CLINICAL ARTICLE
Reconstruction of Periorbital Soft Tissue Defect With Reversed Superficial Temporal Artery Island Flap Yang Wang, MD, Xiao Long, MD, and Xiaojun Wang, MD Background: Periorbital soft tissue reconstruction is a challenge because of its difficulty in regaining both the form and the function. Local f lap is the priority method because it could provide excellent match in skin color and texture. Objective: We aim to investigate the application of pedicled reversed superficial temporal artery island f lap in the reconstruction of periorbital soft tissue defect. Method: Different kinds of reversed superficial temporal artery island f laps were harvested from the auricular area to cover the defect in the periorbital area. Results: Ten patients who suffered congenital or acquired periorbital diseases were treated with this method. One case suffered minor venous congestion postoperatively. All the other cases achieved good aesthetic result in both the donor and the recipient sites. Conclusion: Reversed superficial temporary artery island flap could be safely harvested from the auricular region even in a split pattern. It could be used to cover the periorbital defect with an unconscious scar at the donor site. Key Words: superficial temporal artery flap, reverse-flow flap, facial defect (Ann Plast Surg 2014;73: S70YS73)
S
oft tissue defect of the periorbital area is always a challenge to plastic surgeons. Reconstruction in this area should not only concern about the form but also the function. Skin graft is a traditional and simple method in treating the small-sized defect, whereas usually the aesthetic result and the eyelid function is not satisfied. Dunham is the first one who described the application of superficial temporal artery (STA)Ybased f lap in 18931 and Uchinuma et al reported a case series of full-thickness eyelid reconstruction with this f lap in 1989.2 Ten years later, Bakhach first reported the reverse auricular f lap based on STA.3 According to the perforator anatomy of superficial temporal artery, we designed the reversed STA island f laps to cover different kinds of periorbital defects and have maintained a positive result.
PATIENTS AND METHODS Patients From October 2003 to April 2012, 10 patients who suffered congenital or acquired diseases in the periorbital area were treated with the reversed superficial temporal artery island f lap harvested from the subauricular area (Table 1). The average age of the patients is 26 years (range: 6Y61).
Received for publication March 24, 2014; and revision accepted April 1, 2014. From the Division of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital, Beijing, China. Conflicts of interest and sources of funding: none declared. Reprints: Xiao Long, MD, Division of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital, Shuaifuyuan 1#, Dongcheng District, Beijing 100730, China. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0148-7043/14/7301-S070 DOI: 10.1097/SAP.0000000000000243
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www.annalsplasticsurgery.com
Surgical Technique The anatomy foundation of a reversed STA f lap is the existence of the anastomosis between the frontal (or parietal) branch of STA and the contralateral arteries. Our vascular cast also proved this theory (Fig. 1). We evaluated the size of the defect and measured the distance between the origin of superficial temporal artery and the defect. The f lap could be based on the frontal branch or the parietal branch of STA. Figure 2 shows the f lap design and pedicle location based on the direction of STA perforators. An island or split f lap was designed according to the shape of the defect (Figs. 3Y5). The pedicle was kept wide enough (the same width of the f lap) because usually the superficial temporal vein is not accompanied with the artery. The proximal end of STA is ligated to prolong the pedicle and make the f lap a reverse-f low pattern.
RESULTS Ten patients received this method to cover different sizes of periorbital defects because of various reasons (Table 1). Pedicled f lap was performed on all cases, and one of them received split reversef low STA f lap to cover the divided nevus in both the upper and lower eyelid. The f laps were transferred to the defect area through a subcutaneous tunnel. The donor sites were from the preauricular or subauricular region and were all closed primarily. Minor venous congestion occurred in 1 case postoperatively and recovered 4 days later without any treatment.
Typical Cases Case 1 A 5-year-old girl suffered congenital divided nevus at the middle third of the left upper and lower eyelid (Figs. 4A, B). Split-pattern reversed STA f lap was designed and harvested from the preauricular region based on the frontal branch of STA (Figs. 4C, D). The size of each f lap is 1.5 1 cm with a 13 2 cm pedicle, and the donor site was closed primarily. Both the function and form of the eyelid were satisfied after the operation (Figs. 4E, F).
Case 2 A 4-year-old boy suffered nevus at the left temporal area with the size of 5 2.5 cm. The reversed STA f lap was harvested from the subauricular region with an 11-cm-long pedicle. The f lap totally survived with an invisible scar at the donor site (Fig. 5).
DISCUSSION Alul et al performed the facial soft tissue dissection in 15 fresh cadavers and found that the superficial temporal fascia is part of the subcutaneous musculoaponeurotic system (SMAS).4 Since then, more and more plastic surgeons tried to perform the STA f lap in different kinds of facial defect reconstruction.2,5Y9 Ragip et al discussed the application of superficial temporal artery island f laps in facial defect reconstruction and confirmed its various alternatives Annals of Plastic Surgery
&
Volume 73, Supplement 1, September 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Annals of Plastic Surgery
& Volume 73, Supplement 1, September 2014
Reversed STA Flap to Cover Periorbital Defect
TABLE 1. Clinical Data Diagnosis Divided Nevus Nevus Basal cell carcinoma Periorbital scar Trauma
Case No.
Operation Method
Size of the Flap (On Average)
Complication
2 4 2 1 1
Split reverse STA flap Reverse STA flap Reverse STA flap Reverse STA flap Reverse STA flap
1.5 1 cm and 1.5 1 cm (each split flap) 3.1 2.2 cm 4.2 3.5 cm 4 3 cm 3 3.5 cm
0 0 1 (venous congestion) 0 0
of the donor site.10 Recently, Makoto et al reported the reverse superficial temporal artery f lap from the preauricular region to cover the small facial defect.11 This method has gained more and more attention because of its easy operation procedures and versatile applications.
FIGURE 1. The anatomy of superficial temporal artery shows the perforator of STA in the auricular area (yellow arrow).
Taylor et al published the concept of angiosome in 1987 and revised it again in 2011.12 According to his study, there are 13 angiosomes in the region of head and neck with lots of ‘‘choke vessels’’ between each other. Based on all these research and our anatomy study, we confirmed the existence of STA downward perforators in the pre- and subauricular regions (Fig. 2). The split reversed STA f lap was designed according to the multiple STA perforators, which could reconstruct the upper and lower eyelid simultaneously (Fig. 3). There are several points that need to be paid attention during the f lap elevation. First, the pedicle should be as wide as the base of the skin island to ensure blood supply. Second, the f lap needs to be elevated from the deep layer of SMAS to maintain enough superficial veins in the pedicle to avoid vein congestion. Third, when harvesting a ‘‘split pattern’’ f lap, the superior one-third part of the pedicle should not be divided. The f lap donor site could be altered to the subauricular region to prolong the f lap pedicle. The main advantage of a reverse STA island f lap is the skin color and texture of the donor site. Asian people easily suffer pigmentation contracture after skin graft, which will lead to obvious eyelid deformity, ectropion, or lagophthalmos in the recipient cite. Skin f lap from the periauricular area could provide a better match with the periorbital region than the forward STA forehead f lap (Fig. 5). Also, it is possible to close the donor site primarily even if the f lap is taken with the size of 4.5 4 cm because of the experience of different doctors,13Y16 which will only leave an invisible scar at the donor site finally. There are several limits of the f lap. Donor-site injury could not be neglected because there is possibility of facial nerve injury. By maintaining the proper level during the f lap elevation, this
FIGURE 2. Split pattern and subauricular reversed STA f lap design and the pedicle’s location. * 2014 Lippincott Williams & Wilkins
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Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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Annals of Plastic Surgery
Wang et al
& Volume 73, Supplement 1, September 2014
FIGURE 3. Split-pattern reversed STA f lap harvesting and defect covering.
complication could be avoided. The pin-cushioning appearance is another issue and a loosened tie-over gauze could be put on the f lap in the first 3 days after operation to advance the adhesion of the soft tissues and to avoid this problem. Furthermore, the pedicle
length of the f lap has limited its use to the lateral two-thirds part of the facial area. Indication of the reversed STA f lap include soft tissue defect within the lateral two thirds of periorbital area. Donor site or recipient
FIGURE 4. A 5-year-old girl suffered divided nevus on her left eyelid (A, B). Split-pattern f laps were designed and transferred to the defect area (C, D). Six months after operation (E, F). S72
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* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Annals of Plastic Surgery
& Volume 73, Supplement 1, September 2014
Reversed STA Flap to Cover Periorbital Defect
FIGURE 5. A 4-year-old boy suffered congenital nevus at the left temporal area, and reversed STA f lap was performed to cover the defect after nevus resection. A, preoperation; B, f lap design; C, f lap elevation; D, 7 days postoperation.
site infection, STA injury, or general vessel diseases will be the contraindications of this method.
CONCLUSION The advantages of reversed STA island f lap include easy dissection, reliable and long pedicle to rotate, minimal donor-site morbidity, excellent texture and skin match with the recipient site, and variable design of the skin island. Furthermore, it could be safely split into 2 small f laps with one common pedicle, which increase the f lexible of this f lap. It could be a useful tool in reconstructing the periorbital defect caused by various reasons. ACKNOWLEDGMENT Informed consent was received for publication of the figures in this article. REFERENCES 1. Theodore D. A method for obtaining a skin-flap from the scalp and a permanent buried vascular pedicle for covering defects of the face. Ann Surg. 1893;17:677Y679. 2. Uchinuma E, Sakurai H, Shioya N. Anterofrontal superficial temporal artery island flap for full-thickness eyelid reconstruction. Ann Plast Surg. 1989;23:433Y436. 3. Bakhach J, Riahi R, Demiri E, et al. [The reverse auricular flap. A new flap]. Ann Chir Plast Esthet. 1999;44:253Y261. 4. Abul-Hassan HS, von Drasek Ascher G, Acland RD. Surgical anatomy and blood supply of the fascial layers of the temporal region. Plast Reconstr Surg. 1986;77:17Y28.
* 2014 Lippincott Williams & Wilkins
5. Furukawa M, Miyamoto Y. The superficial temporal artery island flap in ear reconstruction. Br J Plast Surg. 1982;35:183Y184. 6. Harma M, Asko-Seljavaara S. Temporal artery island flap in reconstruction of the eyelid. Scand J Plast Reconstr Surg Hand Surg. 1995;29:239Y244. 7. Kasai K, Ogawa Y, Takeuchi E. A case of sideburn reconstruction using a temporoparieto-occipital island flap. Plast Reconstr Surg. 1991;87:146Y149. 8. Zaoli G. [Filling of the residual depression after parotidectomy with a composite arterial subcutaneous flap]. Ann Chir Plast Esthet. 1989;34:123Y127. 9. Furnas DW. Temporal osteocutaneous island flaps for complete reconstruction of cleft palate defects. Scand J Plast Reconstr Surg Hand Surg. 1987; 21:119Y128. 10. Ozdemir R, et al. Reconstruction of facial defects with superficial temporal artery island flaps: a donor site with various alternatives. Plast Reconstr Surg. 2002;109:1528Y1535. 11. Yamauchi M, et al. The reverse superficial temporal artery flap from the preauricular region, for the small facial defects. J Plast Reconstr Aesthet Surg. 2012;65:149Y155. 12. Ian Taylor G, Shymal RJC, Dhar C, et al. The anatomical (angiosome) and clinical territories of cutaneous perforating arteries: development of the concept and designing safe flaps. Plast Reconstr Surg 2011;127:1447Y1459. 13. Zhu L, et al. Treatment of divided eyelid nevus with island skin flap: report of ten cases and review of the literature. Ophthal Plast Reconstr Surg. 2009;25:476Y480. 14. Cordova A, et al. Superior pedicle retroauricular island flap for ear and temporal region reconstruction: anatomic investigation and 52 cases series. Ann Plast Surg. 2008;60:652Y657. 15. Tan O, Atik B, Ergen D Temporal flap variations for craniofacial reconstruction. Plast Reconstr Surg. 2007;119:152eY163e. 16. Kilinc H, et al. A comparative study on superior auricular artery island flaps with various pedicles for repair of periorbital defects. J Craniofac Surg. 2007;18:406Y414.
www.annalsplasticsurgery.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
S73
Reconstruction of Periorbital Soft Tissue Defect With Reversed Superficial Temporal Artery Island Flap Yang Wang, MD, Xiao Long, MD, and Xiaojun Wang, MD Background: Periorbital soft tissue reconstruction is a challenge because of its difficulty in regaining both the form and the function. Local f lap is the priority method because it could provide excellent match in skin color and texture. Objective: We aim to investigate the application of pedicled reversed superficial temporal artery island f lap in the reconstruction of periorbital soft tissue defect. Method: Different kinds of reversed superficial temporal artery island f laps were harvested from the auricular area to cover the defect in the periorbital area. Results: Ten patients who suffered congenital or acquired periorbital diseases were treated with this method. One case suffered minor venous congestion postoperatively. All the other cases achieved good aesthetic result in both the donor and the recipient sites. Conclusion: Reversed superficial temporary artery island flap could be safely harvested from the auricular region even in a split pattern. It could be used to cover the periorbital defect with an unconscious scar at the donor site. Key Words: superficial temporal artery flap, reverse-flow flap, facial defect (Ann Plast Surg 2014;73: S70YS73)
S
oft tissue defect of the periorbital area is always a challenge to plastic surgeons. Reconstruction in this area should not only concern about the form but also the function. Skin graft is a traditional and simple method in treating the small-sized defect, whereas usually the aesthetic result and the eyelid function is not satisfied. Dunham is the first one who described the application of superficial temporal artery (STA)Ybased f lap in 18931 and Uchinuma et al reported a case series of full-thickness eyelid reconstruction with this f lap in 1989.2 Ten years later, Bakhach first reported the reverse auricular f lap based on STA.3 According to the perforator anatomy of superficial temporal artery, we designed the reversed STA island f laps to cover different kinds of periorbital defects and have maintained a positive result.
PATIENTS AND METHODS Patients From October 2003 to April 2012, 10 patients who suffered congenital or acquired diseases in the periorbital area were treated with the reversed superficial temporal artery island f lap harvested from the subauricular area (Table 1). The average age of the patients is 26 years (range: 6Y61).
Received for publication March 24, 2014; and revision accepted April 1, 2014. From the Division of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital, Beijing, China. Conflicts of interest and sources of funding: none declared. Reprints: Xiao Long, MD, Division of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital, Shuaifuyuan 1#, Dongcheng District, Beijing 100730, China. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0148-7043/14/7301-S070 DOI: 10.1097/SAP.0000000000000243
S70
www.annalsplasticsurgery.com
Surgical Technique The anatomy foundation of a reversed STA f lap is the existence of the anastomosis between the frontal (or parietal) branch of STA and the contralateral arteries. Our vascular cast also proved this theory (Fig. 1). We evaluated the size of the defect and measured the distance between the origin of superficial temporal artery and the defect. The f lap could be based on the frontal branch or the parietal branch of STA. Figure 2 shows the f lap design and pedicle location based on the direction of STA perforators. An island or split f lap was designed according to the shape of the defect (Figs. 3Y5). The pedicle was kept wide enough (the same width of the f lap) because usually the superficial temporal vein is not accompanied with the artery. The proximal end of STA is ligated to prolong the pedicle and make the f lap a reverse-f low pattern.
RESULTS Ten patients received this method to cover different sizes of periorbital defects because of various reasons (Table 1). Pedicled f lap was performed on all cases, and one of them received split reversef low STA f lap to cover the divided nevus in both the upper and lower eyelid. The f laps were transferred to the defect area through a subcutaneous tunnel. The donor sites were from the preauricular or subauricular region and were all closed primarily. Minor venous congestion occurred in 1 case postoperatively and recovered 4 days later without any treatment.
Typical Cases Case 1 A 5-year-old girl suffered congenital divided nevus at the middle third of the left upper and lower eyelid (Figs. 4A, B). Split-pattern reversed STA f lap was designed and harvested from the preauricular region based on the frontal branch of STA (Figs. 4C, D). The size of each f lap is 1.5 1 cm with a 13 2 cm pedicle, and the donor site was closed primarily. Both the function and form of the eyelid were satisfied after the operation (Figs. 4E, F).
Case 2 A 4-year-old boy suffered nevus at the left temporal area with the size of 5 2.5 cm. The reversed STA f lap was harvested from the subauricular region with an 11-cm-long pedicle. The f lap totally survived with an invisible scar at the donor site (Fig. 5).
DISCUSSION Alul et al performed the facial soft tissue dissection in 15 fresh cadavers and found that the superficial temporal fascia is part of the subcutaneous musculoaponeurotic system (SMAS).4 Since then, more and more plastic surgeons tried to perform the STA f lap in different kinds of facial defect reconstruction.2,5Y9 Ragip et al discussed the application of superficial temporal artery island f laps in facial defect reconstruction and confirmed its various alternatives Annals of Plastic Surgery
&
Volume 73, Supplement 1, September 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Annals of Plastic Surgery
& Volume 73, Supplement 1, September 2014
Reversed STA Flap to Cover Periorbital Defect
TABLE 1. Clinical Data Diagnosis Divided Nevus Nevus Basal cell carcinoma Periorbital scar Trauma
Case No.
Operation Method
Size of the Flap (On Average)
Complication
2 4 2 1 1
Split reverse STA flap Reverse STA flap Reverse STA flap Reverse STA flap Reverse STA flap
1.5 1 cm and 1.5 1 cm (each split flap) 3.1 2.2 cm 4.2 3.5 cm 4 3 cm 3 3.5 cm
0 0 1 (venous congestion) 0 0
of the donor site.10 Recently, Makoto et al reported the reverse superficial temporal artery f lap from the preauricular region to cover the small facial defect.11 This method has gained more and more attention because of its easy operation procedures and versatile applications.
FIGURE 1. The anatomy of superficial temporal artery shows the perforator of STA in the auricular area (yellow arrow).
Taylor et al published the concept of angiosome in 1987 and revised it again in 2011.12 According to his study, there are 13 angiosomes in the region of head and neck with lots of ‘‘choke vessels’’ between each other. Based on all these research and our anatomy study, we confirmed the existence of STA downward perforators in the pre- and subauricular regions (Fig. 2). The split reversed STA f lap was designed according to the multiple STA perforators, which could reconstruct the upper and lower eyelid simultaneously (Fig. 3). There are several points that need to be paid attention during the f lap elevation. First, the pedicle should be as wide as the base of the skin island to ensure blood supply. Second, the f lap needs to be elevated from the deep layer of SMAS to maintain enough superficial veins in the pedicle to avoid vein congestion. Third, when harvesting a ‘‘split pattern’’ f lap, the superior one-third part of the pedicle should not be divided. The f lap donor site could be altered to the subauricular region to prolong the f lap pedicle. The main advantage of a reverse STA island f lap is the skin color and texture of the donor site. Asian people easily suffer pigmentation contracture after skin graft, which will lead to obvious eyelid deformity, ectropion, or lagophthalmos in the recipient cite. Skin f lap from the periauricular area could provide a better match with the periorbital region than the forward STA forehead f lap (Fig. 5). Also, it is possible to close the donor site primarily even if the f lap is taken with the size of 4.5 4 cm because of the experience of different doctors,13Y16 which will only leave an invisible scar at the donor site finally. There are several limits of the f lap. Donor-site injury could not be neglected because there is possibility of facial nerve injury. By maintaining the proper level during the f lap elevation, this
FIGURE 2. Split pattern and subauricular reversed STA f lap design and the pedicle’s location. * 2014 Lippincott Williams & Wilkins
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Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
S71
Annals of Plastic Surgery
Wang et al
& Volume 73, Supplement 1, September 2014
FIGURE 3. Split-pattern reversed STA f lap harvesting and defect covering.
complication could be avoided. The pin-cushioning appearance is another issue and a loosened tie-over gauze could be put on the f lap in the first 3 days after operation to advance the adhesion of the soft tissues and to avoid this problem. Furthermore, the pedicle
length of the f lap has limited its use to the lateral two-thirds part of the facial area. Indication of the reversed STA f lap include soft tissue defect within the lateral two thirds of periorbital area. Donor site or recipient
FIGURE 4. A 5-year-old girl suffered divided nevus on her left eyelid (A, B). Split-pattern f laps were designed and transferred to the defect area (C, D). Six months after operation (E, F). S72
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* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Annals of Plastic Surgery
& Volume 73, Supplement 1, September 2014
Reversed STA Flap to Cover Periorbital Defect
FIGURE 5. A 4-year-old boy suffered congenital nevus at the left temporal area, and reversed STA f lap was performed to cover the defect after nevus resection. A, preoperation; B, f lap design; C, f lap elevation; D, 7 days postoperation.
site infection, STA injury, or general vessel diseases will be the contraindications of this method.
CONCLUSION The advantages of reversed STA island f lap include easy dissection, reliable and long pedicle to rotate, minimal donor-site morbidity, excellent texture and skin match with the recipient site, and variable design of the skin island. Furthermore, it could be safely split into 2 small f laps with one common pedicle, which increase the f lexible of this f lap. It could be a useful tool in reconstructing the periorbital defect caused by various reasons. ACKNOWLEDGMENT Informed consent was received for publication of the figures in this article. REFERENCES 1. Theodore D. A method for obtaining a skin-flap from the scalp and a permanent buried vascular pedicle for covering defects of the face. Ann Surg. 1893;17:677Y679. 2. Uchinuma E, Sakurai H, Shioya N. Anterofrontal superficial temporal artery island flap for full-thickness eyelid reconstruction. Ann Plast Surg. 1989;23:433Y436. 3. Bakhach J, Riahi R, Demiri E, et al. [The reverse auricular flap. A new flap]. Ann Chir Plast Esthet. 1999;44:253Y261. 4. Abul-Hassan HS, von Drasek Ascher G, Acland RD. Surgical anatomy and blood supply of the fascial layers of the temporal region. Plast Reconstr Surg. 1986;77:17Y28.
* 2014 Lippincott Williams & Wilkins
5. Furukawa M, Miyamoto Y. The superficial temporal artery island flap in ear reconstruction. Br J Plast Surg. 1982;35:183Y184. 6. Harma M, Asko-Seljavaara S. Temporal artery island flap in reconstruction of the eyelid. Scand J Plast Reconstr Surg Hand Surg. 1995;29:239Y244. 7. Kasai K, Ogawa Y, Takeuchi E. A case of sideburn reconstruction using a temporoparieto-occipital island flap. Plast Reconstr Surg. 1991;87:146Y149. 8. Zaoli G. [Filling of the residual depression after parotidectomy with a composite arterial subcutaneous flap]. Ann Chir Plast Esthet. 1989;34:123Y127. 9. Furnas DW. Temporal osteocutaneous island flaps for complete reconstruction of cleft palate defects. Scand J Plast Reconstr Surg Hand Surg. 1987; 21:119Y128. 10. Ozdemir R, et al. Reconstruction of facial defects with superficial temporal artery island flaps: a donor site with various alternatives. Plast Reconstr Surg. 2002;109:1528Y1535. 11. Yamauchi M, et al. The reverse superficial temporal artery flap from the preauricular region, for the small facial defects. J Plast Reconstr Aesthet Surg. 2012;65:149Y155. 12. Ian Taylor G, Shymal RJC, Dhar C, et al. The anatomical (angiosome) and clinical territories of cutaneous perforating arteries: development of the concept and designing safe flaps. Plast Reconstr Surg 2011;127:1447Y1459. 13. Zhu L, et al. Treatment of divided eyelid nevus with island skin flap: report of ten cases and review of the literature. Ophthal Plast Reconstr Surg. 2009;25:476Y480. 14. Cordova A, et al. Superior pedicle retroauricular island flap for ear and temporal region reconstruction: anatomic investigation and 52 cases series. Ann Plast Surg. 2008;60:652Y657. 15. Tan O, Atik B, Ergen D Temporal flap variations for craniofacial reconstruction. Plast Reconstr Surg. 2007;119:152eY163e. 16. Kilinc H, et al. A comparative study on superior auricular artery island flaps with various pedicles for repair of periorbital defects. J Craniofac Surg. 2007;18:406Y414.
www.annalsplasticsurgery.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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