Case Report: Post-Excision Reductive AVM of the Frontal Region - Superior Eyelid Sinistra

with Defect Closure Reconstruction Using Radial Forearm Fasciocutaneous Free Flap
Kiagus Handrian Parikesit*, I Gusti Putu Hendra Sanjaya**, Agus Roy Rusly Hariantana Hamid**

*Resident of Plastic Reconstructive and Aesthetic Surgery Udayana University/Prof dr. I.G.N.G Ngoerah General Hospital, Denpasar, Bali, Indonesia

**Staff of Plastic Reconstructive and Aesthetic Surgery Division of Udayana University/ Prof dr. I.G.N.G Ngoerah General Hospital, Denpasar, Bali, Indonesia

ABSTRACT RESULT
Background: Arteriovenous malformation (AVM) is a congenital disorder characterized by
abnormal connections between arteries and veins. AVM excision is often required to prevent After undergoing Post Excision and Reduction of AVM in the Frontal
complications and alleviate symptoms. However, excising AVMs in the frontal and superior Region and Superior Eyelid with Reconstruction of Defect using Radial Forearm
eyelid regions can result in significant and complex defects that require reconstruction to restore Fasciocutaneous Free Flap, the patient has shown excellent results. The excision of
function and aesthetics. AVM in the frontal region and superior eyelid was successfully performed, removing
Objective: This case report aims to describe the technique and outcomes of AVM excision in the the troublesome mass and eliminating the potential for complications. The radial
frontal and superior eyelid regions with defect closure using a radial forearm fasciocutaneous free forearm flap harvested from the patient's arm was used effectively for the
flap. reconstruction of the defect, allowing for the restoration of function and aesthetics in
Case Report: A 13-year-old male patient with a diagnosis of AVM in the frontal and superior the affected area. After the surgery, the flap was successfully inset in the area
eyelid regions underwent AVM excision using the radial forearm fasciocutaneous free flap requiring defect closure
technique. The surgical procedure involved incisions, AVM excision, flap harvesting from the
forearm using the radial forearm technique, and defect closure by insetting the flap in the affected
area. Additionally, a split-thickness skin graft (STSG) was taken from the thigh region to
reconstruct a secondary defect on the volar aspect of the forearm.
Results: The surgery was successfully performed without significant complications. The radial
forearm fasciocutaneous free flap was well positioned to cover the frontal and superior eyelid
defects, and the skin graft was successfully applied to the secondary defect on the volar aspect of
the forearm. The patient experienced a good recovery and had no significant complaints during
the follow-up period.
Discussion: The use of radial forearm fasciocutaneous free flap in reconstructing defects resulting Figure 2. Desain Insisi Figure 3. Durante Op
from AVM excision in the frontal and superior eyelid regions is a favorable choice because this
flap can provide sufficient large and flexible tissue to cover complex defects. Additionally,
DISCUSSION
selecting an appropriate donor site for the STSG is an important step in achieving optimal
Post-excision reduction of AVM in the frontal region and superior eyelid is a complex
outcomes.
yet effective procedure for addressing AVM in those areas. The reconstruction
Conclusion: AVM excision in the frontal and superior eyelid regions with defect closure using a
technique using radial forearm fasciocutaneous free flap offers advantages in
radial forearm fasciocutaneous free flap and skin graft is an effective option for restoring function
covering the defect following AVM excision. This flap has a good blood supply and
and aesthetics in the affected area. Therefore, selecting the appropriate reconstruction technique
a structure that closely resembles facial tissue, providing satisfactory aesthetic
and ensuring careful postoperative monitoring are crucial for achieving optimal outcomes in such
outcomes and restoring the function of the affected area.
cases. In this case, the surgery was successfully performed, and the patient experienced a good
recovery. Long-term follow-up and monitoring are necessary to ensure the long-term success of Research shows the success of the radial forearm fasciocutaneous free flap technique
the reconstruction. This intervention can provide significant benefits to the patient in terms of in reconstructing defects in the orbital region and cases of AVM in the frontal region
function and aesthetic appearance. and superior eyelid. Patients experience improved appearance and facial symmetry
after the surgery. The flap inset onto the defect demonstrates good perfusion with no
Keywords: Post-excision, Reduction, AVM, Frontal Region, Superior Eyelid Region, significant vascular complications. The wound healing process progresses smoothly
Reconstruction, Defect Closure, Radial Forearm Fasciocutaneous Free Flap, Arteriovenous without infection or dehiscence.
malformation.
However, the use of radial forearm fasciocutaneous free flap technique also carries
INTRODUCTION risks of complications such as wound infection, hematoma, dehiscence, flap tissue
necrosis, blood clotting, and sensory disturbances in the donor area. Careful post-
Arteriovenous malformation (AVM) is a congenital abnormality characterized by an operative monitoring and preventive measures such as operating field sterilization and
abnormal connection between arteries and veins. AVM occurs when blood vessels do not form prophylactic antibiotic administration can reduce these risks.
properly, resulting in direct blood flow from arteries to veins without passing through capillary
tissue. This can cause high pressure in the veins and enlargement of the involved arteries. AVM In this study, it is necessary to involve a control group and conduct long-term research
in the frontal region and superior eyelid can lead to significant aesthetic and functional issues, to compare the outcomes of the radial forearm fasciocutaneous free flap technique
including vascular enlargement, deformities, and neurological symptoms. Excision o[f the AVM with other reconstruction techniques and assess long-term results. Monitoring the
is necessary to eliminate the malformation. However, AVM excision in the frontal region and flap's perfusion and undertaking corrective measures when necessary are crucial to
superior eyelid can result in extensive and complex defects in the surrounding skin and tissues. maintaining the success of the reconstruction. Subjective evaluation from patients
Therefore, defect closure reconstruction becomes crucial to restore function and aesthetics to the regarding satisfaction and quality of life can also provide valuable insights into the
operated area. development of this technique.
CASE REPORT Overall, the use of radial forearm fasciocutaneous free flap in reconstructing the
defect following excision of AVM in the frontal region and superior eyelid provides
A 13-year-old boy with a diagnosis of AVM in the frontal region and superior eyelid
satisfactory outcomes. However, post-operative care and careful monitoring remain
was referred to the Department of Plastic and Reconstructive Surgery, Division of Plastic
important to reduce the risk of complications.
Reconstructive and Aesthetic Surgery, Faculty of Medicine, Udayana University/Sanglah General
Hospital, Denpasar, Bali, Indonesia, on February 17, 2023. The patient complained of a mass
measuring 8 cm x 6 cm x 1 cm, which appeared purplish-red in color. The mass had well-defined
CONCLUSION
borders, a resilient consistency, and was slightly compressible with a slow response. There were
Excision of AVM in the frontal region and superior eyelid with reconstruction of the
no signs of active bleeding in the mass. Additionally, no bruit or palpable pulsation was observed
defect using a radial forearm fasciocutaneous free flap and skin graft is an effective
in the mass. These symptoms are characteristic of arteriovenous malformation (AVM) in the
choice for restoring function and aesthetics in the affected area.
frontal region and superior eyelid. The surgical procedure involved incision, AVM excision,
harvesting a flap from the arm using the radial forearm technique, and defect closure
reconstruction by placing the flap in the affected area. Furthermore, a split-thickness skin graft
(STSG) was obtained from the femoral region for secondary defect reconstruction on the volar
antebrachial side.

Figure 4. Post Operasi

REFERENCE

Staebler MH, Anzalone CL, Price DL. The Anomalous Radial Artery: A Rare Vascular Variant and Its
Figure 1. Pre Operasi. Implications in Radial Forearm Free Tissue Transfer. Craniomaxillofac Trauma Reconstr. 2020
Sep;13(3):215-218. doi: 10.1177/1943387520904206. Epub 2020 Apr 7. PMID: 33456690; PMCID:
PMC7797967
Lin CS, Lin YS, Lin BS, Lien CF, Liu CF. Radial forearm and forehead flap reconstruction following
resection of a nasal arteriovenous malformation: A case report. Oncol Lett. 2016 Oct;12(4):2868-2871. doi:
10.3892/ol.2016.5022. Epub 2016 Aug 16. PMID: 27698872; PMCID: PMC5038517