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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

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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 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, , 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 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.

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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 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 su- periorly and risorius muscle inferiorly.4–6 The results of this article show that this window contains a sizeable Video 1. See Supplemental Digital Content 1, which displays the versatility of the modiolus perforator flap and range of perforator that is consistently present and can read- motion. This video is available in the “Related Videos” section ily be visualized and identified by CDU. We refer to it of the Full-Text article on PRSGO.com or available at http:// as the modiolus perforator. The facial artery is kinked links.lww.com/PRSGO/A178. in a lazy-S shape in this area, which adds to its mobil- ity during facial expression and mouth opening. This modiolus as predicted by the anatomical landmark added mobility has been beneficial for the advance- and CDU. Nine flaps were propeller flaps rotated ment of some of our flaps up to cm4 especially when 90 to 180 degrees and 5 were V-Y flaps. The size of used in a V-Y fashion (Fig. 3). the flaps varied from 8 to 64 cm2. The reconstruc- Three anatomical studies describe the facial ar- tive goal was achieved in all 14 cases; however, in tery perforators and share findings similar to ours, 3 patients, who were heavy smokers, a revision and indicating the consistency of a perforator lateral to further corrective procedures were needed due to the angle of the mouth. Hofer et al7 described the distal tip necrosis. The perforator was identified by facial artery perforator flap for the first time in a case

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Fig. 3. A lentigo malignant melanoma defect reconstructed using a large modiolus perfora- tor flap in a V-Y fashion and a smaller perforator flap of the lower eyelid. Intraoperative view showing the perforator and adjacent muscles: immediate postoperative and patient shown 6 weeks postoperative. series of 5 patients in combination with an anatomi- The modiolus perforator flap is in fact a variation cal study that showed a high density of perforators of the well-known nasolabial flap and has a great po- lateral to the mouth. Ng et al8 named it reference tential to become a work horse flap for the recon- point A, inferolateral to the angle of the mouth, and struction of lip, cheek, and selected nasal defects. Qassemyar et al9 referred to the perforator lateral to The flap can be designed either as a V-Y advancement the angle of the mouth. CDU is known to be a good flap or a propeller flap depending on the location tool for identification of the facial artery; however, and the size of the defect. It allows for a successful re- localization of the small perforators has until now construction of a whole anatomical subunit, replaces been deemed unclear or unavailable.7–9 like with like, and has a forgiving donor site, which We tested the accuracy of CDU as a tool for iden- can be closed directly. The localization of the per- tification of the modiolus perforator on a random forator with CDU will most certainly make it more sample of 10 individuals (20 hemifaces). We were accessible in the near future. readily able to identify a sizable perforator at the mo- We have successfully used both propeller and diolus level bilaterally in all cases (Fig. 1). advancement modiolus perforator flaps for differ- The modiolus perforator is a consistent finding ent indications, and it has become our first choice and can easily be located by pre- or perioperative for perioral reconstruction. This article appears to CDU or simply by careful exploration just lateral to be the first to recognize the benefits of CDU in the the fibrous skin attachments of the orbicularis muscle. localization of facial artery perforators for a freestyle

4 Gunnarsson and Thomsen • Versatile Modiolus Perforator Flap

Fig. 4. Case of CDU localization of a modiolus propeller flap for a cheek reconstruction, intraoperative, and long-term result 1 year postoperative.

Table 1. Patient Data: The Versatile Modiolus Perforator Flap No. Age Sex Indication Location Comorbidity Flap Size (cm) Complication Outcome 1 67 M BCC UL Smoker P-180 7 × 5 = 35 1-cm tip necrosis CS 2 81 M BCC CH None P-140 5 × 3 = 15 None C 3 71 F BCC N Smoker P-180 12 × 3 = 36 2-cm tip necrosis CR 4 70 F AFX CH None V-Y 7 × 2 = 14 None C 5 75 M SCC LL Smoker P-140 4 × 2 = 8 None C 6 85 F BCC CH None P-140 6 × 4 = 24 None C 7* 81 F BCC UL None P-120 5 × 3 = 15 None C 8* 83 F SCC CH None V-Y 7 × 4 = 28 None C 9* 83 F BCC UL None V-Y 6 × 3 = 18 None C 10* 54 F MM UL None P-135 7 × 4 = 28 None C 11* 57 F TE N Smoker P-180 11 × 2 = 22 1.5-cm tip partial necrosis CS 12* 83 F MM CH/N None V-Y 9 × 5 = 45 None C 13 71 F MM UL None P-90 3 × 1 = 3 None C 14 6 F MM CH None V-Y 4 × 1 = 4 None C Fourteen patients reconstructed with the modiolus perforator flap, patient demographics, and results. *Freestyle without CDU. AFX, atypical fibroxanthoma; BCC, basocellular carcinoma; C, complete reconstruction; CH, cheek; CR, complete after revision; CS, complete after secondary healing; LL, lower lip; MM, malign melanoma; N, nose; P, propeller; SCC, spino cellular carcinoma; TE, trichoid epithelioma; UL, upper lip. flap design, and we postulate that this will positively modern CDU device and verified the consistency affect its application in the future. of a significant facial artery perforator lateral to the angle of the mouth, the modiolus perforator. The average diameter of 1 mm provides a reliable CONCLUSIONS vascular basis for an advancement or propeller We have shown that perforators can readily be flap design for various reconstructive purposes in visualized by the operative plastic surgeon using a the area.

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3. Williams PL, Bannister LH, Berry MM, et al. Gray’s Anatomy. Gudjon Leifur Gunnarsson, MD 38th edn. New York: Churchill Livingstone; 1995:796–799. Telemark Hospital 4. Yu SK, Lee MH, Kim HS, et al. Histomorphologic approach Skien 3710, Norway for the modiolus with reference to reconstructive and aes- E-mail: [email protected] thetic surgery. J Craniofac Surg. 2013;24:1414–1417. 5. Onderoğlu S. Topographical relations of the facial artery Patient Consent in the region of the modiolus anguli oris. Okajimas Folia Anat Jpn. 1999;76:141–147. Patients provided written consent for the use of their 6. Lee JG, Yang HM, Choi YJ, et al. Facial arterial depth images. and relationship with the facial musculature layer. Plast Reconstr Surg. 2015;135:437–444. REFERENCES 7. Hofer SO, Posch NA, Smit X. The facial artery perforator 1. Gunnarsson GL, Jackson IT, Thomsen JB. Freestyle flap for reconstruction of perioral defects. Plast Reconstr facial perforator flaps-a safe reconstructive option Surg. 2005;115:996–1003; discussion 1004. for moderate-sized facial defects. Eur J Plast Surg. 8. Ng ZY, Fogg QA, Shoaib T. Where to find facial artery 2014;37:315–318. perforators: a reference point. J Plast Reconstr Aesthet Surg. 2. Gunnarsson GL, Jackson IT, Westvik TS, et al. The free- 2010;63:2046–2051. style pedicle perforator flap: a new favorite for the re- 9. Qassemyar Q, Havet E, Sinna R. Vascular basis of the fa- construction of moderate-sized defects of the torso and cial artery perforator flap: analysis of 101 perforator ter- extremities. Eur J Plast Surg. 2015;38:31–36. ritories. Plast Reconstr Surg. 2012;129:421–429.

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