Volume 22, Issue 1 , Pages 2-12, March 2011
Philosophy on the closing of facial defects: Choosing the right procedure
Article Outline
- Abstract
- General principles
- Patient-related factors
- Lesion-specific factors
- Conclusions
- References
- Copyright
The reconstruction of defects created from the treatment of skin cancer can be extremely challenging based on endless variability in location, size and depth. This article attempts to synthesize major principles into a guide with which to approach skin cancer reconstruction. Three major areas are addressed when planning a reconstructive strategy and these include: general principles of head and neck reconstruction and defect closure, patient-specific factors, and lesion-specific factors.
Keywords: Skin cancer, Reconstruction, Patient factors, Lesion specific factors, Aesthetic subunits
The defects created by the treatment of skin cancers challenge the surgeon to choose the best procedure for each patient and to execute the surgical plan flawlessly. It is difficult to consistently achieve excellent results because of the great variety of clinical scenarios encountered. Defects may involve any structure or subunit of the face, head, and neck. They range from very small to massive resections. What's more, patients have markedly different skin types and healing capacity, and also differ in both their esthetic expectations and their willingness to undergo extensive surgery or multiple revisions. For these reasons, it is helpful to develop a strategy to organize one's approach to these patients.
The key to any successful reconstruction lies in planning ahead and accounting for either lesion- or patient-specific attributes that could challenge the final result. This chapter will attempt to synthesize the major principles into a guide with which to approach skin cancer reconstruction.
There are three major areas to consider when planning a reconstructive strategy: general principles of head and neck reconstruction and defect closure, patient-specific factors, and lesion-specific factors.
General principles
Several well-established principles of esthetic repair help guide our reconstructive techniques. First, it is important to understand how the human eye processes a face. The “triangle of beauty” describes the region between the eyebrows, eyes, nose, and upper lip as an inverted triangle. An observer's eye will tend to focus on this region in detail, and defects in this area will be markedly pronounced. Any lesion within the triangle of beauty must be dealt with meticulously.1 Important facial landmarks must be respected, as they not only play key functional roles but also give the face an overall sense of proportion and symmetry. These landmarks include the eyebrows, the canthi, eyelid height, auricular height, the vermillion border, and the nasal outline.1, 2 If these landmarks are shifted, and asymmetry results, the human eye will quickly perceive it. It is important to predict the contracture forces a scar will exert on the surrounding tissues and adjust the reconstructive technique if contracture risks deforming facial landmarks. Every attempt should be made to minimize or camouflage scarring.
Incisions should be planned to lay within natural creases, relaxed skin tension lines (RSTLs), or the esthetic boundaries where the interplay of light and shadow will minimize their appearance. These boundaries mark the borders of the esthetic units of the face. Gonzalez-Ulloa et al.3 described this concept in 1954, putting forth a principle widely used today. They subdivided the face into esthetic units based on skin color, texture, thickness, and contour. Burget and Menick4 further subdivided the nose into its own series of subunits. The boundaries of the subunits fall in natural creases and shadows, and scars placed within these boundaries are believed to be less noticeable and hence more cosmetically pleasing. In 1985, they published their first case series applying the subunit principle to nasal reconstruction. If a given defect involved 50% or greater of the subunit, these authors resected the remaining healthy skin and reconstructed the entire subunit. Superior reconstruction was achieved by moving the scar from the center of the subunit to the border between subunits, where they were better camouflaged.5
Although the concept of esthetic subunits is widely accepted and forms the core of effective nasal and facial analysis, some authors have questioned the need to strictly adhere to these principles and resect healthy tissue.1, 6 This enlarges the defect and increases morbidity and disfigurement in the event of a reconstructive failure. Rohrich et al.6 proposed to adhere less strongly to the subunit principle, advocating maximal preservation of native tissue with reconstruction of the defect, not the subunit. They advocated meticulous skin closure techniques followed by dermabrasion or laser resurfacing, ideally 6 weeks after initial reconstruction.
One of the most important concepts to achieve superior cosmetic results is to match skin texture, color, and thickness as closely as possible. This is the concept of replacing “like with like.”1, 4 The simplest application of this principle is primary closure of a lesion. Undermining is often necessary but not always sufficient to overcome tension. When direct closure is not possible, it is preferable to mobilize local transposition, rotational, or advancement flaps using adjacent tissues in areas of laxity. The flap design will be dependent on a variety of factors, such as size of the defect, location, and adjacent structures; however, in general, local tissue mobilization can provide an excellent match to reconstruct a defect.
In certain instances, full thickness skin grafting will provide the best contour in challenging areas, such as the stiff nasal tip, but will do so at the expense of texture and color. Kaufman7 reported good results repairing wounds with adjacent-tissue skin grafting. He recommended this technique for patients in whom primary closure is not possible and local flaps would result in tension or distortion of adjacent facial landmarks. Advancement flaps were mobilized to partially cover a defect, which resulted in standing tissue deformities that were excised and used as skin grafts of good color match to the remaining portion of the lesion.
Lastly, cosmetic results are optimized with meticulous surgical technique. A surgeon should understand skin type differences and their propensity to scarring or keloid formation. Tissue should be handled gently during closure to avoid undue trauma or crush injury. The goal of skin edge eversion is ever-present and achieved by standard techniques entering and exiting the skin at a 90-degree angle. Layered closure allows for the skin to remain tension free. Sutures are removed postoperative day 5 to avoid track mark formation, and Steri strips are often used after suture removal to further diminish tension. The patient should be counseled on postoperative sun exposure avoidance to protect the healing incision from discoloration.
Patient-related factors
There are a number of factors, specific to individual patients, that must be considered when planning the reconstruction. One of the most important considerations is to determine a patient's comorbidities. A surgeon must be able to reconcile a balance between a patient's safety and the cosmetic endpoint.6 This might preclude medically ill patients from a multistage procedure, even thought it might be at the expense of a superior cosmetic result. One-stage local flap or skin graft reconstruction might be necessary instead of a staged or free flap. Age alone is not synonymous with comorbidites. Shumrick et al.8 demonstrated that age does not increase the rate of complications from multistage procedures and should not be a criteria precluding an individual from superior reconstruction.
If a patient is medically fragile, the decision to use local anesthesia instead of general anesthesia may be appropriate. Many large head and neck defects are routinely repaired with local anesthesia. This decreases postoperative recovery time and overall operative cost. Preoperative injections with 1% lidocaine with 1:100,000 epinephrine offers excellent pain control, tumescence, hemostasis, and hydrodissection of tissue planes facilitating flap elevation.9 General anesthesia is preferred for healthy individuals who must endure longer or more complicated reconstructions, large defects that might not be adequately anesthetized locally, and patients with high anxiety.
It is necessary to determine a patient's smoking status. Active smokers have demonstrated compromised skin revascularization during healing and, on occasion, can lead to skin necrosis or entire flap loss. Some surgeons opt to not perform certain types of reconstructions on smokers to avoid complications.10
We encourage smokers to quit at least 2 weeks before reconstruction, and medications can be prescribed to assist patients in this endeavor. If unable to quit preoperatively, the benefits of cessation can be seen if the patient is able to quit at the first operative stage of a delayed flap. In his 15-year review of 1334 cases, Rohrich6 proposes that smokers or recent quitters who require paramedian forehead flap may benefit from a delay procedure before flap transfer or to double the time between flap transfer, division, and inset. Another precaution in the smoking population is to minimize subcutaneous defatting of axial pattern flaps, making sure to preserve the subdermal vascular plexus and reduce the risk of skin necrosis.
A frank discussion with the patient should not only encompass tobacco use, but expectations should also be thoroughly addressed. Abnormal facial appearance from disfigurement following a facial tumor resection can have a major impact on a patient's psychosocial functioning.11, 12 Although reconstruction aims at reestablishing the illusion of normalcy, it is important to prepare the patient to have realistic expectations regarding the final cosmetic outcome. Showing patients pictures of other reconstructions might be helpful. When a delayed flap is to be performed, the patient should be prepared to endure weeks of worsened disfigurement with the hopes of achieving an improved cosmetic result in the end. Lastly, a surgeon should counsel a patient on the possibility of flap failure or skin necrosis, which could require prolonged healing or additional procedures.13 In his series of 30 patients who had undergone (sub) total nasal resection, Moolenburgh found that reconstruction had a positive impact on the psychosocial functioning in patients with active coping styles. In comparison, patients with passive coping styles showed lower satisfaction with results and had a decreased overall survival.14 The identification of a patient with a passive coping style might benefit from a preoperative psychology referral. Despite this, a patient's subjective esthetic outcome is significantly higher than when judged by a professional medical panel.15 Although most patients are willing to undergo several procedures to achieve the best results, many are very resistant to further surgery. Thus, one may, in the patient's best interest, perform a full thickness skin graft rather than a paramedian forehead flap if a patient is incapable of managing the stress of such an approach.
One consideration when facing a large defect is whether to delay closure. This can be advantageous by decreasing the size of the wound due to contraction and allows formation of granulation tissue, which can increase the survival of a skin flap. From a psychosocial standpoint, delayed closure allows a patient to become exposed and accepting of the defect, and some believe that it will increase their satisfaction at the time of reconstruction. Alternatively, the disadvantages of delayed closure include a prolonged healing course, complicated wound care, and contracture that can result in the deformation of nearby structures, such as the mouth, eyebrow, eyelids, nares, or oral commissure.
The characteristics of the patient's skin impact the surgical options and outcomes greatly. Younger patients with minimal laxity, those with thick, sebaceous skin, and patients with darker Fitzpatrick skin tones all present challenges to excellent results. This should influence the preoperative discussion and efforts to ensure realistic expectations, as well as the surgical plan.
Lesion-specific factors
Location is the most important factor in determining the surgical technique that will be used in reconstruction. An analysis of the depth and the tissue layers involved will direct the intricacy of the repair. A lesion that involves only skin will differ from one in which the supportive framework of cartilage, bone, or muscle has been respected. Ultimately, through and through defects require the separate reconstruction of all layers for cosmetic and functional success. Knowledge of the surrounding skin laxity and tissue biomechanics will guide the technique required for a specific location.
Nose
A sequential approach is used during the analysis of a nasal defect. The subunits principle is applied to determine the location and size of the newly excised lesion. Skin characteristics, such as thickness, laxity, color, and texture, will vary depending on the location and possible donor areas of skin are considered depending on surrounding local tissue variation. After the soft tissue cover is analyzed, one must determine the involvement of nasal framework and mucosal inner lining. Each layer must be replaced separately.
The nasal tip is a particularly challenging location. It is very unforgiving: the skin is inflexible, the three-dimensional anatomy is uniquely susceptible to distortion with tension, and the structure lies within the observational center of the face. Thus, the stakes are high, and perfect outcomes elusive. Management of tip defects often comes down to a choice between skin grafting, local flaps, and interpolated flaps. The patient characteristics listed above may guide one's choice.
Tip defects up to 1.5 cm can often be successfully reconstructed with the bilobed flap (Figure 1). When skin laxity is adequate in the upper third of the nose, and particularly for favorable skin types, this is the senior author's preferred method. A dorsal nasal flap is also very effective for such defects. Skin grafts, or composite grafts, are also reasonable options in many patients (Figure 2). Larger defects are treated with a paramedian forehead flap (Figure 3), or in some cases a skin graft (infratip lobule, a patient who does not want multiple surgical procedures, particularly if the skin is thin and pale).
Figure 1.
Full thickness skin defect of the lateral nasal tip measuring less than 1.5 cm closed with a laterally based bilobed flap. (Color version of figure is available online.)
Figure 2.
Full thickness skin defect of the nasal tip and dorsum >1.5 cm before and after it was repaired with a full thickness skin graft. Note the color and texture discrepancy with the surrounding skin. (Color version of figure is available online.)
Figure 3.
Full thickness skin defect on the dorsum of the nose before Mohs and after repair with a paramedian forehead flap. The forehead incision often heals very well, and it provides skin with excellent color and texture match. (Color version of figure is available online.)
For sidewall nasal defects up to 2 cm, full thickness skin grafts are often successful. Lesions that are more superiorly located near the medial canthus will have the best color match when the graft is obtained from the postauricular skin.
Nasal dorsum and sidewall defects measuring more that 2 cm are managed with a paramedian forehead flap or skin graft.
Smaller partial thickness lesions of the nasal alae that lie within the alar crease may be allowed to heal by secondary intention. Larger defects can be treated with excellent results with a superiorly based nasolabial flap (Figure 4). The melolabial flap can be done either as a single stage transposition flap or as a two-stage interpolated flap. The single-stage repair may require a second stage procedure to reestablish the nose–cheek junction. When cartilage is deficient in this area, an auricular composite graft is used.6 Defects of the ala, or at the junction of the ala and tip, can be repaired with a V-to-Y advancement flap.
Figure 4.
Full thickness skin lateral nasal alae defect after Mohs resection and after repair with an inferiorly based melolabial transposition flap (two-staged). (Color version of figure is available online.)
If the nasal framework has been compromised, it must be repaired to avoid nasal envelope scar contracture and eventual nasal collapse. Cartilage grafts in nasal reconstruction are “nonanatomic”;—they are employed to ensure the creation of the desired surface contour and to prevent alar rim retraction, rather than being used to simply replace excised cartilage. Septal cartilage, when available, offers a limited supply that is easily obtainable and matches the strength and flexibility of the excised cartilage. When septal cartilage is insufficient, auricular cartilage can be harvested bilaterally. Rib cartilage is unparalled in its strength and stability and is often the first choice when large portions of the dorsal support have been sacrificed.
To ensure the integrity of the reconstruction, it is imperative to repair the nasal mucosa inner nasal lining as a separate layer. Several options exist, including septal mucosal flaps, inferior turbinate flaps, nasal skin turn-in flaps, vestibular bucket handle flaps, folded forehead flaps, free flaps, and for distal defects, the use of nonvascularized composite ear grafts. In the last example, the ear cartilage is used for the structure, and the ear skin, still adherent, becomes the inner lining. A forehead flap is placed on top as external cover. This technique has become the authors' preferred option for internal lining, for full thickness defects of the ala (Table 1).
Table 1. Pearls for reconstruction of nasal defects
| - You must reconstruct each involved layer individually (skin, framework, lining) |
| - Nasal tip |
| - <1.5 cm: Bilobed flap, dorsal nasal flap, skin graft |
| - >1.5 cm: Paramedian forehead flap |
| - Nasal sidewall |
| - <1 cm: Primary closure, skin graft |
| - <2 cm: Full thickness skin graft, melolabial flap |
| - >2 cm: Paramedian forehead flap, melolabial flap |
| - Options for reconstruction of nasal mucosa lining |
| - septal mucosal flaps |
| - inferior turbinate flaps |
| - nasal skin turn-in flaps |
| - vestibular bucket handle flaps |
| - folded forehead flaps |
| - free flaps |
| - nonvascularized composite ear grafts |
Cheek
The cheek is the largest esthetic unit of the face, and it is bounded by the melolabial fold and nasofacial groove medially, the orbital rim superiorly, and the preauricular crease laterally. The size of a defect and its depth are assessed noting any involvement of deeper structures, such as Superficial Musculo Aponeurotic System (SMAS) or muscle. Its proximity to facial landmarks must be considered, and one must predict possible distortion created by secondary tissue movement. The choices are often between primary closure, smaller rotation or advancement flaps, rhombic flap, or cervicofacial flaps. Pay attention to the lower eyelid for lesions that are near or across the lid cheek junction, particular if lid laxity is present. One must ensure adequate suspension of any flap to prevent ectropion.
Incisions should be placed along the boundaries of esthetic units or RSTLs for camouflage. In the cheek, RSTLs and curvilinear and transition from horizontal to more vertical as one progresses laterally. Repair of smaller defects oriented parallel to RSTLs is often possible with primary closure. Final suture line position can be stabilized along an RSTL by maintaining a subunit intact and undermining the adjacent subunit to meet for closure at the desired site. Skin grafts are rarely used because of poor color and texture match in most instances. Medium-sized defects of the cheek are ideally suited for advancement and rotational flaps, given the loose subcutaneous tissue that can be easily and effectively undermined. Burrows triangles often need to be excised to improve the arc of movement, decrease tension, and decrease prominent standing cutaneous deformities.
Rhombic transposition flaps can also be used with great success on the cheek (Figure 5). The flap should share a common border with the defect and is planned with sides of equal length as well as opposing angles measuring 60 and 120 degrees. The donor site will absorb most of the tension, and because there is significant flexibility as to which orientation in which to place the donor site, the rhombic flap can be modified to avoid causing distortion or tension onto surrounding structures.16 Repair of large defects is most successfully achieved with a cervicofacial rotational flap (Figure 6). Large areas of skin can be mobilized, and skin color and texture match is excellent. The incision is designed similarly to a rhytidectomy, in the preauricular crease with inferior extension around the lobule and extending cervically inferiorly if an increased arc of rotation is needed (Table 2).17, 18, 19
Figure 5.
Mid-sized cheek fat defect with planned rhombic flap outlined in blue. Accompanying picture shows result following rhombic flap repair. (Color version of figure is available online.)
Figure 6.
Large cheek defect closed with a cervicofacial advancement flap. (Color version of figure is available online.)
Table 2. Pearls for reconstruction of cheek defects
| - Skin grafts usually a poor color match |
| - Smaller lesions: |
| - Primary closure (ellipse, M plasty excision, Z plasty, W plasty) |
| - Medium-sized lesions: |
| - Advancement and rotational flaps masking final |
| - Rhombic transposition flap |
| - Bilobed flap |
| - Other frequently used local flaps: O-to-T flap, Burrows triangle advancement flap, O-to-Z flap, V-to-Y flap, island advancement flap |
| - Large lesions: |
| - Cervicofacial advancement flap, cervicothoracic advancement flaps |
Temple
The skin of the temple and lateral forehead has poor elasticity and a slightly convex surface. The space is confined by the brow medially and temple hair bearing skin laterally. This geographic constraint by hair-bearing boundaries, along with the relative inelasticity, make the area a challenge. The choices in this area often are among primary closure, advancement flaps, rotation flaps, and occasionally transposition flaps.
The RSTLs course inferior–superior and are slightly curvilinear, which is optimal to camouflage incisions. Primary closure with subcutaneous undermining is often possible for smaller defects. Care must be taken to prevent damage to the temporal branch of the facial nerve, which could result in ipsilateral paralysis of the frontalis muscle. In the temple region, the temporal branch of the facial nerve is superficial and hence vulnerable. It lies beneath the SMAS layer coursing through the temporoparietal fascia, which invests the temporalis muscle. Dissection should be performed bluntly in the subcutaneous plane, leaving the temporoparietal fascia undisturbed.
Larger defects often can be treated with large rotation advancement flaps, bilateral advancement flaps, or O-to-T closure (Figure 7). Slightly larger lesions that cannot be closed primarily are often amenable to bilobed or rhomboid flaps (Table 3).20
Figure 7.
Medium size defect of the temple. (A) Planned incisions for an O-to-T rotational flap. Additional skin is resected to correct for the inevitable standing cone deformity. (B) Patient following recovery from an O-to-T flap for a temple lesion reconstruction. (Color version of figure is available online.)
Table 3. Pearls for reconstruction of temple defects
| - Beware of temporal branch of facial nerve |
| - Smaller and medium lesions: Primary closure |
| - Medium to large lesions: O-to-T flap, bilobed, rhomboid flap, advancement flaps |
Forehead lesions
Forehead contour, skin laxity, and inherent rhytids vary greatly from patient to patient. Along with defect closure, other goals are to maintain eyebrow symmetry, avoid damage to the facial nerve, align scars along the hairline or eyebrows, and maintain the normal height and contour of the hairline. The choices here are elliptic closure, advancement flaps, scalp flaps, or on occasion, allowing the defect to heal by secondary intention. High forehead defects can often be closed through secondary intention. The skin has a rigid underlying bony platform, with no adjacent structures that can be distorted by scar contracture, making this a reasonable choice. Similarly midline forehead defects can be closed via primary, elliptic closure and a vertical scar with satisfactory cosmetic result. M plasties and W plasties are recommended to smooth out standing cutaneous deformities. Dissection can be performed in the subcutaneous plane; however, for larger wounds in which there is high tension, musculocutaneous flaps can be elevated by widely undermining deep to the frontalis. Care must be taken not to injure the frontal branch of the facial nerve, which courses beneath the frontalis muscle. Defects on either side of the midline are often successfully closed with bilateral, laterally based, rectangular advancement flaps. The horizontal parallel incisions should be placed along the eyebrows, the hairline, or the horizontal forehead rhytids. If the lesion is along the hairline, the superior horizontal incision can be hidden behind the frontal and temporal hairline, creating two inferiorly based rotational flaps.9, 20, 21 O-to-T flaps can be used very effectively, and serve to minimize brow distortion. Very large defects require more complex scalp flaps (Table 4).
Table 4. Pearls for reconstruction of forehead defects
| - High forehead defects: Secondary intention healing |
| - Midline forehead defects: Primary elliptical closure |
 - Lateral defects: Bilateral, laterally based rectangular advancement flaps, O-to-T flaps |
| - Very large defects: Complex scalp flaps |
Scalp defects
In contrast to defects in other locations of the head and neck, the repair of scalp lesions is particularly challenging. The skin of the scalp is the thickest in the body, it is inelastic, and its deeper layers of galea and pericranium are fixed and tethered. Even with undermining it can be difficult to mobilize sufficient tissue to close even small defects. Other considerations are at play, which include preservation of the hairline, conscientious movement of hair-bearing areas, preservation of vascular pedicles, and wound closure without excessive tension. Rotation flaps are the most commonly used in repair, as this strategy minimizes the donor site defect, allowing tension to be disbursed across a wide area. When the pericranium layer can be preserved, skin grafting is often used, being the simplest form of closure with the least operating time and yielding acceptable cosmetic results. Unfortunately, color matching is not always optimal. Healing by secondary intention in the scalp is not usually desirable primarily because of the hair loss. In addition, there is loss in contour and the thin skin regrowth that can be injured easily. For medium-sized and more centrally located lesions, a double or triple (pinwheel) rotational flap can often close the defect (Figure 8). However, due to the inelasticity of the scalp, the incisions marking the sides of the flap may need to be made up to six times the diameter of the defect itself. For larger defects, tissue expanders implanted into the loose alveolar tissue beneath the galea can facilitate the recruitment and mobilization of surrounding tissue. Other times, flap rotation can decrease the size of the defect, and a skin graft can be used in conjunction to cover the remainder of the defect (Table 5).19, 21, 22
Figure 8.
Large scalp basal cell carcinoma. (A) The planned incisions for a “pinwheel” rotational flap. Because of the firm adherence of the scalp to the underlying galea, the arcs of rotation must be made significantly longer than the defect. (B) Appearance of closure immediately at the completion of the procedure. (Color version of figure is available online.)
Table 5. Pearls for reconstruction of scalp defects
| Tissue is inelastic and fixed |
| - For skin grafts to survive, periosteum should be preserved |
| - Medium-sized defects: Double of triple pinwheel rotational flap |
| - Very large defects: Tissue expanders, skin graft |
| - Skin grafts can be used alone or in combination with any of the above mentioned flaps |
Lip reconstruction
The lips are of prime cosmetic importance and serve multiple important functions. Oral competence, speech, deglutition, communication, and expression should be reestablished at all cost. The algorithm to decide on the appropriate technique for reconstruction of this area is usually based on the size of the defect; whether it involves skin, vermillion, or both; its medial or lateral location;and whether it involves the upper or lower lip. Lower lip defects measuring up to one half of the length of the lower lip can usually be reconstructed primarily. Smaller defects can be excised with a V-shaped wedge with direct suture repair, whereas lesions on the larger end of the spectrum are resected with a modified W wedge (Figure 9). This technique allows for the formation of a more rectangular defect and better closure. If the vermillion has been removed with the resection, larger rectangular lesions can also be closed with bilateral, laterally based, advancement flaps. The inferior incision is based in the mental crease and burrows triangles are excised laterally. Meticulous care should be taken to approximate the free edges of the vermillion border on either side of the excision since the misalignment of this landmark is easily perceived by the human eye and is cosmetically displeasing. A careful reanastomosis of the orbicularis oris ring is also important to reestablish its continuity and maintain oral competence necessary in many of the lips' functions. Inferiorly or superiorly based melolabial flaps can be used for upper lip defects, as can V-to-Y or island advancement flaps.
Figure 9.
Left upper lip lesion marked with a planned M plasty excision technique, which will be followed by primary closure. (Color version of figure is available online.)
Lower lip lesions measuring greater than one-half and less than two-thirds of the length of the lower lip cannot be closed primarily without excessive tension. It is often necessary to recruit tissue from adjacent areas, such as the upper lip or the cheek. The concept of “replace like with like” is reflected in the fact that rotating tissue from the upper lip is often used. The Abbe cross lip flap is pedicled on the labial artery and borrows tissue from the upper lip. Its width should not be greater than 2 cm, and it should be approximately one-half of the width of the lower lip defect. After the flap is inset, it will remain in position undivided for 10-20 days. A second stage procedure is necessary to divide the flap. The Estlander flap is similar to the Abbe flap but varies by rotating the upper lip tissue around the oral commissure. A Karapandzic flap is advantageous in that it preserves the neurovascular supply to the orbicularis, which maintains oral competence and arterial blood supply to the area. Patients who have suboptimal wound healing characteristics or a history of radiation are well suited for this flap. Circumoral incisions are placed in the mental and nasolabial creases. The incisions are taken down to, but not through, the intraoral mucosa. The orbicularis oris is gradually freed from the surrounding tissue to maximize advancement. The superior and inferior labial arteries, as well as the branches of the facial nerve that enter the orbicularis oris deep to the muscle, are identified and preserved. Once mobilization is complete, a meticulous tension-free, three-layered closure completes the reconstruction. For lesions involving two-thirds up to the entire lower lip, a “Gate” flap or a “Bernard-Burrow” advancement flap will mobilize cheek tissue to reconstruct the defect. Inner lip mucosa is freed and advanced superiorly and over the free edge of the reconstruction to recreate the pink lip and the vermillion border. If the patient is healthy enough to withstand the risks of microvascular free tissue transfer, a radial forearm free flap can be used along with a tendon graft for suspension and contour.
When upper lip malignancies arise, these are most frequently basal cell carcinomas, which can usually be closed primarily after Mohs excision. When a larger upper lip lesion occurs, an Abbe or Estlander cross lip flap can be used. If the defect involves two-thirds of the upper lip or more, a “Burrow-Diffenbach” flap is designed. In this flap, incisions are created inferior to the nasal collumella; these are then extended to form perialar incisions and two laterally based advancement flaps are mobilized to close the more central lip defect (Table 6).23, 24, 25
Table 6. Pearls for reconstruction of lip defects
| - Lesions involving 1/2 to 1/3 of lip: |
| - Primary closure with V or W wedge excision, bilateral advancement flaps, inferiorly or superiorly based mesolabial flaps, V-to-Y or island advancement flaps |
| - Lesions involving >1/2 to 2/3 of lip: |
| - Abbe flap, Eastlander flap, Karapandzic flap |
| - Lesions involving >2/3 of lip: |
| - Burrow-Diffenbach flap, free tissue microvascular transfer, gate flap, Bernard-Burrow advancement flap |
Eyelid reconstruction
Eyelid reconstruction is challenging mainly because of its vital protective and functional role toward the eye. Reconstruction should be done quickly to prevent any corneal damage and should strive to approximate the thickness, color, and pliability of the native tissue. The aim is for tension-free closure and strategically placed incisions that will not contract and deform the surrounding eyelid, resulting in ectropion or notching. The upper eyelid plays a larger role in protection of the globe, and therefore it is never sacrificed to repair the lower eyelid. It is not uncommon to use a graft from the lower eyelid to reconstruct the upper one. When the defect involves only skin and it does not involve both upper and lower lids, then it is amenable to a full thickness skin graft. The best color match would be from any excess upper eyelid skin, followed by pre- or postauricular skin and finally followed by skin superior to the clavicle. When a full thickness defect involves less than one-third of the length of the affected lid, then primary closure is the best option. Local VY flaps and rhomboid designs can help decrease tension when aligned in an oblique line to the rim that coincides with the RSTLs. If the defect is located adjacent to the medial canthus and periosteum is preserved, a full thickness skin graft will achieve good results. The medial canthal ligament should be resuspended to the bone if it has been detached.
Full thickness defects that involve more than one-third to half of the eyelid length can sometimes still be closed primarily if there is enough skin laxity. If primarily closure is not possible, then a local transposition or advancement flap, preferably from the eyelid itself, is mobilized. A mucosal graft must line the deep portion of the flap to protect the globe, and this can be obtained as a free mucosal graft from buccal lining or from the hard palate. Even larger full thickness defects spanning more than one-half to three-quarters of eyelid length cannot be closed with a flap from within the eyelid. Incisions must be lengthened, and tissue must be recruited from the temporal area. Often a Z-plasty is used in the lateral part of the incision to increase flap length, and the temporal flap is based superiorly to decrease the risk of ectropion.
When the upper eyelid is completely lost, this can be repaired with a bipedicled cutaneous flap from the lower eyelid. The orbicularis is kept intact during harvest because it provides the main support to the lower eyelid and prevents ectropion. The donor site can later be skin grafted for closure. When the lower eyelid is missing, a cheek flap with a releasing Z-plasty and a mucosal graft on the deep surface of the flap is a valuable technique. Only rarely will a patient have both complete upper and lower eyelid loss. Staged repair can be performed with superficial temporal fascial flaps, which can also be obtained as free grafts from the contralateral side. The paramedian forehead flap and cheek flaps can also be used to further aid in reconstruction (Table 7).26, 27, 28
Table 7. Pearls for reconstruction of eyelid defects
| Skin only: Full thickness skin graft |
| - Full thickness: V-to-Y flap, rhomboid |
| - Involving 1/3 to 1/2 of the eyelid: Primary closure, local advancement flaps |
| - Involving >1/2 to 3/4 of the eyelid: Local temporal flap, Free flap, bipedicled lower eyelid (to reconstruct superior eyelid defect), cheek flaps, paramedian forehead flap, skin grafts |
Auricular reconstruction
Skin cancer of the auricle accounts for almost all malignancies of this region. The ear is vulnerable to prolonged sun exposure and is rarely protected with sun-blocking agents. Consequently, basal cell and squamous cell malignancies of the helix and antihelix are common. The resulting defects vary in size, depth, and cartilage invasion, and the analysis of these characteristics, along with knowledge of the complex anatomy of the ear, will help dictate the best reconstructive options. The three-dimensional shape of a normal ear is complicated by ridges, concavities, convexities, and thin skin tightly adherent to cartilage. One reconstructive advantage is that ears, although bilateral, are rarely visualized simultaneously, and oftentimes, small asymmetries are usually not easily perceived. Furthermore, because of their lateral location on the head and partial coverage by hair, several characteristics, such as height, projection angle from the mastoid, overall shape, and size, are more important to an overall sense of symmetry than recreating an exact replica from the contralateral side.
It is rarely possible to undermine and close the skin primarily due to the intimate association between the skin and underlying cartilage. Healing by secondary intention can be an option when confined to superficial skin lesions, especially when present on a concave surface. Skin defects located on a convex surface often do not heal as well by secondary intention.29 The depth and presence or absence of cartilage support of a granulating lesion will greatly affect the time required to heal and eventual scar contracture. Given the wide variety of reconstructive options with good results, healing by secondary intention is reserved for those patients with severe comorbidities.
Skin grafting is widely and successfully used in auricular reconstruction providing excellent coverage, contour, and minimal contracture with healing. Full thickness grafts are preferred and will heal optimally if perichondrium can be spared at the base of the defect. The best color and texture match can be achieved from donor skin obtained from the posterior conchal bowl, post auricular skin, or lateral neck. If cartilage is exposed without perichondrium in a concave region, cartilage can be removed, leaving the skin on the opposite side of the ear intact, and the graft is placed onto the deep surface of the posterior skin. Skin grafting in combination with contralateral auricular cartilage graft or composite condrocutaneous grafts can improve the helical contour but have a higher rate of failure.
When cartilage has been removed, particularly from the helix, closure can be achieved by resecting extra tissue to create a wedge shape and rotating the free edges toward each other. Often, division of the cartilage inferiorly into the concha might be necessary to release tension and prevent cupping of the ear. This technique will result in a slightly smaller ear; however, the overall shape is preserved and overall result is very good. Helical advancement flaps are also frequently used and many variations have been described.30 The helix is partially freed from the scapha with incisions that run parallel to the helix down through anterior skin and cartilage, but leave the posterior skin intact. This maneuver frees the helix and allows it to mobilize enough to juxtapose the free edges for suturing.
For more complex defects, local flaps can be recruited from the postauricular, temporal, or cervical regions. Staged procedures can include prior cartilage implantation with later transfer and inset to reconstruct the auricular framework and skin cover (Table 8).31
Table 8. Pearls for reconstruction of auricular defects
| Small lesions on convex surfaces heal well by secondary intention |
| - Skin grafting is often used: Perichondrium should remain for best healing |
| - Best color/texture match is from posterior conchal bowl |
| - Helical lesions: Wedge excision, bilateral advancement flaps, skin grafts |
| - More complex defects: Local flaps from temporal or cervical lesions, staged procedures with cartilage implantation |
Conclusions
There are many variables that must be considered when planning for the optimal reconstruction of skin cancer defects, and these should be approached in an almost philosophic manner. General principles of tissue biomechanics, wound healing, and surgical technique guide many intraoperative decisions; however, patient-related factors and the location of the defect must be carefully considered preoperatively for ultimate patient satisfaction and surgical success.
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PII: S1043-1810(10)00065-5
doi:10.1016/j.otot.2010.08.009
© 2011 Elsevier Inc. All rights reserved.
Volume 22, Issue 1 , Pages 2-12, March 2011
