Tunneling island pedicled flap after resection of carcinoma on the face

Received on: 7 March 2015
Approved on: 23 May 2015
Financial support: None
Conflict of interest: None

Abstract

Carcinomas on the face are prevalent lesions, with potentially serious repercussions from aesthetic, psychological, and functional perspectives. Surgical reconstruction after excision of these lesions is a challenge for the dermatologic surgeon, requiring good knowledge of the anatomy of the face and accurate implementation of the most appropriate method for each case. Among the various reconstructive procedures are skin flaps, of which the island pedicle flap and its variants stand out. The present article demonstrates the use of the island pedicle flap transferred to the surgical defect through a subcutaneous tunnel, showing the application and characteristics of this method. Reconstruction using a tunneling island pedicle flap after the excision of a facial carcinoma showed good aesthetic and functional results, despite the difficult location of the lesions. This type of flap is a good option for facial reconstruction in difficult areas.

Keywords: CARCINOMA, BASAL CELL; SURGERY, PLASTIC; SURGICAL FLAPS

INTRODUCTION

The island flap has two basic characteristics: 1) the shape of the donor skin resembles an island that is detached from the surrounding epidermis and dermis on all sides; 2) a subcutaneous pedicle is maintained, thereby ensuring vascularization and allowing some mobility to the nearby receptor area. Variations of this type of flap depend on the shape of the island and the way it is transferred to the receptor area. Among these variations are: the traditional triangular island with V-Y advance, which can be single or double (bipedicled); the variant where the shape of the island and its size are similar to those of the defect and the transference is performed by transposition (the skin between the donor and receptor areas is excised) or interpolation (where a pedicle is left between the donor and the receptor area, with its subsequent removal during a second subsequent surgery); and the variant where the island, whose size and shape correspond to those of the surgical defect, is transferred through a tunnel created in the upper portion of the subcutaneous tissue. ¹ The latter variant can be considered a type of interpolation, as the skin between the primary and secondary defects is not excised.

The present article describes two cases of basal cell carcinoma (BCC) in facial areas, each with difficult reconstruction, where the tunneled island flap technique was used, with an aim of demonstrating the application, characteristics, and possible complications of this method.

 

CASE 1

A 57-year-old woman presented with a round shaped basal cell carcinoma (BCC) with elevated and pearly borders in the medial corner of the upper left eyelid (Figure 1A). The patient underwent excision that resulted in a surgical defect 10 mm in diameter. An advancement flap would not be a good option in this case, as it would distort the anatomy of the region. A decision was made in favor of using a non-contiguous donor area (in the glabellar region). ² For the preparation of the flap, a similar shape and size to those of the defect were implemented, however fusiform, aiming at facilitating the closure (Figure 1B). The dissection of the donor area was carried out, preserving a subcutaneous pedicle intended to nourish the flap. In the existing healthy skin between the primary and secondary surgical defects, a tunnel was created in the subcutaneous level using the blunt dissection technique (Figure 2A). Next, the island skin flap - together with the pedicle - was driven through the tunnel using a hook (which may be improvised with a small syringe and a 25x7 needle carefully bent at the tip, as in the present case) (Figure 2B).

Once positioned in the defect, the flap was sutured with 5.0 nylon thread and interrupted sutures. The post-operative period coursed with significant local edema, which is common in these cases and can be minimized with the application of cold compresses for 20 minutes, several times a day. There was no infection or necrosis (Figure 2C). The result was satisfactory, with no trapdoor effect, ³ nevertheless there was a slight bulging of the skin between the donor and the receiving areas (Figure 3). The post-operative histologic control of the surgical specimen revealed free margins.

 

CASE 2

An 86-year-old female patient presented with a centrally ulcerated, pigmented BCC on the upper lip, advancing towards the right nostril, and measuring about 9 mm at its widest diameter. After excision with a 4.0 mm margin, a difficult to correct defect regarding the functional aspect was observed (Figure 4). A decision was made for a tunneled interpolation flap, in which the island's fusiform design in the nasolabial fold allowed for the suture of the secondary defect to be positioned in the fold, providing a good aesthetic appearance to the scar (Figure 5). In order to rebuild the base of the columella, a small island with traditional transposition was performed and tractionned with its pedicle into the defect using 5.0 nylon thread (also used in the suture), in a way that distributed the tension and facilitated the positioning of the tunneled flap (Figure 5). The post-operative period coursed uneventfully (Figure 6). The final result was functionally and aesthetically satisfactory, and the traditional trapdoor defect could be observed in the island ³ (in the columella's base), but not in the tunneled island (Figure 7).

 

DISCUSSION

BCC is the most prevalent skin cancer in humans. However, due to its low metastasizing capacity, it is usually curable with surgical exeresis in a single surgical procedure. ⁴

The tunneled island is a flap with a random pattern, whose blood supply depends on the vascular plexus of the deep dermis and subcutaneous. ⁵ It has the advantage of providing the surgical defect with a skin non-adjacent to the lesion but with the same characteristics of the surrounding area, thereby preserving the local anatomy. ⁶ The transference via a subcutaneous tunnel prevents the need for an incision in the skin between the donor and the receiving areas and allows the flap to be removed from a non-contiguous area ¹, observing local characteristics and yielding a good cosmetic result. ⁷

In Case 1, the tunneled interpolation of the island avoided the distortion of the eyebrow region, as the primary defect was located on the upper eyelid. However, an undesirable effect of this flap is that at the moment of subcutaneous transfer, there is the addition of material beneath the skin, resulting in the elevation in the area through which the tunnel has been created. ¹ This took place in the first case described. Had the lesion been located in the nasociliary region, ² a traditional transposition of the island would have been be the best option, producing however, a secondary defect in the glabellar region. ⁸

In Case 2, due to the fact that the lesion was located on the upper lip, the reconstruction was aimed at preserving the anatomy, owing to the aspects of the functional and aesthetic appearance, requiring extra attention in regards to the positioning of the vermilion and the transition line between the skin and the semimucosa, preserving the lip contour, the position of the philtrum, and the bilateral symmetry regarding the nasolabial folds. ⁹ Among the various techniques available for the reconstruction of this region, the island flap has been shown to be a good option for it causes little distortion of the anatomy and low scar retraction, and also offers ease in positioning the suture of the secondary defect in the nasolabial fold, yielding a good cosmetic result.

 

CONCLUSION

The island flap with subcutaneous tunnel interpolation is a very useful resource in the surgical repair of certain surgical defects following the exeresis of a carcinoma in the face, especially when it is possible to achieve a cosmetically acceptable secondary defect scar - in a natural fold of the skin or in an area where the appearance of rhytids is common - and when seeking consistency between the flap and the skin around the primary defect.

 

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This study was performed with patients operated on at the Fundação Centro de Controle de Oncologia do Estado do Amazonas (FCECON), an associate hospital for supporting the medical residency services of the Fundação de Medicina Tropical Heitor Vieira Dourado (FMT-HVD) and of the Hospital Getúlio Vargas (HUGV) - Manaus (AM), Brazil.