Cummings Chap 24 Reconstruction of facial defects

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Cummings Chap 24 Reconstruction of facial defects

• 10/31/12

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Aesthetic facial units

• Forehead
• Cheeks
• Eyelids
• Nose
• Lips
• Auricles
• Scalp

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Local flap classification

• Local flaps- designed immed adjacent to defect,
  pivotal, advancement, hinge
• Pivotal- shorter flap length? greater degree
  rotation
• a) rotational
• b) transposition
• c) interpolated flap
• Advancement flap- stretched in single vector into
  defect
• a) unipedicled
• b) V-Y advancement
• c) Y-V advancement
• Hinge flap

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Pivotal flaps

• Rotational-
• Curvilinear
• Flap adjacent to defect
• usu random/occ axial blood supply
• best if inferiorly based- allows lymphatic flow
• good for mid face defects.

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Pivotal flaps

• Transposition
• 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
• LW lt13

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Pivotal flaps

• Interpolated
• 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

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Advancement flap

• Unipedicled-
• 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

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Advancement flap

• VY 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

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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

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Facial defects recon

• Nose
• Lip
• Cheek
• Forehead

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Nasal Defects

• Nasal subunits
• T/F Defects involving several subunits should be
  repaired with single flap if possible.
• If defect involved gt ? of the subunit, replace
  the entire subunit

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Nasal Defects

• Nasal subunits
• ala,
• side wall
• columella
• dorsum
• tip
• Facets
• Repair defect of each aesthetic subunit
  separately
• If defect involved gt50 of the subunit, replace
  the entire subunit

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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
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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

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Melolabial and paramedian flap
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Lip defects

• lt1/2 primary closure, w plasty
• 1/2-2/3- lip switch (abbe if away from
  commissure, estlander commissureplasty if near
  commissure) flap width ½ defect width, kerapanzic
• gt2/3- bernard webster bipedicled advancement
  flap, melolabial transposition, temporal forehead
  flap, free flap

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Abbe W plasty Karapanzic Bernard
burrows Estlander
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Cheek defects

• Keep tension away from eye/lip
• Rhomboid- Small-med defects
• Bilobed- large defects, 1st lobe 20 smaller than
  defect,2nd lobe 20 smaller than 1st, inf based
• Advancement flap
• Transposition flap- melolabial, best sup based
  b/c redundant lower cheek skin used for flap

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Forehead defects

• Goals 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

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Forehead defects

• Best results local flapgtsecondary intentgtskin
  graft
• Advancement flap /- tissue expander, AT/OT
• Secondary intent best if near hairline in central
  or lateral 1/3