PMC6484570_01
Male patient 47 years with severe bilateral periorbital cicatricial scarring, left corneal opacity. (A) Preoperative anterior view. (B) Postoperative view after 12-month follow-up, with
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F1
The lower flap reached the most medial point of the palpebral fissure in the vertical plane with the complete resolution of epiphora after 12 months of follow-up [Figure 1B].
Intraoperative photos. (A) Design of the flap, note its extension out of territory. (B) Skin incision of the marked frontal and parietal flaps centered over the frontal and parietal branches. The parietal flap is hairy and located over the extension axis of the parietal branch and designed according to the direction of the eyebrow hair, with two-third of the flap located in the parietal region and the other one-third in the temporal region
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F2
The two skin islands were designed on each side, according to the defect size, [Figure 2B] and marked with an adequate arc of rotation on the axis of both arteries with their extensions outside the temporal region [Figure 3A]. Little subgaleal dissection was made to help direct closure of the donor site without tension; suction drain also was inserted before closure [Figure 2].
(A) Skin incision till the fascia. (B) Elevation of skin and subcutaneous tissue, notice you should preserve the fatty layer underneath the hair follicles to avoid postoperative alopecia
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F3
The two skin islands were designed on each side, according to the defect size, [Figure 2B] and marked with an adequate arc of rotation on the axis of both arteries with their extensions outside the temporal region [Figure 3A]. Then, the borders of the skin islands were incised, with care to the hair follicles, especially in the parietal flap. we included a thin layer of subcutaneous tissue deeper to the hair follicles, the flap elevation was proceeded from distal to proximal with caution to avoid pedicle injury where it enters the flap, and the dissection was extended proximally to the level of the tragus again to avoid any skin tethering or limited arc of rotation of the flaps. [Figure 3B].
With transillumination, both branches of the superficial temporal artery are identified. After that bifurcation starts from distal to proximal
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F4
The two flaps were separated from distal to proximal direction under visualization through indirect transillumination up to the level of bifurcation of the STA [Figure 4].
(A) Transfer of the flaps to cover the defects. (B) Immediate postoperative photos
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F5
A proper subcutaneous tunneling between each flap and its recipient site was dissected; then, the flaps were transferred and sutured to the edges of the defective skin [Figure 5].