Ka-Wai, Liu; Tsung-Chun, Huang; Hung-Chi, Chen Case Report: Aesthetic Unit Reconstruction with Anterolateral Thigh Flap after Wide Excision of Facial Dermatomal Vascular Malformation and Hemangioma Ka-Wai, Liu; Tsung-Chun, Huang; Hung-Chi, Chen Department of Plastic and Reconstructive Surgery, China Medical University Hospital, China Medical University, Taichung, Taiwan
Disclosure Nothing to disclose
Combined hemangioma and vascular malformation
Hemangioma and Vascular malformation Maxillary branch of trigeminal nerve (V2) oral mucosa/cheek/nasal side wall/right lateral philtrum/Right medial canthus/right upper eyelid Size of lesion: 9x 9 centimeters
Magnetic resonance imaging Right cheek vascular malformation Cutaneous to deep soft tissue and masseter muscle
Surgical method Aesthetic unit : One staged ALT flap reconstruction excision and reconstruction Preservation Right great auricular nerve Right facial nerve trunk and its branches Parotid gland One staged ALT flap reconstruction Donor site: partially closed/split thickness skin graft coverage.
17 months after operation
Pathological findings Vascular Malformation (H&E: 40x) Involved margin of hemangioma (H&E:100x)
Discussion
The role of surgical treatments Satisfaction rate: 45~55%, (N=203) laser for dermatomal port-wine stains Poor prognostic factor Capillary malformation : second branch of trigeminal nerve (V2) distribution When port wine stain has become long-standing lesion, wide excision and one stage reconstruction will be the appropriate option Plastic and reconstructive surgery, 2008. 121(4): p. 1173-1180.
Surgical consideration Untreated superficial nodular hemangioma with epidermal invasion 75 % persistent deformity, especially in prior bleeding, ulcer, and infection Matured port-wine stain thickening and cobblestone ectasia turned into fast-flow malformation Plastic and reconstructive surgery, 2011. 127(4): p. 1643-1648. Plastic and reconstructive surgery, 2011. 127(2): p. 784-791.
Reconstructive methods Full thickness skin graft (FTSG) limited size of the donor site Thick split thickness skin graft (STSG) Thick STSG: donor site severe hypertrophic scar Facial expression muscles involvement skin graft will not provide enough soft tissue for volume expansion. Archives of plastic surgery, 2012. 39(2): p. 126-129.
Reconstructive methods Free flap : extended lesions Free radial forearm flap Free anterolateral flap Pre-expanded ultra-thin supraclavicular flap Cervicothoracic skin flap prefabricated by lateral thigh flap Prefabricated induced expanded supraclavicular skin flap
Limitation of this case Slight ectropion lateral part of right lower eyelid Right medial canthus contracture Right lip downward displacement Drooping and bulky flap Color of skin: need tattooing
Conclusion Surgical resection is one of the options to treat facial dermatomal capillary malformation with minimal complications based on aesthetic unit reconstruction. Acceptable contour can be achieved by anterolateral thigh flap with minimal donor site morbidity.