Reconstruction of eyelids with washio flap in anophthalmia

INTRODUCTION

Retroauriculo-temporal flap (Washio flap) was first described in 1962 by Loebe as a temporomastoidal flap. Hiroshi Washio described this flap for reconstruction of the nose in 1969. He performed angiography study on cadavers and has shown presence of various connections between the branches of superficial temporal artery and retroauricular artery, which provide good perfusion in mastoidal area of the flap, which is normally provided by retroauricular artery. In 1972, Washio evaluated the use of this flap in 11 cases. He evaluated the flap as excellent for reconstruction of nasal alae. Its colour and texture is comparable only with the forehead flaps and local flaps. In comparison with these flaps, there is a clear advantage of Washio flap in its relatively hidden donor site. Two basic prerequisites must be fulfilled for the use of the flap - presence of superficial temporal artery, good structural support and quality of tissues in the recipient site. The width of the flap must be at least 6 cm. Vertical incision should be minimal, and only in such extent for the flap to reach the defect. The inclination of the flap is 10^o–15^o backwards from the vertical line and galea must be part of the flap. Another indication of its use are smaller defects on the face, lower eye lids and forehead.

In available literature we found no reports about the use of this fap for reconstruction of the eyelids in anophthalmia.

CASE REPORT

Nine year old female patient was referred to our department with a request to reconstruct the eye lids. The girl was born with right-sided anophthalmus, facial asymmetry, congenital CNS disorder - mild form of Dandy-Walker syndrome and she was also treated for secondary epilepsy.  In early childhood was hospitalized for several times at the Department of Neurology and Department of Ophthalmology, where she underwent surgery without an effect and hypoplastic eyelids disappeared due to necrosis.  It was a complete defect of the eyelids and base of the eye socket consisted of granulation tissue (Fig. 1). Due to the required quantity of tissue, which was needed for the affected area, was decided about reconstruction with Washio flap, which fulfils this requirement with regards to volume as well as colour and texture of skin and donor site remains covered.

In the first stage was mobilized only the part of the flap in the mastoideal area and partially on the back part of the auricle and a full thickness skin graft was sutured on the inner side of the flap, in order to create inner side of future eye lids (Fig. 2).

Within a period of 12 days was raised the whole Washio flap; skin graft at its end was healed. Granulation tissue at the base of the eye socket was excised and the defect was covered with full thickness skin graft harvested from the groin. Mobilized flap was sutured to the defect and there was a spacer inserted underneath, which ensured contact of skin graft with the base of the eye socket. Skin defect in the mastoid area and at the back side of the auricle was also covered with a full thickness skin graft and the remaining secondary defect in the temporoparietal area with synthetic skin cover (Fig. 3).

After 3 weeks was the flap divided at the level of the lateral edge of the orbit, the flap was spread and returned to the original site (Fig. 4). In the next stage with one month interval was the flap in the orbit horizontally divided, modelled and exchange of a spacer was performed (Fig. 5). After healing of the wounds, which was accomplished without complications, was the spacer exchanged for a shell eye prosthesis, which was subsequently adjusted. Due to maturation and scar contracture, there was mild retraction of the flaps creating the eyelids in the area of the medial canthus (Fig. 6). This condition was corrected with mobilisation of the flaps and movement medially.

The condition is stabilized at the moment, the prosthesis is holding well and the patient is already willing and able to walk without dressing covering the eye, which lasted almost for two years (Fig. 7).

DISCUSSION

Reconstruction of the eyelids is a serious problem in case of a complete defect. This condition requires transfer of tissues from a distant area, since usage of tissue from the surrounding area, i.e. from the face or forehead, would result in scaring of these aesthetically important areas. These requirements fulfill the Washio flap, which is able to reach with skin of required quality, colour and texture. Another advantage is inconspicuous scar in hair and the donor site is covered with skin graft and hidden. Certain problem is long term maturation of transferred flap, which is divided to two parts and has a tendency to take a tubular shape, softens very slowly and becomes flat. In spite of this we think that the selected method of reconstruction was an optimal option. We have not found a similar method of reconstruction in the literature.

Address for correspondence:

Assoc. Prof. M. Tvrdek, M.D.

Department of Plastic Surgery

University Hospital Kralovské Vinohrady

Šrobárova 50

100 34 Prague 10

Czech Republic

E-mail: tvrdek@fnkv.cz