A Novel Technique Using a Rotation Flap for Repairing Adjacent Surgical Defects

BACKGROUND: The incidence of head and neck carcinomas continues to rise. Surgical excision is a frequently used method for removing these carcinomas. It is not uncommon to have multiple skin carcinomas present at the same time or in close proximity to each other. Therefore, surgeons can be presented with the challenge of repairing adjacent surgical defects while avoiding unacceptable wound closure tension and distortion of neighboring structures. OBJECTIVE: The presentation of a novel method for repairing adjacent surgical defects with a rotation flap. MATERIALS: Standard excision tray. CONCLUSION : We present a novel method for repairing adjacent surgical defects with a rotation flap. Surgeons are presented with adjacent surgical defects and challenged to find the repair option that will give the most optimal cosmetic result. The options for closing small adjacent surgical defects include making the defects a single large defect for primary closure, full-thickness skin grafting, primary closure of each defect separately, flap coverage, secondary intention healing, or any combination of these. The use of a single rotation flap to cover two adjacent surgical defects provides the surgeon with a convenient and cosmetically acceptable option that avoids unacceptable wound tension and does not distort neighboring structures.     

Management of Large Surgical Defects of the Forehead and Scalp by Imbrication of Deep Tissues

BACKGROUND: When facing surgical defects, the dermatologic surgeon follows certain basic principles that help reduce the inherent tension to allow for a better cosmetic outcome. These commonly include the use of undermining, releasing technique such as galeotomy if applicable, selection of suture material of appropriate tensile strength, and closure along relaxed skin tension lines. OBJECTIVE: To review the imbrication of deep tissues, another surgical principle aimed at wound tension reduction and widely utilized by cosmetic surgeons in forehead lifts and scalp reductions, as it applies to dermatologic surgeons in the repair of large surgical defects of the upper face and scalp. The latter may be utilized both with primary closure and with local flaps. METHODS: We describe in detail the technique of imbrication of deep tissues and provide illustrations for a better understanding of how to correctly use this surgical principle. RESULTS: The dermatologic surgeon has an additional tool, termed imbrication of deep tissues, available to aid in the closure of sizable wounds of the forehead and scalp as seen following Mohs surgery for cutaneous malignancies by providing deep tissue support. CONCLUSION: Imbrication of deep tissue is an effective tool that may be used by dermatologic surgeons in conjunction with the more commonly utilized basic surgical principles to enhance the cosmetic outcome in the closure of large, high-tension defects of the forehead and scalp.     

Repair of Large Defects in the Forehead Using a Median Forehead Rotation Flap and Advancement Lateral U-Shaped Flap

BACKGROUND: The forehead is a large and highly expressive and dynamic cosmetic unit. Most forehead defects that cannot be closed primarily are reconstructed with laterally based advancement flaps. OBJECTIVE: A combination of median forehead rotation flap and advancement lateral U-shaped flap for repair of medium- to-large-size defects in paramedian and lateral forehead is described. METHODS: Technically, the design of median forehead rotation flap based on supratrochlear vessels used here is similar to the median forehead transposition flap used to reconstruct large defects of the nasal dorsum. The length and the movement of the flap are much smaller in this case. Approximately 2/3 of the closure of the defect is achieved by displacing the median forehead flap while the remaining 1/3 corresponds to the advancement of the lateral U-shaped flap. RESULTS: The flaps are simple to perform, have minimal complications, and have good cosmetic results. A representative case is presented with photographs. CONCLUSION: For selected medium- to large-size horizontal defects in the paramedian and the lateral forehead, the combination of a median forehead rotation flap and an advancement lateral U-shaped flap offers a simple, visually pleasing repair that preserves the forehead architecture.     

Applications of the Double O to Z Flap Repair for Facial Reconstruction

Multiple defects are often encountered in the treatment of malignant skin tumors. Nearby defects can present a reconstructive challenge since the closure of one defect may impact the closure of the other defect. The double O to Z flap design is ideally suited to combine the closure of adjacent defects into one technique. This flap technique and design is illustrated and described. Examples include defects on the forehead, temple, cheek, and nose following Mohs micrographic surgery.     

Bilateral cheek-to-nose advancement flap: an alternative to the paramedian forehead flap for reconstruction of the nose

Skin cancer on the nose is commonly treated with surgical excision resulting in defects that require closure. The surgeon is faced with many reconstructive options. The paramedian forehead flap is one commonly used technique. In this study we describe the bilateral cheek-to-nose advancement flap as an alternative to the paramedian forehead flap in patients with strong nasolabial folds and prominent cheek tissue laxity, who require closure of MOHS surgery defects on the nasal dorsum and sidewall. Twelve patients were treated with the latter flap and evaluated after 2 weeks and 6 months. The patients' subjective and the surgeons' objective evaluation after 6 months were either completely satisfied or satisfied. The bilateral cheek-to-nose advancement flap is a reliable tool in the interventional portfolio of the reconstructive surgeon.     

The "Facelift" Flap for Reconstruction of Cheek, Lateral Orbit, and Temple Defects

BACKGROUND: Large defects of the cheek, lateral orbit, zygomatic arch, or the lower temple pose challenges for reconstruction. These defects can be elegantly reconstructed using the "facelift" flap. OBJECTIVE: The facelift flap is a large advancement flap with a rotational component based on rhytidectomy principles. METHODS: Redundant skin from the lower cheek is used as the donor tissue, which is advanced cephalad and posteriorly. Flap design varies slightly for men and women depending on characteristics of the external ear and ear lobe as well as the position and density of the preauricular hairline. Extensive undermining is critical to reduce tension on the flap and allow for complete closure. Traction provided by an assistant aids in the undermining. Specialized instruments are helpful when performing this flap. Rhytidectomy scissors, multipronged skin rakes, hand-held fiberoptic lighted retractor, and insulated forceps are particularly useful. Correct trimming of the flap and ear lobe placement without tension on the lobe are essential for a good cosmetic result. A large standing cone is excised retroauricularly such that the scar is hidden primarily behind the ear. RESULTS AND CONCLUSION: The facelift flap gives superior and elegant results for reconstruction of large cutaneous defects involving the cheek, lateral orbit, zygomatic arch, and lower temple.     

The role of soft tissue reconstruction after melanoma resection in the head and neck

INTRODUCTION: Reconstruction after wide local excision of melanomas in the head and neck can be formidable. Many tumors lie close to vital structures, and excision must carefully balance preservation of form and function. For small defects, primary closure or skin grafting is satisfactory. However, it has become increasingly evident that more advanced reconstructive procedures can improve the outcome in terms of both function and aesthetics. This study was undertaken to determine the effectiveness of flap closure after wide local excision of melanomas in the head and neck and to develop a set of surgical recommendations on the basis of our experience. METHOD: We reviewed 35 patients who underwent 39 flap closures at The University of Texas, M. D. Anderson Cancer Center after wide local excision of head and neck melanomas. Local flaps were primarily used to close defects after the resection of superficial or intermediate-thickness melanomas. Pedicle and free flaps were used to cover larger defects resulting from the excision of extensive tumors. The flap closures were compared with an analogous database of 560 melanoma resections that underwent primary closure or skin grafting. RESULTS: The mean age of the patient population was 57 years. The most common location for tumor presentation was the cheek, followed by the ear, forehead, and lip. Pathologic findings most commonly demonstrated superficial spreading melanoma, and the average defect size was 30.7 cm2. Local flaps were used most often for reconstruction. The only variable that significantly predicted local recurrence was the depth of the tumor. Local, pedicle, or free flaps did not decrease the ability of detecting local recurrence or increase this number compared with primary closure and skin grafting. Major postoperative complications were detected in seven patients. We found flap closure to achieve excellent functional and aesthetic results. CONCLUSION: Although primary closure is the ideal method of reconstruction for small defects, flap closure provides a versatile and safe alternative when simple closure would yield unsatisfactory results. With careful planning, flap closure offers an exceptional functional and aesthetic result and may even enhance contour defects after extensive neck or parotid dissections. Moreover, our experience with flap closure did not appear to delay the detection of local recurrence and may have even served to decrease the incidence of local failure after wide local excision of head and neck melanomas.     

The pedicled occipital artery scalp flap for salvage surgery of the neck.

A small group of patients with complex head and neck cancer present with problems of wound healing following radiotherapy and reconstructive surgery. Provision of skin cover to the neck in these cases is often required and presents a challenge to the reconstructive surgeon. We present the use of a pedicled scalp flap based on the occipital artery for such defects. This flap is an axial patterned scalp flap incorporating hair-bearing skin. It may be up to 15 cm wide and can reach beyond the midline of the chin. The anatomy of the flap is described and its use illustrated in three cases. This flap is a useful addition to the options for reconstruction of neck defects in patients with head and neck cancer.     

Modified Purse-String Closure for Reconstruction of Moderate/Large Surgical Defects of the Face

Background.  Large surgical defects of the face can often be difficult to repair. Extensive adjacent tissue transfer may be necessary and may result in significant scars and possible flap compromise. Often there may be less donor tissue available than is necessary to achieve closure. The alternative is a split-thickness skin graft, which often has a poor cosmetic outcome with poor color match and contour irregularities.
Objective.  A novel approach to closing large surgical defects of the face is described. This relies on a combination of side-to-side bilateral advancement and circumferential tissue recruitment utilizing the purse-string suture.
Methods.  Report of illustrated cases.
Results.  A 3.5 × 5.5 cm preauricular cheek defect, which could not be closed primarily side-to-side, was successfully completely closed in a curvilinear fashion by implementing both side-to-side bilateral advancement and circumferential tissue recruitment. A 3.8 × 5.5 cm cheek defect and a 6.0 × 8.0 cm temple defect were significantly decreased by using the modified purse-string closure. Healing by second intention in these two cases provided an excellent cosmetic result.
Conclusion.  The use of the purse-string closure utilizing circumferential tissue recruitment in combination with side-to-side bilateral adjacent tissue transfer allows seemingly large facial defects to be closed or significantly reduced in size. Such closure is evident even in cases where poor skin laxity and size of the defect would not appear to allow this. The modified purse string closure can result in an excellent cosmetic outcome.     

Reconstruction of the columella using the prefabricated reverse flow submental flap: A case report

BACKGROUND: The reconstruction of columellar defects is still a challenging procedure because of limited local and regional flap options and the characteristics of the anatomy of this site. Although a number of methods are available to repair nasal columella defects, no treatment of choice ensuring an excellent texture- and color-matched tissue in one stage has been determined to date. METHOD: In this case, we used a reverse-flow submental island flap prefabricated with the costal cartilage for the reconstruction of a complex columellar defect. RESULT: The flap survived completely with reversible venous congestion. The cosmetic result and nasal respiratory function were acceptable during the follow-up time of 6 months. CONCLUSION: We propose that the prefabricated reverse submental flap may be an alternative among the surgical options for columellar defects. This flap may also be considered in the reconstructive repertoire of other composite defects of the head and neck region.     

Use of the Z-Plasty Technique for Forehead Defects

BACKGROUND: Surgical defects of the forehead are commonplace for the Mohs surgeon. The relaxed skin tension lines (RSTLs) of this region allow for repairs ranging from direct linear closures to more complex advancement flaps. Defects in which the longitudinal axis orients perpendicular to the RSTLs, whether secondary to wound shape or ease of tissue movement, present a somewhat more challenging problem. OBJECTIVE: To describe the use of the Z-plasty in repairing forehead surgical defects. METHOD: We illustrate two Mohs surgical cases in which the size and location of the forehead defect did not allow for a straightforward and cosmetically acceptable closure. Tissue mobility and defect shape permitted design and implementation of a Z-plasty. RESULTS: Use of the Z-plasty technique allowed a portion of the vertical incision line to be reoriented within the forehead RSTLs, producing a favorable cosmetic outcome. CONCLUSION: Forehead defects that are shaped such that the long axis is perpendicular to the RSTLs or located in a region where tissue mobility more easily permits a vertical closure can present a challenge for the reconstructive surgeon. Knowledge of tissue mechanics and use of rotation and advancement make the Z-plasty a favorable option in many of these situations.     

Dermatofibrosarcoma Protuberans of the Forehead and Scalp with Involvement of the Outer Calvarial Plate: Multistaged Repair with the Use of Skin Expanders

BACKGROUND AND OBJECTIVE: Dermatofibrosarcoma protuberans (DFSP) is a locally aggressive and infiltrative tumor that requires Mohs' micrographic surgery or wide excision to treat. Adequate excision often leaves a cosmetic disfiguring defect, particularly if the tumor is located on the head and neck. Complex defects of the face present special problems, such as distortion, ectropion, and retraction of normal tissues. PATIENT AND METHODS: We present a case of an infiltrating DFSP of the forehead and scalp in a young woman. The tumor was removed, and the defect was reconstructed with multistaged repair, which included bone coverage, local and regional flaps, and the use of expanders. RESULTS: A multistaged repair was performed with good clinical outcome and satisfactory cosmetic results. CONCLUSION: Multistaged repair of the face is a viable alternative surgical approach to preserve facial contours and minimize distortion in the treatment of DFSP. This case illustrates the degree of complexity that the treatment of DFSP may involve.     

Rotation Flaps

Background. Rotation flaps are arcuate repairs that redistribute tension vectors and recruit adjacent and/or distant tissue laxity. Rotation allows for the closure of wounds that cannot be repaired along a single tension vector. A rich and evolving literature details the evolution of rotation as an elegant method of repair for surgical wounds.
Objective. The goal of this article is to understand the basic principles and proper execution of tissue rotation for the repair of facial operative wounds, with special attention given to the concept of pivotal restraint and with a step-by-step regional approach.
Methods and Materials. A review of the literature of dermatologic surgery, plastic surgery, and otolaryngology leads to a detailed understanding of rotation flap design and execution.
Results. Proper rotation flap design allows for the closure of large and complex wounds that will not close along one motion while minimizing tension vectors that affect adjacent free margins.
Conclusions. The concept and execution of rotation are integral to the practice of dermatologic surgery. Proper design and undermining are essential to create an adequately sized flap and to free pivotal restraint to facilitate wound closure. In many cases, the arc of a rotation flap may be hidden within a natural cosmetic boundary, allowing for an elegant and minimally visible reconstruction.     

双叶旋转皮瓣在修复头皮缺损中的应用

目的：探讨和评价应用双叶旋转皮瓣修复头皮缺损的临床效果。方法：手术于局麻下进行,距头皮皮损边缘0.2cm～0.5cm完整切除皮损后,在缺损区周边正常头皮设计双叶旋转皮瓣,修复创面。结果：本组20例,缺损区域面积最大5cm×2.7cm,最小2cm×1.5cm,术后伤口均Ⅰ期愈合,皮瓣颜色、质地与周围头皮基本一致,术后随访1～12个月,皮瓣区毛发生长状况与周围头皮一致,切口瘢痕不明显,无感觉异常。结论：应用双叶旋转皮瓣修复头皮缺损,皮瓣张力小、血运丰富、易于成活,且毛发生长正常,皮瓣与周边头皮衔接良好,达到整形美容效果,是解决中小面积头皮缺损修复的一种良好方法,值得推广应用。     

Cervicofacial and cervicothoracic rotation flaps in head and neck reconstruction

BACKGROUND: Compound cervicofacial and cervicothoracic rotation flaps are highly versatile flaps that may be applied to a variety of defects of the cheek, orbit, periauricular region, and neck. These rotation advancement flaps should be a staple of the head and neck surgeon's reconstructive armamentarium. METHODS: This is a retrospective review of medical records at a university-based head and neck cancer center. RESULTS: Thirty-three patients were identified, with a mean age of 66 years. Primary or recurrent skin neoplasms made up the most common indication for surgery, followed by primary parotid tumors and cervical lymphatic metastases from upper aerodigestive tract malignancies. Defects of the cheek, orbit, periauricular region, and neck were reconstructed with cervicofacial or cervicothoracic flaps, with larger wounds requiring variable extension of the incision onto the chest wall. Other reconstructive modalities were used in 18 cases to increase tissue bulk or provide internal lining. Minor wound complications occurred in 13 patients. There was no statistically significant association between wound complications and smoking or previous radiation therapy. CONCLUSIONS: Compound cervicofacial and cervicothoracic rotation flaps provide a straightforward, reliable, and efficient means to reconstruct complex defects of the face, lateral skull base, and neck, with the potential for excellent cosmetic results.     

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.     

Subcutaneous V-Y advancement flap for closure of nasal tip defect

Our experience with V-Y subcutaneous flaps for nasal tip closure after tumor resection in 10 patients is reported. This method has distinct advantages over previously used methods such as skin graft, rotation, or transposition flap. It allows primary closure of recipient and donor site without the formation of dog-ear or trapdoor deformity. It is easy to design, reliable, and offers good cosmetic results. This method is performed under local anesthesia as an office procedure. It is recommended to plastic surgeons for the closure of nasal tip defects.     

扩张皮瓣在头面颈部皮肤缺损修复中的应用

目的:探讨皮肤扩张皮瓣在头面、颈部皮肤各类缺损修复中的手术方法及临床疗效。方法:总结自2004年以来,应用扩张皮瓣修复头面、颈部皮肤缺损患者23例,根据缺损不同部位情况设计扩张器的大小、形状及埋置方式,二期以旋转,推进,轴形皮瓣方式转移扩张皮瓣修复缺损区。结果:所有23例患者的共使用扩张器36只,一次修复缺损面积最大16.0cm×12.0cm,出现扩张器渗漏1例及扩张器外露1例则选择二期扩张器置入,并发血肿、感染1例,发生率约13%。术后皮瓣均成活,修复后形态自然。随访3个月至5年,疗效满意。结论:充分做好术前设计,提高手术技巧的前提下应用扩张皮瓣是修复头面、颈部皮肤缺损的理想选择。     

The Use of the Spanning Suspension Suture in Facial Reconstruction

BACKGROUND: The closure of large cutaneous defects of the upper face can be challenging, often requiring the use of large rotation, advancement, or transposition flaps or skin grafts. OBJECTIVE: To describe the use of the spanning suspension suture, a technique we have adapted to facilitate closure of large cutaneous defects of the upper face. METHODS: Report of an illustrated case. RESULTS: A large full-thickness defect of the temple was successfully reconstructed using the spanning suspension suture. CONCLUSION: Use of the spanning suspension suture permits recruitment of skin from the lower cheek and neck in the closure of large wounds of the upper face, avoiding the need for transposition or rotation flaps and grafts.