10_31_12_Vorasubin_Cummings_ch24.ppt

Cummings Chap 24 Reconstruction of facial defects10/31/12

Aesthetic facial unitsForeheadCheeksEyelidsNoseLipsAuriclesScalp

Local flap classificationLocal flaps- designed immed adjacent to defect, pivotal, advancement, hingePivotal- shorter flap length greater degree rotationa) rotationalb) transpositionc) interpolated flapAdvancement flap- stretched in single vector into defecta) unipedicledb) V-Y advancementc) Y-V advancementHinge flap

Pivotal flapsRotational-CurvilinearFlap adjacent to defectusu random/occ axial blood supplybest if inferiorly based- allows lymphatic flowgood for mid face defects.

Pivotal flapsInterpolatedaxial blood supplybase distant to defectpedicle must pass over/under normal tissuereq 2nd stage, or can de-ep and tunnel under tissue

Advancement flapUnipedicled-Primary movement: Tissue slides into defectSecondary movement: tissue around defect pushed in2 burrows triangles- z plasty, sewn outBilateral unipedicles H or T plasty

Advancement flapVY advancementV shaped flap covers defect results in triangular defect at donor site closed by advancing 2 edges of the triangle forming stem of the YGood for contracted sites that need lengthening/release eg columella in cleft lip, ectropion of vermillionYV advancement Similar to above ex 1st flap is Y shaped Good for reducing redundant tissue

Hinge flappedicle based on defect border, flipped over like page in book, subcut surface covered w/ 2nd flapGood for defects that req ext and int coverage eg full thickness nasal defects

Facial defects reconNoseLipCheekForehead

Nasal DefectsNasal 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 DefectsNasal subunits: ala, side wall columelladorsumtipFacets

Repair defect of each aesthetic subunit separately

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

Nasal defects- alaAla part of ext nasal valve1.5cm or less- bipedicled mucosa flap for internal lining, septal/conchal cart for alar cartilage, interpolated flap from cheek/forehead for external coverage2.5cm or less- septal hinge mucosal graft Septal hinge

Nasal defects- tip/columellaComposite pivotal septal flapMucoperichondrial leaves form internal lining as bilat hinge flapsCartilage graftParamedian forehead flap for external coverage

Melolabial and paramedian flap

Lip defects2/3- 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 basedAdvancement 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 furrowsAesthetic goals: Eyebrow symmetry, maintain hairline, hide scars (in brow/hairline, keep scars transverse except in midline)Subunits: Median- midlineParamedian- midline to vertical axis above pupilLateral temple- paramedian border to temporal hairline

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