Local Flaps in Facial Reconstruction

27  SCAR REVISION AND LOCAL FLAP REFINEMENT
749
NONSURGICAL OPTIONS AND FILLERS
Silicone sheets placed over scars have been used in the
treatment of hypertrophic, keloid, and burn scars.69 The
sheeting has been shown to improve scar thickness, size,
color, and texture.61,70 This treatment is indicated for
early erythematous hypertrophic or keloid scars, for burn
scars, and as an adjunctive to other procedures.61 It is
unknown exactly how the use of silicone sheeting
improves the appearance of scars. Investigations have
shown that scar improvement is not the result of pres­
sure, change in scar temperature, or oxygen tension.71,72
Silicone gel sheeting is impermeable to water, preventing
evaporation of water from the skin, and thus may serve
to improve hydration as a result of occlusion of the
treated area.73,74 An increase in hydration of subcutaneous
tissue may have an effect on fibroblast activity.75 Hydra­
tion has been shown to inhibit fibroblast production of
collagen and glycosaminoglycans in vitro.76 Silicone
sheeting should be used at least 12 hours a day for 6
months. In a controlled setting, Gold et al73 demon­
strated that the half of a wound on which silicone sheet­
ing was placed healed better than the untreated half.
Another study demonstrated that the use of silicone
sheeting for 2 months after wounding decreased the inci­
dence of hypertrophic scars compared with nontreated
sites.77 For these reasons, the authors of this chapter initi­
ate the use of sheeting as soon as the sutures are removed
from a wound repair if we anticipate that incision lines
may not mature into unobtrusive scars.
Glycosaminoglycan gel injected in the subcutaneous
tissues in the revision of tethered scars has been reported
to decrease scar contracture and to soften scars.78 Vitamin
E is believed to improve scars, but the use of vitamin E
SCAR EXCISION AND SKIN GRAFTING
There are situations in which scar contraction may result
in distortion of facial structures. In other cases, scar con­
tracture may cause stenosis of the nostril, mouth, or
external auditory canal. In such cases, excision of scar
tissue and resurfacing of the resulting wound with a full-
thickness skin graft may improve the condition. Figure
27-25 shows an example of correcting stenosis of the
right nostril and nasal vestibule. Scar tissue was excised
from the anterior floor of the nose. This released the alar
base, which was mobilized laterally, leaving a void of skin
in the floor of the vestibule. An auricular cartilage graft
measuring 3 × 0.5-cm was placed in the tissue void. It was
oriented so that the longer dimension of the graft was
horizontal. One end of the graft was braced against the
nasal spine and the other end against the soft tissues of
the alar base. The cartilage graft served as a splint against
scar contraction and the subsequent medial migration of
the alar base during healing. A full-thickness skin graft
covered the exposed cartilage graft and open wound in
the anterior floor of the nose. The senior author has suc­
cessfully managed nasal vestibular stenosis in this manner.
On some occasions, a Z-plasty is performed in which
the alar base is one triangular flap of the Z-plasty and the
skin immediately lateral to the ala gives rise to the second
triangular flap. Scar is excised within the nasal vestibule,
and the triangular flaps are transposed. Thus, the skin
from the perialar area is transposed into the nasal vesti­
bule to cover the wound resulting from scar excision. In
this situation, a skin graft is usually not required. An
auricular cartilage graft to serve as an internal splint may
be used in such cases if it is deemed helpful in stabilizing
the lateral positioning of the ala.
FIGURE 27-23  ■  A, A 1 × 1.5-cm skin defect of upper lip repaired by primary wound closure. B, Postoperative view at 7 months.
Hypertrophic scar and elevation of vermilion border have occurred. C, Scar treated with three injections of triamcinolone acetonide
suspension (10 mg/mL) separated by intervals of 2 months followed by double Z-plasty. D, Z-plasties completed. E, Five months
after Z-plasties.
A
B
C
D
E

750
SECTION III  ADJUNCTIVE SURGERY
FIGURE 27-24  ■  A 14-year-old boy with bilateral keloids of auricles after reconstructive otoplasties. A-D, Preoperative views and 5
years after excision of keloids and postoperative serial injections of triamcinolone acetonide into scars.
A
B
C
D
too early in scar management may result in reduction of
the tensile strength of the wound, which can lead to
stretched scars and possible wound dehiscence.79 A
double-blind study showed no improvement in the aes­
thetic appearance of surgical scars treated with a topical
application of vitamin E.80 Topical vitamin A in the form
of 0.05% retinoic acid has been shown to lower the level
of elevated scars and to reduce pruritus of scars.81
Compression therapy consists of applying pressure
to scars in an attempt to prevent the development of
hypertrophic scars.82 Compression therapy may be
accomplished with specially designed garments that are
worn over scars for a prolonged interval. Constant pres­
sure on the scar by the garment is thought to produce
tissue hypoxia, reducing collagen synthesis.76
The aesthetic deformity of a scar is magnified if it is
depressed or adherent to underlying fascia, which pre­
vents the normal movement of underlying muscle. Soft
tissue contour depressions have been corrected with
dermal grafts, fat grafts, and a variety of synthetic

27  SCAR REVISION AND LOCAL FLAP REFINEMENT
751
mobility of the recipient bed can affect the survival of
injected fat.87 The greater the movement of the recipient
area from muscle contractions, the less is the survival of
fat grafts.
In addition to fat, other injectable substances known
as fillers include hyaluronic acid, calcium hydroxyapatite,
and poly-L-lactic acid. These materials are injected into
the dermal or immediate subdermal layer of the skin,
whereas fat is injected into the subcutaneous tissue plane.
Fat cannot be injected into the dermis. Dermal fillers can
improve skin creases but do not work as well as fat for
correction of contour depressions. The disadvantages
of most dermal fillers are their temporary nature. In
substances.83 Autologous fat is an ideal material for filling
depressions and contour deformities, but the degree of
fat persistence after grafting is variable.84,85 Even though
some of the fat may be resorbed, the remaining fat may
help prevent the scar from readhering to the underlying
fascia. The best donor site from which to harvest fat is
the lateral thighs and abdomen. Fat is harvested by use
of a large cannula with low-pressure suction in slow back-
and-forth movements to reduce traumatic injury to the
fat cells.86 Harvested fat should be washed and centri­
fuged. Oil, blood, and extracellular fluid are then
separated from the fat cells. Fat is injected into the sub­
cutaneous layer through small-bore cannulas. The
FIGURE 27-25  ■  Stenosis of nostril from scar. A, Scar tissue excised and ala mobilized laterally. Auricular cartilage graft placed in
floor of nasal vestibule to maintain lateral position of ala. Cartilage graft spans gap between nasal spine and alar base (yellow line).
B, Full-thickness skin graft (FTSG) used to cover wound resulting from scar excision. C, Gauze bolster used to secure full-thickness
skin graft. D, E, Preoperative and 4-month postoperative views.
A
Excise scar
Auricular cartilage
graft spans floor of
vestibule and maintains
lateral alar position
FTSG
Suture secures
cartilage graft
Stint over FTSG
B
C
D
E

752
SECTION III  ADJUNCTIVE SURGERY
skin flap is transferred. Flaps that are excessively thick
and cannot be thinned initially because of the risk of
compromising vascularity may require additional con­
touring in a later surgical stage. This is especially true in
situations in which thinning of the flap would be unwise,
such as in patients who smoke, have peripheral vascular
diseases or diabetes, or have been irradiated.92 Likewise,
skin flaps may be dissected in a deep subcutaneous tissue
plane when a thick cutaneous flap is advantageous.
Thicker cutaneous flaps are often required for repair of
skin defects that are accompanied by loss of subcutaneous
fat and underlying muscle. Thus, the thickness of a local
flap is often modulated by the surgeon at the time of flap
dissection and transfer to restore a normal contour to the
area of facial reconstruction.
On flat surfaces such as the forehead and lateral cheek,
revision surgery directed toward improving the contour
of a local flap used to repair skin defects of these areas is
seldom necessary. However, when flaps are used to repair
defects of the lips, nose, or medial cheeks, it is often
necessary to perform a flap contouring procedure that is
in addition to the initial reconstructive surgery. This is
because the central face has a more complex topography
than the lateral face and forehead. The contouring pro­
cedure is aimed at improving the final aesthetic outcome
by restoring to the area of reconstruction a natural-
appearing topography.
Skin defects of the nose reconstructed with interpo­
lated cheek or forehead flaps frequently require a con­
touring procedure 4 to 6 months after inset of the flap.
This is particularly true when flaps are required to repair
defects of the ala, alar groove, or nasal sidewall. For
instance, a contouring procedure to create an alar groove
is a necessary third surgical stage in 75% of cases of alar
reconstruction when an interpolated cheek or forehead
flap is used for repair. Contouring of flaps used to recon­
struct the nose is discussed in Chapters 13 and 18.
Skin defects of the ala that extend into the upper lip
or alar-facial sulcus are a particular problem from the
standpoint of restoring a convex contour to the ala while
at the same time creating a concave contour to the recon­
structed alar-facial sulcus. For this reason, defects that
involve both the ala and cheek or lip are reconstructed
with two or more independent local flaps. Each flap is
used to repair the component of the defect that involves
a single aesthetic region. This approach places the borders
of the flap in aesthetic boundary lines for enhanced scar
camouflage. More important, use of separate flaps to
reconstruct the portion of a defect involving a given aes­
thetic region eliminates the requirement of transferring
a flap across concave aesthetic boundary lines, obliterat­
ing the contour of the concavity. However, in spite of
using separate cutaneous flaps, when defects involve the
entire ala and extend into the cheek skin, it is usually
necessary to perform a secondary contouring procedure
to restore a natural topography to the alar-facial sulcus
and to provide the best possible aesthetic result
(Fig. 27-27).
Contouring of a local flap usually is accomplished by
a template to determine where to place incisions. A tem­
plate is constructed of rubber foam sheeting or foil with
use of the normal side of the face as the model for the
addition to the need for repeated injections, they have a
potential for displacement of the substance into tissue
surrounding the treated area.
Medical-grade makeup can camouflage and actually
adhere to scars. Green-based concealer will cover red
scars, and orange will cover blue pigment. Tattooing is a
more permanent camouflage technique that can be useful
for hypopigmented or abnormally pigmented scars. Scar
hypopigmentation is due to a reduced number of mela­
nocytes in the periphery and complete absence in the
central areas of a scar.88 For tattooing of scars, medical-
grade dyes are used that match the color of the skin
adjacent to the scar.89 A color slightly darker than the
natural skin tone is the best choice and minimizes the
need for multiple sessions.90
Topical treatment of skin is often helpful in minimiz­
ing hyperpigmentation resulting from surgery or resur­
facing procedures. Hydroquinone, kojic acid, retinoic
acid, phenol, and alpha hydroxy acids have been used
for this purpose.91 Hydroquinone produces a reversible
depigmentation of the skin by inhibition of the enzy­
matic oxidation of tyrosine to DOPA and by suppres­
sion of other melanocyte metabolic processes.9 Tretinoin
causes epidermal thickening, increased granular layer
thickness, stratum corneum compaction, and decreased
melanin content, which can lighten postinflammatory
hyperpigmentation.9
LOCAL FLAP REFINEMENT
The purpose of refining a local flap used to repair a skin
defect of the face is to restore as accurately as possible
the natural contour to the reconstructed area. Revision
surgery in the form of flap refinement may also be per­
formed to improve the appearance of unsightly scars or
to correct distortion of facial features caused by contrac­
tion of scars at the borders of flaps. Like traumatic or
incisional scars, scars resulting from reconstruction with
local flaps may widen, become depressed, or develop
trap-door deformities. When a flap is transferred, certain
surgical techniques may be implemented to prevent
unsightly scarring. These techniques have been discussed
in an earlier section of this chapter. However, revision
surgery in the form of scar revision or flap refinement is
often required even when local flaps are used by the most
experienced of surgeons.
Flap Contouring
An important aspect of local flap surgery is contouring of
the flap so that it assumes the natural topography of the
recipient site. This becomes particularly important when
a local flap is used to reconstruct an area of the face that
manifests concave or convex surfaces or in areas where
the native skin is thin or devoid of significant subcutane­
ous fat, such as the auricle (Fig. 27-26). Cutaneous flaps
may often be thinned of accompanying subcutaneous fat
when they are initially dissected if this is required for the
flap to replicate in thickness the depth of the recipient
site wound. In certain circumstances, it may be necessary
to remove nearly all of the subcutaneous fat when the

27  SCAR REVISION AND LOCAL FLAP REFINEMENT
753
FIGURE 27-26  ■  A, B, Postauricular interpolated flap used to reconstruct defect of helix. Flap is bulky with step-off deformity at inferior
aspect. C, D, Four months after contouring of flap and Z-plasty at inferior border of flap.
A
Contour
Contour
Z-plasty
Z-plasty
B
C
D

754
SECTION III  ADJUNCTIVE SURGERY
A
B
C
D
E
FIGURE 27-27  ■  A, A 3 × 4-cm skin and soft tissue defect of ala and medial cheek. Auricular cartilage graft in place for structural
support of ala. Subcutaneous tissue pedicled cheek island flap designed for reconstruction of ala. Arrow indicates plan for cheek
advancement flap to repair cheek component of defect. B, C, Advancement flap dissected and reflected superiorly. D, Island flap
transposed to ala. Cheek flap advanced and sutured. E, F, Postoperative result at 2 months. Alar-facial sulcus has been obliterated
by pedicle of island flap.

27  SCAR REVISION AND LOCAL FLAP REFINEMENT
755
F
G
H
I
J
G, Solid line outlines area of ala and broken line outlines area of advancement flap requiring contouring.
H, Subcutaneous tissue removed during contouring of ala and medial cheek. I, J, Cotton bolster used to maintain constructed alar-
facial sulcus.
FIGURE 27-27, cont’d  ■
Continued
template. Other times, incisions are simply made in old
scars resulting from the initial reconstruction of the area.
The skin of the flap is elevated in the subdermal or super­
ficial subcutaneous tissue plane. The underlying scar
tissue and subcutaneous fat are then sculpted by sharp
dissection in an appropriate tissue plane to restore a
natural topography to the area. This involves frequent
replacement of the skin flap to its in situ position and
assessment of the contour of the area covered by the flap.
For areas that have a natural convex or flat surface, over­
correction during the contouring procedure is not neces­
sary. For concave areas, such as the alar-facial and
nasofacial sulci, slight overcorrection is recommended.
That is, concave surfaces should be sculpted deeper than
their normal contralateral counterpart. This is because
scar deposition occurs after a contouring procedure,
which tends to fill in concavities created by the surgeon.
To retard this natural tendency toward obliteration of
concavities as wounds heal, bolster dressings secured with
percutaneous sutures are frequently employed for 5 days
postoperatively. An alternative to bolster dressings is the
use of quilting sutures, which consist of multiple full-
thickness horizontal mattress sutures placed throughout
the contoured area to eliminate surgical dead space and
to maintain the contour of the area during the early
phases of healing.

756
SECTION III  ADJUNCTIVE SURGERY
appropriately at the initial transfer and preventing hema­
tomas and seromas by use of effective compression dress­
ings postoperatively. Trap-door deformities that do not
resolve with time may respond to subcutaneous tissue
injection of triamcinolone acetonide beneath the affected
area. If this proves ineffective, a contouring procedure is
required to reduce the deformity.
Hematomas of the face resulting from blunt trauma
may occasionally cause a trap-door deformity. This is
presumably the result of the hematoma’s becoming orga­
nized, causing the resulting scar tissue to contract. In
such instances, the trap-door deformity usually resolves
over time but may require triamcinolone acetonide injec­
tions into the substance of the organized hematoma (Fig.
27-28). This type of deformity is not corrected with a
resurfacing procedure such as dermabrasion and usually
Trap-Door Deformity
Trap-door deformity is a common problem associated
with local cutaneous flaps and is usually the result of
concentric contraction forces of the scar and obstruction
of lymphatic and venous drainage. Trap-door deformity
may occur from inadequate undermining of the skin sur­
rounding the periphery of a defect. Flaps that have a
curvilinear configuration are particularly prone to devel­
opment of trap-door deformity, presumably because of
the circular scar, which contracts in a concentric fashion,
producing an upward mushrooming of the skin of the
flap. Hematomas developing beneath local flaps or from
facial trauma may also result in trap-door deformity.
The incidence of trap-door deformity after transfer
of a local flap can be minimized by thinning of the flap
K
L
M
N
K-N, Preoperative and 3-month postoperative views after contouring procedure.
FIGURE 27-27, cont’d  ■

27  SCAR REVISION AND LOCAL FLAP REFINEMENT
757
the flap with a precise thickness.92 Fat and scar tissue from
the deeper portion of the flap are left attached to underly­
ing structures. The fat and scar tissue are then sculpted
with a scalpel and scissors to remove redundant tissue.
The overlying skin is allowed to settle over the contoured
area to determine if additional subcutaneous tissue should
be removed. The ultimate goal is to restore the level of
the skin of the flap to that of the surrounding skin (Fig.
27-30). After a contouring procedure, a compression or
bolster dressing is applied to the surgical area to prevent
requires wide undermining of skin in the involved area
and removal of underlying scar tissue if it does not
respond to conservative management.
When a contouring procedure is performed to correct
a trap-door deformity or simply to improve the contour
of a flap, incisions are made in the scars along the border
of the flap (Fig. 27-29). A portion or all of the flap is
elevated in a superficial subcutaneous tissue plane. A
scalpel blade is positioned parallel to the skin surface in
the immediate subdermal tissue plane and used to dissect
FIGURE 27-28  ■  A, B, One month after blunt trauma to cheek of 12-year-old girl. Soft tissue hematoma organized and contracted,
causing contour deformity that was accentuated on smiling. C, D, One year after three serial injections of hematoma with triamcino­
lone acetonide suspension (40 mg/mL) separated by intervals of 2 months.
A
B
C
D

FIGURE 27-29  ■  A, B, A 5 × 3-cm skin and muscle defect and a 2 × 1.8-cm mucosal defect of upper lip. Second 1 × 1-cm skin defect
of alar-facial sulcus. Modified subcutaneous tissue pedicled V-Y island advancement flap designed for repair of wound. A template
of the contralateral upper lip was used to design V-Y island flap. C, Flap based on subcutaneous tissue of medial cheek. D, Flap in
place. Full-thickness skin graft (FTSG) in floor of nasal vestibule. E, Five months postoperatively. Scar revision surgery planned.
Large Z-plasty incorporating right alar base used to displace alar base laterally. F, Auricular cartilage graft placed horizontally in
floor of nasal vestibule after Z-plasty used to brace against scar contraction and possible displacement of alar base medially.
G, Full-thickness skin graft placed in floor of nasal vestibule covering cartilage graft. Z-plasties and flap contouring completed.
H-K, Before and 2 months after revision surgery.
A
Loss of alar base
Full thickness
defect
Template pattern
Remove this skin
Modified V-Y island flap
FTSG
Subcutaneous tissue pedicle
B
C
D
E
FTSG
Auricular cartilage graft in floor of
vestibule oriented horizontally
Excise redundant skin and mucosa
Z-plasty
Contour
Z-plasty to move
alar base laterally
F
G
H
I
J
K

A
B
SCD
C
Trap-door
Distortion of
vermilion
Z-plasty
Contour
Excise SCD
D
E
F
FIGURE 27-30  ■  A, A 2 × 2-cm skin defect of upper lip. Vertical lines mark planned skin excision to place scars in alar-facial sulcus.
V-Y subcutaneous tissue pedicled island advancement flap designed for repair of wound. B, Flap in place. C, Four months postop­
eratively. Distortion of vermilion border, trap-door deformity of lateral flap, and persistent standing cutaneous deformity (SCD) of
donor site scar are observed. D, Planned revision surgery. E, Revision surgery completed. F, Sixteen months after revision surgery.

760
SECTION III  ADJUNCTIVE SURGERY
Z-plasty should measure 5 mm in length and have a 30°
to 40° angle. The flaps are transposed and secured at each
apex with a deep buried suture of 5-0 polydioxanone. A
small cutting needle with a half-circle configuration is
ideal for this purpose. The skin is approximated with
interrupted simple or vertical mattress 5-0 or 6-0 cutane­
ous sutures. The wound is cared for in the standard
manner, and sutures are removed in 5 to 7 days after the
procedure. Dermabrasion of the scar and adjacent skin
may be performed in 6 to 8 weeks after revision surgery.
On occasion, there may be a persistent contour irregu­
larity or depression of the surface of a flap after facial
accumulation of blood beneath the undermined skin and
for better adherence of the flap skin to the underlying
soft tissues.
When the scar surrounding a flap manifesting trap-
door deformity is curvilinear, it is often helpful to inte­
grate the skin of the flap with the adjacent facial skin by
using multiple small Z-plasties (Fig. 27-31). The scar
bordering the portion of the flap exhibiting the trap-door
deformity is excised, and skin undermining is performed
in the subcutaneous tissue plane for 1 to 2 cm on both
sides of the scar. Multiple Z-plasties are designed along
the length of the excised scar. Each triangular flap of the
FIGURE 27-31  ■  A, Scar of healed bilobe nasal flap outlined by continuous blue line. Wider blue line at inferior border of flap indicates
depressed scar marked for excision and double Z-plasties. Trap-door deformity outlined by broken line. B, Incision for contouring
of flap made in scar at inferior border of flap. Subcutaneous tissue excised shown on surface of contoured area. Two Z-plasties
(broken lines) performed at inferior incision line. C, Z-plasties completed. Bolster dressing in place. D, E, Before bilobe nasal flap
and 6 months after contouring of flap.
A
Z-plasties here
Contour
B
C
D
E

27  SCAR REVISION AND LOCAL FLAP REFINEMENT
761
A
B
C
D
reconstruction. The majority of such deformities signifi­
cantly improve with time. Should a depressed contour
persist after transfer of a cutaneous flap or skin graft, it
may be improved with grafts of fat, fascia, or dermal
allografts placed beneath the skin in the area of the
depressed contour (Fig. 27-32). An incision is made at
the border of the flap or graft, and small Metzenbaum
scissors are used to create a subcutaneous tissue pocket
over the area of depression. Autogenous fascia, fat, or
dermal allograft is positioned in the pocket to produce
the desired contour elevation. The elevation should be
slightly overcorrected to allow some absorption of the
graft material. Large contour depressions, especially on
the cheek, may sometimes be improved with a subcutane­
ous fat flap transfer to the depression from an adjacent
area (Fig. 27-33). This is possible only in instances in
which an adjacent area has an excess amount of subcuta­
neous fat that can be used for construction of the fat flap.
FIGURE 27-32  ■  A, B, A 1.5 × 1.4-cm cutaneous defect of infratip lobule repaired with full-thickness skin graft. C, D, Postoperative
result at 5 years. Contour depression causes unsightly appearance.
Continued

762
SECTION III  ADJUNCTIVE SURGERY
E
Temporalis fascia
Access incision
F
G
H
E, Temporalis fascia graft before its insertion beneath healed skin graft. F, Fascia inserted beneath skin graft
and access incision used to insert fascia graft closed. Sutures peripheral to access incision closure line used to secure fascia in
place. G, H, Postoperative result at 3 months.
FIGURE 27-32, cont’d  ■

27  SCAR REVISION AND LOCAL FLAP REFINEMENT
763
A
B
C
FIGURE 27-33  ■  A, Persistent standing cutaneous deformity from large rotation advancement cheek flap marked by ellipse. Arrow
indicates plans to transfer fat from beneath standing cutaneous deformity to fill depressed contour beneath distal portion of healed
flap. Broken line indicates border of flap. B, Flap undermined. Standing cutaneous deformity elliptical island of skin removed, pre­
serving underlying fat that was transferred medially as hinge flap to improve contour of medial cheek. C, Wound closed.
Continued

764
SECTION III  ADJUNCTIVE SURGERY
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FIGURE 27-33, cont’d  ■

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1995;1:543.
59. Levit E, Daly D, Scarborough DA, et al. The case for nonablative
laser resurfacing. Cosmetic Dermatol 2002;15:39.
60. Warschaw KE, McCullough M. Disorders of collagen. In: Farmer
ER, Hood AF, editors. Pathology of the skin. New York: McGraw-
Hill; 1999. p. 661.
61. Dockery GL, Nilson RZ. Treatment of hypertrophic and keloid
scars with Silastic gel sheeting. J Foot Ankle Surg 1994;33:110.
62. Ghahary A, Shen YJ, Scott PG, et al. Enhanced expression of
mRNA for transforming growth factor-beta, type I and type II
procollagen in human post-burn hypertrophic scar tissues. J Invest
Dermatol 1993;122:465.
63. Murray JD, Pollack SV, Purnell SR. Keloids: a review. J Am Acad
Dermatol 1981;4:461.
64. Berman B, Bieley HC. Adjunct therapy to surgical management of
keloids. Dermatol Surg 1996;22:126.
65. Alster T. Laser scar revision. Dermatol Surg 2003;29:25.
66. Ketchum LD, Robinson DW, Masters FW. The treatment of
hypertrophic scar, keloid, and scar contracture by triamcinolone
acetonide. Plast Reconstr Surg 1966;38:209.
67. Su CW, Alizadeh K, Boddie A, et al. The problem scar. Clin Plast
Surg 1998;25:451.
68. Goett Dr, Odom RB. Adverse effects of corticosteroids. Cutis
1979;23:477.
69. Perkins K, Davey RB, Wallis KA. Silicone gel: a new treatment for
burn scars and contractures. Burns 1982;9:406.
70. Chang CW, Ries WR. Nonoperative techniques for scar manage­
ment and revision. Facial Plast Surg 2001;17:283.
71. Quinn KG. Silicone gel in scar treatment. Burns 1987;13:S33.
72. Sawada Y, Urushidate S, Nihei Y. Hydration and occlusive treat­
ment of a sutured wound. Ann Plast Surg 1998;41:508.
73. Gold MH, Foster TD, Adair MA, et al. Prevention of hypertrophic
scars and keloids by the prophylactic use of topical silicone gel
sheets following a surgical procedure in an office setting. Dermatol
Surg 2001;27:641.
74. Katz B. Silicone gel sheeting in scar therapy. Cutis 1995;56:65.
75. Fulton VE. silicone gel sheeting for the prevention and manage­
ment of evolving hypertrophic and keloid scars. Dermatol Surg
1995;21:947.
14. Engrave LH, Gottlieb JR, Millard SP, et al. A comparison of intra­
marginal and extramarginal excision of hypertrophic burn scars.
Plast Reconstr Surg 1988;81:40.
15. Yang JY. Intrascar excision for persistent perioral hypertrophic scar.
Plast Reconstr Surg 1996;98:1200.
16. Dzubow LM. Scar revision by punch graft transplants. J Dermatol
Surg Oncol 1985;11:1200.
17. Regan JR, Frost TW. Scar revision and camouflage. In: Baker SR,
Swanson NA, editors. Local flaps in facial reconstruction surgery.
St. Louis: Mosby; 1995. p. 587.
18. Mostafapour SP, Murakami CS. Tissue expansion and serial exci­
sion in scar revision. Facial Plast Surg 2001;17:245.
19. Karounis H, Gouin S, Eisman H, et al. A randomized, controlled
trial comparing long-term cosmetic outcomes of traumatic pediat­
ric laceration repaired with absorbable plain gut versus nonabsorb­
able nylon sutures. Acad Emerg Med 2004;11:730.
20. Singer AJ, Hollander JE, Quinn JV. Evaluation and management
of traumatic lacerations. N Engl J Med 1997;337:1142.
21. Holt GR. Treatment of trapdoor scars. In: Thomas JR, Holt GR,
editors. Facial scars: incision, revision, and camouflage. St. Louis:
CV Mosby; 1989.
22. Rodgers BJ, Williams EF, Hove CR. W-plasty and geometric
broken line closure. Facial Plast Surg 2001;17:239.
23. Borges AF. Improvement of antitension lines scar by the “W-plastic”
operation. Br J Plast Surg 1959;12:29.
24. Borges AF. Preoperative planning for better incisional scars. In:
Thomas JR, Holt GR, editors. Facial scars: incision, revision and
camouflage. St. Louis: Mosby; 1989. p. 44.
25. Key SJ, Thomas DW, Shepherd JP. The management of soft tissue
facial wounds. Br J Oral Maxillofac Surg 1995;33:76.
26. Harmon CB, Zelickson BD, Roenigk RK, et al. Dermabrasion after
scar revision. Dermatol Surg 1995;21:503.
27. Katz B, Oca A. A controlled study of the effectiveness of spot
dermabrasion on the appearance of surgical scars. J Am Acad Der­
matol 1991;24:462.
28. Yarborough JM. Ablation of facial scars by programmed dermabra­
sion. J Dermatol Surg Oncol 1988;14:292.
29. Collins PS, Farber GA. Postsurgical dermabrasion of the nose.
J Dermatol Surg Oncol 1984;10:476.
30. Bradley DT, Park SS. Scar revision via resurfacing. Facial Plast
Surg 2001;17:253.
31. Gold MH. Dermabrasion in dermatology. Am J Clin Dermatol
2003;4:467.
32. Capon A, Mordon S. Can thermal lasers promote skin wound
healing. Am J Clin Dermatol 2003;4:1.
33. Anderson RR, Parrish JA. Selective photothermolysis: precise
microsurgery by selective absorption of pulsed radiation. Science
1983;220:524.
34. Ho C, Nguyen Q, Lowe NJ, et al. Laser resurfacing in pigmented
skin. Dermatol Surg 1995;21:1035.
35. Berstein LJ, Kauvar AN, Grossman MC, et al. Scar resurfacing
with high-energy, short-pulsed and flash scanning carbon dioxide
lasers. Dermatol Surg 1998;24:101.
36. Cotton J, Hood AF, Gonin R, et al. Histologic evaluation of
preauricular and postauricular human skin after high-energy,
short-pulse carbon dioxide laser. Arch Dermatol 1996;132:
425.
37. Tanzi EL, Alster TS. Treatment of atrophic facial acne scars with
a dual-mode Er:YAG laser. Dermatol Surg 2002;28:551.
38. Nehal KS, Levine VJ, Ross B, Ashonoff R. Comparison of
high-energy pulsed carbon dioxide laser resurfacing and derma­
brasion in the revision of surgical scars. Dermatol Surg 1998;24:
647.
39. Kwon SD, Kye YC. Treatment of scars with a pulsed Er:YAG laser.
J Cutan Laser Ther 2000;2:27.
40. Walsh JT, Flotte TJ, Deutsch TF. Er:YAG laser ablation of tissue:
effect of pulse duration and tissue type on thermal damage. Lasers
Surg Med 1989;9:314.
41. Kye YC. Resurfacing of pitted facial scars with Er:YAG laser. Der­
matol Surg 1997;23:880.
42. Sawcer D, Lee HR, Lowe NJ. Lasers and adjunctive treatments for
facial scars. J Cutan Laser Ther 1999;1:77.
43. Zachary CB. Modulating the Er:YAG laser. Lasers Surg Med
2000;26:223.
44. Tanzi EL, Alster TS. Laser treatment of scars. Skin Therapy Lett
2004;9:4.

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76. Chang CC, Kuo TF, Chiu HC, et al. Hydration, not silicone
modulates the effects of keratinocytes on fibroblasts. J Surg Res
1995;59:705.
77. Cruz-Korchin NI. Effectiveness of silicone sheets in the prevention
of hypertrophic breast scars. Ann Plast Surg 1996;37:345.
78. Boyce DE, Bantick G, Murison MSC. The use of ADCON-T/N
glycosaminoglycans gel in the revision of tethered scars. Br J Plast
Surg 2000;53:403.
79. Widgerow AW, Chait LA, Stals R, et al. New innovations in scar
management. Aesthetic Plast Surg 2000;24:227.
80. Jenkins M, Alexander JW, MacMillan B, et al. Failure of topical
steroids and vitamin E to reduce postoperative scar formation fol­
lowing reconstructive surgery. J Burn Care Rehabil 1986;7:309.
81. Janssen de Limpens AM. The local treatment of hypertrophic scars
and keloids with topical retinoic acid. Br J Dermatol 1980;
103:319.
82. Ng CL, Lee St, Wong KL. Pressure garments in the prevention
and treatment of keloids. Ann Acad Med Singapore 1983;12:430.
83. Dzubow LM. Scar revision by punch-graft transplants. J Dermatol
Surg Oncol 1985;11:131.
84. Coleman SR. Facial recontouring with lipostructure. Clin Plast
Surg 1997;24:347.
85. Benito JD, Fernandex I, Nanda V. Treatment of depressed scars
with a dissecting cannula and an autologous graft. Aesthetic Plast
Surg 1999;23:367.
86. Boyce RG, Nuss DW, Kluka EA, et al. Use of autogenous fat,
fascia, and nonvascularized muscle grafts in the head and neck.
Otolaryngol Clin North Am 1994;27:39.
87. Illouz YG. Present results of fat injection. Aesthetic Plast Surg
1988;12:175.
88. Breathnach AS. Melanocytes in early regenerated human epider­
mis. J Invest Dermatol 1960;35:245.
89. Guyuron B, Vaughan C. Medical-grade tattooing to camouflage
depigmented scars. Plast Reconstr Surg 1995;95:575.
90. Spear SL, Convit R, Little JW. Intradermal tattoo as an adjunct to
nipple-areola reconstruction. Plast Reconstr Surg 1989;83:907.
91. Kaplan B, Potter T, Moy R. Scar revision. Dermatol Surg 1997;
23:435.
92. Baker SR, editor. Principles of nasal reconstruction. 2nd ed. New
York: Springer; 2011.

767
C H A P T E R 2 8 
MANAGEMENT OF VASCULAR
ANOMALIES OF THE FACE
Marcelo Hochman
INTRODUCTION
For the purpose of this chapter, the term vascular lesion
or vascular anomaly is used to define a variety of cutaneous
neoplasms and malformations originating from blood
vessels and related structures. Owing to major differences
in prognosis and treatment strategies, it is imperative to
accurately differentiate between these various abnormali­
ties. Vascular lesions can be divided into two main groups:
vascular tumors and vascular malformations. Overall, vas­
cular anomalies affect approximately 8% to 10% of births
worldwide, which is nearly 400,000 new cases per year in
the United States alone.1
Infantile hemangiomas, the most common vascular
anomaly, are the most common benign tumor occurring
in infancy and childhood and are present in about 2% of
neonates. They are true tumors exhibiting the features of
all neoplasms, such as increased mitosis and hyperplasia.
Although up to 30% of these tumors may be present at
birth, the majority become apparent in the first weeks of
life. Infantile hemangiomas have a unique and character­
istic natural history.1,2 During the first few months of life,
they increase in size by proliferation (hyperplasia) and
involve skin, mucosa, and subcutaneous tissues to variable
degrees. Proliferation typically ends within the first 4 to
6 months and is followed by a quiescent plateau before
regression begins. Rarely, growth may continue for 12 to
14 months after birth (Fig. 28-1).
The end of the proliferative phase marks the begin­
ning of the involutional phase. During this phase, which
may last years, the hemangioma undergoes varying
amounts of regression in size and replacement with fibro­
fatty tissue. Approximately 30% to 40% of infantile hem­
angiomas involute to a cosmetically and functionally
acceptable point and do not require any treatment. Nec­
essary intervention is sought by the remaining majority
of patients. Cutaneous hemangiomas may involve papil­
lary dermis (superficial), papillary and reticular dermis,
subcutaneous tissue (deep), or both skin and subcutane­
ous tissue (compound). They are most commonly focal,
well-defined growths or diffuse, involving dermatome-
like segments of skin. There are sites of predilection on
the face (midface, nose, lips) for the development of
hemangiomas.3
After involution of hemangiomas is complete, superfi­
cial hemangiomas leave atrophic redundant skin mani­
festing variable degrees of telangiectasia, whereas deep
hemangiomas leave a residual mass of fibrofatty tissue.
Involuting compound hemangiomas show varying degrees
of all these features (Fig. 28-2).
Treatment of infantile hemangiomas is dependent on
multiple factors including the stage of its natural history,
the anatomic location of the tumor, and the age of the
child.4 Accurate diagnosis and treatment of infantile
hemangiomas are entirely dependent on clinical history
and physical examination. Imaging studies are rarely
required and are of limited importance.
Congenital hemangiomas are completely formed and
present at birth and are very different from infantile hem­
angiomas in their natural history and prognosis. Rapidly
involuting congenital hemangiomas appear fully formed
at birth, do not proliferate, and regress within the first
year of life or do not (non–rapidly involuting hemangio­
mas).5 There are other, rarer vascular tumors that are
beyond the scope of this chapter.1 Terms such as straw­
berry or capillary angioma and cavernous hemangioma
are of historic and folkloric interest and should not be
used in communicating about these abnormalities. More
than 60% of infantile hemangiomas occur on the head
and neck, predominantly in white children and somewhat
less commonly in those of African or Asian descent. For
unclear reasons, female neonates are more likely to be
affected than male neonates in a 3 to 5 : 1 ratio. Infantile
hemangiomas are more common in premature infants.
The increased prevalence in premature neonates corre­
lates with decreasing gestational age and birth weight.6,7
A plethora of new knowledge links infantile hemangio­
mas and placenta tissue. Many of the characteristic
molecular markers of infantile hemangioma blood vessels
are expressed uniquely by normal fetal microvessels. In
particular, GLUT-1 (glucose transporter protein) is
exclusively demonstrated by infantile hemangioma and
placenta but not by other vascular anomalies or other
normal tissues. There is also a striking similarity between
the infantile hemangioma mRNA transcriptome and that
of placenta. The leading hypothesis concerning this rela­
tionship is that fetal placental or precursor cells metasta­
size from the placenta to the baby and become implanted
in areas of high flow, such as the head and neck. Little is
known about the mechanism of this process; however,
the link between placental and hemangioma cells is
irrefutable.8
In contrast to infantile hemangiomas, vascular malfor­
mations (Fig. 28-3) are always present at birth, although

768
SECTION III  ADJUNCTIVE SURGERY
typically fade with advancing age and are of passing
significance.
Venular malformations, known as port-wine stains, are
made up of ectatic postcapillary venules. Although they
may be manifested as flat pink macules at the beginning
of life, they usually darken and thicken with advancing
age, forming a cobblestone appearance as the dermal
vessels continue to dilate under constant hydrostatic
pressure. Their distribution patterns often correspond to
dermatomes, and the presumed etiology is deficient or
ineffective postcapillary venule innervation.10 Although
this is the presumed mechanism, no definitive evidence
exists to prove it.
Venous malformations are composed of ectatic veins.
They are usually observed in the lips, tongue, floor
of mouth, and buccal spaces. Patients suffering from
they may not be apparent. They enlarge by hypertrophy,
never proliferate, and never involute. They are true
developmental anomalies, not neoplasms. Their rate of
hypertrophy and hence their functional and cosmetic sig­
nificance are extremely variable. Vascular malformations
may originate from capillaries, veins, venules, lymphatics,
arterioles, or any combination of these structures. Similar
to hemangiomas, vascular malformations may involve
skin, subcutaneous tissues, and mucosa. Like hemangio­
mas, they may be superficial, deep, compound, focal, or
diffuse.9
Capillary malformations are superficial, pink macules
previously known as salmon patch, angel’s kiss, or stork
bite. They most commonly involve the midline of the
nape of the neck, followed by the forehead. Although
they are classified as vascular malformations, these lesions
FIGURE 28-1  ■  A-C, Proliferating compound infantile hemangioma of the periorbital area.
A
B
C
FIGURE 28-2  ■  Examples of involuting (A) and fully involuted (B) infantile hemangiomas. Note the residual telangiectasias, expanded
skin, fibrofatty residual mass effect, and textural changes.
A
B

28  MANAGEMENT OF VASCULAR ANOMALIES OF THE FACE
769
TREATMENT
Infantile Hemangiomas
There is no accepted consensus on the treatment of
infantile hemangiomas, although the prevailing trend is
to intervene rather than to follow the old dictum of
benign neglect (“leave it alone, it will go away”). This is
supported by the fact that a significant number of hem­
angiomas incompletely involute regardless of how long
patients are willing to wait. Incomplete involution often
results in a cosmetic deformity necessitating treatment
because of the high social impact of facial differences. In
addition, the psychology literature has well-documented
the impact of physical appearance on the development
of self-image of children between the ages of 2 and 5
years.12,13 Therefore, early treatment of hemangiomas is
justified. There are numerous treatment options avail­
able. The goal of treatment is to restore to the child as
much as possible normal appearance and function. This
ideally should be accomplished by the age of 3 years and
no later than elementary school age. Treatment of hem­
angiomas depends on the anatomic location and func­
tional and cosmetic impairment the neoplasm is causing.
The depth of tissue involvement, the presence of com­
plicating factors (ulceration, visual axis impingement),
and whether the hemangioma is proliferating or involut­
ing also influence the approach to treatment.
An important decision to make in treatment of hem­
angiomas is whether to intervene and what treatment
modality to use. This decision is best made by asking the
question, Can the surgeon obtain a result with available
treatment modalities that is as effective as allowing the
hemangioma to follow its natural course? If the answer
is yes, intervention is justified. If the answer is no, then
observation is continued until a predetermined point of
re-evaluation. Serial observation is an active treatment
option and is very different from telling parents of chil­
dren afflicted with hemangiomas to wait an indetermi­
nate number of years for the hemangioma to “go away.”
venous malformations frequently complain of swelling
with dependency, pain, limitations in the function of
the affected region, and cosmetic deformity. Superficial
venous malformations are visible as purple masses.
Deeper lesions are manifested as bluish or colorless sub­
cutaneous masses.
Arteriovenous malformations are rare vascular lesions
originating from arteriovenous channels that failed to
regress during fetal development.9 A palpable mass with
an obvious well-developed arterial supply and dilated tor­
tuous veins are typical features. A murmur may be heard
or a thrill may be palpated over the mass. Malformations
must be differentiated from arteriovenous fistulas, which
are usually precipitated by trauma.
Lymphatic malformations (previously known as cystic
hygromas) are dilated lymphatic channels arising from
congenital blockage or arrest of the normal development
of the primordial lymphatic plexus. Although they grow
at a slow steady rate, sudden increase in size may be seen
with infection, trauma, or hormonal changes. More than
80% of lymphatic malformations of the head and neck
are located in the cervical region. They may also involve
the oral cavity, supraclavicular area, and parotid gland.
Some lymphatic malformations tend to be well defined,
with macrocystic features (>2 cm3). Others tend to be
interstitial, infiltrating, and poorly defined microcystic
lesions (<2 cm3). Still others demonstrate both macrocys­
tic and microcystic features. Most lymphatic malforma­
tions are diagnosed in infancy; 90% are clinically apparent
by 2 years of age. Magnetic resonance imaging is the
tool of choice to confirm the diagnosis of lymphatic
malformations.
In contrast to dealing with infantile hemangiomas,
imaging studies are important in assisting with establish­
ment of an accurate diagnosis and planning of treatment
of vascular malformations. Magnetic resonance imaging,
angiography, and ultrasonography are important diag­
nostic tools, and the particulars of differentiating the
different types of vascular malformations by radiographic
studies have been well described.11
FIGURE 28-3  ■  Examples of vascular malformations. A, Capillary malformation (port-wine stain). B, Venous malformation. C, Lym­
phatic malformation.
A
B
C

770
SECTION III  ADJUNCTIVE SURGERY
cartilage in the area of the injection. In addition, the
deposited steroid causes a white plaque to be visible
through the thin skin covering these structures. The goal
of depot steroid injections is to slow proliferation of the
deep component of the hemangioma. Great care must
be taken with use of the PDL to treat focal or diffuse
compound hemangiomas that have been injected with
steroids as there is a higher risk of skin ulceration. This
is particularly true in the malar area. Recent evidence
suggests a synergistic role between propranolol and
PDL leading to earlier clearance of the superficial
component.
Hemangiomas that are life-threatening or do not
respond to propranolol or steroid therapy can be treated
with other medications.15
Surgical management is integral to the overall treat­
ment algorithm of infantile hemangioma.2 Historical mis­
givings and misconceptions about the operability of
hemangiomas have been supplanted by experience and a
better understanding of these tumors. Surgical planes
exist between hemangiomas and surrounding structures
and can be created between the superficial and deep com­
ponents or within the deep component (Fig. 28-4) of
hemangiomas. Hemangiomas are solid tumors with few
isolated feeding vessels. Therefore, meticulous technique
and the routine use of unipolar and bipolar microneedle
electrocautery devices make dissection virtually bloodless.
Conservatism is critical in resecting facial tissue involved
with hemangioma in children. The use of flaps and grafts
is avoided as much as possible. The goal is to resect suf­
ficient tissue and still be able to achieve primary closure
of the wound. When this is not possible because of size
or location of the tumor, serial excision has proved helpful
as with other benign tumors.18 The author avoids the use
of flaps and grafts in small children except in the most
severe, complicated cases in which additional scars result­
ing from use of sophisticated techniques are justified. To
preserve contour or to set the stage for an additional
resection, subtotal excision of the deep component of a
In addition to observation, during the proliferative
period, treatment may include medical therapy, laser
treatment, surgical excision, or a combination of these
treatments.
Superficial cutaneous hemangiomas may be treated
with a yellow light laser, such as the flashlamp-pumped
pulsed dye laser (PDL; 595-nm wavelength). The goal is
to achieve complete resolution of superficial lesions
thinner than 1.5 mm. With use of the PDL, lightening
and retardation of growth may be accomplished with
thicker lesions in preparation for other treatment modali­
ties. If the lesion is compound, the superficial component
may be treated with the laser first in preparation for
surgical excision of the deep component. The PDL is
very useful in assisting the healing of ulcerating heman­
giomas and preventing further scarring from tissue
destruction while waiting for other interventions.14
Rapidly proliferating hemangiomas that pose a serious
functional or cosmetic concern may be treated with
medical therapy. Before 2008, corticosteroids were the
first line of medical therapy. Since then, propranolol has
become the first drug of choice.15,16 Like corticosteroids,
propranolol seems to be most useful during the prolifera­
tive phase. There is some reason to think, however, that
it may be useful during involution as well. Whereas ste­
roids exerted their effect through blunting of neovascu­
logenesis, propranolol seems to have an effect by
vasoconstriction, inhibiting vasculogenesis and promot­
ing apoptosis.17 Much work needs to be done to deter­
mine the exact role for propranolol in the treatment
algorithm.
Steroid injections of infantile hemangiomas are useful
for small, well-defined, deep hemangiomas when the
treatment might be definitive. Select cases of hemangi­
oma involving the parotid gland, eyelid, and midcheek
are treated by direct injection of a mixture of triamcino­
lone (40 mg/mL) and betamethasone (6 mg/mL). Auricu­
lar and nasal tip hemangiomas are not injected with
steroids because it is associated with weakening of the
FIGURE 28-4  ■  Involuting compound infantile hemangioma before (A) and after (B) surgical excision and pulsed dye laser treatment
of residual superficial component.
A
B

28  MANAGEMENT OF VASCULAR ANOMALIES OF THE FACE
771
in noncontact mode. Surgical excision of hypertrophic
port-wine stains or associated venous malformations is a
useful adjunct in management of selected lesions. Adja­
cent skin flaps, tissue expansion, microvascular tissue
transfer, and other reconstructive techniques are all useful
for replacement of the involved tissues.20,21
Venous Malformations
Venous malformations may be treated with laser photo­
coagulation, sclerotherapy, or surgical resection, depend­
ing on the depth, extent, and location of the lesion (Fig.
28-5). A superficial lesion or the superficial component
of a compound malformation is best treated with Nd:YAG
laser photocoagulation as described before. Laser photo­
coagulation diminishes the vascularity of the overlying
skin or mucosa, which may then be preserved during
surgical resection of the deeper component. The deep
component of the malformation is subsequently carefully
resected because of the risk of bleeding due to extremely
fragile ectatic vessels.
In contrast to hemangiomas, and probably the source
of misgivings about the role of surgery for vascular
abnormalities in general, hemostasis during resection of
venous malformations may be quite challenging. Meticu­
lous dissection and hemostasis with vascular clips, periph­
eral transcutaneous sutures, and topical hemostatic agents
are employed to varying degrees. Preparation for possible
blood transfusions is made preoperatively. Resection
of the cutaneous component of venous malformations is
imperative to prevent recurrence. However, the extent of
resection is tempered by morbidity and the knowledge
that cure is rarely achievable.
Sclerotherapy and embolization are the primary
modalities of treatment of venous malformations. They
are also useful as preoperative and postoperative adjunc­
tive treatment. Sclerotherapy is accomplished by percu­
taneous puncture into the venous malformation with
fluoroscopic guidance. An irritant, such as alcohol or
hemangioma is commonly performed. To minimize the
potential psychological sequelae on a child afflicted with
a hemangioma, every effort is made to obtain the best
possible functional and cosmetic result before the child
reaches school age. The author’s threshold for excision of
nasal tip and periorbital hemangiomas is lower than for
other sites because of the obvious potential for severe
functional and cosmetic impairment.19 Recently, the early
treatment of nasal hemangiomas has been supported by
the best available evidence. Treatment is geared to obtain­
ing the best possible result by the social and developmen­
tal milestones previously described. The superficial
component of compound hemangiomas is treated with
photocoagulation if it cannot be entirely resected together
with the deep portion.
When a hemangioma completes involution, the sur­
geon’s focus is directed toward the treatment of residual
atrophic tissue, telangiectasias, and residual excess subcu­
taneous fibrofatty tissue. Atrophic tissue may be treated
with carbon dioxide or erbium laser skin resurfacing.
Telangiectasias respond well to photocoagulation with
the PDL. Residual subcutaneous fibrofatty tissue is
excised and sculpted to obtain a natural contour.
Capillary Malformations
Laser photocoagulation is the preferred method of treat­
ing capillary and venular malformations (port-wine
stains). Safe treatment parameters are used for initial
PDL treatments to evaluate the clinical response and to
set the stage for further treatments.20 Port-wine stains
are typically treated every 6 weeks to a point of improve­
ment that is acceptable to the patient and surgeon.
Because the underlying vessel abnormalities are not
cured, patients are prepared for the necessity of occa­
sional re-treatment if the port-wine stain darkens during
ensuing years. Photocoagulation of a thickened or “cob­
blestoned” port-wine stain can be performed with a
neodymium:yttrium-aluminum-garnet (Nd:YAG) laser
FIGURE 28-5  ■  Venous malformation of the tongue before (A) and after (B) sclerotherapy and interstitial and transmucosal Nd:YAG
laser treatment.
A
B

772
SECTION III  ADJUNCTIVE SURGERY
require a combined approach. Recurrence after “total”
resection of macrocystic malformations is probably due
to the failure to completely remove infiltrating lymphatic
tissue at the interface of resected tissue and normal-
appearing tissue. Prenatal diagnosis of large cervical lym­
phatic malformations allows appropriate management at
birth, including airway control. OK-432 (a lyophilized
mixture of a low-virulent group A Streptococcus pyogenes
incubated with penicillin G) has been successively used
to treat lymphatic malformations but is not approved for
general use in the United States. OK-432 has been used
extensively in Europe and Japan, with results showing up
to 96% complete response of macrocystic malformations.
Bleomycin has also been used with similar results and is
the sclerosant of choice in the United States. Overall, the
literature continues to report good results with sclero­
therapy or surgery in patients with macrocystic disease
only. Microcystic disease, especially if it is extensive, is
likely to require multiple therapies to keep the disease in
check.11,23
SUMMARY
The correct diagnosis of vascular abnormalities of the
head and neck is the major factor in successful treatment.
Hemangiomas must be differentiated from vascular
malformations because of the therapeutic implications.
Medical therapy, lasers, and surgical excision all have a
place in the management of hemangiomas. As more
information is gained about the pathophysiologic mecha­
nism of vascular abnormalities, the management schema
will continue to evolve.
Acknowledgment
This work was supported in part by The Hemangioma
Treatment Foundation (
org).
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1. Marler J, Mulliken J. Vascular anomalies—classification, diagnosis
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2. Hochman M, Adams D, Reeves T. Current knowledge and man­
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3. Waner M, North P, Scherer KA, et al. The non-random distribu­
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4. William EF, Stanislaw P, Dupree M. Hemangiomas in infants and
children: an algorithm for intervention. Arch Facial Plast Surg
2000;2:103.
5. Krol A, MacArthur CJ. Congenital hemangiomas. Arch Facial Plast
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6. Powell TG, West CR, Pharoah PO, et al. Epidemiology of straw­
berry hemangioma in low birthweight infants. Br J Dermatol
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7. Amir J, Mezker A, Krikler R, Reisner SH. Strawberry hemangioma
in preterm infants. Pediatr Dermatol 1986;3:331.
8. Phung TL, Hochman M. Pathogenesis of infantile hemangiomas.
Facial Plast Surg 2012;28:554.
9. Hochman M, Adams D, Reeves T. Current knowledge and man­
agement of vascular anomalies, II. Malformations. Arch Facial Plast
Surg 2011;13:425.
10. Smollen BR, Rosen S. Port wine stains: a disease of altered neural
modulation of blood vessels? Arch Dermatol 1986;122:177.
bleomycin, is injected into the malformation to promote
clotting, inflammation, and eventually fibrosis of the
lesion. Sclerotherapy may require repeated treatments
to maintain control of the malformation and usually
is not considered curative as the lesion may eventually
re-expand. Sclerosing agents, such as absolute alcohol,
sodium tetradecyl, sodium morrhuate, polidocanol, scle­
rosant foam, and ethanolamine, have been used to treat
venous malformations. The amount of sclerosing agent
injected depends on the agent employed and the extent
of the venous malformation. Treatments are spaced at
4- to 6-week intervals. Because veins in the head and neck
region lack valves, injection of sclerosing agents into mal­
formations located in the superior and central third of
the face may risk cavernous sinus thrombosis and should
be done by an interventional radiologist under image
guidance.22
Arteriovenous Malformations
Treatment with lasers, steroids, or irradiation has not
been effective in the management of arteriovenous mal­
formations. Complete surgical excision is difficult and
accompanied by morbidity. If the malformation is resect­
able, combined treatment is appropriate and consists of
highly selective embolization followed by resection
within the following 24 to 48 hours. The natural progres­
sion of arteriovenous malformations is inexorable growth
over time. Therefore, the main goal of surgery is com­
plete eradication with surgical margins free of involve­
ment to prevent recurrence. The sacrifice of structures
involved by an arteriovenous malformation (e.g., man­
dible, facial nerve, muscles of mastication) may be a nec­
essary part of the treatment. The surgical and anesthetic
team must be prepared to replace blood loss with blood
products, using Cell Saver technology in the more
difficult cases. Resection and reconstruction of these and
other related malformations are more akin to traditional
head and neck cancer procedures than those for resection
of infantile hemangiomas. Because of the associated mor­
bidities and low likelihood of cure, interventional radiol­
ogy procedures are the mainstay of treatment for most.9
Research and advances in medical therapy are likely to be
the source for curative treatment in the future for these
lesions.
Lymphatic Malformations
Surgical excision has been the preferred treatment modal­
ity for lymphatic malformations that are focal and dis­
crete. However, interventional therapy is supplanting this
approach because of the lower morbidity. Because of the
difficulty of distinguishing involved tissue from normal
tissue, complete resection of lymphatic malformations
with microcystic infiltrating features is not always pos­
sible. Malformations with well-defined macrocystic fea­
tures are more likely to be completely resected. Superficial
mucosal lymphatic malformations may be treated with a
carbon dioxide laser using 20-W continuous mode until
sufficient depth of destruction is obtained. The wound is
then left to heal by secondary intention. Extensive lesions
involving both mucosa and underlying soft tissue may

28  MANAGEMENT OF VASCULAR ANOMALIES OF THE FACE
773
18. Kulbersh J, Hochman M. Serial excision of facial hemangiomas.
Arch Facial Plast Surg 2011;13:199.
19. Hochman M, Mascareno A. Management of nasal hemangiomas.
Arch Facial Plast Surg 2005;7:295.
20. Kelly KM, Choi B, McFarlane S. Distribution and analysis of treat­
ment for port wine stains. Arch Facial Plast Surg 2005;7:287.
21. Ortiz A, Nelson JS. Port-wine stain laser treatment and novel
approaches. Facial Plast Surg 2012;28:611.
22. Richter G, Braswell L. Management of venous malformations.
Facial Plast Surg 2012;28:603.
23. Banieghbal B, Davies MR. Guidelines for the successful treatment
of lymphangioma with OK-432. Eur J Pediatr Surg 2003;13:103.
11. Balakrishnan K, Perkins J. Management of head and neck lym­
phatic malformations. Facial Plast Surg 2012;28:596.
12. Lande RG, Crawford PM, Ramsey B. Psychosocial impact of vas­
cular birthmarks. Facial Plast Surg Clin North Am 2001;9:561.
13. Williams EF, Hochman M, Rodgers BJ, et al. A psychological
profile of children and families afflicted with hemangiomas. Arch
Facial Plast Surg 2003;5:220.
14. Thomas RT, Hornug R, Manning S, et al. Hemangiomas of
infancy: treatment of ulceration. Arch Facial Plast Surg 2005;7:312.
15. Blei F: Medical management of vascular anomalies. Facial Plast
Surg 2012;28:575.
16. Drolet BA, Frommelt PC, Charin K, et al. Initiation and use of
propranolol for infantile hemangiomas: report of a consensus con­
ference. Pediatrics 2013;131:128.
17. Storch CH, Hoeger PH. Propranolol for infantile haemangiomas:
insights into the molecular mechanisms of action. Br J Dermatol
2010;163:269.

775
INDEX
A
A-T repair, 158-160, 159f
lateral forehead defects, 579, 579f
Abbe (Sabattini) flaps, 504-511, 505f-509f
Abnormal scarring, 701
Accutane, 728-731
Acetylcholine, 14
Acne, 728-731
scar, 731, 747
Acrosyringium, 10
Adenovirus-mediated gene therapy with
VEGF (Ad-VEGF), 26
Adson-Brown forceps, 43
Adson forceps, 43
Advancement flaps, 77t, 84-93, 156-186
for alopecia, 688f
applications of, 156, 157t, 164-168
bipedicle. see Bipedicle advancement
flaps
bipedicle vestibular skin, 417-420, 419f,
442f
case reports on, 168-185
cervical facial rotation, 375
cheek, 89f-90f, 378, 378f-379f, 448f-449f,
454f-455f, 470f-472f
for cheek reconstruction, 686f-687f
design, 84-93, 88f
for eyebrow reconstruction, 582-583,
585f-586f
for forehead reconstruction. see also
Forehead reconstruction
V-Y subcutaneous tissue pedicled,
566-567, 569f
island, 84
labial mucosal, 483f
for lip reconstruction, 470f-472f, 489-491,
490f-491f
melolabial. see Melolabial advancement
flaps
musculocutaneous, 397f
postauricular island, 592, 594-601, 601f,
605-607
rotation. see Rotation advancement flaps
for scalp reconstruction, 647-651, 655,
658f-659f, 683f-684f
skin grafts with. see Skin grafts
subcutaneous tissue pedicle island. see
Subcutaneous tissue pedicle island
advancement flaps
types of, 156, 157t, 377
unipedicle, 77t, 84-89, 88f, 91f, 156-158,
157f
cheek defects, 164-165, 165f, 167,
172-173, 175f
lip defects, 168, 178, 180f
melolabial, 233, 233f, 239-241, 242f
V-Y flap. see V-Y advancement flaps
V-Y subcutaneous tissue pedicled,
434f-435f, 460f-461f, 473f-474f
vermilion, 487, 488f
vermilion reconstruction, 483-484,
483f-484f
Aesthetic borders
defects extending across, 368
facial, 73, 75f-76f
Aesthetic regions, facial, 73, 75f-76f,
415-417, 712-715
Aesthetic units, 73, 75f-76f
facial, 712-715
Alae. see Nasal alae.
Alar defect, full-thickness skin graft, 355f
Alar facial sulcus, 415, 445f-446f
in melolabial interpolated pedicle flaps,
235, 236f, 238, 239f
obliteration of, 712, 713f-714f
preservation of, 235-238, 439-441, 442f
skin defect of, 448f-449f, 466f
Alar groove, 415-417
construction of, 450-451
skin defect of, 434f-435f, 441f, 451f-453f
Albinism, 5
Alcohol consumption, 703-704
Allergic reactions, topical, 700, 701f
Allopurinol, 25
Alopecia, complicating forehead
reconstruction, 584-586
Anagen, 9, 9f
Analgesics, 66
Anatomy, skin, 3-13, 4f
Anchoring fibrils, 6-7, 6f
Anesthesia, 67-68
in dermabrasion, 197-199
in eyelid surgery, 391-392
see also Local anesthesia, eyelid
reconstruction
Anesthetic agents, vasoactive properties of, 24
Angel’s kiss, 768
Angiogenesis, 17-18
steps in, 20f. see also Neovascularization
Angiogenic growth factors, 26
Angiolymphoid hyperplasia, of auricle,
625f-626f
Angiosarcoma, scalp, 357f
Angle of needle failure, 62t
Angular artery, 269-270, 391f, 418f, 428,
530
alar branch of, 433-436
perforating branches of, 235-236, 439-441
Anisotropy, 31
Anotia, 631
Anterior ethmoidal artery, 418f
Anterior ethmoidal nerve, external nasal
branch of, 68-69
Anterior lamella, 391
flaps for eyelid defect, 397f
Antibiotics
preoperative, in tissue expansion, 694
prophylactic
in local cutaneous flaps, 700
skin grafting, 340
Anticoagulant medication, 66
effect in local flaps, 699f
Antiemetic suppositories, 66
Antiviral therapy, 701, 745, 747
Apocrine sweat glands, 4f, 7f, 10
L-Arginine, 25-26
Arnold’s nerve, 589, 630
Arrector pili muscle, 4f, 7f, 8
Arterial blood supply, to auricle, 588-589,
590f
Arterial cutaneous flap, 15-16, 17f
Arterial insufficiency, in flaps, 705-707
Arteries
angular, 418f, 428
ethmoidal. see Ethmoidal artery
palatine, 418f
supratrochlear, 453
Arterioles, 12, 14
critical closing pressure, 16
Arteriovenous malformations, 769
treatment for, 772
Atypical junctional melanocytic hyperplasia
(AJMH), cheek, 142, 369, 370f,
375-380, 376f, 378f, 381f
see also Lentigo maligna, cheek
Auricle
anatomy of, 588-589, 589f, 630, 631f
architecture of, 591, 591f
arterial blood supply of, 588-589, 590f
basal cell carcinoma of, 344f
cartilaginous framework of, 588
congenital malformations of, 593f-594f,
631-634
classification of, 631-632
otologic surgery of, 633
preoperative considerations for, 630,
638f-639f
reconstruction of, 630-640
surgical planning and treatment for,
633-634, 635f-637f
treatment for, 633t
use of implants for, 633
embryology of, 588-589, 630, 631f
innervation of, 589, 591f, 630
lymphatic drainage of, 588-589
prosthetic replacement of, 630
skin posterior to, 352f
venous drainage of, 588-589
Auricular cartilage, 423f, 425f, 427f, 442f,
588
anatomy of, 589f
framework graft, 423f, 443f-446f,
448f-449f, 454f-455f, 460f-461f,
468f-474f, 477f-478f
grafts, for nasal reconstruction, 419f, 429,
430f, 460f-461f, 466f, 468f-469f
rim graft, 441f, 451f-453f, 462f-467f
skin grafting on, 339-340, 344f
Auricular chondrocutaneous composite flaps,
592, 602f, 607-608, 607f-608f
helical root defects, 595f-597f, 601,
603f-605f
Auricular composite grafts, 358-362
donor sites for, 359f
indications for, 358-359
for nose reconstruction, 359, 362f-366f
Page numbers followed by “f” indicate figures, “t” indicate tables, and “b” indicate boxes.

776
INDEX
Auricular defects, 591-592, 593f-594f
large, 615-622
Auricular prosthesis, 627f-629f
Auricular reconstruction, 588-629
anatomic landmarks for, 588
by anatomic location, 594-615
cartilage framework with soft-tissue
coverage in, 592-594
of central and inferior auricular defect,
612f-613f
of conchal bowl and root of helix,
594-601
of congenital deformities, 632-634,
635f-639f
complications in, 634
goal of, 588-629
helical defect, 595f-596f
of inferior third, 613-615, 616f-617f
of large defects, 592-594, 608, 615-622
of middle third, 608-613, 611f-612f,
614f-615f
of preauricular area, 615
principles of, 591-594
skin grafts for, 591-592, 609f-610f,
616f-619f
conchal defects, 594
superior third defects, 601-608
squamous cell carcinoma, 597f
of superior auricle, 606f
tissue expansion in, 677f, 689f, 693, 693f
W-plasty in, 605f
Auricular skin, medial, 588
Auriculectomy, 622, 627f-629f
Auriculotemporal nerve, 530-531, 589,
591f
Autogenous cartilage framework, 610f
Autogenous tarsoconjunctival graft,
404f-405f
Axial pattern (arterial cutaneous) flaps, 15,
75, 77f
ischemia complicating, 704, 706f
B
β6 integrins, 32
Basal cell carcinoma
of auricle, 344f, 614f-617f
of cheek, 123, 126f, 532, 559f
bilobe flap for, 193-197, 196f, 199
flap necrosis in, 715-717, 717f
melolabial advancement flaps for,
238-239, 240f-242f, 245, 260, 262f,
264-266, 264f-265f
melolabial transposition flaps for,
238-239, 245, 248f, 249-252, 252f,
254f
transposition flaps for, 145f-146f,
146-147, 149, 150f, 369-372, 372f
of chin, 183-185, 185f
of eyelids, 399f, 408f
of forehead, 168-169, 168f, 171, 172f
full thickness skin graft for excised, 340f
of lip, 127, 128f, 183
advancement flaps for, 180-183, 180f,
182f-184f
melolabial flaps for, 249-252, 254f,
265f-266f, 266
of malar eminence, rhombic flap for,
225-226, 229f
nasal
bilobe flaps for, 197, 201f-209f,
205-206, 209
melolabial interpolated flaps for, 256,
256f
transposition flap for, 142, 144f
of neck, 123, 126f
of oral commissure, rhombic flap for, 225,
226f
of scalp, 119, 119f, 648f
of shoulder, 127
of temple, 119-120, 120f-121f
advancement flap for, 171-172, 173f
skin graft with local flap, 377, 377f
skin grafts for, 345f
transposition flap for, 142, 143f
Basal cells (keratinocytes), 5, 6f
healing wounds, 41
Bathtub deformity, in tissue expansion, 681,
685f
Bending moment, 62t
Benzodiazepines, 66
Bernard-von Burow opposing cheek
advancement flaps (Bernard
cheiloplasty), 518-519, 519f
Webster modification of, 519,
520f-521f
Bilateral advancement flaps, 89, 91f, 158
for chin defects, 183-185, 185f-186f
for cutaneous lip defects, 167-168
for eyebrow defects, 582-583, 585f
for forehead defects, 164, 171, 171f-172f,
572-573, 574f-576f
for full-thickness lip defects
stair-step design, 498, 498f
using adjacent cheek, 518-519
see also H-plasty
Bilateral rhombic flaps, 220-221,
221f-222f
Bilobe flaps, 140-142, 187-209, 438f, 441f
advantage of, 187
applications of, 141, 189-192
biomechanics of, 187, 188f
case reports on, 193-209
for cheek reconstruction. see under Cheek
reconstruction
design, 82, 82f, 140-141, 187-188, 189f
disadvantages of, 141-142, 188
for nose reconstruction, 100-102,
105f-106f
variations of, 141, 188, 189f
Biomechanics
of bilobe flaps, 187, 188f
of cutaneous tissue, 30-32
of skin flaps, 30-40
Bipedicle advancement flaps, 77t, 93,
162-164, 377
for forehead reconstruction, 571, 572f
for vestibular skin, 417-420, 419f, 442f
Bite injuries, 732f
Blausius, Ernst, 268
Bleeding
complicating local flaps, 697-698
complicating tissue expansion, 695
Bleomycin, 772
Blood flow
flap, 16
delay phenomenon, 23, 23t
effect of nerve section, 18
effects of inflammation/prostaglandins,
19-21, 25
return (reperfusion), 21
skin, 14, 339
during intraoperative tissue expansion,
694
regulation, 15f
wound tension and, 33-34, 36f
Blood substitutes, low viscosity, 24
Blood supply. see Vascular supply.
Blood vessels, 674
expanded skin demonstrating vascular
proliferation, 674f
Bolster dressings, 49, 339, 343f
in cheek skin grafts, 552
in contoured melolabial interpolated flaps,
450-451
in full-thickness skin grafts, 355, 356f
over skin graft, 457f
in transposition flap, 433f
Bone, skin grafting over exposed, 339-340,
645-647, 661f
Bone conduction hearing aid, 632
Bone grafts
in hospitalization, 70
for mandibular reconstruction, 689,
690f-691f
for nasal reconstruction, 304-306, 305f,
307f-309f, 429
recommended medications for, 67t
Bowen’s disease, 9
Bradykinin, 14
Branca, Antonio, 268
Breaking strength, 52t
Broad-based flaps, undermining of, 35, 38f
Brown dermatome, 357-358, 358f
Brows. see Eyebrows.
Buccal unit, skin defects of, 551f
Buck two-flap technique, 513-515, 515f
Bupivacaine, 42, 69
Burn injury
scalp, 118-119, 118f
scar management for, 734, 736f
Burow triangles, 540f
in advancement flaps, 88-89, 158, 159f
in Bernard-von Burow opposing cheek
advancement flap, 518-519, 519f
in interpolated melolabial flaps, 237
inverted, 89, 91f
in lip reconstruction, 97-98
in medial cheek repair, 97
in rotation flaps, 108, 109f
in T-plasty, 160
C
Calcitonin gene-related peptide (CGRP), 24,
33
Calcium channel blockers, 24
Capillaries, healing wounds, 41
Capillarity, of suture material, 52t
Capillary bed, critical closing pressure of,
19f
Capillary malformations, 768, 769f
treatment of, 771
Capsule, around tissue expanders, 674-675,
675f
Capsulopalpebral fascia, 388, 390f, 391
Carbon dioxide laser, for lymphatic
malformations, 772
Carotid artery, 641-644
Carpue, J.C., 268
Cartilage
auricular, 423f, 425f, 427f, 442f
lower lateral, 429f
septal, 423f-425f, 427f
skin grafting on exposed, 339-340, 344f
Cartilage flaps, paramedian forehead flaps,
271f-272f, 278f-281f, 283f-284f,
295f-299f, 304-306
Cartilage grafts, 420f, 430f, 468f-469f
for auricular reconstruction, 423f, 427f,
430f, 592-594, 613, 619f
composite. see Chondrocutaneous
composite grafts
for nasal reconstruction, 420f, 423f, 427f,
429, 430f
on bipedicle advancement flaps,
162-164
Basal cell carcinoma (Continued)

INDEX
777
on melolabial flaps, 235, 236f, 254f,
256, 257f-260f
preoperative preparation for, 67
recommended medications for, 67t
septal, 427f, 460f-461f, 477f-478f
Castroviejo needle driver, 44, 45f
Catagen, 9, 9f
Catecholamines, 18
see also Epinephrine; Norepinephrine
Cell Saver technology, for arteriovenous
malformations, 772
Cephalexin, 67t
Ceruminous glands, 10
Cervical facial flaps, skin grafts with,
374-377, 375f-377f
Cervical lymph nodes, 630
Cervicofacial rotation advancement flaps,
113, 151-153, 153f, 375
anesthesia for, 116
for buccal cheek defects, 552, 553f
case reports on, 121-123, 124f
for cheek defects extending to nose, 560f
fibrin sealants for, 62-63
for lateral cheek defects, 552, 553f
for medial cheek defects, 543, 547f-548f
surgical technique for, 117
Chantix. see Varenicline.
Cheek
advancement flaps for, 164-167, 165f-
166f, 448f-449f, 454f-455f, 470f-472f
case reports on, 172-173, 175f-178f
aesthetic units of, 73, 75f-76f, 530-531,
531f
anatomy of, 530-531, 531f
basal cell carcinoma of, 532, 559f
contour defects of, 558-560
cutaneous defects of, 532
defects extending to eyelids, 557
defects extending to neck, 560, 561f
defects extending to nose, 557-558,
559f-560f
defects extending to periorbital region,
538f, 546f, 557
elliptical (fusiform) excisions of, 532f, 557
lymphatic drainage of, 530
medial cheek defects, 368, 454f-455f,
460f-461f, 473f-474f
melanoma in situ of. see Melanoma in situ,
cheek
melanoma of, 715, 716f, 721f-724f
retaining ligaments of, 530
scar revision of, 448f-450f
sensory nerves of, 530-531
skin defect of, 533f-536f, 544f
vascular supply of, 530
Cheek advancement flaps
for cheek defects extending to nose,
557-558, 560f
for full-thickness lip repair, 518-521,
519f-521f
for lateral cheek defects, 552, 554f
for medial cheek defects, 534, 534f
rotation, dynamics of, 537f
unipedicle, 537f
V-Y subcutaneous tissue pedicle island,
534f
Cheek reconstruction, 530-562
bilobe flaps for, 189-190, 189f, 550-552
case reports on, 196f, 197, 198f-200f
design of, 188
for buccal defects, 550-552
cheek advancement flaps for. see Cheek
advancement flaps
for contour defects, 558-560
Dufourmental flaps for, 550
flap planning for, 531-532
for lateral (mandibular) defects, 97, 102f,
552
for medial defects, 95-97, 98f, 532-550
melolabial advancement flaps for, 233,
233f
case reports on, 238-239, 240f-242f
subcutaneous tissue pedicle island,
260-264, 261f-262f
melolabial transposition flaps for, 232f,
241-249, 243f-248f
for multiregional defects, 557-560
pivotal advancement. see Pivotal
advancement cheek flaps
primary closure. see Primary wound
closure
rhombic flaps for, 225, 557
rotation flap for, 110-112
case reports on, 113, 121-123, 122f,
124f-126f
of lateral defects, 555f-556f
of medial defects, 534-540, 537f
skin grafts for, 550
with advancement flaps, 378-379, 378f
with cervical facial flaps, 372-375,
375f-376f
with pivotal flaps, 368
for small and medium sized defects,
534f-537f
subcutaneous adipose flaps for, 558-560
subcutaneous tissue pedicle island
advancement flaps (V-Y) for. see
Subcutaneous tissue pedicle island
advancement flaps (V-Y)
tissue expansion in, 674f, 686f-687f, 689f,
692f-693f
transposition flaps for, 133, 134f, 146-147,
146f-147f, 149, 150f
of buccal defects, 550
case reports on, 142-146, 145f
of medial defects, 534-540, 536f
of zygomatic defects, 557, 558f
for zygomatic defects, 552-557
Children, scar revision in, 728
Chin
advancement flaps for, 183-185, 185f
rotation flap for, 113
case report on, 123, 126f
transposition flaps for, 153-155, 153f-154f
lip reconstruction, 489, 490f
Chondrocutaneous composite flaps,
auricular. see Auricular
chondrocutaneous composite flaps.
Chondrocutaneous composite grafts,
358-362
see also Auricular composite grafts
Chromic collagen sutures, 55t
Chromic gut sutures, 51f, 52, 55t
Circular skin defects
bilobe flaps for, 141, 188
modified rhombic flaps for, 216,
219f-220f, 221-225, 222f
note flap for, 135, 135f
T-plasty for, 161f-162f
triple rhombic flap technique, 221
Z-plasty for, 138-140, 141f
Cleft lip
nasal deformities, columella lengthening,
161-162, 163f
Z-plasty for scar revision of, 331, 332f
Cleft palate, incomplete, Z-plasty repair of,
337f, 338
CO2 laser, in scar revision, 745-746
Coefficient of friction, 49-52, 52t
of suture materials, 51f
Collagen, 10
biomechanical properties of, 30, 32
deposition in healing wounds, 42
dermal, 10
sutures, 52-53, 53t, 55t
synthesis of, 727-728
during tissue expansion, 673
Columella, 417
as aesthetic unit, 73
framework reconstruction of, 429
reconstruction of, 459
septal composite chondromucosal pivotal
flap for, 423-426, 425f
V-Y advancement flap for lengthening,
161-162, 163f
Commissureplasty, 515-518, 517f-518f
Complications of local flaps, 697-726
case reports on, 715-725
inherent to surgery, 697-703
medical conditions in, 703-704
surgical technique and flap design in,
704-715
Composite flaps, 107
Composite grafts, 339-367, 360f-361f
auricular. see Auricular composite grafts
in auricular reconstruction, 592, 593f-594f
chondrocutaneous, 358-362
eyelid, 367, 409-410
indications for, 359, 364f
lip, 509
other types of, 362-367
perioperative medications for, 359
recommended medications for, 67t
simple tarsal, 409-410
technique, 359-362
Compression therapy, for hypertrophic scars,
750
Conchal bowl defects, 594
Conchal cymba, 429f
Congenital auricular malformation. see
Auricle, congenital malformations.
Congenital hemangiomas, 767
Conjunctiva, 387, 389f-390f
Contour defects, of cheek, 558-560
Contouring, flap, 752-755, 753f, 758f,
760f-764f
in interpolated paramedian forehead flaps,
274f-275f, 278f-283f, 289f-290f,
292f-293f, 295f-299f, 302f-303f,
303-304, 457-459
in nasal reconstruction, 450-451
refinement of, 476
Contractures, Z-plasty release, 734, 736f
Controlled tissue expansion, 660-663
Cornea
complications of eyelid surgery, 399
protection during eyelid surgery, 392
Corrugator supercilii muscle, paramedian
forehead flaps, 269f, 291
Corticosteroids (glucocorticoids), 25
complication from, 703f
composite grafts, 359
in hypertrophic scars and keloids, 701
in scar revision, 748
Costal cartilage framework, 610f, 612f-613f,
620f-621f
Costal cartilage grafts, in auricular
reconstruction, for congenital
deformities, 633, 634f-635f
Cotton suture, 55, 55t
Coumadin, 66, 66t
Cranial/spinal nerves, of auricle, 589, 591f
Creep
biological, 71, 671-672
mechanical, 11, 32, 71, 671
application technique, 44, 44f
Cartilage grafts (Continued)
Cheek reconstruction (Continued)

778
INDEX
Cross-lip flaps
mucosal, 484-485, 485f-486f
transoral, 504-515
Cryptotia, 632
Cup ear deformities, 632
Cupid’s bow, reconstruction of, 178-179,
181f, 733, 733f, 742f
Cutaneous defects, 703f, 708f-709f
Cutaneous hemangiomas, 767
Cutaneous malignant neoplasms, scalp and,
641
Cuticle, 7f-8f, 8-9
Cutler-Beard lid flap, 410-413, 412f
Cyanoacrylate tissue adhesives, 63
Cystic hygromas (lymphatic malformations),
769
Cytokines, 24
D
Dacron sutures, 57t
Dead space
elimination of, in melolabial transposition
flap, 252-256
reduction of, 44-45
subcutaneous tissue pedicle island
advancement flaps, 167
Defects
analysis of, 93-94
preferred flaps, 94-107
primary, 71, 72f
repair options for, 94t
secondary, 71, 72f
size, flap selection, 94
Delay, flap, 23-24, 72-73
melolabial flaps for lip repair, 522,
522f-523f
temporoparietal scalp flaps, 524-525, 526f
Deltopectoral chest flap, lip reconstruction,
526-528
Dendrocytes, dermal, 11-12
Dentures, mouth opening size and, 503f,
504
Depilation
melolabial interpolated flaps, 447-450
paramedian forehead flaps, 273, 277f
Depressed scars/contours, elevation
techniques for, 752-755, 753f, 760f-764f
Dermabrasion, 732f, 740f-746f, 743-745
bilobe nasal flaps, 203f, 205, 436
composite grafts, 362
rotation flaps, 117-118
skin care after, 49
skin grafts and, 339, 743, 743f-744f
technique, 197-199
timing for, 728, 743
viral infections complicating, 701, 701f
vs laser resurfacing, 745
Dermal-epidermal junction (DEJ), 6-7, 6f
hair follicles, 7-9, 8f
Dermal fat grafts
delayed placement under skin grafts,
343-346, 349f
at time of skin graft placement, 343-346
Dermal fillers, 751-752
Dermatomes
Brown, 357-358, 358f
Padgett, 358, 358f
Dermis, 3, 4f, 10-13, 339, 345f
cellular component of, 11-12
changes during expansion, 673
follicular epithelium, 9
papillary, 10-11, 673
response to tissue expansion, 33, 35f
reticular, 10-11, 673
Descending palatine artery, 418f
Design, flap, 34-35
advancement flaps, 84-93
complications of poor, 704-715, 707f,
720-725
facial aesthetic regions and, 73
hinge flaps, 93
pivotal flaps, 77-84
selection of, 94
Dexon sutures, 56t
Diabetes mellitus, 532
Diazepam, 67t
Dieffenbach, Johann Friedrich, 268
Dimethyl sulfoxide, topical, 24
Direct cutaneous arteries. see Septocutaneous
arteries.
Direct mechanotransduction, 32-33
Direct vasodilators, 24
Dissection
flap, 704
soft tissue, 43, 44f
Distant flaps, 73-75
for lip reconstruction, 526-528
Dog bite, injuries from, 732f
Dog ear. see Standing cutaneous deformities
(SCDs).
Dorsal nasal artery, 269-270, 269f, 391f
Dorsal nasal flaps, 113-115, 114f, 436, 437f
modified (dorsal heminasal), 115, 115f,
436, 437f
with reduction rhinoplasty, 115, 116f
Double flap repair, lip defects, 513-515,
515f
Drains, surgical, 697
Drapes, surgical, 68
Dressings, postoperative, 49
skin graft donor sites, 358
skin grafts, 339, 343f, 355, 357f
Dry eyes, 387
Dufourmental flaps, 136-137, 137f, 213
case reports on, 221-225, 224f-226f, 228f
for cheek reconstruction, 550
design, 213, 217f
E
Ear
bilobe flap, 190
external. see Auricle
protruding, 632
squamous cell carcinoma of, 561f
Z-plasty for scar revision on, 327, 329f,
331, 334f
Earlobe
cleft, Z-plasty correction of, 331, 334f
reconstruction of, 619f
Eccrine sweat glands, 10
Edema, after forehead reconstruction, 586
Efferent nerves, in dermis, 12f, 13
Ehlers-Danlos syndrome, 3
Elastic fibers, 10-11
biomechanical properties, 30
Elasticity
skin, 31-32
of suture material, 49-52, 52t
Elastin, 10-11
Elderly
dorsal nasal flaps for, 436
females, full-thickness skin grafts, 346,
349f
lower eyelid distortion, 711, 712f, 724f
lower lip defects, 183, 184f
nasal cutaneous flaps for, 430, 431f
primary closure of nasal defects of, 430
skin graft appearance, 339, 342f
Electrocardiogram, 66
Electronic cigarette (E-cigarette), 26
Elliptical (fusiform) excisions
cheek, 532f, 557
for ice pick acne scars, 747, 748f
for lip tumors, 488-489, 489f
periorbital region, 393f
S-shaped, 394, 395f
for scar revision, 731
Embolization, for venous malformations,
771-772
Epidermal appendages, 3, 7-10, 11f
Epidermis, 3-6, 339, 345f
basal layer of, 3-5, 5f, 672-673
basement membrane zone of, 6-7, 6f
changes during expansion, 672-673, 672f
cornified layer, 3-5, 5f
follicular dermal extension, 9
granular layer, 3-5, 5f
spinous layer, 3-5, 5f
during tissue expansion, 33
wound healing, 41
Epinephrine, 14
avoidance during tissue expansion,
677-678
local anesthesia, 42, 68-69
Epiphora, 387
Estlander flaps, 511-513, 511f-514f
Ethibond sutures, 55-56, 57t
Ethilon sutures, 57t
Ethmoidal artery, 418f
Eversion, skin edge, 43-45, 45f
Excisions
elliptical. see Elliptical (fusiform) excisions
orientation of, 71, 74f
of scar, 731-732, 749
serial, 731, 731f
skin punch, 731, 747
Expansion of tissue. see Tissue expansion.
Exposure keratopathy, 387
Extensibility, skin. see Skin extensibility.
Extracellular dermal matrix, 10
Eye(s)
anterior segment, 387
dry, 387
Eyebrow reconstruction, scalp, strip grafts,
366f
Eyebrows, 565f
alopecia and ingrown hairs, 584-586
composite grafts, 366f-367f, 367
displacement of
primary repair of forehead defects,
566-567
scar revision in, 169-170, 170f
H-plasty repair of defects, 171, 172f,
582-583
lift procedure for, 564
paralytic ptosis of, 564
reconstruction of, 582-583
Eyelid defect, anterior lamella flaps, 397f
Eyelid reconstruction, 387-414
advancement flaps, 167
anesthesia of, 391-392
autogenous tarsoconjunctival graft,
404f-405f
canalicular, 413-414, 413f
composite grafts, 367, 409-410, 411f-412f
Cutler-Beard flap for, 410-413, 412f
full-thickness
algorithm for, 392t
defects of, primary closure of, 394-399
Hughes tarsoconjunctival flap for,
403-407, 406f, 408f
local skin flaps for, 394, 395f
objectives of, 392
postoperative care of, 391
primary repair of, 394-399
semicircular flap for, 399-402

INDEX
779
skin grafts, 350
tarsal rotation flaps for, 409f
tarsal transposition flap for, 407-409, 410f
tarsoconjunctival flap for, 402-403
Z-plasty for scar revision, 324, 325f, 327,
330f
Eyelid repair, 102-107
Eyelids
anterior and posterior lamellae, 391
cheek defects extending to, 538f, 543f,
546f, 557
complications of local flaps, 699-700,
699f, 708f-709f, 723f
distortion/retraction, 350, 711, 712f, 724f
medial cheek flaps, 534-540, 538f-539f
skin grafts with local flaps, 369
full-thickness defect of, 398f
measurements of, 388
orientation of elliptical excisions, 393f
physiology, 387-388
protractor of, 388
relaxed skin tension lines of, 392-394,
393f
rotation flap, 121, 123f
and simple tarsal composite grafts,
409-410
surgical anatomy of, 388-391, 389f-390f
temporary suspension suture, 350
vascular supply of, 391, 391f
zygomatic cheek flaps, 557
F
Face
aesthetic regions of, 73, 75f-76f, 415-417
distortion by adjacent flaps, 711-712, 712f
tissue expansion in, 671-696, 674f,
677f-681f, 686f-689f, 692f-693f
vascular anomalies of, 767-773
Facial artery, 391, 391f, 530
Facial expression, muscles of, 481, 530
innervation of, 530-531
orbicularis oris attachment, 481
Facial (seventh cranial) nerve, 530-531
parotid gland area, 117
surgical injury of, 698
temporal branch, 557, 563, 564f, 630,
641
tissue expansion and, 681
Facioplasty garments, 49
Fasciocutaneous flaps, vascular supply, 17f
Fat
autologous, as a filler, 750-751
subcutaneous, 345f
Fat cells, changes during tissue expansion,
673-674, 673f
Fat grafts
flap contouring, 750-751
see also Dermal fat grafts
Fibrillin, 10-11
Fibrin glues, 62, 63f
Fibrin sealants, 61-63, 63f
Fibroblast growth factor (FGF), 22f
basic (bFGF), 24
Fibroblasts, 11, 339
wound healing, 41-42
Fifths, vertical facial, 415
Filamentous glycoproteins, 11
Fillers, dermal, 751-752
Flap design, 34-35, 188
Flaps
classification and design, 71-107
skin
impaired, 26
tissue engineering in, 26
Floseal, 62
Fluid absorption, 52t
Fluosol-DA, 24
Follicular papilla, 7f-9f, 8-9
Forceps, tissue-grasping, 43
Fordyce spots, 10
Forehead
aesthetic units of, 73, 75f-76f, 565-566,
565f
vertical scar orientation of, 565
anatomy of, 563-564
bilateral advancement flaps, 96f-97f
cutaneous defects of, 567f, 583
expansion of, 306-309
innervation of, 563, 564f
lateral reconstruction of, 577-582,
581f
midline reconstruction of, 566-567
paramedian reconstruction of, 570-576
skin defect of, 568f
tissue expansion in, 678f-680f, 681-685,
686f-687f
tumor, excision of, 572f
vascular anatomy of, 269-270, 269f-270f,
563
vertical scar orientation, 94-95, 96f, 164,
169-170
Forehead flaps, 268-270
for forehead reconstruction, 565
lip reconstruction, 526-528
median, 268
paramedian, 423f, 427f, 453-455,
454f-455f, 462f-465f, 470f-478f
supratrochlear artery, 453
Forehead reconstruction, 563-587
advancement flaps for, 164, 566
case reports on, 168-185, 168f-173f
lateral region, 577-579, 579f
paramedian region, 566-567, 567f,
569f
complications of, 583-586
flaps for, 94-95, 96f-97f, 566-582
functional and aesthetic considerations of,
564-565
lateral defects, 577-582, 578f, 580f
local anesthesia for, 565
midline defects, 566-567, 567f-568f
paramedian defects, 570-576,
571f-577f
primary repair with. see Primary wound
closure, forehead defects
reconstructive principles of, 565-566
rotation flaps for, 113, 566
case report on, 119-121, 120f-121f
lateral region, 579-580
midline region, 567, 570f
surgical technique for, 117
skin grafts for, 565-566, 583, 587f
transposition flaps for, 566
lateral region, 580-582, 582f-584f
Z-plasty for scar revision, 324, 325f, 327,
330f
Free flaps, 73-75
Free radicals, 21, 22f
experimental interventions, 25
Friction, suture materials, 49-52, 51f
Frontalis muscle, 563-564, 641
paramedian forehead flap, 269f, 270,
287f-288f, 291-293, 300f
Frost suture, 350
Fugimori and Stranc island flap, full-
thickness lip repair, 524
Full-thickness skin graft, 608-613, 609f
Furlow palatoplasty, 337f, 338
Fusiform excisions. see Elliptical (fusiform)
excisions.
G
Galea, 641
relaxing incisions (galeotomies), 287f-
288f, 291, 295f-299f, 645, 646f-647f,
655, 659f
Galeal median raphe, anterior extension of,
563
Gene therapy, 26
General anesthesia, 68
Geometric broken-line (GBL) scar revision,
737-741, 740f-741f
Giant pigmented hairy scalp nevus,
681f-682f, 689-693, 692f-693f
Gilles fan flap, lip reconstruction, 515,
516f-517f
Gillies up-and-down flap, 268
Glabella, 565f
cutaneous defect of, 569f
Glabrous skin, 3
Glucocorticoids. see Corticosteroids.
Glucose transporter protein (GLUT-1), 767
GLUT-1 (glucose transporter protein), 767
Glycosaminoglycans, 11
gel, 749-750
Gorlin’s sign, 711, 728
Grafts
auricular cartilage, 429, 430f, 460f-461f,
466f, 468f-469f
defined, 71
rim, 441f, 451f-453f, 462f-467f
septal cartilage, 460f-461f, 477f-478f
Granulation tissue, 41-42
skin grafting over, 340
Great auricular nerve, 589, 591f
Greater palatine artery, 418f
Groin, as skin graft donor site, 678f-680f
Ground substance, dermis, 11
Growing phase, hair follicle, 9
Growth factors
role in wound healing, 26
treatment, 26
Gunshot wounds
tissue expansion in, 689, 690f-691f
Z-plasty for scar revision of, 331,
332f-333f, 335f-336f
Gut sutures, 52, 55t
H
H-plasty, 89, 91f, 96f-97f, 158, 158f-159f
eyebrow defects, 171, 172f, 582-583,
585f-586f
forehead defects, 168-169, 171, 171f-172f,
566, 574f-576f
Hair(s)
growth cycle, 9, 9f
ingrown, 584-586
removal. see Depilation
transplants, 665-666, 666f
Hair-bearing skin, 3
in auricular reconstruction, 588, 620f,
623f
cheek rotation flaps, 110-113
improper flap design, 720-725, 721f
nose reconstruction, 238
paramedian forehead flaps, 273, 276,
278f-281f, 453
upper lip flaps, 167-168, 183
see also Scalp
Hair bulb, 4f, 7f, 8-9, 9f
Hair follicles, 7-9, 8f-9f
bulge, 7f, 8, 9f
changes during expansion, 674
cycles of growth, 9
inferior portion, 7f, 8
infundibulum, 7f, 8
Eyelid reconstruction (Continued)

780
INDEX
inner root sheath, 8-9, 8f
isthmus, 7f, 8
outer root sheath, 8-9, 8f
removal. see Depilation
Hair shaft, 8-9
Hair shock, 674
Hairstyle, forehead camouflage, 565
Halving suture technique, 108, 110f, 123,
157
Hearing, surgery to restore, 633
Hearing aid, bone-conducting, 632
Helical chondrocutaneous composite flaps.
see Auricular chondrocutaneous
composite flaps.
Helical crus, 358-359
Helical defect, postauricular interpolated
flaps, 599f
Helical root, defects of, 601
Hemangiomas, infantile, 767, 768f
congenital, 767
involuting compound, 770f
prevalence of, 767
proliferating compound, 768f
treatment for, 767, 769-771, 770f
Hematomas, 698, 698f-699f
in face, 756-757, 757f
free radical formation, 25
in paramedian forehead flaps, 311
Hemiauricular defect, 610f
Hemidesmosomes, 6-7
Heminasal flap, dorsal, 437f
Hemostasis, perioperative bleeding,
697
Henley’s layer, 8-9, 8f
Herbal supplements, 66t
Herpes simplex infection, 701f, 747
Hillock, 589
Hinge flaps, 75-77, 77t, 93, 423f
contralateral, 460f-461f
postauricular, 613, 614f-618f
septal mucoperichondrial. see Septal
mucoperichondrial hinge flap
subcutaneous fat, skin grafts over, 350,
354f-355f
subcutaneous tissue, 466f
Histamine, 19, 24
Hospital discharge, 293
Hospitalization, 70
Hughes tarsoconjunctival flap, 403-407,
406f, 408f
complications, 409, 409f
postoperative care, 407
Human bite injury, 610f
Huxley’s layer, 8-9, 8f
Hyaluronidase, 392
Hydrogel dressings, 49
Hydrogen peroxide (H2O2), 25
Hydrophilic polyurethane dressings, 358
Hydroquinone, 752
“Hyperadrenergic state”, 18
Hyperbaric oxygen treatment, 25-26
Hyperelastic joints, 727, 730f
Hyperelastic skin, 3, 4f
Hyperpigmentation
full-thickness skin grafts, 349f, 743f
laser resurfacing for, 745-747
scar, 701, 703f
treatment for, 752
Hypertrophic scars, 701, 719f, 723f,
747-748, 749f
inferior neck repair, 127f
lateral lip repair, 127-129
treatment for, 745-748, 750
Z-plasty revision of, 732f
Hypopigmentation, of scar, 752
I
Ibuprofen, 25
Ice pick acne scars, 731, 747, 748f
Immunosuppressive therapy, patients of, 703
Implants, for auricular reconstruction, 633
Incisions, 43
orientation, 160-161
relaxing, 43-44
Indirect mechanotransduction, 33
Indirect vasodilators, 24
Indomethacin, 25
Infantile hemangiomas. see Hemangiomas,
infantile.
Infection
Aeromonas, 705
complicating local flaps, 700-701
complicating tissue expansion, 694
viral or fungal, 701, 701f
Inferior labial artery, 481
Inferior labial vein, 481
Inferior lateral palpebral artery, 391f
Inferior medial palpebral artery, 391f
Inferior palpebral arterial arches, 391f
Inferior tarsal muscle, 388, 390f, 391
Inferior turbinate, 428f
Inflammation, 19-21, 25
after flap elevation, 19
phase of wound healing, 41
suture materials eliciting, 52
Infraorbital artery, 391f, 530
Infraorbital nerve, 530-531
surgical injury of, 698-699
Infraorbital nerve block, 69, 69f
Infratip lobule, skin defect of, 458f
Infratrochlear nerve block, 69f, 392
Integrated Auricular Reconstruction
Protocol (IARP), 632-633, 633t
Integrins, direct mechanotransduction of, 32
Interferon therapy, 747-748
Interleukin-1 (IL-1), 22f
Interleukin-2 (IL-2), 22f
Interpolated flaps, 77t, 83-84, 83f-85f
design, 83-84
melolabial, 436-453, 443f-453f, 468f-469f
cutaneous pedicled, 451f-453f
mucosal cross-lip, 484-485, 486f
patient preparation for, 65
preauricular cutaneous tube, 592, 598f
temporoparietal scalp flaps, 524-526
tongue, 485-487, 487f
Intralabial transposition flaps, cutaneous, 489
Involutional phase, hair follicle, 9
Irradiation, 703
Ischemia
flap, 17, 704-707, 724f
case reports on, 715-725
causative factors, 705, 707f-709f
increased tolerance of, 25-26
during intraoperative tissue expansion,
694
metabolic manipulation, 26
oxygenation in, 25-26
Ischemia-reperfusion injury, 21, 25
Island flaps, 15, 72, 77t, 84, 448f-449f,
460f-461f, 473f-474f
advancement, 84
full-thickness lip repair, 522-524
interpolated melolabial, 443f-444f
pedicle of, 448f-449f
pivotal, 84
subcutaneous tissue pedicled, 434f,
448f-449f, 460f-461f, 468f-469f
transposition, 133-135
Isoflurane, 24
Isotretinoin (Accutane), 728-731
Isoxsuprine, 24
K
Karapandzic flaps, 498-504, 501f-504f
Kazanjian, V.H., 268
Keloids, 747-748, 750f
after local flap surgery, 701, 702f
auricles, 750f
scars, 727
treatment for, 746-748
Keratin filaments, 6-7, 6f
Keratinocytes, 3-5, 6f
basal. see Basal cells (keratinocytes)
Kiesselbach’s plexus, 418f
Kinins, 19, 21-22
Knot-pull tensile strength, 52t
Knot strength, 52t
L
Labial arteries, 481
cross-lip flaps, 509
Labiomandibular crease, 481-482, 482f, 530,
531f
Lacrimal canaliculi, 387-388, 413f
reconstruction, 413-414
Lacrimal drainage system, 413f
damage of, 387-388
Lacrimal intubation, silicone tubing for,
413f
Lacrimal puncta, 387-388
Lacrimal sac, 387-388, 413f
Lagophthalmos, 388
Lamina densa, 6-7, 6f
Lamina lucida, 6-7, 6f
Langerhans cells, 5
Langer’s lines, 31
Laser photocoagulation, 771
Nd:YAG
in capillary malformations, 771
in venous malformations, 771, 771f
Laser resurfacing
in acne scars, 747
in scar revision, 745-747
Lateral canthal tendon, 388
Lateral cantholysis, 398f
primary closure of eyelid defects, 394,
400f
Tenzel semicircular flap, 399, 400f-401f
Lateral canthopexy, medial cheek flaps,
534-540
Lateral canthotomy
primary closure of eyelid defects, 394,
400f
Tenzel semicircular flap, 399, 400f-401f
Lateral canthus, 387, 531f
Latissimus dorsi flap, scalp reconstruction,
660, 661f-662f
Leeches, medicinal, 705
Length-to-width ratio
advancement flaps, 34
biomechanical aspects, 34
blood flow and, 16, 19f
of random cutaneous flaps, 15
transposition flaps, 131
Lentigo maligna, cheek, 745f-746f
advancement flap, 173, 176f
bilobe flap, 197
skin grafts, 342f
skin grafts with advancement flaps, 379f,
380
skin grafts with cervical facial flaps,
375
skin grafts with transposition flap, 371f
see also Atypical junctional melanocytic
hyperplasia (AJMH), cheek
Lesser occipital nerve, 589
Lesser palatine artery, 418f
Hair follicles (Continued)

INDEX
781
Levator palpebrae superioris muscle (and
aponeurosis), 388
Lidocaine, 42, 68-69
toxicity of, 42-43
Lids. see Eyelids.
Limberg, Alexander A., 210-211
Limberg flaps, 135, 136f, 211-213, 227f
applications of, 213
case report on, 224f-225f, 225
for cheek defects, 550
design, 211-213, 214f
disadvantages of, 213
Dufourmental modification. see
Dufourmental flaps
modified for circular defects, 216,
219f-220f, 221
multiple, 221
see also Rhombic flaps
Linen sutures, 55t
Lines of maximal extensibility (LME), 31,
71, 73f-74f, 532f
rhombic flaps, 136-137, 210-213,
211f
Lip
advancement flap, 167-168, 470f-472f
anatomy of, 481-483, 482f
distortion by scars, 712, 713f-714f,
719f
hemangioma of, 497f
scar revision, Z-plasty, 473f-474f
stretching appliance of, 504
upper, aesthetic units, 73, 75f-76f
see also Cupid’s bow
Lip reconstruction, 481-529
advancement flaps for, 167-168
bilateral, full-thickness defects, 496-498,
497f-500f
case reports on, 174-178, 179f-183f
cutaneous defects, 487-495
by Celsus, 482f
circumoral full-thickness rotation
advancement flaps for, 498, 500f
composite grafts for, 509
deltopectoral chest flap for, 526-528
distant flaps for, 526-528
forehead flaps for, 526-528
full-thickness defects, 495-528
fusiform repair, 488-489, 489f
Gilles fan flap for, 515, 516f-517f
history of surgery, 481, 531f
island flaps for, 522-524
Karapandzic flaps for, 498-504,
501f-504f
melolabial advancement flaps, 249-252,
264-266, 264f-266f
melolabial transposition flaps for
case reports on, 246f, 249-252, 252f,
254f-255f, 256
cutaneous defects, 491-495,
492f-494f
full-thickness defects, 521-522,
522f-524f
microsurgical flaps for, 528
myocutaneous flap for, 528
preferred flaps
central region, 97-98, 100f-103f
lateral region, 98-100, 104f
primary repair in, 97-98, 100f-102f,
179-180, 184f, 495-496, 495f-497f
radial forearm flap for, 528
rotation flaps for, 113, 489-491, 491f
case report on, 127-129, 128f-129f
skin grafts, 249-252
T-plasty, 158-160, 160f
temporoparietal scalp flaps for, 524-526,
525f-527f
transoral cross-lip flaps for, 504-515
transposition flaps for, 153-155, 153f-
154f, 491, 492f-494f
chin, 489, 490f
submandibular, 489
wedge or V-shaped full-thickness excision
in, 495, 495f-497f
LME. see Lines of maximal extensibility
(LME).
Local anesthesia
eyelid reconstruction, 392
forehead surgery, 565
local flap surgery, 68-69
skin grafts, 350
techniques, 42-43
Local anesthetic agents, 42-43, 68-69
toxicity of, 42-43
Local cutaneous flaps
classification of, 73-77, 77t
complications. see Complications of local
flaps
contouring. see Contouring, flap
defined, 71
design. see Design, flap
eyelid defects, 394
preferred, 94-107
refinement. see Refinement, flap
with skin grafts, 368
terminology for, 71-73
see also Skin flaps
Lymphatic drainage, 18
of auricle, 588-589
cheek, 530
of ear, 630
melolabial flaps, 235
of scalp, 644
skin flaps, 110
Lymphatic malformations, 769, 769f
treatment for, 772
Lymphatic vessels, 14
M
M-plasty
cheek repair, 533, 533f
with fusiform excision of skin tumors,
488-489, 489f
primary repair of forehead defects, 566,
568f
with rhombic transposition flaps, 135-136
with T-plasty, 160, 161f
Macrophages, 11-12, 41
Macrostomia, bilateral congenital, 331-334,
335f
Macrotia, 632
Makeup, camouflage, 752
Malar fat pad, 530
Male pattern baldness, tissue expansion in,
683f-684f
Mandible
inferior border of, 531f
reconstruction of, tissue expansion in,
689, 689f-691f
Mandibular retaining ligament, 530
Mandibular unit, of cheek, 531f
Mast cells, 11-12
Mastoidectomy defect, 602f
Matrix, hair follicle, 8-9, 8f
Matrix metalloproteinases, 10
Maximum skin extensibility, 71
Maxon sutures, 56t
McGregor flaps, 515, 516f-517f
McGregor’s patch, 530
McHugh island, full-thickness lip repair,
522-524
Mechanical creep. see Creep, mechanical.
Mechanotransduction, 32
direct, 32-33
indirect, 33
and skin, 32-33
Medial canthal tendon (MCT), 388,
390f
Medial canthus, 387
anatomy of, 390f
healing by secondary intention, 394
Z-plasty, 139f
Medial cheek, cutaneous defects of, 368
Median forehead flaps, 268
vascular supply, 269-270, 269f-270f
vs paramedian forehead flaps, 270
see also Paramedian interpolated forehead
flaps
Medical conditions, in local flap
complications, 703-704
Medications
discontinuation before surgery, 66,
697
recommended prescribing, 67t
Medpor (polyethylene) implants, for
auricular reconstruction, 633
Meibomian glands, 10, 387-391, 389f-390f
Meissner’s corpuscles, 12f, 13
Melanin, 5, 673
Melanocytes, 5, 6f
Melanoma
cheek, 532
advancement flap, 172, 174f
melolabial island advancement flaps,
260, 261f
rotation flap, 121, 122f, 124f
skin grafts for, 550
eyelids, 399f
of scalp, 653f
skin grafts for, 603f-604f
Melanoma in situ
cheek, 547f-548f
advancement flap, 173-174,
177f-178f
cervical facial rotation advancement
flaps, 552, 553f
melolabial flaps, 245-249, 249f-250f,
260, 261f-263f
pivotal advancement flap, 541f-542f
rhombic flaps, 212f-213f, 215f-216f,
225, 227f-228f
skin grafts with local flaps, 372,
373f-374f, 383-384
transposition flap, 147-150, 148f-149f,
151f-152f
complications of flap surgery, 708f, 715,
716f, 721f-724f
forehead, advancement flap, 170, 171f
full-thickness skin graft, 353f
nose, paramedian forehead flap,
295f-299f
partial primary wound closure and
full-thickness graft, 383f-384f
skin grafts, 341f
temple
rhombic flap, 221-225, 224f-225f
transposition flap, 142, 144f
see also Atypical junctional melanocytic
hyperplasia (AJMH), cheek; Lentigo
maligna
Melanosomes, 5
Melolabial advancement flaps, 233-235,
233f
case reports on, 239-241, 242f, 256, 257f,
260-264, 261f-262f, 264f-266f, 266
island, 233-235
unipedicle, 233, 233f
Lip reconstruction (Continued)

782
INDEX
Melolabial crease, 231, 448f-449f, 481-482,
482f, 530, 531f, 539f
obliteration of, 713, 714f
primary closure of defects of, 534, 535f
skin defect of, 535f
Z-plasty for scar alignment, 322-323,
322f-323f
Melolabial flaps, 231-267
case reports of, 238-266
classification of, 231-232
types of, 231-232
Melolabial fold, 231
Melolabial interpolated flaps, 83-84, 86f-88f,
231-232
case reports on, 256, 257f-260f
contouring and refinement of, 439
cutaneous pedicle, 238, 239f, 451f-453f
alar reconstruction of, 451-452
disadvantage of, 232
nose reconstruction. see Nose
reconstruction
subcutaneous tissue pedicle, 235-238, 236f
Melolabial rotation flaps, 231-232
Melolabial transposition flaps, 131, 232-233,
232f
advantages of, 232
case reports on, 153-155, 153f-154f,
238-239, 241-252, 243f-248f, 252f,
254f
cutaneous lip defects, 491-495, 492f-494f
full-thickness lip repair, 521-522,
522f-524f
Memory, suture materials, 52t
Mental crease, 481-482, 482f
Mental nerve, 530-531
surgical injury of, 698-699
Merkel cells, 5-6, 12f
Mersilene sutures, 55-56, 57t
Microcystic carcinoma, chin and lower lip,
153-155, 153f-154f
Microstomia
cheek advancement flaps for, 518-519
Karapandzic flaps for, 504, 504f
Microsurgical flaps, 73-75
for lip reconstruction, 528
for scalp reconstruction, 660, 661f-662f
Microsurgical tissue transfer, 660
Microtia, 630-631, 632f
reconstruction principles for, 592-594,
615-622
Middle ear surgery, 632-634
Millard seagull flap, 268-269
Modified T-plasty, 160-161, 162f-163f
Moll’s glands, 10
Monocryl sutures, 55, 56t
Monocytes, 11-12
Motor (dys)function
cross-lip flaps for, 509-510, 510f
forehead reconstruction, 564, 586
opposing cheek advancement flaps for,
520f-521f, 521
Motor nerves
forehead, 563, 564f
scalp, 644
Mucoperichondrial flaps, bilateral, 426f
Mucoperiosteal flaps, turbinate, 428, 428f
Mucosal advancement flaps, labial, 483-484,
483f-484f
Mucosal cross-lip flaps, 484-485, 485f-486f
Mucosal grafts, eyelid reconstruction, 410
Mucosal V-Y island advancement flaps,
vermilion reconstruction, 484, 484f
Müller’s muscle, 388, 389f, 391
Hughes tarsoconjunctival flap, 405-407
Muscle, skeletal, changes during expansion,
674
Musculocutaneous advancement flap, 397f
Musculocutaneous arteries, 14, 16f
Musculocutaneous flaps, 17f
forehead, 566
Mustardé cheek rotation flap, eyelid
reconstruction, 399
Myocutaneous flaps
lip reconstruction, 528
vascular supply, 16
Myofibroblasts, 674-675
N
Nasal airway stenosis, Z-plasty correction,
331, 333f
Nasal alae, 73, 415-417
cutaneous defect of, 467f
design of, 429
distortion after surgery, 711, 712f-713f
framework reconstruction of, 429
full-thickness defect of, 442f, 460f-461f,
470f-474f, 477f-478f, 560f
interpolated melolabial flaps, 436-439
cutaneous pedicle (peninsular),
451-452
melolabial island advancement flaps,
233-234, 234f
reconstruction of, 459-463, 466f-474f
skin defect of, 443f-446f, 448f-449f,
454f-455f, 466f, 468f-469f, 475f-476f
Nasal bones, 415-417
Nasal cartilages, 415-417
Nasal cavity, arterial blood supply of, 418f
Nasal conchae, cartilage grafts, alar
reconstruction, 429, 429f
Nasal cutaneous flaps, 430-432, 431f
Nasal dorsum, 73, 75f-76f, 415-417
framework reconstruction of, 429
full-thickness defect of, 477f-478f
reconstruction of, 463-465
septal composite chondromucosal pivotal
flaps, 426-427, 426f
skin defect of, 431f, 456f, 475f-476f
Nasal facets, 73, 415-417
framework reconstruction of, 429
full-thickness defect of, 362f-364f
reconstruction of, 459
Nasal reconstruction. see Nose
reconstruction.
Nasal sidewalls, 73, 415-417
cheek defects extending to, 348f, 350, 368,
557-558, 559f-560f
interpolated paramedian forehead flaps,
288, 292f-294f
framework reconstruction of, 429
full-thickness defect of, 460f-461f,
470f-472f, 477f-478f, 560f
nasofacial sulcus preservation, 165, 165f
reconstruction of, 465, 475f-478f
skin defect of, 432f-433f, 475f-476f
skin grafts with advancement flaps, 350
Nasal skin, pinch test, 436
Nasal tip, 73, 415-417
deep skin and soft tissue defect, 348f
defect, 84f-85f
bilobe flaps, 194f-195f
dorsal nasal flaps elevating, 115, 436
framework reconstruction of, 429
full-thickness defect of, 442f, 462f-465f,
560f
reconstruction of, 459
septal composite chondromucosal pivotal
flaps, 423-426, 425f
skin defect of, 431f, 438f-440f, 451f-453f,
456f-457f
Nasalis muscle, 434f
Nasofacial sulcus, 531f, 539f
advancement flaps, 164-165, 165f
primary closure of adjacent defects, 534,
536f
skin grafts with advancement flaps, 380
see also Nasal sidewalls, cheek defects
extending to
Nasolacrimal duct, 413f
Nausea, postoperative, 289-291, 293
Nd:YAG laser photocoagulation. see Laser
photocoagulation.
Neck
cheek defects extending to, 560, 561f
rotation flaps, case report on, 123-127,
126f
squamous cell carcinoma of, 561f
tissue expansion in, 676, 685-693,
689f-691f
Z-plasty for scar revision on, 319, 324,
325f, 327, 330f-331f
Necrosis, flap, 698f, 704f, 705, 708f-709f,
716f-717f, 719f, 724f
case reports on, 715-725
causes of, 34
experimental prevention, 22
forehead, 583-584
pathophysiology, 19f
smoking, associated with, 26
wound-closure tension and, 34, 708f,
715-720
wound infection causing, 701-703,
708f-709f
see also Ischemia, flap
Needle drivers (holders), 44
definition of terms, 62t
interaction with suture needle, 59, 60f
Needle ductility, 62t
Needle holder clamping moment, 62t
Needles, suture. see Suture needles.
Neovascularization
growth factors, 24
skin grafts, 343
transposed flaps, 15
Nerve blocks, 42, 68-69, 69f
Nerve endings, free, 12f, 13
Nerves
cutaneous, 13
effects of tissue expansion on, 674
section, skin flaps, 18
Neuropeptides, 33
Neutrophils, 41
Nevus, giant pigmented hairy scalp,
681f-682f, 689-693, 692f-693f
Nicotine, 26, 703-704, 727-728
Nitric oxide, 25-26
Nitric oxide synthase (NOS), 25
Nitroglycerin, topical, 24
Nobecutane spray, 358
Non-hair-bearing, skin, 3
Nonlinearity, stress-strain relationships,
30-31, 31f
Nonsteroidal anti-inflammatory drugs
(NSAIDs), 20
avoidance before surgery, 66t, 697
Norepinephrine, 14
flap blood flow and, 21, 23
skin flap delay, 23-24
Nose
aesthetic units of, 73, 75f-76f, 415-417,
416f
cheek defects extending to. see Nasal
sidewalls
complications of local flaps, 699, 700f
directional nomenclature of, 416f
internal, vascular supply of, 417, 418f
lining of, 417

INDEX
783
primary wound closure of, 430
rhombic flaps, 220-221, 222f
skin thickness, variations of, 456,
456f-457f
topographic analysis of, 415
Nose reconstruction, 415-480
by aesthetic unit, 457-465
aesthetic unit principles of, 417
bilobe flaps, 141, 190-192, 191f-193f, 436,
438f-441f
case reports on, 197-199, 201f-202f,
204f-208f
design, 188, 189f
surgical technique, 194f-195f
composite grafts, 358-359, 359f
covering flaps for, 430-455
dorsal nasal flaps for. see Dorsal nasal flaps
flap refinement of, 476, 479f
framework of, 429
lining flaps for, 304-315, 417-428
median forehead flaps, 268
melolabial interpolated flaps for, 235,
236f, 237-238, 239f, 436-453,
443f-450f
case reports on, 256, 257f-260f
design of, 451-452, 451f-453f
follow-up contouring of, 439
technique of, 451-452
nasal cutaneous flaps for, 430-432, 431f
paramedian interpolated forehead flaps. see
Paramedian interpolated forehead
flaps
preferred flaps, 100-102, 104f-106f
primary repair of, 430
skin grafts for, 346, 455-457
full-thickness, 455-457, 456f-458f,
466f-467f, 473f-474f
over fat hinge flaps and cartilage grafts,
354f
supraclavicular fossa, 456f-457f
V-Y island pedicle advancement flaps for,
433-436, 434f-435f
Nostril, stenosis from scar, 751f
Nostril margin
framework reconstruction of, 429
notching of, Z-plasty correction, 733-734,
735f
Nostril rim, full-thickness defect extending
to, 364f
Note flaps, 135, 135f
cheek, 550
melolabial, 241-245, 247f
skin grafts with, 369
temple/eyebrow defect, 142, 143f
Nurolon sutures, 57t
Nylon sutures, 49-52, 51f, 55-56, 57t
O
O-T plasty, 158-160, 159f-160f
lateral cheek defects, 552
lateral forehead defects, 577-579
lip defects, 178, 180f
O-to-S plasty, eyelids, 395f
O-Z plasty, 94, 95f
eyelids, 394, 395f
lateral forehead, 580
O-Z wound repair, scalp, 112-113, 119,
119f, 652f-653f
Obesity, skin changes, 33
Occipital arteries, 641-644, 643f
Occipitalis muscle, 641
Occipitofrontalis muscle, 563
Ocular anterior segment, physiology of,
387-388
OK-432, 772
Operating room setup, 68f
Ophthalmic artery, 391
OpSite dressings, 358
Oral commissure
distortion of
Estlander flaps, 511-513
Karapandzic flaps, 499, 502f
reconstruction. see Commissureplasty
Z-plasty for repositioning, 334-338,
335f-336f
Oral stoma, 482f
Orbicularis oculi muscle, 387-388, 389f-390f
Orbicularis oris muscle, 481
approximation of, in full-thickness repairs,
496
Orbital rim, 531f
Orbital septum, 388, 389f-390f, 391
Orticochea three-flap technique, 654-655,
655f-656f
Orticochea two-flap technique, 657f
Otologic surgery, for atresia, 633
Oval skin defect, Z-plasty, 138-140, 140f
Oxygen free radicals, 18, 21, 22f, 25
P
Pacinian corpuscles, 12f, 13
Padgett dermatome, 358, 358f
Palpebral fissure, 387-388
Paramedian forehead flaps, 269-276, 423f,
427f, 453-455, 454f-455f, 462f-465f,
470f-478f
complication in, 707f
hair-bearing skin of, 453
as a lining flap, 304-315
refinement and contouring of, 453
supratrochlear artery, 453
thinning of, 476
tissue expansion for, 693
vascular supply, 269-270, 269f-270f
vs median forehead flaps, 270
Paramedian interpolated forehead flaps, 83,
84f-85f, 268-316
advancement, 156
advantages of, 311-315, 312f-315f
applications of, 272, 277f-281f
complications of, 311
contouring, 274f-275f, 278f-283f,
289f-290f, 292f-293f, 295f-299f,
302f-303f, 303-304
depilation, 273, 277f
design, 270, 271f-272f, 274f-275f, 276,
277f-284f, 289f-290f, 292f-299f, 305f,
307f-309f
donor site scars, 272-273, 273f-275f,
277f-281f
historical background, 268-270
hospital admission, 70
hospital discharge, 293
as lining flap, 304-315, 304f-305f,
307f-311f
nasal defects extending to lip or cheek,
284-288, 292f-294f
pedicle separation, 297, 301f-303f
postoperative care, 293-297, 303-304
preoperative preparation for, 65, 276
surgical technique, 274f-275f, 276-304,
281f-290f, 292f-303f
thinning, 270, 293, 295f-300f, 297,
302f-303f
tissue expansion for, 306-309
Parotid gland
dissection over, 117
squamous cell carcinoma of, 561f
Parotid lymph nodes, 630
Pedicle, 72
Pentoxifylline, 24
Peptide growth factors, 22, 22f
Perforator (arterial cutaneous) flaps, 15
Perichondrocutaneous grafts, 362-367
Periorbital region
bruising of, 586
cheek defects extending to, 538f, 546f,
557
see also Eyelids
Periorbital wrinkle, 393f
Periosteal flap, eyelid reconstruction, 401,
402f, 412f
Periosteal tacking (suspension) sutures,
nasofacial sulcus, 165, 165f
Periosteum, scalp (pericranium), 641
full thickness defect in, 654f
Petrali, Natale, 268
Philtrum, 482
Phospholipase A2, 20, 25
Photoaging, 10
Photographs, representative, 65
Photography, 66-67
Physiology
skin, 14
skin flap, 14-29
Pigmented skin, 5
Pilosebaceous unit, 7-8, 339
Pinch test, nasal skin, 114, 436
Pinwheel technique, in scalp reconstruction,
112-113, 119, 651-655, 654f-656f
Pivotal advancement cheek flaps, 540, 540f,
543f
complications of, 715-717, 717f, 723, 724f
Pivotal flaps, 77-84, 78f-79f
cephalic aspect of, 425f
septal composite chondromucosal,
423-426, 426f
with skin grafts, 368-374
types of, 368
Plasmid DNA, 26
Plasticity, of suture materials, 52t
Platelet-derived growth factor (PDGF), 22f,
26
Platelet-rich plasma, 26
Platysmal muscle, cervicofacial rotation
flaps, 117
Pliability, suture materials, 52
Poiseuille equation, 24
Poliglecaprone 25, 49-52, 56t
Polybutester, 49-52, 55-56, 57t
Polycaprolate, 49-52
Polydioxanone (PDS) sutures, 55, 56t
Polyester Ticron sutures, 57t
Polyethylene implants (Medpor), for
auricular reconstruction, 633
Polyethylene terephthalate, 55-56
Polyglycolic acid sutures, 56t
Polyglyconate sutures, 56t
Polymorphonuclear leukocytes, 41
Polypropylene sutures, 49, 57t
Port-wine stains, 768, 769f
treatment for, 771
Postauricular advancement flap, two-stage,
608-613, 611f-612f
Postauricular artery, 588-589, 590f
auricular branch, 592
Postauricular interpolated flaps, 592, 613,
614f-617f
cutaneous tube, 599f
two-stage advancement flap, 608-613
Postauricular skin, as skin graft donor site,
346, 352f, 550
Postauricular subcutaneous tissue pedicled
island advancement flap, 594-601,
605-607, 606f
Nose (Continued)

784
INDEX
Postauricular sulcus, preservation of, 588
Posterior auricular artery, 641-644, 643f
Posterior ethmoidal artery, 418f
Postoperative care
composite grafts, 359
eyelid reconstruction, 391
Hughes tarsoconjunctival flap, 407
paramedian forehead flaps, 293-297,
303-304
patient instructions, 69t
skin grafts, 355, 358
Preauricular crease, 531f
positioning scars in, 552, 554f
Preauricular interpolated cutaneous tube
flap, 592, 598f
Preauricular skin
with composite auricular grafts, 358-359
as skin graft donor site, 346, 351f, 550,
591-592, 601-605
Precapillary sphincter, 14, 15f
Prednisone, 66, 359
Prefabrication, flap, 24
Preoperative consultation, 65-66
Preoperative requirements, 67t
Preparation, patient, 65-70
Preshunt sphincter, 14, 15f
Primary defect, 71, 72f
Primary tissue movement, 71, 72f, 368
advancement flaps, 156, 157f
Primary wound closure, 380-384
auricular defects, 592, 601
cheek defects
buccal region, 550, 551f
lateral region, 552, 554f
medial region, 533, 533f
zygomatic unit, 557
eyebrow defects, 582-583
eyelid defects, 392-394, 398f-399f
forehead defects, 168-169, 168f, 565-566
lateral, 577, 578f
midline, 566-567, 567f-568f
paramedian, 570
paramedian flap donor site, 272-273,
273f-275f, 285f-286f, 302f-303f
lip defects, 97-98, 100f-102f, 183, 184f,
495, 495f-497f
nasal defects, 430, 431f
partial, 383f-384f
in scalp defects, 645, 645f, 647-651, 659f
Prolene sutures, 55-56, 57t
Proparacaine, 391-392
Prophylaxis, antibiotic, in local cutaneous
flaps, 700
Prostacyclin (PGI2), 19-21
Prostaglandins, 19-21, 25
synthesis of, 21f
Prostheses, auricular, 630
Protein, structural, 30
Protein deformation, 32-33
Proteoglycans, 11
Pulsed dye laser (PDL)
flashlamp-pumped, 746-747
for capillary malformations, 771
for infantile hemangiomas, 770, 770f
for venous malformations, 771-772
in scar revision, 745-746
Punch excisions, skin, 731, 747
Pus, 41
R
Radial forearm flap, lip reconstruction, 528
Radiation necrosis, skull, 662f
Radiation therapy, 26, 532
Radovan expander, 675
Random cutaneous flaps, 15
Random pattern flaps, 17f, 75, 77f
ischemia complicating, 704
Rap1 protein, 32-33
Recovery periods, 66t
Redundant skin
bilobe flaps for recruitment, 140-141
forehead, 565-566
Refinement, flap
nose reconstruction, 476
paramedian forehead flaps, 455
see also Contouring, flap; Dermabrasion;
Scar revision
Regional flaps, 73-75
lip reconstruction, 524
in scalp reconstruction, 655
Relaxed skin tension lines (RSTLs), 31, 71,
73f-74f, 188, 727
cheek, 531-532, 532f
eyelids, 392-394, 393f
forehead, 563, 570
lips, 482, 482f
rhombic flaps, 210-213, 221-225
rotation flaps, 108
scars and, 730f, 739f-741f
W-plasty in, 734-737, 736f
Z-plasty, 135, 138-140, 140f, 318t,
322-323
Reperfusion, flap, 21
Resting phase, hair follicle, 9
Retinoic acid, topical, 745
see also Tretinoin
Rheology, alteration of, 24
Rhinoplasty, reduction, dorsal nasal flap
with, 115, 116f
Rhombic flaps, 135-137, 136f, 210-230, 211f
advancement, 156
applications, 137
bilateral, 220-221, 221f-222f
case reports on, 221-226
cheek, 225-226, 227f, 229f, 533f, 557
design, 81, 82f, 135-136, 216-220
Dufourmentel modification of, 136-137
modified for circular defects, 216,
219f-220f
multiple, 221
periocular area, 394
periorbital region, 396f
skin grafts with, 369, 370f
variations of, 135-136, 211, 216-220
disadvantages of, 216-220
wound closure tension with, 81
Z-plasties for base expansion, 221, 223f
Rhomboid transposition flaps, 394
Rhombus defect, 81, 82f
Rib cartilage grafts. see Costal cartilage
grafts.
Rotation advancement flaps, 156, 538f, 546f
cervicofacial. see Cervical facial flaps
circumoral full-thickness, 498, 500f
dynamics of, 537f
forehead reconstruction, 576, 577f
lateral cheek repair, 167
lip reconstruction, 489-491, 490f-491f
Rotation flaps, 77t, 108-130
advantages of, 79, 110
applications of, 112-115
Burow triangle excision, 79, 89, 91f, 108,
109f
case reports on, 118-129
cheek reconstruction. see under Cheek
reconstruction
design, 78-79, 79f, 108, 109f-110f
disadvantages of, 79
forehead reconstruction. see also Forehead
reconstruction
bilateral, 567, 570f
height-to-width ratio, 110, 111f-112f
inappropriate situations for, 110-112
lip reconstruction, 489-491, 490f-491f
melolabial, 231-232
scalp. see Scalp flaps
skin grafts with, 372
surgical technique for, 116-118
triangular skin defects, 372
Round skin defects. see Circular skin defects.
RSTLs. see Relaxed skin tension lines
(RSTLs).
S
S-plasty, 137
Sabattini (Abbe) flaps, 504-511, 505f-509f
Salmon patch, 768
Scalp
anatomy of, 641-644, 642f-643f
angiosarcoma, 357f
skin grafts in, 645-647, 647f, 649f-650f,
661f-662f, 678f-680f
strip grafts, for eyebrow reconstruction,
366f, 367
tight and loose regions of, 643f
tissue expansion in, 678-681, 678f-684f
Scalp flaps, 647-655
advancement, 647-651, 655, 658f-659f,
663f
rotation, 112-113, 647-651, 648f,
651f-652f
case reports on, 118-119, 118f-120f
multiple, 651-654, 652f-654f
surgical techniques in, 649f-650f
transposition, 654-655, 657f
Scalp reconstruction, 641-667
adjuvant techniques in, 660-666
controlled tissue expansion in, 660-663,
663f
goals of, 644
hair transplants in, 665-666, 666f
healing by secondary intention in,
644-645, 645f, 649f-650f
intraoperative tissue expansion in,
663-664, 664f
local flaps in, 647-655, 649f-650f,
652f-655f, 663f-664f
microsurgical tissue transfer in, 660,
661f-662f
preferred flaps, 94, 95f
primary wound closure in, 645, 645f,
647-651, 647f, 659f
regional flaps in, 655, 661f-662f
skin grafting in, 645-647, 647f, 649f-650f,
661f-662f
Scalpel blades, 43, 43f
Scalping flap, 268
Scar irregularization, 732-741
Scar revision, 727-728
in children, 728
dermabrasion in. see Dermabrasion
fillers in, 749-752
flap contouring in, 752-755, 753f, 758f,
760f-764f
forehead, 169-170, 170f
geometric broken-line (GBL) in, 737-741,
740f-741f
irregularization, 732-741
laser resurfacing in, 745-747
local flap refinement in, 752-761
melolabial advancement flaps, 264-266,
264f-265f
melolabial transposition flaps, 241, 246f
nonsurgical options in, 749-752
patient assessment in, 728-731
Rotation flaps (Continued)

INDEX
785
skin grafting in, 749
techniques for, 731-747
timing for, 728
trap-door deformity, 133
wound care after, 741
Z-plasty, 138
Scars
abnormal, 701
classification of, 728
definition of, 727
excision of, 731-732
formation of, 727
hyperpigmented, 701, 727
hypertrophic. see Hypertrophic scars
ideal, 728
maturation of, 728, 729f-730f
skin types and, 3
traumatic, 729f
unsightly, 711, 711f
contributing factors to, 727,
739f-741f
from varicella, 730f
Z-plasty release of contractures, 734,
736f
see also Keloids
SCDs. see Standing cutaneous deformities
(SCDs).
Sclerotherapy, for venous malformations,
771-772, 771f
Seagull flap, Millard, 268-269
Sebaceous gland hyperplasia, 10
bilobe flaps, 188, 199, 202f
unsightly scars, 711, 711f
Sebaceous glands, 7f, 9-10
Sebum, 9-10
Secondary defect, 71, 72f
Secondary intention, healing by, 49
of auricular defects, 594
cheek defects, 532-533
composite grafting after, 359, 360f-361f
forehead defects, 169, 565
forehead donor sites, 272-273,
274f-275f, 278f-281f, 291, 294f,
312f-313f
periocular region, 394
in scalp reconstruction, 644-645, 645f,
649f-650f, 663f, 665-666, 666f
Secondary tissue movement, 71, 72f, 368
advancement flaps, 156, 157f
structures often distorted by, 368
Secretory gland, 10
Semicircular flap, eyelid reconstruction,
399-402, 402f
Sensory (dys)function
cross-lip flaps, 510
forehead reconstruction, 586
Sensory innervation, of scalp, 644
Sensory nerves, 14-15
cheek, 530-531
forehead, 563-564
hair follicle, 8
surgical injury of, 698-699
Septal cartilage, 423f-425f, 427f
full-thickness incision of, 427f
graft of, 460f-461f, 477f-478f
Septal composite chondromucosal pivotal
flaps, 423-426, 426f
nasal dorsum, 426-427, 426f
nasal tip, columella, and dorsum, 427-428,
427f
nasal tip and columella, 423-426, 425f
Septal mucoperichondrial hinge flap
bilateral caudally based, 421, 422f
contralateral dorsal, 421-422, 423f-425f
hospitalization, 70
ipsilateral, 420-421, 420f, 423f-425f,
460f-461f, 470f-474f, 477f-478f
design of, 420-421
unipedicle, 420f
Septocutaneous arteries, 14, 16f
arterial cutaneous flaps, 15
Serial excision, 731, 731f
Serotonin, 19, 23
Seventh cranial nerve
temporal branch, pathway of, 564f
see also Facial (seventh cranial) nerve
Shearing forces, 35
Silicone gel sheeting, 749
Silicone intubation, lacrimal system,
413-414, 413f
Silk suture, 51f, 55, 55t
Simple linear layered closure, 84-88, 89f-90f
Skeletal muscle, changes during expansion,
674
Skin, 30
anatomy of, 3-13, 339
changes during expansion, 672, 672f-674f
mechanotransduction and, 32-33
nerve supply, 13
as organ system, 3
physiology of, 14, 339
vasculature of, 11f, 12, 339
Skin atrophy, 701, 703f
Skin conditions, wound infection risk, 3
Skin extensibility, 71
maximum, 71
see also Creep; Lines of maximal
extensibility (LME)
Skin flap delay, 23-24
Skin flaps
biomechanics, 30-40
classification based on vascular supply,
17f
neurovascular supply, 14-15
physiological changes after elevation,
16-21
physiology of, 14-29
research methods for, 22
undermining of, 39f
vascular design, 15-16
vascular territories, 18f
see also Local Cutaneous flaps
Skin grafts, 188, 197, 198f, 339-367
with advancement flaps, 172, 175f,
377-380
for alopecia, 688f
with cervical facial flaps, 374-377
cheek. see also Cheek reconstruction, skin
grafts
bolster dressings for, 552
lentigo maligna, 342f
melanoma of, 550
color and texture discrepancies of, 339,
341f-342f
cutaneous lip repairs, 249-252
defect preparation, 340-343
dermabrasion in, 339, 743, 743f
eyelids, 350
factors affecting viability, 339
fibrin sealants, 62-63
in forehead reconstruction, 565-566, 583,
587f, 686f-687f
full thickness, 339, 340f, 343-356, 345f
dermal fat grafts under, 343-346,
347f-348f
donor sites, 3, 346, 350f
indications of, 343-346, 345f-346f
with local flap, 368
technique of, 350-356
Hughes tarsoconjunctival flap, 403-407,
406f, 408f
lining full-thickness lip repairs, 521-522,
522f-524f
local anesthesia for, 350
with local flaps, 368-384
nose reconstruction. see Nose
reconstruction
with note flaps, 369
over fat hinge flap and cartilage graft, 350,
354f
partial failure of, 369
with pivotal flaps, 368-374
primary wound closure with. see Primary
wound closure
recommended medications for, 67t
with rhombic flaps, 369, 370f
with rotation flaps, 372
in scalp reconstruction, 645-647, 647f,
649f-650f, 661f, 678f-680f
scar excision and, 749
split thickness, 345f, 356-358
indications of, 356-357, 357f
technique of, 357-358
subcutaneous tissue pedicled island
advancement flap (V-Y) and,
373f-374f
suturing, 355, 356f, 362f-364f
technique, 350-356
temple, 345f
with transposition flaps, 149, 150f-151f,
368, 371f-372f
types of, skin thickness and, 345f
vascular supply of, 339-340
Skin hooks, single-prong
skin edge eversion, 43, 43f-44f
undermining technique, 43, 44f
Skin necrosis, 727-728
Skin punch excisions, 731, 747
Skin tension, variation in, 31
Skin thickness
full-thickness skin grafting and, 346,
349f
skin graft type and, 345f
variations of nose, 456, 456f-457f
SMAS. see Superficial musculoaponeurotic
system (SMAS).
Smoking
local flap complications and, 703-704
tobacco, 26, 66, 532
cheek flap dissection, 117
Soft tissue hematoma, 757f
Soft tissue technique, 43-44
SOOF. see Suborbicularis oculi fat
(SOOF).
Sphenopalatine artery, 428
posterior septal branch of, 418f
Spinal/cranial nerves, of auricle, 589,
591f
Split-thickness skin grafts, 356-358, 622
Squamous cell carcinoma
in auricle, 597f, 627f-629f
cheek, 343f, 532, 561f
rotation flaps, 121-123, 125f
transposition flap, 151-153, 153f
eyelid, 401f, 408f
rotation flap for, 712f
Squamous cell carcinoma in situ, 9
Square technique, 225
cheek, 142-145, 150, 173-174, 176f, 342f,
369, 370f-371f, 376f
forehead, 170, 171f
Staged repair, 65
Stair-step design, bilateral advancement flaps
for lip repair, 498, 498f
Scar revision (Continued)
Septal mucoperichondrial hinge flap
(Continued)
Skin grafts (Continued)

786
INDEX
Standing cutaneous deformities (SCDs),
77-78, 89f-90f, 698f, 712f-713f, 713
advancement flaps, 378-380
interpolated melolabial flaps, 237,
239-245, 240f-243f, 257f
Limberg flaps, 136f, 211, 212f-217f, 213,
219f, 227f
medial cheek flaps, 95-97
melolabial transposition flaps, 244f-245f,
245-249, 247f-250f, 252, 252f-255f
nasal lining flaps, 419-420
persistent, 714f-715f, 739f, 759f, 763f-764f
pivotal flaps, 368
rotation flaps, 79, 108, 111f
in scalp defects, 117
in scalp, 94, 645, 647f
T-plasty, 158-160
transposition flaps, 133, 135, 144f,
148f-150f, 149
unipedicle advancement flap, 88-89
use as skin grafts, 377
Webster 30° flaps, 214
Z-plasty, 138, 140f
Staples, wound closure, 44-45, 50f
Steel sutures, 55t
Step-off deformity, 753f
Steroid injections, for infantile
hemangiomas, 770
Stork bite, 768
Straight-pull tensile strength, 52t
Strain, 30
Stratum corneum, 3-5, 5f
Stratum germinativum (basal layer), 3-5, 5f
Stratum granulosum (granular layer), 3-5, 5f
Stratum spinosum (spinous layer), 3-5, 5f
Streptococcus pyogenes, 772
Stress, mechanical, 30
Stress relaxation, 32
Stress-strain relationships, 30
non-linearity, 30-31, 31f
Sub-brow fat pad, 388
Subciliary line, cheek flap advancement to,
534-540, 539f
Subcutaneous adipose flaps, for cheek
reconstruction, 558-560
Subcutaneous fat, 345f
Subcutaneous tissue, changes during
expansion, 673-674, 673f
Subcutaneous tissue pedicle island
advancement flaps (V-Y), 96-97, 99-100,
99f, 104f, 162, 377, 381f-382f, 600f,
754f-756f, 758f-759f
cheek reconstruction, 165, 166f, 174
case report, 173-174, 177f-178f
large defects, 543, 549f
medium defects, 540, 544f-546f
small defects, 534, 534f
chin defects, 183-185, 185f
lip defects, 167-168, 178-179
case reports, 180-183, 181f-183f
lip defects, complications of, 714f,
718-719, 718f
melolabial, 233-235, 234f
preauricular skin defect, 620f
skin grafts with, 373f-374f, 380
Subcuticular sutures, placement of, 117
Submandibular transposition flaps, lip
reconstruction, 489, 490f
Suborbicularis oculi fat (SOOF), 388
Substance P (SP), 33
Superficial cutaneous hemangiomas, 770
Superficial musculoaponeurotic system
(SMAS), 530, 564f
dissection under, 117, 197
flaps, 558-560
temporal region of, 642f
Superficial temporal artery, 269-270, 269f,
641-644, 643f
auricular branches of, 588-589, 590f, 622,
624f
temporoparietal fascia flaps, 644,
655-660
transverse facial branch, 530
Superficial temporal fascia. see
Temporoparietal fascia.
Superior labial artery, 481
septal branch, 133-135, 418f
Superior labial vein, 481
Superior lateral palpebral artery, 391f
Superior medial palpebral artery, 391f
Superior palpebral arterial arches, 391f
Superoxide anion radical (O2-), 21
Superoxide dismutase (SOD), 23f, 25
Supraclavicular fossa, as skin graft donor
site, 456f-457f, 678f-680f
Supraclavicular region, as skin graft donor
site, 346, 351f, 353f, 550
Supraorbital and supratrochlear nerve block,
68-69
Supraorbital artery, 269-270, 269f, 391f,
563, 641-644, 643f
Supraorbital nerve, 563-564, 644
blocks of, 565
in paramedian forehead flaps, 289-291
surgical injury of, 586, 698-699
Supratrochlear artery, 269-270, 269f, 391f,
563, 641-644, 643f
paramedian forehead flaps, 270, 271f-272f,
276, 291, 453
Supratrochlear nerve, 563-564, 644
blocks of, 565
in paramedian forehead flaps, 289-293
surgical injury of, 586, 698-699
Surgical procedures, number of, 66t
Surgical technique, 42-49
complications of poor, 704-715
see also Suturing; Wound closure
Surgilene sutures, 57t
Surgilon sutures, 57t
Suture materials, 49-61
characteristics of, 49-53, 49t
definition of terms, 52t
natural fiber, 53-55, 55t
selection by region, 53t
synthetic fiber, 55-56, 56t-57t
United States Pharmacopoeia (USP),
suture classification system, 52-53
Suture needles, 56-61, 58f
body and application of, 56, 59, 62t
configurations of, 61f
definition of terms, 62t
interaction with suture holder, 59, 60f
nomenclature for, 57t
point types of, 56, 59f, 59t
swage, 61
taper ratio, 59, 62t
Suture pullout value, 52t
Sutures, 45
absorbable, 52-53, 52t, 54t-56t
coated braided, 49-52, 51f
cutaneous, 45, 46f
deep/subcutaneous/dermal, 45, 45f
distance from wound edge, 45, 46f
horizontal mattress, 45-47, 46f
intracuticular, 47, 47f
monofilament, 49-52, 51f
nonabsorbable, 52-53, 52t, 54t-55t,
57t
simple continuous (running), 45, 46f
simple interrupted, 45, 46f
sizes, 52-53
vertical mattress, 45-47, 46f
Suturing, 45, 46f
halving technique, 88-89, 108, 110f
skin edges of different thickness, 47, 48f
skin grafts, 355, 356f, 362f-364f
wound edge eversion, 43, 43f, 45, 45f
Sweat, 10
Sweat glands
apocrine, 7f, 10
eccrine, 10
Sympathetic nerves
blood flow regulation, 14-15
section after flap elevation, 18
Synthetic framework, 615-622
T
T-plasty, 89, 91f, 158-160, 159f-160f
lip defects, 178, 180f
temple defects, 171, 173f
Tape, for wound closure, 47-48, 48f
Tarsal plates, 388-391, 389f-390f
Tarsal rotation flap, eyelid reconstruction,
409f
Tarsal transposition flap, 407-409, 410f
Tarsoconjunctival flap, Hughes, 403-407,
406f, 408f
complications of, 409, 409f
Tarsoconjunctival grafts, 367, 402-403,
404f-405f
Tattooing, in scar, 752
Tears, 387
Telangiectasia, 701, 703f
Telogen, 9, 9f
Temple, 75f-76f
anatomic layers of, 641, 642f
defect, 102f
rhombic flap, 221-225
rotation flaps, 119-121, 120f-121f
skin defects of, 346f
skin grafts in, 345f, 686f-687f
skin grafts with local flaps, 377, 377f
T-plasty, 171, 173f
transposition flaps, 135, 142, 143f
Temporal artery, posterior branch, 524
Temporal branch, of seventh cranial nerve,
pathway of, 564f
Temporal cavity, resurfacing of, 622
Temporal region, anatomy of, 642f
Temporalis fascia graft, 761f-762f
Temporalis fascial flap, eyelid reconstruction,
402f
Temporalis muscle, 641, 642f
Temporoparietal fascia, 641, 642f
anatomy of, 622, 624f
Temporoparietal fascia flaps (TPFF)
in auricular reconstruction, 592-594, 610f,
622, 625f-629f
microtia and, 615-622
in scalp reconstruction, 644, 655-660
Temporoparietal scalp flaps
lip reconstruction, 524-526, 525f-527f
for preauricular skin defects, 623f
Tensile strength, 52
profiles, suture materials, 55t-56t
of suture material, 52t
Tenzel flap
indications for use of, 399-400
semicircular, 399, 400f-401f
complications of, 402, 402f
periosteal and temporalis fascial flaps,
401, 402f
Terminology, 71-73
Tetracaine, 391-392
Thirds, horizontal facial, 415
Thromboxane, synthesis of, 21f
Thromboxane synthetase, 20

INDEX
787
Tip angle, 62t
Tissue adhesives, 63
Tissue engineering, 26
Tissue expansion, 25, 671-696
biomechanics, 33, 34f
dermal thickness after, 35f
capsule development during, 674-675,
675f
complications associated with, 677f, 685f,
689f, 694-695
devices in, 664-665, 665f, 675-676, 675f
selection of, 676
in ear reconstruction, 677f, 689f, 693,
693f
external injection port of, 675-676, 683f,
692f-693f, 693-694
in face and neck, 685-693, 686f-693f
forehead, 306-309, 678f-680f, 681-685,
686f-688f
history of, 671
intraoperative, 694
eyelid reconstruction, 400
forehead reconstruction, 573, 577f
in scalp reconstruction, 663-664, 664f
modern use of, 671
physiologic and morphologic changes
during, 671-675
preoperative antibiotics in, 694
in scalp, 644, 660-665, 663f-664f,
678-681, 678f-684f
in scar revision, 731
techniques for, 676-678
Tissue-grasping forceps, 43
Tissue movement, 368
Tissue sealants, 61-63
Tissue transfer, 156
Tobacco, 26
usage of, 728-731
Tongue flaps, vermilion reconstruction,
485-487, 487f
Topical anesthesia, 68
ocular surface, 391-392
Tracheotomy scar, Z-plasty for revision of,
327, 328f
Transforming growth factor-α (TGF-α),
22f
Transforming growth factor-β (TGF-β),
22f
Transforming growth factor β1 (TGF-β1),
32-33
Transoral cross-lip flaps, 504-515
Transposition, 81
Transposition flaps, 77t, 131-155
advantages, 131
anterior lamellar defect, 396f
applications, 133-142
case reports, 142-155
cheek reconstruction. see under Cheek
reconstruction
classic design, 133, 134f
configurations of, 132t
cutaneous intralabial and perilabial, 489
design, 79-83, 80f-81f, 131, 132f
disadvantages, 133
forehead reconstruction, 566
full-thickness skin graft with, 372f
intralabial, 489
island, 133-135
melolabial. see Melolabial transposition
flaps
nasal, 432-433, 432f-433f
periocular area, 394
skin graft with, 368, 371f
submandibular, 489, 490f
tarsal, 407-409, 410f
Transverse facial artery, 391f
Trap-door deformities, 402f, 700f, 707-710,
710f, 712f, 756-761, 759f-760f
bilobe flaps, 141-142, 188, 190-192, 199,
203f-204f, 205, 208f-209f
cross-lip flaps, 510-511, 511f
melolabial transposition flaps, 492
scar revision for, 737-741, 745f-746f
transposition flaps, 133
Z-plasty correction of, 138, 324, 326f,
331, 332f-333f, 338
Traumatic auricular defect, 611f-612f
Traumatic avulsion, auricle, 618f
Traumatic defects
oral commissure and lip, 334-338,
335f-336f
in scalp, 645f, 657f, 663f, 666f, 678f-681f
Tretinoin, 10, 728-731, 745, 752
Triamcinolone acetonide
complication from, 703f, 710
for hematoma, 757f
for hypertrophic scars and keloids, 701,
702f, 747-748, 750f
for scar revision, 729f, 748, 749f
Triamcinolone injections, trap-door
deformities, 117-118, 133, 199
Triangular (A-shaped) defect, T-plasty,
158-160, 159f
see also Burow triangles
Triangular-shaped defects, rotation flaps,
78-79, 79f
Triangular skin defects, rotation flaps, 372
Triple rhombic flap technique, 221, 223f
Turbinate mucoperiosteal flaps, 428, 428f
Two-flap technique, Buck, 513-515, 515f
U
U-plasty. see Advancement flaps, unipedicle.
Ultimate moment, 62t
Undermining, 34-35, 43-44, 72
advance skin flap after, 39f
asymmetric, cheek repairs, 550
in broad-based flaps, 38f
technique, 43, 44f
Unipedicle advancement flap, 88-89, 88f
skin and muscle defect, 396f
United States Pharmacopoeia (USP)
classification system, 52-53
Up-and-down flap, Gillies, 268
V
V-shaped full-thickness lip excision, 495,
495f-497f
V-Y advancement flaps, 77t, 92-93, 92f, 99f,
161, 163f
periocular region, 394
in scar revision, 741-743, 758f
vermilion reconstruction, 161-162, 164f,
484, 484f
V-Y island pedicle advancement flaps
full-thickness lip repair, 522-524
nose reconstruction, 433-436, 434f-435f
see also Subcutaneous tissue pedicle island
advancement flaps (V-Y)
Varenicline, 26
Vascular anatomy
of skin, 705f
Vascular anomaly, 767
Vascular endothelial growth factor (VEGF),
21, 26
gene transfer, 26
Vascular lesion, 767
Vascular plexuses
deep, 11f, 12, 339
superficial, 11f, 12
Vascular supply
of auricle, 630
cheek, 530
eyelids, 391f
forehead, 269-270, 269f-270f, 563
impairment of, 16-18, 20f
internal nose, 417, 418f
lips, 481
of scalp, 641-644, 643f
skin flaps, 14-15
attempts to alter, 22-26
classification of, 17f
effects of nerve section, 18
skin grafts, 339-340
Vasculature, skin, 11f, 12, 339
Vasodilation, 14
Vasodilators, direct and indirect, 24
VEGF. see Vascular endothelial growth
factor (VEGF).
Venous insufficiency, of flap, 705
Venous malformations, 768-769, 769f
treatment for, 771-772, 771f
Venous outflow, skin flap elevation, 18
Venular malformations, 768
Vermilion, 530
advancement flaps, 179f, 487, 488f
approximation, full-thickness repair,
496
bipedicled mucosal advancement flap in,
744f
defect of, 483f
distortion of, 759f
full-thickness defect of, 488f
mucosal flaps, 483-484
notching/distortion of, 713f, 715f,
718f-719f
reconstruction, 483-487
tongue flaps, 485-487, 487f
V-Y advancement flaps in, 161-162, 164f,
484, 484f, 741-742, 742f
Z-plasties for border realignment, 324,
324f, 331, 332f, 335f-336f, 338,
732f-734f, 733, 749f
Vermilion flap, 518f
Vermilion line
mucocutaneous or anterior, 481
posterior, 481
Vessels, perfusion pressure, flaps, 16
Vestibular skin advancement flaps, bipedicle,
417-420, 419f, 442f
Viability
flap
attempts to alter, 22-26
wound-closure tension and, 33-34
skin grafts, factors affecting, 339
Vicryl sutures, 51f, 55, 56t
Viral infections, 701, 701f
Viscoelasticity, 31-32, 31f
Viscosity, blood, alterations to, 24
Vitamin E, preoperative discontinuation of,
66t, 697, 728-731
Vitiligo, 5
Von Bruns circumoral full-thickness rotation
advancement flaps, 498, 500f
W
W-plasty
forehead defects, 566, 568f-569f, 574f,
581f
in scar revision, 734-737, 736f-739f
Webster 30° rhombic flap with, 214,
218f
W-shaped full-thickness lip excision, 496,
496f-497f
Warren, J.M., 268

788
INDEX
Webs, skin, Z-plasty, 138, 139f, 324, 325f,
327, 331, 333f
Webster 30° rhombic flaps, 211, 214
design, 214, 218f
Webster modification of Bernard-von Burow
opposing cheek advancement flaps, 519,
520f-521f
Wedge-shaped full-thickness excision
in auricle, 592
lip, 495, 495f-497f
Weerda’s system, of congenital auricular
deformities, 631-632
Whitnall’s ligament, 391
Whitnall’s tubercle, 388
Wound breaking strength, 52t
Wound care, postoperative, 69-70
composite grafts, 359
dermabrasion, 49, 743-745
in scar revision, 741
skin grafts, 343, 357-358
Wound closure, 41-64
apposition techniques, 44-49
layered, 43-44
materials available for, 44
primary. see Primary wound closure
scar revision surgery for, 731
soft tissue technique, 43-44
subcuticular sutures, placement of,
117
surgical technique, 42-49
suture materials for, 49-61
suture needles for, 56-61
tension-free, 43-44
tissue sealants, 61-63
Wound closure tension, 71
advancement flaps, 88f, 91f, 156
excessive
case reports about, 715-720
causing flap ischemia, 704-705,
707f-708f
skin grafts for relieving, 369
forehead repairs, 583
Limberg flaps, 211-213
minimization techniques, 44-45, 71
pivotal flaps, 77-84, 78f-80f
suture type and, 52
tape closure and, 47-48, 48f
transposition flaps, 131, 135
Wound dehiscence, 701-703, 704f
Wound dressings, postoperative. see
Dressings, postoperative.
Wound edge eversion, 45, 45f
Wound healing, 21-22, 41-42
contributing factors to, 727-728
factors affecting, 42t, 703-704
stages of, 727
Wound infections, 700-701
effects on healing, 41
risk factors, 3
Wound strength, 42
Wound tension
blood flow and, 33-34, 36f
effect of, 37f
X
Xanthine oxidase, 21, 25
Y
Y-V advancement flaps, 77t, 92-93, 92f,
161-162
periocular region, 394
in scar revision, 741-743
Yield moment, 62t
Z
Z-plasty, 125f-126f, 137-140, 139f, 317-338
bilobe flap, 187, 197, 198f, 204f, 205
case reports on, 327-338
with curved limbs, 320, 321f
four-flap, 319-320, 320f, 324
geometry and design of, 317-320,
318f-320f, 318t
indications for, 138, 317
melolabial transposition flap revision,
245-249, 246f, 249f-251f
rhombic flap base, 221, 223f
in scar irregularization, 732-734,
732f-736f
surgical application and technique,
320-324, 321f-327f
with unequal angles, 319-320, 320f, 324,
327f, 335f-336f
Zygomatic unit, of cheek, 531f
skin defects of, 558f
Wound closure (Continued)