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Syddansk Universitet the Versatile Modiolus Perforator Flap CORE Metadata, citation and similar papers at core.ac.uk Provided by University of Southern Denmark Research Output Syddansk Universitet The Versatile Modiolus Perforator Flap Gunnarsson, Gudjon L.; Thomsen, Jørn Bo Published in: Plastic and Reconstructive Surgery, Global Open DOI: 10.1097/GOX.0000000000000611 Publication date: 2016 Document version Final published version Document license CC BY-NC-ND Citation for pulished version (APA): Gunnarsson, G. L., & Thomsen, J. B. (2016). The Versatile Modiolus Perforator Flap. Plastic and Reconstructive Surgery, Global Open, 4(3), [e661]. DOI: 10.1097/GOX.0000000000000611 General rights Copyright and moral rights for the publications made accessible in the public portal are retained by the authors and/or other copyright owners and it is a condition of accessing publications that users recognise and abide by the legal requirements associated with these rights. • Users may download and print one copy of any publication from the public portal for the purpose of private study or research. • You may not further distribute the material or use it for any profit-making activity or commercial gain • You may freely distribute the URL identifying the publication in the public portal ? Take down policy If you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediately and investigate your claim. Download date: 19. Apr. 2017 Divya ORIGINAL ARTICLE Original Article Reconstructive xxx The Versatile Modiolus Perforator Flap XXX Gudjon Leifur Gunnarsson, MD* Background: Perforator flaps are well established, and their usefulness as 2016 Jorn Bo Thomsen, MD, PhD† freestyle island flaps is recognized. The whereabouts of vascular perfora- tors and classification of perforator flaps in the face are a debated subject, despite several anatomical studies showing similar consistency. In our ex- Plastic & Reconstructive Surgery-Global Open perience using freestyle facial perforator flaps, we have located areas where perforators are consistently found. This study is focused on a particular 4 perforator lateral to the angle of the mouth; the modiolus and the versatile modiolus perforator flap. Methods: A cohort case series of 14 modiolus perforator flap reconstruc- 3 tions in 14 patients and a color Doppler ultrasonography localization of the modiolus perforator in 10 volunteers. Results: All 14 flaps were successfully used to reconstruct the defects in- Versatile Modiolus Perforator Flap volved, and the location of the perforator was at the level of the modiolus as predicted. The color Doppler ultrasonography study detected a sizeable per- Gunnarsson and Thomsen forator at the level of the modiolus lateral to the angle of the mouth within a radius of 1 cm. This confirms the anatomical findings of previous authors and indicates that the modiolus perforator is a consistent anatomical find- ing, and flaps based on it can be recommended for several indications from the reconstruction of defects in the perioral area, cheek and nose. Conclusions: The modiolus is a well-described anatomical area containing a sizeable perforator that is consistently present and readily visualized using color Doppler ultrasonography. We have used the modiolus perforator flap success- fully for several indications, and it is our first choice for perioral reconstruction. (Plast Reconstr Surg Glob Open 2016;4:e661; doi: 10.1097/GOX.0000000000000611; Published online 22 March 2016.) erforator pedicle flaps are largely replacing the some large perforators appears to be consistent and concept of random flaps in our practice, and for predictable.1,2 Lateral to the angle of the mouth, cor- the past 8 years, freestyle perforator flaps have responding to the modiolus area, is a reliable perfora- P 1 been our first choice local flap for facial reconstruction. tor that we have previously referred to as “the modiolus During this time, we have noticed that the location of perforator.”1 The modiolus is a landmark representing a dermal insertion and decussation of muscles derived From the *Department of Plastic Surgery, Telemark Hospital, from the second branchial arch.3 Studies have shown Skien, Norway; and †Department of Plastic Surgery, that the facial artery is located lateral to the modiolus em- Lillebaelt Hospital and Odense University Hospital, bedded in a fibrofatty tissue that allows for its mobility.4,5 Denmark. The aim of this article was to evaluate the consistency Received for publication August 13, 2015; accepted December of the modiolus perforator, based on our clinical ex- 31, 2015. perience and random sample evaluation using color Drs. Gunnarsson and Thomsen contributed equally to the preparation of this article. Copyright © 2016 The Authors. Published by Wolters Disclosure: The authors have no financial interest Kluwer Health, Inc. on behalf of The American Society of to declare in relation to the content of this article. The 13August2015 Plastic Surgeons. All rights reserved. This is an open-access Article Processing Charge was paid for by The Plastic article distributed under the terms of the Creative Commons Surgery Department, Telemark Hospital. Attribution-Non Commercial-No Derivatives License 4.0 31December2015 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot © 2016 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Supplemental digital content is available for this be changed in any way or used commercially. article. Clickable URL citations appear in the text. Society of Plastic Surgeons. All rights reserved. DOI: 10.1097/GOX.0000000000000611 10.1097/GOX.0000000000000611 www.PRSGlobalOpen.com 1 PRS Global Open • 2016 Doppler ultrasonography (CDU), and review of our Digital Content 1, which displays the versatility of the findings in the context of the current literature. modiolus perforator flap and range of motion. This video is available in the “Related Videos” section of MATERIALS AND METHODS the Full-Text article on PRSGlobalOpen.com or avail- We performed a volunteer study to confirm the able at http://links.lww.com/PRSGO/A178.) The perfo- location of the modiolus perforator using a CDU on rator was not skeletalized in any of the cases. A simple 20 hemifaces and a prospective clinical series using detachment of the surrounding adhesions to the zy- the modiolus perforator as a pedicle for a freestyle gomaticus major, risorius, and depressor anguli oris perforator flap design. muscles was done to enable flap rotation (Fig. 3). CDU Volunteer Study CDU-guided Technique We examined 10 volunteers bilaterally by CDU, The facial artery was identified below the angle 3 men and 7 women aged 26 to 57 (43), using a of the mouth. The artery was then followed by a very BK Medical color Doppler ultrasonographer with slow movement upward until the modiolus perfora- a 10- to 12-mHz linear transducer. The technique tor was identified. The location was then marked by was performed as described above, and the loca- a permanent marker. The flap was designed based tion of the perforator was marked with a perma- on the CDU findings and the size of the defect and nent marker (red dot). The corresponding CDU surgery commenced as described above (Fig. 4). screen images are shown next to the clinical image (Fig. 1). RESULTS Clinical Study CDU Volunteer Study We reviewed 14 cases, 3 male and 11 female pa- We identified a usable perforator close to the tients aged 6 to 85, reconstructed by an island flap modiolus by CDU bilaterally in 10 subjects, 3 males based only on the modiolus perforator lateral to the and 7 females, median age 42 (26–57) years. In angle of the mouth. Four patients were smokers. The the majority of cases, we found that the perfora- surgical indications were defects following removal tor branched off from the main artery as a single of basal cell carcinoma in 6 cases, malignant mela- branch; however, in a few cases, it divided into 2 or noma in 4 cases, 2 squamous cell carcinoma, 1 atypi- 3 branches. In most cases, the perforator was curved cal fibroxanthoma, and 1 trichoid epithelioma. The or even S-shaped as it passed between the muscles. reconstructions were performed on the cheek in 6 The perforator branching point from the facial cases, upper lip in 5, nose in 2 and lower lip in 1. The artery was marked with a red dot in the figures. operative technique was either freestyle exploration Despite the observed perforator branching point or guided by preoperative CDU localization. variations, it appeared to pass through to the sub- cutis lateral to the angle of the mouth at the level of Freestyle Technique the modiolus in all cases. The perforator location was explored through a nasolabial incision in a caudal direction until the Clinical Study perforator was localized. The flap was dissected cir- We performed 14 perforator flaps based on the cumferentially around the perforator enabling a free modiolus perforator in 14 patients (Table 1). The rotation (Fig. 2 and Video 1) (See Supplemental location of the perforator was at the level of the Fig. 1. CDU findings appeared consistent as shown in all 10 volunteers (20 hemifaces). Modiolus location indicated by red dot. CDU picture on each side. 2 Gunnarsson and Thomsen • Versatile Modiolus Perforator Flap Fig. 2. Intraoperative exploration and reconstruction of nasal dorsum using a cervical ex- tension of the modiolus flap in a patient with previous nasolabial flap reconstruction and a recurrence (operative and 1-year postoperative image). surgical exploration in 6 cases and guided by CDU in the latter 8 cases. DISCUSSION The modiolus has been described to be a fibrous chiasma, a condensation of the deep and superficial facial fascia, where the facial muscles join to form in- sertion at the angle of the mouth.3,4 The facial artery runs lateral to it, superficial to the buccal fat pad, in a window marked by the zygomaticus major muscle su- periorly and risorius muscle inferiorly.4–6 The results of this article show that this window contains a sizeable Video 1.
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