Glabellar Flap Reconstruction After Mohs Surgery

Procedure: The procedure in this video demonstrates a bi-lobed glabellar flap reconstruction after Mohs micrographic excision of a basal cell carcinoma in the medial canthus of the eyelids. Introduction: The medial canthus is a frequent location of periorbital skin cancers. Thus, many patients present for reconstruction after wide local excision, often by Mohs micrographic surgery. Glabellar flap reconstruction is often utilized for medial canthal defects. Bi-lobed glabellar flaps provide an abundance of tissue to close defects and enable surgical reconstruction with good aesthetic results. Indications/Contraindications: Glabellar flap reconstruction may be indicated in individuals presenting after cancer excision, trauma, or burns. It is contraindicated in individuals without a suitable vascular bed to ensure flap survival. Materials and Methods: Key instruments include scleral shell, #15 blade, Westcott and Iris scissors, and sutures (4-0, 5-0, 6-0 vicryl and 5-0 prolene). Important steps include carefully planning and delineating the donor site in the glabellar region, dissecting the flap to an appropriate thickness, undermining the surrounding tissues, tethering the flap edges with sutures, securing the flap with a deep periosteal anchoring suture, and approximating the skin edges with a running suture. Results: A successful flap will allow for maintenance of eyelid position and function, have an acceptable aesthetic appearance, mimic the contour of the natural medial canthal region, and be without infection, hematoma, and wound dehiscence along both the donor and recipient sites. Conclusion: The bi-lobed glabellar flap is advantageous for moderate to large size defects in the medial canthal area. Flaps from the glabellar region are similar in skin texture, thickness, and color to the recipient medial canthal site, thus leading to an excellent cosmetic result.

Glabellar flap reconstruction is often the procedure of choice for surgical reconstruction of medial canthal defects. The anatomy of the medial canthus and its natural depth create a challenging landscape for reconstruction.1 The medial canthus is, however, a frequent location of periorbital skin cancers, as this region is adjacent to the nose, one of the most sun exposed areas of the human body.2 Thus, many patients present for reconstruction after wide local excision, often by Mohs micrographic surgery, or from defects following trauma or burns.3 A flap is a procedure in which a section of skin from a healthy area is dissected, leaving an area with an intact blood supply connected, creating an isthmus that can be used to cover a defect.4 A graft is a procedure in which a section of skin from a healthy area is removed and replaced over a defect.4 Flaps and grafts may be contraindicated in individuals without a suitable vascular bed to ensure their survival.5 Depending on the size of the defect, medial canthal and lid reconstruction can be successful utilizing a number of techniques including direct closure, full thickness skin graft, regional flaps, rhomboid flaps, bi-lobed glabellar rotational flaps, mid-forehead flaps, and V to Y flaps.6 Benefits of the bi-lobed glabellar rotational flap include minimal tension on the sutured edges of the wound, as the tension is spread over two lobes, which promotes healing.6 Further, the flap can prevent the need for a larger forehead flap and the shape can respect the natural depth of the medial canthus. Disadvantages include the potential for eyebrow distortion and a forehead scar.6 Potential complications of any medial canthal defect include hypertrophic scar formation and cutaneous web formation, though this can be avoided by utilizing less inflammatory suture material such as prolene and nylon, and by placing a full-thickness suture to secure the flap to the periosteum, respectively.6

Preoperative Workup: Evaluation of the patient includes a history of present illness and review of past medical history, as well as a thorough ophthalmic examination and identification of an intact vascular pedicle for the flap. Risks and benefits of the procedure should be discussed with the patient and informed consent obtained. Note whether the patient is on anticoagulation therapy and cease administration 2 to 14 days prior to surgery, depending on the specific agent, with the permission of the prescribing physician, as a hematoma could result in flap failure.7 Setup: After undergoing Mohs surgery for biopsy confirmed basal cell carcinoma, the patient presented for repair. Informed consent was obtained. The patient was placed under monitored anesthesia care (MAC) anesthesia, prepared, and draped in the standard sterile fashion for periocular surgery. A scleral shell was placed over the eye with the medial canthal defect to be addressed: the left eye, as seen in the video. The area adjacent to the defect and the glabellar region were injected with 2% lidocaine with epinephrine 1:100,000 mixed 1:1 with 0.75% bupivacaine hydrochloride using a 30-gauge ½ inch needle. Instrumentation: Materials and instruments included a scleral shell, 2% lidocaine with epinephrine 1:100,000 mixed 1:1 with 0.75% bupivacaine hydrochloride, surgical marking pen, #15 blade, Westcott and Iris scissors, 4-0, 5-0, 6-0 vicryl and 5-0 prolene sutures, 0.5 Castroviejo forceps, Castroviejo locking needle driver, suction, gauze, and erythromycin ophthalmic ointment. Anatomy: Important anatomy includes the medial canthal and glabellar regions. The medial canthal tendon provides support to the proximal lacrimal system and is critical to the medial commissure of the lid.6 The medial eyelid commissure can be sutured to the periosteum of the medial orbital wall in cases where there is no medial canthal tendon present.6 This allows for proper eyelid to globe contact.6 The glabellar region (donor area) is supplied by the supraorbital and supratrochlear arteries and located on the frontal bone between the two superciliary arches.8 Procedure: The defect depicted in the associated video measured 20 by 25 mm and spanned the left medial canthal region, including the medial upper, lower lids, and nasal wall. Using a surgical marking pen, a glabellar bi-lobed rotational flap was delineated over the donor region, outlining a lobe that was approximately 80% the size of the defect and a second lobe that was approximately 50% the size of the first lobe.6 An incision was made with a #15 blade along the delineated area. The flap was dissected using Westcott scissors, followed by Iris scissors, to a depth commensurate with the depth of the defect. Undermining of the surrounding tissue was performed in order to produce wound edges at the donor site amenable to apposition. The flap was then rotated into position. Utilizing 4-0 vicryl suture, half-buried horizontal mattress sutures were placed at the two points separating the flap lobes in order to tether the flap to the recipient region, orienting the flap for the remainder of the closure. Importantly, a quilting 4-0 vicryl suture was placed through the flap to the periosteum, anchoring the flap to the periosteum in order to recreate the natural contour of the medial canthal region.6 Subcutaneous 6-0 vicryl suture was used to close the dead space left by the flap in the donor region. 4-0 and 5-0 vicryl sutures were used to further anchor the edges of the flap. A running 5-0 prolene suture was used to approximate the skin edges. The scleral shell was removed, revealing the final frame of the video. Erythromycin ophthalmic ointment was spread over the suture lines and placed in the eye following the procedure.

The primary goal of the bi-lobed glabellar flap is to cover a medial canthal defect. As depicted in the final frame of the associated video, this flap was successful; it has a good aesthetic appearance and mimics the contour of the natural medial canthal region. No complications were observed (including infection, hematoma, and wound dehiscence along both the donor and recipient sites).6,9

Medial canthal defects can arise from trauma, burns, or, as in this case, excision of a malignancy.3 The bi-lobed glabellar flap is useful for moderate to large size defects in this region.6 Flaps from the glabellar region are similar in skin texture, thickness, and color to the recipient medial canthal site, leading to an excellent cosmetic result.9 Common modifications include thinning the flap to cover a defect of less depth and extending the flap to cover a larger defect, as well as other variations on depth, size, and angle.6, 10 Caution must be taken to avoid compromising the flap blood supply by ensuring one has preserved either the supratrochlear or supraorbital artery branches and to avoid transferring hair from the brow to an unplanned location.6 Further, the patient must be informed of the potential risks of periorbital bleeding, infection, and scarring. Important steps as described in detail above include the following: carefully planning and delineating the donor site in the glabellar region, dissecting the flap with undermining of the donor wound edges, tethering the flap edges with sutures, securing the flap with a deep periosteal anchoring suture, and approximating the skin edges with a running suture.

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1. Bertelmann E, Rieck P, Guthoff R. Medial canthal reconstruction by a modified glabellar flap. Ophthalmologica. 2006;220(6):368-71. doi: 10.1159/000095862. PMID: 17095881. 2. Rogers-Vizena CR, Lalonde DH, Menick FJ, Bentz ML. Surgical treatment and reconstruction of nonmelanoma facial skin cancers. Plast Reconstr Surg. 2015;135(5):895e-908e. doi:10.1097/PRS.0000000000001146 3. Başağaoğlu B, Ali K, Hollier P, Maricevich RS. Approach to Reconstruction of Nasal Defects. Semin Plast Surg. 2018;32(2):75-83. doi:10.1055/s-0038-1642639 4. Plastic Surgery: How It's Performed. National Health Service. https://www.nhs.uk/conditions/plastic-surgery/what-happens/. Published June 8, 2018. Accessed May 3, 2021. 5. Lo Torto F, Losco L, Bernardini N, Greco M, Scuderi G, Ribuffo D. Surgical Treatment with Locoregional Flaps for the Eyelid: A Review. Biomed Res Int. 2017;2017:6742537. doi:10.1155/2017/6742537 6. Freitag S, Lee NG, Lefebvre D, Yoon M. Medial Canthal Eyelid Reconstruction. In: Eyelid Reconstruction. Thieme Medical Publishers; 2020:42-59. 7. Stuart A. Perioperative management Of Antithrombotics. https://www.aao.org/eyenet/article/perioperative-management-of-antithrombotics. Published April 26, 2016. Accessed May 4, 2021. 8. StatPearls. Anatomy, Head and Neck, Glabella. StatPearls. https://www.statpearls.com/articlelibrary/viewarticle/36070/. Published July 27, 2020. Accessed April 29, 2021. 9. Marcasciano M, Tarallo M, Maruccia M, et al. Surgical Treatment with Locoregional Flap for the Nose. Biomed Res Int. 2017;2017:9750135. doi:10.1155/2017/9750135 10. Koch CA, Archibald DJ, Friedman O. Glabellar flaps in nasal reconstruction. Facial Plast Surg Clin North Am. 2011;19(1):113-122. doi:10.1016/j.fsc.2010.10.003