Cummings Chap 24 Reconstruction
of facial defects
10/31/12
Aesthetic facial units
Forehead
Cheeks
Eyelids
Nose
Lips
Auricles
Scalp
Local flap classification
Local flaps- designed immed adjacent to defect, pivotal,
advancement, hinge
1. Pivotal- shorter flap length greater degree rotation
a) rotational
b) transposition
c) interpolated flap
2. Advancement flap- stretched in single vector into
defect
a) unipedicled
b) V-Y advancement
c) Y-V advancement
3. Hinge flap
Pivotal flaps
Rotational• Curvilinear
• Flap adjacent to defect
• usu random/occ axial
blood supply
• best if inferiorly basedallows lymphatic flow
• good for mid face
defects.
Pivotal flaps
Transposition
• Linear
• Can be adjacent or
distant to defect 
more options for skin
donor, better
scar/orientation of
donor site
• usu random/occ axial
blood supply
• small-med defect
• L:W <1:3
Pivotal flaps
Interpolated
• axial blood supply
• base distant to
defect
• pedicle must pass
over/under normal
tissue
• req 2nd stage, or can
de-ep and tunnel
under tissue
Advancement flap
Unipedicled• Primary movement:
Tissue slides into defect
• Secondary movement:
tissue around defect
pushed in
• 2 burrows triangles- z
plasty, “sewn out”
• Bilateral unipedicles 
H or T plasty
Advancement flap
VY advancement
• V shaped flap covers defect  results in triangular defect
at donor site  closed by advancing 2 edges of the
triangle forming stem of the Y
• Good for contracted sites that need lengthening/release
eg columella in cleft lip, ectropion of vermillion
YV advancement
• Similar to above ex 1st flap is Y shaped
• Good for reducing redundant tissue
Hinge flap
• pedicle based on defect border, flipped
over like page in book, subcut surface
covered w/ 2nd flap
• Good for defects that req ext and int
coverage eg full thickness nasal defects
Facial defects recon
Nose
Lip
Cheek
Forehead
Nasal Defects
• Nasal subunits:
• T/F Defects involving several
subunits should be repaired
with single flap if possible.
• If defect involved > ? of the
subunit, replace the entire
subunit
Nasal Defects
• Nasal subunits:
•
•
•
•
•
•
ala,
side wall
columella
dorsum
tip
Facets
• Repair defect of each aesthetic
subunit separately
• If defect involved >50% of the
subunit, replace the entire
subunit
Nasal defects- ala
• Ala part of ext nasal
valve
• 1.5cm or lessbipedicled mucosa flap
for internal lining,
septal/conchal cart for
alar cartilage,
interpolated flap from
cheek/forehead for
external coverage
• 2.5cm or less- septal
hinge mucosal graft
Septal hinge
Nasal defects- tip/columella
• Composite pivotal
septal flap
• Mucoperichondrial
leaves form internal
lining as bilat hinge
flaps
• Cartilage graft
• Paramedian forehead
flap for external
coverage
Melolabial and paramedian flap
Lip defects
<1/2 – primary closure, w plasty
1/2-2/3- lip switch (abbe if away from commissure, estlander + commissureplasty if
near commissure) flap width ½ defect width, kerapanzic
>2/3- bernard webster bipedicled advancement flap, melolabial transposition,
temporal forehead flap, free flap
Abbe
W plasty
Karapanzic
Bernard burrows
Estlander
Cheek defects
Keep tension away from
eye/lip
Rhomboid- Small-med
defects
Bilobed- large defects, 1st
lobe 20% smaller than
defect,2nd lobe 20%
smaller than 1st, inf based
Advancement flap
Transposition flapmelolabial, best sup based
b/c redundant lower
cheek skin used for flap
Forehead defects
Goals: preserve frontalis fxn,
presernve sensation, place scars
withinhorizontal furrows
Aesthetic goals: Eyebrow symmetry,
maintain hairline, hide scars (in
brow/hairline, keep scars
transverse except in midline)
Subunits:
• Median- midline
• Paramedian- midline to vertical
axis above pupil
• Lateral temple- paramedian
border to temporal hairline
Forehead defects
Best results: local flap>secondary intent>skin graft
Advancement flap +/- tissue expander, AT/OT
Secondary intent best if near hairline in central or lateral 1/3