Part 2 book “Facial flap surgery” has contents: Anatomy and biomechanics, repair of the tragus, antitragus, and lobule, bioanatomy and biomechanics, repair of the upper lip subunits, rotation and advancement flaps, repair of medial canthal wounds, transposition flaps, island pedicle flaps, eyebrow reconstruction,… and other contents.
CHAPTER Ear ANATOMY AND BIOMECHANICS The ear is a complex cartilaginous structure enveloped by a thin fascia The anterior surface is highly convoluted with a rich topography (Fig 8.1) The skin here is stretched tight like a drum and provides minimal resource for adjacent tissue transfer The helical rim creates a sharp reflection posterior to which the skin and subcutaneous tissues are somewhat thicker, more richly vascular, and mobile The lower helix and lobule contain abundant fat and are loose and freely mobile Toward the reflection with the mastoid scalp, the ear receives tendinous muscular fibers from the auricular musculature which are more adherent to the perichondrium 374 375 Figure 8.1 Nomenclature of the ear The vascular supply of the ear is rich and redundant (Fig 8.2) The majority of the posterior surface of the ear and the lobule are supplied by branches of the posterior auricular artery, a direct branch off of the external carotid The superior helical rim, the triangular fossa, and the scapha are supplied by a superior auricular branch off of the superficial temporal artery The conchal bowl is largely supplied by perforators from the posterior auricular artery 376 Figure 8.2 Arterial supply of the ear 377 Sensory innervation of the ear is from three sources (Fig 8.3) The majority of the ear is innervated from the greater auricular nerve that arises from the second and third cervical nerves and passes over the sternomastoid to arrive at the ear right at the base of the lobule Portions of the anterior surface of the ear and superior ear are innervated by the auriculotemporal nerve, which is a direct branch from the mandibular nerve of the fifth cranial nerve The inner conchal bowl and outer canal derive sensory input from cranial nerves VII, IX, and X 378 379 Figure 8.3 Sensory innervation of the ear Repair of the ear is indicated both for aesthetics, and for structural and functional integrity The upper helix holds our glasses, and the integrity of the conchal bowl is important for the wearing of a hearing aide The shape of an ear and its size relative to the contralateral ear are less important in terms of symmetry than of the nose, perioral and periocular region However, a helix with a notch in it may be aesthetically displeasing, and sharp edges of cartilage with inadequate cutaneous coverage can be substantially painful and predisposed to chondrodermatitis nodularis helices Because of the innate complexity of the ear and the lack of available local tissues, reconstruction of the ear requires creativity SKIN GRAFTS AND SECOND INTENTION HEALING While this is a text about adjacent tissue transfer, no discussion of ear reconstruction is reasonable without addressing healing by second intention and the use of skin grafts Moderate wounds of the ear on the anterior or posterior pinna with preserved perichondrium will heal well by second intention If cartilage is exposed, removal of the underlying cartilage followed by healing from the opposing perichondrium will speed healing and prevent chondritis Broad wounds of the anterior pinna and helical rim are resurfaced beautifully with skin grafts (Fig 8.4) Appropriate donor sites are the preauricular skin, postauricular sulcus, mastoid, or neck Such grafts should be appropriately thinned A larger graft resurfacing the ear is often remarkably aesthetically pleasing, often to the point of near invisibility For this reason, grafts should be strongly considered when the cartilaginous structure of the ear is intact and the perichondrium is preserved Even in cases with some loss of cartilage along the helical rim, a skin graft will function well 380 381 382 Figure 8.4 Full-thickness skin grafts are excellent repairs on the ear for wounds with preserved perichondrium (A1-A3) A large defect of the anterior surface of the ear is repaired with a postauricular full-thickness skin graft The repair is shown immediately and at months (B1-B3) An extensive defect of the conchal bowl and canal is repaired with a preauricular full-thickness skin graft While this area may heal by second intention, a skin graft prevents webbing and contraction of the operative wound The follow-up is at months (C) Defects of the outer helix are reliably and superiorly resurfaced with a full-thickness skin graft The repair is shown immediately and at months 383 for pinna reconstruction, 171f Medial canthal region, repair of, 236 (see also Eyelid) Medial canthus wound, 70, 71f Medial cheek rotation flaps, 253–254, 254f (see also Cheek) Medial forehead (see also Forehead, Medial forehead) advancement, 266–267, 266f, 267f island pedicle flaps, 269, 269f-270f rotation flaps, 267–269, 268f transposition flaps, 270, 271f Meibomian glands, 222 Mental nerve, 305 Mental rotation flaps, for chin, 306, 307f (see also Chin) Mobility on chin, 305 on scalp, 292–293, 292f-293f Motor innervation, of face, Mucosal advancement flap, 208f, 209f Multidirectional motion, addition of, 29–30 cosmetic units, 29–30 Multiple rhombic flaps, 51 Mustarde flap, 249 N Nasal ala, 86, 134–135 (see also Bilobed flap, atlas of) alar rotation, 136, 136f-137f rotation, 135–136 transposition, 136, 137f Nasal bridge mid and lower linear, 114, 114f nasal sidewall, 114, 115f advancement, 116, 117f, 118f island, 116–118 linear repairs, 116 rotation, 116 804 transposition, 119–120 nasal tip, 120–121 advancement, 121–122 linear, 121 transposition, 123–125 upper advancement, 109, 109f linear repairs, 108–109 rotation, 109, 110f transposition, 109, 111f-113f Nasal contours, 125 Nasalis flap and full-thickness graft, 133–134, 134f-135f Nasal sidewall, 114, 115f advancement, 116, 117f, 118f island, 116–118 linear repairs, 116 rotation, 116, 119f transposition, 119–120, 121f Nasal tip, 120–121 advancement, 121–122 bilobed flap step by step, 124t bilobed transposition flap, 123, 123f-124f linear, 121 repair, cheek-to-nose flap for, 91f transposition, 123–125 Nasofacial sulcus, 244 Nasolabial flap, 52–53, 52f, 152, 210f, 211, 211f-212f and alar crease blunting and bridging, 330, 332 revision of, 332, 333f-334f for chin, 308, 310f (see also Chin) reconstruction, single-staged, 210f for superolateral chin wound repair, 310f tips pitfalls and pointers, 141–142, 141t 805 for upper lip, 199–202, 200f-202f Nasolabial fold, 86, 186 of lip, 185 Nasolabial pedicle flap, 87 design and preparation, 86–87 inferiorly based, 88 interpolated, 86f, 87 Nerves, of face, 4–6, 5f, 6f Nose, 75–82 aquiline, 104 bioanatomy and biomechanics of, 104–108, 105f-108f bony/cartilaginous structure of, 104 celestial, 104 foldover flaps, 80, 81f-82f forehead, 78–79, 79f, 80f full-thickness defects of hinge flaps, 149–151, 149f-151f septal mucosal flap, 147–149, 148f turnover flaps, 152, 152f-154f greek, 104 hawk, 104 healing and expectations, 79 hooked, 104 nubian, 104 paramedian forehead flap, 75–77, 76f, 77f pedicle, 78, 79f pointers, pitfalls, and revisions, 80–82, 82f pug, 104 roman, 104 skin types in, 104, 104f straight, 104 subunit of, 107 three-staged forehead pedicle flaps, 79–80 two-staged paramedian forehead flap, 77–78, 77f, 78f 806 O Oral commissure, wounds of, 217–219, 219f Oral incompetence, deep wounds with, 211–214 bilateral advancements, 212–214, 213f-215f lip wedge, 211–212, 213f Orbicularis musculature, 98 Orbicularis oculi, 225 Orbicularis oris, 65, 98 O-T flaps, 28, 28f Otoplasty repair, 180 O-Z flap, 35, 36f (see also Rotation flap) P Paramedian forehead flap, 74, 87, 152, 238, 240f (see also Eyelid, Nose) anatomy, 75–76 atlas, 83f-85f forehead flap design and preparation, 76–77, 76f, 77f two-staged flap elevation, 77, 77f initial flap inset, 77–78, 78f Parotid gland, Pedicle, 78, 79f Pedicle flap, 74, 109 ear reconstruction with alternative pedicle flaps, 97 mastoid pedicle, 93–96, 94f, 95f pointers and pitfalls, 96–97 lip reconstruction with Abbe flap, 97–98, 99f-100f anatomy, 98 design, 98 execution, 98–100 flap delay, 100–101 flap division, 101 healing and expectations, 101 807 pointers and pitfalls (see Interpolated Flap) Percutaneous galeotomy, Periauricular region, Periosteum, of scalp, 293 Philtral subunit, of lip, 184 Philtrum, 186 and central upper lip, 204–206, 205f (see also Lip) Piecemeal closure of scalp wound, 302, 302f on temple, 287, 289f-290f Pincushioning, 58–59, 58f, 59f, 71, 79, 89f Pivotal restraint, release of, 33–34, 33f, 34f (see also Rotation flap) Postauricular pedicle flap, 93 Postauricular skin, 163 Postauricular sulcus pedicle flap, 97 Preauricular pedicle flap, 97, 172–174, 173f, 174f (see also Ear) for ear, 172–174, 173f, 174f (see also Ear) Proximal helical rim wounds, 97 R Retroauricular pedicle flap, 94f Rhombic design, 42 Rhombic flap, 274 biomechanical design, 43–44, 43f-45f circular wounds, closure of, 48–51, 51f Dufourmentel flap, 48, 50f multiple rhombic flaps, 51 primary and secondary motions, sharing tension between, 46–51 reducing primary motion tension vectors, 44–46 tension modifications, 44, 46f webster 30° angle flap, 46–48, 48f, 49f history, 42 for lateral mandibular wound repair, 313, 313f-314f for scalp wound repair, 298, 298f, 299f for temple wound repair, 287, 289f 808 usage of, 256–258, 257f-258f Rhomboid transposition flap, 119 Rotation flap, 11, 11f, 31 biomechanical design basic construct, 31–33 bilateral opposing rotation flaps, 35, 36f bilateral rotation flaps, 35, 36f cheek, 38 dorsal nasal rotation, 39, 40f flap curvatures, 35, 35f flap length, 34, 34f forehead and temple, 36, 37f infraorbital rotation, 36–38, 38f lateral upper lip, 39, 40f primary tension, adjustment of, 33–34, 33f, 34f regional applications, 35–36 scalp, 36 for chin defects, 306, 309, 310f bilateral rotation flap, 306f mental rotation flaps, 306, 307f classic, standard design, 32f for lateral temple wound, 284, 287f for medial forehead, 267–269, 268f for medial temple wound, 284, 288f pedicle of, 31 for scalp defects, 294, 294f large operative wounds, 294, 296f-297f small-to-modest wounds, 294, 294f-295f for temple, 284, 287f, 288f (see also Temple) uniqueness of, 31 S Scalp, 292 bioanatomy and biomechanics, 292–293, 292f, 293f adipose layer, 292 809 dermis, 292, 292f galea, 292, 292f, 293 layered system, 292, 292f mobility, 292–293, 292f-293f periosteum, 292, 293 vascular arteries, 292 drum-tight, 292, 292f loose, 292, 292f repairs Scalp bilaterally opposed rotation flaps, 294, 296f-297f flap and back graft, 300–302, 301f-302f flaps closure under tension, 298, 298f inadequately sized rotation flap, consequences of, 294, 297f island flaps, 300, 300f of large wounds, 302, 303f linear repairs, 294 piecemeal closure, 302, 302f rotation flaps, 36, 37f, 294, 294f single rotation flaps, 294, 294f-295f transposition flaps, 298, 298f, 299f skin cancer of, 292 Sensory innervation, of face, Septal mucosal flap, 147–149, 148f (see also Nose) Shark island pedicle flap, 144–147, 144f-146f Single rotation flap, for scalp, 294, 294f-295f Single-staged nasolabial flap, 42, 141, 141t, 210f, 330 tips for, 141t Skin grafts, 236, 237f Smoking and flap failure, 321, 323f-326f, 326 Spear flap, 65, 67f, 142–144, 142f-143f (see also Bilobed flap, atlas of) Staged pedicle flaps (see also Interpolated Flaps, Pedicle Flap) flap dynamics, 74–75 regional application 810 cheek-to-nose interpolation flap, 86–88 cheek-to-nose pedicle flap atlas, 89f-92f ear reconstruction with pedicle flaps, 93–97 lip reconstruction with pedicle flaps, 97–101 nose, 75–82 paramedian forehead flap atlas, 83f-85f Subcutaneous fatty tissue, of cheek, 244 Subcutaneous island pedicle flap, 62 Subcutaneous vascular plexus, Superficial fascia, 2, 2f, 9f fibrous portion of, 3f temporal vessels in, 7f Superficial musculoaponeurotic system (SMAS), 2, 4f, 9f, 38, 177, 244 Superior labial artery, 98 Superolateral orbit, 222 (see also Eyelid) Supratrochlear artery, 76 Surgicel®, 78, 79f T Tarsal suture, 225 Tarsoconjunctival flap, 223, 235 Temple, 282 bevel-antibevel closure on, 283, 284f bioanatomy and biomechanics, 282–283, 282f auriculotemporal nerve, 283, 283f frontal branch of facial nerve, 283, 283f inferior border, 282 medial border, 282 superior border, 282 temporalis fascia, 283 vascular supply, 282–283, 283f broad, 282f diminutive, 282f linear repairs on, 283, 284f advancement, 283–284, 285f 811 advancement and rotation combination, 284, 285f classic flap, 284, 285f-286f full-thickness graft, 287, 290f-291f minor flap adjustments, 284, 288f piecemeal closure, 287, 289f-290f rotation flap, 284, 287f, 288f transposition, 287, 289f rotation flaps of, 36, 37f typical, 282f undermining plane on, 283f variations in anatomy of, 282, 282f Temporal artery, 282–283, 283f Temporalis fascia, 283 Temporal nerve, frontal branch of, 283, 283f Tension redistribution, 11–12 rotation flap, 11, 11f transposition flap, 12, 12f Tension reduction, 6–11, 10f Tenzel flap, 231 classic, 233f and periosteal flap, 234f Tenzel semicircular flap, 36 Tissue cones, redistribution of, 24–25 Tissue movement bioanatomy of fascia, 2–3 nerves, 4–6 vasculature, 3–4 biologic plan of, mechanical plan of, mechanics of dog-ear manipulation, 12, 13f tension redistribution, 11–12, 11f, 12f tension reduction, 6–11 812 Tragus, repair of, 177, 177f-180f TRAM flap, 64 Transposition flap, 12, 12f, 236–237, 238f, 239f (see also Eyelid) banner, 51–52, 51f nasolabial flap, 52–53, 52f bilobed flap, 53–54 design and execution principals, 54–57, 54f-57f on cheek, 255–256 banner flaps, 256 bilobed flaps, 258–259, 258f rhombic flaps, 256–258, 257f-258f for chin, 309, 311 for eyebrow, 279, 280f (see also Eyebrow) for lateral forehead, 274–275, 274f, 275f for medial forehead, 270, 271f rhombic flap biomechanical design, 43–44 reducing primary motion tension vectors, 44–46 sharing tension between primary and secondary motions, 46–51 tension modifications, 44 rhombic flap history, 42 for scalp, 298, 298f, 299f trapdoor phenomenon, 58–59, 58f, 59f trilobed flap, 58, 58f Trapdoor phenomenon, 58–59, 58f, 59f Trilobed flap, 42, 58, 58f, 130–131, 130f (see also Bilobed flap, atlas of) pitfalls and pointers, 131–132 rotation, 131, 131f-132f Turnover flap, 152, 152f-154f (see also Nose) Turnover island pedicle flaps, 65 Turnover pull-through flaps, 175–176, 175f, 176f (see also Ear) U Unilateral pedicle, 64, 71 Upper lip Abbe-Estlander flap, 206–207, 207f 813 apical triangle, 65, 68f (see also Island pedicle flap) horizontally oriented defects, 203–206, 203f, 204f island pedicle flaps, 196–199, 197f-199f lateral subunits advancement, 191–195, 192f-194f linear repairs, 186–187, 187f, 188f lip wedge, 187–191, 189f-191f rotation, 195–196, 196f nasolabial flaps, 199–202, 200f-202f Upper nasal bridge advancement, 109, 109f linear repairs, 108–109 rotation, 109, 110f transposition, 109, 111f-113f V Vasculature, of face, 3–4, 4f Vaseline-impregnated gauze, 78 Vermillion border, 186 Vermillion defects and shallow wounds, 208–210, 208f, 209f V-Y advancement, 62 W Warfarin, 315–316 Webster advancement, feature of, 28 Webster 30° angle flap, 46–48, 48f, 49f Webster-Fries method, 214 Whitnall’s tubercle, 222 X Xerophthalmia, 223 Z Zitelli modification, of bilobed flap, 57 Z-plasty, 166, 335–338 basic mechanics, 335, 336f 814 to flatten and reorient, 339f for repositioning, 338, 338f to resolve surgical web, 337f use of, 335–336, 338 Zygoma, 225 815 目录 Facial Flap Surgery Copyright Page Dedication Contents Foreword Preface Chapter 1: Introduction 10 12 14 Bioanatomy of tissue movement Mechanics of tissue movement 15 28 Chapter 2: Advancement 61 Introduction Biomechanics of advancement Advancement flap subtypes 61 62 74 Chapter 3: Rotation Flaps 85 Introduction Biomechanics of rotation Rotation flap sites 85 86 98 Chapter 4: Transposition Flaps Rhombic flap and variations Banner flaps Bilobed transposition flaps 116 116 138 145 Chapter 5: Island Pedicle Flaps Introduction Geometry and flap dynamics Island flap variations Regional application of the island pedicle flap Chapter 6: Staged Pedicle Flaps Introduction and flap dynamics Regional application The paramedian forehead flap 165 165 167 178 183 197 197 198 198 816 Cheek to nose pedicle flaps Mastoid pedicle flaps to the ear Cross-lip pedicle flaps 223 241 249 Chapter 7: Nose 259 Bioanatomy and biomechanics Repair of the nasal bridge Repair of the nasal sidewall Repair of the nasal tip including the bilobed transposition flap Repair of the nasal ala including the single-stage nasolabial transposition flap Reconstruction of full-thickness nasal wounds Chapter 8: Ear 259 270 285 296 300 331 338 356 374 Anatomy and biomechanics Repair of the helical rim Repair of the anterior surface of the ear Repair of the tragus, antitragus, and lobule Repair of the posterior surface of the ear Chapter 9: Lip 374 389 409 422 433 439 Bioanatomy and biomechanics Repair of the upper lip subunits Repair of the lower lip 439 446 491 Chapter 10: Eyelid and Periocular Bioanatomy and biomechanics Lid wedge and linear repairs Transposition flaps Rotation and advancement flaps Repair of medial canthal wounds Chapter 11: Cheek 522 522 531 536 546 562 578 Bioanatomy and biomechanics Advancement and rotation flaps Transposition flaps Island pedicle flaps 578 589 603 610 817 Chapter 12: Forehead 616 Bioanatomy and biomechanics Linear repairs Repair of the medial forehead Repair of the lateral forehead Eyebrow reconstruction 616 620 624 634 649 Chapter 13: Temple 657 Bioanatomy and biomechanics Linear repairs Advancement and rotation Transposition 657 660 664 678 Chapter 14: Scalp 686 Bioanatomy and biomechanics Linear repairs Rotation flaps Transposition flaps Island flaps 686 690 691 701 705 Chapter 15: Chin 715 Bioanatomy and biomechanics Linear repairs Advancement and rotation flaps Transposition and island flaps Repair of the jawline 715 715 720 730 732 Chapter 16: Complications and Revisions Hematoma Flap failure Hypertrophic scarring Depressed scars and their revision Revision of the nasolabial flap Z-plasty Index 738 739 752 767 769 775 783 792 818 ... rim advancement flap with an intact postauricular pedicle is richly vascularized Given the dead space created on the postauricular surface of the flap and the tendency of the flap tension to... Six-month final result Banner Transposition Flaps Defects of the upper helical rim are often beautifully repaired with postauricular banner flap (Fig 8.10) 12, 13 and defects of the root of the helix... Planned banner flap (C) The flap is elevated just above fascia (D) Immediate repair (E) Repair at months (Reproduced with permission from Cook JL, Goldman GD Random Pattern Cutaneous Flaps In: Robinson