32 189 Nasal Reconstruction It must also be noted that the thickness of the skin of the nose varies consider- ably. The skin of the upper dorsum and sidewalls of the nose (zone I) is smooth, thin, relatively nonsebaceous and moves fairly easily over the underlying skeleton. The skin of the supratip, tip and alae (zone II) is thick, dense and sebaceous. Finally the skin of the soft triangles, alar magins, infratip and columella (zone III) is smooth, thin and relatively nonsebaceous, but unlike the dorsum and sidewalls is densely adherent to the underlying cartilaginous skeleton and does not move easily. Preoperative Considerations As with all surgery, routine preoperative risk stratification should be undertaken, particularly when planning an extensive multi-staged reconstruction. A plan should be outlined for “replacing like with like.” A functional nose must possess three basic elements: lining, support and cover. Options for replacing these tissues are outlined in Table 32.1. Several authors advocate the use of a preoperative or intraoperative template to plan the design of flaps. Classically the aluminum foil wrapper from a chromic suture is used to create a three dimensional template of the nasal subunits which need to be replaced. This template is then flattened out to reveal the actual size of the flap or skin graft which needs to be harvested. Skin defects comprising greater than 50% of a given aesthetic subunit should be enlarged to encompass the entire subunit to avoid noticeable scars and contour deformities within individual subunits. One must be cautious when analyzing the defect. Factors such as edema, scarring, previous attempts at repair, wound contracture, secondary healing, gravity and skin tension can all distort the true size and shape of the defect, and one must take any or all of these factors into account. Figure 32.1. Surface anatomy of the nose: the aesthetic subunits. (1) Dorsum, (2) sidewall, (3) tip, (4) soft triangle, (5) alar-nostril sill, (6) columella. 32 190 Practical Plastic Surgery Operative Technique Primary Closure The relatively mobile nature of zone I skin can allow for primary closure of some small defects. As always, lines of relaxed skin tension should be utilized when able. The relatively thick, immobile nature of zone II and III skin makes for difficult mobilization. If primary approximation of the wound results in unacceptable ten- sion or deformity, a skin graft or local flap should be used. Skin Graft Skin grafts can be of use in reconstruction of fairly superficial defects of the nose, particularly the nasal sidewalls which are planar subunits and well approximated by the flat contraction of a skin graft (as opposed to the convex contraction of a flap reconstruction). Appropriate donor sites in terms of color and texture match in- clude preauricular and supraclavicular skin. Full-thickness skin should be used to minimize contraction and provide the best match for the depth of the defect. When relevant, perichondrium and periosteum at the recipient site should be preserved to facilitate skin graft take. Full-thickness defects including some nasal cartilage can also be addressed through an appropriately designed composite graft including au- ricular skin and cartilage. Locoregional Flaps The relatively mobile skin of the nasal dorsum and sidewalls can be used in a typical V-Y advancement fashion for small defects. The bilobe and rhomboid flaps Table 32.1. Autogenous tissue options for nasal reconstruction Lining Full-thickness skin graft Turnover flap Nasolabial lining flap Bipedicle alar margin ribbon flap Contralateral mucoperichondrial flap Septal pivot flap Microvascular free flap Support Septal cartilage Conchal cartilage Costal cartilage (6th through 9th ribs) Costocondral junction graft (usually 8th rib) Cranial bone graft Iliac crest bone graft Costal bone graft Surface Coverage Local advancement flap Preauricular skin graft Bilobed flap Nasolabial flap Paramedian forehead flap Scalp flap Microvascular free flap 32 191 Nasal Reconstruction can be used to address small defects of the nasal dorsum and sidewall, but in practice often generate distorting dog ears which must be carefully planned so as not to distort the normal contours of the nasal surface. The skin of the glabellar region can be mobilized in an advancement, V-Y, or transposition fashion to address defects of the upper third of the dorsum or sidewall. The nasolabial flap has been used for reconstruction of defects of the nasal alae since the earliest descriptions of facial plastic surgery. The flap can be advanced or rotated into place based on an inferior or superior pedicle respectively, relying on random extensions of an axial blood supply derived from the angular branch of the facial artery. The flap provides reliable coverage, and the donor defect is easily con- cealed in the natural crease of the nasolabial fold. The superiorly based flap generally requires secondary revision of the cone of tissue generated by rotation of the flap into place. The inferiorly based flap results in a donor defect which can often be closed primarily and requires revision only to correct any excessive distortion of lip height. The paramedian forehead flap is the workhorse for larger full-thickness defects of the lower two-thirds of the nose. Forehead skin is the ideal donor for the thick, seba- ceous skin of zone II, and convex contracture of the flap results in an ideal contour match for the nasal tip and alae. The flap is based on random extensions of axial blood supply from both the supratrochlear and supraorbital arteries. The flap is designed over the contralateral supratrochlear artery to allow for greater ease of rotation. The base should include approximately 1.5 cm of width, with incisions designed to fall naturally into the procerus and corrugator skin creases. The distal portion of the flap is shaped based on a foil suture-package pattern designed to match the nasal subunits requiring replacement, taking care to accurately account for shortening of the flap with rotation. The distal flap is elevated in the subdermal plane to better approximate the depth of the defect it will be filling. The remainder of the flap is transitioned to a submuscular plane to optimize the vascular pedicle. The flap is divided after a period of three weeks allowing for inosculation of the distal flap. Composite Flaps and Free Tissue Transfer Significant loss of underlying structural elements and nasal mucosal lining re- quire adequate replacement. Conchal, septal or rib cartilage may be harvested and shaped into structural support grafts to provide stability for overlying soft tissue reconstructions. Nasal lining may be provided by skin grafts, locoregional flaps or free microvascular tissue transfer. Contralateral mucoperichondrial flaps and facial artery musculomucosal flaps have been described for nasal lining. Recent reports have described the use of radial forearm skin as a thinned free flap for replacement of nasal lining in extreme defects. Postoperative Care The extent of postoperative care depends on the complexity of the repair. Head elevation, cold compresses and avoidance of nose blowing are recommended. In- cisions should be washed daily to avoid crusting which makes suture removal very difficult. Intranasal saline spray should be used when needed. Skin grafts can be bolstered using cotton soaked in mineral oil and covered with Xerform® which is held in place with nylon sutures. Splints may be employed if significant osteocartilagenous reconstruction was undertaken. Use of devascularized tissues (cartilage, skin, or bone grafts) generally indicates some period of postoperative antibiotic coverage. Patients should be adequately counseled as to the multi-stage nature of more extensive reconstructions. 32 192 Practical Plastic Surgery Pearls and Pitfalls • Most surface contours of the nose are either flat (such as the dorsum) or convex (such as the alae). Reconstruction of flat surfaces is best done with a skin graft that contracts in a linear fashion, whereas convex surfaces should be reconstructed with a flap that contracts in a spherical manner. • When designing a flap for nasal reconstruction, for example the forehead flap, it is critical to account for loss of flap length that results from the arc of rotation. A Raytek® sponge can be used to determine the designed length of the flap. By holding one end of the sponge over the base of the flap and rotating the other end into the defect, the amount of extra length needed to overcome the arc of rotation can be determined. • There are exceptions to the rule of replacing “like with like” tissue. For ex- ample, the alar rims normally have a convex shape even though they do not contain cartilage. However, their convexity can best be restored using carti- laginous support. Suggested Reading 1. Burget GC, Menick FJ. The subunit principle in nasal reconstruction. Plast Reconstr Surg 1985; 76(2):239. 2. Burget GC, Menick FJ. Nasal reconstruction: Seeking a fourth dimension. Plast Reconstr Surg 1986; 78(2):145. 3. Menick FJ. Artistry in aesthetic surgery. Aesthetic perception and the subunit prin- ciple. Clin Plast Surg 1987; 14(4):723. 4. Millard Jr DR. Aesthetic reconstructive rhinoplasty. Clin Plast Surg 1981; 8(2):169. 5. Singh DJ, Bartlett SP. Aesthetic considerations in nasal reconstruction and the role of modified nasal subunits. Plast Reconstr Surg 2003; 111(2):639. Chapter 33 Practical Plastic Surgery, edited by Zol B. Kryger and Mark Sisco. ©2007 Landes Bioscience. Lip Reconstruction Amir H. Taghinia, Edgar S. Macias, Dzifa S. Kpodzo and Bohdan Pomahac Introduction The lips are not only a major aesthetic component of the face, but are also im- portant for facial expression, speech and eating. Goals in lip reconstruction are to restore normal anatomy, oral competence and contour. These goals are easily at- tained following repair of small lip defects. However, restoring these characteristics of the lips in large defects remains a more arduous task. Although many different methods of lip reconstruction have been described in the literature, a few of the important and more commonly utilized methods are outlined in this chapter. Anatomy The subunits of the surgical upper and lower lips are shown in Figure 33.1. The surgical upper lip includes the entire area from one nasolabial fold to the other, and all structures down to the oral orifice. It extends intraorally to the upper gingivola- bial sulcus. It is divided into the vermilion, one central and two lateral aesthetic subunits. The lower lip includes all structures superior to the labiomental fold in- cluding the vermilion and continuing intraorally to the inferior gingivolabial sulcus. Extending from the nasal base are bilateral philtral columns flanking the cen- trally located philtrum (Fig. 33.2). The philtral columns extend downward to meet the vermilion-cutaneous junction (also known as the ‘white roll’) of the upper lip. Cupid’s bow is the portion of the vermilion-cutaneous junction located at the base of the philtrum. The tubercle is the fleshy middle part of the upper lip from which the vermilion extends bilaterally to meet the commissures. The vermilion of the lower lip is bisected by the central sulcus which is prominent in some individuals. The lower lip is considered less anatomically complex than the upper lip because it lacks a definitive central structure. The vermilion is made of a modified mucosa with submucous tissue and orbicu- laris oris muscle underneath. The large number of sensory fibers per unit of vermil- ion is reflected in its comprising a disproportionately large part of the cerebral cortex. It has a high degree of sensitivity to temperature, light touch and pain. The natural lines of the vermilion are vertical, thus scars on the vermilion should be placed vertically if possible. The muscular anatomy of the lips is shown in Figure 33.3. The primary muscle responsible for oral competence is the orbicularis oris muscle. This muscle func- tions as a sphincter, puckering and compressing the lips. The fibers of the orbicu- laris oris muscle extend to both commissures and converge with other facial muscles just lateral to the commissures at the modiolus. The major elevators of the upper lip are the levator labii superioris, levator anguli oris and the zygomaticus major. 33 194 Practical Plastic Surgery The mentalis muscle elevates and protrudes the middle portion of the lower lip. The major depressors of the lips are the depressor labii inferioris and depressor anguli oris. The risorius muscle pulls the commissures laterally. The blood supply to the lips comes from the superior and inferior labial arteries, which in turn are branches of the facial arteries (Fig. 33.3). The paired superior and inferior labial arteries form a rich network of collateral blood vessels, thus providing a dual blood supply to each lip. These vessels lie between the orbicularis oris and the buccal mucosa near the transition from vermilion to buccal mucosa. There are no specific veins; instead there are several draining tributaries that eventually coalesce Figure 33.1. Subunits of the surgi- cal upper and lower lips. The na- solabial folds on either side com- prise the lateral borders of the upper and lower lips. The upper lip is made of the upper vermilion (4), two lateral subunits (1,3) and one central subunit (2) and the philtrum. These subunits are separated by the philtral columns and the white roll. The lower lip is made of the lower vermilion (6) and a large central unit that ends inferiorly at the la- biomental fold. Figure 33.2. Topographic anatomy of the lips. 33 195 Lip Reconstruction Figure 33.3. Anatomy of the perioral facial muscles. The facial nerve is not shown. See text for details. 33 196 Practical Plastic Surgery into the facial veins. The lymphatic channels of the upper lip and lateral lower lip drain into the submandibular nodes; whereas, the central lower lip lymphatics drain into the submental nodes. Motor innervation of the perioral muscles is from facial nerve branches. The buccal branches of this nerve supply motor input into the lip elevators; whereas, the marginal mandibular branches supply the lip depressors. The motor nerve enters each individual muscle on its posterior surface. Sensory supply to the upper lip comes from the infraorbital nerve (second trigeminal branch) and the lower lip is supplied by the mental nerve (third trigeminal branch). Primary Closure Lip lesions are typically due to trauma, infection, or tumors. Defects less than one-fourth to one-third of the total lip length can be closed primarily. This involves the apposition of the lateral margins of the wound on both sides and direct layered closure. The muscle is approximated with interrupted deep absorbable sutures. The white roll is closely approximated and then the labial mucosa and vermilion are closed. Finally, the skin is closed with fine nonabsorbable sutures. Ideally, primary closure should cause minimal aesthetic and functional defor- mity; however, it can sometimes result in reduction of the oral aperture as well as asymmetry of the involved lip. Furthermore, primary closure in the upper lip can be problematic because opposing the edges of a large wound may create unfavorable distortion of the philtrum. Vermilion Reconstruction The vermilion spans the entire length of the oral aperture, becoming increas- ingly narrow and tapering laterally as it approaches the commissure on both sides. It forms the transition zone between skin and mucosa of the inner mouth. Defects involving the vermilion can range from superficial, such as leukoplakia in which there is limited compromise of the integument, to significant, in which tissue deficit extends to deeper muscle and mucosal tissue. Although small defects of the vermil- ion can be primarily closed or left alone to heal by secondary intention, larger de- fects require reconstruction. Precise alignment of the vermilion-cutaneous margin on both sides ensures a curvilinear appearance of the border and avoids step-offs or lip notches after heal- ing. The traditional labial mucosal advancement flap can replace vermilion resec- tions that span the entire length of the lower lip. The mucosa on the buccal surface of the lower lip is undermined and advanced to the previous mucocutaneous junc- tion. Maximal use of blunt undermining helps to preserve sensory innervation of this vermilion-to-be. Additional advancement can be achieved using a transverse incision in the gingivobuccal sulcus and in the process creating a bipedicled mucosa flap based laterally (Fig. 33.4). Extensive flap mobilization usually results in an in- sensate flap. A notched appearance of the vermilion can result from scar contractures or ver- milion volume deficiency (due to previous surgery or trauma). Scar contractures can be released with a Z-plasty. This procedure recruits vermilion tissue on either side of the scar to functionally lengthen the scar in the antero-posterior and supero-inferior direction. A notched appearance due to volume deficiency can be corrected with a local musculomucosal V-Y advancement flap (Fig. 33.5). 33 197 Lip Reconstruction The next option of donor tissue is a flap from the ventral surface of the tongue but it is less than ideal because of color mismatch. Pribaz described the facial artery musculomucosal (FAMM) flap, which is a based on the facial artery and is used to reconstruct defects involving vermilion, lip, palate and a host of other oral struc- tures. Labia minora grafts can also be used to reconstruct the vermilion. Figure 33.4. Vermilion reconstruction using labial mucosal advancement flap— cross-sectional view. Figure 33.5. Repair of lower lip vermilion notch using V-Y advancement flap. 33 198 Practical Plastic Surgery Commissure Reconstruction Commissure deformities often result from electrical burns, trauma, or reconstruc- tive lip surgery. For post-burn commissure contractures, splinting techniques have reduced the need for surgical correction. Nevertheless, repairing deformities that do not respond to conservative measures remains complex. The intricate network of adjoining perioral muscle fibers at the modiolus (which is crucial for oral competence and facial animation) is nearly impossible to reconstruct. Furthermore, the contralat- eral commissure is the gold standard of comparison when evaluating the results of a unilateral reconstruction, thus leaving little room for discrepancy. Various approaches attempt to repair mucosal defects involving the commissure including the simple rhomboid flap, in which intraoral mucosa is advanced to reconstruct the commissure angles after an incision is made to widen the commissure laterally. The tongue flap also may be used when the mucosal defect is thick in the region of the commissure. Despite many proposed techniques, commissure reconstruction remains a difficult task and attempts at reconstruction often yield poor results. Upper Lip Reconstruction Upper lip cancers are usually basal cell carcinomas that spare the vermilion. The central aesthetic subunit of the upper lip, the philtrum, makes upper lip reconstruc- tion more challenging than lower lip reconstruction. Upper lip defects can be di- vided into partial-thickness and full-thickness defects. Partial-thickness Defects Partial-thickness philtral defects can be allowed to heal by secondary intention or skin grafting. The triangular fossa skin-cartilage composite graft is well-described for reconstructing the philtrum in burn patients (Fig. 33.6). Partial-thickness de- fects of the lateral subunits can be repaired by a variety of means (Fig. 33.7). For larger lateral subunit defects, an inferiorly-based nasolabial flap may be employed (sometimes to replace the entire lateral subunit). Upper lip defects that are next to Figure 33.6. Conchal skin-cartilage composite graft to repair the philtrum in burn patients. [...]... the Karapandzic flap In: Evans GRD, ed Operative Plastic Surgery New York: McGraw-Hill, 2000:29 8-3 07 4 Kroll SS Staged sequential flap reconstruction for large lower lip defects Plast Reconstr Surg 1991; 88 (4) :62 0-6 25 5 Pribaz J, Stephens W, Crespo L et al A new introral flap: Facial artery musculomucosal (FAMM) flap Plast Reconstr Surg 1992; 90(3) :42 1 -4 25 6 Spira M, Hardy SB Vermilionectomy: review... lower lip reconstruction 200 Practical Plastic Surgery A B C Figure 33.8 Repair of partial-thickness upper lip defects The lesion (A) is excised leaving a circular partial-thickness defect The defect can be closed with an inferiorly-based nasolabial flap (B) or using advanced tissue from the cheek and lip (C) The nasolabial flap is less ideal in men because the flap is not hair-bearing Lower Lip Reconstruction... Reconstr Surg 19 64; 33:3 9 -4 6 7 Wechselberger G, Gurunluoglu, Bauer T et al Functional lower lip reconstruction with bilateral cheek advancement flaps: Revisitation of Webster method with a minor modification in the technique Aesthetic Plast Surg 2002; 26(6) :42 3 -4 28 8 Zide BM Deformities of the lips and cheeks In: McCarthy JG, ed Plastic Surgery New York: WB Saunders Co., 1990 Chapter 34 Mandible Reconstruction... Behmand RA, Rees RS Reconstructive lip surgery In: Achauer BM, Eriksson E, Guyuron B, Coleman IIIrd JJ, Russell RC, Vander Kolk C, eds Plastic Surgery: Indications, Operations, and Outcomes St Louis: CV Mosby, 2000:119 3-1 209 2 Kroll SS Repair of lip defects with the Abbe and Estlander flaps In: Evans GRD, ed Operative Plastic Surgery New York: McGraw-Hill, 2000:28 9-2 97 3 Kroll SS Repair of lip defects... with the Karapandzic, Abbe or Estlander flaps (see below) 202 Practical Plastic Surgery A B C D Figure 33.11 Full-thickness excisions of the lower lip Defects up to one-third of the lower lip can be excised and closed primarily Lateral defects or larger central defects may require partial-thickness wedge excisions from the labiomental fold (A-D) If the commissure is involved, both the Karapandzic and... commissure 208 A Practical Plastic Surgery Figure 33.16 BernardBurow’s technique for reconstruction of large lower lip defects Partial-thickness Burow’s excisions laterally in the cheek and labiomental fold help to close the defect (A) The neo-ver milion is constructed using buccal mucosa (B) B Bernard-Burow’s Technique Application: Lower lip (mainly) and upper lip reconstruction Defect size: Two-thirds to... screws Delayed reconstruction is of particular importance in gunshot wounds It is advisable to wait until any sepsis or bacteremia has resolved, the soft tissue demonstrates that it is viable and tissue availability and quality is sufficient Practical Plastic Surgery, edited by Zol B Kryger and Mark Sisco ©2007 Landes Bioscience 212 Practical Plastic Surgery Figure 34. 1 Anatomy of the mandible When mandibular... curved body region; 1 0-1 4 cm of 34 corticocancellous bone can be harvested The vascular pedicle consists of the deep circumflex iliac artery and vein providing up to 6 cm of length The soft tissue island can measure as large as 16 cm in length, and it can be harvested with the internal oblique muscle Drawbacks may include donor site morbidity, abdominal wall weak- 2 14 Practical Plastic Surgery ness or herniation,... Surg 1996; 3 (4) :213 2 Herford AS, Ellis E Use of a locking reconstruction bone plate/screw system for mandibular surgery J Oral Maxillofac Surg 1998; 56:1261 3 Hidalgo DA Aesthetic improvements in free-flap mandible reconstruction Plast Reconstr Surg 1989; 84: 71 4 Ilizarov GA The principles of the Ilizarov method Bull Hosp Jt Dis Orthop Inst 1988; 48 :1 5 Mathes S, Nahai F Reconstructive surgery principles,... Reconstruction of the paralyzed face Grabb and Smith’s Plastic Surgery 5th ed Philadelphia: Lippincott-Raven, 1997: 545 3 Baker DC Reanimation of the paralyzed face: Nerve crossover, cross-face nerve grafting, and muscle transfers Head and Neck Cancer Philadelphia: B.C Decker, 1985 4 Braam MJ, Nicolai JP Axonal regeneration rate through cross face grafts Microsurg 1993; 14( 9):589 5 Harii K et al Free gracilis muscle . reconstruc- tion more challenging than lower lip reconstruction. Upper lip defects can be di- vided into partial-thickness and full-thickness defects. Partial-thickness Defects Partial-thickness. mobility (B). Figure 33.10. Perialar cres- centic partial-thickness exci- sions for primary closure of full-thickness upper lip defects. 33 202 Practical Plastic Surgery If the commissure is involved,. V-Y advancement flap. 33 198 Practical Plastic Surgery Commissure Reconstruction Commissure deformities often result from electrical burns, trauma, or reconstruc- tive lip surgery. For post-burn