Regional and Free Flaps
Lahey Clinic Medical Center, Burlington, Massachusetts, U.S.A. To enhance the survival of extended skin flaps, Owens 1 incorporated underlying muscle and the musculocutaneous vessels. This report led to several applications of musculocutaneous flaps including one of the most useful flaps in head and neck reconstruction the pectoralis musculocutaneous flap 2 . The skin component of a musculocutaneous flap is supplied via musculocutaneous arterial perforators from a source artery. These...
Fan Flap
The fan flap, originally described by Gillies in 1954, derived its name from its resemblance to the rotational opening of a handheld fan. The flap is full-thickness including mucosa and is based on the opposing lip's labial artery. In designing the flap, the opposing lip's white line is marked at a point away from the lateral aspect of the defect along the vermilion equal in length to the width of the defect. This mark represents the area on the opposing lip that will become the new commissure...
Periosteal Strips
Strips of deep temporalis fascia and periosteum pedicled near the orbital rim are useful for replacement of the lateral tarsus and conjunctiva 4,5 . The strip is oriented at a 45 degree angle from the lateral orbital rim either in a superior direction for lower lid defects or in an inferior direction for upper lid defects. The inner surface of the periosteal strip will re-epithelialize from the bordering conjunctiva. The anterior lamella is reconstructed with musculocutaneous flaps for...
Facial Balance
A common standard cited for overall facial aesthetics is the so-called golden proportion based on pythagorean mathematics, yielding the basic ratio 1 1.618 2 . Phidias applied this in ancient Greek art most notably and this ratio is called phi in his honor. This divine proportion is duplicated in nature and represents a union of geometry and mathematics. A three-point compass dubbed the golden divider maintains Table 1 Guidelines for Photography using a 105-mm Macro Lens 3' Malar view optional...
OTAT plasty
The T-plasty consists of bilateral random-pattern sliding skin advancements transforming an O-shaped defect O-T plasty or an A-shaped defect A-T plasty into a final T-shaped scar. A circular defect is converted to an A shape by excising a superior wedge of tissue creating a partial ellipse with a blunt base. The base is closed Figure 6 Sequence of a typical nasolabial V-Y advancement flap. Figure 6 Sequence of a typical nasolabial V-Y advancement flap. through bilateral tissue advancement with...
Breast Carcinoma
Approximately 6.3 of patients with breast carcinoma experience cutaneous involvement, but in only 3.5 of cases is this the initial presentation. More than 50 of metastatic lesions occur as direct extension from the tumor mass in the form of Paget's disease or as nodular-ulcerative lesions. Other common presentations are inflammatory carcinoma and carcinoma en cuirass. IHC stains may aid in the diagnosis of highly undifferentiated tumors adenocarcinomas GCDFP-15 antigen is highly specific for...
Facial Platysma Flap
The facial platysma flap is a skin-muscle flap based on the pars modiolaris portion of the platysma 41 . The pars modiolaris represents the muscle fibers that extend over the mandible to insert on the ipsilateral modiolus, and are located just lateral c to the lateral border of the depressor anguli oris muscle. Motor innervation is via the marginal branch of the facial nerve and sensory innervation is from the mental nerve trigeminal . Vascular supply is via the facial artery as it crosses the...
Palatal Arena
The palatal flap i.e., Arena flap was originally described in 1977 33 . It is a muco-periosteal flap that can encompass up to 85 of the palatal mucosal based on a sin- gle greater palatine artery Fig. 26 . The flap tissue can be rotated 180 degrees to cover defects in the posterior oral cavity. Dissection involves incising through the mucoperiosteum along the perimeter of the hard palate and ligating the opposite greater palatine neurovascular bundle. The flap is raised with a periosteal...
Skin Typing
Skin typing is helpful in predicting the response of different types of skin to chemical peeling or laser resurfacing. Grading the skin content of melanin is important to assess the risk of postinflammatory hyperpigmentation. The Fitzpatric classification 30 of skin types defines them as I white skin always burns first summer exposure , never tans II white skin, usually burns III white skin, sometimes burns IV moderate brown skin, rarely burns V dark brown, very rarely burns VI black, never...
CutlerBeard
The Cutler-Beard flap is a staged lid-sharing procedure that transfers a full-thickness flap from the lower eyelid to an upper eyelid defect 10 Fig. 7 . The technique involves creating a transcutaneous full-thickness horizontal incision below the level of the marginal vessels in the lower eyelid 4 mm below the lid margin , equal in extent to the upper eyelid defect. Full-thickness vertical inferior cuts are made that create a rectangular flap based inferiorly that is pulled superiorly under the...
Keratoacanthoma
Keratoacanthoma KA is a tumor derived from hair follicle epithelium and associated with HPV 9, 16, 19, 25, and 37. It is a rapidly growing neoplasm that resembles SCC. Whites are more commonly affected than other racial groups and the tumors present in sun-exposed areas of the extremities, head, and neck. KA affects all age groups occurring most often in the middle-aged and elderly and it has a 3 1 predominance in men. Sun exposure is the main predisposing factor, but immuno-suppression and...
Disadvantages Arr
The vascular supply to the rib via the periosteum is tenuous and its use for mandibular segmental defects is associated with a high rate of failure. Marginal necrosis of the skin paddle is relatively common, especially if the distal part of the skin paddle extends beyond the underlying muscle 18 . The subcutaneous tissue can be bulky, especially in women in whom the incisional scars may be less acceptable. The weight of the flap and the tendency for regional flaps to return to their site of...
Leiomyoma
Leiomyoma 70 is derived from the arrector pili muscle of hair follicles or from muscle fibers present in the wall of blood vessels. In the multiple familial type, lesions are distributed over neck and limbs. Onset is in childhood and tumors are red, pink, or brown. A characteristic feature is that pain can be elicited by pressure or low temperature. Also, lesions may shrink when the skin is chilled. The solitary leiomyoma occurs anywhere in the body including the nipple and areola. It is also...
Estlander Flap
Estlander 35 described a single-stage full-thickness cross-lip flap based on the labial artery for closure of lower lip defects near the commissure of the mouth. As with the Abbe flap, the width of the flap should be one-half the width of the defect, and the height should equal the height of the defect. The Estlander flap transfers the lateral portions of the opposite lip around the existing commissure to replace the missing lip tissue. Blunting of the commissure is expected and secondary...
Depressor Anguli Oris Flap
The depressor anguli oris flap is a full-thickness musculocutaneous flap that provides functional both sensory and motor lower lip and oral sphincter reconstruction 40 . Flap dimensions reflect the size of the underlying depressor muscle and are approximately 4 cm long by 2 cm wide. The vascular pedicle is the inferior labial artery off the facial artery entering the flap near the oral commissure. Sensation is derived from the mental nerve trigeminal and the motor innervation is from the...
Other Cutaneous Nevi or Hamartomas
Nevus Verrucosus 12 appears at birth as a well-defined, raised, and verrucous plaque Fig. 5 . It may be unilateral nevus unis lateralis or bilateral, extensive, and Figure 5 Nevus verrucosus of the midanterior trunk. The lesion is a congenital, verrucous, and hyperpigmented plaque with linear arrangement. Figure 5 Nevus verrucosus of the midanterior trunk. The lesion is a congenital, verrucous, and hyperpigmented plaque with linear arrangement. Figure 6 Becker's nevus of the right shoulder. The...
Specialized Local Facial Flaps for the Eyelids and Lips
Lahey Clinic Medical Center, Burlington, Massachusetts, U.S.A. The goals of eyelid reconstruction are to Restore nonkeritanized internal lining Provide form and rigidity to the eyelid margin Re-establish fixation at the medial and lateral canthi Provide corneal protection Restore the thin and supple skin over the eyelids for proper function and cosmesis Provide appropriate elevation of the upper eyelid by the action of the levator muscle Knowledge of eyelid anatomy is essential to planning...
Hard Palate Graft
The hard palate is composed of variably keratinized stratified squamous epithelium, a lamina propria made up of densely packed collagen fibers, a submosal layer with adipose and glands, periosteum, and the maxillary and palatine bones. The covering layers are used to replace posterior lamella Fig. 5 . This can be done under local or intravenous sedation. A bite block is used to keep the mouth wide open. The soft palate, midline of the hard palate, and arteries should be avoided the greater and...
Sweat Gland Differentiation
Microcystic adnexal carcinoma MAC shows dual differentiation into sebaceous gland and sweat gland structures. There are no known causative factors, although in some cases there is history of ionizing radiation exposure. The incidence in men and women is approximately equal and the median age at presentation is 65 years range, 11-82 . MAC presents clinically as a nodule, plaque, or cyst that grows slowly over years 173 . The lesion is markedly indurated and has surface telangiec-tasias. It...
Mustarde Cheek Rotation Flap for Lower Eyelid Repair
A Mustarde cheek flap is a large rotation flap with its leading edge at the lateral canthus extending laterally and arching like a Tenzel flap 12 . The incision is then continued laterally to the preauricular crease toward the level of the earlobe. A wide subcutaneous undermining proceeds, the extent of which is determined by the laxity of the skin and the extent of the defect. The posterior lamella must be reconstituted and Mustarde recommends a composite graft of nasal septal cartilage and...
Melolabial Nasolabial
The melolabial nasolabial flap is a random-pattern local flap based either superiorly or inferiorly along the melolabial sulcus and cheek-nasal sidewall. The type of tissue movement is lifting either by transposition into the defect or by interpolation. If the intervening skin between the melolabial sulcus and the defect remains intact, then a staged interpolation flap may be necessary. The flap is harvested preserving the subdermal plexus distally and is based on a skin-subcutaneous pedicle...
Leech Therapy
Leeches are hermaphroditic ectoparasites of the class Hirudinea. There are several species of leech, but the most commonly used medicinal leech is Hirudo medicinalis. Leech therapy is indicated for relief of venous congestion in a failing flap. Improved tissue blood flow in leech-treated venous compromised flaps has been demonstrated 39 . Leech therapy has also been used to treat a variety of other conditions including soft tissue swelling, periorbital hematoma, cauliflower ears, ecchymoses,...
Bilobe
Originally described by Esser in 1918 for reconstruction of nasal tip defects 14 , it consists of two lifting-type random-pattern transposition flaps that pivot into position. The first flap fills the defect and the second flap fills the donor site Fig. 9 . The release of tension by raising the second flap is analogous to that associated with a Z-plasty. The angles between the defect and each lobe of the flap should be narrow enough to limit the transposition arc to 90 degrees to avoid standing...
Cheek Advancement
This is a laterally based random-pattern sliding skin-subcutaneous flap several variations are described 31 . Wide subcutaneous undermining is necessary, creating a Figure 23 Nasolabial island flap for total columellar reconstruction intraoperative sequence. Figure 23 Nasolabial island flap for total columellar reconstruction intraoperative sequence. cervicofacial flap that can be advanced into the defect. Incisions should be placed along topographical borders such as the melolabial and...
Polymers
Commonly referred to as plastic material, polymers have arguably made the most significant impact on the science of implantation. Polymerization refers to the process by which carbon links are chained together in a repeating monomeric unit. The physical attributes of polymeric material are dictated by the degree of polymerization, cross-linking, the size of the repeating unit, and the position of the repeating unit in the chain 70 . Polymers are classified into several groups based on their...
Blepharoplasty
Preoperative analysis for blepharoplasty should begin with an evaluation of ocular function including visual acuity, intraocular pressure, tear production, preseptal and intraocular slitlamp examination, funduscopy, and extraocular movement 16 . Brow position should be assessed next to determine the contribution of brow ptosis to upper eyelid skin redundancy. Measurements and evaluation of symmetry of the vertical eyelid fissures are performed to detect congenital or acquired blepharoptosis or...
Flap Classification and Local Facial Flaps
Lahey Clinic Medical Center, Burlington, Massachusetts, U.S.A. Flap classification is based on an evolving paradigm as new uses and new flaps are discovered. The earliest report of a facial flap the midline forehead flap is found in the Sushruta Samhita, a Hindu holy book, in 600 bce 1 . Flap development was largely ignored or relegated to the unholy in the period between the emergence of Buddhism in India to the 16th century 2 . In the 1500s, Tagliacozzi perfected the arm-pedicled technique of...
Rhombic
The nomenclature surrounding this flap is inconsistent. Flaps called rhombic rhomboid rhombus all share a common origin with Limberg's original flap described in 1963 16 . These designations do not reflect the shape of the flap but more literally the shape of the defect. A rhombic defect has the shape of a rhombus an equilateral parallelogram . Limberg's flap is rhombic i.e., a rhombic flap with opposing angles of 60 and 120 degrees that is random-pattern and lifting. A rhombic flap is similar...
Distraction Osteogenesis
Distraction osteogenesis is a process that results in the creation of new bone in an enlarging gap between two bone fragments caused by their gradual separation 59 . Originally described by Codivilla 1904 for lengthening lower extremity bones, the process gained wider acceptance after Gavril Ilizarov, a Russian surgeon, studied the mechanics and physiology of limb lengthening in 1954. Dr. Ilizarov continued his work and has contributed much of the current clinical knowledge of the method and...
References 1
1. Goslen JB. Wound healing for dematologic surgeons. J Dermatol Surg Oncol 1988 14 4 959-972. 2. Kanzler MH, Gorsulowsky DE, Swanson NA. Basic mechanisms in the healing cutaneous wound. J Dermatol Surg Oncol 1986 12 1156-1164. 3. Kirsner RS, Eaglstein WH. The wound healing process. Dermatol Clin 1993 11 4 629-640. 4. Pollack SV. Wound healing, a review, the biology of wound healing. J Dermatol Surg Oncol 1979 5 389-393. 5. Schaffer CJ, Narrey LB. Cell biology of wound healing. Int Rev Cytol...
Skin Surface Analysis
Skin surface analysis is often tailored to the goals of restorative surgery or nonsur-gical treatments. Patients undergoing scar revisions require analyses to include the resting skin tension lines. In the patient undergoing nasal reconstructive surgery after Mohs' resection, an analysis of the topographical units of the face is important. If cutaneous resurfacing is planned, an analysis of skin type and reaction to solar damage are also needed. Koebner's phenomenon is also an important...
The Proliferative Phase
The proliferative phase entails neoangiogenesis, autolytic debridement of dead tissue, wound matrix formation, and re-epithelialization of the wound by migrating Figure 3 The macrophage is a key actor in the initial phases of wound repair. The myriad functions of the macrophage within the wound are shown. From Ref. 7. Figure 3 The macrophage is a key actor in the initial phases of wound repair. The myriad functions of the macrophage within the wound are shown. From Ref. 7. keratinocytes. The...
PROCEDURESPECIFIC ANALYSES Rhinoplasty
The aesthetic proportion-based measurements include the following Figs. 2-4 From the basal view, columellar length twice the length of the lobule. A transverse line across mid-nostril on basal view should be equidistant from the nasal tip and alar crease. From the lateral view, 2-4 mm of columellar show the amount of columella visualized on lateral view A nasolabial angle of approximately 90 in men and 110 in the women. The presence of a supratip depression in women an area cephalic to the...
Regional Blocks
Regional anesthesia is defined here as direct injection into or around the nerves supplying a specific anatomical or surgical site. Regional anesthesia in the head and neck follows many of the principles discussed in the previous sections. A full pre-operative evaluation should be completed. In a cooperative patient, regional anesthesia with or without supplemental sedation and analgesia will often provide excellent anesthesia. The procedure needs to be relatively short, because although the...
Maxillary Nerve
Blocking the maxillary nerve produces profound anesthesia in the hemimaxilla, cheek, and upper jaw. The maxillary nerve is the second division of the trigeminal nerve and exits through the foramen rotundum. It crosses the pterygopalatine fossa and subsequently becomes the infraorbital nerve. The nerve can be approached by a lateral or anterior approach. The lateral approach requires palpation of the sigmoid notch on the zygoma. With the patient's jaw relaxed, a long needle is inserted inferior...
Dermis
The dermis is divided into two layers papillary and reticular Fig. 13 . The thin papillary dermis is just below the basement membrane and contains loose collagen and fibrocytes. The reticular dermis is relatively thick and contains compact collagen and a few fibrocytes. The reticular dermis includes the origins of the epidermal appendages. Collagen is synthesized by fibrocytes, mainly in the papillary dermis. Skin collagen decreases by 1 per year as patients age 20 . Reticulin fibers are found...
Facialplasty
Preoperative analysis should address three distinct areas of the face forehead and brows, cheeks and jowls, and neck and submentum. Surgical correction of deformities in these areas often requires different techniques that may be combined in a single surgical encounter for an optimal outcome. Evaluation of the forehead begins with a description of the horizontal and vertically oriented rhytids. Horizontal rhytids are formed by the action of the frontalis muscle. The corrugator supercilii...