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.     

Firm elevation of the auricle in reconstruction of microtia with a retroauricular fascial flap wrapping an autogenous cartilage wedge.

During conventional reconstruction of the auricle in patients with microtia, simply separating the auricle from the mastoid region with a full-thickness skin graft usually fails to create firm elevation and sufficient projection. To achieve frontal symmetry is difficult, and sometimes the normal auricle needs to be set back. We reconstructed the auricle in patients with microtia in two major stages using a modified Nagata's method. Using a wide W-incision skin flap, the first stage includes implantation of a cartilage framework and transposition of the ear lobule. Our modification lies in the second stage. Instead of using the superficial temporoparietal fascial flap, we elevated a retroauricular fascial flap from the mastoid region, turning it over to wrap an autogenous costal-cartilage wedge, and covered it with a full-thickness skin graft. Between June 1996 and May 1999, eight patients underwent this operation. All the fascial flaps and overlying full-thickness skin grafts survived well. The advantages of our technique include firm elevation, good frontal projection and a natural appearance of the posterior aspect of the ear. Additionally, by using this fast and practical procedure, we avoid creating additional scars on the scalp and preserve the superficial temporoparietal fascia and superficial temporal vessels.     

The full-thickness retroangular flap

In reconstruction of full-thickness nasal defects, excellent outcome from both the cosmetic and functional viewpoints is desired, and minimal scar in the flap donor site is favored. The authors describe a new reconstructive method in which full-thickness nasal defects are repaired with a full-thickness island flap collected from the nasolabial region, with the retrograde angular artery as the pedicle. The authors call this flap the full-thickness retroangular flap, and used it to repair full-thickness nasal defects generated by resection of cutaneous malignant tumors in 2 patients. The advantages of this method were the following: reconstruction of the external side of the nose and lining of the nasal cavity could be performed with one flap; the color and texture of the reconstructed nose were favorable; being an arterial flap, good blood circulation was obtained; and closing of the flap donor site was easy.     

Gracilis free muscle transfer for morpho-functional reconstruction of the lower lip

BACKGROUND: Large full-thickness defects of the lower lip need free tissue transfer. The free forearm flap is the more widespread technique for free flap lower lip reconstruction, but it results in a static lip. The authors describe a technique of morphodynamic sensate reconstruction of the lower lip with a free gracilis flap and a musculomucosal flap. METHODS: Three patients underwent reconstruction with an innervated free muscular gracilis flap, an innervated musculo-mucosal flap for the vermillion (2 cases), and a full-thickness skin graft. RESULTS: No significant complications were observed. Static function and vermillion sensitivity were immediately restored. The skin color match was excellent. After 9 months, contraction of the transferred muscle was evident. CONCLUSION: The lip is a dynamic unit. The innervated gracilis muscle seems ideal for lip reconstruction in that it correctly replaces all the lip layers and compensates for the lost function much better than a static technique.     

Full-thickness eyelid reconstruction with a single upper eyelid orbicularis oculi musculocutaneous flap

Eyelid tumors affecting the eye in general prove to be highly challenging to plastic surgeons. Reconstruction must be precisely detailed when dealing with lesions that primarily affect the skin but progressively the eyelid margin. Conjunctiva invasion damage is estimated to one-third or less in size when compared with the damage caused on the anterior wall of the eyelid. Although serial techniques for extent and location of full-thickness eyelid reconstruction have been detailed, the orbicularis oculi muscle can be easily raised as an island musculocutaneous flap. The eyelid's bilaminar wall is recreated by folding the flap on itself and full-thickness eyelid reconstruction is achieved sacrificing minimal accessory tissue. The small cutaneous section in contact with the globe becomes tolerable. As no single method for full-thickness eyelid reconstruction applies to extent and location to a wide range of defects, the proposed flap is safe, reliable, and beneficial to oculoplastic surgery.     

The sandwich technique for closure of a palatal fistula

A full-thickness fistula of the hard palate can be closed by various methods. Recurrences are seen many times and more stable methods of closure have been researched. The authors attempted to close a palatal fistula by adhering to the main rule of reconstruction as stated by Gillies, "replace the lost tissues in kind." They used a buccinator musculomucosal transposition flap for the nasal lining, a cranial bone graft for the palatal bone, and a local mucoperiosteal transposition flap for the oral closure. The flaps and bone adapted well to the fistula. There were no recurrences during 12 months of follow-up. This "sandwich flap"--a three-layer closure--is a reliable technique for the repair of a full-thickness palatal fistula.     

婴儿先天性头皮全层缺损的修复

目的 探讨婴儿先天性头皮全层缺损的修复方法.方法 1996至2008年,对6例先天性头皮伞层缺损的患儿采用换药、皮瓣转移、扩张器扩张二期颅骨修补术等方法进行治疗.结果 6例头顶创面全部愈合.5例术后随访3个月至1年,2例有部分斑秃,2例瘢痕不明显.1例失访.结论 对缺损较小的头顶创面可换药愈合;对中等创面可用皮瓣修复;对巨大全层缺损创面先行换药,同时埋置扩张器扩张,二期行颅骨修补加扩张皮瓣转移术.     

Modified Texier mediodorsal transposition island skin flap of the nose. Report of four cases of ala nasi reconstruction

First described by Texier in 1994, the mediodorsal transposition flap of the nose is an island flap. The paramedian dorsal arteries (anastomosed to the interdomal plexus) ensured the axial vascularisation in SMAS plane. The authors will discuss their personal approach to the surgical procedure for the improvement of final result, with four clinical cases. This flap can be used for aesthetic unit reconstruction of cutaneous or mucosal different alar defect (partial or complete, full-thickness or not). This reliable flap represents an alternative technique of composed grafts, of different nasolabial flaps, and of forehead flap.     

Reconstruction of the anterior surface of the ear using a postauricular pull-through neurovascular island flap

The auricular conchal cavity is a shallow structure in the central part of the ear. It is not only 3-dimensional, but it is a gateway to the external ear canal. Many methods have been described for reconstruction of the defect of concha-antihelix: split- or full-thickness skin grafts, regional skin, chondrocutaneous and musculocutaneous flaps, but none of the authors have described this flap with neurovascular pedicle. We used postauricular neurovascular pedicle island flap for conchal and periconchal areas of anterior surface of the external ear because it matches to the skin color, thickness and texture; scars are well hidden, and there is no donor-site morbidity. Moreover, it has a constant and reliable neurovascular pedicle. The flap edema which was present in the early postoperative period began to resolve gradually after 3 weeks and disappeared in a few months. The esthetic results were excellent in all of the patients and very satisfying for the patients, too. The sensibility was positive by light touch, pin-prick, temperature and static 2-point discrimination in the postoperative control. The static 2-point discriminations in the transferred flap and in the other ear, which corresponds to the same area, were measured. The results were nearly the same as normal values. We advocate postauricular neurovascular pedicle island flap for conchal and periconchal areas of anterior surface of the external ear because it matches the skin color, thickness and texture; scars are well hidden, and there is no donor site morbidity. Moreover, it has a constant and reliable neurovascular pedicle.     

Peninsular Conchal Axial Flap to Reconstruct the Upper or Middle Third of the Auricle

BACKGROUND: The reconstruction of partial amputations of the auricle is a continuous subject of publications, in particular, the techniques of ear reconstruction with postauricular flaps. OBJECTIVE: To present in detail the surgical procedure of a new peninsular conchal transposition flap. MATERIALS AND METHODS: This new conchal transposition flap has been used since 1998 to reconstruct seven partial amputations of the upper or middle third of the auricle. If we compare the flap to a tennis racket, the head corresponds to a skin-cartilage-skin flap harvested from the concha and the shaft to a post- and supra-auricular cutaneous and subcutaneous pedicle based around the posterior auricular artery and the superior auricular branch of the superficial temporal artery. The blood supply is reliable because the superior branch of the posterior auricular artery anastomoses with the superior auricular branch of the superficial temporal artery. RESULTS: There have been no significant complications, except one case of partial rim necrosis, which responded well to wound healing by secondary intention. CONCLUSION: Our peninsular flap could be an alternative to more complex procedures involving costal cartilage harvesting, provided that auricle amputations are confined to the upper or middle third of the peripheral structures and spare the concha.     

Upper eyelid defect by dog bite reconstructed by an ipsilateral advanced tarsoconjunctival flap with skin graft

A technique for reconstruction of a traumatic upper-eyelid marginal defect utilizing a local tarsoconjunctival advancement flap with a skin graft is presented. A 22-year-old woman was bitten by a dog, resulting in a full-thickness loss of approximately the central half of her left upper eyelid. Debridement was performed under topical anaesthesia followed by one-stage upper eyelid reconstruction. The residual tarsal plate was used as a tarsoconjunctival advancement flap to reconstruct the posterior lamella of the defect. Skin from the posterior aspect of the left ear was grafted onto the reconstructed posterior lamella with two setting tarsorrhaphy sutures. One month postoperatively, the patient had an excellent cosmetic result with appropriate upper eyelid height and curvature, although cilia were not transplanted. The technique described offers a one-stage procedure with a simple surgical method providing on appropriate cosmetic and functional result.     

Precision transverse rectus abdominis muscle flap breast reconstruction: a reliable technique for efficient preoperative planning

The reconstructive plan of full-thickness nasal defects should include recreation of internal nasal lining, skeletal and cartilaginous support and external cover. We performed nasal reconstruction combined with turn-over island nasal skin flap for nasal lining reconstruction in 12 patients who underwent full-thickness resection of nasal area because of skin cancer. The flap filled the nasal lining defect of the alar area and provided a good support for skeletal reconstruction. The external skin coverage, which was enlarged according to the subunit principle, was restored by the forehead skin flap at the same operation. Enlarging the nasal defect according to the subunit principle and using the residual skin as a turn-over skin island flap for nasal lining, combined with forehead skin flap for external coverage, provides an excellent nasal reconstruction in a single operation.     

Transposition movement of V-Y flaps for facial reconstruction.

BACKGROUND: The V-Y advancement flap has been widely used for the reconstruction of cutaneous defects for decades; however, the movement of a V-Y flap is sometimes limited, allowing only for rotation or advancement movement. To overcome this limitation, the present study introduces a transposition movement of the V-Y flap and assesses its clinical outcome for facial reconstruction. MATERIALS AND METHODS: A modified V-Y flap was designed with a single laterally based pedicle and transferred to the defect through a transposition movement. The transposition movement was demonstrated with photographs and the clinical outcome was described in six patients. RESULTS: This modified V-Y flap was reliable and robust, and could be moved easily with less tension. Meanwhile, the flap allowed for a primary closure of the defects along the nasolabial fold or preauricular crease. More importantly, all six patients achieved satisfactory functional and cosmetic outcomes in facial reconstruction. Temporary sensory alteration was common in the flap skin during the initial postoperative period, but improved as time passed and disappeared about 6 months later. CONCLUSION: This modified transposition V-Y flap may serve as an alternative option for aesthetic reconstruction of facial defects.     

Scars after total ear reconstruction with porous polyethylene: the patients’ perspective

Background

Total ear reconstruction with porous polyethylene implants leads to three typical skin scars: a scalp scar from harvesting the temporoparietal fascia flap as well as a groin scar and a contralateral postauricular scar from harvesting full-thickness skin grafts. This study evaluates the annoyance of these scars from the patients’ perspective.

Methods

Fifteen patients received structured questionnaires covering the aesthetical outcome and daily impairment by the three scar types, as well as validated questionnaires measuring health-related quality of life.

Results

The ear reconstruction had raised the health-related quality of life in 14 patients. The scalp and groin scars were rated “satisfactory,” and the postauricular scar was “good” on an average. In contrast to the postauricular scar, the annoyance by scalp and groin scars was substantial: Half of the patients had sensation disorders on the scalp or groin. The scalp scar impaired a third of the patients wearing a desired hairstyle and the groin scar a third of the patients wearing swimsuits. A fifth of the patients experienced feelings of shame in the public due to the scalp and groin scars.

Conclusions

While not preventing the beneficial effect of ear reconstruction on patients’ health-related quality of life, scalp and groin scars are annoying for a relevant percentage of the patients. Therefore, the temporoparietal fascia flap should be harvested with the smallest incision possible, full-thickness skin grafts from the groin should be harvested as small as possible, and harvesting areas for full-thickness skin grafts other than the groin should be evaluated. Level of Evidence: III.     

Innovations in the Island Pedicle Flap for Cutaneous Facial Reconstruction

BACKGROUND: The island pedicle flap is a useful method of reconstruction in dermatologic surgery. Traditionally, the pedicle has been centrally and inferiorly based, with flap movements by rotation or advancement. With innovations, however, the flap is remarkably applicable to a variety of facial defects. OBJECTIVE: Our purpose is to introduce modifications of the island pedicle flap, including (1) single lateral pedicle, (2) transposition, and (3) interpolation movements. METHODS: Modifications of the island pedicle flap were applied in nine cases of cutaneous repair after Mohs micrographic surgery. Patient records and postoperative photographs were reviewed retrospectively. Both patients and other surgeons were asked to assess outcome variables. RESULTS: Patients and physicians judged overall outcome as "excellent" or "good" in 100% and 90.7% of evaluated cases, respectively. CONCLUSIONS: Variations of the island pedicle flap, including (1) single lateral pedicle, (2) transposition, and (3) interpolation movements, are viable options in the reconstruction of facial defects after Mohs micrographic surgery.     

颞顶筋膜瓣在修复外耳再造术后支架外露的应用

目的：探讨应用颞浅血管为蒂的颞顶筋膜瓣在外耳再造术后支架外露后进行修复的效果。方法：根据软骨支架外露形状,设计颞浅血管为蒂的颞顶筋膜瓣旋转包裹外露支架,加游离移植中厚皮、抗感染治疗。结果：8例患者术后再造耳支架外露修复效果良好,再造耳外形无明显改变。结论：外耳再造术后如发生再造耳皮瓣破溃、软骨支架外露的并发症,选择颞顶筋膜瓣旋转包裹外露支架,加游离移植中厚皮、抗感染治疗的治疗方法,可获得较满意的修复效果。     

Reconstruction of full-thickness ear defects using conchal cartilage and pedicled temporoparietal fascia

We describe method for reconstructing full-thickness ear defects using conchal cartilage graft covered by a pedicled temporoparietal fascial flap with a full-thickness skin graft. We treated eight partial, full-thickness defects of the ear in eight patients, two males and six females. The patients' ages ranged from 10 to 68 years. In five patients, the ear defects were caused by malignant tumor resection (three) and trauma (two). In the remaining three patients, the defect was created after correction of congenital ear deformity (constricted ear). In all cases, the defect included the helical rim and involved the upper third of the ear. The defect size to be reconstructed ranged from 10×14 mm to 16×20 mm. The ipsilateral conchal cartilage could be harvested without any problems in all cases. Grafted skin was obtained from the lower lateral abdomen. In all cases, the blood supply to the fascial flap was good, and the grafted skin took completely. The post-operative course was uneventful in all donor sites for cartilage, temporoparietal fascia, and full-thickness skin. Post-operative shrinkage was not significant and the reconstructed ear was close to the expected contour and size. In all cases, the defects were reconstructed almost completely satisfactorily in terms of contour of the helical rim and support. Although the color match of the grafted skin was not ideal, all patients were satisfied with the results. No donor deformity of the conchal cartilage was found in any case, and the donor scar of the temporoparietal fascia was hidden by the hair. We conclude that the use of conchal cartilage graft and temporoparietal fascial flap with full-thickness skin graft is useful in one-stage reconstruction of medium-sized full-thickness defects of the ear.An invited commentary to this paper is available at     

Total auricular reconstruction without skin grafting

Successful ear reconstruction depends on two factors: an ear framework and the skin covering the framework. However, the relative deficiency of skin for coverage of the cartilage framework remains an issue. This new method for total auricular reconstruction is a three-stage operation and involves the use of two tissue expanders. First, two skin expanders are implanted, one underneath the scalp and the other sited behind the microtic ear. At the second stage, after lobule transposition, the two expanded skin flaps (upper and lower) and mastoid fascial flap are raised. At the same time, the autogenous rib cartilage is harvested and the framework constructed. The cartilage framework is then anchored between the upper expanded skin flap and the fascial flap with its inferior pole inserted into the rotated earlobe. The upper expanded skin flap covers the whole anterior surface of the framework and drapes over the margins of the fascial flap, which wrap the framework from beneath. The raw surface of fascial flap is covered with the lower expanded skin flap. The formation of a pseudomeatus and tragus is performed at the third stage. Deficiency of skin is the major problem encountered with the other conventional methods. Our innovations using two tissue expanders in combination with an autogenous rib cartilage framework eliminate this problem completely.     

Superiorly Based Nasolabial Interpolation Flap for Repair of Complex Nasal Tip Defects

BACKGROUND: Reconstruction of full-thickness defects of the nasal tip is one of the most challenging aspects of cutaneous oncologic surgery. It is imperative that the cutaneous surgeon be intimately familiar with all the available surgical options to provide for the best postoperative outcome. OBJECTIVE: To describe an additional surgical option for reconstruction of complex small to medium-size full-thickness nasal tip defects involving more than one cosmetic unit. METHODS: Three patients underwent reconstruction of complex full-thickness nasal tip defects using a two-stage nasolabial interpolation flap. RESULTS: Closure of each surgical defect was achieved with the two-stage nasolabial interpolation flap with good cosmetic results in the first postoperative year. CONCLUSIONS: The two-stage nasolabial interpolation flap is a useful tool in the reconstruction of complex full-thickness defects of the nasal tip.     

A large lower eyelid reconstruction: nasojugal flaps plus V-Y advancement flap

Lower eyelid reconstruction still represents one of the finest expressions in oculoplastic surgery. A 76-year-old male presented with a basal cell carcinoma (BCC) of the lateral canthus, involving the inferior eyelid. After ablative surgery, the resulting full-thickness defect was reconstructed with a mucosal graft from the buccal sulcus and a nasolabial flap subcutaneously pedicled on a V-Y advancement flap. The above techniques, joined together, allow better nasojugal transposition and should be considered when lateral half of the lower eyelid and lateral canthus reconstruction are performed.