Cummings Chap 24 Reconstruction of facial defects

1. Cummings Chap 24 Reconstruction of facial defects 10/31/12

2. Aesthetic facial units Forehead Cheeks Eyelids Nose Lips Auricles Scalp

3. 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

4. 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.

5. 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 • L:W <1:3

6. 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

7. 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

8. 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

9. 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

10. Facial defects recon Nose Lip Cheek Forehead

11. 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

12. 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

13. 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

14. 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

15. Melolabial and paramedian flap

16. Lip defects <1/2 – 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 >2/3- bernard webster bipedicled advancement flap, melolabial transposition, temporal forehead flap, free flap

17. Abbe W plasty Karapanzic Bernard burrows Estlander

18. 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

19. 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

20. Forehead defects Best results: local flap>secondary intent>skin graft Advancement flap +/- tissue expander, AT/OT Secondary intent best if near hairline in central or lateral 1/3