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CASE REPORTS
NUMBER 4 YEAR 2007
Versatility of Mustarde Cheek Rotation Prelaminated Flap for Reconstruction of the Wide Full Thickness Lower Lid Defects
1 Department of Plastic and Reconstructive Surgery, Grigore T. Popa University of Medicine, Iasi

Correspondence to:
Assoc. Prof. Dragos Pieptu, MD, PhD, EBOPRAS Fellow, 3 Aurora Str., Fl. B5, Apt. 5, 700474 Iasi, Romania, Tel. +40-232-213310
Email: dpieptu@iasi.mednet.ro
REZUMAT
Reconstructia defectelor de grosime completa ce afecteaza mai mult de doua treimi din lungimea pleoapei inferioare (asociate sau nu cu defecte in regiunea geniana sau nazala), rezultate dupa excizia tumorilor sau traumatisme, poate pune probleme tehnice chirurgului plastician. Lamboul rotat de obraz de tip Mustarde, prelaminat cu mucoasa si cartilaj, reprezinta prima optiune in majoritatea cazurilor. Prelaminarea este esentiala pentru a respecta si reconstrui structura anatomica trilamelara a pleoapei inferioare. Zece pacienti avind carcinoame care afectau pleoapa inferioara au fost operati utilizind aceasta metoda. Pentru prelaminare s-au utilizat fie grefon muco-cartilaginos din septul nazal, fie o combinatie de grefon cartilaginos din concha si grefon de mucoasa bucala. in toate cazurile am obtinut o buna acoperire si un suport adecvat al pleoapei inferioare. Nu am avut necroza si nici ectropion. in doua cazuri se remarca o pozitionare joasa a marginii libere a pleoapei inferioare, evidentiata dupa diminuarea edemului, dar ramasa fara afectare functionala. Toti pacientii au prezentat un oarecare grad de rigiditate a pleoapei reconstruite chirurgical. Totusi inchiderea ochiului nu a fost afectata, deoarece pleoapa superioara a fost functionala si/sau usor ptotica. Dupa aproape 40 de ani de la descrierea tehnicii, lamboul rotat de obraz Mustarde ramine cea mai adaptabila metoda de reconstructie a pleoapei inferioare, deoarece asigura o acoperie satisfacatoare si un rezultat functional acceptabil. Curba de invatare (experienta) chirurgului joaca un rol important in cresterea calitatilor functionale si estetice ale rezultatelor obtinute.

ABSTRACT
Reconstruction of full thickness defects of more than two thirds of the lower lid (associated or not with cheek defects) after tumor resection might represent a challenge for plastic surgeon. Mustarde cheek rotation flap represents the first choice in most of the cases. In order to simulate the anatomical appearance and the three-lamellar structure the lower eyelid, the flap should be laminated with both cartilage and mucosa. Ten patients with basal cell carcinoma of the lower eyelid were treated by this method. For flap prelamination we used either nasal mucocartilaginous or conchal graft combined with oral mucosa. In all cases we obtained good coverage, and good eyelid support was observed. No skin necrosis or ectropion was remarked. In two cases a lower position of the free edge of the new eyelid was noticed after diminishing edema, without important functional impairment. All the patients have an acceptable degree of rigidity and immobility of the new eyelid. However, the eye closure was not affected since the upper eyelids were functional and slightly ptotic. Mustarde cheek rotation flap, after almost 40 years, remains the most versatile method since it ensures good coverage and satisfactory functional and aesthetic results in case of large full thickness defects of the lower eyelids. Surgeons experience with this technique may expand flaps adaptability.
INTRODUCTION

Reconstruction of wide (more than two thirds) deep defects of the lower lid might be challenging especially in the cases where the defect exceeds the lids limits, extending either to the cheek or over inner cantal area. Such situations, appearing most often after tumor resection, may raise many questions for surgeons with regard to the choice of the flap and its reliable design, looking up the superficial tension lines and the requirements for a normal eyelid structure.1 One of the most versatile flaps for these situations still remains Mustarde cheek rotation flap. Described for the first time by Mustarde in 1971 and then by Callahan & Callahan (1980), the large rotation cheek flap is often used to reconstruct the defects involving wide full-thickness part of the lower lid.2-4
Understanding this flap’s design and versatility is important for all surgeons involved in the treatment of tumors in the orbito-palpebral area.

MATERIAL AND RESULTS

We performed eight cases of reconstruction of wide full thickness defects for advanced basal cell carcinoma of the lower lid using the Mustarde check rotation flap. Three of them were primary tumors. The other five were recurrent tumors previously operated for two to five times. In only four cases the tumors were located only in lower lid. In the other four there was invasion of the adjacent regions (inner cantal area, lateral cantal area, cheek). In all cases, the reconstruction of the lower lid and cheek defects has been good both functionally and aesthetically. No skin necrosis or ectropion was remarked. In one case, after edema decreasing, a lower position of the free border of the flap was noticed, due to the inadequate suspension of the flap on to the orbital rim.

Operative Technique
First, the tumor is outlined with a 2-5 mm free border in the lateral and medial sides. The final defect, including the tumor marks, should also include a triangle with its base along the lower lid eyelash edge and the apex toward the cheek (the triangle height is about two times its base). From the lateral angle of the triangular defect, the line of incision is carried out to the lateral cantus and then upwards and outwards crossing the zygomatic area.5-7 Reaching the temporal hairline, the line is drawn in a similar way to that used in facelift. After full-thickness lower lid resection with tumor removal, the described incision is performed, tracing the upper and lateral limits of the cheek flap. The undermining of the cheek flap is achieved superiorly to the superficial musculo-aponevrotic system (SMAS), with an extension of about 1 cm below to the apex level of the defect, allowing the flap to be sufficiently rotated to the medial side. Few subcutaneous stitches fixed the medial part of the flap to the adjacent skin, establishing the new position of the flap. The upper rim of the flap is fitted into the overcorrection position and stabilized with sutures passed at 1.5-2 cm distance from the free border, hitching the subcutaneous tissue of the flap to periosteum of the lateral orbital rim periosteum. This can prevent the ectropion due to the gravitational force.
For posterior lamella reconstruction we have two choices. The first option is the muco-cartilaginous graft harvested from the nasal septum. One should keep in mind that the mucosa should overlap the cartilage in order to be sutured in place. The cartilage is thick and lacks concavity, but scalpel linear incisions on the rough surface solve this problem. The second option is the auricle cartilage combined with buccal mucosa graft. A 2.5/1 cm cartilage segment is harvested from the concha through retroauricular incision and a 3/1.5 cm mucosa graft is raised from the buccal mucosa. The buccal donor site is either closed directly with absorbable sutures (5.0 Vicryl) or left for secondary epithelisation. The cartilage graft is applied on the subcutaneous surface of the flap with its concavity towards the eyeball, while the mucosa graft is spread out across the cartilaginous segment, overlapping its limits. All the muco-chondro-cutaneous components are joined together with 6.0 resorbable sutures.
The 6.0 nylon stitches from the free margin of the new eyelid are left long enough and fixed with steri-strip tapes on the frontal area for 5-7 days. Pull out 6.0 nylon stitches placed for defining the lower lid sulcus are fixed with steri-strip tapes on the cheek area for 5-7 days. Finally, the cheek flap is sutured in its final position to the adjacent lateral and medial skin by separated stitches (5.0 nylon). The drainage is allowed by placing Penrose drains in the medial and preauricular part of the incision for 2-3 days. Steri-strip tapes are placed across the line of incision on entire length for diminishing the superficial tension. A slight compressive dressing prevents the hematoma.

CASE REPORTS

Case 1
A 52 years old man, with long history of multiple basal cell carcinomas of the face and trunk was admitted in our department for an ulcerated tumor involving the entire left lower lid, the inner cantal area and the nose. (Figures 1, 2)
Figure 1. Ulcerated tumor involving the entire left lower lid, the inner cantal area and the nose.
Figure 2. Ulcerated tumor involving the entire left lower lid, the inner cantal area and the nose; close-up view.
Under general anesthesia, the entire tumor involving the eyelid was excised. The reconstruction was done using the Mustarde flap laminated conchal cartilage and oral mucosa graft. Since the defect was very wide, we dissected a wide flap extending upward in the temporal area and lateral in the neck region. Thus, it was possible to pull the flap more towards the midline. The nasal defect was covered with skin graft. After an uneventful evolution the patient was discharged in the seventh postoperative day: the flap looked well, the buccal mucosa graft was alive, there was no conjunctiva irritation.
Figure 3. Aspect after two years. Eyes opened.
Figure 4. Aspect after two years. Eyes closed.

After two years the patient is free of tumor. (Figures 3,4) Even there is no ectropion, one can notice that the lower eyelid does not cover all of its normal eyeball territory, although the flap was wide enough. This is due to two factors: first is the skin structure with lack of any elasticity; second is the flap stretching to the midline, beyond its normal area. However, the functional result is fair since the patient has a ptotic upper eyelid. One can also notice a fair lower lid sulcus. (Fig. 5)
Figure 5. Aspect after two years. A fair lower lid sulcus.
 

Case 2
A 71 years old man was admitted in our department for a tumor of the left lower eyelid. With a five years history of slow-growing, the lesion started to ulcerate in the last two years, spreading it along almost the entire length of the eyelid and invading the cheek, the inner cantus and the nasal skin. (Figures 6, 7)
Figure 6. Ulcerated tumor spread along almost the entire length of the eyelid and invading the check, the inner cantus and the nasal skin.
Figure 7. Ulcerated tumor spread along almost the entire length of the eyelid and invading the check, inner cantus and the nasal skin; close-up [...]
Under general anesthesia, the entire lower eyelid was resected. The defect included also the inner cantus, one fourth of the upper eyelid and the nasal skin. (Fig. 8)
Figure 8. The defect included the lower lid, the inner cantus, one fourth from the upper eyelid and the nasal skin.
 
The reconstruction was performed following the same procedure – cheek rotation flap widely dissected and pulled to the midline, laminated with muco-cartilaginous graft from the nasal septum, skin graft on the nose and advancement flap for the upper eyelid. Moderate conjunctival congestion was noticed in first days after surgery.
After an uneventful evolution the patient was discharged in the seventh postoperative day: the flap looked well, the buccal mucosa graft was alive, there was no conjunctiva irritation. The result after one year is good. (Figures 9, 10) The patient’s only complaint is epiphora.
Figure 9. Result after one year; lateral view.
Figure 10. Result after one year; lateral view; close-up.

DISCUSSION

The reconstruction of the lower lid and cheek defects after tumor excision is a challenging task, especially in neglected cases, where the tumor invaded the adjacent regions especially the inner cantus. In planning reconstruction, the normal anatomical layers of the eyelid (anterior and posterior lamellae) should be taken into account. There is a three-lamellar structure: the anterior lamella consists of skin and muscle, while the posterior one is represented by tarsal plate and conjunctiva, which ensure the skeletal support of the lid, respectively the mucus-secreting lining. Therefore, the full-thickness loss of the lid implies reconstruction of all layers.
For 37 years, Mustarde cheek rotation skin flap has proved to be the most reliable and versatile technique for reconstructing full thickness defects involving more than one half of the lower lid.2,5,6 The Mustarde flap brings additional cheek tissue beyond the lateral cantus to rebuild the skin layer. We preferred the subcutaneous plane for skin undermining instead of deep dissection under the orbicularis oculi and SMAS.2,5 This allowed us to obtain an intermediate-thickness flap, with appropriate mobility and no excess tissue.
The reconstruction of the posterior lamella is possible either from tarsal and conjunctival remnants or by free cartilage and mucosa grafts. These grafts may be harvested either from the nasal septum (muco-cartilaginous graft) or from the pinna and oral mucosa free graft.5,6
Although the nasal septum offers both cartilage and mucosa graft at the same time and the septal cartilage has better elasticity, in our cases we used both septal and conchal cartilage.7,8 The latter ensures a comparable curvature to that of the normal tarsus and good consistence for the eyelid to support the weight of the cheek flap.
The use of the mucosa graft is imperious for lining the cartilage segment in order to obtain the trilamelar structure. It also represents the secreting layer and protects the bulb from irritation. In all patients, the mucosa graft take evolved, without scarring and contraction and thus, preventing the entropion development of the reconstructed eyelid.
In patients with long standing wide tumors involving not only the eyelid, but also the surrounding area (especially the inner cantus), the resulted eyelids have a limited vertical dimension. Even if there is no ectropion, one can notice that the lower eyelid does not cover all of its normal eyeball territory.

CONCLUSIONS

Mustarde cheek rotation skin flap lined either with nasal muco-cartilaginous graft or with conchal cartilage and buccal mucosa grafts is a reliable and versatile method for covering wide defects of the lower eyelid and cheek with satisfactory functional and aesthetical results.
It remains the first choice because it allows high functional and aesthetic quality in reconstruction. The flap not only brings additional skin with good color and matching texture, but also ensures the adequate blood supply to the chondromucosal complex attached to the subcutaneous layer of the flap. Flap design is well-known and seems quite simple. However, experience is required in order to approximate the dimensions of the flap and its rotation capacity towards the median line.

ACKNOWLEDGMENTS

In conducting this study we had the financial support of the Romanian CNCSIS Grant 834/8/Gr 61/16.05.2006 and 15/Gr 18/09.05.2007.
REFERENCES

1. Boutros S, Zide B. Cheek and eyelid reconstruction: the resurrection of the angle rotation flap. Plast Reconstr Surg. 2005;116(5):1425-30.
2. Mustarde JC. Reconstruction of eyelids. Repair and reconstruction in the orbital region. 2nd Ed. Edinburgh, London: Churchill Livingstone, 1971, p.116-62.
3. Callahan MA, Callahan A. Mustarde flap lower lid reconstruction after malignancy. Ophtalmology 1980;87(4):279-86.
4. Matsumoto K, Nakanishi H, Urano I et al. Lower eyelid reconstruction with a cheek flap supported by fascia lata. Plast Reconstr Surg. 1999;103(6):1650-54.
5. Strauch B, Vasconez LO, Hall-Findlay EJ. Cheek rotation skin (Mustarde) flap to the lower eyelid. In: Straush B, Vasconez LO, Hall-Findlay EJ, Editors. Grabb’s Encyclopedia of flaps. 2nd Ed. Philadelphia-New York: Lippincott-Raven, 1998, p. 56-60.
6. Codner MA. Reconstruction of the Eyelids and Orbit. In: Achauer BM, Erikson E, Editors. Plastic Surgery: Indications, Operations, and Outcomes. 1st Ed. Missouri: Mosby, 2000, p. 1425-63.
7. Stricker M, Gola R. Paupiere tumorale. Chirurgie plastique et reparatrice des paupiers et de leurs annexes. 1st Ed. Paris: Masson, 1990, p. 45-53.
8. Ambrozova J, Mestak J, Smutkova J. Reconstruction of the lower eyelid after excision of major tumours. Acta Chir Plast. 1993;35(3-4):131-45.



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