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Part 1 book “Facial flap surgery” has contents: Bioanatomy of tissue movement, mechanics of tissue movement, biomechanics of advancement, advancement flap subtypes, biomechanics of rotation, rotation flap sites, rhombic flap and variations, bilobed transposition flaps, geometry and flap dynamics,… and other contents.
Copyright © 2013 by The McGraw-Hill Companies, Inc All rights reserved Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher ISBN: 978-0-07-175602-0 MHID: 0-07-175602-7 The material in this eBook also appears in the print version of this title: ISBN: 978-0-07-174925-1, MHID: 0-07-174925-X All trademarks are trademarks of their respective owners Rather than put a trademark symbol after every occurrence of a trademarked name, we use names in an editorial fashion only, and to the benefit of the trademark owner, with no intention of infringement of the trademark Where such designations appear in this book, they have been printed with initial caps McGraw-Hill eBooks are available at special quantity discounts to use as premiums and sales promotions, or for use in corporate training programs To contact a representative please e-mail us at bulksales@mcgrawhill.com Notice Medicine is an ever-changing science As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required The authors and the publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication However, in view of the possibility of human error or changes in medical sciences, neither the authors nor the publisher, nor any other party who has been involved in the preparation or publication of this work, warrants that the information contained herein is in every respect accurate or complete, and they disclaim all responsibility for any errors or omissions or for the results obtained from use of the information contained in this work Readers are encouraged to confirm the information contained herein with other sources For 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noncommercial and personal use; any other use of the work is strictly prohibited Your right to use the work may be terminated if you fail to comply with these terms THE WORK IS PROVIDED “AS IS.” McGRAW-HILL AND ITS LICENSORS MAKE NO GUARANTEES OR WARRANTIES AS TO THE ACCURACY, ADEQUACY OR COMPLETENESS OF OR RESULTS TO BE OBTAINED FROM USING THE WORK, INCLUDING ANY INFORMATION THAT CAN BE ACCESSED THROUGH THE WORK VIA HYPERLINK OR OTHERWISE, AND EXPRESSLY DISCLAIM ANY WARRANTY, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE McGraw-Hill and its licensors not warrant or guarantee that the functions contained in the work will meet your requirements or that its operation will be uninterrupted or error free Neither McGraw-Hill nor its licensors shall be liable to you or anyone else for any inaccuracy, error or omission, regardless of cause, in the work or for any damages resulting therefrom McGraw-Hill has no responsibility for the content of any information accessed through the work Under no circumstances shall McGraw-Hill and/or its licensors be liable for any indirect, incidental, special, punitive, consequential or similar damages that result from the use of or inability to use the work, even if any of them has been advised of the possibility of such damages This limitation of liability shall apply to any claim or cause whatsoever whether such claim or cause arises in contract, tort or otherwise DEDICATION This book is dedicated to our friends and mentors in dermatologic surgery I thank David Leffell for providing me with an outstanding residency education in dermatologic surgery and Leonard Dzubow for teaching me his artful understanding of tissue motion The core of this text reflects his insight into the complexities of biomechanics in facial reconstruction I thank Joel and Jonathan Cook for inspiring me with their beautiful reconstructions and for sharing their expertise and criticism throughout my career Jonathan has provided several of the figures for this text I am grateful to my residents and fellows, with whom it is so much easier and more enjoyable to operate To Todd Holmes I owe special thanks He was my second fellow, and he is now my outstanding associate His contributions to this book are artful My last fellow, Christopher Yelverton spent hundreds of hours carefully editing and providing voiceovers for the DVD Videography was ably provided by my medical assistant, Leah Fox My first technician, Elizabeth Robson spent a dozen years cutting many thousands of histology sections, arranging my schedule, and assisting me in surgery as I learned my craft Lastly I am indebted to the many inspired surgeons who created the path for us to follow Every time I think that I have done something new, I find that someone else has been there before Our goal in writing this text was to analyze the accomplishments of the many who came before us, and to distill their successes and failures into a guide for aesthetic and functional reconstruction CONTENTS Foreword Preface Chapter 1: Introduction Bioanatomy of tissue movement Mechanics of tissue movement Chapter 2: Advancement Introduction Biomechanics of advancement Advancement flap subtypes Chapter 3: Rotation Flaps Introduction Biomechanics of rotation Rotation flap sites Chapter 4: Transposition Flaps Rhombic flap and variations Banner flaps Bilobed transposition flaps Chapter 5: Island Pedicle Flaps Introduction Geometry and flap dynamics Island flap variations Regional application of the island pedicle flap Chapter 6: Staged Pedicle Flaps Introduction and flap dynamics Regional application The paramedian forehead flap Cheek to nose pedicle flaps Mastoid pedicle flaps to the ear Cross-lip pedicle flaps Chapter 7: Nose Bioanatomy and biomechanics Repair of the nasal bridge Repair of the nasal sidewall Repair of the nasal tip including the bilobed transposition flap Repair of the nasal ala including the single-stage nasolabial transposition flap Reconstruction of full-thickness nasal wounds Chapter 8: Ear Anatomy and biomechanics Repair of the helical rim Repair of the anterior surface of the ear Repair of the tragus, antitragus, and lobule Repair of the posterior surface of the ear Chapter 9: Lip Bioanatomy and biomechanics Repair of the upper lip subunits Repair of the lower lip Chapter 10: Eyelid and Periocular Bioanatomy and biomechanics Lid wedge and linear repairs Transposition flaps Rotation and advancement flaps Repair of medial canthal wounds Chapter 11: Cheek Bioanatomy and biomechanics Advancement and rotation flaps Transposition flaps Island pedicle flaps Chapter 12: Forehead Bioanatomy and biomechanics Linear repairs Repair of the medial forehead Repair of the lateral forehead Eyebrow reconstruction Chapter 13: Temple Bioanatomy and biomechanics Linear repairs Advancement and rotation Transposition Chapter 14: Scalp Bioanatomy and biomechanics Linear repairs Rotation flaps Transposition flaps Island flaps Chapter 15: Chin Bioanatomy and biomechanics Linear repairs Advancement and rotation flaps Transposition and island flaps Repair of the jawline Chapter 16: Complications and Revisions Hematoma Flap failure Hypertrophic scarring Depressed scars and their revision Revision of the nasolabial flap Z-plasty Index FOREWORD A teacher affects eternity; he can never tell where his influence stops —Henry Brooks Adams The honor of writing a foreword is usually bestowed upon wise, skilled, and qualified experts and teachers As a perennial student of the authors of this superb work, I feel not only privileged and overjoyed but also humbled by the prospect of writing an introduction for an essential text for surgeons Perhaps the youth of today’s dermatologic surgery will take for granted yet another treatise on surgical reconstruction of the face Yet it was not so long ago that a handful of dermatologic surgeons were pioneering their way into unchartered and at times what may have felt like unwelcome territory for their beloved specialty We often forget that the surgical flaps we readily perform in our offices are the distilled product of years of surgical reconstructive evolution brought about by our multiple and diverse predecessors’ creativity, curiosity, necessity, refinement, and courage sprinkled in with some serendipity As readers of this text, we have the incredible good fortune to learn from two masters, an ingenious and magnificently understated teacher and his daring and creative student who pushes the reconstructive envelope further and is now teaching others This comprehensive text reviews the fundamental principles of surgical reconstruction and then describes the ideal use of those principles in each anatomic region of the face Solely the work of its authors (and unlike edited texts), this book reads more uniformly and hence its ability to guide the reader from simple to more complex reconstruction never falters That same uniform quality is manifested in the invaluable clinical photographs that capture the full story of the reconstruction with abundant intraoperative photographs The text is replete with the complex and challenging defects surgeons face in their daily reality and it explains, using both clarity and honesty, how to progress from “preoperative” to “postoperative” with unpretentious warnings of pitfalls for the beginner And the authors not shy away from critically evaluating the limitations of beautiful yet theoretical geometric principles and their use in the very tangible and practicality of a patient’s face Finally, to top it all off, a collection of narrated videos revealing step-by-step instruction provides the reader with essentially the magician’s secrets and perhaps the 10 forms a suitable lining for even sizeable nasal wounds The graft is sewn into place first as a fairly tight “drum” of tissue, and once the appropriate flap is placed, a number of through-and-through sutures can be utilized to meld the graft to the deep vascular bed of the flap A temporary nasal airway can be utilized in the same manner as a bolster in order to anneal the graft to the overlying flap Such grafts have a very high take rate, and they are much easier on the patient and surgeon than a septal flap While the nose is no longer lined in part by mucosa, the ease of this repair, and the lack of morbidity, often favors a carefully thinned graft over a septal flap 359 Figure 7.34 A full-thickness skin graft is used for distal alar lining The wound was then repaired with a cartilage graft and a nasolabial pedicle flap Hinge Flaps Lining of the distal nare can be created using skin of the upper nasal sidewall (Fig 7.35) This is most reasonable in older patients with relatively nonsebaceous type skin of the upper nose In order to create a hinge flap, the skin of the upper nose is incised to muscle and an island flap based on the nasalis muscle is created The flap is then folded down and turned over like a hinge to close the lining defect Distal alar wounds may, in select cases, be appropriately reconstructed in one stage with a turnover hinge flap based on the nasal musculature (Fig 7.36).38 360 361 362 Figure 7.35 A large full-thickness wound of the nose is repaired with a turnover hinge flap (A) Wound following Mohs surgery (B) Design of hinge flap (C) The flap is turned down to create nasal lining The diminutive but richly vascularized nasalis sling pedicle is visible (D–F) The defect is resurfaced with a paramedian forehead flap 363 364 Figure 7.36 Turnover hinge flap A distal alar defect is repaired with a turnover hinge flap (A) A full-thickness operative wound of the left lateral ala (B) A turnover hinge flap has been elevated and turned over to form nasal lining The flap is perfused by richly-vascular nasalis muscle (C) The flap has been folded back onto itself to create a “sandwich” which provides enough stability to the repair to obviate the need for a cartilage graft (D) Repair at six months 365 Turnover Flaps In appropriate cases, a very long standard nasolabial flap, paramedian forehead flap, or turnover (spear) flap can successfully recreate both internal and external nasal lining Such flaps are best utilized when there is no evidence of actinic injury to the skin of the cheek or forehead such that precancerous lesions are not placed inside the nose Flaps should be of adequate length to allow for transposition into place under essentially no tension, or the kinked/folded portion of the flap will not survive It is essential in such cases to thin the flap extensively to avoid a bulky, unaesthetic reconstruction that can also lead to nasal valve dysfunction In a surprising number of cases, a stabilizing cartilage graft is not needed, as the folded cheek or forehead skin will have sufficient “turgor” to stabilize the nose In cases where alar collapse appears likely, a broad, long wafer of cartilage from the pinna of the ear is utilized as a stabilizing brace (Fig 7.37) The ability to perform a successful turnover flap balances precariously the vascularity of the flap with the need for thinning It is fortunate that most nasolabial and forehead flaps can be thinned to very shallow adipose, thus allowing for not only folding but even throughand-through sutures to meld the inner and outer portions of the flap 366 367 368 369 Figure 7.37 Turnover nasolabial flap for a through-and-through defect of the nose/ala In this case, a cartilage graft is inserted to maintain patency (A) Two operative wounds of the nose including one through-and-through defect (B) A large single staged nasobial flap with adequate length to perform a turnover flap is designed to repair the wound (C) The wound is made full-thickness, the remaining alar rim is removed, and the flap is elevated (D) A cartilage graft is harvested from the ear (E and F) As the ala is recreated the cartilage is used as a support The tip of the flap is used as lining and the flap is folded around the cartilge (G) Immediate 370 reconstruction (H) Reconstruction at one year with a good, albeit imperfect result REFERENCES Burget GC Aesthetic reconstruction of the tip of the nose Dermatol Surg 1995;21:419-429 Burget GC, Menick FJ The subunit principle in nasal reconstruction Plast Reconstr Surg 1985;76: 239-247 Rintala AE, Asko-Seljavaara S Reconstruction of midline skin defects of the nose Scand J Plast Reconstr Surg 1969;3:105-108 Field LM The glabellar transposition “banner” flap J Dermatol Surg Oncol 1988;14:376-379 Campbell LB, Ramsey ML Transposition island pedicle flaps in the reconstruction of nasal and perinasal defects J Am Acad Dermatol 2008;58: 434-436 Cook J, Zitelli JA Primary closure for midline defects of the nose: a simple approach for reconstruction J Am Acad Dermatol 2000;43:508-510 Bennett JE Reconstruction of lateral nasal defects Clin Plast Surg 1981;8:587-598 Yoo SS, Miller SJ The crescentic flap revisited Dermatol Surg 2003;29:856-858 Zavod MB, Zavod MB, Goldman GD The dorsal nasal flap Dermatol Clin 2005;23:73-85 10 Lambert RW, Dzubow LM A dorsal nasal advancement flap for off midline defects J Am Acad Dermatol 2004;50:380-383 11 Bugatti L, Filosa G ‘East-west’ advancement flap for nasal reconstruction Clin Exp Dermatol 2008;33:498-499 12 Esser JFS Gestielte locale Nasenplanstik mit Zweizipfligem lappen Deckung des Sekundaren Detektes vom ersten Zipfel durch den Zweiten Dtsch Z Chirurgie 1918;143:385-390 13 Zitelli JA The bilobed flap for nasal reconstruction Arch Dermatol 1989;125:957-959 14 Cook JL A review of the bilobed flap’s design with particular 371 emphasis on the minimization of alar displacement Dermatol Surg 2000;26:354-362 15 Collins SC, Dufresne RG, Jellinek NJ The bilobed transposition flap for single-staged repair of large surgical defects involving the nasal ala Dermatol Surg 2008;34:1379-1386 16 Albertini JG, Hanson JP Trilobed flap reconstruction for distal nasal skin defects Dermatol Surg 2010;36:1726-1735 17 Rieger RA A local flap for repair of the nasal tip Plast Reconstr Surg 1967;40:147-149 18 Marchac D Lambeau de rotation frontonasal Ann Chir Plast Esthet 1970;15:44-49 19 Marchac D, Toth B The axial frontonasal flap revisited Plast Reconstr Surg 1985;76:686-694 20 Rigg BM The dorsal nasal flap Plast Reconstr Surg 1973;52:361-364 21 Green RK, Angeles J A full skin rotation flap for closure of soft tissue defects in the lower one-third of the nose Plast Reconstr Surg 1996;98:163-166 22 Willey A, Papadopoulos DJ, Swanson NA, et al Modified single-sling myocutaneous island pedicle flap: series of 61 reconstructions Dermatol Surg 2008;34:1527-1535 23 Salmon P, Stanway A Nasalis flap and graft repair provides reliable closure for denuded defects of the nose Dermatol Surg 2005;31:692696 24 Winton GB, Salasche SJ Use of rotation flaps to repair small surgical wounds on the ala nasi J Dermatol Surg Oncol 1986;12:154-158 25 Humphreys TR, Goldberg LH, Wiemer DR Repair of defects of the nasal ala Dermatol Surg 1997;23:335-349 26 Neltner SA, Papa CA, Ramsey ML, et al Alar rotation flap for small defects of the ala Dermatol Surg 2000;26:543-546 27 Walkinshaw MD, Caffee HH The nasolabial flap: a problem and its correction Plast Reconstr Surg 1982;69:30-34 28 Field LM The nasolabial flap—a definitive reappraisal J Dermatol Surg Oncol 1990;16:429-436 29 Zitelli JA The nasolabial flap as a single-stage procedure Arch Dermatol 1990;126:1445-1448 372 30 Spear SL, Kroll SS, Romm S A new twist to the nasolabial flap for reconstruction of lateral alar defects Plast Reconstr Surg 1987;79:915920 31 Goldman GD One-stage reconstruction following complete alar loss Dermatol Surg 2006;32:418-422 32 Cook JL Reconstruction of a full-thickness alar wound with a single operative procedure Dermatol Surg 2003;29:956-962 33 Zitelli JA, Fazio MJ Reconstruction of the nose with local flaps J Dermatol Surg Oncol 1991;17:184-189 34 Krathen RA, Meunnich E, Donnelly HB Island pedicle flap for alar defects Dermatol Surg 2010;36: 386-391 35 Cvancara JL, Wentzell JM Shark island pedicle flap for repair of combined nasal ala-perialar defects Dermatol Surg 2006;32:726-729 36 Burget GC, Walton RL Optimal use of microvascular free flaps, cartilage grafts, and a paramedian forehead flap for aesthetic reconstruction of the nose and adjacent facial units Plast Reconstr Surg 2007;120:1171-1207 37 Menick FJ Nasal reconstruction Plast Reconstr Surg 2009;125:138e150e 38 Lee KK, Gorman AK, Swanson NA Hinged turnover flap: a one-stage reconstruction of a full-thickness nasal ala defect Dermatol Surg 2004;30:479-481 373 ... flap sites Chapter 4: Transposition Flaps Rhombic flap and variations Banner flaps Bilobed transposition flaps Chapter 5: Island Pedicle Flaps Introduction Geometry and flap dynamics Island flap. .. fibrous fascia interlinking and enveloping the facial musculature integrates and coordinates complex facial movements (Fig 1. 3) 16 17 Figure 1. 1 The superficial fascia has two layers separated... island pedicle flap Chapter 6: Staged Pedicle Flaps Introduction and flap dynamics Regional application The paramedian forehead flap Cheek to nose pedicle flaps Mastoid pedicle flaps to the ear