JOURNAL of the AmeRiCaN ACaDemy OF DerMaTOLOGY VOLUME 29 NUMBER 6 DECEMBER 1993 .= Continuing medical education Facial cutaneous reconstructive surgery: Facial flaps Bradley K. Summers, MD, and Ronald J. Siegle, MD Columbus, Ohio Basicprinciples of aesthetics and function important for successful facial cutaneous reconstructivesurgery with local flaps include the use of appropriatetissue donor sources, knowledge of the mechanisms, dynamics, and effects of tissue movement, and techniques for scar camouflage. Usefulflapsfordefects in eachof the facialcosmetic units are reviewedwiththese principles used as guidelines. (J AM ACAD DERMATOL 1993;29:917-41.) In a previous article we discussed basic concepts useful for approaching surgical defect management. We also reviewed factors that should be considered when planning a local flap repair, including tissue reservoirs, mechanisms and effects of tissue movement, and favorable incision placement. Surgical techniques that maximize the aesthetic outcome were alsodiscussed.1 This article uses these concepts as guidelines and reviews useful flap reconstructive alternatives for each of the major cosmetic units of the face. The discussion will be directed to repair of cutaneous defects of the face of up to 4 em. Relevant anatomy in each cosmetic unit will also be reviewed. THE CHEEK Management of most surgical defects ofthe cheek is usually straightforward because of the availability of excesstissue laterally and inferiorly. Excellent functional and good to excellent cosmetic results usually can be achieved. Primary closure is often possible, but care must be taken to avoid tension on important free margins and to avoid excessively long straight or curved incisions that will result in easily TheCME articlesare madepossible throughaneducational grant from the Dermatological Division, Ortho Pharmaceutical Corporation. From the Department of Otolaryngology, The Ohio State University. No reprints available. Copyright@ 1993 by the American Academyof Dermatology, Inc. 0190.9622/93 $1.00 +.10 16/2/50634 noticed scars. Closure of larger defects of the cheeks may cause facial asymmetry if the melolabial fold or other creases and wrinkles are significantly flattened. When primary closure is not possible or is compromised because of these potential problems, a local flap should be used. Cheek defects should rarely be managed with healing by second intention or with skin grafts because of poor cosmetic results. Anatomic considerations In general, the cheek is one of the safer facial cosmetic units in which to perform cutaneous surgery. However, the facial nerve and its branches are potentially at risk. 2,3 Laterally (posteriorly), the nerve is protected by the superficial lobe of the parotid gland. There it divides into its five major branches. However, when these branches exit the gland, they are covered only by the skin and superficial fascia of the superficial musculoaponeurotic system (SMAS) before they enter the posterior surface of the facial muscles that they innervate.f 5 The branches most at risk for injury are the marginal mandibular and temporal (Fig. 1). After leaving the parotid gland, the marginal mandibular branch usually lies superior to the mandible but may be up to 1.0 em below before it crosses the facial artery. Anterior to the facial artery it lies above the mandible but is covered only by skin, subcutaneous fat, and the platysma muscle before it enters the depressor muscles of the lower lip (depressor anguli oris, depressor labii inferioris, and mentalis) and the orbicularis oris mus- 917 918 Summers and Siegle Journal of the American Academy of Dermatology December 1993 Dermis Subcutaneous ':~:--:-.~ Fascia ,.........-=== Frontalis muscle Temporal branch Fig. 1. Cross-sectionalanatomy of facialsoft-tissuelayersin relation to the facial nerveand its temporal and marginal mandibular branches, which are most at risk during facial cutaneoussurgery. (Modifiedfrom May M, SobolSM, MesterSJ. Laryngoscope 1990;100:I067.) cle.6• 7 The platysma muscle is not a reliable surgical guide because it is often thin and easily missed. Transection of the marginal mandibular nerve results in apparent drooping of the contralateral lower lip. The actual deformity is a flattening, inversion, and slight elevation of the lower lip on the same side as the injury. The involved lip also cannot move downward and laterally, and the vermilion border cannot be everted.f The temporal branch of the facial nerve is at risk for injury at the lateral-superior border of the cheek as it crosses the zygomatic arch and enters the temple region. Here it lies within the superficial temporalis fascia and is afforded little protection by the thin layer of skin and fat above.? Injury to this nerve results in paralysis of the frontalis muscle and, subsequently, inability to wrinkle the forehead and raise the eyebrow. In the medial cheek, the consequences of facial nerve resection are not so great. Multiple anastomosing branches exist so that injury to one branch is usually not significant. In addition, they are deeply situated below the facial muscles so only deeply penetrating tumors will necessitate removal of the branches. Two major vessels may be encountered in surgery of the cheek. The facial artery courses from the medial border of the masseter muscle just above the mandible diagonally to the angle of mouth and then continues toward the medial canthus as the angular artery. The superficialtemporal artery arises deep to the parotid gland and, as it exits the gland, liesin the deep subcutaneous fat anterior to the tragus. Because of the rich vascular supply of the face, transection of these major vessels or other minor subcutaneous arteries of the cheek does not pose a risk of vascular compromise. The parotid duct (Stenson's duct) lies in the mid cheek where it exits from the parotid gland and courses above and perpendicular to the masseter muscle just below the SMAS and above the masseteric fascia. Injury to the duct will cause a chronic draining sinus if it is not surgically repaired. to However, because of its relatively deep location, cutaneous flap surgery of the cheek is unlikely to injure it. Journal of the American Academy of Dermatology Volume 29, Number 6 Summers and Siegle 919 temporal hairline (paramedian forehead! .... , I lateral forehead I - .... , TEMPLE " , _ UPPER EYELID LOWER _ EYELID - nasofacial _ sulcus CHEEK" mandibular" border _ _ pre -auricu lar crease --- NOSE philtra I .-_ - _.... crest := ,,- .- " ...--" __ - philtrum CUTANEOUS UPPER LIP - - - - white roll ,/' .- " '" / / '" / cupid 's bow - - - - - vermillion border ........... - .... - CUTANEOUS LOWER LIP Fig. 2. Facial cosmetic units (capital letters), forehead subunits (brackets) , and junction lines. In general, the cheek is a relatively safe area to undermine. Undermining can be done at the levelof the upper to mid subcutaneous fat without causing vascular compromise of the flap. In men, the plane should be below the level of the follicles. Deeper defects should be reconstructed with thicker flaps except in those areas with potential for nerve transection and functional compromise as discussed earlier. Aesthetic considerations The cheek is demarcated by several junction lines that hide scars particularly well (Fig. 2). These include the nasofacial sulcus, melolabialline, and pretragal sulcus. Also useful is the junction between the cheek and lower lid where incisions can be made to create advancement and rotation flaps for upper cheek defects. Unfortunately, based on the size of the cheek, most defects are not adjacent to a junction line. Thus, although flap design may utilize tissue in such a way that part of a repair may be in a junction line, many closures will be more central within the cosmetic unit. Therefore utilization of skin tension lines is critically important. These lines generally are directed in a curvilinear manner, from a horizontal direction medially to a vertical direction laterally (Fig. 3). Placement of incisions within or parallel to the tension lines of the cheek with extra care to evert wound edges is of paramount importance in cheek reconstruction. The free margins that are subject to tension and potential distortion are the lower eyelid, the upper lip, and the oral commissure. Wound repair near the lower lid should not only avoid increased tension on the lid, but also if possible should be done to decrease slightly baseline tension so that any scar contraction during maturation does not result in delayed ectropion. In contrast, with surgery near the lip, a moderate amount of eclabion is acceptable because with wound maturation and continued use of the underlying facial muscles the normal anatomy is reestablished. In reconstruction of cheek defects it is important to evaluate lower eyelid and/or upper lip position after key sutures are placed. This is best accomplished by having the patient sit up so that the 920 Summers and Siegle Journal of the American Academy of Dermatology December 1993 donor sites) should be considered when flaps are selected for cheek reconstruction. Reconstruction options effects of gravity are also considered. Having the patient gaze upward while sitting is also a helpful maneuver to assess maintenance of proper lower lid position. Reconstructive alternatives for aesthetic closure vary in specific cheek subunits. We will consider the cheek in three separate areas or subunits-preauricular cheek, medial cheek, and mid cheek-for each the reconstructive goals are different. * The preauricular cheek is the area adjacent to the pretragal crease. The medial cheek includes the area in proximity to the major junction lines of the mid face, the nasofacial sulcus and nasolabial crease. These lines can often be used to hide incisions. The mid cheek, the area between the other two subunits, is not bounded laterally or medially by junction lines, and incisions are not easily hidden in this region. The skin of the cheek is relatively uniform in thickness and texture. The skin of the medial cheek is more sebaceous than that of the lateral cheek; thus more attention to wound edge eversion is required. In addition, terminal hair content is greater on the lateral cheek, as well as in men. The baseline presence or absence of terminal hair in a surgical site (defect and Defects of the preauricular cheek are closed best with the extra tissue of the cheek and neck via advancement and/or rotation in lateral and/or superior directions. Simple advancement of tissue medial to the defect toward the ear will allow primary closure of smaller defects parallel to the skin tension lines or pretragal crease. For larger defects, inferiorly based lower cheek/upper neck single advancement or rotation flaps with incisions posteriorly in or along the pretragal crease are preferred (Fig. 4). II Dog ears can be excised as a Burow's wedge behind the lobule or can be sewn out. Plication sutures from the deep surface of the flap to the SMAS of the cheek are sometimes useful to reduce wound edge closure tension. 12, * Reconstruction of medial cheek defects is accomplished effectivelyby medial advancement of lateral cheek tissue (Fig. 5). The closure must be done with horizontal tension to avoid downward pull on the eyelid or upward pull on the upper lip and oral commissure. Incisions can be hidden in the medial and superior junction lines (the nasofacial sulcus, melolabial groove, and infraorbital crease). If the defect is not adjacent to a junction line, one may consider enlarging the defect by excising additional normal tissue so that some incisions fall within the junction line. Tension at the skin edges can be reduced by suspension sutures from the flap dennis to the periosteum of nasal bone or maxilla or to the deep soft tissue of the nasofacial sulcus. 13, 14 Defects of the upper medial cheek can also be closed by advancement/rotation flaps that primarily move tissue from the inferior cheek by incising along the nasofacial sulcus and melolabial groove (Fig. 6). However, the tension of closure is then more vertical and the risk of ectropion greater. The tension may be lessened by using a back-cut inferiorly. Another way to mobilize lower cheek tissue is via a superiorly advancing subcutaneous island pedicle flap that uses the medial junction lines to hide most incisions." Again, downward pull on the eyelid is a concern with this flap. Primary defect closure tension and undesirable secondary movement can be minimized in both of these flaps through suspension sutures. *MonhcitGD. Reconstruction of facialdefects:thecheeks.CourseNo. 201,intermediatesurgery.Presentedat the FiftiethAnnual Meeting, Dallas, Tex, Dec. 7-12, 1991. "MonheitGD. Reconstruction offacial defects: thecheeks.CourseNo. 20I, intermediatesurgery. Presented at the FiftiethAnnual Meeting, Dallas,Tex, Dec. 7-12,1991. Fig. 3. Facial skin tension lines. Journal of the American Academy of Dermatology Volume 29, Number 6 Summers and Siegle 921 ...-.... "'" ......... Fig. 4. Preauricular cheek defect closed by advancement of lower cheek tissue. Upper medial dog ear is removed by M-plasty to shorten scar length. Burow's triangle is excised behind lobule. Fig. 5. Advancement flap for medial cheek defect. Key sutures are placed so that tension of closure is directed horizontally to avoid ectropion. Fig. 6. Advancement/rotation flap for medial cheek defect. Back cut increases tissue movement and lessens closure tension of primary defect. Larger defects of the upper medial and mid cheek require more tissue for closure. This may be recruited through rotation flaps developed from the skin of the lateral and upper cheek (Fig. 7). Incision is made in the infraorbital crease as for pure advancement flaps. It is continued with an arched incision onto the temple and then inferiorly, either in a natural cheek crease or the preauricular crease, to 922 Summers and Siegle Journal of the American Academy of Dermatology December 1993 made in the infraorbital crease is edema of the lower eyelid. This may be prolonged (up to 12 months), and patients should be informed that it may occur. The upper incision may be made in the subciliary line or the mid-lower eyelid, which may lessen the chance of edema. 18 Most defects in the central to lower region of the mid cheek cannot be closed with incisions in junction lines. Often they can be closed primarily along the axis of the skin tension lines. However, long linear or curved scars on the central part of the cheek may not be aesthetically pleasing. Thus, in that circumstance, the goal for reconstruction is to create flaps that use smaller but more numerous incisions and result in a broken-line scar that is less noticeable. Inferiorly based rhombic transposition flaps with tissue from the preauricular cheek are useful in this regard (Fig. 8). 19 The Webster 30-degree transposition flap also works well and can be designed and positioned so that all but one of the closure lines are oriented in the general direction of the skin tension lines.2o THE FOREHEAD Fig. 7. Rotation flap for upper mid cheek defect. Flap design incorporates increasedheightof leadingedgeonto templeskin to accountfor shortening that occurs as it rotates medially. allow tissue rotation toward the defect. As the flap rotates medially, it is tethered around its pivot point, thereby shortening its vertical height. Therefore a key point in executing this flap is that the superior edge of the flap must be designed to include some skin of the temple. This is a variation based on the concept of the Mustarde flap used for lower eyelid reconstruction. 16, 17 The transfer of the "hump" of temple skin medially maintains the necessary elevation and position of lower lid skin and helps to prevent ectropion. Another important technique to avoid tension on the eyelid is the placement of periosteal suspension sutures. Depending on the extent of the flap and the location of the defect, these can be sutured to the zygoma, lateral orbital rim, upper medial maxilla, or nasal bone. Although these flaps are large and require relatively long incisions, they mobilize significant amounts of tissue and can close large defects. A potential complication that may occur with this flap and any flap in which incisions are Primary closure and local flaps are preferred in the management of surgical defects of the forehead. Although there is often not an abundance of extra tissue for wound closure, in most instances adequate tissue can be mobilized from the temple, the glabella, or, in older patients, from the redundancies between the horizontal creases of the forehead. There are significant differences between patients in the degree of forehead laxity. Pinching the skin vertically and horizontally is a reasonably good test of tissue laxity. However, the forehead skin is relatively inelastic, especially in older patients and those with actinic damage, and local undermining may not free up significant additional tissue for closure. Therefore large defects may pose a significant challenge. When undermining does not mobilize sufficient tissue, two procedures are available that may be useful to recruit additional tissue for closure of forehead defects. Relaxing incisions are useful for primary closure of defects of the upper forehead. This procedure is done by an incision in the scalp that extends through the galea and is 2 to 3 cm posterior to the hairline and parallel to the forehead ellipse. Undermining is then done at the subgaleallevel from the relaxing incision to the primary defect. This allows an additional I to 2 em of tissue movement Journal of the American Academy of Dermatology Volume 29, Number 6 and essentially creates a bipedicled advancement flap.21,22 A second procedure that can provide additional tissue and is a useful adjunct to wound closure on the forehead is tissue expansion. Intraoperative expansion with the Foley catheter or other inflatable expansion devices can be used to generate as much as 2.5 em of additional tissue that may be used for side-to-side closure or flap creation.P:24 The newly described suture tension adjustment reel may also be used to generate extra tissue locally.25 The aesthetic result of healing by second intention and skin grafts is generally poor on the forehead; these options are not favored. Older patients with lighter skin that is thin and less sebaceous may have acceptable results with a full-thickness skin graft, especially on the upper forehead. Because of the often sebaceous quality of forehead skin, as well as the convex contour, scars have a tendency to be depressed. Therefore wound edge eversion during closure is important. Anatomic considerations Sensory nerves of the forehead are branches ofthe first division of the trigeminal nerve. The vascular supply medially is based on the internal carotid system and laterally on the external carotid system. The supratrochlear nerves and vessels supply the medial forehead and anterior scalp. They enter the forehead at the medial aspect of the supraorbital rim. After passing through the corrugator supercilii muscle, they lie in the deep subcutaneous fat as they pass superiorly to the anterior scalp. The supraorbital nerves and vessels supply the mid and lateral forehead. They arise along the supraorbital rim at an average of 2.5 em from the midline. This neurovascular bundle passes through the fibers of the frontalis muscle, then courses superiorly in the deep subcutaneous fat. The anterior branch of the superficial temporal artery supplies the lateral forehead. It lies in the deep subcutaneous fat as it enters the forehead from the temple. Its tortuous course is often visible and/or palpable. Knowledge of its location can often prevent profuse and difficult-to-control bleeding. The relatively superficial location of the vessels and sensory nerves of the forehead places these structures at risk for injury when undermining in the deep subcutaneous fat. To preserve sensory function, the preferred level of undermining is the upper to mid fat. For larger defects and flaps, the subfront a- Summers and Siegle 923 ~pj: ~ ~~t " .':::: : .•.. ~\P 1r~1 ~ ,:!"> ....: " ~}; ~:::~. . . ' , " .,'i. .';_::\ .: .::' ".:.,:? Fig. 8. Rhombictranspositionflapfor mid cheek defect. With this design, two of four closure lines are parallel to skin tension lines. lis plane offers an avascular site for undermining. When incisions to this level are made, the neurovascular bundles should be spared whenever possible. Transection of one or mo re of the arteries of the forehead is of little consequence because ofmultiple anastomosing branches, but injury to the sensory nerves may cause anesthesia, paresthesia, and/or dysesthesia of the forehead and anterior scalp.These symptoms may last for months, but sensation usually returns to normal. Motor function is supplied to the frontalismuscle by the temporal branch of the facial nerve, that enters the deep aspect of the muscle at its lateral aspect. Branches of the nerve are at risk for injury when 924 Summers and Siegle Journal of the American Academy of Dermatology December 1993 Fig. 9. Bilateral advancement flap (A-to-T) for midline forehead defect. Many defects in this location can be closed primarily in vertical direction. surgery involves the lower subcutaneous tissue and temporoparietal fascia (SMAS) of the far lateral forehead and templef- 26 Injury of the nerve causes paresis of the ipsilateral forehead and brow, often with brow asymmetry. The asymmetry (but not the immobility) can be corrected if it is of cosmetic or functional concern to the patient by suspending the brow with permanent buried periosteal sutures ("browpexy") through an incision hidden in the superior portion of the brow. 27 Aesthetic considerations The junction lines of the forehead include the anterior hairline and the eyebrow. A more subtle line occurs at the lateral border of the forehead, the temporal ridge. Incisions placed in the hairline and brow generally heal well, assuming there has been proper recognition of hair follicle orientation. The forehead skin tension lines are generally transversely oriented (see Fig. 3). Laterally they curve downward towards the temple. Vertical or oblique creases may be found in the glabella and occasionally on the lateral forehead. Most often, the preferred direction of incision placement is horizontal and within or parallel to a transverse crease. When vertical or oblique creases are present and well-defined, incisions within them hide scars well. Midline vertical closures take advantage of the anterior extension of the galea and usually heal nicely. The eyebrow is an important aesthetic landmark that is similar to a free margin. Significant elevation or lateral or medial distortion is easily noticed and may unacceptably alter facial appearance. In the reconstruction of forehead defects, it is important to examine eyebrow position with the wound under the proposed closure tension and before final sutures are placed. Because patients in the supine position do not show the natural pull of gravity on their skin, it is often beneficial to have the patient sit up during the operation to confirm the presence of eyebrow symmetry. In some persons, significant postoperative brow elevation (up to 1 ern) may be tolerated because it usually falls to its baseline position after a few to several weeksbecause of the dynamic action of the periocular muscles. The forehead may be divided into cosmetic subunits that are helpful in guiding reconstructive decisions. These include the midline forehead, the paramedian region from midline to mid brow, and the lateral region from the mid brow to the temple. 28 Reconstruction options Midline forehead Primary vertical closure is preferred for midline forehead defects. An M-plasty often can be designed inferiorly to fall in oblique glabellar creases if they are present. For defects that lie slightly off the midline, it is helpful to widen the defect by excising normal tissue from the opposite side to allow closure centered on the midline. Horizontal primary closure is also aesthetically pleasing, but often there is less tension in the vertical direction, depending on the defect size and shape. If primary closure is not possible, a local flap should be used. Advancement flaps with incisions in the brow, the hairline, the transverse creases, or parallel to the skin tension lines are most useful. Single or double advancement flaps may be used. A-to-T type flaps with varying degrees of advancement and rotation may be designed with the base along the frontal hairline and the vertical component in the midline (Fig. 9). Bilateral rotation flaps closed in an O-to-Z manner are not preferred for the mid- Journal of the American Academy of Dermatology Volume 29, Number 6 Summers and Siegle 925 ....•. ...': • • •• • • . " " .;~'. • • :: '0' I :/ : 'I Fig. 10. Unilateral advancement flap (halfH-plasty) for paramedian forehead defect. This flap maximizes use of preferred horizontal incisions while minimizing vertical ones. Closure tension is directed away from theeyebrow. Fig. 11. Unilateral advancement flap (Burow's wedge type) for lateral forehead defect. Notethat defect lies above the brow butis extended to the brow to allow for incision placement injunction line. line,nor the forehead in general, becauseofthe conspicuous Z shape that may result from the oblique middle scar line. Transposition flaps may be used on lower midline defects to utilizeglabellar skin and can be designed with incisions in glabellar creases.P Closeattention must be given to eyebrowposition, however, because closure ofthe donordefectoften creates medialbrow asymmetry. Paramedian forehead Paramedian defects are those located over the convexity of the forehead from the midline to the mid brow. They are mostfavorably reconstructed by primary closure or by advancement flaps. Primary closure shouldbe in the transverse direction parallel to the skintension lines or within a horizontal crease or wrinkle line. Scars falling exactly within preexisting transverse creases are well hidden. Consider- ation should be givento excisingtissue beyondwhat is neededfor lesion removal to center the defect over a crease if sufficient laxity is present to still allow primary closure. Marking the creases before local anesthetic infiltration may be helpful. Advancementflapsare usefulbecause they can be designedto maximize horizontal incisions and minimize verticalincisions, thereby placing scars in the expected forehead lines. Unilateral flaps (Burow's wedge or half H-plasty) or bilateral flaps (A to T type or classic H-plasty) can be used (Fig. 10). Tissue protrusions(dog ears) can be repositioned to fall laterally, which is usually preferred. If possible, dog ears shouldbe sewnout by the rule of halvesto limit vertical scars. If the closure is still tight after flap development and undermining, suspension sutures from the flap baseseveral millimeters from the edge to the deepsoft tissue or periosteum will reduce ten- 926 Summers and Siegle sion. Intraoperative expansion can also be helpful in this situation. Rotation and transposition flaps leave less desirable curved, oblique,or vertical lines and are in general not preferred. Vertical closure off midline is also generally not preferred, with the exception that some patients have lateral forehead creases that are vertical and may be useful for hiding scars. Lateral forehead The lateral forehead includes the area from the mid brow to the temple and the contour here is flat to concave as opposed to the slight convexity of the paramedian forehead. Options for optimal reconstruction of lateral forehead defects are multiple and include those described earlier as well as several rotation and transposition flaps. The first choice should be side-to-sideclosureif anatomic boundaries can be preserved. If a flap is needed , the tissue reservoirs of the temple and even the lateral cheek skin may be utilized. Undermining should be done cautiously to avoid temporal nerve transection. Unilateral advancement flaps with a Burow's triangle removed in the "crow's feet" lines of the temple are useful (Fig. 11). Inferiorly based rotation flaps with tissue lateral to the defect take advantage of the curving skin tension lines in this area. Transposition flaps (rhombic, 30-degree) designed to redirect tension from the eyebrow and hairline also often give good results. THE TEMPLE There are multiple options for management of surgical defects ofthe temple. It is a reservoir of excess skin and thus primary closure or local flaps within the cosmetic unit can usually be accomplished. Healing by second intention and skin grafts generally give good results. The primary surgical concern is to avoidinjury to the temporal branch of the facial nerve. It is susceptible to injury in this area, as it is protected only by the skin, subcutaneous fat, and superficial temporal fascia . These layers may be thin in some persons,especially in older patients with extensive actinic damage. Aesthetic concerns of the temple include maintaining the position of the lateral canthal area and eyebrow and avoidingdistortion ofthe natural hairline, including the temporal tuft. Incisions can be favorably placed along the hairline, or in the skin tension lines that include curvilinear lines continuing from the forehead and radial "crew's feet" lines. A variety of flaps are useful for the temple Journal of the American Academy of Dermatology December 1993 including advancement, rotation, and rhombic transposition flaps. Advancement/rotation flaps with incisions lateral in the hairline are useful. Medial tissue redundancy can be excised with an M-plasty. Flaps should be cautiously undermined in the upper subcutaneous fat. Thus, with the exception of concern about the temporal branch of the facial nerve, reconstruction of the temple is usually straightforward because of the availability oftissue, multiple options to closethe defect without secondary distortion of surrounding tissue, and numerous junction and skin tension lines in which to hide the surgical scars. THE NOSE Management of surgical defects of the nose is often challenging. Maintenance of an aesthetically and functionally normal nose requires careful preoperative planning and meticulous surgical technique. However, the multiple junction lines and skin tension lines of the nose often allow even large and complex repairs to be wonderfully camouflaged . One of the challenges in nasal reconstruction is the lack of excessskin within the nasal cosmetic unit. The lower third of the nose has minimally mobile skin because of its fibrosebaceous nature and relative absence of subcutaneous fat. The upper two thirds of the nose has more mobile skin that may be utilized for primary closure or local flaps. However, this source may be limited in some persons. Significant sources of recruitable tissue are in adjacent cosmetic units, including the glabella, midline forehead, melolabial fold, and cheek. A second challenge in nasal reconstruction is maintaining the normal position of the alar rims and the lower eyelids, free margins commonly placed under increased tension by reconstruction and wound healing. In many situations there may be sufficient tissue available to close a wound by primary closure or a local flap,but the secondary movement created leads to an unacceptable free margin distortion. Closure plans must take this into consideration. The combination of the presence of free margins and the paucity of recruitable tissue makes skin graft reconstruction a necessity for many nasal defects, particularly on the lower third of the nose. The return of normal contour, color, and texture that can be achieved by flap repair makes this our first choice for most nasal reconstruction when primary closure is not possible. When local flaps are not feasible or too complex, or when the patient's cosmetic require- Journal of the American Academy of Dermatology Volume 29, Number 6 ments are not great, properly selected skin grafts offer a good alternative. When cutaneous surgery of the nose is performed , it must be remembered that the structure ofthe nose, including cartilage, bone, and skin, is crucial for maintenance of its respiratory function. Deep or large defects may result in loss of supporting structure. In those cases, more advanced reconstruction with cartilage or composite grafts may be necessary. The most beautifully designed and technically wellexecuted flaps will fail functionally if the internal as well as external structure is not respected. Anatomic considerations Sensory nerve supply to the nose is by branches of the first and second divisions of the trigeminal nerve. The root and upper lateral sidewalls are supplied by the infratrochlear nerve (a branch of V1) that arises just below the medial eyebrow. The dorsum and tip transmit sensation via the external nasal branches of the anterior ethmoid nerve, also derived from the ophthalmic division of the trigeminal nerve. The lower sidewalls, alae, and columella are supplied by the infraorbital nerve (V2). Transection of these sensory nerves during tumor resection or reconstruction leads to temporary anesthesia, with return of sensation anticipated in fewer than 12 months. Transection of motor nerves to the nasal muscles is of minimal consequence. Surgical anesthesia of specific areas of the nose may be obtained by local infiltration proximally along the specific sensory nerve supply. Total nasal anesthesia is achieved through injections at the root of the nose (advanced toward each medial canthus), the mid dorsum of the nose (advanced toward the tip), and at each alar base (advanced superiorly along the nasofacial sulcus and medially along the nasal sill toward the philtrumj.e? The vascular supply of the nose is rich and includes branches of the internal and external carotid systems. The lower nose is supplied by branches of the superior labial artery (alae, columella, and vestibule) and the angular artery (alae). The angular artery contin ues superiorly to give off branches to the sidewalls and dorsum. It also anastomoses laterally with branches of the infraorbital artery. The dorsum is also supplied by the external nasal artery that enters the nose with the external nasal branch of the anterior ethmoid nerve. This artery then courses inferiorly to the nasal tip. The upper nose is supplied by the dorsal nasal artery (a termi- Summers and Siegle 927 nal branch of the ophthalmic artery of the internal carotid system) and the distal segments of the angular artery. These vessels supply the root and dorsum of the nose from the medial canthal area and can be used as the basis of the vascular pedicle for the axial frontonasal rotation flap for nasal tip defects (see later). The plentiful nasal bloodsupply is reflected in the generally high survival rate of local flaps and grafts on the nose. The musclesthat affect nasal function include the procerus, which elevates the nose, and the levator labii superiorus alaeque nasi, the nasalis, and the depressor septi, each of which helps to dilate the nostrils. The nasal musculature in part inserts into the dermis of the nasal skin. There is thus no welldefined plane at the subdermal level for undermining as in some other facial areas in which a dermalsubcutaneous interface is readily separated. The preferred level of undermining on the nose is below the muscle layer and above periosteum and perichondrium. This plane is also relatively avascular, and there are no significant motor or sensory nerves at this level. Aesthetic considerations The junction lines of the nose include the nasofacial sulcus, the lateral ridges, the supratip crease, and the alar creases (Fig. 12).These lines, along with the skin tension lines, should be used to camouflage the majority of incisions. The cosmetic subunits of the nose include the root, dorsum, lateral sidewalls, tip, alae nasi, columella, and soft triangles. Repair within these subunits or by borrowing from adjacent subunits with incisions in their junction lines gives the most acceptable results in terms of tissue matching and incisioncamouflage.'! Often tissue must be borrowed from adjacent cosmetic units. Borges'? described the relaxed skin tension lines of the nose as being transversely oriented from the root to the tip, except on the alae where they become vertical. A series of furrows and wrinkle lines, different from those of Borges, is formed by contraction of the nasal muscles and may be seen more definitively by having the patient "wince" or " wrinkle their nose." These lines are obliquely oriented from the medial canthus to the dorsum and are preferred for incision placement. The tip and alae are generally regarded as "neutral areas" without welldefined skin tension lines. The nostril rim and the nasal tip are important free margins of the face. The effects on these struc- Journal of the American Academy of Dermatology December 1993 928 Summers and Siegle Options for reconstruction ___ -glabella lateral ridge - - - .. , - nasoractat sulcus :- - lateral sidewall __ columella - - - root - _ dorsum alar groove"" ala nasI _ ' ,::0.: ... . . ' ~C --9upratlp ~_, -tip l lobule :~)I. --sf/I~ngle '. '''---columella Fig. 12. Nasal cosmetic subunits and junction lines. tures must be considered for all options of defect management on the nose, including healing by second intention, primary closure, grafts, and flaps. Even minor degrees of elevation or asymmetry of the alar rims is easily noticed. Scars contract and shorten as they mature, and a vertically oriented scar may lead to additional rim elevation with completion of healing. Compromise of the respiratory function of the nose may also occur if these free margins are not respected in surgical planning.33 Elevation of the rim is often associated with infolding of the alar dome of the lower lateral cartilage with possible nasal obstruction. It is important to examine the nose from different angles before and during surgery. The degree of tip ptosis should be noted as a guide to the amount of elevation of the tip that may be acceptable with wound closure. Preoperative assessment of nasal function and symmetry including alar and tip position is important because minor deviations are commonly present. In addition to lateral and frontal views,the basilar view is important to assess because deformities may be noted that are otherwise not perceivable. Reconstruction: Upper two thirds Many small defects ofthe upper two thirds of the nose can be repaired by primary closure within junction lines or along the orientation of the skin tension lines and normal creases. On the root of the nose closure should be oriented transversely. On the sidewalls an oblique orientation from medial canthus to the midline supratip is best, and on the dorsum a vertical closure is preferred in the midline or along the lateral ridges. If primary closure is not possiblewithout undue tension or distortion, a functional and aesthetic local flap can usually be designed. Skin grafts are occasionally used when local tissue mobility is limited or for larger defects. Burow's grafts, in which the donor site is skin immediately adjacent to the defect, often give a better result than grafts from a distant site and are useful for lower midline dorsal defects. 34 The design of a local flap should begin by consideration of the use of donor skin from the same or an adjacent subunit. Transposition flaps are often an excellent choice because they tend to be relatively small when compared with other flap types and they allow redirection of tension vectors, both important considerations for nasal reconstruction. On the lateral sidewall, rhombic flaps with an inferior and lateral base are useful (Fig. 13).35 They can be constructed so that the tension of closure is redirected via the secondary defect to the cheek, laterally and away from the less desirable vertical direction. The donor defect can be closed in the nasofacial sulcus. Defects of the dorsum can be closed with a 3D-degree transposition flap, with the use of tissue laxity from one lateral sidewall in an inferiorly based flap and from the opposite sidewall as direct advancement (Fig. 14). The secondary defect closes parallel with the skin tension lines of the sidewall. Bilateral 30-degree flaps can be used but are not preferred because of multiple incisions. Small rotation flaps within the cosmetic unit can be used for some defects of the upper nose, particularly the sidewalls.36 However, these are useful only for small defects because the length of the flap must be relatively long and tissue mobility is limited. Carefully planned and properly executed back cuts or Z-plasties can increase flap rotation while minimizing increase in size of the flap. Advancement flaps utilizing only nasal tissue are not often used for reconstruction of the upper nose because limited amounts of tissue can be mobilized Journal of the American Academy of Dermatology Volume 29, Number 6 ..- .-;' Summers and Siegle 929 ..:.:..-~~:::- .... Fig. 13. Laterally based rhombic transposition flap for lateral nasal sidewalldefect. in this way. One flap that is occasionally useful on the upper nose is a superiorly based A-to-T type bilateral advancement flap for lower dorsum defects. The flap takes advantage of the supratip crease and vertical midline for incisions that are thus well hidden, but if the flap is sutured under tension, the contour of the dorsal nose may be altered significantly. Another advancement flap that we have found useful for dorsal defects of the upper nose is a superiorly and inferiorly based bipedicled advancement flap. This is created by incising along the nasofacial sulcus on the side of the nose closest to the defect to free lateral nasal tissue. Incisions can be made on both sides if more tissue movement is required. These releasing incisions are optimally placed in junction lines and allow for vertical closure of the defect under significantly less tension than primary closure. The medial cheek is advanced to close the secondary defect in the nasofacial sulcus and is secured with suspending sutures to the nasal bone periosteum. When the defect cannot be closed with donor skin from adjacent subunits, skin from an adjacent unit must be borrowed. The glabella and cheek are good sources. Glabellar skin may be transferred via rotation, transposition, and occasionally advancement flaps. Rotation flaps are best used for defects of the root, the dorsum, and for sidewall defects that are medially located. An incision is made from the lateral side ofthe defect and continued superiorly to the glabella where it is hidden in the ipsilateral glabellar creases (Fig. 15). A back cut made for additional movement can similarly be hidden. After the primary defect is closed, the glabellar defect can then be closed in one of two ways. If the trailing edge of the flap is thick and sebaceous, it is best to amputate by triangulation and close the glabella primarily. If the distal flap skin is supple and less sebaceous, it can ~~: ······1 -. . . . . . ""':':'. ~ >:. . , .,;;> . /$') . -~\ Fig. 14. Thirty-degree transposition flap for dorsal defect of uppertwo thirdsof the nose. M-plasty inferiorly to removedogear keeps incisions within the same cosmetic subunit. be incorporated into the glabella closure in a V-to-Y fashion. Glabellar transposition flaps are useful for defects on the lateral root. Similar to rotation flaps, they utilize the glabellar creases to hide incisions, but the take-off point is often from the medial or the superior portion of the defect. Classic rhombic-type or 930 Summers and Siegle Journa l of the Amer ican Academy of Dermatolog y December 1993 Fig. 15. Rotation flap uses glabellar tissue for closure of upper lateral nasal defect. In this instance the glabellar defect is repaired by V-to-Y closure with skin of distal edge of flap. rounded banner-type transposition flaps can transfer large amounts of glabellar tissue with ease to the lateral root of the nose. There are two potential disadvantages of using glabellar tissue for nasal reconstruction. The first is a flattening of the natural concavity of the nasal root and medial canthus that gives the nose a lengthened appearance. Oversizing the flap and suspending sutures attached to underlying periosteum can minimize this problem. A second concern is the poor match of the thicker and more sebaceous glabellar skin to upper nasal skin. This can be minimized by aggressive but cautious thinning of the flap. Cheek tissue can be used for repair of some lateral sidewall defects that abut the nasofacial sulcus. It can be advanced medially with incisions nicely hidden in the infraorbital crease and melolabial groove, or rotated superiorly from the lower medial cheek with similar incisions. In either case, blunting of the nasofacial sulcus is a problem, but deep suspending sutures from the flap to the maxilla and/or nasal bone periosteum minimize it.13 Reconstruction: Lower third of nose The most useful flaps for the lower nose are transposition flaps. The bilobed flap is useful for defects less than 1.5 em involving the lateral tip, supratip, the lower sidewall, and medial alae. It is a double transposition flap that uses tissue laxity of the upper sidewall and dorsum to close lower nasal wounds (Fig. 16). A laterally based flap is preferred , but it can be designed with a medial base for more laterally located defects. In the classic flap design, the primary lobe of the flap is designed as two thirds of the size of the surgical defect, 37, 38 When used for nasal repair, it is often necessary to match the flap size to the defect size to prevent unwanted tip or alar rim elevation. Modifications of the traditional design as described by Zitelli 39 allow this flap to be used with little risk of tip distortion and pincushioning. These include rotation of each lobe of the flap only 45 degrees (total flap rotational arc 90 to 100 degrees), the use of Burow's triangle at the point of rotation, and wide undermining in the submusc1e plane. The distant donor closure is often in the relaxed skin tension lines and the arciform incisions often heal beautifully in the more tension line-neutral areas of the nose. The nasolabial flap is another useful transposition flap for the lower nose (Fig. 17). The preferred design uses redundant medial cheek skin in a superiorly based flap with donor site incisions hidden in the melolabialline. It should be considered for small to large defects involving the lower sidewall and ala. With variations, it can be used for full-thickness defects.35, 40, 41 Zitelli,42 who argues correctly that this flap should be a one-stage procedure, has also described modifications that reduce the possibilityof pincushioning and flattening of the nasofacial sulcus. These include wide undermining of the defect and donor sites, periosteal sutures to help re-create the nasofacial sulcus, and thinning of the flap. In addition, he recommends removal of a large Burow's triangle above the initial wound. This adds a significant element of advancement to the basic movement of transposition that widens the flap base and significantly decreases the arc of rotation. This gives it an increased vascularity as well as increased outflow, thereby minimizing edema formation and possible pincushioning. Glabellar tissue may also be mobilized as described earlier in a rotation flap for lower nasal defects involving the tip and supratip (dorsal nasal flap).43 This flap was described by Rieger,44 and modifications allowing increased mobility were described by Marchac and Toth. 45 The skin of the glabella and entire dorsal nose superior to the defect Journal of the American Academy of Dermatology Volume 29, Number 6 Summers and Siegle 931 Fig. 16. Bilobed flap for lower nasal defect. Note arc of rotation is less than 180 degrees (approximately 100 degrees). Other key features of this flap are excision of a Burow's triangle at point of rotation (in this case along the alar groove) and wide undermining of defect. Fig. 17. Nasolabial transposition flap. Cheek advancement, facilitated by removal of large Burow's triangle above defect, is significant component of this flap. is mobilized and rotated, with incisions hidden in the lateral junction lines and glabellar creases (Fig. 18). The extensive incisions and undermining necessary are disadvantages of this flap. In addition, the inferior transverse closure line cannot be hidden well and may be prominent after healing. The major advantage of this flap is it allows wounds that otherwise might require skin grafts or staged forehead flaps to be repaired with adjacent nasal skin. As a rule, advancement and rotation flaps are not considered to be frequently useful flaps for the lower nose. Straight advancement of nasal dorsum and root skin, with or without a glabellar-releasing incision creating a bipedicle flap, can be used for tip and supratip defects. 46, 47 However, this may unacceptably elevate the nasal tip and / or change the contour of the dorsum. Small rotation flaps hidden in the creases can be used, but they may cause secondary distortion of the underlying cartilaginous infrastructure." Sliding island pedicle advancement flaps based on the nasalis muscle have been described for defects of the nasal tip, but we have found them to be useful only rarely.49-51 Many additional flaps have been described for upper and lower nasal reconstruction and, when used in the appropriate situations, may be anticipated to bring excellent functional and aesthetic outcomes. 52, 53 More advanced reconstruction is needed for nasal defects that involve loss of the cartilage and/or bony infrastructure. The reader is referred to other sources for a discussion of these concepts. 54-58 932 Summers and Siegle Journal of the American Academy of Dermatology December 1993 Fig. 18. Dorsal nasal rotation flap, making excellent use of junction lines, for nasa! tip defect. THE UPPER LIP The upper lip is a major cosmetic unit both for function and aesthetics. Minimal distortion can be disfiguring or cause functional compromise. Repair within the unit is preferred but is limited to small defects because minimal amounts of donor tissue are available. Tissue may be recruited from the melolabial fold and medial cheek for reconstruction of larger defects. Healing by second intention and skin grafting generally give poor results and are not preferred alternatives for most upper lip defects. Anatomic considerations The sensory innervation to the upper lip is via the infraorbital nerve (maxillary division of the trigeminal nerve). Anesthesia of the upper lip can be obtained locally or with an infraorbital nerve block.59 Blood is supplied by the superior labial artery that courses transversely along the inferior margin of the lip in the submucosa beneath the orbicularis oris muscle. Transection of the artery should not cause vascular compromise. Undermining should be below the level of the hair follicles and above the muscle to preserve its function and to avoid the labial artery. Aesthetic considerations The lip represents an aesthetic challenge because it is a free margin and it has many geographic landmarks that, if even minimally altered, may cause significant disfigurement. The upper lip has two main components, cutaneous and mucosal. The junction lines include the melolabial groove laterally, the combination of the alar base, nasal sill, and columella superiorly, and the cutaneous-vermilion junction inferiorly (Fig. 2). The cutaneous upper lip has three subunits, two lateral ones and the central philtrum created by the bilateral philtral crests. As with other facial cosmetic units, optimal incision lines include the junction lines and the skin tension lines, which on the lip are roughly vertically oriented (Fig. 3). In addition to these lines, a special line exists on the upper lip. This is known as the white roll, which is a smooth convex linear band just above the vermilion that reflects light, giving it its white color (Fig. 2). This is the ideal line in which to place transverse incisions when working at the vermilioncutaneous border. Disfigurement of the lip will be dramatic if this border is not perfectly aligned. To help prevent this, it is always important to mark the vermilion border before injection of anesthesia. Disfigurement can also occur, although to a lesser degree, if the philtral crests are significantly displaced or flattened. Borrowing tissue from lateral sources as much as possible for flap repair will minimize this. The mucosal portion of the lip includes the vermilion and the labial mucosa that ends internally at the labiogingival sulcus. Eclabion or mucosal show may be not only disfiguring but also produce functional compromise. Proper flap design can minimize these potential complications. Reconstruction options Advancement flaps are useful for cutaneous upper lip repair. For small to large defects, they can be designed to advance lateral lip tissue and, if needed, medial cheek tissue.6o Incisions can often be hidden in the white roll or at the lip-nose juncture or sometimes in both lines by excisinguninvolved skin below Journal of the American Academy of Dermatology Volume 29, Number 6 Summers and Siegle 933 Fig. 19. Cosmetic unit advancement flap for mid upper lip defect. Additional tissue is excised above and below defect to allow for camouflage of incisions. .; . Fig. 20. Bilateral advancement flaps (A-to-T) for small upper lip defects. Depending on position of defect, base of flap may either be along white roll or nose-lip junction line. or above the defect (Fig. 19). Here, more than in many areas, the concept of replacing an entire subunit is beneficial with regard to final aesthetic outcome. Burow's triangles can be excised along the cheek-alar junction and lateral to the oral commissure. Downward displacement of the vermilion may be avoided by excising tissue at the inferior edge of the flap. One disadvantage of this flap is that it flattens the melolabial groove. This may be minimized by using a periosteal suspension suture from the base of the flap to the piriform aperture of the maxilla to create a new a new groove.61 Smaller defects may be repaired within the cosmetic unit by using A-to-T type advancement flaps, with the base of the flap either superior or inferior in the junction lines and the vertical component parallel to the skin tension lines (Fig. 20). Burow's triangles may be removed lateral to the oral commissure or along the cheek-alar junction as described earlier, or the unequal wound sides may be closed by the rule of halves. This can prevent the need for removing a triangle through the vermilion border. Small defects of the mid to lateral upper lip may be repaired with rotation flaps that are created by incising superiorly from the defect to the melolabial groove and then inferiorly within it to mobilize laterallip tissue (Fig. 21). Tissue redundancy is excised inferior to the defect in the skin tension lines. The resultant scars are well hidden. As the lateral and inferior lip tissue rotates superiorly toward the defect, there is a vertical component of tension created that may elevate the lateral lip. A small degree of ec1abion is acceptable and will usually correct within I or 2 months. In addition, the lip beneath the defect may become depressed with this flap as the tissue is moved medially to close the defect. This also usually corrects with time. Defects of the superior-lateral region can be effectively repaired by inferolaterally based subcutaneous island pedicle flaps (Fig. 22).62 This flap 934 Summers and Siegle Journal of the American Academy of Dermatology December 1993 Fig. 21. Rotation flap for upper lip defect. In this case, downward displacement of upper lip beneath defect has occurred. Far lateral lip elevation may also occur with this flap. ;, .... ~ Fig. 22. Subcutaneous island pedicle flap for a superior and lateral upper lip defect. Sutures should be placed so that closure tension is horizontal to avoid lip elevation. At completion, flap's lateral and superior incisions are hidden in junction lines. advances tissue of similar characteristics into the primary defect, and the secondary defect is closed with horizontal tension, which avoids lip elevation. If the defect is at the level of the alar base or intentionally extended to the alar base, two of the three closure lines become perfectly camouflaged. Transposition flaps offer an effective means to transfer large amounts of tissue from the cheek to the upper lip.63 Their compromise is that they tend to obliterate the melolabial groove even with underlying suspension sutures. They also tend to pincushion. However, they may be useful for large defects. For lateral lip defects, either superiorly or inferiorly based transpositions can be used based on the melolabial line. For medial and superior defects, inferiorly based transposition flaps that utilize tissue from the medial cheek can be created by incising superior to the defect in the nasofacial sulcus with subsequent closure of the secondary defect along this junction line. Care must be taken not to cause ectropion, which may occur with donor defect closure, or eclabion, which may result from undersizing the flap. THE LOWER LIP Reconstructive considerations for the lower lip are similar to those for the upper lip. It has a free margin, the skin tension lines are generally radially oriented from the vermilion junction (although there is some variability), and the key cosmetic boundary that must be maintained in normal position is the vermilion-cutaneous junction. The mentolabial crease is the other primary junction line. As with the upper lip, primary closure or local flaps are preferred because healing by second intention and skin grafts generally do not give aesthetically pleasing results. Advancement flaps are useful for lower lip reconstruction. Defects of the cutaneous portion can be repaired by direct advancement of lower cheek tissue with most incisionsin the junction lines (Fig. 23). Single or bilateral flaps can be used, the latter for more centrally located defects between the vermilion and mentolabial crease. A-to-T type flaps can be designed that use these upper or lower junction lines as the base of the flap with the vertical component in the skin tension lines. Journal of the American Academy of Dermatology Volume 29, Number 6 Summers and Siegle 935 Fig. 23. Advancement flap, with excess laterallipand medial cheektissue, for midlinelower lip defect. Transposition flaps are an excellent means to harvest medial lower cheek tissue to resurface lateral cutaneous lip defects. These may be either inferiorly or superiorly based and donor sites may be hidden in the melolabial fold or infraoral crease. Defects of the lower lip are often complex, with involvement of both the mucosal surface and cutaneous surface. Traditional teaching has suggested that defects of up to one third of the lip are often best managed by extending the defect into a full-thickness triangular one and following with a wedge-type repair. 64 With proper alignment of the vermilion and three-layered closure (mucosa, orbicularis oris, and skin) the functional and aesthetic outcome is usually good. However, this has significant associated morbidity, including some degree of microstomia. Our preference is to avoid this often extensive removal of uninvolved tissue and focus on reconstruction of individual cosmetic units. The mucosal portion of the defect can be reconstructed with direct advancement of the mucosa and submucosa with closure in a transverse plane. If the defect is narrow, the mucosa can often be simply closed side to side in a vertical plane with appropriate removal of Burow's triangles. The cutaneous portion of the lip defect is then closed separately.f Large lower lip defects, especially those involving extensive muscle loss or full-thickness tissue loss,require more extensive repair. If a wedge repair will not suffice, procedures such as the Abbe-Estlander pedicle flap from the upper lip, or the Karapandzic flap, a large cheek-lip advancement flap, can be used. 66-68 THE CHIN Reconstruction of chin defects is often a challenge. The skin is thick, sebaceous, and relatively in- elastic. Most persons have minimal excess skin, and to repair large defects skin must be borrowed from the neck or lower medial cheeks. The combination of sebaceous and immobile skin on a convex surface leads to scars that are often depressed. Suturing must be done to accomplish maximal eversion and minimize tension. In addition, flap design must account for the intimate association of the chin and lower lip cosmetic units so that chin repair does not compromise lip position. Anatomic considerations Anesthesia of the chin and lower lip can be obtained by a regional block of the mental nerve. This branch of the mandibular division of the trigeminal nerve exits from the mental foramen in the middle portion of the mandible below the second premolar (mid pupillary line). 69 There are no significant motor nerves or arteries at risk for injury. Aesthetic considerations The junction lines of the chin are the labial-mental crease superiorly, the subtle mandibular lines inferiorly, and the creases at the cheek-chin junction laterally (see Fig. 2). These lateral lines are variable; some patients have a long and continuous melolabial groove, whereas others may have an infraoral crease that extends obliquely from the oral coinmissures. Some persons have no lateral lines. The best line for incision placement is the transverse to semicircular labial-mental crease. Because transverse closure within this crease is associated with vertical tension and possible depression of the lip, local flaps that redirect tension vectors to a horizontal plane while hiding one or more of the incisions are optimal. The skin tension lines should also be used for in- 936 Summers and Siegle t '~~~5~) v~ . ".'.\\\:: :;"',x·. Fig. 24. Bilateraladvancementflap (A-to-T type),with useof defect enlargementand junction lines, for chin defect. cision placement. The skin tension lines of the chin are usually directed vertically or in a laterally oblique fashion and are in continuation from the cutaneous lower lip lines (see Fig. 3). However, there is significant variability and in some cases ambiguity in their direction. They may be horizontal or semicircular or have mixed patterns. It may be helpful to undermine before final incisions are made so that the local tension and favorable lines of incision become more evident. The effect of tissue movement and repositioning on lower lip position and function should be assessed before final suturing. This may be done by having the patient sit and gently open and close his mouth, smile, and pucker. Reconstruction options The most useful flaps for the chin are advancement flaps. An A-to-T type bilateral advancement flap can often be designed with the base in the mentolabial sulcus (Fig. 24). These are obviously most useful for defects near this junction but can be used Journal of the American Academy of Dermatology December 1993 for other defects with the principle of removing additional normal tissue within a cosmetic unit to allowincisions to fall in the junction lines. Flaps of this type also have varying degrees of rotation depending on the size and location of the defect and on the shape of the mentolabial crease. With an increasing rotational component there is additional vertical tension needed to close the secondary defect and greater risk for pull on the lower lip.70 Oversizing the flaps minimizes the vertical tension. Pure rotation flaps following the curved lines of the chin may also be useful in some instances. A variation on an advancement flap that we have used for larger lower chin defects is a bipedicle advancement flap with lateral bases." This is designed to use redundant skin of the midline neck and is created by a horizontal submental relaxing incision with wide undermining. The donor defect is then closed with additional mobilization of lower neck tissue. Transposition flaps are occasionally useful for the chin. Larger defects of the upper lateral chin can be resurfaced with inferiorly based melolabial fold flaps or with superiorly based flaps using submental and anterior neck tissue. A drawback to using tissue below the chin is that the incisions that cross the mandibular line tend to become depressed and leave a "notched" appearance ofthe chin. Larger defects of the lower mid chin can be closed with bilateral or bilateral-opposing rhombic flaps (W-plasty).72,73 Although the scars created by rhombic flaps on the chin are not all favorably oriented along skin tension lines, they may not be significantly noticeable because of the broken-line closure principle of scar camouflage.74 THE EAR The external ear is composed of skin and an underlying cartilaginous structural framework, both of which are crucial for functional and cosmetic integrity. Loss of helical cartilage, change of the natural concavity of the ear, change of its anterior-posterior position, or reduction of vertical dimension or circumference all may significantly alter appearance. Eyeglass support is one of the major functions of the external ear, and reconstruction should seek to maintain or restore this function. The external ear plays an important but not critical role in auditory function. The skin of the ear is generally immobile and inelastic. The lobule and often the posterior surface of Journal of the American Academy of Dermatology Volume 29, Number 6 the auricle are exceptions, and skin for reconstruction may be recruited from these subunits. The helix may also serve as a limited donor source for cutaneous and composite flaps and grafts. For many defects, there is insufficient tissue within the cosmetic unit for repair, and adjacent or distant sites must be used. Frequently used donor sites for flaps and grafts include the preauricular and postauricular areas. Summers and Siegle 937 Crura of antihelix Scaphoid fossa Triangular f055a Crus of helix Helix Antihelix External auditory mealus Aesthetic considerations The ear is a morphologically complex structure. Significant loss of tissue is usually not of major aesthetic consequence unless it involvesthe free margin. Thus defect coverage is the goal for repair of nonhelical defects. In contrast, free margin defects require both tissue coverage and restoration of baseline structure. Skin tension lines on the ear are not well defined, and the orientation of incisions is less crucial than on other facial units. Depressed scars are common with transverse closures on the helical rim so maximal eversion, with or without Z-plasties, should be sought. Flaps developed from the preauricular and postauricular areas offer a good tissue match and allow closure in adjacent junction lines. Reconstruction options When healing by second intention, skin grafting, or primary closure will not adequately restore function and cosmesis to the ear, a flap should be considered. Useful flaps are discussed for each subunit, including the helical rim, central ear, lobule, tragus, and posterior ear. The central ear comprises the antihelix (including the upper and lower crura), the scaphoid and triangular fossae, and the concha (Fig. 25). Defects of the superior helical rim can be repaired by using the preauricular or postauricular tissue for superiorly based transposition flaps (Fig. 26).75 The flaps should be designed with sufficient length to cover the defect and avoid pulling tension on the ear. Sutures securing the base of the flap to the soft tissue of the sulcus help reestablish natural contours. Postauricular flaps allow the secondary defect to be closed in a less noticeable area. These flaps can be used as interpolation flaps when the defect and flap are separated by intact skin and the flap courses over that skin. In this case, a two-stage procedure is used and the flap pedicle is divided 2 to 3 weeks after the initial surgery. Fig. 25. The external ear. Many helical rim defects can be repaired with helical advancement flaps. Small defects without cartilage loss can be closed with bilateral skin advancement flaps designed as a classic H-plasty.76 However, such closures are limited by the buckling of the underlying cartilage that begins to appear with even moderate closure tension. Larger skin defects and full-thickness defects require advancement of cartilage and skin from above and/or below the defect (chondrocutaneous advancement flaps)." The flaps are mobilized by incising anteriorly through skin and cartilage just inside the helical rim. We prefer to leave the posterior skin intact to provide a broad vascular pedicle (Fig. 27). More tissue can be advanced from an inferior flap that takes advantage oflaxity in the lobule. Burow's triangles can be removed in the lobule if necessary. Incisions superiorly can be continued to the crus of the helix that can be advanced and closed in a V-to-Y fashion." Wedge excisionsof the ear utilize primary closure of skin and cartilage and may be used for full-thickness defects of the central and peripheral ear including the helix and antihelix. Simple wedges (Vshaped) are limited to a small size because approximation of the cartilage tends to push the upper and lower ear outward, thereby producing a bowing or cupping effect. To avoid this, secondary wedges can be removed in a fashion analogous to Burow's triangle excision. A variety of geometric patterns can be designed with this technique.P The primary disadvantage of wedge excisions is that they result in a smaller ear, which may be noticeable in the frontal view. However, if properly designed, they maintain the shape and position of the ear and usually give acceptable results. Wedge excisions should be generally limited to a size one fourth of the circumference of the auricle.s? Cartilaginous closure can be 938 Summers and Siegle Journal of the American Academy of Dermatology December 1993 Fig. 26. Transposition flap from postauricular donor site for superior helical defect. This flap redirects closure tension from primary defect to secondary defect in the postauricular sulcus, which allows free edge of ear to maintain normal position. Fig. 27. Chondrocutaneous advancement flap for helical defect. Note that posterior skin is left intact to increase vascularity of pedicle. Double Z-plasty is used to close the helix to minimize chance of notching. accomplished either with a clear permanent suture or with a long-acting absorbable suture. Helical rim defects and combined defects involving portions of the central ear (including full-thickness defects) can be repaired in a staged procedure with postauricular skin to create a pedicle flap8 1, 82 (Fig. 28). This flap is especially useful to reestablish the normal helical rim contour and in situations in which loss of perichondrium precludes skin grafting. An incision is made just posterior to the postauricular sulcus on the mastoid skin and the tissue undermined toward the scalp. The anterior edge of the ear defect is then sewn to the skin of the posterior side of this incision, thus burying the initial defect. Two to 3 weeks later, a second mastoid incision posterior to the initial one divides and frees the pedicle. The flap, already attached as originally sewn to the anterior portion of the ear defect, is then trimmed, folded on itself if necessary to create a new helical rim, and sewn to the posterior edge of the de- feet. The secondary defect created by removal of mastoid skin is closed primarily if possible or may be grafted or allowed to heal by second intention. Defects in the central ear are most commonly managed with a skin graft or by second-intention healing. When a flap is preferred (e.g., when perichondrium or cartilage have been removed), tunneled or pull-through flaps can be used. Superiorly based preauricular transposition flaps can be passed through an incision under the superior/anterior helix.8o Postauricular skin can be tunneled through a conchal incision.83 Standard nontunne1ed preauricular transposition flaps (superior or inferior base) may be useful for conchal and external ear canal defects." The lobule often may be repaired by primary closure or variations of direct closure. Incorporating a Z-plasty will lengthen the scar and reduce the chance of notching. The medial portion of the external ear includes Journal of the American Academy of Dermatology Volume 29, Number 6 Summers and Siegle 939 B o C Fig. 28. Staged postauricular pedicle flap for defect of helical rim and central ear. A, Defect of helix (full-thickness) and central ear, with planned incisions of postauricular skin. B, Flap incised and elevated. C, First stage complete, showing flap sewn to anterior edge of defect. Surgical dressing should be placed both underneath flap and on top of surgical site. D, Second stage complete. Posterior edge of flap has been released and sewn to posterior edge of defect, recreating normal helical contour. Secondary defect has been closed side to side. Fig. 29. Rotation flap for posterior auricular defect. This defect could also be closed by a postauricular transposition flap similar to that shown in Fig. 26. the tragus, antitragus, and the crus of the helix. Although grafts and healing by second intention may be appropriate, defects in this area usually can be closed with ease by advancement, rotation, or transposition of preauricular skin. The posterior ear has several management options. Skin grafts and healing by second intention again are effective and acceptable. Flap repairs of defects of the posterior ear can take advantage of the close availability of the post auricular skin reservoir 940 Summers and Siegle and the laxity of the posterior surface of the ear. Traditional rotation or transposition flaps are the most useful (Fig. 29). To maximize flap viability, the flap base should be broad. For large defects, it should probably be based on the sulcus tissues. Whenever possible, flaps with an inferior base should have preference over superiorly based ones to minimize pincushioning. CONCLUSION We have outlined frequently useful flaps for each of the facial cosmetic units. The principles reviewed can be useful guidelines in consideration of reconstructive alternatives for cutaneous surgical defects of the face. However, reliance on a "cookbook" approach to reconstruction may not result in optimal cosmetic and functional outcomes in all cases and will be significantly limiting when challenged with more complex defects. Surgical expertise comes through knowledge and application of basic principles of reconstructive surgery, as well as experience. We thank Nancy Sally of The Ohio State University for her preparation of the illustrations in this article and the November 1993 CME article. REFERENCES I. Summers BK, Siegle RJ. Facial cutaneous reconstructive surgery: general aesthetic principles. J AM ACAD DERMATal 1993;29:669-81. 2. Bernstein L, Nelson RH. Surgical anatomy of the extraparotid distribution of the facial nerve. Arch Otolaryngol 1984;110:177-83. 3. May M, Sobol SM, Mester SJ. Managing segmental facial nerve injuries by surgical repair. Laryngoscope 1990; 100:1062-7. 4. Barton FE Jr. The SMAS and the nasolabial fold. Plast Reconstr Surg 1992;89:1054-7. 5. Thaller SR, Seok K, Patterson H, et al. The submuscular aponeurotic system (SMAS): a histologic and comparative anatomy evaluation. Plast Reconstr Surg 1990;86: 690-6. 6. Liebman EP, Webster RC, Gaul JR, et a!. The marginal mandibular nerve in rhytidectomy and liposuction surgery. Arch Otolaryngol Head Neck Surg 1988;114:179-81. 7. Stern SJ. Precise localization of the marginal mandibular nerve during neck dissection. Head Neck 1992;14:328-31. 8. Moffat DA, Ramsden RT. The deformity produced by a palsy ofthe marginal mandibular branch of the facial nerve. J Laryngol OtolI977;91:401-5. 9. Stuzin JM, Wagstrom L, Kawamoto HK, et a!. Anatomy of the frontal branch of the facial nerve: the significance of the temporal fat pad. Plast Reconstr Surg 1989;83:265-71. 10. Salasche 5J, Bernstein G, Senkarik M. Surgical anatomy of the skin. Norwalk, Conn: Appleton & Lange, 1988:256. 11. Field LM. The combination of a cheek advancement rotation flap with an M-plasty for upper preauricular excisions. J Dermatol Surg On col 1985; II :974-6. Journal of the American Academy of Dermatology December 1993 12. Webster RC, Smith RC, Smith KF. Face lift, part 4; use of superficial musculoaponeurotic system suspending sutures. Head Neck Surg 1984;6:780-91. 13. Salasche SJ, Jarchow R, Feldman BD, et a!. The suspension suture. J Dermatol Surg Oncol 1987;13:973-8. 14. Zitelli JA. Tips for wound closure: pearls for minimizing dog ears and applications of periosteal sutures. Derrnatol Clin 1989;7:123-8. 15. Jackson IT. Local flaps in head and neck reconstruction. St Louis: CV Mosby, 1985:234-6. 16. Callahan MA, Callahan A. Mustarde flap lower lid reconstruction after malignancy. Ophthalmology 1980;87:27986. 17. Mustarde' JC. Repair and reconstruction in the orbital region. Edinburgh: Churchill Livingstone, 1991:125-90. 18. Bahr W, Bagambisa FB, Schlegel G, et al. Comparison of transcutaneous incisions used for exposure of the infraorbital rim and orbital floor: a retrospective study. Plast Reconstr Surg 1992;90:585-91. 19. Bennett RG. Local skin flaps on the cheeks. J Derrnatol Surg OncoI1991;17:161-5. 20. Webster RC, Davidson TM. The thirty degree transposition flap. Laryngoscope 1978;88:85-94. 21. Stoner JG, Swanson NA. Use of the bipedicled flap for forehead reconstruction. J Dermatol Surg Oncol 1984; 10:213-5. 22. Tromovitch TA, Stegman SJ, Glogau RG. Flaps and grafts in dermatologic surgery. Chicago: Year Book, 1989:88. 23. Baker SR, Swanson NA. Rapid intraoperative tissue expansion in reconstruction of the head and neck. Arch Otolaryngol Head Neck Surg 1990;116:1431-4. 24. Sasaki GH. Intraoperative sustained limited expansion (ISLE) as an immediate reconstructive technique. Clin Plast Surg 1987;14:563-73. 25. Cohen BH, Cosmetto AJ. The suture tension adjustment reel. J Dermatol Surg Oncol 1992;18:112-23. 26. Dzubow LM. The fasciae of the face: an anatomic and histologic analysis. J AM ACAD DERMATOl 1986;14:502-7. 27. McCord CD, Doxanas MT. Browplasty and browpexy: an adjunct to blepharoplasty. Plast Reconstr Surg 1990; 86:248-24. 28. Siegle RJ. Forehead reconstruction. J Dermatol Surg Oncol 1991;17:200-4. 29. Tromovitch TA, Stegman SJ, GlogauRG. Flaps and grafts in dermatologic surgery. Chicago: Year Book, 1989:87. 30. Auletta MJ, Grekin RC. Local anesthesia for dermatologic surgery. New York: Churchill Livingstone, 1991:50-2. 31. Burget GC, Menick FJ. The subunit principle in nasal reconstruction. Plast Reconstr Surg 1985;76:239-47. 32. Borges AF. Relaxed skin tension lines (RSTL) versus other skin lines. Plast Reconstr Surg 1984;73: 144-50. 33. Robinson JK, Burget Gc. Nasa! valve malfunction resulting from resection of cancer. Arch Otolaryngol Head Neck Surg 1990;116:1419-24. 34. Zitelli JA. Burow's grafts. J AM ACAD DERMATOl 1987; 17:271-9. 35. Zitelli JA, Fazio MJ. Reconstruction of the nose with local flaps. J Dermatol Surg Oncol 1991; 17:184-9. 36. Salasche SJ, Grabski WJ. Flaps for the central face. New York: Churchill Livingstone, 1990:36-7. 37. Zimany A. The bilobed flap. Plast Reconstr Surg 1953; 11:424-34. 38. McGregor JC, Souitar DS. A critical assessment of the bilobed flap. Br J Plast Surg 1981;34:197·205. 39. Zitelli JA. The bilobed flap for nasal reconstruction. Arch Dermato! 1989;125:957-9. Journal of the American Academy of Dermatology Volume 29, Number 6 40. Spear SL, Kroll SS, Rornm S. A new twist to the nasolabial flapfor reconstructionof lateral alar defects. Plast Reconstr Surg 1987;79:915-20. 41. Robinson JK, Horan DB. Modified nasolabialtransposition flap provides vestibular liningand cover of alar defect with intact rim. Arch DermatoI1990;126:1425-7. 42. Zitelli JA. The nasolabial flap as a singlestage procedure. Arch Dermatol 1990;126:1445-8. 43. Rigg BM.The dorsal nasal flap. Plast ReconstrSurg 1973; 52:361-4. 44. Rieger RA. A local flap for repair of the nasal tip. Plast Reconstr Surg 1967;40:147-9. 45. Marchac D, Toth B. The axial frontonasal flap revisited. Plast Reconstr Surg 1985;76:686-94. 46. Strauch B, Fox M. V-Y bipedicle flap for resurfacing the nasal supratip region. Plast Reconstr Surg 1989;83:899903. 47. Zook EG, Van Beek AL, Russell RC, et al. V-Y advancement flap for facial defects. Plast Reconstr Surg 1980; 65:786-97. 48. Winton GB, Salasche SJ. Use of rotation flaps to repair small surgicaldefectson the ala nasi.J DermatolSurg Oncol 1986;12:591-6. 49. Staahl TE. Nasalis myocutaneous flap for nasal reconstruction. Arch Otolaryngol Head Neck Surg 1986; 112:302-5. 50. Rybka FJ. Reconstruction of the nasal tip using nasalis rnyocutaneous sliding flaps. Plast Reconstr Surg 1983; 71:40-4. 51. ConstantineV. Nasalis myocutaneousslidingflap: repair of nasalsupratipdefects.J DermatoiSurgOncol1991 ;17:43944. 52. JacksonIT. Local flaps in head and neck reconstruction. St Louis: CV Mosby, 1985:87-88. 53. Tromovitch TA, Stegman SJ, Glogau RG. Flapsand grafts in dermatologic surgery. Chicago: Year Book, 1989:12168. 54. Burget GC. Aesthetic restoration of the nose. Clio Plast Surg 1985;12:463-80. 55. Burget Gc. The axial paramedian forehead flap. In: Strauch B, Basconez LO, Hall-Findlay EJ, eds. Grabb's encyclopedia of flaps. Boston: Little, Brown, 1990:204-15. 56. ThomasJR, Griner N, Cook TA. The precisemidlineforehead flap as a musculocutaneous flap. Arch Otolaryngol Head Neck Surg 1988;114:79-84. 57. Adamson JE. Nasal reconstruction with the expanded forehead flap. Plast Reconstr Surg 1988:81: 12-20. 58. Burget OC, Nasal reconstruction: seekinga fourth dimension. Plast Reconstr Surg 1986;76:145-57. 59. Auletta MJ, Grekin RC. Localanesthesiafor dermatologic surgery. New York: Churchill Livingstone, 1991:59-62. 60. WebsterJP. Crescenticperialarcheek excision forupperlip flap advancement. with a short history of upper lip repair. Plast ReconstrSurg 1955;16:434-64. Summers and Siegle 941 61. Zitelli JA. A regionalapproach to reconstruction of the upper lip. J Dermatol Surg.OncoI1991;17:143-8. 62. Skouge JW. Upper lip repair: the subcutaneous island pedicle flap. J Dermatol Surg Oncol 1990;16:63-8. 63. Lawrence WT. The nasolabial rhomboid flap. Ann Plast Surg 1992;29:269-73. 64. Knowles RW. Wedge resection of the lower lip. J Dermatol Surg 1976;2:141-2. 65. Field LM. An improveddesign for vermilionectomywith a mucous membrane advancement flap. J Dermatol Surg OncoI1991;17:833-4. 66. Karapandzic M. Reconstruction of lip defects by local arterial flaps. Br J Plast Surg 1974;27:93-7. 67. Baker SR, Krause CJ. Pedicle flapsin reconstructionof the lip. Facial Plast Surg 1983;1 :61-8. 68. Maves MD, BoozanJA. Major upper and lower lip reconstruction. Facial Plast Surg 1989;6:204-23. 69. Salasche SJ, Bernstein G, Senkarik M. Surgical anatomy ofthe skin.Norwalk,Conn:Appleton & Lange, 1988:118-9. 70. Dzubow LM. Facial flaps: biomechanics and regional application. Norwalk, Conn:Appleton & Lange, 1990: 145-6. 71. Snow JW. Submental advancement skin flapto the chin.In: Strauch B, Basconez LO, Hall-Findlay EJ, eds. Grabb's encyclopedia of flaps. Boston: Little, Brown, 1990:448-9. 72. Wheeland RG. Reconstruction of the lower lip and chin using local and random-pattern flaps. J Dermatol Surg Oncoll991;l7:605-15. 73. Becker H. Rhomboid-to-W flap. Ann Plast Surg 1983; 11 :125-30. 74. Webster RC, DavidsonTM, Smith RC. Geometric broken line closure. Clin Plast Surg 1977;4:263-74. 75. Mellette JR. Ear reconstruction with local flaps. J Dermatol Surg Oncol 1991; 17:l76-82. 76. TromovitchTA,StegmanSJ, Glogau RG. Flapsand grafts in dermatologicsurgery. Chicago: Year Book, 1989:193-5. 77. Antia NH, Bueh VI. Chondrocutaneous advancement flap for the marginal defect of the ear. PIast Reconstr Surg 1967;39:472-7. 78. Koranda FC, Grande DJ. Reconstruction of the upper helix of the ear. J Dermatol Surg OncoI1982;8:477-81. 79. CeilleyR. The ear. In: Roenigk RK, Roenigk HH. Dermatologicsurgery:principlesand practice. New York: Marcel Dekker, 1989:357-81. 80. Tebbetts JB.Auricular reconstruction:selectedsingle-stage techniques. J Dermatol Surg Oncol 1982;8:557-66. 81. Jackson IT. Local flaps in head and neck reconstruction. St Louis: CV Mosby, 1985:262-6. 82. Millard DR Jr. Reconstruction of one-third plus of the auricular circumference. Plast Reconstr Surg 1992;90:475-8. 83. Jackson IT. Local flaps in head and neck reconstruction. St Louis: CV Mosby, 1985:257-61.
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