Hai-sheng YU, Si-ding LU

Department of plastic surgery,the First Affiliated Hospital of Guangxi Medical University,Nanning City,Guangxi Province,530021,China

ABSTRACT Objective To investigate the therapeutic effect of expanded scalp flaps pedicled with superficial temporal vessel in the repair of facial skin scars.Methods From May 2017 to October 2018,4 patients with facial skin scars were treated with expanded scalp flaps pedicled with superficial temporal vessels and laser hair removal.All patients were followed up for at least 6 to 12 months.Results The flaps of all 4 patients survived well,and the color,texture and thickness of the flaps matched well with the surrounding skin tissue.Conclusion Expanded scalp flaps pedicled with superficial temporal vessel is a good option for repairing facial skin scars,which is worthy of clinical application.

KEY WORDS Expanded scalp flap;face; skin scar

Facial trauma,flame or chemical burn can cause scar formation,loss of facial features,and severely limit facial movement and expression.Reconstruction of these extensive deformities involves not only the coverage of larger skin defects,but also the fine formation of each central unit and the formation of fine features of each central unit.However,although the reconstruction technique has made great progress,it is still difficult to meet the reconstruction requirements of the central and peripheral facial units and provide a consistent skin color and texture for the face,and a higher technology is required.In order to solve these shortcomings,we have tried to repair such wounds by using the expanded scalp flap pedicled with superficial temporal vessel,and performed laser hair removal in the second stage.We have gained some experience in the early stage[1],and the results are satisfactory with few complications.Now,it is reported as follow:

PATIENTS AND METHODS

Clinical materials

From May 2017 to October 2018,four patients (all male)aged from 18 to 29 years (average 23.5 years old)underwent skin defect repair surgery with expanded scalp flaps pedicled with superficial temporal vessel after facial scar resection.All facial scars were caused by burns, including unilateral facial scars in 3 cases and bilateral facial scar in 1 case.The flap size ranged from 7cm×11cm to 8cm×12cm,and the average follow-up time was 6 months (ranged from 6 to 12 months).

Methods

The pedicled expanded scalp flap was prefabricated by taking the superficial temporal vessels as the pedicle.

The prefabrication process of expanded scalp flapAn appropriate skin expander was selected according to the area and shape of the facial lesions.Doppler ultrasound blood stream detector was used to precisely locate the direction of the superficial temporal artery as well as determine the implantation range of the expander and the location of the incision.Then,the dissection was performed under the superficial temporal fascia and the galea aponeurosis,and the appropriately sized expander was implanted under the fascia.The incision was sutured,the negative pressure drainage was placed for 2 days,the stitches were removed 1 week after the surgery,the water was regularly injected into the expander,2 to 3 times per week,and the injected water volume was determined by the skin tension of the expanded area and the tolerance of the patient.According to the follow-up measurement,when the expanded skin tissue volume can meet the needs of repairing the facial skin defects and can be sutured to repair the donor area,the water injection was stopped,and the patient rested for 1-2 months before the second-stage operation.

Flap transferThe superficial temporal vessels were examined by ultrasonography before flap transfer.After the facial scar tissue was removed,the flap was transferred to cover the facial defect,the donor area was sutured directly,the drainage tube was placed for 24 to 48 hours,and the stitches were removed one week after surgery.

Postoperative care and laser hair removal After the surgery,the patients were given daily dressing changes in the first 3 days,the blood supply of the flap was observed,and antibiotics were applied 24 hours.Two weeks after the surgery,if the wound healed well,Palomar laser hair remover (Palomar Medical Technologies,Inc.)was used.Palomar wavelength 650-1200nm laser was used to clean the skin,scrape off the hair in the treatment area,and the appropriate treatment parameters was adjusted according to the density,thickness and skin tone of the patient’s hair.The pulse width was 20ms for the first,third and fifth time and 100ms for the second,fourth and sixth time.The specific energy should be adjusted according to the response of the treated skin[1].There was slight or moderate swelling or slight or moderate erythema around the hair follicle at the end of the treatment .Generally,the treatment is 4-6 times,each treatment interval is about 1 month.After the operation,ice packs were applied for 15-30 minutes,and the patients should take measures for sun protection and avoid applying sunscreen.

RESULT

After the flap transfer and the laser hair removal,no obvious complications were found in the 4 patients.The color,texture and thickness of the flap matched well with the surrounding skin tissue,the effect was satisfactory,and the scar was not obvious.

Typical case 1:male,29 years old,diagnosed left facial skin scar (Fig.1a).A 150ml cylindrical expander was implanted in the left temporoparietal area.Three months after the surgery (Fig.1b),the second stage expanded flap was transferred to repair the left facial scar and laser hair removal was performed.One year after the surgery,the color and texture of the flap were good (Fig.1c,1d).

Fig 1 Typical case 1:male,29 years old,diagnosed left facial skin scar (Fig.1a).A 150ml cylindrical expander was implanted in the left temporoparietal area.Three months after the surgery (Fig.1b),the second stage expanded flap was transferred to repair the left facial scar and laser hair removal was performed.One year after the surgery,the color and texture of the flap were good (Fig.1c,1d).

Fig 2 Typical case 2:male,20 years old,diagnosed bilateral facial skin scar (fig 2a,2b),A 150ml cylindrical expander is implanted in bilateral temporoparietal area,3 months after the surgery (fig 2c),the second stage expanded flap was transferred to repair the left facial scar and laser hair removal was performed.One year after the surgery,the color and texture of the flap were good (fig 2d,2e,2f).

Typical case 2:male,20 years old,diagnosed bilateral facial skin scar (Fig2a,2b),A 150ml cylindrical expander is implanted in bilateral temporoparietal area,3 months after the surgery (Fig2c),the second stage expanded flap was transferred to repair the left facial scar and laser hair removal was performed.One year after the surgery,the color and texture of the flap were good (Fig2d,2e,2f).

DISCUSSION

It is generally believed that facial reconstruction is a treatment challenge.Extensive facial soft tissue lesions not only affect facial appearance,but also cause mental health problems of patients[2].Local flap,skin graft,free flap or expanded flap are usually used to repair extensive facial soft tissue defects.Local flap is usually the first choice.When the local flap can not provide enough tissue to cover the wound,skin graft is a simple and effective option.However,the color and texture of the skin graft surface do not match the color and texture of the facial skin.Wang Hongyuan[3]used free perforator flap to repair the huge soft tissue defect of scalp and face,which is considered as a good method to reconstruct malignant tumor.However,careful execution requires good micro-surgical skills to prevent free flap necrosis.When aesthetic elements of the transplanted flap such as luster,texture and elasticity are considered,the tissues in other parts of the body do not match the facial skin well.

The use of scalp skin is considered to be an ideal surgical reconstruction method for full thickness skin burns and scar lesions.The skin taken from the split-thickness skin can be multiple times without affecting the growth of hair[4].Since 1982,Radovan has introduced the use of skin and soft tissue expansion techniques for the first time,which provides“additional” skin repair for breast cancer patients undergoing radical surgery[5].Over the years,the application technique of skin expander flap has developed rapidly,the scalp tissue is close to the face skin,and the undamaged scalp skin after expansion can be used to repair the wound defects after the facial soft tissue lesions are removed.The transplantation of expanded scalp flap pidicled with superficial temporal blood vessels has the following advantages:①The anatomical structure of temporal blood vessels has little change,which facilitates the dissection,and the color,thickness and texture of scalp skin after laser hair removal match well with the facial skin.②The blood supply of the flap is sufficient,and the expanded scalp flap is not easy to become necrotic.③The scalp skin after expansion can provide a large area of skin tissue,and the scalp in the donor area can be directly sutured without skin grafting.④If the expanded flap is large enough,it can be transferred to any part of the face to repair the defect.However,there are some shortcomings in the repair of facial lesions with expanded scalp flap pedicled with superficial temporal blood vessels:after laser hair removal,the skin texture and color of temporal scalp flap are basically similar to those of cheek,nose and forehead.But for the repair of the upper and lower eyelid lesions,the expanded temporal flap is still not suitable because of its bloated appearance[6],and the local adjacent flap transfer or skin grafting can achieve better repair effect[7].In addition,for the simple superficial skin scar tissue,the repair effect is not as good as laser treatment.

CONCLUSION

The expanded scalp flap pedicled with superficial temporal vessels provides a good tissue for repairing facial skin scar.The color and texture of the flap are well matched with the surrounding facial skin tissue,which has little impact on the donor area.The blood supply of the flap is good and anatomically constant ,and the expanded flap is not easy to become necrotic.

Fundation

The Scientific Research Project of Guangxi Health and Family Planning Commission (Z2015559)