Cummings Chap 24 Reconstruction of facial defects

10/31/12

Aesthetic facial units

ForeheadCheeksEyelidsNoseLipsAuriclesScalp

Local flap classificationLocal flaps- designed immed adjacent to defect, pivotal,

advancement, hinge1. Pivotal- shorter flap length greater degree rotation

a) rotationalb) transpositionc) interpolated flap

2. Advancement flap- stretched in single vector into defect

a) unipedicledb) V-Y advancementc) Y-V advancement

3. Hinge flap

Pivotal flapsRotational-• Curvilinear• Flap adjacent to defect• usu random/occ axial

blood supply• best if inferiorly based-

allows lymphatic flow• good for mid face

defects.

Pivotal flapsTransposition• Linear• Can be adjacent or

distant to defect more options for skin donor, better scar/orientation of donor site

• usu random/occ axial blood supply

• small-med defect• L:W <1:3

Pivotal flapsInterpolated• axial blood supply• base distant to defect• pedicle must pass

over/under normal tissue

• req 2nd stage, or can de-ep and tunnel under tissue

Advancement flapUnipedicled-• Primary movement:

Tissue slides into defect

• Secondary movement: tissue around defect pushed in

• 2 burrows triangles- z plasty, “sewn out”

• Bilateral unipedicles H or T plasty

Advancement flapVY advancement• V shaped flap covers defect results in triangular defect

at donor site closed by advancing 2 edges of the triangle forming stem of the Y

• Good for contracted sites that need lengthening/release eg columella in cleft lip, ectropion of vermillion

YV advancement• Similar to above ex 1st flap is Y shaped• Good for reducing redundant tissue

Hinge flap

• pedicle based on defect border, flipped over like page in book, subcut surface covered w/ 2nd flap

• Good for defects that req ext and int coverage eg full thickness nasal defects

Facial defects recon

NoseLipCheekForehead

Nasal Defects• Nasal subunits:

• T/F Defects involving several subunits should be repaired with single flap if possible.

• If defect involved > ? of the subunit, replace the entire subunit

Nasal Defects• Nasal subunits:

• ala, • side wall • columella• dorsum• tip• Facets

• Repair defect of each aesthetic subunit separately

• If defect involved >50% of the subunit, replace the entire subunit

Nasal defects- ala• Ala part of ext nasal

valve• 1.5cm or less-

bipedicled mucosa flap for internal lining, septal/conchal cart for alar cartilage, interpolated flap from cheek/forehead for external coverage

• 2.5cm or less- septal hinge mucosal graft

Septal hinge

Nasal defects- tip/columella• Composite pivotal

septal flap• Mucoperichondrial

leaves form internal lining as bilat hinge flaps

• Cartilage graft• Paramedian forehead

flap for external coverage

Melolabial and paramedian flap

Lip defects

<1/2 – primary closure, w plasty1/2-2/3- lip switch (abbe if away from commissure, estlander + commissureplasty if

near commissure) flap width ½ defect width, kerapanzic>2/3- bernard webster bipedicled advancement flap, melolabial transposition,

temporal forehead flap, free flap

AbbeW plastyKarapanzicBernard burrowsEstlander

Cheek defectsKeep tension away from

eye/lipRhomboid- Small-med

defectsBilobed- large defects, 1st

lobe 20% smaller than defect,2nd lobe 20% smaller than 1st, inf based

Advancement flapTransposition flap-

melolabial, best sup based b/c redundant lower cheek skin used for flap

Forehead defectsGoals: preserve frontalis fxn,

presernve sensation, place scars withinhorizontal furrows

Aesthetic goals: Eyebrow symmetry, maintain hairline, hide scars (in brow/hairline, keep scars transverse except in midline)

Subunits: • Median- midline• Paramedian- midline to vertical

axis above pupil• Lateral temple- paramedian

border to temporal hairline

Forehead defects

Best results: local flap>secondary intent>skin graftAdvancement flap +/- tissue expander, AT/OTSecondary intent best if near hairline in central or lateral 1/3