491
A CONCEPTUAL APPROACH TO LOCAL FLAPS CHARLES J. KRAUSE, MD ANN ARBOR, MICHIGAN Few procedures offer the surgeon a greater opportunity to exercise his surgical and aesthetic judgement than the design and Implementation of local flaps about the head and neck. Considerations include skin color ilnd texture match) adequacy of nap blood supply; size, location, and characterlstlcs of the donor site defect; functionill Cilpability of the proposed f1i1P; nature of skin tension lines created; and number of surgical procedures required. A systematic approach to local flap design and implementiltion is presented, ilnd iIIustriltions of the geometric principles Involved are included.
ALTHOUGH local skin flaps about the face provide close color and texture match and single-stage reconstruction, their design requires careful judgement and thoughtful application of aesthetic and geometric principles. For this reason, considerable mystique has developed with regard to their design. The truth is, however, that even a relatively inexperienced surgeon can design local flaps effectively by applying a few basic principles of tissue selection and geometric concept in a carefully thought-out plan of action. This paper is intended to assist the surgeon in selection of an appropriate local flap for closing most defects about the head and neck. Attention is focused on general principles of tissue selection and flap design rather than on an enumeration of the myriad flaps that have been
Subrnitted for publication Jan 18. 1979. From the Department of Otorhinolaryngology. University of Michigan Hospital, Ann Arbor. Presented al the 1978 Annual Meeting of the American Academy of Otolaryngology, Las Vegas, Sept 10· U.
described.' Rarely is a single flap design the "only acceptable one." The surgeon must select, from several potential designs, the flap that best meets the needs of the patient and his own experience. Planning Time Plenty of time should be taken to review the several options available. When the tissue loss is due to trauma, it may be best to delay closure for a few hours until an appropriate plan for reconstruction has been devised. When extensive soft tissue injury surrounding a defect threatens to compromise the viability of local flaps, it is usually best to cover the defect temporarily with a splitthickness skin graft. This is readily excised later, and the defect is reconstructed when tissue healing is completed. Exceptions are tissue defects of the lower eyelid and those that result in extensive exposure of the facial nerve. Even throughand-through defects into the nose or mouth can be managed temporarily by closing mucosa to skin. Availability of Tissue In selecting tissue for a local flap, one should consider first those areas that usually contain an excess of skin and subcutaneous tissue (Fig 1). In general, the amount of tissue available increases with advancing age. The nasolabial, cheek, glabellar, preauricular, and temporal areas all yield a considerable amount of tissue, as do the forehead and neck. The upper eyelids will usually supply full-thickness skin that can be used either as a flap or as a free-skin graft. In other locations, the skin is quite taut or prone to develop thick, wide scars. These should be avoided in designing
Orolaryngol Head Neck Surg 87:491-496 (July-Aug) 1979 Downloaded from oto.sagepub.com at UNIV OF LETHBRIDGE on June 9, 2016
492
CHARLES
J. KRAUSE skin graft and is nearly always possible about the face. When a skin graft is required, a full-thickness postauricular or supraclavicular graft should be used for non hair-bearing sites, and scalp can be used when hair-bearing skin is needed.
Fig 1.-Areas from which excess skin is usually available.
flaps. For instance, the skin of the nasal dorsum is quite taut, and scars in this area are extremely apparent. Scars crossing the body of the mandible, scars extending laterally from the oral commissure, and vertical forehead scars lateral to the middle third tend to widen badly and are difficult to camouflage. Certain other areas such as the nasal ala, the philtrum of the upper lip, and the eyebrow should be avoided whenever possible, because their reconstruction always lacks the delicacy of the natural architecture. The lower eyelid should be avoided as well, since injudicious excision of skin may result in an ectropion.
Care should be taken to keep the amount of linear scarring to a minimum and to place those scars within natural skin lines whenever possible (Fig 2 and 3). In some instances, however, it is advisable to use a flap that actually creates a greater length of scar if, in doing so, the incisions are placed in natural skin lines. Figures 4 and 5 illustrate a situation in which a far greater length of scar is created than if, for instance, a rotation flap had been used. However, because the bilobed design places the scars within natural skin lines, the resulting deformity is less apparent than if a more simple design had been used.
Placement of Secondary Defect
When a flap is used, a secondary defect is created. The most important step in selecting an appropriate flap is to carefully think through the nature and location of the secondary defect .that will be created. Consideration should be given to which of the several local flaps available will give the least amount of secondary deformity. A poorly conceived flap may result in unsightly scarring at the donor site in addition to the anticipated scars at the margins of the original defect. This can always be avoided by carefully thinking through each step of the procedure ahead of time, including exactly how the secondary defect is to be closed. Primary closure of the donor site is far more acceptable than coverage with a
Fig 2.-Estlander flap from upper lip to replace two wedges resected from lower lip.
Characteristics of the Donor Site
A donor site should be selected in which the skin color and texture closely approximate those of the recipient site. In general, the closer the flap is located geographically to the recipient site, the closer will be the color and texture match. In addition, the thickness of the flap should approximate the depth of the recipient defect whenever possible, al-
Otolaryngol Head Neck Surg 87:491-496 (July-Aug) 1979 Downloaded from oto.sagepub.com at UNIV OF LETHBRIDGE on June 9, 2016
LOCAL flAPS
493
Fig 3.-Esllander flap shown in Fig 2 curved lnto nasolabial crease so that secondary scar is roughly symmetric with opposite nasolabial fold.
Fig 5.-Same patient as Fig 4. Scars lie in skin lines, and secondary defecI on neck is closed.
skin should be used for the face in women and in all other recipient sites that are usually free of hair . Blood Supply
Fig • .-Bilobed flap from cheek and neck 10 fill cheek and upper lip defect.
though it is possible to defat a flap or add subcutaneous bulk beneath a flap later if necessary. It is particularly important to have adequate subcutaneous bulk when covering a bony prominence. Hair-bearing skin should always be used when the recipient site is in the beard area of a man. Even when the beard is shaved, the shadow effect of the whiskers is essential in obtaining close color and texture match. Nonhair-bearing
Although many axial pattern flaps are available on the face, even random flaps here possess an abundant blood supply, so that it is rarely necessary to delay these flaps. Whenever possible, however, a named artery should be included in the flap pedicle to give even greater assurance of adequate blood supply. Care should be taken to avoid existing scars when designing the flap. Even though blood flow does develop through an established scar, the amount is dependent upon a number of variables including the location, depth, and width of the scar. It is best to simply avoid established scars whenever possible. DESIGN OF LOCAL FLAPS
Although the number and variety of local flaps that have been described are vast, they are all merely adaptations or combinations of a few basic geometric configurations. The surgeon should familiarize himself with the characteristics of each design and then carefully evaluate
Oto/aryngol Head Neck Surg 87:491-496 (july-Aug) 1979 Downloaded from oto.sagepub.com at UNIV OF LETHBRIDGE on June 9, 2016
CHARLES J. KRAUSE
494
the appropriateness of each, used singly or in combination, for closing a specific defect. Advancement
Simply mobilizing the skin around the margin of the defect and advancing it toward the center to attempt primary closure should always be the first step, but it is one that may be overlooked as the surgeon thinks, instead, of a complex flap design. Even when the defect is too large to close primarily, it is usually possible to reduce its size through advancement of the margins. This may allow closure with a small flap rather than a large one. The surgeon's first action should be to gain maximum advantage from advancement of the defect margins before beginning the design of a flap. Single pedicle advancement flaps (Fig 6, top) are particularly useful when the skin is lax or possesses considerable elasticity. Such a flap is much less useful on the forehead or scalp, where the tissue stretches little. Excision of Burow's triangles (Fig 6, middle) or inclusion of Zplasties will increase the amount of advancement that can be achieved. One must excise the triangles laterally and not medially across the pedicle base in the case of Burow's triangles, and be certain of adequate blood supply in the case of the Z-plasties. Widening the base will allow the Z-incisions to be made without unduly compromising the flap's blood supply (Fig 6, bottom). An extension of the advancement principle Is the V-V flap. A triangular flap is brought forward (V) with linear closure of the secondary defect into a Y. This technique is particularly useful when there is excess tissue immediately adjacent to the area of inadequate tissue. Rotation
A curvilinear incision is made through 180°, allowing the flap to rotate around
t
Fig 6.-Advancement flaps. Unipedic1e flap is useful when pedicle will stretch (top). Advancement may be enhanced by excision of BUrow's triangles (middle) or use of Z-plasties (bottom).
an axis and fill a triangular defect (Fig 7, top). The line of maximum tension extends across the pedicle base. A backcut will significantly increase the amount of rotation that can be achieved. The rotation flap principle is versatile and has many applications' about the head and neck. It is particularly useful when the flap tissue possesses little elasticity, as with scalp or palatal flaps. In these locations, rotation flaps should be used with a backcut. In most other sites where there is greater tissue elasticity, little or no backcut is necessary. When a larger square or rectangular defect is to be closed, paired rotation flaps can be used (Fig 7, bottom). Each flap is responsible for closing a single triangular portion of the defect.
Otolaryngol Head Neck Surg 87:491-496 (July-Aug) 1979 Downloaded from oto.sagepub.com at UNIV OF LETHBRIDGE on June 9, 2016
495
lOCAL FLAPS
C\18w f'j Fig 7.-Rotation flaps. Top, Rotation around an axis to dose triangular defect. Bottom, Paired rotation flaps are particularly useful for scalp.
Transposition A transposition flap is any elongated unipedicle flap that is rotated around an axis. The line of maximum tension flows diagonally along the pedicle from the pivot point to the opposite corner (Fig 8, top). This line must be carefully measured, and the flap must be of adequate length. Transposition flaps can be designed in a variety of shapes, including rectangular, triangular, rhomboid, or curvilinear. In most instances, the resultant scar will be less apparent if curved incisions rather than a sharply angular pattern are used. A modification of the transposition flap that warrants special mention is the bilobed flap (Fig 8, bottom). This flap is designed with two lobes nourished by a single pedicle. Each lobe is designed at an angle of approximately goo to the defect into which it will be placed. In addition, each lobe may be approximately 20% smaller than the defect into which it will be placed. The secondary defect is then approximately 40% smaller than the original defect. This usually allows primary closure of the secondary defect. An additional advantage is that although the effect is one of transposing tissue through an arc of 180°, the pedicle itself is rotated only 90°. The major disadvantage of the
Fig B.-Transposition flaps. Top, Transposition flap illustrating line of maximum tension. Bottom, Bilobed flap allows conservation of tissue and rotation angle.
bilobed flap design is that it creates a considerably greater length of scar than its single-lobe counterpart. Its use should be limited to those sites in which the linear scar is readily hidden in natural skin lines.
Z-flaps A Z-plasty consists of two triangular flaps that are transposed in opposite directions of rotation. This results in a reorientation of tissue tension lines and a lengthening of tissue along the long axis of the Z. Alone or in combination with other flaps, the Z-plasty has a multitude of uses.! Figure 9 illustrates the impact of flap angle upon the amount of lengthening achieved. The surgeon should be familiar with the principles of Z-plasty design and be prepared to incorporate them whenever necessary into the design of local flaps.
7!iYt.
!SO". _--------
!i-~:::::-
Fig g.-Z·f1aps. Effect of flap angle upon amount of lengthening achieved.
Oto/aryngol Head Neck Surg 87:491-496 (July-Aug) 1979 Downloaded from oto.sagepub.com at UNIV OF LETHBRIDGE on June 9, 2016
496
CHARLES
PRINCIPLES OF FLAP USE After selecting an appropriate donor site and deciding upon a flap design, the final step is to use the flap. Several principles are important in completing this final step.
J.
KRAUSE In most instances when both the inner mucosal layer and the overlying skin have been lost (ie, oral cavity, nose), it will be necessary to reconstruct both layers. It is usually possible, however, to reconstruct the mucosal layer with local flaps from within the oral cavity or nose itself. After advancing the mucosal margins as much as possible, rotation flaps may be used to close the remaining mucosal defect.
Measure the primary defect size after its exact dimensions have been established to be certain that the flap will be large enough. When mature scar tissue is It usually is not necessary or advisable to be removed, this should be done first, to be concerned with structural support since scar contracture can cause the surat the time of the primary defect closure. geon to greatly underestimate the actual . Support derived from a layer of scar size of the defect that will result. When a tissue beneath the flap is frequently adeneoplasm is to be removed, all margins quate, even in rather large defects. When should be clear histologically before support proves to be inadequate later, beginning reconstruction. As discussed supportive tissue grafts can be readily earlier, the wound margins should be implanted beneath the flap at a secondadvanced as much as possible before ary procedure. measuring the defect size. As with an incision about the face, Measure the proposed pedicle length careful attention is essential in closing the to be certain it is adequate. This is best wound precisely, in multiple layers, and done by measuring from the defect to the without tension. If the wound closes proposed pivot point along the line of under tension on the initial attempt, the maximum tension, then from the pivot sutures should be removed and steps point to the proposed flap tip. Nothing is taken to remove the tension. This may worse than to discover that a flap, already require additional undermining, judicious incised and elevated, is not long enough use of a backcut, or implementation of or large enough to adequately cover the additional flaps. defect. It is frequently far better to use two or more small flaps rather than one large flap. The purpose is to create two or more small secondary defects that can each be closed primarily, rather than a single large secondary defect that may be too large to close primarily. However, each flap must relate appropriately with each of the other flaps if the desired result is to be achieved.
REFERENCES
1. Converse JM, Wood-Smith D, Macomber WB: Deformities of the lips and cheeks, in Converse 1M (ed): Reconstructive Plastic Surgery, ed 2. Philadelphia, WB Saunders Co, 1977, vol J, pp 1540-1594. 2. Bernstein l: Z-plasty in head and neck surgery. Arch Otolaryngol 89:574-584, 1969.
Otolaryngol Head Neck Surg 87:491-496 (july-Aug) 1979 Downloaded from oto.sagepub.com at UNIV OF LETHBRIDGE on June 9, 2016
A CONCEPTUAL APPROACH TO LOCAL FLAPS CHARLES J. KRAUSE, MD ANN ARBOR, MICHIGAN Few procedures offer the surgeon a greater opportunity to exercise his surgical and aesthetic judgement than the design and Implementation of local flaps about the head and neck. Considerations include skin color ilnd texture match) adequacy of nap blood supply; size, location, and characterlstlcs of the donor site defect; functionill Cilpability of the proposed f1i1P; nature of skin tension lines created; and number of surgical procedures required. A systematic approach to local flap design and implementiltion is presented, ilnd iIIustriltions of the geometric principles Involved are included.
ALTHOUGH local skin flaps about the face provide close color and texture match and single-stage reconstruction, their design requires careful judgement and thoughtful application of aesthetic and geometric principles. For this reason, considerable mystique has developed with regard to their design. The truth is, however, that even a relatively inexperienced surgeon can design local flaps effectively by applying a few basic principles of tissue selection and geometric concept in a carefully thought-out plan of action. This paper is intended to assist the surgeon in selection of an appropriate local flap for closing most defects about the head and neck. Attention is focused on general principles of tissue selection and flap design rather than on an enumeration of the myriad flaps that have been
Subrnitted for publication Jan 18. 1979. From the Department of Otorhinolaryngology. University of Michigan Hospital, Ann Arbor. Presented al the 1978 Annual Meeting of the American Academy of Otolaryngology, Las Vegas, Sept 10· U.
described.' Rarely is a single flap design the "only acceptable one." The surgeon must select, from several potential designs, the flap that best meets the needs of the patient and his own experience. Planning Time Plenty of time should be taken to review the several options available. When the tissue loss is due to trauma, it may be best to delay closure for a few hours until an appropriate plan for reconstruction has been devised. When extensive soft tissue injury surrounding a defect threatens to compromise the viability of local flaps, it is usually best to cover the defect temporarily with a splitthickness skin graft. This is readily excised later, and the defect is reconstructed when tissue healing is completed. Exceptions are tissue defects of the lower eyelid and those that result in extensive exposure of the facial nerve. Even throughand-through defects into the nose or mouth can be managed temporarily by closing mucosa to skin. Availability of Tissue In selecting tissue for a local flap, one should consider first those areas that usually contain an excess of skin and subcutaneous tissue (Fig 1). In general, the amount of tissue available increases with advancing age. The nasolabial, cheek, glabellar, preauricular, and temporal areas all yield a considerable amount of tissue, as do the forehead and neck. The upper eyelids will usually supply full-thickness skin that can be used either as a flap or as a free-skin graft. In other locations, the skin is quite taut or prone to develop thick, wide scars. These should be avoided in designing
Orolaryngol Head Neck Surg 87:491-496 (July-Aug) 1979 Downloaded from oto.sagepub.com at UNIV OF LETHBRIDGE on June 9, 2016
492
CHARLES
J. KRAUSE skin graft and is nearly always possible about the face. When a skin graft is required, a full-thickness postauricular or supraclavicular graft should be used for non hair-bearing sites, and scalp can be used when hair-bearing skin is needed.
Fig 1.-Areas from which excess skin is usually available.
flaps. For instance, the skin of the nasal dorsum is quite taut, and scars in this area are extremely apparent. Scars crossing the body of the mandible, scars extending laterally from the oral commissure, and vertical forehead scars lateral to the middle third tend to widen badly and are difficult to camouflage. Certain other areas such as the nasal ala, the philtrum of the upper lip, and the eyebrow should be avoided whenever possible, because their reconstruction always lacks the delicacy of the natural architecture. The lower eyelid should be avoided as well, since injudicious excision of skin may result in an ectropion.
Care should be taken to keep the amount of linear scarring to a minimum and to place those scars within natural skin lines whenever possible (Fig 2 and 3). In some instances, however, it is advisable to use a flap that actually creates a greater length of scar if, in doing so, the incisions are placed in natural skin lines. Figures 4 and 5 illustrate a situation in which a far greater length of scar is created than if, for instance, a rotation flap had been used. However, because the bilobed design places the scars within natural skin lines, the resulting deformity is less apparent than if a more simple design had been used.
Placement of Secondary Defect
When a flap is used, a secondary defect is created. The most important step in selecting an appropriate flap is to carefully think through the nature and location of the secondary defect .that will be created. Consideration should be given to which of the several local flaps available will give the least amount of secondary deformity. A poorly conceived flap may result in unsightly scarring at the donor site in addition to the anticipated scars at the margins of the original defect. This can always be avoided by carefully thinking through each step of the procedure ahead of time, including exactly how the secondary defect is to be closed. Primary closure of the donor site is far more acceptable than coverage with a
Fig 2.-Estlander flap from upper lip to replace two wedges resected from lower lip.
Characteristics of the Donor Site
A donor site should be selected in which the skin color and texture closely approximate those of the recipient site. In general, the closer the flap is located geographically to the recipient site, the closer will be the color and texture match. In addition, the thickness of the flap should approximate the depth of the recipient defect whenever possible, al-
Otolaryngol Head Neck Surg 87:491-496 (July-Aug) 1979 Downloaded from oto.sagepub.com at UNIV OF LETHBRIDGE on June 9, 2016
LOCAL flAPS
493
Fig 3.-Esllander flap shown in Fig 2 curved lnto nasolabial crease so that secondary scar is roughly symmetric with opposite nasolabial fold.
Fig 5.-Same patient as Fig 4. Scars lie in skin lines, and secondary defecI on neck is closed.
skin should be used for the face in women and in all other recipient sites that are usually free of hair . Blood Supply
Fig • .-Bilobed flap from cheek and neck 10 fill cheek and upper lip defect.
though it is possible to defat a flap or add subcutaneous bulk beneath a flap later if necessary. It is particularly important to have adequate subcutaneous bulk when covering a bony prominence. Hair-bearing skin should always be used when the recipient site is in the beard area of a man. Even when the beard is shaved, the shadow effect of the whiskers is essential in obtaining close color and texture match. Nonhair-bearing
Although many axial pattern flaps are available on the face, even random flaps here possess an abundant blood supply, so that it is rarely necessary to delay these flaps. Whenever possible, however, a named artery should be included in the flap pedicle to give even greater assurance of adequate blood supply. Care should be taken to avoid existing scars when designing the flap. Even though blood flow does develop through an established scar, the amount is dependent upon a number of variables including the location, depth, and width of the scar. It is best to simply avoid established scars whenever possible. DESIGN OF LOCAL FLAPS
Although the number and variety of local flaps that have been described are vast, they are all merely adaptations or combinations of a few basic geometric configurations. The surgeon should familiarize himself with the characteristics of each design and then carefully evaluate
Oto/aryngol Head Neck Surg 87:491-496 (july-Aug) 1979 Downloaded from oto.sagepub.com at UNIV OF LETHBRIDGE on June 9, 2016
CHARLES J. KRAUSE
494
the appropriateness of each, used singly or in combination, for closing a specific defect. Advancement
Simply mobilizing the skin around the margin of the defect and advancing it toward the center to attempt primary closure should always be the first step, but it is one that may be overlooked as the surgeon thinks, instead, of a complex flap design. Even when the defect is too large to close primarily, it is usually possible to reduce its size through advancement of the margins. This may allow closure with a small flap rather than a large one. The surgeon's first action should be to gain maximum advantage from advancement of the defect margins before beginning the design of a flap. Single pedicle advancement flaps (Fig 6, top) are particularly useful when the skin is lax or possesses considerable elasticity. Such a flap is much less useful on the forehead or scalp, where the tissue stretches little. Excision of Burow's triangles (Fig 6, middle) or inclusion of Zplasties will increase the amount of advancement that can be achieved. One must excise the triangles laterally and not medially across the pedicle base in the case of Burow's triangles, and be certain of adequate blood supply in the case of the Z-plasties. Widening the base will allow the Z-incisions to be made without unduly compromising the flap's blood supply (Fig 6, bottom). An extension of the advancement principle Is the V-V flap. A triangular flap is brought forward (V) with linear closure of the secondary defect into a Y. This technique is particularly useful when there is excess tissue immediately adjacent to the area of inadequate tissue. Rotation
A curvilinear incision is made through 180°, allowing the flap to rotate around
t
Fig 6.-Advancement flaps. Unipedic1e flap is useful when pedicle will stretch (top). Advancement may be enhanced by excision of BUrow's triangles (middle) or use of Z-plasties (bottom).
an axis and fill a triangular defect (Fig 7, top). The line of maximum tension extends across the pedicle base. A backcut will significantly increase the amount of rotation that can be achieved. The rotation flap principle is versatile and has many applications' about the head and neck. It is particularly useful when the flap tissue possesses little elasticity, as with scalp or palatal flaps. In these locations, rotation flaps should be used with a backcut. In most other sites where there is greater tissue elasticity, little or no backcut is necessary. When a larger square or rectangular defect is to be closed, paired rotation flaps can be used (Fig 7, bottom). Each flap is responsible for closing a single triangular portion of the defect.
Otolaryngol Head Neck Surg 87:491-496 (July-Aug) 1979 Downloaded from oto.sagepub.com at UNIV OF LETHBRIDGE on June 9, 2016
495
lOCAL FLAPS
C\18w f'j Fig 7.-Rotation flaps. Top, Rotation around an axis to dose triangular defect. Bottom, Paired rotation flaps are particularly useful for scalp.
Transposition A transposition flap is any elongated unipedicle flap that is rotated around an axis. The line of maximum tension flows diagonally along the pedicle from the pivot point to the opposite corner (Fig 8, top). This line must be carefully measured, and the flap must be of adequate length. Transposition flaps can be designed in a variety of shapes, including rectangular, triangular, rhomboid, or curvilinear. In most instances, the resultant scar will be less apparent if curved incisions rather than a sharply angular pattern are used. A modification of the transposition flap that warrants special mention is the bilobed flap (Fig 8, bottom). This flap is designed with two lobes nourished by a single pedicle. Each lobe is designed at an angle of approximately goo to the defect into which it will be placed. In addition, each lobe may be approximately 20% smaller than the defect into which it will be placed. The secondary defect is then approximately 40% smaller than the original defect. This usually allows primary closure of the secondary defect. An additional advantage is that although the effect is one of transposing tissue through an arc of 180°, the pedicle itself is rotated only 90°. The major disadvantage of the
Fig B.-Transposition flaps. Top, Transposition flap illustrating line of maximum tension. Bottom, Bilobed flap allows conservation of tissue and rotation angle.
bilobed flap design is that it creates a considerably greater length of scar than its single-lobe counterpart. Its use should be limited to those sites in which the linear scar is readily hidden in natural skin lines.
Z-flaps A Z-plasty consists of two triangular flaps that are transposed in opposite directions of rotation. This results in a reorientation of tissue tension lines and a lengthening of tissue along the long axis of the Z. Alone or in combination with other flaps, the Z-plasty has a multitude of uses.! Figure 9 illustrates the impact of flap angle upon the amount of lengthening achieved. The surgeon should be familiar with the principles of Z-plasty design and be prepared to incorporate them whenever necessary into the design of local flaps.
7!iYt.
!SO". _--------
!i-~:::::-
Fig g.-Z·f1aps. Effect of flap angle upon amount of lengthening achieved.
Oto/aryngol Head Neck Surg 87:491-496 (July-Aug) 1979 Downloaded from oto.sagepub.com at UNIV OF LETHBRIDGE on June 9, 2016
496
CHARLES
PRINCIPLES OF FLAP USE After selecting an appropriate donor site and deciding upon a flap design, the final step is to use the flap. Several principles are important in completing this final step.
J.
KRAUSE In most instances when both the inner mucosal layer and the overlying skin have been lost (ie, oral cavity, nose), it will be necessary to reconstruct both layers. It is usually possible, however, to reconstruct the mucosal layer with local flaps from within the oral cavity or nose itself. After advancing the mucosal margins as much as possible, rotation flaps may be used to close the remaining mucosal defect.
Measure the primary defect size after its exact dimensions have been established to be certain that the flap will be large enough. When mature scar tissue is It usually is not necessary or advisable to be removed, this should be done first, to be concerned with structural support since scar contracture can cause the surat the time of the primary defect closure. geon to greatly underestimate the actual . Support derived from a layer of scar size of the defect that will result. When a tissue beneath the flap is frequently adeneoplasm is to be removed, all margins quate, even in rather large defects. When should be clear histologically before support proves to be inadequate later, beginning reconstruction. As discussed supportive tissue grafts can be readily earlier, the wound margins should be implanted beneath the flap at a secondadvanced as much as possible before ary procedure. measuring the defect size. As with an incision about the face, Measure the proposed pedicle length careful attention is essential in closing the to be certain it is adequate. This is best wound precisely, in multiple layers, and done by measuring from the defect to the without tension. If the wound closes proposed pivot point along the line of under tension on the initial attempt, the maximum tension, then from the pivot sutures should be removed and steps point to the proposed flap tip. Nothing is taken to remove the tension. This may worse than to discover that a flap, already require additional undermining, judicious incised and elevated, is not long enough use of a backcut, or implementation of or large enough to adequately cover the additional flaps. defect. It is frequently far better to use two or more small flaps rather than one large flap. The purpose is to create two or more small secondary defects that can each be closed primarily, rather than a single large secondary defect that may be too large to close primarily. However, each flap must relate appropriately with each of the other flaps if the desired result is to be achieved.
REFERENCES
1. Converse JM, Wood-Smith D, Macomber WB: Deformities of the lips and cheeks, in Converse 1M (ed): Reconstructive Plastic Surgery, ed 2. Philadelphia, WB Saunders Co, 1977, vol J, pp 1540-1594. 2. Bernstein l: Z-plasty in head and neck surgery. Arch Otolaryngol 89:574-584, 1969.
Otolaryngol Head Neck Surg 87:491-496 (july-Aug) 1979 Downloaded from oto.sagepub.com at UNIV OF LETHBRIDGE on June 9, 2016
