallyinthecontextofeyelid reconstruction.However,thepreliminary use of this single-stage reconstructive technique leaves other surgical alterna-tives open in the event of re-operation forarecurrenttumour.4

Theauthorsrecommendtheuse ofthe SOOFflapasanalternativetotheuseof otherstandardizedflapstocoverdefectsin the peri-orbital–infraorbital–nasal area with avascularizedtissueornoble struc-tureexposure.TheuseoftheSOOFflapin achievingskingrafttakeonexposedfacial bone does notexclude its suitability for other reconstructivepurposes.

Funding

We wish to confirm that there was no significantfinancialsupportforthiswork thatcouldhaveinfluencedtheoutcome. Competinginterests

We wish to confirm that there are no knownconflictsofinterestassociatedwith thispublication.

Ethicalapproval

TheEthicsCommitteeoftheUniversityof Naples ‘‘Federico II’’ notes that at the time ofthe programming ofthis clinical study, there was neither the obligation nor the express opportunitytosubmitin advancetheresearchprojecttotheethics committee inorder to obtainformal ap-proval for the realization of the same (referenceno.805/16).

Patientconsent

Written patient consent was obtained to publishtheclinicalphotographs.

References

1.LoebR.Fatpadslidingandfatgraftingfor leveling lid depressions. Clin Plast Surg 1981;8:757–76.

2.HamraST.Arcusmarginalisreleaseand orbit-al fat preservation in midface rejuvenation. PlastReconstrSurg1995;96:354–62.

3.Renaud-Vilmer C,Basset-SeguinN.Basal cellcarcinomas.RevPrat2014;64:37–44.

4.CogrelO,OfaicheJ.Reconstructionofthe medial nasal canthususing a single-stage paramedian forehead flap. Ann Dermatol Venereol2015;142:220–1.

5.Dog˘an F, O¨ zyazgan I. New flap for the reconstructionoftheperinasalregion.Facial PlastSurg2014;30:676–80.

6.TironeL,SchonauerF,SposatoG,MoleaG. Reconstructionoflowereyelidand periorbi-tal district: an orbicularis oculi myocuta-neous flap.J PlastReconstrAesthet Surg 2009;62:1384–8.

7.Fante G,HawesM.Reconstruction ofthe eyelids.In:BakerSR,editor.Localflapsin facialreconstruction.3rded.Elsevier Saun-ders;2014.p.388.

8.HwangK,KimDJ,ChungRS.Pretarsalfat compartmentinthelowereyelid.ClinAnat 2001;14:179–83.

9.GoldbergRA.Transconjunctivalorbitalfat repositioning: transposition of orbital fat pedicles intoa subperiostealpocket.Plast ReconstrSurg2000;105:743–8.

10.TostevinPM,EllisH.Thebuccalpadoffat:a review.ClinAnat1995;8:403–6.

Address: AnnalenaDiMartino ViaPansini5 80131Naples Italy E-mail:annalena.dimartino@gmail.com 4 DiMartinoetal. YIJOM-3513;NoofPages4

Pleasecitethis articleinpressas:DiA,etal.Useofsuborbicularisoculifatflaptocoverperi-orbitalboneexposure,IntJOral MaxillofacSurg(2016),http://dx.doi.org/10.1016/j.ijom.2016.09.015

Fig.8. Illustrationofthesuborbicularisoculifatflap.B:boneexposure;M:medial compart-mentofsuborbicularisoculifat;C:centralcompartmentofsuborbicularisoculifat;L:lateral compartmentofsuborbicularisoculifat.