TOTAL FRONTAL FLAP IN THE RECONSTRUCTION OF HEMIFACIAL AREAS.

PROBLEM CASE: GIANT CRANEOFACIAL MELANOCYTIC CONGENITAL NEVUS.

e.g. Jorge O. Gerrissi* ; Nicolas M. Leal* ; Alonso M. Cuello Barros *
* Servicio Ciruga Plstica, Hospital General de Agudos Dr. Cosme Argerich, C.a.b.a., Argentina.

TOTAL FRONTAL FLAP IN THE RECONSTRUCTION OF HEMIFACIAL AREAS. PROBLEM CASE: GIANT CRANEOFACIAL MELANOCYTIC CONGENITAL NEVUS. Summary

A case of a 27 years old male patient is presented, with clinical and histopathological diagnostic of giant melanocytic congenital nevus (NMCG) that affects the right side of the face, including the brow, lids, bulbar and palpebral conjuctive, ocular globe, cheek, nose and the parieto-temporal sector. According to dimensions and extension of the lesion the resection and reconstruction was programmed in three successive stages: in the first, resection of the melanocytic lesion located in cheek, forehead, lids and nose; in the second resection in the temporoparietal area; and the third at level of the ocular globe treatment. In the first operation the reconstructive was made by the transposition of a total forehead flap are described in this paper showing the feasibility in total hemiface reconstruction.

TOTAL FRONTAL FLAP IN THE RECONSTRUCTION OF HEMIFACIAL AREAS. PROBLEM CASE: GIANT CRANEOFACIAL MELANOCYTIC CONGENITAL NEVUS.

Material and Methods

Male patient 27 years, who presents a injure with clinical and histopathological diagnosis of congenital melanocytic nevi, brownish, irregular, affecting the right side of the face, including the eyebrows, eyelids, palpebral and bulbar conjunctive, zygomatic-malar area, cheek and parieto-temporal sector of the scalp.
Resection is planned in three stages: 1 - Removal of the lesion in the right half forehead, cheekbone area, cheeks, eyelids and nose. 2 - parieto-temporal 3 - eyeball

TOTAL FRONTAL FLAP IN THE RECONSTRUCTION OF HEMIFACIAL AREAS. PROBLEM CASE: GIANT CRANEOFACIAL MELANOCYTIC CONGENITAL NEVUS.

In the first surgical resection was performed partial injury zygomatic-malar area, forehead, cheek, eyebrow, eyelid and nose. The reconstruction was done by transposing a flap of full frontal scalp and skin graft to the hole nose. The secondary defect to flap elevation in the area of the forehead was covered with a skin graft taken from the low umbilical region

TOTAL FRONTAL FLAP IN THE RECONSTRUCTION OF HEMIFACIAL AREAS. PROBLEM CASE: GIANT CRANEOFACIAL MELANOCYTIC CONGENITAL NEVUS.

In the second surgical time was made the separation of the flap. In the third surgical time the treatment was performed in the eyeball

TOTAL FRONTAL FLAP IN THE RECONSTRUCTION OF HEMIFACIAL AREAS. PROBLEM CASE: GIANT CRANEOFACIAL MELANOCYTIC CONGENITAL NEVUS. In the post operation, hair observed in the right eyebrow is part of the scalp, and the hair is attached using the flap for the reconstruction of the eyebrow.

3 year later

TOTAL FRONTAL FLAP IN THE RECONSTRUCTION OF HEMIFACIAL AREAS. PROBLEM CASE: GIANT CRANEOFACIAL MELANOCYTIC CONGENITAL NEVUS.

Discussion
Esthetic considerations, and the risk of transformation into melanoma, are enough to indicate surgery. Nevus size and its extention in different regions involving different types of tissue, are key factors that influence the planning of the surgical technique more appropriate for treatment. Reconstruction of half of the face requires multiple interventions, and options range from free skin grafts, free flaps, rotation flaps, advancement and transposition. The front flap pedicle was mainly based on the superficial temporal artery and secondarily in the posterior auricular and occipital It is important to note that the characteristics of color, texture and suppleness of the frontal skin with the eyelids and cheek, is one of the main reasons why this flap alternative was chosen.
Barkovich A. J.,FriedenI. J., Williams M.l. MR of neurocutaneous melanosis. AJNR 1994; 15:859-867. 2 Mateos Gonzalez M. E., Nieto del Rincn N., Torres Valdivieso M. J., y col. Melanosis Neurocutnea: Anales de Pediatra. 2000;52:573-576. 3 Allcutt D., Michowiz S., Weitzmman S., Becker L., Hoffman HJ et al. Primary leptomeningeal melanoma: an unusually aggresive tumor in childhood. J Neurosurg. 1993;32:721-729. 4 Humes Ra, Roskamp J, Eisenbrey AB. Melanosis and hydrocephalus: report of four cases. J Neurosurg. 1984; 61:365-68.

TOTAL FRONTAL FLAP IN THE RECONSTRUCTION OF HEMIFACIAL AREAS. PROBLEM CASE: GIANT CRANEOFACIAL MELANOCYTIC CONGENITAL NEVUS.

Conclusions
The excellent aesthetic and functional results obtained with the use of this flap in this case demonstrate that their use in extensive facial reconstruction is an indication that should be taken into account. To date, in the review of the worlds bibliography there wasnt found a description of this flap for complete reconstruction of half of the face. Aftermath all the scars and the skin graft on the right side will be able to be retouched or modified in the future
5 Walton, R. G. et al. Pigmented lesions in newborn infants. Br. J. Dermatol. 1976;95:389. 6 Clemensen, O. J. et al. The histologic of congenital features in early acquired melanocitic nevi. J. Am. Acad. Dermatol. 1988; 19:742. 7 Converse JM, Guy CL, Molenaar A. The treatment of giant hairy pigmented naevi of the face. Br J Plast Surg. 1969;4:302-8. 8 Guerrissi J. O., Jeandet F. Scalping Forehead for Extranasal Reconstructions: Total reconstruction of the lower lid: The journal of Craneofacial Surgery. 2002; 13: 706-708.

TOTAL FRONTAL FLAP IN THE RECONSTRUCTION OF HEMIFACIAL AREAS. PROBLEM CASE: GIANT CRANEOFACIAL MELANOCYTIC CONGENITAL NEVUS.

Dr. Jorge O. Gerrissi Plastic Surgeon joguerrissi@gmail.com 54.9.11.4414.2656

Dr. Alonso M. Cuello Barros Plastic Surgeon alonsocuello12@hotmail.com 54.9.11.56565510 Dr. Nicolas M. Leal Plastic Surgery Resident leal_plastica@hotmail.com 54.9.11.5562.3307