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