Frontal Reconstruction with Frontal Musculocutaneous V-Y Island Flap

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Sir: We are very honored to reply to Dr. Sharma et al. about our article, “Frontal Reconstruction with Frontal Musculocutaneous V-Y Island Flap.”1 Even large flaps survive on a single supraorbital or supratrochlear pedicle because of the wide net of their anastomosis within the muscle, the subcutaneous level, and the skin itself, especially due to the absence of valves in the veins of the forehead.2 We recently had a patient with Edward syndrome in whom none of these vessels were found during surgical dissection and the flap developed total necrosis. This has been seen before by others.3 We understand that elevation of a patch of periosteum close to the pedicle behaves as a safe envelope to protect the vessels during dissection of the pedicle, and this is very important and useful advice. Osteotomy is an intraoperative decision, useful for short pedicles. We have used this flap to treat the donor site in 17 cases of nose reconstruction, with a frontal paramedian flap in a single procedure. We believe that the position, size, and shape of the skin island depend on the purpose of the reconstruction. Sometimes there are forehead wrinkles that invite incision placement and best hide scars (Fig. 1).Fig. 1.: Patient A. Intraoperative view shows a left paramedian frontal flap harvested high on the forehead to permit a long left supratrochlear pedicle (arrow on the left) to be transferred to the nose through the glabellar tunnel shown by the scissors. Simultaneously, a musculocutaneous V-Y island flap based on both the supraorbital and supratrochlear vessels (arrows on the right) is prepared to be transferred to the first flap donor site.Depending on the arc of rotation, both pedicles can be wisely preserved, but when the skin island is advanced to a wide defect, a necessary back-cut leads to division of the supraorbital pedicle; then the entire flap has to be based on the supratrochlear vessels only.1 The use of temporal skin, as suggested by Sharma and colleagues, enlarges the V-Y island flap but reduces the donor-site deformity (Figs. 2 and 3).Fig. 2.: Patient B. Preoperative exposition of bone after the excision of a basal cell carcinoma. The neighboring skin has scars secondary to previous attempts to treat by cauterization.Fig. 3.: Patient B. Intraoperative view shows a right paramedian 4.0 × 4.0-cm frontal flap based on the right supratrochlear vessels transferred to the nose through a glabellar tunnel to cover the bone exposition and to substitute for the neighboring skin. In the same single procedure, a musculocutaneous V-Y island flap based on the left supraorbital and supratrochlear vessels was harvested from the left half of the forehead and temporal area and transferred to treat the right-side defect.Lorenzo Sampaio Rocha, M.D., Ph.D. Geruza Rezende Paiva, M.D., M.S. Ivan Oliveira Santos, M.D., Ph.D. Department of Medicine Federal University of Rondônia Hospital do Câncer de Rio Branco Acre, Brazil