The versatility of the laterally based cervicofacial flap for cheek repairs.

The versatility of the laterally based cervicofacial flap is described for coverage of defects following removal of cancers of the head and neck. It requires no delay procedures, and it gives excellent results in terms of both function and appearance.     

A cervicopectoral rotation flap for cheek coverage.

A massive cervicopectoral rotation flap is described for coverage of large cheek defects. The advantages and complications with this flap are discussed.     

The double-door tongue flap for total cheek mucosa defects

Lining of total cheek mucosa defects can be accomplished by opening the tongue along its lateral border and preparing two myomucosa flaps that can be swung upward and downward like a double door to be sutured into the defect. The tongue is released 3 weeks later in a second-stage operation. The operation is quick and easy compared with other methods to achieve lining for such defects. Tongue function is not impaired after healing of the second-stage operation.     

Mechanics of movement for rotation flaps and a local flap template

After studying the mechanics of rotational movement, it has become apparent that there exists a local flap template for triangulated defects. Predominant rotation and transposition movements lie at extreme ends of its spectrum. This concept offers a design improvement by which these flaps can be executed with ease and confidence in all areas of the body. Several design variations are available from the template, making the hypothesis versatile and flexible. Underlying this success is the strategic placement of the triangulated defect within an imaginary circle of skin tissue around it. The concept also provides a logical and comprehensive teaching model.     

The superiorly based nasolabial flap for simultaneous alar and cheek reconstruction.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand the epidemiology of skin cancer in a patient with preexisting skin cancer. 2. Understand the indications for the use of a nasolabial flap and nonanatomic alar strut graft. 3. Describe the blood supply to the nasolabial flap.The goals of reconstructing deformities of the face acquired secondary to skin tumors include optimizing donor-site aesthetics and reconstructing the area with similar types of tissue when possible. Multiple skin-cancer defects are often seen by the plastic surgeon and complicate the reconstruction, requiring more than one flap or skin graft. A case analysis of an innovative application of the nasolabial flap for reconstruction of a simultaneous medial cheek and alar-base nasal defect is presented. Concepts in nasal reconstruction are reviewed, and the authors' approach to alar reconstruction is presented.     

Lower eyelid reconstruction with a cheek flap supported by fascia lata.

The use of a cheek rotation flap is a well-known method for reconstruction of a large defect of the lower eyelid. In this technique, a separate lining tissue supporting the cheek flap is required for full-thickness reconstruction. Previously, a chondromucosal graft or conchal cartilage has been used to support this flap. Recently, we have used a homologous or autologous fascia lata as support for the cheek flap instead of rigid tissues like cartilages. A fascia lata strip is fixed with tolerable tension to the medial canthal tendon and lateral orbital rim. The inner surface of the fascia and the cheek flap is lined with a buccal mucosa graft to decrease irritation of the conjunctiva and cornea. We present here seven patients in whom this procedure was used for lower eyelid reconstruction following resection of a malignant skin tumor. Based on follow-ups of 7 to 22 months, the functional and aesthetic results have been good in all cases. This procedure may be applicable for total or subtotal reconstruction of the lower eyelid.     

Use of the free dorsalis pedis flap in head and neck repairs.

Many defects of the head and neck can be readily repaired with a free dorsalis pedis flap, and we report success with these flaps in 9 of 12 cases. A precise knowledge of the anatomy of the arterial supply of the flap is necessary. Preoperative arteriography is recommended if the dorsalis pedis artery is not easily palpable, or if an anomalous distribution of the artery along the dorsum of the foot is sus pected. However, the transfer of the flap should be delayed for two weeks after preoperative arteriography is performed. The one-stage soft tissue reconstruction with a free dorsalis pedis flap has been associated with minimal morbidity and good acceptance by patients. A delay procedure for the flap seems to enhance the chances of complete survival which is so necessary in the repair of intraoral and pharyngeal defects. Careful attention to details and close monitoring of the flap will minimize morbidity. In case of an early failure of a flap, a secondary reconstruction by a different flap can be done in the first 48 to 72 hours. Early postoperative radiotherapy has been well tolerated over these free flaps.     

Bilateral latissimus dorsi V-Y musculocutaneous flap for closure of a large meningomyelocele

Reconstruction of a large meningomyelocele defect with bilateral latissimus dorsi V-Y musculocutaneous flaps is reported. This procedure provides a reliable, well-vascularized soft-tissue coverage over the neural repair with minimum donor-site morbidity.     

Reconstruction of concomitant lip and cheek through-and-through defects with combined free flap and an advancement flap from the remaining lip

Massive facial defects involving the oral sphincter are challenging to the reconstructive surgeon. This study presents the authors' approach to simultaneous reconstruction of complex defects with an advancement flap from the remaining lip and free flaps. From January of 1997 to December of 2001, 22 patients were studied following ablative oral cancer surgery. Their ages ranged from 32 to 66 years. Nineteen patients had buccal cancer, two patients had tongue cancer, and one patient had lip cancer. In all cases, the disease was advanced squamous cell carcinoma. Nine patients underwent composite resection of tumor with segmental mandibulectomy, and seven patients underwent marginal mandibulectomy. Cheek defects ranged from 15 x 12 cm to 4 x 3 cm, and intraoral defects ranged from 14 x 8 cm to 5 x 4 cm in size. One third of the lower lip was excised in nine patients, both the upper and lower lips were excised in 10 patients, and only commissure defects were excised in three patients. An advancement flap from the remaining upper lip was used for reconstruction of the oral commissure and oral sphincter. Then, the composite through-and-through defect of the cheek was reconstructed with radial forearm flaps in 13 patients, fibula osteocutaneous flaps in five patients, double flaps in three patients, and an anterolateral thigh flap in one patient. The free flap survival rate was 96 percent, and only one flap failed. With regard to complications, there were two patients with cheek hematoma, six patients with orocutaneous fistula or neck infection, and one patient with osteomyelitis of the mandible. All but one patient had adequate oral competence. All patients had an adequate oral stoma and could eat a regular or soft diet; two patients could eat only a liquid diet. For moderate lip defects, immediate reconstruction of complex defects took place using an advancement flap from the remaining lip to obtain a normal and functional oral sphincter; the free flap can be used to reconstruct through-and-through defects. This simple procedure can provide patients with a useful oral stoma and acceptable cosmesis.     

Perforator-preserving chondrocutaneous rotation flap reconstruction of auricular defects

A technique of chondrocutaneous flap reconstruction of the ear that preserves the perforating branches of the posterior auricular artery is described. Preservation of the perforators offers improved safety in high-risk patients because it maintains the blood supply to the anterior surface of the ear. This perforator-preserving technique also emphasizes simplicity of flap design, concealment of scars, and preservation of ear shape. It is best suited for reconstructing defects of the scapha, antihelix, or triangular fossa up to approximately 2 cm in diameter. A variety of chondrocutaneous rotation flaps have been developed for reconstructing helical and nonhelical defects. These flaps have been designed on the basis of the size and location of the surgical defect. Although previously described techniques are usually reliable, extensive dissection and mobilization can injure perforators, leading to vascular compromise. When flap reconstruction is used in high-risk patients, it is necessary to protect the blood supply, and perforator-preserving flap reconstruction offers improved safety. The perforator-preserving technique was used in six consecutive high-risk patients during a 2-year period. Good results were obtained in all cases, including in patients who smoked cigarettes or had extensive medical problems.