Functional and Aesthetic Outcomes of Fricke lap in Periorbital Reconstruction – A Retrospective Study

The reconstruction of the periorbital tissue defects is often challenging due to its complex anatomy. A wide variety of reconstruction options were implemented based upon aesthetic unit, type of defect and skill of surgeon. Fricke lap is a laterally basedmonopedicled lap used to reconstruct eyelid and periorbital defects. The study evaluates the aesthetic and functional outcome of Fricke lap in patients who underwent periorbital reconstruction at Saveetha Medical College & Hospital. The post-operative record of 20 patients with lateral periorbital defect treatedwith Fricke lapwere analyzed to grade the outcome. 70% of the patients had history of immediate trauma. The primary management after debridement with Fricke lap yields better esthetic (70%) and functional outcome (90%). Case illustration of two patients have been provided who underwent immediate periorbital reconstruction post soft tissue injury due to RTA. The study was conclusive of Fricke lap as a valuable and simple model in periorbital reconstruction.


INTRODUCTION
The periorbital region, a junction of the upper and mid-face, constitutes less than 1% of the total body's surface with complex anatomy. Trauma, congenital and acquired malformations, burns and tumours create soft tissue defects which often require anatomical, functional and aesthetic reconstruction of this facial subunit. Regardless of the aetiology, reconstruction begins with an evaluation of the defect depending on the type, location, depth of the defect and the layers involved along with ophthalmic examination (Newman and Spinelli, 2007).
The periorbital zones, as described by Spinelli and Jelks, are divided into ive, upper eyelid zone, lower eyelid zone, medial canthus zone, lateral canthus zone and surrounding tissue and formed reconstruction algorithm (Spinelli and Jelks, 1993). A spectrum of reconstruction methods has been advocated by Mustarde and Hughes, such as transposition lap, Tripier lap, Fricke lap, cutaneous rim graft, the hard palate graft myocutaneous advancement lap, the cheek lap supported by fascia lata, the island tarsoconjuctival mucochondrocutaneous lap, etc. (Hughes, 1976;Herman and Bennett, 2005).
This study aims to evaluate the aesthetic and functional outcome of Fricke lap in periorbital reconstruction, thereby presenting our clinical experience and treatment outcome.

MATERIALS AND METHODS
Patients who underwent periorbital reconstruction using Fricke lap from January 2018 to January 2020 at the Department of Plastic and Reconstructive Surgery, Saveetha Medical College, were reviewed retrospectively. Twenty patients who met the inclusion criteria were identi ied. Inclusion criteria include patients between 20 to 70 years of age of any gender, with lateral periorbital defect treated exclusively with Fricke lap. Patients with concomitant facial fractures, or who underwent facio-maxillary or aesthetic surgeries were excluded. The postoperative records and photographs of the patients for a follow-up period of 3 months were analyzed to grade the functional and aesthetic outcomes of the surgery. The demographic details, aetiology, site and size of the defect along with aesthetic subunit involved, were documented. Any functional disturbances or complications reported during this follow up period were also documented.
The functional outcomes were graded as 1) Excellent, with no ocular discomfort, 2) Good, with minimal functional disturbance and not requiring therapy, 3) Fair, conclusive of functional disturbance requiring nonsurgical treatment, and 4) Poor, requiring surgical intervention. The aesthetic outcomes were graded postoperatively by an independent observer by viewing the photographs of the patients. Eyebrow asymmetry and appearance of the reconstructed eyelid were the criteria being analyzed for an aesthetic outcome, which was graded as Excellent, Good, Fair and Poor. Ethical clearance for the study was obtained from the Institution Review Board. Written consent was obtained from the patients to use their data for the research and to use their photograph if necessary.

RESULTS
We identi ied 20 patients who underwent periorbital reconstruction with Fricke lap. The population under consideration consisted of 14 males and 6 females with a male to female ratio of 7:3. The age ranges from 20 to 67, with a mean of 38.7±15.21. The characteristics of the study and the distribution of the functional and aesthetic outcome of the study population are provided in Table 1 and Table 2.

Case illustration
Case 1 21year old gentleman presented to the Department of Plastic and Reconstructive Surgery for the management of soft tissue injury in the left lateral canthal region and infraorbital region following Road Traf ic Accident (RTA). On evaluation, approximately 2 x 2 cm tissue defect extending laterally to left lateral canthal region without involving the lateral canthal tendon extending to the infraorbital area and not affecting the tarsal plate was noticed. Thorough debridement was done, and wound edges were revised. Periorbital region was reconstructed with Fricke lap.
Temporally based monopedicled lap was designed with dimensions according to the size of the defect, and the inferior border of the lap was positioned along the superior aspect of the eyebrow. Supraorbital foramen was marked so that the distal aspect of lap lies lateral to the foramen. Length of the lap corresponds to the medial border of the defect to the pivot point of the lap. The planned lap area was marked and anaesthetized with 2% lignocaine with 1:200000 adrenaline. A skin incision was made with 15 number Bard-Parker blade. The skin and subcutaneous tissue were dissected from the muscle bed of frontalis and orbicularis oculi with the utmost care given to avoid injury to the temporal branch of the facial nerve. Meticulous hemostasis was achieved. The lap was thinned, rotated and inset into the defect with 4-0 vicryl and 5-0 ethilon. The donor site was undermined, and closure was done with 4-0 vicryl and 5-0 ethilon in an interrupted fashion. A pressure dressing was provided. The patient was instructed to perform brow massage in a downward direction for at least four times daily for 5 minutes.     20 year old, the lady presented to the Department of Plastic and Reconstructive Surgery, was diagnosed with post-traumatic ectropion right lower lateral lid. Scar revision is done, and the defect of 2.5x1.5 cm was created. Fricke lap was planned in reverse from right supraorbital region lap harvested and inset done with 5-0 ethilon secondary defect closed primarily with 3-0 vicryl and 5-0 ethilon (Figure 4, Figure 5 & Figure 6). During the follow-up, the brow lift was noted on the right side ( Figure 6).

DISCUSSION
The lateral temporal inferiorly based forehead lap or Fricke lap was introduced in 1829 by Johann Karl Fricke. It was mainly used for defects that affect the entire length of the lower lid or upper lid, lateral canthal defect or to introduce vascularised tissue to anterior orbital defects (Fricke, 1829). The degree of rotation around the pivotal axis of the lap is less than 90 degree, contributing to less risk of compromised blood supply. The signi icant disadvantages include an elevation of the level of eyebrow and an increase in the thickness of forehead skin. The raised level of the eyebrow can be managed by downward massage of the brow postoperatively or by excising skin from the opposite side (Wilcsek et al., 2005;Subramanian, 2011).
Even though Mustarde lap and Tenzel lap were used for zone I, II and III defects, utilizing lateral periorbital skin when this skin is involved in the defect, Fricke lap or its modi ication can be better employed (Mustardé, 1991 (Wilcsek et al., 2005).
In the study, 70% of the patients had a history of immediate trauma, and primary management after debridement with Fricke lap yields better esthetic (70%) and functional outcome (90%). The majority of cases (80%), has defect size between 50-75% of lid length. 80 % was the defect involved in the lower lid (Aesthetic zone II). The brow lift was the aesthetic complication noted in the study (4/20). The preoperative plan for periorbital reconstruction should focus on the orientation of camou lageable incisions, resultant tension vectors, size shape and location of the electively created defect.

CONCLUSION
Although advocated as outmoded or last resort technique by many surgeons, the study was conclusive of a valuable and straightforward model that can be utilized in the anterior lamella reconstruction in the upper eyelid, lower eyelid and lateral canthus.