Local flaps in Facial

Reconstruction

Moderated be Dr Marzouq Amareen

Prepared by Hanan Mansour, MD
References
Basic skin concepts…
The PRECAPILLARY SPHINCTER
regulates nutritive blood flow to skin
and responds to locally produced
stimuli.

The PRESHUNT SPHINCTER is

involved in thermoregulation and is
affected by sympathetic stimuli from
the central nervous system.
In the past, random skin flaps were
thought to have a strict numeric length-
to-width ratio: the wider the base,
the longer the flap. However, if the
wider base simply involves additional
vessels with the same perfusion
pressure, the length of surviving flap is
unaltered.
Relaxed skin
tension lines
(RSTLs)
Result from the orientation of the collagen fibers in the
skin
Langer’s
lines
“cleavage lines” in a cadaver, they were
not intended to delineate the ideal lines
for incisions
Lines of Maximum
Extensibility (LM
E)
depend on the orientation and stretching of the elastic
fibers.
Where possible, incisions
should be made parallel to
the RSTL as this will place
the maximum closure
tension to be perpendicular
to the LME and parallel to
the RSTL.
Aesthetic facial units

The principal aesthetic units of

the face; forehead, eyelids, nose,
cheek, lips, chin and pinna.

Within which the skin has similar

characteristics; color, thickness,
amount of subcutaneous fat,
texture and presence of hair.
The preferred flap for
reconstruction is frequently one
that can be designed within the
same aesthetic unit as that
containing the primary defect.

Scars are best concealed by

placing incisions along aesthetic
borders!!
Aesthetic subunits
Basics flap concepts …
local cutaneous flap: an area of skin and subcutaneous tissue with a
direct vascular supply that is transferred from its in-situ position to a
site located immediately adjacent to or near the flap
Primary defect:
the wound to be closed by a
local cutaneous flap.

Secondary defect:
the wound created when a
skin flap is transferred to
repair the primary defect
The challenge of reconstructive surgery is to design a flap that places the secondary
defect in the most advantageous location. This usually translates into harvesting of the
flap from areas of the face and neck that have greater skin laxity!
Cutaneous flaps may be classified by;
- The nature of their blood supply (random vs. arterial)
- The method of transferring the flap
- The configuration (rhomboid, bilobed)
- The location (forehead, cheek, lip)
Classification of skin flaps based on
vascular supply.
A, Random. B, Arterial cutaneous. C,
Fasciocutaneous. D, Musculocutaneous.
Classifying flaps by method of transfer, which is method of tissue movement, is usually the
most convenient way of discussing flaps relative to their use in repair of facial cutaneous
defects.
Pivotal Flaps

All pivotal flaps are moved toward the defect by pivoting the flap
around a fixed point at the base of the pedicle.

There are four types of pivotal flaps:

rotation, transposition, interpolated, and island.
Pivotal Flaps
Pivoting a flap with a cutaneous pedicle 45° from its in-
situ position reduces the effective length 5%. A 90° and
180° pivot reduces effective length by 15% and 40%,
respectively.

To limit these restricting factors, a flap’s arc of pivot

should not exceed 90° whenever possible.
Rotation Flap
Rotation flaps are pivotal flaps with a
curvilinear configuration. They are designed
immediately adjacent to the defect and are
best used to close triangular defects.

In designing rotation flaps on the face, the

length of the incision should be four times the
width of the defect.
Transposition Flaps
Transposition flaps are pivotal flaps with a
linear configuration.
Two types of transposition flaps are frequently used:

rhombic flaps bilobed flaps

Rhombic Flap
Bilobed Flap
Bilobed flaps are double transposition flaps
that can recruit tissues that are not
immediately adjacent to the defect.

It is best suited for circular defects.

The key to the success of the bilobed flap is

the distribution of tension over both limbs of
the flap.
Interpolated Flap
The interpolated flap is transferred by
pivotal movement and has a linear
configuration, but it differs from
transposition flaps in that its base is not
continuous with the defect. Thus the
pedicle must cross over or under
intervening tissue.
paramedian forehead flap
melolabial flap
Advancement Flaps
These are flaps that are moved forward into the defect by primarily a sliding and stretching
movement. One of the margins of the defect will form the leading edge of the flap.

Advancement flaps may be categorized as:

unipedicle, bipedicle, V-Y, Y-V, and island.
Uni-pedicle Advancement Flap created by
parallel incisions that allow a sliding
movement of tissue in a single vector
toward a defect.

In certain locations on the face, unipedicle

advancement flaps work particularly well:
the forehead (particularly in the vicinity of
the eyebrow), helical rim, upper and lower
eyelids, and medial cheek. Unipedicle
mucosal advancement flaps are useful for
vermilion reconstruction.
Bilateral unipedicle advancement flaps are commonly combined to close various defects,
resulting in H- or T-shaped repairs.
V-Y and Y-V Advancement Flaps

The flap is optimally designed

so that the common limb of
the Y falls in the boundary of
neighboring aesthetic regions
or within a natural crease, fold,
or wrinkle.

V-Y advancement is particularly

useful when a structure or
region requires lengthening or
release from a contracted
state.
Island Flap
The skin around all the borders of the flap is
incised, and the subcutaneous tissue beneath
is preserved to act as the pedicle. The
principal movements are advancement or
transposition.
Defect Analysis
 Key points:

• the closure must not conceal residual tumor.

• the risk of tumor recurrence must be assessed.

• the surgeon should select the technique that will render the best possible aesthetic and
functional results.
 ladder
Reconstructive

least
inva
sive

mos
t inv
asiv
e
Two important pearls can be applied to all local flaps:

- Before deciding on the flap, draw the surrounding subunits, including

and adjacent to the defect.
- Close the donor site for the flap before the flap is sutured in position.
This maneuver decreases tension on the flap and makes closure
easier.
Preferred Flap for Forehead defects
The most effective technique for reconstruction of the forehead usually involves one or
more advancement flaps. Despite the relative inelasticity of forehead skin, the use of
advancement flaps versus pivotal flaps is preferred because they typically produce the best
cosmetic results.

H-plasty is one of the most commonly used methods for closing forehead defects
Preferred Flap for Forehead defects
The supraorbital and supra-trochlear nerves traverse the
bony orbital margins, pierce the overlying muscles and
run in the subcutaneous plane, just above the
frontalis/galea up to the vertex. If attempting to
preserve the sensation of the forehead, horizontal
incisions and undermining should be limited to the
subcutaneous plane.
In case of central vertical incisions, undermining can be
undertaken in the plane deep to frontalis/galea.
Preferred Flap for Cheek defects
In elderly patients, great laxity and redundancy is usually
present; therefore, primary closure along RSTLs is the
simplest and best reconstructive option for small defects.
However, for medium-to-large defects, local flap coverage
is required.

The most common local flaps used for cheek

reconstruction are advancement rotation flaps
Medial Cheek
Because of the elasticity of skin in this area and the relative abundance of redundant facial
skin. The preferred method of flap repair is usually by a transposition or advancement flap.
Lateral Cheek
Lateral cheek skin has less subcutaneous fat and is more adherent to the underlying fascia.
For this reason, subcutaneous tissue pedicle island advancement flaps work less well here.
The preferred flap for smaller defects of the lateral cheek is the transposition flap. Larger
defects are best repaired with advancement flaps designed to recruit upper cervical skin
into the flap.
Preferred Flap for Lip defects
Goals of lip reconstruction include maintenance of oral competence, including both
motor and sensory innervation and preservation of an adequate gingival-labial
sulcus without distortion of surrounding structures.

The first step in reconstruction is consideration of the complete sphincter formed

by the orbicularis oris muscle, which is the foundation for lip reconstruction. If
restoration of the complete sphincter is unattainable, reconstruction of the lower
lip takes precedence because the lower lip is slightly more important to oral
competence; that is, the upper lip functions more like a curtain, while the lower
lip functions more like a dam.
Preferred Flap for Lip defects
Full-thickness defects involving more than 40% of either the upper or the lower lip
generally require a 2-staged lip flap, namely, a Karapandzic, Abbe, or Estlander flap.
Abbe Flap
Abbe Flap
Abbe-Estlander Flap
Karapandzic Flap
Preferred Flap for Nose defects

Nasal reconstruction is based on the principle of restoration of anatomic structural layers.

In general, defects of the superior two thirds of the nose that involve the dorsal and/or
sidewall subunits are reconstructed with thinner, less sebaceous skin than that used in the
inferior third of the nose.
The paramedian forehead flap
Based on supratrochlear artery
The lower third of the nose, with its
complex contours and thicker, more
sebaceous, and less elastic skin, is
more challenging to reconstruct. For
defects smaller than 1.5 cm in the
greatest dimension, the bilobed flap,
when properly designed, is an
excellent flap.
Ala
The alar subunit requires cartilage support between the internal and external linings to
prevent upward contracture. If the defect is confined only to the alar subunit, the best
choice of local flaps for the external lining usually is a melolabial flap. If the defect includes
the adjacent tip subunit, a paramedian forehead flap is often the best choice.
Preferred Flap for Pinna defects

The goal of reconstruction is to try and

preserve the shape, size and position of the
pinna.
Special Considerations
• Use 4.0/5.0 long-standing absorbable sutures, on a round bodied/tapercut needle to
approximate cartilage.
• Take particular care to accurately approximate the helical rim, to prevent notching.
• Consider a pressure dressing to prevent the occurrence of a haematoma.
• Avoid clothing which needs to be removed over the head in the immediate postoperative
period.
Postauricular Artery Island Flap

Indications: Skin + cartilage defects, posterior skin intact

Postauricular Transposition Flap
Indications: Skin + cartilage defect, posterior skin intact
Helical Rim Advancement Flap
Indications: Medium-sized full-thickness defects
 Complex defects crossing multiple subunits

Reconstruction of composite defects of the face require special consideration. These

commonly occur at critical junctions in the central face and involve either the
eyelid/cheek/nose or the cheek/nose/lip.

When considering these defects, the nose is generally reconstructed last as it “rests” on
a foundation, namely the cheek and especially the upper lip.

Similarly, the eyelid “rests” on the cheek, so adequate inferior cheek support for the
lower eyelid reconstruction is paramount.
 The Use of Skin Grafts with Local Flaps.

Full-thickness skin grafts can be useful adjuncts to local flaps in reconstruction of large facial
cutaneous defects. Repair of such defects with a single local flap may occasionally result in
undesirable secondary tissue movement, which in turn causes distortion of adjacent facial
features. Skin grafts can be used to prevent undesired secondary tissue movement. The graft is
positioned between the flap and the most distal portion of the defect to relieve wound closure
tension. Skin grafts can also be used in conjunction with local flaps to preserve aesthetic borders
or to assist with closure of the flap donor defect. Aesthetic and functional outcomes are
frequently enhanced with this dual treatment approach. Skin grafts can subsequently be removed
with serial excisions if it is deemed necessary for improved aesthetic results.
Thank you 