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Management of Vascular Anomalies of the Face

INTRODUCTION For the purpose of this chapter, the term vascular lesion or vascular anomaly is used to define a variety of cutaneous neoplasms and malformations originating from blood vessels and related structures. Owing to major differences in prognosis and treatment strategies, it is imperative to accurately differentiate between these various abnormalities. Vascular anomalies can be divided into two main groups: vascular tumors and vascular malformations. Overall,…

Scar Revision and LOCAL Flap Refinement

INTRODUCTION The definition of a scar in Webster’s dictionary is a “mark left after injured tissue has healed.” Any full-thickness injury of the skin, planned or unplanned, will leave a scar. It is the body’s way of repairing itself. Although scars are vital in the reparative process, they can be aesthetically and functionally disruptive. Scars can interfere with normal motion and be disfiguring, decreasing a person’s…

Complications of Local Flaps

INTRODUCTION Complications associated with surgery are perhaps nowhere more apparent and devastating than when they occur on the face. Conley spoke of surgical complications by saying, “These untoward events, unpredictable, and unwanted, lurk in all surgical arenas, in the biologic process and in the patient. They give credence to our frailty, from which there is no escape.” It is essential that all facial surgeons become familiar…

Controlled Tissue Expansion in Facial Reconstruction

INTRODUCTION During the past three decades, many reconstructive surgical procedures have been developed or improved, providing a functional and aesthetic benefit. Among these, tissue expansion offers a unique potential to preserve both form and function. One of the major benefits of tissue expansion for correction of cutaneous defects is the ability to use tissue optimally matched in color, texture, thickness, and hair-bearing qualities. It may also…

RECONSTRUCTION OF THE SCALP

INTRODUCTION The scalp is a common site for cutaneous malignancies and is frequently subjected to trauma. As such, the surgeon is often faced with complex scalp defects in need of repair. The scalp presents unique challenges to the reconstructive surgeon: it is thick and inelastic; it is hair-bearing; it covers a convex surface; and it provides the sole soft tissue covering for the cranium. In particular,…

Reconstruction of Congenital Auricular Malformations

INTRODUCTION The treatment and care of patients with auricular malformations requires a detailed and comprehensive approach for optimal outcomes. It is ideal to establish a relationship with patients and their families early in diagnosis to provide accurate information and address unanswered questions. When ear reconstruction is undertaken by inexperienced teams, outcomes can be variable, sometimes devastating, and may limit opportunities for revision or other therapeutic options.…

Reconstruction of the Auricle

INTRODUCTION Reconstruction of the auricle presents a significant reconstructive challenge, the ultimate goal of which is to achieve as normal an appearance and position of the auricle as possible. The orientation, size, and shape of the reconstructed ear should closely approximate the opposite ear. The postauricular sulcus should be preserved, and the relationship of the postauricular skin to the scalp should be maintained. There is an…

RECONSTRUCTION OF THE FOREHEAD

INTRODUCTION A paralyzed and ptotic eyebrow, an oblique midforehead scar, focal alopecia in a brow, an asymmetric hairline – for the skilled reconstructive surgeon these deformities would be considered complications of forehead reconstruction. For the unskilled and unknowledgeable surgeon these are more likely to simply be written off as common sequelae of reconstruction. Reconstructive surgery of cutaneous defects of the forehead may be simple or complex.…

RECONSTRUCTION OF THE CHEEK

Videos available online INTRODUCTION Achieving aesthetic surgical outcomes after reconstruction of cutaneous cheek defects requires knowledge of cheek anatomy and facial aesthetic regions. The size and location of the defect and the structures adjacent to the defect are assessed to determine where tissue can be recruited for construction of skin flaps without adversely affecting the nose, lips, and eyelids by secondary tissue movement. Analysis of each…

Reconstruction of the LIPS

Videos available online INTRODUCTION The upper and lower lips comprise a distinct anatomic unit that is the principal feature of the lower face. The lips play a major role in facial appearance and function. Reconstruction of the lip can present a challenge to the reconstructive surgeon who seeks excellence in restoration of the aesthetics and functioning of this unique structure. Descriptions of lip reconstruction date back…

RECONSTRUCTION OF THE NOSE

Videos available online INTRODUCTION Over the last decade, reconstruction of the nose has reached a high level of sophistication with enhancement of aesthetic results. This has been achieved by emphasizing the necessity of replacing surgically ablated tissue with like tissue. Skin is replaced with skin that matches in color and texture as closely as possible. Cartilage and bone are replaced, and mucosa is used to replace…

RECONSTRUCTION OF THE EYELIDS

Videos available online INTRODUCTION During the past two centuries, hundreds of surgical procedures have been described for the purpose of eyelid reconstruction, perhaps because of the great value attached to the eyes and vision by our culture. The list of eponymous flaps and techniques is daunting for any student in this field, but rather than overwhelm the reader with their diversity, the goal of this chapter…

The Use of Skin Grafts with Local Flaps

INTRODUCTION The optimal aesthetic reconstruction using a local cutaneous flap is dependent on the size of the cutaneous defect and the orientation of the flap in relationship to relaxed skin tension lines (RSTLs). The effects on surrounding facial structures from primary and secondary tissue movement also influence the final outcome. Primary tissue movement is the movement of a cutaneous flap necessary to close a defect. Secondary…

Skin and Composite Grafts

INTRODUCTION The epidermis, the most superficial layer of skin, consists of keratinizing stratified squamous epithelium. The predominant cell type is the keratinocyte, making up 80% of the cells. Layers of the epidermis include the basal cell, prickle cell, granular cell, and keratin layers, with the overall thickness varying from 0.075 to 0.15 mm. The epidermis is thin at birth, becomes thicker during early adulthood, and thins…

Z-PLASTY

Videos available online INTRODUCTION The principle of Z-plasty is one of the most versatile concepts in reconstructive surgery. The dynamics of tissue movement that occur with Z-plasty are particularly suited for certain types of scar revision. A clear understanding of the underlying principles of Z-plasty will allow the reconstructive surgeon to apply this technique to a wide array of clinical situations. The history of Z-plasty has…

INTERPOLATED PARAMEDIAN FOREHEAD FLAPS

Videos available online INTRODUCTION Median forehead flaps were first described in an Indian medical treatise, the Sushruta Samita, in approximately 700 BCE. The operation was performed by members of a caste of potters known as the Koomas . The need for this operation arose from the common Indian practice of amputating the tip of the nose as punishment for a variety of crimes, ranging from robbery…

MELOLABIAL FLAPS

Videos available online INTRODUCTION The melolabial crease delineates the cheek from the caudal nose and from the upper and lower lips. It is created by the insertion of the superficial muscular aponeurotic system (SMAS) into the skin at the junction of the cutaneous lips and the cheek. Medial to the crease, the skin of the lips is tightly attached to the orbicularis oris and there is…

RHOMBIC FLAPS

Videos available online INTRODUCTION Ever since the advent of Mohs’ micrographic surgery for the treatment of cutaneous malignant neoplasms, complex surgical defects of the head and neck have become increasingly challenging to repair with an acceptable functional and aesthetic result. Primary wound closure for many skin defects is impossible; thus recruitment of adjacent tissue is often required for repair. Over the years, careful study and practice…

BILOBE FLAPS

Videos available online INTRODUCTION The original design of the bilobe flap is attributed to Esser, who described its use in 1918 for reconstruction of nasal tip defects. Ziminy and others expanded the use of the flap to reconstruct defects on the trunk and soles. Nevertheless, most authors now share the opinion that this flap is most useful for facial reconstruction, particularly of the nose. Esser’s original…

ADVANCEMENT FLAPS

INTRODUCTION Most local cutaneous flaps used in the head and neck have some component of advancement during movement of the flap to the recipient site. An example is the paramedian interpolated forehead flap. Although this flap is classified as pivotal, it frequently is necessary to undermine the pedicle in the brow area to gain additional mobility and length to the flap. Thus the pedicle is advanced…