Junior Lecture

Otolaryngology Facial Plastics and Reconstructive Surgery

Karen H. Calhoun, M.D., FACS

1. This first slide shows the lines of maximum tension. The areas where the wrinkles develop are usually perpendicular to the pulls of the muscles and generally it works well to orient scars along the lines where wrinkles will develop because this helps to camouflage the scars. So on the forehead, for example, we would want to make a horizontal incision wherever possible. On the cheeks we would want to make a down and out type of incision, and around the lips we would want to make radial incisions.

2. The simplest kind of a flap is actually the advancement flap that we use when making an elliptical excision of a skin defect. Suppose you have a circular lesion and you take that lesion out with a 2 to 3 millimeter margin. You’re then left with a circle. When you try to close this, if you pull it together in the middle you will see tucks or puckers developing at both ends. That’s the reason that we use an ellipse instead, and the long axis of the ellipse is located along the relaxed skin tension lines or along the lines where wrinkles will develop. After you have taken out the ellipse, you have to undermine on each side and pull the tissue together towards the midline. This then becomes the very simplest form of a bilateral advancement flap.

3. Another type of general flap that we use is a rotation flap as you see here. Tissue from the area next to the defect is rotated into the defect.

4. This is a patient example. You see that this patient has both a lesion on her right cheek and then one on the left just below the medial edge of the eye.

5. Here is a close-up of the defect on the cheek. The patient is lying on the operating room table, her head is towards the left and her chin is towards the right.

6. In this slide you see that the defect has been excised with a 2 to 3 millimeter margin. It’s a fairly large defect. You can think of a number of different ways that we could put this back together for the patient. Certainly one option would be to let it heal by second intent--to let it granulate in. The biggest problem with that in this location is that it can pull the lower lid down, causing an ectropion or outward slanting of the lower lid. This in turn can lead to pooling of tears because they longer contact the tear drainage area at the medial canthus. So that’s not an ideal method in this area. A second option is simply to put a skin graft on the area. This would work and it’s certainly what we would choose in a very ill patient, but it’s not the best choice as far as ultimate appearance because it’s going to be a poor color and texture match, and also this is a relatively deep defect—deeper than the thickness of a skin graft. So, a skin graft placed on this would give an indented-looking area. The best possible choice is a local skin flap and often we find that the size of the flap that we use is much larger than the defect that it’s going to cover up. This allows us to spread the tension of closure of the defect over a greater area.

7. As you see in this next slide, Slide 7, a fairly large flap was made, using the cheek and the neck skin to rotate into this defect.

8. And here it is with the defect closed—and you can see that this gives a relatively nice appearance.

9. Here is the patient postoperatively. Look at the cheek and you can see that she still has a fairly red scar. That color will fade with time. Also look at the left medial canthal area because this is the postop of the procedure on the eye that you will see in just a moment.

10. This is a rhomboid flap and this is a flap for you to remember. Any defect that can be turned into a 60/120 degree rhomboid can be closed using this technique. The best thing about this flap is that for any defect there are 4 possible flaps you can use. You begin by drawing a line across the short axis of the flap out the same distance as the short axis on either side. And then from the end of each of those you draw a line parallel to the side of the flap. This gives you 4 possible options so for every defect like this you can sit and draw the 4 possible options and decide which one is going to give you the best looking scar with the least tension in a place where you don’t want tension. And this is how the flap is done. Let’s say that you choose the flap that is on the uppermost part as shown in this slide. So there’s the defect in Figure B. Point X is actually going to be rotated down into the left-hand corner of the defect and Point Y is going to be rotated down into the right-hand corner of the defect. The two edges of the donor site will come together for closure. Spend a moment looking at this so you can actually picture what happens as it’s closed.

11. Here is the same patient and this is a close-up of the defect in her medial canthal area.

12. This is what it looked like after excision and we’re doing a variation of a rhomboid flap, a rhomboid-to-w flap. As you can see looking at this eye there are many options you could choose for closing it that would put tension on the lower eyelid. Again, we really don’t want to pull the medial part of the lower lid away from the eye because this is where the tear drainage area is.

13. This is a diagram of how the rhomboid-to-w flap works for those who are interested. The exact details are not particularly important for you to remember.

14. Here is a close-up of the way the patient looks immediately after closure of the flap.

15. Here is a patient with a small basal cell carcinoma on her chin.

16. And here is a picture of her after complete excision of the basal cell cancer.

17. Here is a close-up of the defect and the rhomboid flap that we have chosen to close it. Either of the upper possible flaps would have resulted in retraction of the lip. The medial lower flap would have been more obvious from a frontal view and would have been drawn from an area where there was less excess of moveable skin. So the lower cheek or lateral flap of the 4 possible rhomboid flaps was the best choice in this patient.

18. And you see her postoperatively about 7 weeks. There is still redness evident from the scar, but that will fade with time.

19. This Z-plasty is an important concept for you to understand. It is used primarily for lengthening scars, say a scar that’s tethering the neck down towards the chest or one that’s keeping the arm from being fully extendible. So the scar is the line from 1 to 2. The lines drawn off on the sides of this are the arms of the Z that are drawn for lengthening of the scar. As you see in the second figure the tips are labeled 1 and 2, and after undermining these are simply passed over each other so that the tip labeled 1 fits into the potential crotch area next to 2 and vice versa. In the third figure you can see them being passed over each other and then how they’re oriented. Please study this until you understand how it’s done.

20. The amount of lengthening you get from a Z-plasty depends on the angle between the scar and the arm of the flap. The narrower the angle, the lesser the lengthening. In practical experience we really don’t use a 30-degree flap because the tip is so narrow that we run into some problems with necrosis. Some place in the 45 to 60 degree area is what is usually used clinically.

21. Here is a man with a large defect on his forehead. The limitations on what kinds of flaps we can use closing this are that we don’t want to elevate his eyebrow and we don’t want to distort his hairline by pulling it forward.

22. So here is an option where you can use 3 rhomboids put together. If you can picture the 120 degree corners of 3 rhomboids put together to make a 360 degree circle, then these rhomboid flaps are drawn out from this—they’re all drawn in the same direction,

23. allowing closure of the defect without elevation of the brow or distortion of the hairline.

24. Here is another large defect in the vertex of the scalp. The scalp is relatively inelastic so that there are not very good options for pulling the edges of such a defect together. Many times defects of this size will require tissue expanders placed beneath the skin in order to expand the skin over a period of 6 to 10 weeks before the defect can be closed. This necessitates 2 separate surgeries and it also means that during the final stages of the expansion the patient looks very peculiar and it can be difficult for them socially.

25. Instead in this case we were able to again utilize the triple rhomboid flap allowing us to borrow from three areas of the scalp.

26. As you can see this was closed under a fair amount of tension as indicated by the blanching--

27. But it did heal successfully and gave the man good coverage of the back of his head without requiring more than one surgical procedure.

28. Here is a small defect on the tip of the nose. If we were to let this heal by second intent he would have a tenting-up of the ala on that side or alar notching. So instead we want to use a local skin flap.

29. Here is a bilobed flap. The skin from the lower bulge of the flap is moved into the defect and the skin from the upper bulge of the flap is put into the lower bulge. The defect left by harvest of the upper bulge is closed primarily.

30. Here you see a similar patient intraoperatively.

31. And here is the original patient with his defect and flap healed. As you see, there is a fair amount of bunching up of the flap, or pincushioning.

32. What we can turn to in cases like this is early dermabrasion.

33. Dermabrasion like chemical peels or laser abrasion is a physical means of injuring the superficial skin allowing the deeper elements of the skin to regenerate a smoother covering. So here you see this gentleman immediately after dermabrasion with what looks like a raw surface across the entirety of his nose.

34. Here you see it about 8 weeks later completely healed. You can see that the bulginess of the flap has flattened down considerably.

35. Here is another difficult defect on the forehead. Obviously we can’t pull the edges of this together to give the horizontal line that is in line with relaxed skin tension lines. So we have to think in terms of what kind of scar can we leave that’s going to be as unnoticeable as possible, and give her the least distortion of normal anatomic features.

36. Here we have chosen to develop this into an ellipse. The irregular lines you see at the top and the bottom will give her a geometric broken line closure, one that is irregularly irregular rather than straight. This helps camouflage the scar because the eye follows a straight line more easily than an irregularly irregular line.

37. Here you see this patient about 3 weeks postoperatively and there is still some redness. The distortion of the eyebrow is minimal.

38. Here you see her about 6 months after surgery with a very acceptable result.

39. This gentleman has a defect in the medial canthal area. About the only place that one can easily borrow skin to close this is from the forehead.

40. Here you see the development of a midline forehead flap. This is an axial flap supplied by the supratrochlear vessels.

41. Here is the flap sewn into place and the defect closed on the forehead. The bulginess across the bridge of the nose is the pedicle of the flap. This will be left in place for 2 to 3 weeks until a new blood supply reestablishes itself from underneath and then this will be divided and set back in.

42. Here you see the flap inset with a satisfactory result.

43. Now the next 12 or 14 slides are going to be all of the same patient’s procedure to show you how we go about approaching a very complex reconstructive situation. In this slide you see a woman half of whose nose is missing. So you are looking directly at the septum. The cartilage, the mucosal lining and the skin of her hemi-nose are all gone. This was from a basal cell carcinoma.

44. Here you see us developing a little medial cheek flap to pull inward to fill in the place where cheek skin was missing.

45. You can harvest virtually the entire cartilage of the concha of the ear without causing any cosmetic defect. So here you see us making an incision that will be camouflaged by its position in the rim of the ear.

46. Here you see the size of the cartilage that we can obtain this way.

47. And here you see the ear, which is not distorted at all.

48. We’re back to the patient. Her forehead is towards the left, lower corner of the slide and her chin is towards the right, upper corner. We have made a flap inside the nose out of mucosa from over the turbinate. This is a bipedicled flap meaning that it’s attached on both ends but loose in the middle, and can swing sort of the way the handle of a pail would swing.

49. Here you see an instrument passed through the open part of the flap to give you an appreciation of how it is swinging.

50. Here you see the cartilage in place. We’re using this to replace the cartilaginous tissue that is missing from the nose.

51. Here is a view from the bottom of where the cartilage sits in the nose.

52. Here we are developing another midline forehead flap.

53. If you look down towards the base you can see the vascular pedicle.

54. And here she is with the midline forehead flap in place.

55. Here is a view from the bottom of what the reconstructed nose looks immediately after the first surgery.

56. Here is the patient with the pedicle still in place.

57. Here she is after the first takedown of the pedicle and dermabrasion of the forehead.

58. Here is the patient about 8 months postoperatively. You can see that the forehead is healed very well. She has some asymmetry of the nasolabial folds.

59. On the lateral view some apparent notching of the nasal ala. I rank this as a satisfactory result. I would have liked to create an alar crease for her, but she declined any further surgery at this point.

60. Here you see a lady with a defect on the tip of her nose.

61. And here she is after placement of a midline forehead flap over the dorsum of the nose.

62. Another nasal tip defect.

63. Her appearance after repair.

64. This is the incision we use for cosmetic procedures, allowing us to see inside the nose when we’re doing repair of the nasal structures. There is this little, fine incision across the columella and the rest of the incision is made inside the nose.

65. Here you see the incision which then allows us to lift up the skin of the tip of the nose sort of the way you would lift up the hood of a car to see what exactly what is wrong with the structures in there and to change them directly and suture them into place.

66. These are the kinds of changes we make when doing a rhinoplasty, taking the bone off when it makes an excessive nasal hump.

67. When we take a hump off the nose we are left with a flat-topped pyramid, so we need to break the bones laterally and fold them together to give a nice, narrow nose again.

68. Here you see the path that’s used by the osteotomes to break the bones and reposition them when performing nasal surgery.

69. An intraoperative appearance of the nose seen from the basal view. Sutures are being placed to hold the tissue in place.

70. Here you see a side view of a man with a saddle nose deformity or deficit of support tissue over the bridge of the nose.

71. And on Slide 71 you see his appearance postoperatively with augmentation of nasal dorsum.

72. The same patient preop on Slide 72. You see him from the frontal view.

73. Postop from the frontal view.

74. Basal view preop.

75. Basal view postop.

76. You see a preop rhinoplasty picture.

77. A postop of the same patient.

78. Now we’re going to switch back to reconstructive issues. One of the hardest things we do in operating on big cancers is when bone of the mandible has to be resected. Bone of the lateral mandible is not as bad, because if that is not repaired the patient can sometimes function fairly well. But if a resection requires sacrifice of the anterior part of the mandible, the patient will not be able to swallow or speak or even keep his own spit in his mouth unless we repair that bone with a rigid structure. So the state-of-the-art for repairing these now is free flaps, that is, borrowing tissue from another place in the body along with its supplying artery and vein, and hooking this artery and vein up to an artery and vein in the recipient area. The fibula is the main one used for the reconstruction of the mandible. Iliac crest and rib to a lesser degree.

79. Another free flap that we use frequently is the radial forearm flap. This is ideal for relining the intraoral cavity after resection of a tumor. On most people this skin is thin, pliable, usually non-hairy.

80. Here you see this intraoperatively. This is a forearm flap and you can see the long, supplying pedicle of the radial artery and vein.

81. Here you see a fibula flap being harvested.

82. Here you have an intraoral view of a fibula flap in place. Native tongue is visible on the right-hand side of the slide, and on the left-hand side of the slide you see skin from the leg.

83. This is a gunshot wound patient. You can see that the gunshot wound has destroyed much of the tissue of his face including mandible and maxilla.

84. You see a lateral view of the same patient. This destroyed his left eye in addition to the other structures. Reconstruction of a patient like this is a long and complex process. This young man has undergone two separate free flaps, one from the fibula and one from the scapula as part of his reconstruction as well as numerous other reconstructive procedures.

85. This you see the scapula bone and soft tissue in place to reconstruct the missing maxilla and hard palate. There is a nasal trumpet in place to maintain the patency of the nasal airway.

86. and 87. This is the size that neglected basal cell carcinomas can become from time to time.

88. Here you see harvest of a latissimus flap from the back of a patient.

89. Here is the flap.

90. Here it is being transposed up to the head and neck.

91. Here you see a patient with a maxillary sinus tumor. Note that this incision is placed pretty much in anatomic boundaries so that once it is healed, the scarring is not that obvious.

92. Here you see the maxillary sinus tumor exposed.

93. This is what happens when an anterior mandible is resected and not replaced. It can be referred to as an Andy Gump deformity, and you can see that the man is an oral cripple, unable to hold food or liquids in his mouth, unable to swallow, and with very poor articulation.

94. Here is a young woman who met the windshield of her car with her forehead during a motor vehicle accident. As you can see, she luckily missed damaging her eye, but essentially had a degloving injury of her scalp. You could actually reach your hand under the skin all the way around to her occiput. These injuries usually look far worse than they actually turn out to be.

95. In Slide 95 you see another view of her injury.

96. In Slide 96 this is what she looked like immediately postoperatively.

97. This shows her about 10 days postoperatively.

98. You see her at about 6 months postoperatively. What appeared to be a devastating injury has actually left her with fairly minimal deficit.

99. We are talking about reconstruction of the lip. The lower lip especially is a very common place for squamous cell carcinomas to occur both related to sun exposure and to people’s habit of holding a cigarette there. Here you see a diagram depicting resection of the center part of the lower lip with simple primary closure. This is our preference when the defect is small enough to allow it to repair the lip with lip tissue.

100. You see a squamous cell carcinoma on the lip and the area of the resection is outlined in marking pen.

101. Here in Slide 101 you see what it looks like after the skin and tumor has been resected.

102. What it looks like after the lip is brought back together.

103. This shows you the concept of a lip-switch flap, that is, when you have had to take a lot of one lip, you can sometimes use tissue from the other lip to even out the defect so that you are sharing the amount of the defect between the two lips. So, this diagram shows borrowing tissue from the lower lip to repair a defect of the upper lip. This is how it is traditionally done.

104. Slide 104 shows that flap being put into place. It can be based either medially or laterally on the labial artery, and again that pedicle is left intact for two to three weeks before it is divided and the bits inset. That means that nutrition can be a bit of a problem during the time before that flap is taken down. The person will probably have to use a straw and blenderized diet. It is an inappropriate flap therefore to use for someone who may have uncontrolled vomiting like an alcoholic or perhaps a problem for someone who has poorly controlled seizures or other medical contraindications to having temporary difficulty accessing the oral cavity.

105. You see a gentleman whose entire lower lip has had to be resected for a squamous cell carcinoma.

106-7. You see developing flaps from the cheek to swing parts of the upper lip around to take the place of the lower lip. The limitations of this are that you don’t want to create a functional microstomia, that is, an oral opening so small that the patient can’t get his toothbrush in, get his spoon in, get dentures in and out, etc.

108. Shows the postop appearance of this patient, and you can see that the lower lip is noticeably shorter than the upper lip but it still gives him a reasonably functioning oral cavity with reasonably good appearance.

109. Switching back to cosmetic surgery again in Slide 109. In the face and neck, the main places that we use liposuction are in the neck area, occasionally in the jowl or nasolabial fold area.

110. You see us inserting a liposuction cannula through a postauricular stab incision to access the jowl area.

111. You see a patient marked preoperatively for a liposuction.

112. Diagrams the fanning movement we use through a submental stab incision for suctioning submental and neck fat.

113. Shows through the incision that we use for most facelifts, that is going into the temporal hairline then down across the front of the ear, around the earlobe up on to the posterior surface of the ear, and then about two-thirds of the way back the incision is carried straight across and back into the post mastoid hairline.

114. A photograph during a facelift of pulling the dense or subcutaneous tissue back.

115. Resecting the excess skin.

116. Shows you one of our patients preoperatively for a facelift and browlift. Note the wrinkling on his upper forehead, the relative lowness of his eyebrows, the wrinkling of the nasolabial folds and the cheek, and the early jowling.

117. Shows you the patient postoperatively. You can see the improvement in his brow position, the jowling and the wrinkling.

118. The same patient, lateral view. You see the early turkey gobbler deformity as well as the softening on his jowls.

119. The postop view. You see the marked improvement of his neck contour.

120. The facial area of an unfortunate patient who was riding a minibike in his backyard, apparently hit a rock and was flipped off of the minibike, and had the misfortune to come down on the propeller of a boat that was up in blocks in his backyard. So if you look at the top of the slide you see his eye and his nose and you see his upper teeth, and then way down towards the bottom of the slide you see his lower teeth. This is another one of the complex reconstructions that we will sometime have to tackle.

121. Shows you his tongue and some of his mandible.

122-3. Gives you a little bit different view.

124-6. You can see the portion clearly that has been sliced off. Initially, an attempt was made to reconnect this hoping that the few residual vessels would be enough to support its continued survival. As you can see from its duskiness, this was not the case. Unfortunately, this same injury had also destroyed most of the vessels in his neck, so that our usual next line of approach, which would be a free flap that contained bone, was not a real option for him. So what was done for him was a pedicled latissimus flap incorporating the bony part of Rib 9 for reconstruction of his mandible.

127. And in the final slide of this series, Slide 127, you see the latissimus flap in place, and he has developed some contracture of his neck, holding his face down towards his neck on the right. There is insufficient native skin to correct this and it is a little bit more than a Z-plasty can handle, so we’re using tissue expanders to create more skin that we can use for releasing the neck contracture. There is one on his shoulder and one on his chest. The principle of the tissue expander is that it is a plastic balloon that is placed under the skin and is gradually expanded over six to ten weeks, creating more skin in sort of the fashion that a pregnant woman’s belly will expand. The injection in the slide is being made into a remote port that is connected to the tissue expander on his shoulder, and on each of these we expand until the skin becomes tense or the skin over the tissue expander blanches and then leave it alone for another week to allow that skin to loosen then continue to expand it. This was done successfully with him. I don’t yet have the postop slides in this series, but he is now able to move his head freely and has returned to his work as a truck driver.

kc/jrlect/jrslide 20jun01