Flaps Practical Reconstructive Surgery

528
II Reconstructive Flaps A-to-Z
Fig. 49.5 Posterior cervical wound with exposed subcutaneous tissue at base of wound after tumor
extirpation.
Step 2: Position the Patient
Place the patient in the prone or lateral decubitus position with
all pressure points padded.
Step 3: Identify the Wound
Identify the wound that needs to be covered and template out the
size (Fig. 49.5). Con rm that the skin paddle will reach and cover
this defect.
Step 4: Skin Paddle Incision (Lateral)
Make the initial skin incision laterally if elevating a myocutaneous
trapezius ap. Dissect through the skin and subcutaneous tissue.
Step 5: Identify the Trapezius
Muscle
It is critical to include the fascia of the latissimus dorsi muscle as
one moves lateral to medial. This will lead to the lateral border
of the trapezius muscle. Once the lateral border of the trapezius
muscle is reached, the dissection stops.
Step 6: Skin Paddle Incision (Medial)
Make the m edial skin incision in the posterior m idline over
the transverse processes. Carry the incision through the skin,
subcutaneous tissue, and super cial fascia of the back. Stop once
the deep fascia over the trapezius muscle is identi ed.
Step 7: Skin Paddle Incision
(Inferior)
Make the inferior skin paddle incision. This incision should not
extend beyond the T12 transverse process.
Step 8: Skin Paddle Incision
(Superior)
Make the superior skin paddle incision. This incision extends
to the m idpoint of the scapula. Carry the incision through the
skin, subcutaneous tissue, and super cial fascia of the back.
Stop once the deep fascia over the trapezius m uscle is identi ed
(Fig. 49.6).
Step 9: Trapezius Muscle Elevation
Raise the m uscle from caudal to cranial (Fig. 49.7). Release all
bers to the thoracic vertebrae and fascial attachm ents to the
latissim us dorsi. Release the m uscle ber attachm ents of the
trapezius from the scapula. At this level, release the anterior
surface of the trapezius m uscle from the rhom boid m uscle.
Take care to preserve the lateral clavicle and acrom ioclavicular
joint.

49 Trapezius Flaps
529
Fig. 49.7 Muscle ap completely raised o surrounding attachments.
Step 10: Secure the Skin Paddle
When raising the skin paddle w ith the muscle, it is important not
to shear the skin paddle. Suturing the skin paddle to the under-
lying trapezius m uscle with a few absorbable stitches w ill help in
this e ort.
Step 11: Identi cation of Vascular
Pedicle
Identify the dorsal scapula artery between the rhomboid mus-
cles (Fig. 49.8). Locate the descending branch of the transverse
cervical artery on the deep surface of the trapezius muscle and
medial and superior to the dorsal scapular artery. This is found
im mediately superior to the rhomboid minor muscle. Ligate m i-
nor pedicles arising from the perforating intercostal arteries and
veins.
Step 12: Subcutaneous Tunnel
Create a wide subcutaneous tunnel to allow the myocutaneous
trapezius ap to be inset into the appropriate head and neck de-
fect (Fig. 49.9). Use a lighted retractor and obtain meticulous he-
mostasis using monopolar cautery.
Fig. 49.6 Skin paddle islandized over inferior portion of trapezius muscle.

530
II Reconstructive Flaps A-to-Z
Fig. 49.8 Identi cation of vascular pedicle between rhomboid muscles.
Fig. 49.9 Creation of subcutaneous tunnel to allow passage of the ap.
Step 13: Tension-Free Zone
When insetting the ap, con rm there is no tension on the ap or
undue pressure from the subcutaneous tunnel by observing the
ap and proximal pedicle (Fig. 49.10).
Step 14: Donor Site Closure
Close the donor site back defect in a multilayer fashion over
closed suction drains (Fig. 49.11). Typically, the authors advocate
for using absorbable suture to close the super cial fascia and der-
mis. Assure that the closure is tension-free to avoid skin necrosis.
Step 15: Postoperative
Management
There is no restriction on postoperative am bulation status. Take
care not to have the patient lay in the supine position in order to
not place pressure on the ap or its vascular pedicle.

49 Trapezius Flaps
531
Fig. 49.10 (a) Full arc of rotation established in a tension-free zone. (b) The ap is inset into the posterior defect.
a
b

Important Anatomical
Structures
Identi ed and raised with the ap:

●
Required muscle ap

●
Dominant supplying vascular pedicle(s)
Identi ed and preserved:

●
Spinal accessory nerve

Clinical Perspectives
The trapezius myocutaneous ap is a well-described ap option
for coverage of defects in several anatomic regions: head and neck,
oral cavity, axilla, posterior trunk, and shoulder. It is usually trans-
ferred as a pedicled muscle ap. Variations are discussed above.
Prior to reconstruction, stabilize and debride the wound. Optimize
the patient’s nutrition. Investigate preoperative vascular status
and rule out prior neck dissection as this procedure may cause
compromise to the source blood supply. See the case in Fig. 49.12.

532
II Reconstructive Flaps A-to-Z
Fig. 49.11 The donor site wound is primarily closed, and a closed suction drain is placed deep in the wound bed.
a
Fig. 49.12 The same clinical case as shown in previous gures: a patient with history of spine malignancy with prior sur-
gical procedure and radiation therapy for sarcoma. The patient presented with tumor recurrence. (a) Posterior cervical
wound with exposed subcutaneous tissue at base of wound after tumor extirpation. (continued)

49 Trapezius Flaps
533
is based on the super cial cervical artery. This ap should not
include the acromion.
Although not commonly performed, a trapezius turnover
(muscle) ap based on intercostal perforators can be used to pro-
vide coverage of midline, posterior defects.

Hints and Tips

●
Make all attempts to prim arily close the donor site. Skin
grafts are unsightly in this anatomic region. Furthermore,
secondary contracture can cause disruption of normal an-
atomic function.
b
Fig. 49.12 (continued) (b) View of posterior cervical defect and proposed skin paddle for myocutane-
ous trapezius ap. (c) Flap rotation complete with maximized arc of rotation and no tension placed
on pedicle. (continued)
c

Flap Variations
The trapezius ap can be raised as myocutaneous ap based on
any one of the following arteries: ascending branch of transverse
cervical artery, descending branch of transverse cervical artery,
dorsal scapular artery, and occipital artery. Less muscle is sacri-
ced in myocutaneous aps based on the dorsal scapular artery
as compared to the super cial cervical artery.
This ap can be transferred as a free ap, but perforator aps
are not recommended. It is di cult to identify perforators in the
dissection, and aps based on perforators are tenuous. Free aps
can contain one or more than one pedicle.
The trapezius ap can be harvested as an osteomyocutaneous
ap by incorporating a portion of the scapular spine. The pedicle

534
II Reconstructive Flaps A-to-Z

●
The surgeon should wear a headlamp and loupes.

●
Autom atic vascular clip appliers facilitate e cient
hem ostasis.

●
When skeletonizing the pedicle, it is unnecessary to take
a cu of rhomboid muscle. Sacri cing a portion of this
muscle during this step can increase donor site morbidity.

●
In cases where the patient has undergone a radical neck
dissection, there is a possibility that the main pedicle
source artery (transverse cervical artery) has been pre-
viously compromised, which precludes the use of this
muscle ap.
Suggested Further Reading
Baek SM, Biller HF, Krespi YP, Lawson W. The lower trapezius island
myocutaneous ap. Ann Plast Surg 1980;5:108–114
Chandrasekhar B, Terz JJ, Kokal WA, Beatty JD, Gottlieb ME. The inferior
trapezius m usculocutaneous ap in head and neck reconstruction.
Ann Plast Surg 1988;21:201–209
Demergasso F, Piazza MV. Trapezius myocutaneous ap in reconstructive
surgery for head and neck cancer: an original technique. Am J Surg
1979;138:533–536
Gantz BJ, Panje WR. “How I do it”–plastic surgery. Practical suggestions
on facial plastic surgery. Trapezius myocutaneous island ap.
Laryngoscope 1981;91:1196–1199
Haas F, Weiglein A, Schwarzl F, Scharnagl E. The lower trapezius muscu-
locutaneous ap from pedicled to free ap: anatom ical basis and
clinical applications based on the dorsal scapular artery. Plast Re-
constr Surg 2004;113:1580–1590
McCraw JB, Magee WP Jr, Kalwaic H. Uses of the trapezius and sterno-
m astoid myocutaneous aps in head and neck reconstruction. Plast
Reconstr Surg 1979;63:49–57
Ogawa R, Murakami M, Vinh VQ, Hyakusoku H. Clinical and anatomical
study of super cial cervical artery aps: retrospective study of re-
constructions with 41 aps and the feasibility of harvesting them
as perforator aps. Plast Reconstr Surg 2006;118:95–101
Papadopoulos O, Tsakoniatis N, Georgiou P, Christopoulos A. Head and
neck soft-tissue reconstruction using the vertical trapezius muscu-
locutaneous ap. Ann Plast Surg 1999;42:457–458
Tan KC, Tan BK. Extended lower trapezius island myocutaneous ap: a
fasciomyocutaneous ap based on the dorsal scapular artery. Plast
Reconstr Surg 2000;105:1758–1763
Vacher C, de Vasconcellos JJ. The anatomical basis of the osteo-musculo-
cutaneous trapezius ap in m andibular reconstruction. Surg Radiol
Anat 2005;27:1–7
Figure Credits
1. THIEME Atlas of Anatomy, General Anatomy and Musculoskeletal
System, p174 © Thieme 2005, Illustration by Karl Wesker.
Fig. 49.12 (continued) (d) Patient follow-up at 3 months with all wounds
healed.
d

●
If utilizing a pedicled middle trapezius ap, immobilize the
shoulder joint for 2 weeks to avoid compromising ap via-
bility, inset, and donor site complications.

●
Due to the course of the spinal accessory nerve, one must
take caution to not sacri ce it. The course of the nerve is in
proximity to the main pedicle; therefore, there is no need
to divide the nerve.

●
When harvesting an osteomyocutaneous ap, preserve
the acrom ion. Any disruption of this structure will lead to
shoulder joint instability.

535
Ulnar Artery Forearm
Fasciocutaneous Flaps
Adrian Sjarif and Pouria Moradi
50

Classif cation

●
Mathes-Nahai: type B/type C

●
Cormack-Lamberty: type C

Vascular Pedicle
Flap is based on the ulnar artery, which is the larger of the two
terminal branches of the brachial artery. The diameter of the ulna
artery is 3 mm proximally and 2.5 mm distally. The ulna artery
consistently has two or three perforators supplying the forearm
skin, which should be included in the ap to ensure viability of
the skin paddle. Recent anatomical studies have dem onstrated
that these perforators are found at 7, 11, and 15.5 cm proxim al to
the distal wrist crease.

Patient Positioning
Supine; nondom inant arm preferred, placed on an arm board
with tourniquet on the upper arm.

Innervation
Medial antebrachial cutaneous nerve (C8-T1) travels with the ba-
silic vein dividing into anterior (supplying anteromedial forearm)
and posterior (supplying posteromedial forearm) branches.

Surface Markings
1. The ap occupies medial aspect of forearm.
2. Mark the pisiform and the medial epicondyle of the humerus.
3. A line is drawn between the medial epicondyle and the radial
border of the pisiform ; this m arks the course of the ulnar ar-
tery, which commences at a point 1 cm below the center of the
antecubital fossa (Fig. 50.1).
4. Flap should be centered on this line with at least one-third of
skin paddle on radial side of line. The distal margin of the ap
should be sited approximately 5 cm proximal to wrist crease.
5. Doppler can be used to mark perforators: usual locations are
at 7, 11, and 15.5 cm proxim al to pisiform in average adult
(Fig. 50.2).

Raising the Flap
Step 1: Preparation of the Limb
Preoperatively, an Allen’s test should be performed on the non-
dominant donor arm. This arm should not be used for venipunc-
ture or intravenous cannulation prior to ap harvest. Sim ilar to
Fig. 50.1 Line drawn from medial epicondyle to pisiform marks out
course of ulnar artery. Flap should be centered in distal third of the fore-
arm with this line as axis.1

536
II Reconstructive Flaps A-to-Z
the raising of a radial forearm ap, a tourniquet should be applied
to the upper arm and the arm elevated to partially exsanguinate
the lim b and then activated, ensuring that the course of the
basilic vein is noted and marked out in the event that it is re-
quired for inclusion in the ap. The tourniquet should be set at
100 mm Hg above systolic pressure. Full exsanguination of the
limb is to be avoided as it makes identi cation of both the venous
component of perforators as well as the super cial venous sys-
tem more di cult.
Step 2: Radial Incision
Dissection of the ulnar artery ap is com m enced from radi-
al to ulnar. The radial incision is com m enced w ith a scalpel
dow n to the deep derm is and then deepened using m onopolar
diathermy through subcutaneous fat dow n to deep fascia. The
deep fascia is incised w ith the scalpel and then the skin paddle
re ected in a subfascial plane using scalpel dissection until the
interm uscular septum is reached. The septocutaneous vessels
that nourish the skin paddle are found w ithin this fascial sep-
tum that separates the exor digitorum super cialis and exor
carpi ulnaris m uscles. These vessels m ust be carefully protected
throughout.
Step 3: Ulnar Incision
Although most commonly described as being raised initially in
an ulnar direction, the ulnar forearm ap can also be raised in
a radial direction following an initial ulna-sided incision as is
demonstrated in the following examples. The ulna vessels are ex-
posed by retracting the exor carpi ulnaris medially (Figs. 50.3
and 50.4). The muscular branches to the exor carpi ulnaris and
exor digitorum need to be divided to free the skin paddle as long
as su ciently sizeable septocutaneous perforators are con rmed
within the intermuscular septum (Fig. 50.5).
Fig. 50.2 Expected position of perforators should be marked out with
Doppler and ap designed incorporating these.
Fig. 50.3 Medial portion of the ap with deep fascia is raised from exor
carpi ulnaris, which is retracted medially to visualize the ulnar neurovas-
cular bundle. The intermuscular septum is carefully preserved: 1, Basilic
vein and medial cutaneous nerve of forearm; 2, ulnar artery, vein, and
nerve; 3, exor carpi ulnaris m.1
Fig. 50.4 Ulnar artery and venae comitantes can be visualized at the base of
the intermuscular septum with medial retraction of the exor carpi ulnaris.

50 Ulnar Artery Forearm Fasciocutaneous Flaps
537
Step 4: Retrograde Pedicle
Dissection
Distally, the ulnar vascular bundle is identified w here it is in-
tim ately bound to the ulnar nerve (the nerve located m edial
to the artery). Prior to division of the pedicle, the circulation
Fig. 50.5 Two ulnar artery perforators can be seen entering the skin pad-
dle. Muscular branches entering the muscle belly of exor digitorum su-
per cialis need to be ligated as the ap is raised in a retrograde fashion.
of the hand should be checked by clam ping the ulna artery
at this point and releasing the tourniquet. Only once this cir-
culation has been confirm ed should the pedicle be divided.
Working from distal to proxim al, the ulnar artery is then care-
fully separated from the nerve and any other soft tissue at-
tachm ents taking care not to skeletonize the nerve (Figs. 50.6
and 50.7).
Use of electrocautery and m onopolar diathermy is avoided
during the dissection. The skin incision is extended proximal to
the skin paddle to explore the origin of the ulnar artery where it
bifurcates with the common interosseous. The basilic vein and
medial antebrachial cutaneous nerve (Fig. 50.6) are preserved
within the ap if it is to be used as a sensate ap, and these
should be traced as far proximal as possible to maximize their
useable length (Fig. 50.8).
Fig. 50.6 The ulna artery is separated from the ulna nerve, taking care
not to skeletonize the nerve.
Fig. 50.7 As much tissue as possible should be left attached to the nerve
to ensure it does not become de-vascularized.
Fig. 50.8 The medial antebrachial nerve should be preserved so that it
can be neurotized at the time of ap transfer (e.g., to the lingual nerve)
for a sensate ap. It should be traced as far proximally as dissection will
allow, as should the ulnar artery, veins, and basilic vein, if preserved.

538
II Reconstructive Flaps A-to-Z
Fig. 50.9 With tourniquet released, ap viability is con rmed and hemo-
stasis is achieved prior to pedicle division and donor site closure.
Step 5: Check Flap Vascularity
Once ap elevation is complete, the tourniquet is released and the
circulation of both the skin paddle and hand is again con rmed
(Fig. 50.9).
A marking pen is used to identify pedicle orientation to min-
imize the risk of kinking during ap inset. The ulnar artery, venae
com itantes, basilic vein, and m edial antebrachial cutaneous nerve
are then ligated at the chosen proximal level and divided sharply
with scissors prior to ap transfer (Fig. 50.10).
Step 6: Donor Site Closure
As with radial forearm donor sites, sm all skin paddles are
am enable to direct skin closure. Larger donor sites in which pri-
mary closure is not possible should be resurfaced w ith a skin
graft. The ulnar artery ap can be raised in a suprafascial plane
leaving a bed that m ay m ore readily support a graft. The skin
graft should be bolstered w ith a foam tie-over dressing and then
the forearm splinted in short arm plaster until graft review to
prevent skin graft shearing. Skin graft take is checked on post-
operative day 5.

Important Anatomical
Structures
Identi ed and raised with the ap:

●
Ulnar artery and venae com itantes: two to three cutaneous
perforators

●
Basilic vein if present

●
Medial antebrachial cutaneous nerve
Identi ed and preserved:

●
Ulnar nerve: take care not to handle excessively

●
Median nerve: near the origin of the ulnar vessels, m ore
retraction is required to visualize the pedicle. Care must be
taken not to put too much traction on the median nerve at
this point.

Clinical Perspectives
The ulnar forearm ap is useful when a thin, pliable fasciocuta-
neous ap is required. Advantages over the radial forearm ap
are that it tends to leave a more aesthetically pleasing donor site
and the harvested ap tends to be relatively hairless (Fig. 50.11).
This is particularly useful in patients who do not receive adjuvant
radiotherapy, as hair-bearing aps such as the radial forearm do
tend to lose their hair when the follicles are irradiated. Because
of the hairless characteristic of this ap, it is also considered the
preferred ap for urethral reconstruction in gender reassignment
surgery.
Fig. 50.10 The free ulnar artery fasciocutaneous ap is demonstrated
here along with the ulnar artery and venae comitantes and medial ante-
brachial cutaneous nerve. The basilic vein was not included.
Fig. 50.11 The ulnar artery ap inset for a lateral tongue defect. Note the
thin, pliable nature of the ap and the absence of hair, which make it an
ideal option for this indication.

50 Ulnar Artery Forearm Fasciocutaneous Flaps
539
vein choice in the event the venae com itantes are not
suitable.
Suggested Further Reading
Glasson DW, Lovie MJ, Duncan GM. The ulnar forearm ap in penile
reconstruction. Aust NZ J Surg 1986;38:398
Lovie MJ. The ulnar artery forearm free ap. Br J Plast Surg 1984;38:101
Mathy JA, Moaveni Z, Tan ST. Perforator anatomy of the ulnar forearm
fasciocutaneous ap. J Plast Reconstr Aesthet Surg 2012;65(8):
1076–1082
Strauch B, Yu HL. Ulnar forearm ap. In: Atlas of Microvascular Surgery.
Stuttgart: Thieme; 1993:69–73
Yu P, Chang EI, Selber JC, Hanasono MM. Perforator patterns of the ulnar
artery perforator ap. Plast Reconstr Surg 2012;129(1):213–220
Figure Credits
1. Strauch B, Yu HL. Atlas of Microvascular Surgery: Anatomy and Oper-
ative Approaches. 2nd ed. New York, NY: Thieme; 2006

Flap Variations

●
Pedicled or free

●
Fasciocutaneous ap

●
Fasciocutaneous ap with exor carpi ulnaris

●
Fasciocutaneous ap with ulna bone

●
Flow-through ap

Hints and Tips

●
Avoid handling the ulnar nerve while raising the ap, as
even minor traction injury can lead to temporary reduc-
tions in grip strength.

●
When available, a basilic vein entering the proxim al as-
pect of the ap should be preserved as an alternative

540
Vertical or Oblique Rectus Abdominis
Myocutaneous Flaps for Perineal
Reconstruction
Charles A. T. Durrant and Sim on H. Wood
51

Classif cation
The vertical or oblique rectus abdom inis myocutaneous (VRAM
or ORAM) ap is a Mathas-Nahai type III ap. The rectus muscle
has two separate dominant blood supplies from the deep supe-
rior epigastric vessels and the deep inferior epigastric vessels,
respectively. The overlying skin paddle relies on the perforating
branches of these vessels.

Vascular Pedicle
The main pedicle is the deep inferior epigastric artery, which
arises from the external iliac artery immediately above the ingui-
nal ligament and enters the deep lateral edge of the rectus muscle
in a variable fashion 7 to 14 cm from its origin.

Patient Positioning
The patient is supine on the operating table in the Lloyd-Davis
position (Fig. 51.1). This allows exposure of the abdomen and
also the perineal defect (Fig. 51.2).

Surface Markings
The patient is m arked in the supine position (Fig. 51.1). A midline
laparotomy marking is made 4 to 5 cm superior to the umbilicus,
extending inferiorly to the pubis. A Doppler probe is used to iden-
tify perium bilical perforators, which are then m arked. From this
point, the marking deviates obliquely toward the inferior tip of
the ipsilateral scapula in a line that runs parallel to the intercostal
spaces in the anterior axillary line. This line forms the axis of the
Fig. 51.1 The cross represents the identi ed periumbilical perforator and forms the base of the obliquely orientated skin paddle.
Note the existing stoma on the contralateral side.

51 Vertical or Oblique Rectus Abdominis Myocutaneous Flaps for Perineal Reconstruction
541
Step 3
The rectus m uscle is divided cephalad to the identi ed perfora-
tors. It is possible to take the entire rectus muscle if extra bulk is
needed. Once divided, the cephalad edge of the rectus is dissected
o the posterior rectus sheath and the ap continues to be raised
in a superior-to-inferior direction in the subrectus plane. Ensure
that great care is taken with the oblique skin paddle to prevent
shearing or stretching of the perforators between the skin and
the m uscle. The rectus continues to be dissected from the abdo-
men until its origin is reached, taking care to preserve the deep
inferior epigastric vessels that can be seen entering the deep
lateral edge of the muscle a few centimeters from its insertion
(Fig. 51.4).
Step 4
The myocutaneous ap has now been elevated and rem ains at-
tached by the muscular insertion on the pubis and by the deep
inferior epigastric pedicle. At this point, the loose fascial tissue
between these is divided and the tendinous attachment reduced,
especially on its m edial side (Fig. 51.5). This allows easier rota-
tion and m anipulation of the ap through the pelvis, while pro-
viding structural support to the pedicle to minim ize the chance
of damage. An opening is made in the peritoneum between the
vascular and tendinous pedicle origins to allow direct routing of
this composite pedicle through the pelvis into the perineal defect
(Fig. 51.6).
oblique skin paddle. The length of the oblique paddle depends
on requirem ents and m ay be 10 to 30 cm long. The width of the
paddle can be estimated using Taylor’s “pinch test” and is usually
8 to 10 cm.

Raising the Flap
Step 1
The initial incision is m ade along the superior and inferior
margins of the oblique skin paddle (Fig. 51.1). The incision
extends through skin, subcutaneous fat, and Scarpa’s layer to the
underlying m uscle fascia. The ap is raised in a lateral-to-medial
fashion in the suprafascial plane.
Step 2
Upon reaching the lateral edge of the rectus muscle, care must be
taken to identify the perforating vessels as they arise through the
rectus muscle in the periumbilical region. Once identi ed, the
rectus fascia is breached on either side of the perforators and split
inferiorly along the length of the underlying rectus (Fig. 51.3).
The fascia is dissected o the underlying rectus m uscle m edially
and laterally. The medial skin incision is completed. A vertical
skin paddle (see Flap Variations later) was also used in this case
because of the extensive defect from skin necrosis secondary to
infection at presentation.
Fig. 51.2 The defect includes the anus, perineal skin, ischiorectal space, and posterior wall of the vagina (white arrow).

542
II Reconstructive Flaps A-to-Z
Fig. 51.3 The lateral aspect of the ap has been raised to expose the periumbilical perforator (white arrow). The fascia has been
re ected o the rectus muscle inferiorly (blue arrow). A vertical paddle is also harvested in this case.
Fig. 51.4 The ap has been raised o the abdominal wall. The deep inferior epigastric vessels can be seen entering the deep lateral
surface of the ap (white arrow). Note that our orientation has changed and we are looking caudally from the patient’s left side.

51 Vertical or Oblique Rectus Abdominis Myocutaneous Flaps for Perineal Reconstruction
543
Fig. 51.5 The loose fascial tissue between the tendinous insertion and the vascular pedicle has been divided (white arrows). The
medial segment of the tendinous insertion is divided, but an attachment is left to protect the vascular pedicle (blue arrow).
Fig. 51.6 The ap is delivered into the defect. Note how the skin paddle has been sutured to the muscle to prevent shearing of
the perforators during ap transfer (white arrow).

544
II Reconstructive Flaps A-to-Z
Step 5
The m uscular part of the ap is used to ll intrapelvic dead space.
If there is adequate perineal skin for closure, the skin of the ap
may be de-epithelialized and used to close the pelvic inlet to
prevent bowel herniation. If epithelialized structures such as the
vaginal wall or perineal skin need coverage, then the intact skin
ap can be used to reconstruct these areas. However, in our illus-
trative case w ith a m ore extensive defect, the skin paddle of the
vertical element is used to reconstruct the posterior vaginal wall,
the muscle aids in lling the pelvic dead space, and the oblique
skin paddle covers the perineal excisional defect (Fig. 51.7).
Split-thickness skin grafts were applied to the rem aining super-
cial areas. A large-bore soft drain is placed in the pelvis and a
suction drain is placed super cially (Fig. 51.8).
Step 6
The donor site is closed. The fascia is double-breasted and reinforced
with Prolene mesh (Ethicon, Somerville, NJ) if necessary. The over-
lying abdominal skin is closed in layers using absorbable sutures.

Important Anatomical
Structures
Identi ed and raised with the ap:

●
Oblique skin paddle with periumbilical perforators

●
Rectus muscle
Fig. 51.7 The thin pliable skin is used to reconstruct the posterior vaginal wall. The muscle is lling the dead space.
Identi ed and preserved:

●
Rectus sheath

●
Deep inferior epigastric vessels

●
Medial rectus insertion

Clinical Perspectives
Applications include reconstruction of the trunk, thigh, groin,
and perineum; obliteration of irradiated intrapelvic dead space;
and vaginal reconstruction.

Flap Variations
The rectus may be harvested in its entirety or only as far as the
perforating vessels. Alternatively, the skin paddle may be raised
in a muscle-sparing fashion if a skin-only reconstruction is re-
quired. It is possible to take an additional vertically orientated
skin paddle inferior to the umbilicus as per the standard VRAM if
extra skin is needed. This skin paddle m ay be contiguous with the
oblique component or isolated as a separate skin island for more
advanced skin ap designs. The oblique skin paddle is thin and
pliable and has a greater range than the VRAM, allowing more
tailored reconstruction of di cult pelvic defects.

Hints and Tips

●
We favor the preoperative use of computed tomogra-
phy angiography to help identify preferred periumbilical

51 Vertical or Oblique Rectus Abdominis Myocutaneous Flaps for Perineal Reconstruction
545
Fig. 51.8 The remaining oblique skin paddle is used to resurface the perineum. In this case, split-thickness skin graft was used to
resurface the super cial skin defect laterally.
perforators on which to base the oblique skin island. If
previous abdominal surgery in the region of the rectus has
taken place, this is needed to assess the status of the deep
inferior epigastric vessels.

●
When raising the rectus muscle, suture the skin paddle to
the m uscle to prevent shearing or stretching forces on the
perforators.

●
If the general surgeons are performing a concurrent lap-
arotomy, ensure that their incision passes around the
um bilicus on the ipsilateral side to the planned ORAM to
prevent umbilical necrosis. If this is not feasible due to pre-
vious surgery, then determine if the umbilicus is nonviable
and excise it particularly if a mesh closure has been used.

●
Ideally stomas should not be created on the side of the rec-
tus harvest to reduce the risk of stom al herniation. In total
pelvic exenteration, it is better to harvest the right rectus
so the ileal conduit is on the harvested side.

●
We nd that by sparing the rectus fascia and closing the fas-
cia in a double-breasted fashion, mesh closure can be avoid-
ed, but if there is concern, we use it to reenforce the closure.
Suggested Further Reading
Lee M, Dumanian GA. The oblique rectus abdominis m usculocuta-
neous ap: revisited clinical applications. Plast Reconstr Surg
2004;114(2):367–373
Moon HK, Taylor GI. The vascular anatomy of the rectus abdominis m us-
culocutaneous aps based on the deep superior epigastric system .
Plast Reconstr Surg 1988;82:815
Sakai S, Takahashi H, Tanabe H. The extended vertical rectus abdominis
myocutaneous ap for breast reconstruction. Plast Reconstr Surg
1989;83:1061
Taylor GI, Boyd JB. The versatile deep inferior epigastric ap. Br J Plast
Surg 1984;37:330
Taylor GI, Corlette R, Boyd JB. The extended deep inferior epigastric ap:
A clinical technique. Plast Reconstr Surg 1983;72:751
Tobin GR, Pursell SH, Day TG. Re nements in vaginal reconstruction using
rectus abdom inis aps. Clin Plast Surg 1990;17:705

(Trang không có chữ)

III
Section III
Masterclasses in
Reconstructive Flaps

(Trang không có chữ)

549
Meeting the Aesthetic Challenges of
Complex Facial Reconstructions
Marc A. M. Mureau
52

Introduction
Facial reconstruction, the interface of aesthetic and reconstruc-
tive surgery, rem ains the cornerstone of plastic surgery. Its di -
culty is determ ined by the unique character of the face and the
lim ited availability of local m atching tissues. Facial reconstruc-
tion has challenged surgeons for m any centuries as illustrated
by early descriptions of cheek and forehead aps for nasal recon-
struction perform ed in ancient India. During the past century,
reconstruction of extensive facial defects has improved through
the technologic evolution of tissue transfer from the delay phe-
nom enon to regional myocutaneous and distant pedicled aps.
Only since the introduction of m icrosurgery in the early 1970s,
when there were still relatively few aps available, has there
been a revolution in term s of potential donor sites and ap op-
tions, because of renewed interest in the vascular anatomy of
aps and better understanding of perforator anatomy to expand
the repertoire of aps. The latest frontier in aesthetic facial re-
construction through vascularized composite allotransplanta-
tion, the ultim ate repair of “like with like” tissue, is currently
being challenged.

Principles of Aesthetic
Facial Reconstruction
The goals of aesthetic facial reconstruction are to restore a nor-
mal, aesthetic appearance as well as to restore normal eating,
breathing, and facial expression with the ability to communicate
and interact socially. Nowhere in the body is it more di cult to
restore normal form and function than in the head and neck area,
especially after extensive oncological resections, m ajor traum a
with extensive loss of skin and underlying tissues, or burns to
the central, mobile parts of the face. A major di culty with head
and neck reconstruction is that highly specialized tissues are
involved, with complex three-dimensional problems.
In the past, facial reconstruction was considered success-
ful when a hole was closed w ith a ap. However, in recent de-
cades, the concept of aesthetic facial reconstruction has been
popularized. The face can be divided into adjacent topographi-
cal regions or (sub)units with characteristic skin quality (color,
texture, thickness, hair-bearing character), border outline, and
three-dimensional contour (Fig. 52.1).
The peripheral units are the forehead, cheek, and chin. They
are at, expansive areas with a variable outline and, like a pic-
ture fram e, are of secondary visual interest. For instance, scars
on the forehead or lateral to an imaginary vertical line through
the lateral canthus are less conspicuous, and therefore also have
less aesthetic donor site morbidity, even if they run through an
aesthetic unit. In contrast, the central units of the nose, lips, and
eyelids are highly three-dimensional and with a xed border
outline. Because the entire area of these central units is seen in
most views, its comparison with the contralateral norm al side
(e.g., ala with ala) demands symmetry in position, outline, and
shape. If the face is to look normal, these central (sub)units must
be restored.
One of the cornerstones of aesthetic facial reconstruction is
meticulous defect analysis, during which additional emphasis
is placed on the di erent aesthetic units involved as well as the
quality of the tissues and the possible structural support needed
by those tissues. During this analysis, it is important to visual-
ize what is missing, aesthetically as well as anatomically. If the
deformity is unilateral, the best guide is a comparison with the
opposite side. If the deformity is more extensive, then it may be
helpful to use an old photograph as a guide for reconstruction.
This analysis leads to the use of the reconstructive “elevator”
rather than the reconstructive “ladder,” in which the most ap-
propriate ap or combination of aps is chosen that will give the
most aesthetically pleasing as well as functional outcom e. The
Fig. 52.1 The major subunits of the face.1

550
III Masterclasses in Reconstructive Flaps
principles of aesthetic facial reconstruction, largely derived from
Menick, are as follows.

●
The norm al is determined by the restoration of facial
contour, skin quality, and regional outline. The presence or
absence of scars is of lesser importance as long as they are
positioned at the borders of the aesthetic (sub)units or in
natural facial folds or contour lines.

●
Restore aesthetic (sub)units; do not ll holes. This means
that the defect may have to be altered in size, site, shape,
outline, and depth, repositioning normal facial landmarks.
This principle particularly holds true if more than 50% of a
convex central facial (sub)unit as the ala nasi, nasal tip, eye-
lids, or lips needs to be resurfaced with a transposition ap.
Flaps should be designed to replace convex facial units, be-
cause, unlike grafts, aps pincushion. When an entire con-
vex subunit is resurfaced, the pincushion e ect causes the
ap to bulge, e ectively augmenting the e ect of cartilage
support grafts in re-creating a convex external unit shape.

●
Replace missing tissue in exact quantity. Therefore, aps
and grafts should be designed using precise templates
based on the contralateral normal or ideal, not the shape
or size of the defect.

●
Choose ideal donor tissues. “Like” tissue (nearly identical
to what is missing) is best replaced with “like” tissue. Thus,
cheek for cheek, lip for lip, and forehead or nasolabial tissue
for nose. However, except for smaller and moderate-sized
defects, these local tissues are usually not available, and con-
sequently, regional or distant autologous tissue is necessary
to achieve wound closure. Unfortunately, distant tissues do
not match facial skin in color, texture, or thickness. Thus, ini-
tially free aps should be used for lining, obliteration, sub-
cutaneous contouring, or temporary cover. At a later stage,
locoregional skin, which may have to be pre- expanded rst,
is used for aesthetic cover. For reconstruction of most max-
illary or mandibular defects, free vascularized bone aps
with or without fascio- or myocutaneous extensions are
mandatory to reestablish a facial platform.

●
Do not use one ap for one defect in one operation. The
obvious temptation when repairing a composite defect is
to ll the single defect with a single ap, often during a
single operation. Unfortunately, it is di cult to reproduce
the delicate three-dim ensional character of m ultiple units
with a single ap. Subsequent revisions undertaken to di-
vide a single ap into a cheek, lip, and nose usually fail.
Frequently, the single ap appears as a bulging and over-
sized patch. Scar contraction also draws a single ap into
a dome-like mass, outlined by patch-like peripheral scars.
Use of separate aps for each facial unit should be consid-
ered when repairing composite defects.

●
Stage the reconstruction and use it to advantage. There are
many advantages of surgical staging. First, time perm its a
repair to mature, ensuring a stable platform. Second, vas-
cular viability of transferred tissues can be veri ed be-
fore continuing the next reconstructive stage. Third, the
use of excess material is permitted for hinge-over aps
or other secondary applications such as ap delaying,
prelam ination, or prefabrication. Fourth, interm ediate
stages can be used for soft tissue sculpturing.

●
For nasal reconstruction, build upon a stable platform. The
nose must be positioned on a newly reconstructed, stable
platform of lip and cheek at a precise location and angle.
Displacement of a successful nasal repair can create signif-
icant distortion. Soft tissues frequently shift because of the
e ects of resolving edem a, tension, scar contraction, and
gravity. If the reconstructed nasal platform is unstable, it
may shift a reconstructed ala inferiorly and laterally over
time. The larger and deeper the defect, the greater the risk.
Thus, in deep, larger defects, the lip and cheek should be
repaired during a rst stage. At a later stage, the nose is
rebuilt as soon as the underlying platform is stable.

●
Contour is the primary determinant of normal and should
be integrated in each stage. Use cartilage and bone grafts
to create a support framework before the completion of
wound healing. They can be placed primarily at the time of
ap transfer or in a delayed primary fashion at an interme-
diate operation before forehead ap division. Use detailed
subcutaneous sculpture to shape soft tissues into a middle
supportive architecture during the intermediate opera-
tions of a three-stage forehead ap and during revisions.
Preexisting scars can often be ignored and direct incisions,
disregarding old scars, often allow more precise subcuta-
neous sculpture, improving the nal result.

Illustrative Case Reports
Case 1
A 64-year-old man presented with a T2N0M0 well-di erentiated
squamous cell carcinoma of the right vestibulum nasi (Fig. 52.2).
After complete excision of the tumor, a composite defect resulted,
involving the subtotal nose, the right paranasal cheek, and
right upper lip and philtrum (Fig. 52.3). Because the patient
needed to undergo adjuvant radiation therapy within 6 weeks
postoperatively and because there existed a rather large lip-cheek
defect, it was decided to rst reconstruct a stable nasal platform.
Using a template of the norm al left upper lip, a facial artery
perforator (FAP) ap was designed at the right jowl area over the
course of the facial artery (Fig. 52.4). The marked facial artery
perforator had been preoperatively identi ed using a handheld
Doppler device and was intraoperatively visualized through an
exploratory incision along the cranial side of the planned ap.
Next, the ap was dissected and raised in a plane above the facial
muscles. Rarely does a clearly identi able vein run with the facial
artery perforator, and most of the time, venous drainage will be
from the brofatty tissue around the artery (Fig. 52.5).
The ap was rotated 180 degrees and set in while retaining
adequate vascularity after adjusting the defect to the hemi-lip
subunit borders (Fig. 52.6). To close the donor site as well as the pa-
ranasal cheek and nasal sill defect, a cheek advancement ap was
raised in a subcutaneous plane (Fig. 52.7). The cranial dog ear was
excised, resulting in a scar at the junction of the cheek and lower
eyelid units. The philtrum was reconstructed with a full-thickness
skin graft (FTSG), using excess skin from the right upper lip.
Finally, a tie-over dressing was applied for 5 days to secure the
FTSG (Fig. 52.8). Subsequently, the patient was radiated 33 times

52 Meeting the Aesthetic Challenges of Complex Facial Reconstructions
551
Fig. 52.2 Patient with a squamous cell carcinoma of the right vesti-
bulum nasi.
Fig. 52.3 Composite central facial defect after complete tumor excision.
Fig. 52.4 Design of a facial artery perforator  ap after Doppler identi ca-
tion of the perforator.
Fig. 52.5 After dissection of facial artery perforators. Note absence of
clearly identi able veins.

552
III Masterclasses in Reconstructive Flaps
Fig. 52.6 The facial artery perforator  ap was rotated 180 degrees to 
reconstruct the right upper lip.
Fig. 52.7 To close the donor site defect, a cheek advancement  ap was 
raised in a subcutaneous plane.
Fig. 52.8 End result after inset of the FAP and cheek  aps as well as a 
FTSG to reconstruct the philtrum.
Fig. 52.9 Result 6 months after radiotherapy (66 Gy). Note the inferolat-
eral displacement of the FAP  ap, nasal collapse, and superior displace-
ment of the vermillion.

52 Meeting the Aesthetic Challenges of Complex Facial Reconstructions
553
Fig. 52.10 Re-creation of the philtrum defect after excision of the FTSG
and correction of the upper lip retraction.
Fig. 52.11 The FAP  ap was repositioned and thinned and to prevent 
pin-cushioning, quilting sutures were used. A modi ed Abbe  ap was 
used to reconstruct the cutaneous defect of the philtrum and nasal sill.
Fig. 52.12 A three-stage folded forehead  ap with a Converse scalping 
ap design was planned to reconstruct the full-thickness nasal defect.
with a total dose of 66 Gy. Fig. 52.9 shows the patient 6 months after
the rst stage of the reconstruction and radiotherapy. The FAP ap
is too bulky and is retracted inferiorly and laterally, the remnants of
the left ala and nasal tip are collapsed, and the vermillion is supe-
riorly displaced because of postradiation contraction of the FTSG.
The FTSG was excised and the retraction of the upper lip
vermillion was corrected, re-creating the defect of the philtrum
(Fig. 52.10). The FAP ap was elevated and thinned after which it
was repositioned. To prevent pin-cushioning and accumulation of
uid underneath the re-elevated FAP ap, quilting sutures were
used for 48 hours (Fig. 52.11). A modi ed Abbe ap was used to
Fig. 52.13 Result after inset of the folded forehead  ap, modi ed Abbe 
ap, and revision of the FAP  ap.
reconstruct the cutaneous defect of the philtrum and nasal sill. Note
that the orbicularis oris muscle and vermillion part of the Abbe ap
were not set into the upper lip and that the orbicularis oris of the
philtrum, which was still functioning, was left intact (Fig. 52.11).
For reconstruction of the subtotal, full-thickness nasal de-
fect, a three-stage folded forehead ap was used with a Converse
scalping ap design, after excision of the contracted scars and
re-creation of the defect (Figs. 52.12 and 52.13). The dog ear at
the cranial donor site defect was excised and the forehead defect
was left to heal by secondary intention (Fig. 52.13).

554
III Masterclasses in Reconstructive Flaps
Fig. 52.14 Intermediate result, 3 weeks postoperatively.
Fig. 52.15 The patient was intubated after division of the Abbe  ap 
pedicle under local anesthesia.
Fig. 52.16 The forehead  ap was elevated in a 2- to 3-mm plane, leaving 
the columellar part to ensure its vascularization.
Fig. 52.17 All excess soft tissues were aggressively excised, and the nasal
lining was thinned.
Fig. 52.14 shows the intermediate result 3 weeks after the sec-
ond stage of the reconstruction. To facilitate intubation under gen-
eral anesthesia, the pedicle of the Abbe ap was rst divided under
local anesthesia (Fig. 52.15). Subsequently, the pedicle was trimmed,
the Abbe ap was set in, and the lower lip was repaired. Next, the
subunits of the nose were marked and the forehead ap was elevated
in a 2- to 3-mm plane, leaving the columella part attached to ensure
vascularization of the lining part of the forehead ap (Fig. 52.16).
All excess soft tissues were aggressively excised and the na-
sal lining was thinned (Fig. 52.17). Subsequently, rib cartilage
grafts from the right eighth and ninth ribs as well as concha
cartilage grafts from both ears were harvested to reconstruct

52 Meeting the Aesthetic Challenges of Complex Facial Reconstructions
555
Fig. 52.18 (a,b) Rib and concha cartilage grafts were harvested to reconstruct the nasal framework and brace the
reconstruction.
a
b
the nasal fram ework and brace the reconstruction (Fig. 52.18).
Cantilever, columellar strut, upper lateral, and alar batten grafts
were designed and xed with polypropylene 5-0 sutures. The
forehead ap was sutured back in place including some quilting
sutures for 48 hours to de ne the alar creases (Fig. 52.19).
Four weeks later, the pedicle of the forehead ap was
divided and the proximal part was thinned and repositioned in
an inverted V-manner to reconstruct the medial brow. The distal
part of the pedicle, including the cranial part of the forehead ap
at the nasal dorsum and lateral side walls, was thinned, trimmed,
and set in using quilting sutures.
Fig. 52.20 shows the patient 8 months postoperatively. The
forehead scar, including the secondary healed cranial part, as well as
the scars of the cheek and upper lip are inconspicuous, because the
latter were placed at the borders of the facial (sub)units. The patient
was o ered further improvement of the aesthetic result by reduc-
ing the dorsal nasal hump and thinning the columella and philtrum.
He declined, however, because he was happy with the result.
Case 2
A 62-year-old smoker with diabetes mellitus type 1 and coronary as
well as peripheral arterial occlusive disease presented with a 55 3
44 mm recurrent micronodular basal cell carcinoma of his right
cheek and upper lip, which previously had been incompletely ex-
cised followed by reconstruction with a cranially based nasolabial
ap (Fig. 52.21). The tumor was completely excised with Mohs’ mi-
crographic surgery, resulting in an extensive composite defect of the
Fig. 52.19 The forehead  ap was sutured back in place including some 
quilting sutures to de ne the alar shape.

556
III Masterclasses in Reconstructive Flaps
Fig. 52.20 (a,b) End result 8 months postoperatively. The forehead defect healed by secondary intention, leaving an 
acceptable scar. The cheek and upper lip scars are inconspicuous, because they were placed at the borders of the facial
(sub)units.
a
b
Fig. 52.21 Patient with a recurrent basal cell carcinoma of his right cheek and upper lip, which previously had
been incompletely excised followed by reconstruction with a cranially based nasolabial  ap.

52 Meeting the Aesthetic Challenges of Complex Facial Reconstructions
557
Fig. 52.22 Extensive composite defect of the right medial cheek with
exposed bone, the right hemi-upper lip, and the right hemi-nose after
complete tumor excision.
Fig. 52.23 Design of an Estlander-Abbe  ap for construction of the right 
upper hemi-lip and oral commissure.
right medial cheek with exposed maxillary bone and premaxilla, the
right hemi-upper lip, including the oral commissure, and the right
hemi-nose (Fig. 52.22). Because of the large defect size, the upper lip
and cheek were reconstructed rst to create a stable nasal platform.
For reconstruction of the right upper hemi-lip and oral
com m issure, an Estlander-Abbe ap was used based on the left
inferior labial artery (Figs. 52.23 and 52.24). For reconstruc-
tion of the cheek defect, an anterior-based angle rotation cheek
ap according to Schrudde was raised in a subcutaneous plane
(Fig. 52.25). This m odi cation of the classic advancem ent rota-
tion cheek ap elevates and rotates the cheek skin sim ultane-
ously using a postauricular “angle” ap (as a Burrow’s triangle),
Fig. 52.24 Lips after inset of the Estlander-Abbe  ap based on the left 
inferior labial artery.
Fig. 52.25 The cheek defect was reconstructed with an anterior-based angle
rotation cheek  ap according to Schrudde, which was raised subcutaneously.

558
III Masterclasses in Reconstructive Flaps
leaving an inconspicuous donor site while placing the angled ap
ideally in the preauricular zone (Fig. 52.26). Its design can be
used in combination with tissue expansion and its value is best
seen in leaving no scars on the neck or chest and its ability to be
re-elevated for future advancement. To prevent lower eyelid ec-
tropion, anterior-based cheek aps should be overcorrected, ten-
sion should be minimized, and the lateral superior border should
be planned above the lateral canthal-helical root plane, suspend-
ing the ap higher than the eyelid margin to the periosteum of
the lateral orbital rim.
In addition, a third temporoparietal scalp ap, which was
rotated in an opposite direction to facilitate closure of the pre-
auricular donor site of the cheek ap, was used (Fig. 52.27).
Advantages of the additional use of this temporoparietal ap are
that there is no need to undermine the cheek beyond the lower
border of the mandible and that the cheek ap is suspended by
the opposing temporoparietal scalp ap, preventing secondary
sagging of the cheek ap.
Fig. 52.28 shows the interm ediate result 10 weeks post-
operatively. There still is some edema of the lower eyelid with
a slight medial ectropion, paralytic sagging of the oral commis-
sure, which is ill-de ned and positioned too medially due to the
Estlander-Abbe ap, a contour de ciency of the m edial cheek due
to the absence of subcutaneous soft tissues, and the absence of
the right hemi-nose.
Four and a half m onths after the rst stage of the reconstruc-
tion, the patient was scheduled for the second stage. A bipad-
dled radial forearm free ap including a de- epithelialized part
Fig. 52.26 An inconspicuous postauricular scar results after closure of
the postauricular “angle”  ap donor site.
Fig. 52.27 Result after closure of the preauricular cheek  ap donors site 
defect with the postauricular “angle”  ap and a temporoparietal scalp 
ap, which was rotated in an opposite direction.
Fig. 52.28 Result 10 weeks postoperatively. Note the slight medial ectropion; 
a sagging, ill-de ned, and malpositioned oral commissure; a contour de -
ciency of the medial cheek; and the absence of the right hemi-nose.

52 Meeting the Aesthetic Challenges of Complex Facial Reconstructions
559
was designed on the left forearm using templates (Fig. 52.29).
The skin paddles were used for reconstruction of the inner lin-
ing and temporary cover of the nose and the de-epithelialized
part was positioned subcutaneously for augm entation of the
cheek contour defect after re-elevation of the previous cheek
ap (Fig. 52.30). This is a good example of the previously de-
scribed fourth principle of aesthetic facial reconstruction: ap-
plying distant tissue in an aesthetic m anner by burying it or
using it as lining.
Fig. 52.29 Design of a bipaddled radial forearm free  ap, including a de-epithelialized 
part using templates.
Fig. 52.30 (a,b) The radial forearm skin paddles were used to reconstruct the inner lining and temporary cover of the
nose and the de-epithelialized part was positioned subcutaneously to augment the cheek contour defect.
b
a
The radial forearm skin paddles were supported and braced
w ith prim ary concha cartilage grafts from the right ear, which
were designed as alar batten and upper lateral buttress grafts
(Fig. 52.31). The radial artery and concomitant vein were
anastom osed to the right super cial temporal vessels (Fig. 52.32).
To save a split-thickness skin graft donor site and to reduce do-
nor site m orbidity of the radial forearm ap, a triangular full-
thickness skin graft was harvested from the proximal forearm to
close the distal forearm defect.

560
III Masterclasses in Reconstructive Flaps
Seven weeks postoperatively, all wounds had healed pri-
marily (Fig. 52.33). The right ostium nasi was adequate because
of su cient lining and support. Note the color m ism atch of the
temporary nasal cover part of the free radial forearm ap, which
was worse compared to im m ediately after the operation, causing
a patch-like appearance of the right hem i-nose (Fig. 52.33). The
base of the ala nasi is som ewhat drifted laterally and there is a
persistent cicatricial ectropion of the medial lower eyelid.
Four months later, the third stage of the reconstruction was
planned. The aesthetic subunits of the cheek, upper lip, and nose
were outlined, the correct position of the base of the right ala
nasi was m arked, and a right param edian forehead ap was de-
signed using mirrored templates of the left normal hemi-nose
(Fig. 52.34). Note the vertical orientation of the forehead ap,
which is preferred over an oblique orientation, because oblique
aps (1) transect the vertically oriented, supratrochlear vessels,
creating a less vascular random extension; (2) increase eyebrow
distortion after secondary healing of the forehead defect; and
(3) scar both sides of the forehead, m aking the harvest of a sec-
ond forehead ap m ore di cult if necessary in the future. Also
note that the forehead ap was designed on the ipsilateral side
of the defect because the base of an ipsilateral pedicle is closer
to the defect, permitting a shorter ap and decreasing the risk of
tension, which is a primary cause of necrosis.
Next, the cover part of the radial forearm ap was excised
and the soft tissues were debulked until the level of the cartilage
grafts (Fig. 52.35). In addition, according to the second principle of
Fig. 52.31 The radial forearm skin paddles were supported and braced
with primary concha cartilage grafts.
Fig. 52.32 End result after inset of the radial forearm  ap, anastomosis to 
the super cial temporal vessels, and replacement of the cheek  ap.
Fig. 52.33 Intermediate result 7 weeks postoperatively. Note the color
mismatch of the temporary nasal cover part of the free radial forearm
ap, the lateral displacement of the right alar base, and the cicatricial ec-
tropion of the medial lower eyelid.

52 Meeting the Aesthetic Challenges of Complex Facial Reconstructions
561
Fig. 52.34 The aesthetic subunits of the cheek, upper lip, and nose were
outlined, the correct position of the right alar base was marked, and a
right paramedian forehead  ap was designed.
Fig. 52.35 The cover part of the radial forearm  ap was excised and the 
soft tissues were debulked until the level of the cartilage grafts.
Fig. 52.36 The nasal defect was altered in size and shape by excising
the skin of the right nasal tip until the midline and the forehead  ap was 
raised.
aesthetic facial reconstruction, the nasal defect was altered in size
and shape by excising the skin of the right nasal tip until the midline
(Fig. 52.36). The base of the right ala was repositioned medially and
the distal part of the cover part of the radial forearm ap was thinned
further and turned over to lower the edge of the right nostril to the
correct position (Figs. 52.35 and 52.36). The forehead ap was trans-
ferred and the donor defect was subtotally closed, the medial part of
the cheek ap was readvanced medially to correct the ectropion, and
the oral commissure was positioned more laterally (Fig. 52.37).
Three weeks later, the full-thickness forehead ap was ele-
vated and thinned in a 2- to 3-mm plane, and the soft tissues of
the nose were sculpted into the desired shape and contour. Sub-
sequently, the forehead ap was sutured back to the nose, includ-
ing multiple quilting sutures at the lateral nasal side to prevent
pin cushioning and to improve contour of the nose and de nition
of the supra-alar crease.
Again, 4 weeks later, the fth and nal stage of the recon-
struction was perform ed. The pedicle of the forehead ap was
divided and the proximal part was thinned and repositioned in
an inverted V-manner to reconstruct the medial brow. The dis-
tal part of the pedicle, including the cranial part of the forehead
ap, was thinned, trimmed, and inset using quilting sutures
(Fig. 52.38). Because the oral comm issure still was ill-de ned and
placed too medially, a commissuroplasty according to Gillies and
Millard was performed. A triangular skin excision was designed
to accommodate elongation of the commissure after which a ap
of vermilion was raised from the lower lip. Next, the vermilion
ap was rotated and sutured laterally to reconstruct the oral

562
III Masterclasses in Reconstructive Flaps
com m issure (Fig. 52.39). Finally, the vestibular mucosa was ad-
vanced externally to reconstruct the vermilion of the lower lip.
Fig. 52.40 shows the nal result 3 months postoperatively. In
general, the scars are inconspicuous because they are strategically
positioned along the borders of facial units. Skin color match and
contour are good, which are important determ inants for the -
nal aesthetic outcome. The recurrent cicatricial ectropion of the
medial lower eyelid only caused very mild symptom s and the pa-
tient did not request any further corrections.
Case 3
A 67-year-old woman, who was an active smoker with diabetes
mellitus type 2, was referred to us after complete excision of a
rapidly growing tumor of the dorsal nose. At rst, the tumor was
diagnosed as a keratoacanthoma, but after de nite pathology, it
appeared to be a well-di erentiated squamous cell carcinoma.
The m ultidisciplinary head and neck tum or board did not indi-
cate adjuvant radiation therapy because all tumor m argins were
clear w ith adequate m argins. After resection of the tum or, m ost
of the cover and lining of the nose including the anterior septum
were missing (Fig. 52.41). Only the distal part of the nasal tip, the
caudal edges of the alae nasi, and the colum ella, which were all
cranially rotated due to scar contracture causing an obtuse naso-
labial angle and retracted alar rims, were still intact.
As a rst stage of the subtotal nasal reconstruction, the pa-
tient was scheduled for reconstruction of the nasal lining and
Fig. 52.38 The pedicle of the forehead  ap was divided and the forehead 
ap was thinned, trimmed, and inset using quilting sutures.
Fig. 52.39 The oral commissure was repositioned laterally, after which a
ap of lower lip vermilion was rotated and sutured laterally to reconstruct 
the oral commissure.
Fig. 52.37 The forehead  ap was transferred and the donor defect was 
subtotally closed, the ectropion was corrected, and the oral commissure
was positioned more laterally.

52 Meeting the Aesthetic Challenges of Complex Facial Reconstructions
563
Fig. 52.40 (a,b) The  nal result 3 months postoperatively. Scars are inconspicuous because they are strategically posi-
tioned along the borders of facial units. Skin color match and contour are good, improving the  nal aesthetic outcome.
a
b
Fig. 52.41 (a,b) Full-thickness nasal defect. Most of the nasal cover and lining are missing, including the anterior septum.
Only the distal part of the nasal tip, the caudal edges of the alae nasi, and the columella, which were all cranially rotated
due to scar contracture, were still intact.
b
a

564
III Masterclasses in Reconstructive Flaps
Fig. 52.42 Design of a bipaddled radial forearm free  ap using templates.
Fig. 52.43 A cantilever rib graft was sandwiched between the lining and
cover paddles of the radial forearm  ap to support the reconstruction.
Fig. 52.44 The radial forearm  ap was inset, folded, and sutured.
temporary nasal cover with a bipaddled radial forearm free ap
using templates (Fig. 52.42). In addition, a cantilever graft harvest-
ed from the seventh rib on the right side was sandwiched between
the lining and cover paddles of the radial forearm ap to support
the reconstruction (Fig. 52.43). After carving the rib graft into the
correct shape, it was xed to the frontal and nasal bones with a
mini plate and screws. The blood vessels of the ap were hooked
to the left super cial temporal vessels after folding and insetting
of the ap (Fig. 52.44). Despite the use of templates, which were
meticulously designed having the ideal in mind, there still was a
shortage of the cover part of the radial forearm ap, pointing out
how di cult proper planning of these complex central facial de-
fects is. The rest defect was closed with the use of a remnant of the
full-thickness skin graft of the proximal part of the forearm which
was used to close the radial forearm donor site defect (Fig. 52.45).
All wounds seemed to heal well; however, during the post-
operative course, the patient had three periods of redness and
swelling of the cover part of the radial forearm ap, which were
successfully treated as an infection with oral antibiotics. In addi-
tion, the patient was asked to refrain from smoking.

52 Meeting the Aesthetic Challenges of Complex Facial Reconstructions
565
Fig. 52.45 Despite the use of meticulously designed templates, there still
was a shortage of the cover part of the radial forearm  ap, which was 
closed with an FTSG.
Fig. 52.46 Typically, the width of a forehead  ap for a total nasal recon-
struction is 8–9 cm and the width of the base of the pedicle is about 
1.2 cm to allow easy transposition of the  ap.
Three and a half m onths later, the patient was scheduled for
the second stage of the nasal reconstruction. Steri-Strips (3M,
St. Paul, MN) were taped on the nose, after which the borders
of the nasal units were m arked with a m arking pen resulting
in a three-dimensional template. Next, this three-dimensional
template was transferred to a piece of tin foil, converting it
into a two-dimensional template, which was cut out. This
two-dimensional template was then used to design the ap on
the forehead. Typically, the width of a forehead ap for a total
Fig. 52.47 After excision of the cover part of the radial forearm  ap, there appeared to 
be a defect at the right vestibulum, probably due to tip necrosis of the  ap.
nasal reconstruction is 8 to 9 cm and the w idth of the base of
the pedicle is about 1.2 cm to allow easy transposition of the ap
without kinking of the pedicle (Fig. 52.46).
After excision of the cover part of the radial forearm ap,
it appeared that the recurrent infections of the nose had been
caused by a sm all defect in the lining part of the radial forearm
ap at the right vestibulum, probably due to tip necrosis of the
ap (Fig. 52.47). Therefore, to decrease the risk of a postoperative
infection, it was decided not to insert primary cartilage grafts,

566
III Masterclasses in Reconstructive Flaps
Fig. 52.49 (a,b) The forehead  ap was sutured in place and a skin graft had to be used to cover the area of the right nostril 
rim, due to the bulk of the buried extension of the forehead  ap.
a
b
Fig. 52.48 A de-epithelialized extension of the forehead  ap was planned 
to close the lining defect and to decrease the risk of a postoperative
infection.
but to close the lining defect with a de-epithelialized extension
of the forehead ap instead (Fig. 52.48). The forehead ap was
sutured in place and a skin graft had to be used to cover the area
of the nostril rim at the right side due to the bulk of the buried
extension of the forehead ap (Fig. 52.49). The forehead donor
site defect was left open to heal by secondary intension.
Three weeks later, the third stage of the reconstruction was
performed. The forehead ap was re-elevated in the 2- to 3-mm
plane and the nasal soft tissue bulk was sculpted down. Next, pri-
mary delayed concha cartilage grafts from both ears were used
as alar batten, columellar strut, and tip shield grafts (Fig. 52.50).
The grafts were secured with polypropylene 5-0 sutures. Final-
ly, the forehead ap was sutured back including some quilting
sutures to de ne the supra-alar creases (Fig. 52.51). Note that
some periosteum was missing at the donor site of the forehead
ap, due to inadequate wound management. The exposed frontal
bone was left to heal by the “bridging” phenomenon.
Again 4 weeks later, the pedicle of the forehead ap was di-
vided and the proximal part was thinned and repositioned in an
inverted V-manner to reconstruct the medial brow. The distal
part of the pedicle, including the cranial part of the forehead ap,
was elevated until the supra-alar creases on both sides and was
thinned, trimmed, and set in using quilting sutures.
Two weeks later, the patient had to be operated on for a fth
time, due to a full-thickness necrosis of the proxim al part of the
thinned forehead ap (Fig. 52.52). Possibly, this full-thickness
necrosis resulted from a combination of aggressive thinning and
the absence of a vascularized wound bed, because the m ini plate
was still in place (Fig. 52.53). The necrosis was debrided, the mini

52 Meeting the Aesthetic Challenges of Complex Facial Reconstructions
567
Fig. 52.50 The forehead  ap was re-elevated in the 2–3 mm plane, the na-
sal soft tissue bulk was sculpted down, and primary delayed concha carti-
lage grafts were used as alar batten, columellar strut, and tip shield grafts.
Fig. 52.51 The forehead  ap was sutured back including some quilting 
sutures to de ne the supra-alar creases. Note that some periosteum was 
missing at the forehead wound, which was left to heal by the “bridging”
phenomenon.
Fig. 52.52 Full-thickness necrosis of the proximal part of the thinned
forehead  ap.
Case 4
A 65-year-old woman was referred to our outpatient clinic af-
ter a failed reconstruction of a left-sided hemi-maxillectomy
defect using a radial forearm free ap and an obturator. The
hemi-maxillectomy had been performed because of a locally
advanced basal cell carcinoma and the patient had been radiat-
ed postoperatively as well. She had m ultiple large orocutaneous
Fig. 52.53 The full-thickness necrosis resulted from a combination of ag-
gressive thinning and the absence of a vascularized wound bed, because
the mini plate was still in place.
plate and screws were removed, the defect was closed with a gla-
bella ap, and the resulting donor defect was left to heal by sec-
ondary intention (Fig. 52.54).
Three and a half months later, the patient was operated on for
the sixth time. The glabella ap was re-elevated and thinned and
the proximal part of the cantilever graft was carved down, creating
a nasofrontal angle and improving the contour of the radix nasi. In
addition, the nasal lining ap was aggressively thinned in combi-
nation with a reduction of the distal cantilever rib graft, improv-
ing the airway passage through the vestibulum nasi on both sides.
Fig. 52.55 shows the nal result 6 months after the sixth operation.

568
III Masterclasses in Reconstructive Flaps
Fig. 52.55 (a–c) The  nal result 6 months post-
operatively after thinning of the glabella  ap and 
nasal lining  aps improving the airway passage 
through the vestibulum nasi on both sides.
a
b
c
Fig. 52.54 The necrosis was debrided, the plate was removed, and the defect was
closed with a glabella  ap.

52 Meeting the Aesthetic Challenges of Complex Facial Reconstructions
569
anastomosed to the left super cial temporal vessels (Fig. 52.59).
The super cial temporal vessels tend to have a poor reputation
for their use as recipient vessels in reconstructive microsurgery.
However, in complex facial and scalp reconstructions, they are
our rst choice recipient vessels with reliable ow and good cal-
iber, if they are dissected further proximal into the parotid gland
in front of the tragus.
The postoperative course was complicated by partial necro-
sis of the lateral part of the bula ap skin paddle, probably
Fig. 52.56 Result after a failed reconstruction of a left-sided hemi-
maxillectomy defect using a radial forearm free  ap and an obturator. The 
patient had multiple large orocutaneous  stulas and an oronasal  stula.
Fig. 52.57 Design of an osteomyocutaneous peroneal artery-based com-
bined free  bula  ap with the inclusion of partial soleus muscle based on 
an independent myocutaneous perforator.
Fig. 52.58 After removal of the obturator and re-creation of the defect,
the lateral edges of the zygomatic arch and the premaxilla were dissected
free.
stulas and an oronasal stula, connecting the m axillary si-
nus with the nasopharynx, oropharynx, and the outer world
(Fig. 52.56). These connections could not be sealed by the obtu-
rator, causing di culties with eating and drinking. In addition,
the left ala nasi was missing.
The patient was scheduled for reconstruction of the
composite defect of the left superior alveolar process, left pal-
ate, lateral nasal wall, and cheek using an osteomyocutaneous
peroneal artery-based combined free bula ap with the inclusion
of partial soleus muscle based on an independent myocutane-
ous perforator (Fig. 52.57). After removal of the obturator and
re-creation of the defect, the lateral edges of the zygomatic arch
and the premaxilla were dissected free (Fig. 52.58). A too-large
skin paddle was designed at the lateral aspect of the right lower
leg, after identi cation of two perforators using a handheld Dop-
pler device. The soleus muscle part was only dissected after in-
traoperative identi cation of a suitable perforator to the m uscle.
Next, the old radial forearm ap was transected just lateral to the
ideal position of the future alar base and the inner rem ucosalized
part of the ap was discarded. Subsequently, the bula ap was
shortened and xed to the premaxilla and zygomatic arch using
mini plates and screws (Fig. 52.59).
The soleus muscle part was used to obliterate the m axillary
sinus, close the palatal defect, and separate the nasopharynx from
the maxillary sinus and oropharynx. Finally, the skin paddle of
the bula ap was tailored according to the cheek defect size and
the radial forearm ap rem nant was used to cover the left, supe-
rior neoalveolar process (Fig. 52.60). The peroneal vessels were

570
III Masterclasses in Reconstructive Flaps
because the perforator was located at the m edial edge of the
skin island. The necrotic skin was debrided at the outpatient
clinic and the resulting defect was left to heal secondarily
(Fig. 52.61).
Seven m onths later, the patient was operated on by the m ax-
illofacial surgeon. All her remaining teeth were extracted and os-
teointegrated implants were placed in the mandible, right maxil-
la, and bula (Fig. 52.62).
Again 2 m onths later, the patient was operated on for the sec-
ond stage of the reconstruction. A left-sided paramedian forehead
Fig. 52.59 The  bula  ap was shortened and  xed to the premaxilla and 
zygomatic arch using mini plates and screws. The soleus muscle part was
used to obliterate the maxillary sinus, close the palatal defect, and sepa-
rate the nasopharynx from the maxillary sinus and oropharynx.
Fig. 52.60 The skin paddle of the  bula  ap was tailored according to the 
cheek defect size and the radial forearm  ap remnant was used to cover 
the left, superior neoalveolar process.
Fig. 52.61 Result after secondary healing of a partial skin necrosis of the
lateral part of the  bula  ap skin paddle, probably because the perforator 
was located at the medial edge of the skin island.
Fig. 52.62 All the remaining teeth were extracted and osteointegrated
implants were placed in the mandible, right maxilla, and  bula.

52 Meeting the Aesthetic Challenges of Complex Facial Reconstructions
571
ap was designed using mirrored templates of the right normal
ala nasi (Fig. 52.63). Rem nants of the previous radial forearm ap
were cranially incised, turned over, and thinned to reconstruct
the upper vault of the m issing lining (Fig. 52.64). The vestibulum
nasi was reconstructed with an extension of the forehead ap,
which was folded inward (Fig. 52.65). Care was taken to add an
additional centimeter to facilitate the inward folding of the lining
Fig. 52.63 A left-sided paramedian forehead  ap was designed using 
mirrored templates of the right normal ala nasi.
Fig. 52.64 Remnants of the previous radial forearm  ap were cranially incised, 
turned over, and thinned to reconstruct the upper vault of the missing lining.
part, which was designed using an exact template of the missing
vestibular lining (Fig. 52.65).
If it is impossible to perfectly set in the folded part of the
forehead ap due to its thickness, then it is safer to leave it and
correct it during the next stage of the nasal reconstruction, when
the ap as well as the lining part can be safely thinned, than to
thin it imm ediately (Fig. 52.65). The forehead donor site could be
Fig. 52.65 (a,b) The vestibulum nasi was reconstructed with an extension of the forehead  ap, which was 
folded inward. The forehead donor site could be closed primarily after bilateral wide undermining until the
level of the temporal crests.
b
a

572
III Masterclasses in Reconstructive Flaps
aggressively thinned and sutured to the concha cartilage alar
batten graft to get a concave curve (Fig. 52.67). A second part of
concha was used to keep the internal nasal valve open, mimick-
ing an upper lateral nasal cartilage. Finally, the forehead ap was
sutured back, including quilting sutures to de ne the supra-alar
crease (Fig. 52.68).
closed primarily after bilateral wide undermining until the level
of the temporal crests.
Four weeks later, the forehead ap was re-elevated in
the 2- to 3-mm plane and the soft tissues were debulked and
shaped using an exact template of the contralateral norm al
side (Fig. 52.66). Also, the lining part of the forehead ap was
Fig. 52.66 The forehead  ap was re-elevated in the 2- to 3-mm plane and the lining part
of the forehead  ap was aggressively thinned.
Fig. 52.67 Concha cartilage grafts were used as the alar batten graft and
upper lateral graft to keep the internal nasal valve open.
Fig. 52.68 The forehead  ap was sutured back, including quilting sutures 
to de ne the supra-alar crease.

52 Meeting the Aesthetic Challenges of Complex Facial Reconstructions
573
Fig. 52.69 (a–c) The  nal result 2 months postoperatively. The patient did not have any problems with eat-
ing and drinking anymore, because all  stulas were closed and she had osteointegrated dental implants.
c
a
b
Again, 4 weeks later, the pedicle of the forehead ap was
divided and the proxim al part was thinned and repositioned in
an inverted V-m anner to reconstruct the m edial brow. The distal
part of the pedicle, including the cranial part of the forehead
ap, was elevated until the supra-alar crease and was thinned,
trimmed, and set in using quilting sutures.
Fig. 52.69 shows the nal result 2 months after the last op-
eration. The patient did not have any problems with eating and
drinking anym ore, because all stulas were closed and she had
osteointegrated dental implants. Despite the nasal fram ework
grafts, there still was some retraction of the alar rim. There ex-
isted some asymptomatic cheek scar contracture, due to the sec-
ondary healing of the cheek after the partial necrosis of the bula
skin paddle. The patient refused any further improvem ents of her
cheek, but this could have been achieved with a pre-expanded
Schrudde cheek ap, resurfacing the cheek until the nasolabial
fold, and converting the bula skin paddle into a hemi upper lip
unit.
Case 5
A 37-year-old man presented with multiple large orocuta-
neous stulas and an oronasal stula, connecting the maxil-
lary sinus with the nasopharynx, oropharynx, and the outer
world (Fig. 52.70). He had previously undergone a right-sided
hemi-maxillectomy, including the orbital oor, followed by a
failed reconstruction with a median forehead ap and a Mustardé

574
III Masterclasses in Reconstructive Flaps
cheek rotation ap as well as postoperative radiation therapy for
a T4N0M0 squamous cell carcinoma. Because of secondary scar
contractures and a severe trismus due to the previous radiation
therapy, it was di cult to correctly t an obturator, causing dif-
culties with eating and drinking. In addition, there existed a se-
verely retracted lower eye lid and a vertical dystopia of the right
globe, because the orbital oor had not been reconstructed pre-
viously (Fig. 52.70).
The patient was scheduled for reconstruction of the compos-
ite defect of the right superior alveolar process, right palate, and
cheek defect, using an osteomyocutaneous peroneal artery-based
com bined free bula ap with the inclusion of partial soleus
muscle based on an independent myocutaneous perforator. After
excision of the scarred cheek tissues and following re-creation of
the defect, the lateral edges of the zygom atic arch and prem ax-
illa were dissected free (Fig. 52.71). It was judged impossible to
correct the vertical dystopia of the globe and it was decided not
to reconstruct the orbital oor. The bula ap was shortened to
t the hem i-m axillectomy defect and xed to the prem axilla and
zygomatic arch using mini plates and screws. The soleus muscle
part was used to obliterate the maxillary sinus, close the palatal
defect, and separate the nasopharynx from the maxillary sinus
and oropharynx. Next, the skin paddle of the bula ap was tai-
lored according to the cheek defect size after repositioning of the
lower eyelid. Finally, the peroneal vessels were anastomosed to
the right superior thyroid vessel through a separate neck incision.
Fig. 52.72 show the patient 2 weeks, 1 month, and 7 months
postoperatively, illustrating the recurrence of the lower eyelid
Fig. 52.70 (a,b) Patient after a hemi-maxillectomy, including the orbital  oor, followed by a failed reconstruction with a 
median forehead  ap and a cheek rotation  ap as well as postoperative radiation therapy. It was di cult to correctly  t an 
obturator, causing di culties with eating and drinking. In addition, there existed a severely retracted lower eye lid and a 
vertical dystopia of the right globe.
a
b
Fig. 52.71 After excision of the scarred cheek tissues and following
re-creation of the defect, the lateral edges of the zygomatic arch and pre-
maxilla were dissected free.

52 Meeting the Aesthetic Challenges of Complex Facial Reconstructions
575
Fig. 52.72 (a–c) The patient 2 weeks, 1 month, and 
7 months postoperatively, illustrating the recurrence of
the lower eyelid retraction due to scarring, tissue shortage,
and lack of support.
a
c
b

576
III Masterclasses in Reconstructive Flaps
Fig. 52.73 Progressing remucosalization of the soleus part of the  bula  ap at 1 month.
retraction due to scarring, tissue shortage, and lack of support.
In addition, there was a shortage of the upper lip. Fig. 52.73
illustrates the gradual remucosalization of the soleus part of the
bula ap at 1 month.
Eleven m onths after the rst stage, an Abbe ap was used to
correct the upper lip shortage, reducing the lower lip at the sam e
time, thereby restoring the balance of the upper and lower lip
Fig. 52.74 An Abbe  ap was used to correct the upper lip shortage, re-
ducing the lower lip at the same time, thereby restoring the balance of
the upper and lower lip.
Fig. 52.75 The patient 5 months postoperatively, illustrating the dete-
rioration of the lower eye lid retraction due to ongoing scar contracting
forces and lack of support.
(Fig. 52.74). Four weeks later, the pedicle of the Abbe ap was di-
vided, the ap was set in, and the lower lip was repaired. During
the same procedure, the maxillofacial surgeon extracted the re-
maining teeth of the m axilla and subsequently placed osteointe-
grated implants.
Fig. 52.75 shows the patient 5 m onths postoperatively,
illustrating the deterioration of the lower eye lid retraction