Facial Reconstruction after Mohs Surgery

Fig. 21.4 A 78-year-old male with classic dermatitis from topical antibiotic ointment use with previous sensitivity. Rash rapidly resolved with cessation
of topical ointment with no long-term sequelae.
Fig. 21.5 A 58-year-old male patient with ear chondritis after Mohs resection and attempted secondary healing. Treatment required intravenous
antibiotics with multidrug coverage for Pseudomonas aeruginosa. Results shown at 2 months with no sequelae.
Management of Complications and Revisions
184

21.1.5 Flap Failure
The absolute flap failure is gratifyingly rare, but when it does
occur the reason for its loss needs to be accurately determined.
For a surgeon, losing one flap is devastating, but losing a second
“rescue” flap is an order of magnitude more devastating for the
patient as it is frequently the last chance at a reasonable recon-
struction that is lost. Evaluation of a flap in jeopardy during the
immediate postoperative period should include patient assess-
ment and removal of any flap dressings that may contribute to
venous or arterial compression. Additionally, evaluation of the
flap pedicle to ensure no compression and removal of a portion
of the inset sutures may promote flap survival.
For flaps with venous congestion, the use of topical nitrogly-
cerin ointment is beneficial, as is the use of leech therapy, but
the utilization of hyperbaric oxygen or intravenous anticoagu-
lants is of questionable benefit and of significant expense.14,18
With flap failure, if it occurs, the decision on secondary recon-
struction needs to be made with careful identification of the
reason for the initial failure.
Many pedicled flaps that show distal flap tip loss can be con-
verted to a successful reconstruction by simple debridement
and flap re-advancement ( Fig. 21.6 and Fig. 21.7).
Wound Disruption
Something that occurs infrequently, but is devastating w hen
it does, is complete wound disruption or flap disruption
from inset pedicled flaps or local flaps. If it is from a trau-
matic injury, a fall, or actual disruption, the best results will
be obtained from returning the patient to the operating
room , thoroughly cleaning and debriding the wound to clean
healthy bleeding tissue, and then re-insetting it as it was
done initially ( Fig. 21.8).
Fig. 21.6 A 70-year-old female patient with partial flap loss after “Dallas design” forehead flap. This flap design is inherently poor because it converts
an axial-pattern flap unnecessarily to a random pattern flap. Additionally, the transverse brow incision both irreversibly elevates the contralateral
eyebrow and renders the contralateral brow useless for a rescue flap. Reconstruction was salvaged by flap revelation and advancement. Final results
shown at 5 months.
Management of Complications in the Acute Healing Stage
185

Fig. 21.8 A 63-year-old male patient with
hemiagnosia due to brain tumor. He presented
with posterior alar defect caused by nasogastric
tube-induced necrosis. He initially underwent
posterior alar repair with nasolabial flap. The flap
was subsequently disrupted by the patient.
Nasolabial flap was debrided and re-attached and
ultimately failed. An ill-advised forehead flap was
then performed and was also disrupted twice by
the patient. Flap ultimately failed.
Fig. 21.7 A 77-year-old female status post with poorly designed and executed cervical facial flap reconstruction of large cheek Mohs defect. Inevitable
flap failure with partial loss. Reconstruction salvaged with color-matched full-thickness skin graft. Final results shown at 4 months.
Management of Complications and Revisions
186

References
[1] Alam M, Ibrahim O, Nodzenski M, et al. Adverse events associated with Mohs
micrographic surgery: multicenter prospective cohort study of 20,821 cases
at 23 centers. JAMA Dermatol. 2013; 149(12):1378–1385
[2] Kirkorian AY, Moore BL, Siskind J, Marmur ES. Perioperative management of
anticoagulant therapy during cutaneous surgery: 2005 survey of Mohs sur-
geons. Dermatol Surg. 2007; 33(10):1189–1197
[3] Nast A, Rosumeck S, Erdmann R, Dressler C, Werner RN. Current guidelines in
dermatology: a selection of clinically relevant recommendations. Hautarzt.
2016; 67(5):391–396
[4] Larson RJ, Aylward J. Evaluation and management of hypertension in the
perioperative period of Mohs micrographic surgery: a review. Dermatol Surg.
2014; 40(6):603–609
[5] Zoumalan R, Rizk SS. Hematoma rates in drainless deep-plane face-lift sur-
gery with and without the use of fibrin glue. Arch Facial Plast Surg. 2008; 10
(2):103–107
[6] Delaney A, Diamantis S, Marks VJ. Complications of tissue ischemia in derm a-
tologic surgery. Dermatol Ther (Heidelb). 2011; 24(6):551–557
[7] Esposito S, Bassetti M, Bonnet E, et al. International Society of Chemotherapy
(ISC). Hot topics in the diagnosis and management of skin and soft-tissue
infections. Int J Antimicrob Agents. 2016; 48(1):19–26
[8] McClain SL, Bohan JG, Stevens DL. Advances in the medical management of
skin and soft tissue infections. BMJ. 2016; 355:i6004
[9] Russo A, Concia E, Cristini F, et al. Current and future trends in antibiotic ther-
apy of acute bacterial skin and skin-structure infections. Clin Microbiol Infect.
2016; 22 Suppl 2:S27–S36
[10] Sukumaran V, Senanayake S. Bacterial skin and soft tissue infections. Aust
Prescr. 2016; 39(5):159–163
[11] Furue M, Chiba T, Tsuji G, et al. Atopic derm atitis: immune deviation, barrier
dysfunction, IgE autoreactivity and new therapies. Allergol Int. 2017 Jul;
66(3):398–403
[12] Petry V, Bessa GR, Poziomczyck CS, et al. Bacterial skin colonization and infec-
tions in patients with atopic dermatitis. An Bras Dermatol. 2012; 87(5):729–
734
[13] Spałek M. Chronic radiation-induced derm atitis: challenges and solutions.
Clin Cosmet Investig Dermatol. 2016; 9:473–482
[14] Childs DR, Murthy AS. Overview of wound healing and management. Surg
Clin North Am. 2017; 97(1):189–207
[15] Sandhu A, Gross M, Wylie J, Van Caeseele P, Plourde P. Pseudomonas aerugi-
nosa necrotizing chondritis complicating high helical ear piercing case
report: clinical and public health perspectives. Can J Public Health. 2007; 98
(1):74–77
[16] Sosin M, Weissler JM, Pulcrano M, Rodriguez ED. Transcartilaginous ear pierc-
ing and infectious complications: a systematic review and critical analysis of
outcomes. Laryngoscope. 2015; 125(8):1827–1834
[17] Liu ZW, Chokkalingam P. Piercing associated perichondritis of the pinna: are
we treating it correctly? J Laryngol Otol. 2013; 127(5):505–508
[18] Erba M, Jungreis CA, Horton JA. Nitropaste for prevention and relief of vascu-
lar spasm. AJNR Am J Neuroradiol. 1989; 10(1):155–156
Management of Complications in the Acute Healing Stage
187

22 Management of Complications in the Late Healing Stage
James F. Thornton and Jourdan A. Carboy
Sum m ary
The management of complications in the late healing stage
including hyper- and hypopigmentation as well as contour
abnormalities is discussed. Treatment modalities including der-
mabrasion, laser therapy, steroid injection, and surgical revision
are outlined. The identification of cancer recurrence after Mohs
resection is also described.
Keywords: hypertrophic, hypopigmentation, hyperpigmenta-
tion, dermabrasion, cancer recurrence, contour abnormalities,
laser therapy, steroid injection
Summary
● Hyperpigmentation can be common with full-thickness
skin grafts that have prolonged healing. Dermabrasion
and/or laser therapy is very e cacious in improving final
appearance.
● Hypopigmentation is often unpredictable in occurrence and
di cult to correct.
● The treatment of contour abnormalities begins with e ective
scar management including massage, silicone sheeting, and
intralesional triamcinolone. If contour abnormalities are not
resolved with final scar maturation, then revision surgery is
indicated.
● Although rare in postoperative Mohs patients, practitioners
must remain vigilant about the possibility of cancer recur-
rence.
22.1 General Considerations
The management of complications in the late healing stage
involves poor color match of the flap or graft, poor contour of
the flap or graft, unexpected hypertrophic or keloid scarring of
the flap or graft, as well as functional issues such as nasal air-
way obstruction or lip ectropion and then finally cancer recur-
rence after the initial resection. Unfortunately, the management
of late complications also encompasses the management of
suboptimal results from the patient’s perspective. These can
either be true suboptimal surgical results or failure of the
patient’s expectations matching expected surgical results. Pa-
tient education can obviate and minimize many of the expected
results. A perfectly fine and acceptable, even very good, surgical
result can be viewed by the patient as an abject disaster if their
expectations do not match the surgical reality. It is foolish of the
surgeon and of low yield to continue to point out “how good”
the results are if the patient remains unhappy. Education with
time spent discussing the procedure, as well as the patient’s per-
ception of the results that include representative postoperative
photographs, is time well spent. Additionally, a second opinion
can also help temper this often di cult clinical situation.
22.1.1 Hypo- and Hyperpigmentation
The management of color complications can be hypo- or hyper-
pigmentation. More commonly, hyperpigmentation with
healed full-thickness skin grafts or flaps is often the result of
continued surface desquamation despite adequate graft take,
and this will require multiple episodes of dermabrasion to
improve the final color.1,2 Laser has some proven benefit and
pulsed-dye laser can commence as early as 6 weeks after graft
inset, often in conjunction with dermabrasion. The manage-
ment of hypopigmentation is more di cult and its occurrence
is somewhat unpredictable even with good graft take. Well-
vascularized healthy grafts may have a period of transient
hypopigmentation that corresponds to the absent vasomotor
function, but this will be restored as the vasomotor function
returns. Unfortunately, some hypopigmentation will never
resolve and long-term management of can be di cult
(Fig. 22.1 and Fig. 22.2).
22.1.2 Contour Abnormalities
Unacceptable contour abnormalities are initially managed with
rigorous postoperative scar therapy including silicone sheeting
and massage.3,4 If there is a hypertrophic scar component to
this, then intralesional triamcinolone on a scheduled injection
series is added to the treatment protocol.5,6 No attempt is made
to revise contour abnormalities until the graft or flap repair has
entered the supple healing stage and the skin is pliable.
Depressed contour abnormalities in the late healing stage are
fairly easily managed by flap re-elevation and placement of a
Fig. 22.1 Hyperpigmentation.
Management of Complications and Revisions
188

dermal fat graft, cartilage graft, or fat grafting.7,8,9 The manage-
ment of hypertrophic or keloid scars depends on the accurate
identification of either. Keloid scars can be tremendously di -
cult to manage and with simple excision alone or simple steroid
injection alone show an unacceptable (as high as 90%) recur-
rence rate.6,10,11 Multimodal therapy, including surgical excision
and intralesional steroids with or without mitomycin, is the
only acceptable management for keloid therapy.6,10,11 Recurrent
keloids are best managed by multimodality therapy that
includes surgical excision and immediate short-term radiation
therapy.6,10,11 Simpler to manage are hypertrophic scars and the
management should include a patient discussion that everyone
heals along a continuum and hypertrophic scars are a normal
portion of this continuum. Aggressive management should
include silicone sheeting, scar massage, as well as scheduled
intralesional steroid therapy10,12 (Fig. 22.3).
22.1.3 Cancer Recurrence
Cancer recurrence is gratifyingly rare in post-Mohs patients;
however, it should always be kept in mind as an etiology for
poor contour abnormalities or recurrent skin lesions surround-
ing the repair. Remember that cancer recurrence is always at
the forefront of the patient’s mind and there is no greater per-
ceived catastrophe in treating cancer recurrence as a hypertro-
phic scar over a period of 3 to 6 months. Understand that in a
high-volume Mohs repair practice, even though the actual rate
of recurrence is very low, the surgical practitioner will see sev-
eral episodes yearly of cancer recurrence. The simplest solution
is a punch biopsy of any suspected lesions, or, if a patient
returns to the operating room for a revision procedure, then
biopsy and submission of pathologic specimens at the time
(Fig. 22.4a, b).
Fig. 22.2 Hypopigmentation.
Fig. 22.3 Hypertrophic scars.
Management of Complications in the Late Healing Stage
189

References
[1] Chan JC, Shek SY, Kono T, Yeung CK, Chan HH. A retrospective analysis on the
management of pigmented lesions using a picosecond 755-nm alexandrite
laser in Asians. Lasers Surg Med. 2016; 48(1):23–29
[2] Sofen B, Prado G, Emer J. Melasma and post inflammatory hyperpigmenta-
tion: management update and expert opinion. Skin Therapy Lett. 2016; 21
(1):1–7
[3] Alberti LR, Vicari EF, De Souza Jardim Vicari R, Petroianu A. Early use of CO2
lasers and silicone gel on surgical scars: Prospective study. Lasers Surg Med.
2017
[4] Commander SJ, Chamata E, Cox J, Dickey RM, Lee EI. Update on postsurgical
scar management. Semin Plast Surg. 2016; 30(3):122–128
[5] Davison SP, Dayan JH, Clemens MW, Sonni S, Wang A, Crane A. E cacy of
intralesional 5-fluorouracil and triamcinolone in the treatment of keloids.
Aesthet Surg J. 2009; 29(1):40–46
[6] Del Toro D, Dedhia R, Tollefson TT. Advances in scar management: prevention
and management of hypertrophic scars and keloids. Curr Opin Otolaryngol
Head Neck Surg. 2016; 24(4):322–329
[7] Gutiérrez Santamaría J, Masiá Gridilla J, Pamias Romero J, Giralt López-de-
Sagredo J, Bescós Atín MS. Fat grafting is a feasible technique for the sequelae of
head and neck cancer treatment. J Craniomaxillofac Surg. 2017; 45(1):93–98
Fig. 22.4 (a) An 81-year-old male presented 1 to 2 years status post Mohs excision of basal cell carcinoma at dorsal nose that was allowed to heal
secondarily. He returned with a present lesion that measured 1.2 cm × 1.3 cm. Biopsy of the lesion revealed basal cell carcinoma. The working
diagnosis was recurrent basal cell carcinoma. Two stages of Mohs surgery required to achieve clear margins (defect = 2.0 × 2.3 cm). Final repair was
done with dorsal nasal rotation flap. (b) A 78-year-old male presented 1 year status post Mohs excision for squamous cell carcinoma. Current lesion
present for approximately 8 months with crusting, itching, and rapid growth. The lesion measured 0.5 cm × 0.7 cm (not counting linear scar that was
also excised with Mohs stage). Biopsy of the lesion revealed squamous cell carcinoma. The working diagnosis is squamous cell carcinoma. One stage of
Mohs surgery required resulting in defect measuring 2.5 × 2.5 cm.
Management of Complications and Revisions
190

[8] Levy LL, Zeichner JA. Management of acne scarring, part II: a comparative
review of non-laser-based, minimally invasive approaches. Am J Clin Derma-
tol. 2012; 13(5):331–340
[9] Thomas JR, Somenek M. Scar revision review. Arch Facial Plast Surg. 2012; 14
(3):162–174
[10] Heppt MV, Breuninger H, Reinholz M, Feller-Heppt G, Ruzicka T, Gauglitz GG.
Current strategies in the treatment of scars and keloids. Facial Plast Surg.
2015; 31(4):386–395
[11] Khan MA, Bashir MM, Khan FA. Intralesional triamcinolone alone and in com-
bination with 5-fluorouracil for the treatment of keloid and hypertrophic
scars. J Pak Med Assoc. 2014; 64(9):1003–1007
[12] Khansa I, Harrison B, Janis JE. Evidence-based scar management: how to
improve results with technique and technology. Plast Reconstr Surg. 2016;
138(3) Suppl:165S–178S
Management of Complications in the Late Healing Stage
191

23 Skin Graft Revisions
James F. Thornton and Jourdan A. Carboy
Sum m ary
The management of skin graft complications in both the acute
and late healing stages is discussed. The management of
contour abnormalities, both concavities and convexities, is
outlined.
Keywords: skin graft, full-thickness skin graft, fat grafting,
cartilage graft, dermabrasion
Summary
● Even though on initial postoperative visits skin grafts are
often marginal in appearance, they very rarely need
complete revision once healed.
● Skin graft contour abnormalities are most commonly
concavity and can be relatively easily corrected with dermal
fat, cartilage grafting, or fat grafting.
● Skin grafts can be safely re-elevated and undermined within
6 weeks of initial surgery.
23.1 General Principles
The disappointment with skin grafts is their unpredictability
regarding take rate with multiple, sometimes uncontrollable,
factors a ecting their successful take. It should be understood
that unquestionably thicker grafts will oftentimes have a rock-
ier course to final healing, but even duskier poor-appearing
grafts can most frequently go on to heal completely. The inci-
dence of partial graft loss is great, but the incidence of total
graft loss or partial graft loss that requires reoperation is
actually very low.
23.1.1 Initial Postoperative Visit
During the initial postoperative visit, if the graft is dusky or has
poor wound appearance, particularly thicker-appearing grafts,
and if there is a hematoma or seroma, certainly attempt to re-
evacuate it on the initial visit, which is between days 5 and 7.1
This will allow thicker grafts to incorporate and if there is some
superficial slough, it is appropriate to change the antibiotic
ointment to plain Vaseline and allow the patient to shower and
continue simple local wound care. Plan to re-evaluate on a
weekly basis until the graft has declared itself, which may be
several weeks. Even on larger areas of superficial slough, weekly
debridement back to clean healthy bleeding tissue with local
wound care will convert many partial failures on to successful
healing (Fig. 23.1).
23.1.2 Unacceptable Color Match or
Scar Contour
If the graft heals with unacceptable color and scar formation,
then simple scar management techniques that include dermab-
rasion at 6-week intervals or even injection with Kenalog are
appropriate for management.2,3,4 For full-thickness grafts that
heal with significant depression, it is realized that these can be
re-elevated, even over 100% of their perimeter, and then at
6-week intervals, the contour deformity can be addressed with
either a dermal fat graft or fat injection to improve the final
contour.5,6 Understand that slight overcorrection with dermal
fat will be required and significant overcorrection with fat
grafting may also be required. For full-thickness skin grafts that
heal thickly with fuller contour, silicone sheeting begun at
6 weeks and then periodic fairly low-dose Kenalog injection
with multiple episodes over a period of 3 months can provide
adequate final contour.2,7 Alternatively, after 3 months, grafts
can be re-elevated, thinned, and contoured, and inset to
improve the final contour. Mismatched color on full-thickness
grafts can best be managed with both initial dermabrasion and
laser therapy as illustrated.2,4
23.1.3 Dermabrasion
Dermabrasion is an exceedingly useful adjunct for improving
the appearance of scars, full-thickness grafts, and flaps. Most
patients are o ered dermabrasion beginning at no less than
6 weeks postoperatively. The procedure is done in the clinic uti-
lizing a cylindrical diamond bur and a dedicated dermabrasion
hand power tool. Topical anesthetic is utilized with no infiltra-
tion of local anesthetic. The dermabrasion is performed to deep
punctate bleeding, often called paprika bleeding, and after der-
mabrasion, the resulting wound is given a single application of
triple antibiotic ointment and then the patient is instructed to
stay out of the shower for 1 day and then follow up with 3 to
5 days of petroleum-based ointment until healing. The patient
is cautioned to avoid significant sun exposure 3 to 6 months
postoperatively after dermabrasion. Dermabrasion is o ered at
6-week intervals, usually for no more than three times. Under-
stand that dermabrasion has no e ect on significant contour
Fig. 23.1 A 56-year-old female patient with marginal initial appearance
of skin graft 5 days postoperatively. No additional treatment was
required and the graft healed without incident, as shown 5 months
postoperatively. This is not an unusual occurrence.
Management of Complications and Revisions
192

Fig. 23.2 A 49-year-old male 6 months status
post color-matched full-thickness skin graft from
scalp donor site for 2-cm Mohs resection at nasal
tip. He complained of poor graft contour. He had
graft re-elevated over 60% of its maximal volume
and dermal fat graft placed underneath the
original full-thickness skin graft. Final
postoperative results shown at 2 months.
Fig. 23.3 A 72-year-old male status post inappropriate skin graft done outside of UTSW to repair left alar defect. He complained of poor graft site
contour and nasal airway collapse. Alar rim was reconstructed with conchal cartilage graft and scar excision. Final postoperative results shown at
2 weeks.
Fig. 23.4 A 59-year-old female status post skin graft to left nasal tip. She complained of contour deformity. She was treated with scar excision and
re-elevation and inset of graft. Final postoperative results shown at 4 months.
Skin Graft Revisions
193

abnormalities. It is particularly e cacious in improving small
incision line roughness or contour abnormalities and is particu-
larly e ective at improving final color on hyperpigmented full-
thickness skin grafts.8,9,10,11,12
Dermabrasion is also routinely performed in the operating
room. It is performed on most forehead flap donor sites, as well
as routinely performed on inset of all nasolabial flaps. This
occurs at approximately 3 to 4 weeks postoperatively and the
same procedure is performed with the exception that local
injection is injected along the incision line to be dermabraded.
The majority of dermabrasion performed in the operating room
is performed with a sterile Bovie scratch pad folded in half and
again is performed to deep punctate bleeding. It is actually our
preference to use a Bovie scratch pad over a hand-powered tool
for dermabrasion given that we feel it is safer and delivers more
predictable results. Unfortunately, patients are uniformly
underwhelmed to have Bovie scratch pad dermabrasion as an
awake clinic procedure.
Great care and caution should be utilized when using the
power dermabrasion device because it can be associated with
significant soft-tissue trauma if it abrades an eyelid or lip, for
example. Also, it is incumbent upon the assistant to not place
any gauze within the proximity of the dermabrader because if
it becomes entangled in the cylindrical tip, it is a significant
hazard that can lead to corneal abrasion (Fig. 23.2, Fig. 23.3,
Fig. 23.4, Fig. 23.5).
References
[1] Glass GE, Nanchahal J. Why haematomas cause flap failure: an evidence-
based paradigm. J Plast Reconstr Aesthet Surg. 2012; 65(7):903–910
[2] Alberti LR, Vicari EF, De Souza Jardim Vicari R, Petroianu A. Early use of CO2
lasers and silicone gel on surgical scars: prospective study. Lasers Surg Med.
2017
[3] Block L, Gosain A, King TW. Emerging therapies for scar prevention. Adv
Wound Care (New Rochelle). 2015; 4(10):607–614
[4] Commander SJ, Chamata E, Cox J, Dickey RM, Lee EI. Update on postsurgical
scar management. Semin Plast Surg. 2016; 30(3):122–128
[5] Gutiérrez Santamaría J, Masiá Gridilla J, Pamias Romero J, Giralt López-de-
Sagredo J, Bescós Atín MS. Fat grafting is a feasible technique for the
sequelae of head and neck cancer treatment. J Craniomaxillofac Surg. 2017;
45(1):93–98
[6] Thomas JR, Somenek M. Scar revision review. Arch Facial Plast Surg. 2012; 14
(3):162–174
[7] Davison SP, Dayan JH, Clemens MW, Sonni S, Wang A, Crane A. E cacy of
intralesional 5-fluorouracil and triamcinolone in the treatment of keloids.
Aesthet Surg J. 2009; 29(1):40–46
[8] Bhalla M, Thami GP. Microdermabrasion: reappraisal and brief review of
literature. Dermatol Surg. 2006; 32(6):809–814
[9] Cayce KA, Feldman SR, McMichael AJ. Hyperpigmentation: a review of com-
mon treatm ent options. J Drugs Dermatol. 2004; 3(6):668–673
[10] Spencer JM. Microdermabrasion. Am J Clin Dermatol. 2005; 6(2):89–92
[11] Spencer JM, Kurtz ES. Approaches to document the e cacy and safety of
microdermabrasion procedure. Dermatol Surg. 2006; 32(11):1353–1357
[12] Taylor SC, Burgess CM, Callender VD, et al. Postinflammatory hyperpigmenta-
tion: evolving combination treatment strategies. Cutis. 2006; 78(2) Suppl 2:
6–19
Fig. 23.5 A 77-year-old male status post skin graft at left nasal side wall. He complained of contour deformity, which was subsequently excised and
replaced by bilobed flap. Final postoperative results shown at 10 months.
Management of Complications and Revisions
194

24 Local Flap Revisions
James F. Thornton and Jourdan A. Carboy
Sum m ary
The identification, timing, and management of local flap con-
tour abnormalities are discussed. Revision techniques, including
dermabrasion, steroid injection, silicone sheeting, and direct
surgical revision are covered.
Keywords: scar massage, steroid injection, dermabrasion, sili-
cone sheeting, contour abnormalities
Summary
● The most frequently indicated revision for local flaps is
correction of contour abnormalities. The final result is best if
maximal scar maturation is achieved prior to revision.
● Alar contour abnormalities often require direct alar rim
incision and significant soft-tissue debulking along nasal
sidewall.
● Incisions across the very vascular face can be made with little
regard to previous incisions.
24.1 Complications and
Their Management
24.1.1 Noninvasive Management
The issues with local flaps involve early healing with contour
abnormalities, as well as color. Most color issues including
poor border scar appearance can be addressed with judicious
scar management like any other Mohs procedure. This includes
early (6 weeks) dermabrasion and pulsed-dye laser if indicated
for color.1,2 The management of contour abnormalities, particu-
larly with interpolated bilobed flaps or posterior labial flaps,
entails early scar care with massage, which has proven to be
remarkably e cacious, as well as a light dose of steroid
injection.2,3,4 Understand that straight volume requirement or
disruptions of natural creases are rarely improved to the point
of not requiring later revision surgery and the role of scar
massage and Kenalog should be viewed as optimizing the
appearance prior to definitive surgery. For this reason, the use
of multiple rounds of laser therapy might best be saved until
after the final revision when the contour is right to improve
the final color for the patient’s lifetime result (Fig. 24.1,
Fig. 24.2, Fig. 24.3).
24.1.2 Revision Surgery
When the decision to proceed with revision surgery is made,
very careful assessment of the patient’s perception of the defect
is paramount to ensure that it matches the surgeon’s. Other
factors important to consider in this decision making are the
multiple variables that contribute to final scar appearance,
including the patient’s persistence, the wound healing phase or
the stage of wound healing, and the severity of the defect.
Understand that left entirely with no other factors and left
entirely to the plastic surgeon, the majority of plastic surgeons
would elect to perform scar revisions somewhere in between
18 to 24 months when maximal healing is allowed.2 However,
when there is an untoward scar on somebody’s face, now is not
the time to either be dogmatic or academic and it is best to
weigh all the factors regarding management of revisions. If one
is able to achieve a reasonable facial result with an early initial
revision, then “time is on the surgeon’s side” and one is able to
wait a great deal longer prior to planning of the next or often
final stage of surgery. Simple flap contour deformities will wor-
sen the border scar appearance just from the shadowing and
highlighting and the would-be flap is able to be re-elevated.
A significant amount of thinning can be performed safely even
to the point of re-elevating the flap 100% and base the circula-
tion on the deep soft tissue, and one is able to provide an
improvement in contour across the entire border (Fig. 24.4,
Fig. 24.5, Fig. 24.6, Fig. 24.7).
Fig. 24.1 (a) It is extremely easy to inject underneath lesion, which will only lead to long-term and often irreversible fat atrophy. (b) To avoid this, the
scar tissue itself must be injected with a Luer Lock needle and syringe.
Local Flap Revisions
195

24.1.3 Z-Plasty
Z-plasty, which is mathematically defined by Limberg, is an
extraordinarily useful plastic surgery technique.5 The Z-plasty
is able to lengthen a contracted scar, break up a straight line
scar, and shift soft-tissue contour all through soft-tissue rota-
tion. The tenet of appropriate Z-plasty design depends on pre-
cise symmetry.5 The length of each lateral limb and the central
limb must all be identical. The most common prescribed angle
between the lateral and central limbs is 60 degrees.5 Appropri-
ately designed and executed, the elevation and rotation of
the resultant triangular flaps reorients the forces of scar
contracture and allows nearby tissue recruitment to lengthen a
contracted scar.
For scars that cross natural concavities, that is, the medial
and/or lateral canthus, a Z-plasty is invaluable to provide
predictable scar revision (Fig. 24.8, Fig. 24.9, Fig. 24.10).
Fig. 24.2 A 53-year-old female status post ergotrid flap that resulted in pincushioning. Pincushioning resolved over time with appropriate scar care,
including silicone sheeting, scar creams, and three cycles of 20 mg/mL of 2- to 10-mL Kenalog injection over 18 weeks. Final results shown after 1 year.
Fig. 24.3 (a) A 59-year-old female status post direct closure of Mohs defect at left cheek. Patient shown at 5 days and 2 weeks postoperatively prior to
scar management. Patient expressed concern over scar redness. Laser treatment initiated 1 month postoperatively. (b) Results shown 1 month after
first laser treatment with 532-nm wavelength at 6 J for 3 ms at 7-mm spot size and 2 weeks after second laser treatment with 532-nm wavelength at
6.2 J for 3 ms at 7-mm spot size. (c) Final results 5 months postoperative shown 1 month after third laser treatment with 532-nm wavelength at 6.2 J
for 3 ms at 7-mm spot size completed.
Fig. 24.4 A 65-year-old female status post Estlander flap. This case illustrates why the practice at UTSWMC has abandoned the use of Estlander flaps
as it completely obliterates the very difficult-to-reconstruct oral commissure. Revision required re-elevation and re-inset of the flap with simultaneous
commissuroplasty. Final postoperative results shown at 9 months.
Management of Complications and Revisions
196

Fig. 24.5 A 56-year-old female status post poorly
executed left upper lip repair with cheek
advancement that healed with significant
tethering and distortion of the upper lip. Revision
involved excision of the scar and re-elevation of
the flap with proper inset to return the lip to its
normal anatomic location. Final postoperative
results shown at 5 months.
Fig. 24.6 A 51-year-old female status post single-
stage melolabial interpolation flap that
subsequently pincushioned with obliteration of
the alar groove and cheek–nose junction. Flap
was almost completely re-elevated and thinned
out. It was then re-inset with internal tacking
sutures along the alar groove. Final postoperative
results shown at 2 months.
Fig. 24.7 A 61-year-old female status post single-
stage interpolated melolabial flap that resulted in
diminished alar groove. Revision involved direct
excision of alar groove based on the normal
contralateral side. Postoperative results shown at
2 months.
Local Flap Revisions
197

Fig. 24.8 (a) Classic Z-plasty application. A thickened and tethered scar that crosses the natural concavity of the lateral canthus. A Z-plasty is designed
with two lateral limbs that are of identical length to the central limb placed on the scar and are designed at 60-degree angles. (b) The flap is elevated
in the deep subcutaneous place and properly designed will inset with no tension. (c) Final corrected scar with resultant relaxed tension at lateral
canthus.
Fig. 24.9 A 63-year-old male status post cervicofacial advancement flap for Mohs resection repair. He had tethering of scar at lateral brow and lateral
canthus. The scar was excised and tethering reversed with small Z-plasty. Final postoperative results shown at 8 months. Hooding, or tenting, of either
the lateral or the medial eyelid with or without canthal involvement can rarely be corrected with scar massage and/or steroid injection. Surgical
revision with Z-plasty is almost invariably required.
Fig. 24.10 A 74-year-old female patient’s linear closure that resulted in a short upper lip. Revision involved a simple Z-plasty. Final postoperative
results shown at 4 months.
Management of Complications and Revisions
198

References
[1] Alberti LR, Vicari EF, De Souza Jardim Vicari R, Petroianu A. Early use of CO2
lasers and silicone gel on surgical scars: prospective study. Lasers Surg Med.
2017
[2] Commander SJ, Chamata E, Cox J, Dickey RM, Lee EI. Update on postsurgical
scar management. Semin Plast Surg. 2016; 30(3):122–128
[3] Davison SP, Dayan JH, Clemens MW, Sonni S, Wang A, Crane A. E cacy of
intralesional 5-fluorouracil and triamcinolone in the treatment of keloids.
Aesthet Surg J. 2009; 29(1):40–46
[4] Thomas JR, Somenek M. Scar revision review. Arch Facial Plast Surg. 2012; 14
(3):162–174
[5] Rohrich RJ, Zbar RI. A simplified algorithm for the use of Z-plasty. Plast
Reconstr Surg. 1999; 103(5):1513–1517, quiz 1518
Local Flap Revisions
199

25 Pedicled Flap Revisions
James F. Thornton and Jourdan A. Carboy
Sum m ary
In this chapter, management of contour abnormalities in
nasolabial and forehead flap reconstruction is discussed. Both
acute- and late-stage revisions utilizing steroid injection,
dermabrasion, and surgical excision are discussed.
Keywords: nasolabial flap, paramidline forehead flap, contour
abnormalities, pincushioning, three-stage forehead flap
Summary
● Contour abnormalities in pedicle flap reconstruction are
common and easily managed with appropriate revision.
● Edema and soft-tissue contour abnormalities present at the
time of flap division and inset will not resolve predictably. It
is safer to wait until it resolves spontaneously or the flap is
converted to a three-stage flap.
● After 6 weeks, most pedicle flaps can be aggressively re-
elevated and defatted over 80% of their volume.
25.1 Introduction
Over 90% of reconstruction patients would like some improve-
ment of their operative scars and it is incumbent on the treating
surgeon to help the patient set expectations and select e ca-
cious and appropriate treatment modalities.5
Scar massage, silicone sheeting, dermabrasion, pulsed-dye
laser treatment, and fat injection have all shown benefit in
improving final scar appearance.
25.2 General Principles
Of the two pedicled flaps covered—the nasolabial and the fore-
head flap—the nasolabial flap is much more likely to su er par-
tial loss due to its random arterial inflow. Fortunately, even the
more tenuous nasolabial flap rarely su ers a complete loss
requiring a repeat flap procedure. Usually, the nasolabial flap
will su er only a partial loss that allows su cient deep soft
tissue to develop in the base and allow full-thickness skin graft-
ing as a conversion to a completed reconstruction. Given the
geometry of the nasolabial flap design, there is rarely enough
length available to salvage the flap-by-flap elevation and
re-advancement.
25.2.1 Early Healing Stage
The majority of forehead flap complications in the early healing
stage are due to improper flap design, usually as conversion to a
random-pattern flap versus remaining axial pattern. Remaining
as an axial pattern flap, the forehead flap is very robust and will
tolerate significant thinning on inset without distal tip loss.
A significant number of well-designed and robust forehead
flaps will show early venous stasis reflected in a dusky
appearance. This worrisome initial appearance will usually
resolve within 24 hours and topical application of nitropaste
does speed resolution.1 For forehead flaps that do in fact prog-
ress to partial necrosis, usually manifested by distal tip loss, the
reconstruction can be salvaged by simple flap revelation and
advancement.2,3,4
25.2.2 Contour Abnormalities and Late
Healing Stage Revisions
For nasolabial flaps that heal with significant pincushioning
almost all can be managed with significant (>60%) flap re-ele-
vation, aggressive thinning, and re-inset as early as 6 weeks
after division and inset. The volume and geometry of nasolabial
flaps do not usually tolerate internal or external tacking sutures
on inset.
For forehead flaps that present with significant pincushion-
ing or contour abnormalities prior to division and inset, any
forehead flap can be converted to a three-stage flap by leaving
the flap pedicle intact and flap revelation and inset, including
tacking sutures to improve contour.2,3,4 The likelihood of a flap
that is significantly thickened or pincushioned before division
and inset correctly recontouring after division and inset is
very low. The safest and the most time-e ective route to
achieving acceptable contour is conversion to a three-stage flap
with aggressive thinking, tacking suture placement, and re-
contouring done at the second stage. The third and final stage,
which includes pedicle division and inset, occurs 4 to 6 weeks
after the second stage, provided acceptable contour is reached.4
For forehead flaps that pincushion after division and inset
most frequently with disruption or e acement of the alar
groove, revision involves direct incision of the alar groove based
on the normal contralateral side with careful debulking above
the groove and tacking sutures placed during re-insert to main-
tain the shape. If there is a combined cheek and alar defect,
then the same principles can be applied to the cheek–nose
junction with direct linear incision along the junction, debulk-
ing of the cheek and nasal sidewall, and inset.
Often, patient issues after a successful nasal reconstruction
with a forehead flap involve the donor site and not the nasal
reconstruction. Frequently, the inset flap pedicle itself can
become thickened and distort the eyebrow and if a widened
(>1.5 cm) pedicle was required, then forehead scar depression
may result.
To address these issues, maximal improvement with nonop-
erative management, including silicone sheeting, triamcinolone
injection, laser therapy, and dermabrasion, is performed.5,6,7
At 4 to 9 months after division and inset, the patient can be
returned to the operating room for final revision of the fore-
head flap donor site scar.
The flap pedicle is re-elevated and maximally thinned before
re-insetting or if the geometry of the eyebrow permits is simply
excised and the remaining defect closed as a linear incision.
Careful attention is paid to maintaining eyebrow symmetry
and position.
Management of Complications and Revisions
200

If the forehead scar is significantly depressed, the scar itself is
bluntly freed from the often adherent skull by elevation from
the eyebrow incision with a Penfield no. 4 elevator.
At this point, autologous fat is often injected in a crosshatch
pattern with a 21-gauge needle ( Fig. 25.1, Fig. 25.2,
Fig. 25.3, Fig. 25.4, Fig. 25.5, Fig. 25.6).
25.2.3 Autologous Fat Grafting
The benefits of autologous fat grafting and final graft appear-
ance are well supported by current literature and the technique
becomes a useful adjunctive therapy to improve final scar
result.6,8,9 Fat grafting can be performed under general anes-
thetic, intravenous (IV) sedation or local anesthetic and requires
very limited specialized equipment. The ideal fat source with
regard to patient draping and comfort is from a fat roll from the
lateral abdomen. The area is widely infiltrated with 1% lido-
caine and 0.25% Marcaine for both hemostasis and a wetting
solution. The fat is harvested with a short blunt-tip cannula and
a xed to a Luer Lock 10-mL syringe. Fat is harvested from a
single lateral stab wound incision and the fat roll is elevated o
the patient’s abdomen and great care is taken to maintain the
Fig. 25.1 A 66-year-old female status post
forehead flap reconstruction of a nasal tip defect.
She complained of “bottle-cap” appearance and
would have benefited from a subunit as opposed
to defect-only reconstruction. Revision
performed at 2 months illustrates the ability to
fully re-elevate the flap 360 degrees across the
perimeter, leaving only a central portion
unelevated. Re-inset in this fashion greatly
improves flap contour. Final postoperative results
shown at 3 months.
Fig. 25.2 An 84-year-old male 5 months status
post forehead flap and conchal cartilage graft
reconstruction of complete heminasal defect.
Initial results shows poor inset, bulky flap, and
obliterated alar groove. Revision includes 50%
flap revelation, direct excision of the alar groove
based on the contralateral side, debulking
superior to the alar groove, and flap re-inset.
Results shown at 3 months.
Pedicled Flap Revisions
201

direction of travel of the lipoaspiration probe parallel to the
patient’s body. After harvest, the fat is squirted onto a sterile
Telfa pad and then rolled back and forth until the wetting solu-
tion and supernatant are absorbed by the Telfa pad. The
remaining dry fat at this point is manually placed into 1-mL
Luer Lock syringes. The fat is then injected in the deep dermal
plane with 21-gauge needles a xed to the 1-mL Luer Lock
syringes in a crosshatch pattern. Slight overcorrection is
achieved on the initial fat injection. The patient is placed in a
stockinette dressing with an ABD pad overlying it and then
instructed to avoid manual compression for 5 to 7 days. The dif-
ficulty with fat injection lies in the unpredictability of the
absorption, and expectations are best managed preoperatively
with the patient and significant contour abnormalities may well
require a secondary grafting procedure. If the patient requires a
secondary fat grafting procedure, then an estimate of the
amount of fat that needs to be overcorrected performed on the
secondary procedure can be based on the patient’s rate of
absorption seen during the first procedure ( Fig. 25.7,
Fig. 25.8, Fig. 25.9).
Fig. 25.3 (a) A 71-year-old female status post-Mohs repair of nasal tip and partial right ala with a forehead flap. She sought second opinion due to
displeasure with nasal appearance, particularly right alar retraction. (b) Existing nasal reconstruction salvaged with conchal cartilage graft placement
and transposition flap from existing forehead flap to correct alar retraction. (c) Forehead flap divided after second-stage repair at 4 weeks. Final results
shown at 1 year.
Fig. 25.4 A 70-year-old female status post nasal
tip and dorsum reconstruction with forehead
flap. At flap division and inset, a blunt periosteal
elevator is used to elevate forehead scar from
frontal bone and a Bovie scratch pad is used to
dermabrate scar to deep punctate bleeding to
improve scar color and quality. Final results
shown at 4 months.
Management of Complications and Revisions
202

Fig. 25.5 (a) A 75-year-old female status post poorly designed and executed nasolabial flap for right ala and sidewall reconstruction. She sought
second opinion after flap revision performed showed no improvement. The poorly designed flap has significant pincushioning and blunts both the alar
groove and the cheek–nose junction. (b) Revision involved elevating the flap over 80% of its perimeter and significant flap thinning and size reduction.
Internal tacking sutures were placed, to better define both the alar groove and the cheek–nose junction. (c) The donor site scar on the cheek was
improved with Bovie scratch pad dermabrasion, scar subcision with a 14-gauge IV (intravenous) needle and fat grafting. (d) Final results shown at 1
month.
Pedicled Flap Revisions
203

Fig. 25.6 (a) A 72-year-old male status post left heminasal reconstruction with paramidline forehead flap. Initial results show poorly defined alar
groove and tissue redundancy on nasal side wall. (b) Alar crease is drawn based on template made from normal contralateral side. Direct alar crease
incision is made and superior flap skin is significantly elevated and debulked. Flap re-inset with internal tacking sutures and 5–0 nylon sutures spanning
alar crease. Forehead donor site is also dermabraded. (c) Initial results shown at 5 days and final results shown at 1 month.
Management of Complications and Revisions
204

Fig. 25.8 A 76-year-old female status 6 months status post linear
cheek closure. She complained of contour abnormality, which was
treated with 4 mL of fat injected in a crosshatch pattern with a 21-
gauge needle. Results shown at 3 months.
Fig. 25.7 A 71-year-old female status post right heminasal reconstruction for alar loss due to inadvertent intravascular injection of soft-tissue filler.
Patient shown 2 years after nasal reconstruction with slightly depressed and discolored forehead sight scar. About 2 mL of fat is harvested from the
abdomen and injected in a crosshatch pattern with a 14-gauge IV (intravenous) needle. Results shown at 6 months.
Fig. 25.9 A 46-year-old female status post multiple Mohs repairs at left cheek referred from outside provider for scar management. Scars were treated
with 4 mL of fat injected in a crosshatch pattern with a 21-gauge needle. Results shown at 3 years.
Pedicled Flap Revisions
205

References
[1] Erba M, Jungreis CA, Horton JA. Nitropaste for prevention and relief of vascu-
lar spasm. AJNR Am J Neuroradiol. 1989; 10(1):155–156
[2] Menick FJ. Nasal reconstruction with a forehead flap. Clin Plast Surg. 2009;
36(3):443–459
[3] Menick FJ. An approach to the late revision of a failed nasal reconstruction.
Plast Reconstr Surg. 2012; 129(1):92e–103e
[4] Menick FJ. Forehead flap: master techniques in otolaryngology-head and
neck surgery. Facial Plast Surg. 2014; 30(2):131–144
[5] Alberti LR, Vicari EF, De Souza Jardim Vicari R, Petroianu A. Early use of CO2
lasers and silicone gel on surgical scars: Prospective study. Lasers Surg Med.
2017
[6] Commander SJ, Chamata E, Cox J, Dickey RM, Lee EI. Update on postsurgical
scar management. Semin Plast Surg. 2016; 30(3):122–128
[7] Thomas JR, Somenek M. Scar revision review. Arch Facial Plast Surg. 2012; 14
(3):162–174
[8] Gutiérrez Santamaría J, Masiá Gridilla J, Pamias Romero J, Giralt López-de-
Sagredo J, Bescós Atín MS. Fat grafting is a feasible technique for the sequelae
of head and neck cancer treatment. J Craniomaxillofac Surg. 2017; 45(1):93–
98
[9] Klinger M, Caviggioli F, Klinger FM, et al. Autologous fat graft in scar treat-
ment. J Craniofac Surg. 2013; 24(5):1610–1615
Management of Complications and Revisions
206

207
Index
Note: Page numbers set bold or italic indicate headings or figures, respectively.
A
Abbe flaps 161, 162–163
ability, of surgeon 3
ACell 22–23, 26–27
advancement flaps, see V-Y
advancement flap
– cervicofacial 147
– perialar crescentic 146
– principles, technique 67, 69–70
a ability, of surgeon 3
AlloDerm 22, 163, 164
anaphylaxis, perioperative 180
anesthesia
– elderly patients 8
– general 8
– hypertension 9
– hypotension 9
– local, agents commonly used 9–10
– malignant hyperthermia 11
– monitored care 7
– obstructive sleep apnea 11, 11
– o ce-based, considerations 12
– OR fires 12, 179, 180–181
– postoperative cognitive
dysfunction 12
– postoperative cognitive dysfunction,
risk factors 12
– preoperative assessment 7
– preoperative phone call 7
– principles 4, 7
– recovery 10
– technique 8, 8, 10
– types of 7
Apligraf 22
atypical fibroxanthomas 19
autologous fat grafting 201, 205
B
banked frozen allograft 43, 43
banner flaps 98
basal cell carcinoma 18, 18
bilobed flaps
– chin 152, 152
– eyelid 135, 135, 139–140
– nasal 98, 98, 101
– principles, technique 71, 71, 72–75
bronchospasm 180
buccal 156
bupivacaine (Marcaine) 9–10
C
cancer recurrence 189, 190
canthal defects
– lateral 133, 135, 137–138
– medial 132, 134–136
cartilage grafts
– banked frozen allograft 43, 43
– complex nasal reconstruction 111, 112
– conchal bowl donor site 40, 41–43
– donor-site selection 40
– rib cartilage donor site 41
– septal cartilage donor site 41
– summary 40
cervicofacial advancement flap 146,
147–149
cheek reconstruction
– algorithm 143, 143, 144
– cervicofacial advancement flap 146,
147–149
– closure methods 144
– combined chin, cheek defects 144
– complications 143
– general considerations 143, 143, 144
– perialar crescentic advancement
flap 146, 146
– postoperative management 150
– primary closure 144, 144, 145
– skin graft (full-thickness) 144, 148,
149–150
– summary 143
– upper cutaneous lip defects 144
– V-Yadvancement flap 144, 145, 146
chin reconstruction
– algorithm 151, 151
– bilobed flaps 152, 152
– closure methods 151
– postoperative management 153
– primary closure 151, 152
– skin graft (full-thickness) 152
– summary 151
– V-Yadvancement flap 152, 153
chloroprocaine 10
chondritis 183, 184
color match 192, 193
combined cheek, nasal sidewall
reconstruction 119, 121–122
combined chin, cheek defects 144
complete defect reconstruction 125,
128–129
complex nasal defects, see nasal
reconstruction (complex defects)
complications management
– acute healing stage 182
– bronchospasm 180
– cancer recurrence 189, 190
– chondritis 183, 184
– contour abnormalities 188, 189
– corneal injuries 180
– dermatitis 182, 184
– flap failure 185, 185, 186
– hematoma 182, 183
– hypo-, hyperpigmentation 188
– hypo-, hyperpigmentation 188–189
– infections 182, 183
– late healing stage 188
– nerve injuries 181
– noninvasive 195, 195, 196
– OR fires 12, 179, 180–181
– patient consent 179
– perioperative anaphylaxis 180
– principles 179, 182, 188
– wound disruption 185, 186
conchal bowl donor site 40, 41–43
consent 179
contour abnormalities 188, 189, 200,
201–204
Cook, J. 71
corneal injuries 180
D
Derderian, C. 170
dermabrasion 192, 193–194
Dermagraft 22
dermatitis 182, 184
dermatofibrosarcoma protuberans 19
dermoconductive CTPs 22
dermoinductive CTPs 22
Die enbach flap 168, 169
dorsonasal flap 71, 75–76, 98, 100, 102
dorsum reconstruction 118, 120–121
E
ear reconstruction
– algorithm 166, 166
– anatomy 166, 167
– closure methods 167
– Die enbach flap 168, 169
– folded postauricular two-stage
flap 168, 169
– local flap wedge, closure 167, 168
– Medpor technique, see Medpor
technique
– secondary closure 167, 167
– skin graft (full-thickness) 167, 167,
168
– summary 166
– total reconstruction 170
elderly patients, anesthesia 8
Epicel 22
ergotrid flaps 157, 158
eyebrow defects 93, 94–95
eyelid reconstruction
– algorithm 131, 133
– anatomical considerations 131, 131,
132–133
– bilobed flaps 135, 135, 139–140
– canthal defects 134
– canthal defects (lateral) 133, 135,
137–138
– canthal defects (medial) 132,
134–136
– full-thickness defects 136, 140–142
– lacrimal outflow anatomy 132
– no canthus involvement 135, 138
– partial-thickness defects 135, 139
– skin graft (full-thickness) 135, 139
– summary 131
F
fentanyl 8
flap failure 185, 185, 186
folded postauricular two-stage
flap 168, 169
forehead flaps
– complex nasal reconstruction 106,
108–110
– contour abnormalities 200, 201–204
forehead reconstruction
– algorithm 91, 91
– closure methods 92
– delayed healing, acellular
adjuncts 92, 92, 93
– direct closure 93, 93
– eyebrow defects 93, 94–95
– general considerations 91
– postoperative management 94
– summary 91
free tissue transfer
– complex nasal reconstruction 113
– scalp reconstruction 88, 89
G
GRAFTJACKET 22
H
helical root free flap 114, 115–117
hematoma 182, 183
hydralazine 9
hypo-, hyperpigmentation 188
hypo-, hyperpigmentation 188–189
I
infections 182, 183
informed consent 179
Integra 23, 23, 23, 24–25, 87
K
karapandzic flap 162, 164
L
labetalol 9
lidocaine 9–10
linear closure 66, 67
lip reconstruction
– Abbe flaps 161, 162–163
– advancement closure 162, 163–164
– algorithm 154, 155
– AlloDerm 163, 164
– anatomy 155
– buccal advancement flaps 154, 156
– closure methods 154
– combined skin, mucosal defects 160,
161
– delayed healing, acellular
adjuncts 154, 156
– direct closure 156, 156, 157
– direct closure, with or without
wedge resection 160, 161–162
– ergotrid flaps 157, 158
– karapandzic flap 162, 164
– lateral commissure defects 162,
163–164
– mucosal-only defects 154, 156
– perialar crescentic advancement
flap 157, 159
– principles 154
– rotation flaps 161, 162–163
– skin graft (full-thickness) 157,
158–160
– skin-only defects 156, 157
– summary 154
– upper lip central defects 161
– upper-lower mismatch 163, 164
– V-Yadvancement flap 157, 158–159
lipid emulsion therapy 10
local flaps
– advancement flaps 67, 69–70
– bilobed flap 71, 71, 72–75
– dorsonasal flap 71, 75–76

– general considerations 66
– linear closure 66, 67
– melolabial flap 73, 76–78
– nasal reconstruction, simple
defects 98
– note flap 76, 79–80
– rotation flaps 66, 68–69
– summary 66
– transposition flaps 69, 70–71
local flaps revisions
– noninvasive 195, 195, 196
– summary 195
– surgery 195, 196–197
– Z-plasty 196, 198
M
malignant hyperthermia 11
Medpor technique
– advantages, drawbacks 170
– dressings 174, 174
– implant insertion 171, 173–174
– implant preparation 171, 173
– operative setup 171
– postoperative care 170
– principles 170, 172
– procedure details 171, 173
– sutures 173, 174
melanoma 18
melolabial flap
– nasal reconstruction 97–98, 100,
100, 103
– principles, technique 73, 76–78
mepivacaine 10
Merkel cell carcinoma 19
microcystic adnexal carcinoma 19
midazolam 8
MMS, see Mohs micrographic surgery
Mohs micrographic surgery
– advantages, disadvantages 14
– antibiotic prophylaxis 15
– biopsy report 15
– complications 17
– history 15
– indications 14
– overview 14
– postoperative care 17
– preoperative considerations 15
– technique 15, 16–17
– tum ors amenable to 19
Mohs repair practice
– anesthesia, see anesthesia
– anticoagulation 4
– availability, accessibility 3–4
– eye stretchers 6
– instruments, selection of 4, 5
– next-day repairs, advantages 4
– operation, conduct of 6
– operative planning 3–4
– pain management, postoperative 6
– postoperative care 4, 6
– principles 3
– surgical prep 4
Mohs, F. E. 15
N
nasal ala defects reconstruction 122,
124–127
nasal reconstruction
– banner flap 98
– bilobed flap 98, 98, 101
– dorsonasal flap 98, 100, 102
– melolabial flap 97–98, 100, 100, 103
– note flap 98, 98, 100
– postoperative management 101
– primary closure 98, 100
– principles of 96
– principles, technique, simple
defects 98
– regional considerations 97
– secondary healing 97, 97
– simple defect closure techniques 97
– skin graft (full-thickness) 97, 97, 99
– summary 96
– V-Yadvancement flap 98, 100, 103
nasal reconstruction (complex defects)
– cartilage grafts 111, 112
– flap division, inset 109, 110
– forehead flaps 106, 108–110
– free tissue transfer 113
– helical root free flap 114, 115–117
– late revisions 111
– lining, cartilage support 111
– nasolabial flaps 105, 106
– postoperative management 111
– principles 105
– problems, complications 114
– radial forearm flap for coverage 114,
114, 115
– radial forearm flap for nasal
lining 113, 113
– radial forearm free flap 113
– summary 105
– three-stage forehead flap 111
nasal reconstruction (subunit-based)
– algorithm 118, 118, 119
– combined cheek, nasal sidewall 119,
121–122
– complete defect 125, 128–129
– dorsum 118, 120–121
– nasal ala defects 122, 124–127
– nasal tip defects 122, 123–124
– sidewall 118, 119–120
– soft triangle defects 125, 127–128
– subunit anatomy 119
– summary 118
nasal tip defects reconstruction 122,
123–124
nasolabial flaps
– complex nasal reconstruction 105,
106
– design 45, 46–49
– elevation, inset 49, 49, 50–51
– general considerations 45, 46
– postoperative care 49
nerve injuries 181
nonmelanoma skin cancers 18
note flaps
– nasal reconstruction 98, 98, 100
– principles, technique 76, 79–80
O
Oasis 22
obstructive sleep apnea 11, 11
OR fires 12, 179, 180–181
P
paramidline forehead flap
– contraindications 52
– design 55, 58
– division, inset 52, 52, 53–55
– dressing, management 59, 61
– elevation, inset 59, 60
– forehead scar optimization 62,
64–65
– general considerations 45, 56–57
– postoperative care 59
– three-stage flap conversion 61,
62–63
patient consent 179
pedicled flaps
– general considerations 45
– nasolabial flap, see nasolabial flap
– paramidline forehead flap, see
paramidline forehead flap
– postoperative care 62
– summary 45
pedicled flaps revision
– autologous fat grafting 201, 205
– contour abnormalities 200, 201–204
– early healing stage 200
– late healing stage 200
– principles 200
– summary 200
perialar crescentic advancement
flap 146, 146, 157, 159
perioperative anaphylaxis 180
PONV 10
PONV predisposing factors 10
postoperative cognitive dysfunction
– anesthesia and 12
– risk factors 12
prilocaine 10
procaine 10
R
radial forearm free flap
– complex nasal reconstruction 113
– for coverage 114, 114, 115
– for nasal lining 113, 113
rib cartilage donor site 41
ropivacaine 10
rotation flaps
– lip reconstruction 161, 162–163
– principles, technique 66, 68–69
– scalp reconstruction 86, 86, 87
S
scalp reconstruction
– algorithm 83, 83, 84
– bone exposure 84
– calvarial defects 84
– closure methods 84
– direct closure 84, 84, 85
– free tissue transfer 88, 89
– general considerations 83
– postoperative management 89
– rotation flaps 86, 86, 87
– skin graft (full-thickness) 86, 87
– skin graft (split-thickness) 86
– skin graft (split-thickness), Integra
and 87, 88–89
– summary 83
scar contour 192
sebaceous carcinomas 19
septal cartilage donor site 41
sidewall reconstruction 118, 119–120
skin graft (full-thickness)
– algorithm 28, 28
– bolstering 29
– cheek reconstruction 144, 148,
149–150
– chin reconstruction 152
– color-matched 29
– conchal bowl skin 29
– donor site selection 29
– ear reconstruction 167, 167, 168
– elevation, inset 29
– eyelid reconstruction 135, 139
– lip reconstruction 157, 158–160
– lower third nasal defects 29
– nasal reconstruction 97, 97, 99
– postoperative care 30, 30, 31–32
– scalp reconstruction 86, 87
– summary 28
– supraclavicular skin 29
skin graft (split-thickness)
– donor-site selection 33, 35
– general considerations 33
– graft inset 34, 34, 35–39
– harvest technique 33
– scalp reconstruction 86
– scalp reconstruction, Integra
and 88–89
– summary 33
skin graft revisions
– color match 192, 193
– dermabrasion 192, 193–194
– initial postoperative visit 192,
192
– principles 192
– scar contour 192
– summary 192
soft triangle defects
reconstruction 125, 127–128
squamous cell carcinoma 18
STOP-Bang questionnaire 11
Swiss eye therapy 10
T
tetracaine 10
TheraSkin 22
three-stage forehead flap 61, 62–63,
111
transposition flaps 69, 70–71
V
V-Yadvancement flap
– cheek 144, 145, 146
– chin 152, 153
– lip 157, 158–159
– nasal 98, 100, 103
W
Willink, J. 179
wound care (cell, tissue-based), see
specific products
– acellular dermal matrix 23
– algorithm 22, 22
– extracellular dermal matrix 23,
26–27
– summary 22
wound disruption 185, 186
Z
Z-plasty 196, 198
Index
208