Segmental Reconstruction of the Face

BACKGROUND: Aesthetic facial reconstruction requires understanding regional anatomy and tissue movement and the ability to use innovatively the tissue adjacent to the defect to create a reconstruction that preserves the function of the area and the cosmetic facial units. OBJECTIVE: Facial reconstruction after Mohs micrographic resection of nonmelanoma skin cancer confined to one cosmetic unit was compared with reconstruction of two or more units using techniques to place scars at the junction of cosmetic units with combinations of local flaps and grafts. Acute complications, function, and final appearance of the reconstruction were evaluated. METHODS: During a 10-year period, 500 cases acquired prospectively had facial surgical defects repaired. Tissue was removed to place the closure line at the junction of cosmetic units and was mobilized from within one cosmetic unit with primary closure or local advancement, rotation, or transposition flaps. When the defect bridged cosmetic units, segmental repair was performed with combinations of flaps and grafts placing scars at the junction of cosmetic units. Segmental repair often combined advancement flaps to restore contours with full-thickness skin grafts to prevent distortion in areas with minimal loss of contour. Scars were more often unfavorably placed with single flap repair within a cosmetic unit. There was more flap loss with single flap repair of a single unit than with segmental facial repair using a combination of flaps and/or grafts. CONCLUSION: Segmenting the wound into smaller units reflecting the underlying cosmetic units of the face was useful to develop a reconstruction plan to replace tissue with similar tissue and to provide consistently satisfying aesthetic results. Facial contours were restored without distorting surrounding structures.     

Large bilobed flap in the repair of face and neck defects

While the bilobed flap is an extremely useful flap and its usefulness in coverage of the small facial defects has been well described, there is no report related to its usage as an alternative to regional flaps, tissue expansion technique and free tissue transfers in the face and neck reconstruction. This report presents our experience with nine patients who had skin defects of their face and neck areas reconstructed with large bilobed flaps from adjacent areas. The results of the repair were satisfactory with respect to colour match, texture and functional properties. The purpose of this paper is simply to emphasize that this old and well-known technique for small-sized defects can also be suitable for reconstruction of large defects in the face and neck in selected cases.     

The versatility of the hatchet flap in soft tissue reconstruction and a proposed new classification

The Hatchet flap is a well-known flap used to cover round defects with primary closure of the donor sites in a V–Y fashion. This provides a stable coverage of the defect by a skin flap from the adjacent area and thus having similar color, texture, and sensation to the lost skin. Literature showed the application of the hatched flaps in facial, fingertip, pressure sores, and meningomyelocele reconstruction but not in the other anatomic areas. The aim of this study was to demonstrate the versatility and reliability of two types of hatchet flaps to reconstruct soft tissue defects at various anatomical regions of the body. Forty-six hatchet flaps were used in 40 patients to reconstruct defects located at scalp, face, neck, chest, axilla, back, sacrum, trochanter, genitalia, perineum, buttock, thigh, knee, foot, and fingertip. The causes of defects were infection, trauma, tumor excision, pressure necrosis, congenital meningomyelocele, chemical burn, and radiation. Mean follow-up period was 6.6 months. Hatchet type I flaps were advanced without undermining using the viscoelastic properties of the skin, while hatchet type II flaps were undermined before rotation advancement. All defects were successfully covered. The flaps survived completely. Partial dehiscence occurred at the donor site of three flaps but healed without problems after re-suturing. In conclusion, hatchet flaps are versatile flaps that provide a simple but efficient solution to defects of different etiologies located at different anatomical regions in the body. Minimal blood loss and short duration of surgery make them first option flaps for patients with co-morbidities.     

Subcutaneous Pedicle Limberg Flap for Facial Reconstruction

Background. A residual dog-ear arising from the traditional Limberg flap transposition sometimes influences the cosmetic outcomes, and the Limberg flap with a subcutaneous pedicle is an innovation applicable to a variety of facial defects and free from the dog-ear.
Objective. To investigate the outcome of the subcutaneous pedicle Limberg flap for the reconstruction of medium-sized facial skin defects.
Materials and Methods. From August 2002 to June 2004, the subcutaneous pedicle Limberg flap was designed to repair facial skin defects in 17 patients (19 flaps), and the size of the lesions ranged from 2.0 × 1.9 cm to 5.0 × 4.5 cm.
Results. All flaps survived with primary healing postoperatively. The patients were followed up from 1 to 22 months, and functionally and cosmetically satisfactory outcomes were achieved.
Conclusions. This subcutaneous pedicle Limberg flap provides a competitive repair alternative for the treatment of medium-sized skin defects in the face.     

Pre-fabricated lined axial flaps for reconstruction of extensive post-burn facial and forehead full-thickness composite defects

From January 1996 to February 1998, three patients who suffered extensive post-burn facial and forehead composite defects were treated successfully in our Burn Unit. The delto-pectoral flap and reverse radial forearm flap were pre-fabricated with lining of free split skin grafted onto the underside of the flap. The pre-fabricated flaps were sutured in situ for 2 approximately 3 weeks. The pre-fabricated lined axial flaps were then transferred for the reconstruction of facial and forehead composite defects. The flap had good blood supply and the wounds healed by first intention. The three cases presented all achieved satisfactory functional and aesthetic results. The results show that pre-fabricated lined axial flaps for the reconstruction of extensive facial and forehead composite defects are safe, effective and relatively easy for clinical application.     

皮下组织蒂岛状皮瓣在面部皮肤缺损修复中的应用

目的介绍皮下组织蒂岛状皮瓣在面部皮肤缺损中的应用。方法以面部皮下组织作为皮瓣的供血蒂,转移皮瓣修复面部缺损。皮瓣面积为1.0cm×1.0cm至3.0cm×4.0cm。结果本组25例患者,切口均Ⅰ期愈合,皮瓣全部成活,术后面部形态满意,术区平整,无"猫耳"畸形,切口瘢痕不明显。结论皮下组织蒂岛状皮瓣修复面部皮肤缺损可以达到良好的美学效果。     

Experiences in the clinical use of the medial genicular flap

Four cases with defects at varying sites were reconstructed with the medial genicular flap. Three cases utilized free microvascular skin flaps based on the saphenous artery and one case a pedicled flap based on the same artery. All flaps survived well with satisfactory functional and cosmetic results. Regional anatomy is briefly reviewed, dissection of the flap is described in detail, and some special technical points are mentioned.     

Subcutaneous island pedicle flap: variations and versatility for facial reconstruction

PURPOSE: Reconstruction of facial skin defects may be a clinical challenge in respect to esthetic considerations, and the V-Y advancement island pedicle flap has been a versatile and reliable method. Besides the V-Y flap, this article is to introduce the variations of subcutaneous island pedicle flaps and their versatility for facial reconstruction. METHODS: From August 1994 to August 2005, 179 cases of medium-sized facial skin defects within 1 cosmetic unit were reconstructed with the variations of island pedicle flaps, and the length and width of the defects following removal of lesion ranged from 1.2 cm x 0.8 cm to 6.2 cm x 5.4 cm. RESULTS: Ninety-nine facial defects all over the face were reconstructed with the V-Y flaps, and the traditional and modified transposition island pedicle flaps were used to reconstruct 80 cases of relatively larger width of defects in the nose, lip, and upper cheek, especially in the young patients. Through careful planning and implementation, all flaps survived with primary healing postoperatively. With a follow-up from 6 to 30 months, well-concealed, soft, flat scars, together with good matching of the recipient sites and the flaps, were recorded. Patients and surgeons judged final overall outcome as excellent or good in 94.4% and 92.2% of evaluated patients, respectively. The main complications included visible trapdoor deformation in 9 patients, bulky flap pedicle in 8 patients, and low-grade ectropion of lower eyelid in a young boy, which all were readily revised at the second stage. Temporary alteration of sensation in the flap skin was another possible complication but usually improved with time. CONCLUSIONS: Variations of subcutaneous island pedicle flaps can be designed and may be versatile and reliable methods for esthetic reconstruction of medium-sized facial defects.     

斧形皮瓣修复面颊部软组织缺损

目的 探讨斧形皮瓣修复面颊部软组织缺损的效果和意义.方法 参照面颊部自然曲线走向,在软组织缺损一侧设计斧形皮瓣,推进修复面颊部软组织缺损.结果 自2006年以来,共修复面颊部软组织缺损13例,面积最小1.8 cm×2.0 cm,最大2.5 cm×3.5 cm.术后皮瓣成活良好,均一期愈合.随访3个月～1.5年,术后瘢痕纤细隐蔽,对面颊部自然曲线的影响较小,外形满意.结论 斧形皮瓣修复面颊部软组织缺损,能够避免对面部自然曲线的破坏,达到较佳视觉效果,可以作为修复面颊部软组织缺损的较好的方法.     

斧形皮瓣在修复面颊部不同区域组织缺损中的应用

目的 探讨斧形皮瓣修复面颊部不同区域组织缺损的设计原则、效果和意义.方法 利用内外眦垂直线,把面颊部分为3个区域:PⅠ、PⅡ、PⅢ.在不同区域内,参照面颊部自然曲线走向特征,在组织缺损一侧设计不同形式的斧形皮瓣,修复组织缺损.2005年8月至2009年8月,共修复面颊部中小面积组织缺损29例.其中男性17例,女性12例;年龄19～81岁,平均(45±16)岁.组织缺损面积最小者1.5 cm×1.5 cm,最大者2.5 cm×3.5 cm.术后6个月问卷调查患者对色泽和质地匹配、瘢痕隐蔽性、术区外形和功能的满意度.结果 皮瓣全部成活良好.随访6～18个月,皮瓣色泽和质地匹配好,瘢痕隐蔽,术区无明显畸形,功能良好.术后6个月患者对各评价项目的满意度较高.组织缺损位于PⅠ区患者对瘢痕的满意度低于位于PⅢ区患者,两者差异有统计学意义(P=0.028).结论 参照面颊部不同区域自然曲线特征,设计不同形式的斧形皮瓣修复组织缺损,能够取得较佳的视觉效果和功能恢复.     

Trilobed Skin Flap on the Face: For Reconstruction of Full-Thickness or Commissural Defects

BACKGROUND: Although many local skin flaps have been described for reconstruction of defects on the face, there are still some difficulties in reconstruction of full-thickness defects of alar and ear region and commissural defects in periorbital and perioral region. OBJECTIVE: A trilobed skin flap can offer single-stage reconstruction of difficult full-thickness or commissural defects. We performed trilobed skin flaps in reconstruction of the defects on the face. The design of the flap and outcomes of the procedures are presented. METHODS: Twelve patients with skin cancer on the face were operated under general or local anesthesia. After tumor resection, defects were closed with a trilobed skin flap. Patients were followed-up for a minimum 6 months. RESULTS: There was no early or late complication in all patients. Oral competence was achieved in reconstruction of the oral commissure. A new lateral canthus with angles as in the original one was created. Alar and ear reconstructions were performed at one session using the same flap without a graft. The outcome was satisfactory. CONCLUSION: Because it is easy to obtain a trilobed skin flap, it can be used for reconstruction of canthal, oral, and commissural defects, and the new canthus, mouth, and commissures with angles as in the original ones can be created. In addition, the flap can be used for reconstruction of full-thickness defects in the alar region and the ear.     

Reverse-Flow Retroauricular Island Flap in Facial Reconstruction

BACKGROUND Reconstruction of facial skin defects requires good-quality skin cover to satisfy aesthetic expectations of patient, especially when the skin defect is on the uncovered area of the face. Limitations in the available local tissue and donor-site morbidity restrict the options.
OBJECTIVE In an effort to solve these problems, we have begun to use a subcutaneous pedicled retroauricular reverse-flow flap.
METHODS Between January 1997 and December 2005, reverse-flow subcutaneous pedicled retroauricular island flap was used to cover facial defects in 12 patients who underwent surgical excision of skin tumor. The patients ranged in age from 44 to 81 years with a mean age of 58 years.
RESULTS Only one case experienced a superficial necrosis in the distal one-quarter part of the flap. The functional and aesthetic results were satisfactory for both patients and surgeons, and no tumor recurrence was observed during the 12 to 28 months (mean, 18.8 months) follow-up period.
CONCLUSIONS This flap can be used reliably for the reconstruction of facial skin defects of small and medium size. The preference of frontal branch pedicled flap enables more distal facial area defects to be covered, such as dorsal nasal, nasolabial, and upper lip, than flaps based on parietal branch.     

眼睑局部皮瓣在修复睑缘色素痣切除后创面中的应用

目的：介绍睑缘色素痣手术切除后创面修复的方法。方法：根据睑缘色素痣切除后眼睑缺损创面的层次、大小及形状,选用适当的眼睑局部皮瓣修复睑缘缺损,如：＂A-T＂皮瓣、＂风筝＂皮瓣、＂H＂形推进皮瓣。共施行手术38例,其中缺损创面位于上睑缘者23例,下睑缘者15例;睑缘全层缺损9例,睑缘前层皮肤缺损29例;睑缘缺损面积最小者约为0.5cm×0.6cm,最大者约为1.6cm×0.8cm。共利用＂A-T＂皮瓣16例、＂风筝＂皮瓣13例、＂H＂形推进皮瓣9例。结果：本组患者术后皮瓣全部成活,切口均Ⅰ期愈合,其中33例术后获得随访1周～16周,眼睑外观形态良好,眼睑切口无明显瘢痕,睑缘弧线正常自然,双眼睑形态对称,眼睑闭合功能正常。结论：睑缘色素痣因其位置的特殊性,灵活选用眼睑局部皮瓣修复睑缘缺损,能获得满意的眼睑功能和美容性重建效果。     

岛状皮瓣在面部较大面积皮肤软组织缺损修复中的应用

目的探讨应用岛状皮瓣I期修复面部较大面积皮肤软组织缺损的可行性及优越性。方法针对各类面部较大面积皮肤软组织缺损患者,无合适局部带蒂皮瓣可供利用者,根据缺损部位、面积大小设计应用耳前皮下蒂侧颌颈岛状皮瓣、颏下动脉岛状皮瓣、内眦动脉岛状皮瓣、眼轮匝肌蒂岛状皮瓣及鼻唇沟皮下蒂岛状皮瓣等进行I期修复。结果共48例面部较大面积皮肤软组织缺损患者,采用上述岛状皮瓣修复,术后皮瓣全部成活,其中35例患者随访1～36个月,均获得良好的外形和功能恢复,效果满意。结论上述岛状皮瓣血供可靠,肤色质地好,供区多较隐蔽,手术操作也较为简单,安全快速,是I期修复面部较大面积皮肤软组织缺损的理想方法。     

斧状皮瓣在头面部皮肤缺损修复中的应用

目的:探讨头面部皮肤组织缺损手术治疗中应用斧状皮瓣进行转移修复的效果。方法:利用头面部皮肤缺损周围正常皮肤的弹性及皮肤纹理走向,于缺损周边设计斧状皮瓣,修复皮肤组织的缺损。结果:自2010年以来,共利用斧状皮瓣修复头面部皮肤缺损缺损53例,均完全成活,切口Ⅰ期愈合,效果满意。结论:该方法设计简便,效果可靠,皮瓣易成活,是修复头面部皮肤缺损的一种较理想方法。     

局部皮瓣在面部皮肤缺损修复中的应用

目的：探讨运用不同的面部局部皮瓣修复面部的各种缺损、病灶、畸形,以求取得最佳的美容效果。方法：根据面部病损切除后皮肤缺损面积的大小、位置,设计合适的随意型局部旋转、推进、易位等各型皮瓣Ⅰ期修复皮肤缺损创面。结果：48例面部皮瓣全部成活,无1例发生坏死及并发症。结论：在切除面部病损的同时,选用合适的随意型局部皮瓣Ⅰ期修复皮肤缺损创面,可避免直接缝合及皮片移植后出现的瘢痕、畸形、色素改变及皮片收缩等不良反应。术后瘢痕不明显,无收缩变形。美容效果好,患者满意。     

The Use of Combined Nasolabial V-Y Advancement and Glabellar Flaps for Large Medial Canthal Defects

BACKGROUND: Reconstruction of the medial canthal area presents many challenges for surgeons. It has many functional and cosmetic peculiarities. The combined use of glabellar and nasolabial V-Y advancement flaps is an effective method for repairing large medial canthal defects. OBJECTIVE: To describe and illustrate a technique to repair medial canthal defects. METHODS: Our experience with combined usage of nasolabial V-Y flap and glabellar flaps for medial canthal closure after tumor resection in 23 patients is reported. RESULTS: All resections and reconstructive procedures were performed under local anesthesia. All patients were treated without any complications such as flap loss, wound dehiscence, lymphedema, or ectropion. Fine results were achieved from both the functional and aesthetic point of view. CONCLUSION: This combination has many advantages over skin grafts and other local flaps. It is easy to design, reliable, and offers good cosmetic results. This combination is recommended to plastic surgeons as a safe and effective procedure for reconstruction of medial the canthal area.     

Single-stage maxillary and nasal floor reconstruction with the double-paddle rectus abdominis musculocutaneous free flap

Palatal integrity is essential for useful speech, deglutition, good oral hygiene, and prevention of nasal regurgitation. Maxillary defects after tumor extirpation, therefore, can have serious functional and cosmetic implications. Given the often disappointing results obtained with local and regional pedicled flaps for maxillary reconstruction, a variety of microvascular free flaps have been utilized in recent years, including the rectus abdominis, fibular, radial forearm, and latissimus dorsi flaps. Experience with these techniques has been documented in a limited number of case reports. We describe our single-stage approach to maxillary and nasal floor reconstruction with the double skin-paddle rectus abdominis musculocutaneous free flap. A series of five patients is presented; six of these immediate free flap reconstructions were performed for defects resulting from tumor resection. A vertical rectus abdominis musculocutaneous free flap was used in all cases, designing two separate skin paddles to accommodate the measured maxillary and nasal floor deficiencies. Anastomoses of the deep inferior epigastric artery and vena comitans were performed end-to-end to the facial artery and vein, respectively. In addition, orbital floor reconstruction with calvarial bone grafts or titanium mesh was performed in all five patients. Separation of the oral and nasal cavities was maintained postoperatively. No intraoperative complications, perioperative mortalities, flap losses, instances of skin paddle necrosis, hematomas, or oronasal fistulae were observed. One patient required bedside drainage of a surgical site abscess that resolved without adverse sequelae. Over the past 4 years, the double skin-paddle rectus abdominis musculocutaneous free flap has provided reliable results at our institution for single-stage reconstruction of maxillary and nasal floor defects. This reconstructive technique should be considered a viable method that can alleviate the functional and cosmetic debility associated with these defects.     

Nasolabial flap in intraoral reconstruction: Review of 55 cases

The nasolabial skin flap has proved very useful in reconstruction of anterior intraoral defects after ablation for cancer. The technique allows immediate single-stage reconstruction with local tissue. Minimal functional or cosmetic deformity results at the donor site. Fifty-five consecutive patients who underwent anterior intraoral reconstruction with 68 nasolabial flaps were followed up for 1 to 10 years. Only two flaps were total failures. Three flaps had partial tissue loss. Successful reconstruction without complication was obtained with 93 percent of the flaps. Technical refinements and considerations in flap design are presented.     

斧形皮瓣在颜面部圆形缺损修复中的应用

目的:评价应用斧形皮瓣修复颜面部皮肤缺损的效果。方法:我们利用颜面部圆形缺损周围正常皮肤的弹性力学和几何学原理,于缺损周边设计斧形皮瓣,修复缺损直径最大者4.2cm。结果:自2000年以来,共利用斧形皮瓣修复颜面部圆形缺损17例,均完全成活,切口Ⅰ期愈合,美容效果满意。结论:该方法设计简便,效果可靠,是修复颜面部圆形缺损的一种理想方法。