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Cummings Chap 24 Reconstruction of facial defects

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1 Cummings Chap 24 Reconstruction of facial defects

2 Aesthetic facial units
Forehead Cheeks Eyelids Nose Lips Auricles Scalp

3 Local flap classification
Local flaps- designed immed adjacent to defect, pivotal, advancement, hinge Pivotal- shorter flap length greater degree rotation a) rotational b) transposition c) interpolated flap Advancement flap- stretched in single vector into defect a) unipedicled b) V-Y advancement c) Y-V advancement Hinge flap

4 Pivotal flaps Rotational- Curvilinear Flap adjacent to defect
usu random/occ axial blood supply best if inferiorly based- allows lymphatic flow good for mid face defects.

5 Pivotal flaps Transposition 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

6 Pivotal flaps Interpolated 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

7 Advancement flap Unipedicled-
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

8 Advancement flap VY 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

9 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

10 Facial defects recon Nose Lip Cheek Forehead

11 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

12 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

13 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

14 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

15 Melolabial and paramedian flap

16 Lip defects <1/2 – primary closure, w plasty 1/2-2/3- 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

17 Abbe W plasty Karapanzic Bernard burrows Estlander

18 Cheek defects Keep tension away from eye/lip Rhomboid- Small-med defects Bilobed- large defects, 1st lobe 20% smaller than defect,2nd lobe 20% smaller than 1st, inf based Advancement flap Transposition flap- melolabial, best sup based b/c redundant lower cheek skin used for flap

19 Forehead defects Goals: 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

20 Forehead defects Best results: local flap>secondary intent>skin graft Advancement flap +/- tissue expander, AT/OT Secondary intent best if near hairline in central or lateral 1/3

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