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Research Article| Volume 24, ISSUE 1, P36-44, March 2013

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Facial reconstruction after resection for cutaneous malignancies

  • Frank G. Garritano
    Affiliations
    Section of Facial Plastic and Reconstructive Surgery, Division of Otolaryngology—Head & Neck Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
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  • Fred Fedok
    Correspondence
    Address reprint requests and correspondence: Fred Fedok, MD, Section of Facial Plastic and Reconstructive Surgery, Division of Otolaryngology––Head & Neck Surgery, Penn State Hershey Medical Center, 500 University Drive, Box H091, Hershey, PA, 17033
    Affiliations
    Section of Facial Plastic and Reconstructive Surgery, Division of Otolaryngology—Head & Neck Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
    Search for articles by this author
      The reconstruction of facial defects after the resection of cutaneous malignant lesions is challenging. Knowledge of several key principles, such as that of facial subunits and of the reconstructive ladder, is paramount to achieving functionally and aesthetically pleasing surgical outcomes. Various reconstructive modalities, from local flap closure to free tissue transfer, are available to the practicing surgeon depending on the defect requiring reconstruction. In this article we describe several of the most commonly used local and regional flaps in facial reconstruction as well as some of the special challenges faced when reconstructing areas such as the eyelid, the lips, the nose, and the ear.

      Keywords

      The reconstruction of facial defects after the resection of cutaneous malignant lesions is challenging. A thorough understanding of the facial anatomy, the expected surgical defect, and the available reconstructive options is critical to achieving optimal patient outcomes. The goals of facial reconstruction are primarily two-fold: the restoration of form and the preservation of function. There is a large body of literature that discusses the various reconstructive options used in facial reconstruction, and this article will discuss some of the principles involved in facial reconstruction and provide descriptions of several of the most commonly used flaps.
      The facial subunit principle is a well-recognized principle that organizes the skin of the face into discrete subunits that are characterized by their color, texture, hair growth pattern, and surrounding skin.
      • Larrabee W.F.
      • Sherris D.A.
      • Murakami C.S.
      Principles of Facial Reconstruction, vol xi.
      • Papel I.D.
      Facial Plastic and Reconstructive Surgery, vol xxi.
      • Gonzalez-Ulloa M.
      • CASTILLO A.
      • STEVENS E.
      • et al.
      Preliminary study of the total restoration of the facial skin.
      The face is classically divided into 6 subunits: the forehead, the eye and brow, the nose, the lips, the cheek, and the chin (Figure 1). Some subunits, such as the nose, are divided into further subdivisions. When considering the reconstruction of a facial soft-tissue defect, the consideration of the facial subunits involved can be helpful, as each subunit affects the aesthetic of surrounding subunits. In addition, because the facial subunits are defined by anatomical boundaries formed by light reflections and the shadows of facial contours, scars lying within these transition zones appear more concealed.
      • Papel I.D.
      Facial Plastic and Reconstructive Surgery, vol xxi.
      Figure thumbnail gr1
      Figure 1An illustration depicting the major facial subunits and their subdivisions.
      The reconstructive ladder conceptualizes the various and progressively more complex treatment options that are available when faced with reconstructing a complex surgical defect (Figure 2). As each “rung” of the ladder is ascended, a more complex surgical reconstructive option is faced. This can range from the extremely simple at the bottom of the ladder (eg, healing by secondary intention) to the extremely complex at the top of the ladder (eg, healing using a microvascular free flap). For cutaneous facial defects that are not amenable to the simplest options, such as secondary or primary closure, other options such as skin grafting, composite grafts, local flaps, regional pedicled flaps, and free tissue transfer can be used to achieve an adequate and cosmetically pleasing wound closure.
      Figure thumbnail gr2
      Figure 2The reconstructive ladder. (Color version of figure is available online.)
      Local flaps have several advantages when compared with more complex reconstructions using regional and distant tissue. First, local flaps by definition involve skin adjacent to the surgical defect in question, and therefore have favorable color and texture matching. Several local flaps are commonly used in facial reconstruction after resection for cutaneous malignancy, including the bilobe flap, rhombic flap, and cervicofacial advancement flap. These will all be discussed briefly.
      The bilobe flap was first described by Esser in 1918.
      • Esser J.
      Gestielite Iokale Nasenplastik mit zweizipfligem Lappen, Deckung des sekundaren Defektes vom ersten Zipfel durch den zweiten [in German].
      The original description was of 2 flaps of equal shape and size, separated by a 90° angle, rotated to cover a donor site defect. This was more widely adopted after it was redesigned by Zitelli in 1989, who solved a number of problems with the original flap design, such as the formation of a dog-ear deformity.
      • Zitelli J.A.
      The bilobed flap for nasal reconstruction.
      The bilobe flap is a cutaneous, double transposition, random flap that is made up of 2 separate lobes based on a single pedicle (Figure 3). One major advantage of a bilobe flap is that it allows for a great range of coverage options over a much greater distance than a single transposition flap would otherwise allow for. The bilobe flap is simple to design, has favorable tissue-matching characteristics, is extremely reliable, and is versatile (Figure 4). For nasal soft-tissue reconstruction, it is ideally suited for relatively small defects (<1.5 cm), although this flap can be used to cover larger defects in other areas.
      • Chu E.A.
      • Byrne P.J.
      Local flaps I: bilobed, rhombic, and cervicofacial.
      Patients with thin loose skin may be suitable candidates for reconstruction of larger defects with this technique, whereas patients with thick sebaceous skin may present difficulty when dealing even with relatively smaller defects.
      • Chu E.A.
      • Byrne P.J.
      Local flaps I: bilobed, rhombic, and cervicofacial.
      Figure thumbnail gr3
      Figure 3An example of a patient with a circular temporal defect that was closed using a bilobe flap. (Color version of figure is available online.)
      Figure thumbnail gr4
      Figure 4An artist's rendition of the design and execution of the bilobe flap.
      When designing a bilobe flap, a single large flap that is slightly smaller than the intended donor defect is designed immediately adjacent to the site of the planned defect. A second flap, with a width ranging from equal to one half of the width of the first flap, is designed at an angle of <90° to the original flap. A larger-width secondary flap allows greater ability to close the primary defect, whereas a smaller width allows greater ability to close the tertiary defect.
      The rhombic flap was first described by Limberg
      • Limberg A.A.
      Modern trends in plastic surgery Design of local flaps.
      in 1946 for closing 60° rhomboid-shaped defects, and has undergone several modifications, including by Dufourmentel
      • Dufourmentel C.
      Closure of limited loss of cutaneous substance Socalled “LLL” diamond-shaped L rotation-flap.
      in 1962, who used it to close defects of any angle, and Webster
      • Webster R.C.
      • Davidson T.M.
      • Smith R.C.
      The thirty degree transposition flap.
      in 1978, who described the use of a 30° flap and M-plasty to close the defect base. A rhombic flap, like a bilobe flap, is considered a cutaneous, transpositional, random flap. It is commonly used for closing small- to medium-sized cutaneous cheek defects, but has also been used to reconstruct the scalp, neck, chin, temple, and eyelid (Figure 5). The rhombic flap uses a combination of rotation and advancement to advance an area of lax donor tissue over stationary skin and into the surgical defect. There are several advantages to a rhombic flap. The rhombic flap uses adjacent tissues, which maximizes tissue-match characteristics; it redistributes and redirects the tension of wound closure more evenly across the entire wound; and the flap can be oriented in several directions to minimize scar tension and maximize wound closure.
      Figure thumbnail gr5
      Figure 5An example of a patient with a glabellar defect that was closed using a rhomboid flap (Note: the design of the flap was modified to accommodate the patient's eyebrows). (Color version of figure is available online.)
      The classic Limberg rhombic flap is created from a rhombic-shaped defect, which is based on 2 equilateral 60° triangles.
      • Limberg A.A.
      Modern trends in plastic surgery Design of local flaps.
      To design the flap, a horizontal line is extended off of the short axis of the defect, and a third line is extended to run parallel to the associated edge of the rhomboid defect (Figure 6). This creates a third equilateral triangle, which will be the basis of the donor area for reconstructing the surgical defect. The flap has 4 potential geometric variations, one for each of the 4 directions on which the incoming donor area can be based.
      Figure thumbnail gr6
      Figure 6An artist's rendition of the design and execution of the rhomboid flap.
      The Dufourmentel
      • Dufourmentel C.
      Closure of limited loss of cutaneous substance Socalled “LLL” diamond-shaped L rotation-flap.
      modification of the rhombic flap also involves a rhombic-shaped defect, but one in which the angles of the involved triangles can vary from between 60 and 90°. This makes the Dufourmentel flap more versatile than the classic Limberg flap. The Dufourmentel flap design also involves a horizontal line extended off of the short axis of the defect. A second line is drawn representing a direct extension of the side of the triangular defect. A third line that bisects these 2 lines is drawn and is equal in length to one side of the triangle is the basis for the incision. An equilateral 60° triangle is then created by extending the incision, creating the donor area used for reconstruction of the defect.
      The Webster flap
      • Webster R.C.
      • Davidson T.M.
      • Smith R.C.
      The thirty degree transposition flap.
      is the final modification of the rhombic flap. This variation is similar in design to a Dufourmentel flap, but involves partial closure of the rhombic-shaped defect at the base using an M-plasty. The donor flap tip angle is then reduced from 60 to 30°, which reduces the size of the donor defect and decreases the amount of tension needed to close the wound.
      The cervicofacial flap is a combination rotation and advancement flap. First described by Mustardé in 1980, the cervicofacial flap is commonly used for reconstruction of the cheek, periorbital, and periauricular regions.
      • Mustardé J.C.
      Repair and Reconstruction in the Orbital Region: A Practical Guide.
      A major advantage of the cervicofacial flap is its ability to cover a moderate- to large-sized surgical defect owing to the large amount of skin laxity in the cheek.
      • Chu E.A.
      • Byrne P.J.
      Local flaps I: bilobed, rhombic, and cervicofacial.
      Disadvantages of the cervicofacial flap include the large amount of skin that requires mobilization, which can cause the appearance of facial asymmetry, and the relatively superficial plane of dissection, which leads to an unpredictable blood supply and the potential for flap compromise, particularly at the most distal aspect of the flap. Because of this concern, some authors have therefore advocated that at least a portion of the flap be raised in a sub-superficial muscular aponeurotic system plane.
      The design of a cervicofacial flap can include either a superiorly based or inferiorly based blood supply, depending on the clinical situation (Figure 7, Figure 8). The design of an inferiorly based cervicofacial flap involves extending an incision superiorly from the superolateral aspect of the resection margin (Figure 9). This should reach the periorbital region, where the incision then extends laterally along a subciliary crease, past the lateral canthus, and to the pretragal region. There the incision extends inferiorly into a neck crease, similar to a standard parotidectomy incision. The surgical defect can then be closed primarily. If the defect extends into the lower eyelid, care must be taken to secure the flap to the periosteum of the orbital rim or of the zygoma to minimize the risk of developing postoperative ectropion, a risk associated with this type of closure. Placing the horizontal portion of the incision at the lid–cheek junction as opposed to in a subciliary crease can also help minimize this risk.
      Figure thumbnail gr7
      Figure 7An example of a patient with a large cheek defect closed using an inferiorly based cervicofacial advancement flap. (Color version of figure is available online.)
      Figure thumbnail gr8
      Figure 8An example of a patient with a large cheek defect closed using a superiorly based cervicofacial advancement flap. (Color version of figure is available online.)
      Figure thumbnail gr9
      Figure 9An artist's rendition of the design and execution of the cervicofacial advancement flap.
      The forehead flap is an axial interpolated flap that has been in use for hundreds of years, and it is one of the most commonly used flaps in the reconstruction of large defects of the nose and periorbital region. It has several distinct advantages, including favorable tissue-match characteristics, an acceptable donor site closure, a robust and dependable blood supply, and the ability to cover large defects.
      • Papel I.D.
      Facial Plastic and Reconstructive Surgery, vol xxi.
      The major disadvantages are the requirement for a 2-stage operation and the need for wound care in the immediate perioperative period.
      The forehead flap is a pedicled flap based on the supratrochlear artery. In addition to the supratrochlear artery, the secondary blood supply to the flap is extremely robust and includes distributaries of the angular, supraorbital, and superficial temporal arteries.
      • Shumrick K.A.
      • Smith T.L.
      The anatomic basis for the design of forehead flaps in nasal reconstruction.
      Some studies suggest that the flap could survive even in the face of an occlusion of the ipsilateral supratrochlear artery. Although initially described as using a midline skin paddle, subsequent revisions have shifted the skin paddle to the paramedian position directly overlying the course of the supratrochlear artery.
      • Menick F.J.
      Aesthetic refinements in use of forehead for nasal reconstruction: the paramedian forehead flap.
      Although a midline flap provides for a more favorable scar located directly in the center of the forehead, the paramedian flap location overlying the vascular pedicle makes for improved reliability.
      The design of the paramedian forehead flap is centered over the ipsilateral supratrochlear artery, which generally lies 1.7 to 2.2 cm from the midline. The flap pedicle may be designed with a width of between 1.0 and 1.5 cm (Figure 10). The width of the working portion of the flap should be designed based on the anticipated defect requiring coverage, and if necessary, the length of the flap can be extended by carrying it into the hairline, below the supraorbital rim, or obliquely across the forehead.
      • Baker S.R.
      • Swanson N.A.
      Oblique forehead flap for total reconstruction of the nasal tip and columella.
      The flap is typically elevated in the subgaleal plane; however, some practitioners will switch to a subperiosteal dissection at the level of the orbital rim as a means of better protecting the vascular pedicle. The flap can be debulked and thinned before being inset, so that it more closely approximates the characteristics of the tissue in the region being reconstructed. The donor site can frequently be closed primarily. After 3 to 4 weeks, the vascular pedicle can be divided and the flap can be additionally debulked, as necessary. Some authors advocate an intermediate stage of debulking before final division of the pedicle.
      Figure thumbnail gr10
      Figure 10An example of a patient with a large complex nasal alar defect reconstructed using a paramedian forehead flap. (Color version of figure is available online.)
      The melolabial flap is another flap that is commonly used for reconstruction of defects of the lower portion of the nose. It can be designed as an interpolated flap, such as the forehead flap, which later requires division, or it can be designed as a single-stage transposition flap. One advantage of this flap is the proximity to the nose and lips, which requires less flap transposition when covering defects in these areas. A major disadvantage of the melolabial flap is the limited tissue available for defect reconstruction as well as the potential for facial asymmetry resulting from disruption of the ipsilateral melolabial fold.
      The flap is designed with a pedicle of between 1.5 and 2.0 cm with the medial border of the flap aligned along the ipsilateral melolabial fold (Figure 11). A template based on the surgical defect is designed along the melolabial crease in such a way as to provide adequate length for flap rotation. The flap is elevated in the subcutaneous plane and with sufficient thickness to maintain vascularity and is then rotated into the defect. The donor site can then be closed primarily and after 3 to 4 weeks, the pedicle can be divided and thinned, as appropriate.
      Figure thumbnail gr11
      Figure 11An example of a patient with a complex nasal base and columellar defect closed with a melolabial flap. (Color version of figure is available online.)

      Special considerations

      Eyelid reconstruction

      There are numerous options available for reconstruction of eyelid defects. Small superficial defects can be allowed to be closed by secondary intention, whereas small full-thickness defects can be closed primarily. Larger defects require the use of more complex reconstructive procedures, such as the Tenzel semicircular advancement flap or the Hughes tarsoconjunctival flap (Figure 12). It is important, however, to keep in mind the support system of the eyelid when performing reconstructive procedures. For example, weakening of the lateral canthal tendon can lead to ectropion, the most common form of eyelid malposition.
      • Moe K.S.
      • Linder T.
      The lateral transorbital canthopexy for correction and prevention of ectropion: report of a procedure, grading system, and outcome study.
      Other eyelid complications, such as ptosis and ectropion, can also occur if the anatomical support system of the lid is not adequately addressed during reconstruction.
      Figure thumbnail gr12
      Figure 12An example of the Tenzel flap used for closure of eyelid defects.

      Lip reconstruction

      Lip reconstruction options differ depending on the size of the tissue defect and the relative percentage of the involved lip (Figure 13). Options range from primary closure for small defects to the use of Abbe, Estlander, Gilles, and Karapandzic flaps for reconstructing large lip defects with or without involvement of the oral commissure. Lip reconstruction can leave the patient with significant functional deficits, such as oral incompetence, which can significantly impair patient quality of life, and this should be considered and discussed with the patient before reconstruction.
      Figure thumbnail gr13
      Figure 13An approach to the closure of complex upper- and lower-lip defects. (Color version of figure is available online.)

      Nasal reconstruction

      Nasal reconstruction can be complicated by cutaneous, cartilaginous, and nasal mucosal defects that require reconstruction. Small cutaneous defects can often be closed with local tissue flaps, such as a bilobe flap
      • Fedok F.G.
      • Burnett M.C.
      • Billingsley E.M.
      Small nasal defects.
      (Figure 14). Cartilaginous defects can be reconstructed with auricular or septal cartilage, although auricular cartilage is preferable, given its natural convexity and similarity in shape to the lower lateral cartilages. Nasal mucosal defects can be repaired primarily or with soft-tissue flaps, such as the septal mucoperichondrial flap, the inferior turbinate mucosal flap, or the paramedian forehead flap. Care should be taken with the reconstruction to avoid postoperative complications such as vestibular stenosis.
      Figure thumbnail gr14
      Figure 14An example of a patient with a small cutaneous nasal tip defect closed with a bilobe flap. (Color version of figure is available online.)

      Auricular reconstruction

      Reconstruction of the auricle is one of the most challenging aspects of facial reconstruction. Options for reconstruction differ depending on the thickness and the specific subsite of the defect to be repaired. This is further discussed in this issue in the accompanying article on auricular reconstruction.

      Adjunctive therapies

      There are numerous treatment modalities available for scar revision after facial reconstruction. Unfavorable scars can be simply excised or broken into smaller segments using techniques such as Z- and W-plasty, which helps to camouflage the scar by disturbing its linearity. Resurfacing procedures, such as dermabrasion, laser resurfacing, and chemical peels, are also frequently used to help minimize the appearance of scars postoperatively by stimulating collagen remodeling and neocollagenesis. Tissue augmentation techniques, such as the injection of fat or other dermal fillers, can be useful in cases of tissue loss or tissue contracture. Other techniques such as steroid injections and the application of silicone sheeting can help mitigate prominent scarring. Medical grade makeup can also be used to camouflage areas of cutaneous dyschromia.

      Conclusions

      The reconstruction of facial defects after surgery for cutaneous malignancy is a complex endeavor that requires careful consideration. There are many different reconstructive strategies available depending on the particular facial subunit that requires reconstruction. Careful recognition of the principles of the reconstructive ladder and of the facial subunits as well as in-depth knowledge of the variety of surgical techniques available will equip the surgeon to achieve the best possible functional and aesthetic outcome.

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