cummings chap 24 reconstruction of facial defects
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Cummings Chap 24 Reconstruction of facial defects. 10/31/12. Aesthetic facial units. Forehead Cheeks Eyelids Nose Lips Auricles Scalp. Local flap classification. Local flaps- designed immed adjacent to defect, pivotal, advancement, hinge - PowerPoint PPT PresentationTRANSCRIPT
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Cummings Chap 24 Reconstruction of facial defects
10/31/12
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Aesthetic facial units
ForeheadCheeksEyelidsNoseLipsAuriclesScalp
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Local flap classificationLocal flaps- designed immed adjacent to defect, pivotal,
advancement, hinge1. Pivotal- shorter flap length greater degree rotation
a) rotationalb) transpositionc) interpolated flap
2. Advancement flap- stretched in single vector into defect
a) unipedicledb) V-Y advancementc) Y-V advancement
3. Hinge flap
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Pivotal flapsRotational-• Curvilinear• Flap adjacent to defect• usu random/occ axial
blood supply• best if inferiorly based-
allows lymphatic flow• good for mid face
defects.
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Pivotal flapsTransposition• Linear• Can be adjacent or
distant to defect more options for skin donor, better scar/orientation of donor site
• usu random/occ axial blood supply
• small-med defect• L:W <1:3
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Pivotal flapsInterpolated• axial blood supply• base distant to defect• pedicle must pass
over/under normal tissue
• req 2nd stage, or can de-ep and tunnel under tissue
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Advancement flapUnipedicled-• Primary movement:
Tissue slides into defect
• Secondary movement: tissue around defect pushed in
• 2 burrows triangles- z plasty, “sewn out”
• Bilateral unipedicles H or T plasty
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Advancement flapVY advancement• V shaped flap covers defect results in triangular defect
at donor site closed by advancing 2 edges of the triangle forming stem of the Y
• Good for contracted sites that need lengthening/release eg columella in cleft lip, ectropion of vermillion
YV advancement• Similar to above ex 1st flap is Y shaped• Good for reducing redundant tissue
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Hinge flap
• pedicle based on defect border, flipped over like page in book, subcut surface covered w/ 2nd flap
• Good for defects that req ext and int coverage eg full thickness nasal defects
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Facial defects recon
NoseLipCheekForehead
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Nasal Defects• Nasal subunits:
• T/F Defects involving several subunits should be repaired with single flap if possible.
• If defect involved > ? of the subunit, replace the entire subunit
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Nasal Defects• Nasal subunits:
• ala, • side wall • columella• dorsum• tip• Facets
• Repair defect of each aesthetic subunit separately
• If defect involved >50% of the subunit, replace the entire subunit
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Nasal defects- ala• Ala part of ext nasal
valve• 1.5cm or less-
bipedicled mucosa flap for internal lining, septal/conchal cart for alar cartilage, interpolated flap from cheek/forehead for external coverage
• 2.5cm or less- septal hinge mucosal graft
Septal hinge
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Nasal defects- tip/columella• Composite pivotal
septal flap• Mucoperichondrial
leaves form internal lining as bilat hinge flaps
• Cartilage graft• Paramedian forehead
flap for external coverage
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Melolabial and paramedian flap
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Lip defects
<1/2 – primary closure, w plasty1/2-2/3- lip switch (abbe if away from commissure, estlander + commissureplasty if
near commissure) flap width ½ defect width, kerapanzic>2/3- bernard webster bipedicled advancement flap, melolabial transposition,
temporal forehead flap, free flap
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AbbeW plastyKarapanzicBernard burrowsEstlander
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Cheek defectsKeep tension away from
eye/lipRhomboid- Small-med
defectsBilobed- large defects, 1st
lobe 20% smaller than defect,2nd lobe 20% smaller than 1st, inf based
Advancement flapTransposition flap-
melolabial, best sup based b/c redundant lower cheek skin used for flap
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Forehead defectsGoals: preserve frontalis fxn,
presernve sensation, place scars withinhorizontal furrows
Aesthetic goals: Eyebrow symmetry, maintain hairline, hide scars (in brow/hairline, keep scars transverse except in midline)
Subunits: • Median- midline• Paramedian- midline to vertical
axis above pupil• Lateral temple- paramedian
border to temporal hairline
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Forehead defects
Best results: local flap>secondary intent>skin graftAdvancement flap +/- tissue expander, AT/OTSecondary intent best if near hairline in central or lateral 1/3