Local Flaps in Facial Reconstruction

344
SECTION I  FUNDAMENTALS
FIGURE 15-5  ■  A, Basal cell carcinoma of auricle. B, After tumor resection, windows made through cartilage for portals of ingrowth
of blood vessels to nourish skin graft. C, Thin full-thickness skin graft in place. D, Postoperative view at 6 months. No adjunctive
procedures performed. (Courtesy Shan R. Baker, MD.)
A
B
Windows
C
D

15  SKIN AND COMPOSITE GRAFTS
345
FIGURE 15-6  ■  Relationship of skin graft type to thickness of skin.
Epidermis
Dermis
Subcutaneous
Fat
Split Thickness Skin Graft
Full Thickness
Skin Graft
Thin Intermediate Thick
A
B
FIGURE 15-7  ■  A, A 2 × 2-cm skin defect of temple. B, Six months after repair with preauricular full-thickness skin graft. No adjunctive
procedures performed.

346
SECTION I  FUNDAMENTALS
forehead, melolabial fold, preauricular, postauricular, and
supraclavicular areas (Fig. 15-13). In selecting a donor
site, the thickness of the skin surrounding the recipient
site is assessed and donor skin is selected accordingly.
Regions of the face with thicker skin include the fore­
head, medial cheek, caudal nose, and chin. Skin defects
in these areas can be repaired with grafts from contralat­
eral facial donor sites and periauricular or supraclavicular
areas (Fig. 15-14). Regions of the face with thinner skin,
such as the eyelids and cephalic two-thirds of the nose,
are best repaired with skin grafts obtained from the eyelid
or periauricular area that are thinned appropriately. Skin
grafts harvested from the postauricular area are often
preferred in men because they are hairless. Men tend to
have shorter hair than women do, causing the postauricu­
lar skin to more likely manifest solar aging, which pro­
vides an improved skin color match with the facial skin
(Fig. 15-15). In contrast, preauricular skin is often the
preferred source for skin grafts in women. Preauricular
skin in women is hairless and has more solar aging com­
pared with postauricular skin. The supraclavicular region
is an excellent source for skin grafts, especially if a large
graft is required (Fig. 15-16). Supraclavicular skin has
moderate thickness, but the dermis of this donor skin can
be thinned so that the thickness of the graft will match
the depth of the recipient site.6
There are occasions when the author will use skin
grafts to repair shallow skin defects of the face even when
it is anticipated that the graft will result in a contour
depression or noticeable mismatch of skin texture or
color with adjacent native skin. These situations often
arise in caring for elderly debilitated patients who have
life-threatening illnesses. Another indication for use of a
skin graft in place of a more desirable local flap is in
described the use of dermal grafts at the time of skin graft
placement to help prevent contour depression after repair
of deeper defects. Their technique involves the place­
ment of dermal tissue in linear strips within the wound
bed, leaving adequate exposure of the wound bed to
provide nourishment to an overlying skin graft.5 The
author’s preference is to perform a delayed dermal fat
graft 3 months postoperatively if a significant contour
deformity exists.
The ideal cutaneous defect to repair with a full-
thickness skin graft is superficial, with loss of skin but not
underlying muscle. The vascularity of shallow wounds is
greater than that for defects extending through the
muscle to the underlying cartilage or bone. The ideal
defect is separated from the free margin of critical struc­
tures, such as the eyelid, nostril, and vermilion.
There is a wide variation of skin thickness among
individuals, and the overall thickness of the facial skin is
an important preoperative consideration. For similar
defects, a skin graft may provide a perfect match in terms
of thickness for one person and a poor match for another.
There are individuals who have thin skin covering the
entire face. These individuals are often fair-skinned
elderly women, and full-thickness skin grafts may be used
in these patients for superficial cutaneous defects any­
where on the face without concern for color or textural
discrepancies between graft and facial skin (Fig. 15-12).
The only exception to this rule is in the area of the
margins of the nostril, eyelid, and vermilion; scar con­
traction after skin grafting will likely distort the border
of these structures.
A number of donor sites for skin grafts are available
in most individuals, depending on the location and size
of the facial defect. Donor sites include upper eyelid,
FIGURE 15-8  ■  A, A 6 × 6-cm skin defect of temple after micrographic surgery for basal cell carcinoma. B, Five months after repair
with full-thickness skin graft from supraclavicular fossa. No adjunctive procedures performed. (Courtesy Shan R. Baker, MD.)
A
B

15  SKIN AND COMPOSITE GRAFTS
347
FIGURE 15-9  ■  A, B, A 1.5 × 1-cm-deep defect of ala repaired with full-thickness skin graft from supraclavicular fossa. C, D, Postopera­
tive views at 7 months. Scar tissue beneath graft assists with filling depth of wound, preventing contour discrepancy between graft
and adjacent nasal skin. Graft was dermabraded. (Courtesy Shan R. Baker, MD.)
A
C
B
D

348
SECTION I  FUNDAMENTALS
FIGURE 15-10  ■  A, B, A 2 × 2-cm-deep skin and soft tissue defect of nasal tip and sidewall. Repair with paramedian forehead flap
recommended but patient declined. Defect repaired with full-thickness skin graft from supraclavicular fossa. C, D, Postoperative
result at 5 months. No adjunctive surgery performed. No contour deformity occurred secondary to scar tissue deposition beneath
skin graft. (Courtesy Shan R. Baker, MD.)
A
B
C
D

15  SKIN AND COMPOSITE GRAFTS
349
FIGURE 15-11  ■  A, A 2 × 1.5-cm skin defect of nasal sidewall with exposed periosteum. Defect repaired with full-thickness skin graft.
B, Depressed contour of graft 3 months later. C, One year after staged dermal fat graft placed beneath skin graft and subsequent
dermabrasion of skin graft.
A
B
C
FIGURE 15-12  ■  A, One month after full-thickness skin grafting of cheek. Graft harvested from supraclavicular fossa. B, Three months
later. Graft has developed postinflammatory hyperpigmentation. C, Postoperative view at 10 months. Hyperpigmentation has
resolved. There are fewer skin color and textural discrepancies between graft and native skin in fair-skinned elderly patients. (Courtesy
Shan R. Baker, MD.)
A
B
C

350
SECTION I  FUNDAMENTALS
covering over the hinge flap, thereby completing a single-
stage reconstruction (Fig. 15-18).7
When skin defects of the nasal sidewall that extend to
the medial cheek are repaired with a skin graft, the cheek
component of the defect is reconstructed with a cutane­
ous advancement flap developed from the remaining
medial cheek skin. The flap is advanced to the level of
the nasofacial sulcus and anchored in place with deep
sutures that pass from the medial border of the flap to
the periosteum of the nasal sidewall. A full-thickness skin
graft is then used to resurface the sidewall. The cheek
advancement flap enables the placement of scars in the
aesthetic boundary between the cheek and nose. If the
cheek defect is of considerable size, the standing cutane­
ous deformities that occur from advancement of the
cheek flap may be excised and used as full-thickness skin
grafts to cover the sidewall defect (see Fig. 15-17).
Defects of the upper and lower eyelid that involve skin
and potentially muscle are often repaired with adjacent
tissue; however, this may not be available in sufficient
quantity, and reliance on local tissue only for repair could
result in a significant secondary deformity. For superficial
defects of the eyelids, skin grafts are a reasonable option.
Donor sites for the graft include the opposing and con­
tralateral eyelids, which provide skin with similar texture
and thickness. When skin grafts are used for periocular
reconstruction, it is important to determine whether the
structural integrity of the eyelid will withstand contrac­
tion forces associated with healing. For example, in lower
eyelid reconstruction, tightening of the lower eyelid by a
lateral tarsal strip procedure may help prevent develop­
ment of ectropion or eyelid retraction. In addition, the
author routinely uses a temporary lower eyelid suspen­
sion suture (Frost suture) during the initial 2 weeks after
lower eyelid skin grafting. By suspending the orbicularis
muscle, adhesions within the muscle that could lead to
lower eyelid retraction are avoided, and the likelihood of
ectropion is minimized.
Technique
All patients undergoing skin grafting receive preoperative
intravenous antibiotics, usually consisting of 1 g of
cefazolin or 600 mg of clindamycin if the patient is aller­
gic to penicillin. Oral antibiotics may be administered
during the first week postoperatively. The procedure is
performed with the patient receiving intravenous seda­
tion and local anesthesia (1% lidocaine with 1 : 100,000
concentration of epinephrine). The wound and donor
sites are cleaned with a povidone-iodine (Betadine) solu­
tion. The 45° bevel of defects resulting from micro­
graphic excision of skin cancer is maintained to assist the
transition between the graft and native skin. This creates
an incline from the base of the wound to the surface of
the surrounding skin and lessens the “step-down” contour
deformity that may develop. Additional beveling of the
defect may be performed if the skin graft is substantially
thinner than the depth of the recipient site.
A template is made of the recipient site by outlining
the periphery of the wound with a surgical marker and
pressing a nonadherent dressing pad over the marking. If
patients who have skin malignant neoplasms with aggres­
sive histologic growth patterns that predispose the patient
to recurrent tumor. In these instances, skin grafts may be
used as a temporary covering for a 2- or 3-year interval
while the patient is at greatest risk for recurrence of the
skin cancer.
Defects involving more than one facial region are often
repaired with separate techniques. For example, defects
located on the lateral nasal ala immediately adjacent to the
nasofacial sulcus may be repaired by a number of options.
If the defect extends into the cheek, the cheek component
of the defect is usually repaired with a cheek advancement
flap. The alar component may be repaired with an inter­
polated cheek or paramedian forehead flap if the defect is
large. For smaller defects, especially in very young patients,
full-thickness skin grafts and composite grafts are consid­
ered. Full-thickness grafts are best suited for superficial
defects not extending to the nostril border. In the case of
deep alar defects, skin grafts do not lend any structural
support, and subsequent nasal valve collapse may lead to
compromise of the nasal airway. One option for patients
with small, laterally located deep alar defects is the transfer
to the defect of subcutaneous cheek tissue in the form of
a hinge flap (Fig. 15-17). The flap partially fills the defect
and nourishes a cartilaginous alar framework graft placed
deep to the hinge flap to lend structural support to the
nostril. A full-thickness skin graft is placed as an external
FIGURE 15-13  ■  Common donor sites for full-thickness skin grafts
used in facial reconstruction.
Text continued on p. 355

15  SKIN AND COMPOSITE GRAFTS
351
FIGURE 15-14  ■  A, B, A 4 × 3-cm superficial skin defect of nasal dorsum and tip in patient with thin skin. C, D, Eight months after
repair with full-thickness skin graft harvested from supraclavicular fossa. Z-plasties performed at border of graft. (Courtesy Shan R.
Baker, MD.)
A
B
C
D

352
SECTION I  FUNDAMENTALS
FIGURE 15-15  ■  Skin posterior to auricle is the ideal source of full-thickness grafts to cover cutaneous defects of cephalic nose. Skin
from inferior aspect of region has greater solar aging and provides better color match with facial skin.
Less solar aging
Greater solar aging

15  SKIN AND COMPOSITE GRAFTS
353
FIGURE 15-16  ■  A, An 8.5 × 4.8-cm melanoma in situ. Peripheral suture line marks planned excision. B, Melanoma excised. C, Defect
repaired with full-thickness skin graft from supraclavicular fossa. D, E, Postoperative views at 10 months. (Courtesy Shan R. Baker,
MD.)
A
B
C
D
E

354
SECTION I  FUNDAMENTALS
FIGURE 15-17  ■  A, Fat hinge flap outlined by broken line is turned medially to cover cartilage graft placed along alar margins. Flap
fills soft tissue void. B, Broken line in melolabial crease represents incision necessary to enable medial advancement of cheek skin
to level of nasofacial sulcus. C, Borders of hinge flap tucked beneath nasal skin surrounding alar defect. D, Standing cutaneous
deformities from advancement flap excised and used as full-thickness skin grafts to cover hinge flap and to resurface ala. (From
Baker SR: Subcutaneous hinge cheek flaps. In Baker SR, editor: Principles of nasal reconstruction, ed 2, New York, Springer, 2011, p 252.)
A
B
C
D

15  SKIN AND COMPOSITE GRAFTS
355
sutures. Placement of petroleum-based antibiotic oint­
ment between the dressing layers helps stabilize the
bolster during suture fixation. Alternatively, cotton balls
covered with petroleum-based antibiotic ointment may
be wrapped with petrolatum 3% bismuth tribromo­
phenate (Xeroform) to create a similar bolster material
that is particularly helpful in covering larger wounds.
Larger bolsters are usually secured with interrupted 3-0
silk sutures placed in pairs into the surrounding skin 1 to
2 mm from the actual wound edge (see Fig. 15-19).
The bolster is left in place for 5 days. On removal, any
fluid collection beneath the skin graft is gently wicked
away by a rolling motion with a cotton-tipped applicator.
Any type of shearing motion is avoided as it may disrupt
vascularization of the graft. The patient is instructed to
keep the graft dry and to return in 1 week for reassess­
ment of the skin graft’s condition. If the graft has survived
and adheres well to the recipient site, the patient is
allowed to bathe the area.
The graft may appear cyanotic during the first few
days after transfer. It then transitions to a hyperemic
stage, which fades during weeks to months. On occasion,
a cyanotic graft may not survive. If the entire graft dies,
it will suppurate and separate from the recipient site
within 2 weeks. More commonly, the deeper portion of
the graft will survive while the more superficial portion
forms an eschar, which remains fixed to the wound bed.
When this occurs, the eschar is left in place as a biologic
dressing, allowing healing by secondary intention.
Re-epithelialization will occur from the wound edges and
from the viable deeper dermal component of the graft.
Sufficient dermis often survives to prevent the develop­
ment of a depressed scar after complete healing; however,
pigmentary and textural differences between facial skin
the defect is round, the shape may be modified by excis­
ing skin to create “corners.” This causes the defect and
covering graft to have angulated borders, which lessens
the likelihood of development of a trap-door deformity.
The template is fashioned and used to design the size and
configuration of the graft. Realizing that most full-
thickness skin grafts contract 10% to 15% after excision
from the donor site,8 the graft is designed slightly larger
than the defect to accommodate this contraction. The
graft is excised, and all subcutaneous tissue is removed
from the deep surface of the graft with use of curved iris
scissors. This is best accomplished by placing the graft
over the index finger, epidermal side down, and trimming
off excess fat until shiny dermis is visible. If reducing the
thickness of the graft is desirable, the same scissors are
used to remove portions of the exposed deep surface of
the dermis.
The skin graft is transferred to the recipient site and
oriented in a manner to maximize contact between wound
and graft. Excess graft is trimmed, leaving a slight redun­
dancy. The graft may be secured with multiple “tacking”
sutures that serve to attach the graft to the underlying
tissue, thereby maximizing surface adherence and graft
survival. Placement of tacking sutures may lead to punc­
tate areas of epidermolysis and eventual textural and
color discrepancies; therefore, the author attempts to
place these sutures along boundary lines separating aes­
thetic regions and units whenever possible. Graft edges
are secured to the borders of the recipient site with simple
interrupted 5-0 polypropylene or chromic sutures. One
end of each suture is left sufficiently long to be tied
with another suture at the opposite side of the graft
(Fig. 15-19). A bolster dressing is made from non­
adherent bandage or gauze and secured with opposing
FIGURE 15-18  ■  A, A 1 × 1.5-cm-deep alar defect, extending to but not through vestibular skin. Full-thickness skin graft used for repair
because of young age, propensity for future skin cancers, and desire to avoid cheek scar. Wound bed augmented with subcutaneous
tissue hinge flap followed by skin grafting. B, Postoperative view at 2 years. No adjunctive surgery performed.
A
B

356
SECTION I  FUNDAMENTALS
the office with use of local anesthesia and is usually per­
formed 8 weeks after successful grafting. The color and
textural match of skin grafts with adjacent facial skin
nearly always improves after dermabrasion. Grafts are
occasionally dermabraded a second time if the first treat­
ment fails to yield acceptable results.6
SPLIT-THICKNESS SKIN GRAFTS
Split-thickness skin grafts consist of epidermis and a vari­
able portion of underlying dermis. They have more capil­
laries exposed on their undersurface compared with
full-thickness grafts, permitting greater absorption of
and the skin graft are usually more apparent than when
the graft survives completely.
Adjunctive procedures to optimize the aesthetic
appearance of a graft may be performed 6 weeks after the
graft has healed. Trap-door deformities usually resolve
over time, especially if steroids are injected beneath the
graft. Grafts rarely require a surgical contouring proce­
dure, but Z-plasties are occasionally performed at the
border of the graft to enhance the appearance of the
transition between graft and native skin. Dermabrasion
of all full-thickness skin grafts used to resurface nasal
cutaneous defects is recommended. In addition to the
graft, the skin of the entire aesthetic unit surrounding the
graft is dermabraded. Dermabrasion is accomplished in
FIGURE 15-19  ■  Variations of tie-down bolster dressing. A, Tie-over sutures placed at wound edge as part of perimeter fixation of
graft. B-D, Alternatively, bolster sutures are placed 1 to 2 mm from wound edge.
B
A
C
D

15  SKIN AND COMPOSITE GRAFTS
357
nutrients from the wound bed. In addition, split-thickness
skin grafts consist of less tissue that requires revascular­
ization. As a result, split-thickness grafts are often used
for wounds in which revascularization is a concern.
However, because of their likely poor color and texture
match with normal skin and their tendency to contract,
split-thickness skin grafts are selectively used in facial
reconstruction. Some indications for split-thickness
skin grafts are to cover defects too large to be repaired
with a local flap (Fig. 15-20), to facilitate monitoring for
FIGURE 15-20  ■  A, Angiosarcoma of scalp. B, Area resected and covered with split-thickness skin graft. Area too large to be repaired
with local flap. C, Cotton bolster dressing. D, Postoperative view at 3 months. (Courtesy Shan R. Baker, MD.)
A
B
C
D
potential cancer recurrence, and to provide temporary
coverage of a wound bed before definitive reconstruction.
Most split-thickness grafts are between 0.012 and 0.030
inch in thickness; thicker grafts have a relatively better
color and texture match with facial skin.3
Technique
The electric Brown dermatome is a commonly used
device to harvest split-thickness skin grafts, usually from

358
SECTION I  FUNDAMENTALS
FIGURE 15-21  ■  Brown dermatome.
FIGURE 15-22  ■  Padgett dermatome.
the anterolateral thigh (Fig. 15-21). The dermatome is
assembled before use, placing the disposable metal blade
over the projecting rivets. The screws on the back of the
dermatome are tightened, and the device is calibrated.
Calibration involves setting the dermatome dials to 0,
then moving both dials simultaneously to set the graft
thickness dial at 0.015 inch, which corresponds to the
passage of the beveled portion of a Bard-Parker No. 15
blade between the blade and casing. The donor site is
marked, with the length of the graft equal to the greatest
dimension of the recipient site plus an additional 15% to
20% in anticipation of some graft shrinkage.3 Grafts may
be harvested under general anesthesia without use of a
local anesthetic. If the patient is receiving intravenous
sedation or no sedation, a local anesthetic consisting of
1% lidocaine with 1 : 100,000 concentration of epineph­
rine is injected subcutaneously at the donor site. After
skin preparation, mineral oil is placed over the donor site.
While the surgeon provides countertraction with his or
her nondominant hand, an assistant provides traction
with a tongue blade at the superior aspect of the donor
area. Light downward pressure is applied to the derma­
tome on the donor site while the dermatome is advanced.
Forceps are used to keep the graft from getting caught
in the dermatome; at the end of the donor area, the der­
matome is lifted away from the skin while still cutting.
This facilitates tapering of the graft in that area. Split-
thickness skin grafts are bolstered to the wound bed in a
fashion similar to full-thickness skin grafts. Before place­
ment of a compression dressing, small incisions may be
made in the graft at evenly spaced intervals to allow fluid
egress during the healing phase. Wound care after dress­
ing removal is the same as that for full-thickness grafts.
A gas-sterilized dermatome that is commonly used in
the operating room is the Padgett dermatome (Fig.
15-22). This dermatome comes with three templates,
allowing grafts with widths of 2, 4, or 6 inches to be
harvested. No calibration is necessary, and grafts are har­
vested in a fashion similar to that with the Brown
dermatome.
The donor site wound is dressed with gauze soaked in
hydrogen peroxide to facilitate hemostasis. The gauze is
then removed, the wound is padded dry, and a sterile
Tegaderm OpSite dressing is placed. Dry gauze secured
by tape is placed over the OpSite as a light compression
dressing, with care taken not to wrap the tape circumfer­
entially around the leg. Any fluid collection beneath the
dressing may be drained after removal of the gauze at 48
hours. This is accomplished by insertion of a sterile
needle through the OpSite to aspirate fluid, then “patch­
ing” of the needle hole with a small piece of OpSite. The
OpSite is left in place for 5 to 7 days, and on removal,
the wound is cared for by daily cleaning with saline and
application of bacitracin and a nonadherent gauze dress­
ing. Alternatively, hydrophilic polyurethane dressing
(Allevyn), which is highly absorbent and nonadherent,
may be used as a donor site dressing.3 This dressing
has an external layer similar to OpSite and an inner
layer that has an absorbent nature, which helps prevent
fluid buildup and leaks. Brodovsky et al9 suggested that
Nobecutane spray is an effective temporary dressing for
skin graft donor sites. The spray contains a modified
acrylic resin in an organic solvent and tetramethylthiu­
ram disulfide, which is a bactericidal-fungicidal agent.
When it is sprayed on a wound, the spray forms a trans­
parent plastic film that is shed spontaneously with epi­
dermal regeneration.9
COMPOSITE CHONDROCUTANEOUS GRAFTS
Composite grafts contain two or more tissue layers and
often are unsuccessful secondary to high metabolic
demands.10 They obtain their nourishment through
plasma imbibition during the first 24 hours after transfer.
This is followed by vascular inosculation. Ingrowth of
capillaries from the edges of the graft begins by the third
day.11,12
Composite grafts were first described by Konig,13 who
used composite auricular grafts to repair alar defects,
noting a 53% graft survival. Composite grafts have been
used to repair columellar defects14,15 and deficiencies in
nasal lining.16 During the first half of the 20th century,
Limberg17 advocated the cavum and cymba of the concha
as the preferred donor site of composite grafts used to
repair the nose, and Gillies18 described the transfer of
composite grafts to the undersurface of forehead flaps for
nasal reconstruction. Symonds and Crikelair19 also used
composite auricular grafts for nasal reconstruction,
reporting an 89% graft survival rate.
Composite grafts are commonly used to repair small
full-thickness nasal defects. The auricle is an excellent
donor source for composite grafts used for nasal recon­
struction because it provides a contoured graft of skin
and cartilage (Fig. 15-23). Certain segments of the auricle
can loosely replicate the delicate topography of the

15  SKIN AND COMPOSITE GRAFTS
359
FIGURE 15-23  ■  Common donor sites for composite grafts used
for nasal reconstruction.
columella, facet, and nostril margin, where composite
grafts are commonly employed. The skin is tightly
attached to the underlying cartilage at the columella and
to the fibrofatty tissue of the alae and facets. Likewise,
the skin covering the lateral aspect of the auricle is firmly
attached to the underlying cartilage. Common auricular
donor sites are helical crus, helical rim, antihelix, tragus,
antitragus, and fossa triangularis. The helical crus pro­
vides a good contour match for small nostril margin
defects and provides the option of incorporating in the
graft a segment of preauricular skin. Incorporation of
preauricular skin with the composite graft is useful for
resurfacing of larger nasal defects requiring considerable
skin but minimal framework replacement.6
The traditional recommendation is to limit the size of
composite grafts to 1 cm or less.20 Considerably larger
grafts may be successful if they are placed in a vascular
recipient site and the graft is designed so that no portion
is more than 1 cm from a wound edge.21-24 Skouge advo­
cated a tongue-and-groove technique when composite
grafts are used. This technique involves insetting the
border of the graft between two layers of tissue at the
recipient site.4 This method of graft attachment has
the effect of increasing surface contact between graft and
recipient site by 50%.20 If a defect is allowed to heal by
secondary intention and then reconstructed with a com­
posite graft, there is a greater success rate. In such
instances, a hinged flap of scar and epithelium formed
during secondary healing can be dissected to increase
the surface area for attachment of a composite graft
(Fig. 15-24).25
The ideal nasal defect for a composite auricular graft
is a small (1 cm or less) full-thickness defect of the facet,
columella, or nostril margin. The nasal skin in these areas
is extremely thin, lacking subcutaneous fat, and is tightly
attached to the alar cartilage in the case of the columella
and fibrous connective tissue in the case of the facets and
alae. Skin flaps used to repair the facet or columella
convey skin with subcutaneous fat and are thicker than
the native nasal skin. In contrast, composite auricular
grafts obtained from the helical crus provide a graft with
thin skin attached to a delicate segment of cartilage. The
cartilage provides structural support, and the skin closely
resembles the adjacent nasal skin of the columella and
facet (Fig. 15-25).
Perhaps more commonly, composite grafts are used to
repair small defects of the nostril margin (Fig. 15-26).
Deep wounds in this location may lead to notching of the
nostril margin. Composite grafts may be used to maintain
structural integrity and to provide a smooth continuous
border to the nostril.7 Weisberg and Becker26 described
the use of auricular composite grafts with stabilizing
struts for repair of such defects. The stabilizing struts are
extensions of cartilage that are placed beneath the adja­
cent nasal skin in a tongue-and-groove fashion similar to
Skouge’s original description (see Fig. 15-25).
The use of perioperative corticosteroids is beneficial
in enhancing survival of composite grafts in animals.
Rabbits treated with preoperative and postoperative
methylprednisolone demonstrated improved graft sur­
vival compared with animals receiving no steroids or
postoperative doses only. Attempts to salvage compro­
mised grafts with delayed administration of steroids were
not successful.27,28 Cooling of composite grafts has also
been demonstrated to improve survival. Cooling reduces
biologic requirements and improves graft survival in
irradiated, atrophic, or scarred recipient sites. Conley
demonstrated that constant application of ice and ice
compresses for 14 days effected a fall in skin temperature
from 38°F to 17°F. Composite grafts ranged in size from
1 × 1-cm to 2 × 2-cm. Of 12 composite grafts transferred
to the nose and treated with ice compresses, 10 survived
completely. Five of the grafts had been placed in recipient
sites with scarring or postirradiation fibrosis.29
Technique
Patient selection is important in considering the use of a
composite graft. The author restricts the use of compos­
ite grafts to small (<2 cm) nostril margins or columellar
defects in patients who are younger than 65 years, do not
use tobacco, and have no systemic illnesses that would
compromise graft revascularization. Patients receive anti­
biotics, wound preparation, and anesthesia similar to that
described for skin grafts. In addition, 60 mg of predni­
sone is administered on the day before surgery. The ste­
roids are tapered by 10 mg each day, eventually to 5 mg
on the seventh postoperative day.
There is an improved survival rate if grafting is delayed
until the defect has healed by secondary intention. The
defect is then prepared by removal of the epithelium and
subepithelial scar tissue, and a template is created that
measures 2 mm larger than the defect in all dimensions.

360
SECTION I  FUNDAMENTALS
A
B
C
D
FIGURE 15-24  ■  A, B, Full-thickness defect of nostril margin allowed to heal by secondary intention before repair with composite
auricular graft. C, D, Template 0.2 cm larger than defect used to design composite graft of antitragus.

15  SKIN AND COMPOSITE GRAFTS
361
E
F
G
H
E, Flap of soft tissue hinged on border of defect developed to enhance surface contact with graft. F, Composite
graft secured to recipient site with limited number of cutaneous sutures. G, H, Six months after grafting.
FIGURE 15-24, cont’d  ■

362
SECTION I  FUNDAMENTALS
A
B
Pattern for template
Template used to design graft
Skin
Cartilage
Epithelial hinge flap
C
D
G
E
F
FIGURE 15-25  ■  A, Full-thickness defect of nasal facet. B, Template designed from contralateral facet. C, D, A 1.2 × 1-cm composite
graft harvested from helical crus and donor site closed primarily. E, Ear cartilage extended between soft tissue leaves at recipient
site margin. F, Epithelial hinge flap created to maximize contact surface between graft and recipient site. G, Graft sutured in place.
Harvesting a graft that is slightly larger than the defect
accommodates the inevitable contraction of the graft.
Whenever possible, a flap of soft tissue hinged on a
border of the defect is developed to enhance surface
contact with the graft. A composite graft containing skin
and cartilage is harvested from the region of the auricle
that most closely matches the contour and thickness of
the recipient site (Fig. 15-27). The graft is placed in cold
saline, and the donor site is closed primarily with 5-0
polydioxanone sutures to approximate the edges of the
auricular cartilage and 5-0 polypropylene vertical mat­
tress sutures for the skin. The graft is transferred to the
recipient site and secured in place with 5-0 polypropylene
simple cutaneous sutures while limiting the degree of
graft manipulation. Subdermal or subcutaneous sutures
are not employed. With use of as few sutures as possible,
precise approximation of skin edges is accomplished. If
the graft is small, no sutures are placed through the car­
tilage. Larger grafts will require a few sutures approxi­
mating the cartilage of the composite graft to the cartilage
of the recipient site (Fig. 15-28). Limiting the number of
sutures used to fix the graft in place is thought to be
beneficial in enabling earlier and more abundant vessel
ingrowth.
An intranasal bolster in the form of a dental roll is
occasionally used to limit motion of the graft and to
prevent fluid accumulation between graft and recipient
site. Ice-saline compresses are applied for the first 3 days.
Successful grafts transition in color during the first week:
blanched at initial transfer, pink at 6 hours, cyanotic by
24 hours, and gradually becoming pink in 3 to 7 days.
Dermabrasion may be performed after 8 weeks. Compli­
cations include partial or complete graft loss, contracture,
pigmentary changes, and contour abnormalities.
OTHER COMPOSITE GRAFTS
Other types of composite grafts have been described for
nasal reconstruction. Composite grafts consisting of skin
and subcutaneous fat from the earlobe or full-thickness
Text continued on p. 367

15  SKIN AND COMPOSITE GRAFTS
363
H
I
J
K
H-M, Preoperative and 1-year postoperative views. Small Z-plasty at margin of graft and nostril performed 6
months postoperatively. Graft also dermabraded. (Courtesy Shan R. Baker, MD.)
FIGURE 15-25, cont’d  ■
Continued

364
SECTION I  FUNDAMENTALS
L
M
FIGURE 15-26  ■  A, C, Full-thickness defect, extending to nostril rim. Composite graft from ipsilateral antitragus used for reconstruc­
tion. B, D, Postoperative views at 18 months. Contouring procedure performed 3 months postoperatively.
A
B
C
D
FIGURE 15-25, cont’d

15  SKIN AND COMPOSITE GRAFTS
365
FIGURE 15-27  ■  A, B, Full-thickness defect of ala. C, D, Composite auricular graft harvested from antitragus. E, Hinge flap of epithelium
used to line interior of ala and to provide greater surface contact with composite graft. F, G, Composite graft sutured in place with
limited cutaneous sutures. H, I, Postoperative views at 3 months. No adjunctive surgery performed. (Courtesy Shan R. Baker, MD.)
A
B
C
D
E
F
G
H
I

366
SECTION I  FUNDAMENTALS
FIGURE 15-28  ■  Attachment of auricular composite graft to recipient site on nose. Suture knots tied external to graft.
INCORRECT
CORRECT
Cartilage to cartilage
Skin to skin
FIGURE 15-29  ■  Orientation of donor strip grafts from scalp to
eyebrow.
FIGURE 15-30  ■  Multidirectional orientation of hair growth of
eyebrow.

15  SKIN AND COMPOSITE GRAFTS
367
segments of the contralateral alar base may be used to
repair defects of the alar base or nostril margin.13 Stucker
and Shaw30 described the use of perichondrocutaneous
grafts that consist of epidermis, dermis, scant subcutane­
ous tissue, and a perichondrial layer. The grafts are har­
vested from the cavum concha, and an island pedicled
skin flap from the postauricular sulcus is used to repair
the donor site. These authors reported excellent aesthetic
results, with no contraction of the graft.31
Composite grafts may also be used in eyelid (see dis­
cussion in Chapter 17) and eyebrow reconstruction. Tar­
soconjunctival grafts are sometimes used for reconstruction
of the posterior lamellae of the eyelid. Furthermore, strip
grafting, involving the transfer of skin, hair follicles, and
fat from the scalp, has been used for eyebrow reconstruc­
tion (Fig. 15-29). Survival may be impaired in eyebrow
defects that are severely scarred. Although the results are
acceptable, strip grafting has been largely replaced by
microfollicular hair transfer.3 The multidirectional orien­
tation of eyebrow hair should be considered during
eyebrow reconstruction (Figs. 15-30 and 15-31).
REFERENCES
1. Johnson TM, Nelson BR. Anatomy of skin. In: Baker SR, Swanson
NA, editors. Local flaps in facial reconstruction. St. Louis: Mosby;
1995. p. 3.
2. Goding GS, Hom DB. Skin flap physiology. In: Baker SR, Swanson
NA, editors. Local flaps in facial reconstruction. St. Louis: Mosby;
1995. p. 15.
3. Glogau RG, Haas AF. Skin grafts. In: Baker SR, Swanson NA,
editors. Local flaps in facial reconstruction. St. Louis: Mosby; 1995.
p. 247.
4. Skouge JW. Skin grafting. New York: Churchill Livingstone; 1991.
5. Meyers S, Rohrer T, Grande D. Use of dermal grafts in recon­
structing deep nasal defects and shaping the ala nasi. Dermatol Surg
2001;27:300.
6. Jewett BS. Skin and composite grafts. In: Baker SR, editor. Prin­
ciples of nasal reconstruction. St. Louis: Mosby; 2002. p. 58.
7. Jewett BS. Repair of small nasal defects. Facial Plast Surg Clin
North Am 2005;13:283.
8. Hill TG. Reconstruction of nasal defects using full-thickness grafts:
a personal reappraisal. J Dermatol Surg Oncol 1983;12:995.
9. Brodovsky S, Dagan R, Ben-Bassatt M. Nobecutane spray as tem­
porary dressing of skin graft donor sites. J Dermatol Surg Oncol
1986;12:386.
FIGURE 15-31  ■  Orientation of harvested composite graft from contralateral eyebrow. Care is taken to maintain correct orientation of
hair growth at recipient eyebrow.
10. Konior RJ. Free composite grafts. Otolaryngol Clin North Am
1994;27:81.
11. Clairmont AA, Conley JJ. The uses and limitations of auricular
composite grafts. J Otolaryngol 1978;7:249.
12. McLaughlin CR. Composite ear grafts and their blood supply. Br
J Plast Surg 1954;7:274.
13. Konig F. Über Nasenplastik. Beitr Klin Chir 1914;94:515.
14. Converse JM. Reconstruction of nasolabial area by composite graft
from the concha. Plast Reconstr Surg 1950;5:247.
15. Meade RJ. Composite ear grafts for construction of columella.
Plast Reconstr Surg 1959;23:134.
16. Dingman RO, Walter C. Use of composite grafts in correction of
the short nose. Plast Reconstr Surg 1969;43:117.
17. Limberg A. Rhinoplasty using free transplant from concha. Sovet
Khir 1935;9:70.
18. Gillies HD. A new free graft applied to the reconstruction of the
nostril. Br J Surg 1943;30:305.
19. Symonds FC, Crikelair GF. Auricular composite grafts in nasal
reconstruction. Plast Reconstr Surg 1956;37:433.
20. Ballantyne DL, Converse JM. Vascularization of composite auricu­
lar grafts transplanted to the chorio-allantois of the chick embryo.
Transplant Bull 1958;5:373.
21. Ruch M. Utilization of composite free grafts. J Int Coll Surg
1958;30:274.
22. Becker OJ. Extended application of free composite grafts. Trans
Am Acad Ophthalmol Otolaryngol 1960;64:649.
23. Avelar JM, Psillakis JM, Viterbo F. Use of large composite grafts
in the reconstruction of deformities of the nose and ear. Br J Plast
Surg 1984;37:55.
24. Davenport G, Bernard FD. Improving the take of composite grafts.
Plast Reconstr Surg 1959;24:175.
25. Converse JM. Reconstructive plastic surgery, vol 2. Philadelphia,
WB Saunders; 1964.
26. Weisberg NK, Becker DS. Repair of nasal ala defects with conchal
bowl composite grafts. Dermatol Surg 2000;26:1047.
27. Aden KK, Biel MA. The evaluation of pharmacologic agents on
composite survival. Arch Otolaryngol Head Neck Surg 1992;
118:175.
28. Hartman DF, Good RL. Pharmacologic enhancement of composite
graft survival. Arch Otolaryngol Head Neck Surg 1987;113:720.
29. Conley JJ, Van Fraenkel P. The principle of cooling applied to the
composite graft in the nose. Plast Reconstr Surg 1956;17:444.
30. Stucker FJ, Shaw GY. The perichondrial cutaneous graft. Arch
Otolaryngol Head Neck Surg 1992;118:287.
31. Portuese W, Stucker F, Grafton W, et al. Perichondrial cutaneous
graft: an alternative in composite skin grafting. Arch Otolaryngol
Head Neck Surg 1989;115:705.

368
C H A P T E R 1 6 
THE USE OF SKIN GRAFTS WITH
LOCAL FLAPS
Jeffrey S. Moyer  •  Shan R. Baker
INTRODUCTION
The optimal aesthetic reconstruction with a local cutane­
ous flap is dependent on the size of the cutaneous defect
and the orientation of the flap in relationship to relaxed
skin tension lines (RSTLs). The effects on surrounding
facial structures from primary and secondary tissue move­
ment also influence the final outcome. Primary tissue
movement is the movement of a cutaneous flap necessary
to close a defect. Secondary tissue movement is the
movement of skin and facial structures adjacent to a
defect during the process of wound repair with a local
flap. Large cutaneous defects of the face are often difficult
to completely close with local flaps without significant
distortion of surrounding anatomy caused by secondary
tissue movement. When large facial skin defects are
reconstructed, facial structures that are frequently dis­
torted from secondary tissue movement include the
eyelid, eyebrow, nostril margin, anterior hairline, and
vermilion border. Of particular concern is ectropion of
the lower eyelid in elderly patients with significant laxity
of the canthal tendons. Retraction or ectropion of the
lower eyelid is common among these patients when skin
defects in the vicinity of the lower eyelid are repaired
with local flaps. To prevent distortions associated with
primary and secondary tissue movements after the trans­
fer of local flaps, full-thickness skin grafts can be used in
conjunction with the flaps to minimize distortion of facial
structures and to achieve optimal reconstruction.
Cutaneous defects of the medial cheek frequently
extend to the nose, crossing the aesthetic borders of the
alar-facial or nasofacial (cheek–nasal sidewall junction)
sulcus. For defects involving more than one aesthetic
facial region, reconstruction with a single cutaneous flap
may result in blunting or obliteration of the boundary
lines that topographically separate the regions. This may
lead to a suboptimal outcome. This is especially true of
concave boundary lines between the nose, cheek, and lip.
The concomitant use of a full-thickness skin graft and a
local flap to repair these types of defects will separate the
reconstruction into two distinct regions of healing and
may prevent blunting of aesthetic boundaries. The skin
graft is usually used to resurface the nasal component of
the defect, and an advancement flap is used to repair the
cheek component of the defect.
A full-thickness skin graft can also be combined
with a local flap in other ways. For instance, a flap of
subcutaneous tissue or muscle can be transferred to fill a
soft tissue void. A skin graft is then placed over the flap
to provide an epithelial cover for the repair. This tech­
nique is used to repair small but deep defects of the lateral
alae. Another situation in which a local flap may be com­
bined with a skin graft is for reconstruction of large facial
cutaneous defects that cannot be repaired with a local flap
alone or when excessive wound closure tension will occur
if a local flap is used by itself. Skin grafts may also be used
to cover the secondary defect resulting from transfer of
a local flap; an example of this is use of a graft to repair
the donor site of an intranasal bipedicled vestibular skin
advancement flap or a scalp flap. Using skin grafts to
close secondary defects rather than allowing the wound
to granulate reduces wound contraction.
PIVOTAL FLAPS WITH SKIN GRAFTS
There are four types of pivotal flaps: rotation, transposi­
tion, interpolated, and island.1-3 All pivotal flaps are
moved toward the defect by pivoting the flap around a
fixed point at the base of the pedicle. Except for island
flaps skeletonized to the level of their nutrient vessels,
the greater the arc of pivot, the shorter is the effective
length of the flap (see discussion in Chapter 6). Thus,
pivotal flaps must be carefully designed to accommodate
this reduction in length. As the flap turns in an arc
around its relatively fixed pivotal point, redundant
tissue, known as a standing cutaneous deformity (dog-
ear), develops at the base. Similar to the effective length
of the flap, there is a positive correlation between the
degree of pivoting of the flap and the size of the stand­
ing cutaneous deformity that forms. The greater the
pivot, the larger the deformity. Thus, increasing the
flap’s pivot will change the flap’s shape, shorten its effec­
tive length, and deform the flap’s base from develop­
ment of a standing cutaneous deformity. To limit these
restricting factors, a flap’s arc of pivot should not exceed
90° whenever possible. In addition to the development
of larger standing cutaneous deformities as a pivotal flap
turns on its base, the larger the size of the flap, the
larger in surface area is the deformity for a given pivotal
arc. For large pivotal flaps, this deformity can be of suf­
ficient size to allow its excision and use as a full-thickness
skin graft to assist the resurfacing of a portion of a cuta­
neous defect.

16  THE USE OF SKIN GRAFTS WITH LOCAL FLAPS
369
overall wound closure tension. It also enabled the use of
separate and different skin to reconstruct a defect involv­
ing two aesthetic regions of the face, the cheek and eyelid.
This in turn facilitated a more distinct topographic sepa­
ration of the eyelid from the cheek. The skin of the
standing cutaneous deformity was non–hair-bearing skin.
This skin was also thinner than the skin of the lower face.
Both of these qualities made the standing cutaneous
deformity of the transposition flap the ideal donor site
for the full-thickness skin graft. In this case, the skin graft
did not survive completely. As a result, the patient devel­
oped a minor ectropion of the lower eyelid. The possible
partial or complete failure of the skin graft is one of the
disadvantages of combining skin grafts with local flaps to
repair facial defects. The other major disadvantage of the
combined approach is the possible discrepancy of skin
color and texture between flap and graft. However, this
is uncommon when the source of the graft is the standing
cutaneous deformity formed by the local flap. When skin
grafts are harvested from a more distant site, skin color
and texture discrepancies are more likely to be observed.
Case 2
The note flap, a transposition flap originally described by
Walike and Larrabee,4 allows the closure of a circular
defect with a triangular flap. The design of this flap con­
sists of drawing a line tangent to a border of a circular
cutaneous defect and parallel to RSTLs for a distance of
1.5 times the defect diameter. A second line the same
length as the diameter of the defect is drawn at 50° to
60° to the first line to create a triangle-shaped flap. The
final flap design resembles a musical eighth note when it
is drawn. The surface area of the flap is typically 75% of
the surface area of the defect. Although ideally the flap is
used to repair skin defects smaller than 2 cm, larger
defects can be closed with this design. The major disad­
vantage with larger note flaps, as with most large trans­
position flaps, is that the standing cutaneous deformity
is also larger and requires removal. In addition, the
major tension vector is perpendicular to the tangential
border of the triangular flap, and it is this force that is
magnified with larger flaps. (See discussion of note flaps
in Chapter 8.)
A 74-year-old woman with a basal cell carcinoma of
the right cheek underwent micrographic surgical exci­
sion. The resulting skin defect measured 4 × 2.5-cm. A 5
× 1.8-cm laterally based note flap was designed for repair
(Fig. 16-3). In retrospect, the flap was not designed suf­
ficiently large enough to close the wound without exces­
sive wound closure tension. This was a particular problem
because of the proximity of the defect to the lower eyelid
in an elderly patient with lower eyelid laxity. When the
flap was transposed, tension caused the lower eyelid to
retract from secondary tissue movement. Thus, in addi­
tion to the flap, it was elected to use a 2.5 × 1-cm full-
thickness skin graft that was placed between the flap and
the inferior border of the eyelid. The skin graft was
obtained from the standing cutaneous deformity marked
in Figure 16-3A. Figure 16-3B shows the patient 5 days
after reconstruction and immediately after the removal
of a skin graft bolster dressing and sutures. The skin graft
Pivotal flaps are highly versatile and can be used to
repair many types of facial cutaneous defects. Whereas a
pure pivotal flap turns in an arc at its base and is not
stretched, most pivotal flaps have some component of
advancement. Provided the flap is the same size as the
defect, it is the advancement that can cause an increase
in wound closure tension and distortion of surrounding
facial structures. It is in these situations that the addition
of a skin graft can be beneficial. The combined use of
pivotal flaps and full-thickness skin grafts is usually
reserved for repair of very large defects in instances in
which the use of a skin graft is necessary to prevent exces­
sive wound closure tension. The other instance in which
this combination is used is when there is insufficient skin
at the flap donor site to close the secondary defect.
Case 1
A 52-year-old man presented for excision of atypical
junctional melanocytic hyperplasia of the cheek and
lower eyelid. This skin abnormality is considered to be
at high risk for transitioning to an invasive melanoma.
Margins free of disease around the lesion were obtained
by the square technique. (See discussion of the square
technique in Chapter 8, Case 3.) This resulted in an area
requiring resection that measured 4 × 4-cm (Fig. 16-1).
The patient’s facial skin was taut and the area of skin
excision large relative to the total surface area of the
cheek. A rhombic flap was designed for repair of the
cheek defect after resection of the lesion. Although
the rhombic flap was designed correctly, when the flap
was transposed to the recipient site after excision of the
skin lesion, excessive wound closure tension was noted.
The tension caused a downward pull on the lower eyelid
skin, raising concern for retraction or even ectropion of
the eyelid. For this reason, a full-thickness skin graft was
used to assist with repair. The graft was harvested from
the standing cutaneous deformity resulting from pivoting
of the flap. The skin graft was positioned between the
distal border of the flap and the lower eyelid. This com­
pletely relieved wound closure tension, and the wound
healed without distorting the eyelid. The proximity of
the donor site and the recipient site of the skin graft
ensured the best possible skin color and textural match
with adjacent facial skin.
A patient with the same disease as in Case 1 is shown
in Figure 16-2. It was necessary to resect a large area of
cheek skin in addition to skin of the lower eyelid. In this
case, a superiorly based transposition flap was selected for
repair to facilitate recruitment of skin for construction of
the flap from the jowl area. The jowl region has the great­
est skin redundancy of the face. The defect was too large
to completely cover with a transposition flap without
causing excessive wound closure tension. In this case,
such tension was likely to cause lower eyelid retraction
or ectropion. To prevent distortion of the lower eyelid, a
full-thickness skin graft was used to cover the eyelid com­
ponent of the defect after resection of the skin lesion.
The skin from the standing cutaneous deformity result­
ing from transfer of the flap (vertical lines of flap marked
in Fig. 16-2A) was excised and used as the source for the
skin graft. The skin graft served the purpose of reducing

370
SECTION I  FUNDAMENTALS
FIGURE 16-1  ■  Rhombic flap and full-thickness skin graft. A, Atypical junctional melanocytic hyperplasia measuring 4 × 4-cm. Tumor-
free margins around lesion determined by square technique. B, Inferiorly based rhombic flap designed for repair after excision of
lesion. C, Transposed flap combined with 3.5 × 2-cm full-thickness skin graft. Graft used to prevent downward traction on lower
eyelid. Skin graft obtained from standing cutaneous deformity excised at base of flap. D, Postoperative view at 13 months. No revi­
sion surgery performed.
A
B
C
D

16  THE USE OF SKIN GRAFTS WITH LOCAL FLAPS
371
FIGURE 16-2  ■  Transposition flap and full-thickness skin graft. A, B, A 4 × 5-cm lentigo maligna melanoma of cheek and lower eyelid.
Tumor-free margins around lesion determined by square technique. Transposition flap designed for repair of cheek defect after
resection of melanoma. Vertical marks indicate anticipated standing cutaneous deformity. C, D, Lesion excised and flap transposed.
E, Full-thickness skin graft (FTSG) used to repair lower eyelid component of defect. F, Postoperative view at 3 months. Mild retrac­
tion of lower eyelid developed from partial necrosis of skin graft.
A
B
C
D
E
F
FTSG

372
SECTION I  FUNDAMENTALS
The patient shown in Figure 16-4 developed a mela­
noma in situ of the right cheek. Tumor-free margins were
obtained around the skin lesion by the square technique.
The resulting area requiring excision measured 5 ×
3.5-cm. A 7 × 3.5-cm V-Y subcutaneous tissue pedicled
advancement flap was designed to reconstruct the cheek
after resection of the skin lesion (Fig. 16-4A). The
advancement flap proved to be of insufficient size to
cover the defect because of the limited superior mobility
of the flap. A 3 × 2.5-cm full-thickness skin graft was
obtained from the supraclavicular fossa and used to cover
the most superior portion of the defect (Fig. 16-4C).
Figure 16-4D shows the results of the reconstruction 6
months postoperatively. The skin graft was moderately
unsightly, and there was a depressed scar along the lateral
border of the transferred flap. For these reasons, a second
operation was performed in which incisions were made
along the superior and lateral borders of the healed flap.
The skin of the flap was widely undermined to develop a
cutaneous pedicled advancement flap. The mobilized
skin was advanced superomedially. Advancement was
such that most of the full-thickness skin graft was removed
and the resulting skin defect covered with the advance­
ment flap (Fig. 16-4E). Figure 16-4F-I shows the patient
before resection of her melanoma and 7 months after the
second-stage surgical procedure.
Similar to the last case, this case represents an example
of poor clinical judgment in designing a local flap. The
defect was large, the facial skin was taut, and the flap did
not provide sufficient skin to reach the most superior
aspect of the defect. A better method for reconstruction
of the patient would have been to use a large cervical
facial rotation advancement flap. Such a flap may have
prevented the need for use of a full-thickness skin graft.
healed completely and perfectly matched the skin color
and texture of the flap and adjacent facial skin. Most
important, however, was the maintenance of a normal
lower eyelid position and contour. This case represents
an example of selecting an inappropriate local flap to
repair a cutaneous defect. It was fortunate that a major
complication (ectropion or eyelid retraction) was avoided.
Avoidance of the likely complication of eyelid retraction
was made possible by use of a full-thickness skin graft to
assist the local flap in reconstruction of the defect.
Case 3
Rotation flaps are pivotal flaps with a curvilinear configu­
ration. They are designed immediately adjacent to the
defect and are best used to close triangular defects. In
such instances, the triangular defect is covered by a
portion of the standing cutaneous deformity, thus facili­
tating the pivotal movement of the flap and lessening the
need to excise the deformity. The greatest wound closure
tension of rotation flaps is at the advancing border of the
flap. A back cut at the base of the flap shifts the position
of the pivotal point and thus changes the wound closure
tension vector as well as the location of the standing
cutaneous deformity. There are several advantages of
rotation flaps. The flap has only two sides; thus it lends
itself to placement of one side in a border between aes­
thetic regions of the face. The flap is broad based, and
therefore its vascularity tends to be reliable. There is
great flexibility in the design and positioning of the flap.
When possible, the flap should be designed so that it is
inferiorly based, which promotes lymphatic drainage and
minimizes flap edema. Rotation flaps are discussed in
detail in Chapter 7.
FIGURE 16-3  ■  Transposition flap and full-thickness skin graft. A, A 5 × 1.8-cm laterally based transposition flap designed to close
4 × 2.5-cm skin defect of cheek. Vertical marks indicate anticipated standing cutaneous deformity. B, Five days after transfer of flap
combined with 2.5 × 1-cm full-thickness skin graft (FTSG). Graft was used to prevent lower eyelid retraction. C, Postoperative view
at 5 months. No revision surgery performed.
A
B
C
FTSG

16  THE USE OF SKIN GRAFTS WITH LOCAL FLAPS
373
A
B
C
D
E
FTSG
FTSG
FIGURE 16-4  ■  V-Y subcutaneous tissue pedicled island advancement flap and skin graft. A, A 5 × 3.5-cm melanoma in situ marked
for excision. B, Melanoma excised. A 7 × 3.5-cm V-Y subcutaneous tissue pedicled advancement flap designed for repair of cutane­
ous defect. C, V-Y flap in place. A 3 × 2.5-cm full-thickness skin graft (FTSG) used to cover remaining portion of defect. D, Postopera­
tive view at 6 months. Healed FTSG outlined in blue. Horizontal markings represent the superior portion of the V-Y advancement
flap. Arrow represents direction of movement of planned cutaneous pedicled advancement flap. E, Advancement flap in place.
Majority of FTSG resected and resulting defect covered by advancement flap.
Continued

374
SECTION I  FUNDAMENTALS
CERVICAL FACIAL FLAPS WITH
SKIN GRAFTS
Cervical facial flaps are usually designed as rotation
advancement flaps. The cervical facial rotation advance­
ment flap is primarily a rotation (pivotal) flap with a
curvilinear configuration. The flap pivots at its base and
has one border adjacent to the defect. What distinguishes
this flap from a pure rotation flap is that depending on
However, in repairing very large cutaneous cheek defects
with a cervical facial rotation advancement flap, it is not
uncommon that the flap must be combined with a skin
graft to achieve wound closure.
This case demonstrates the advantage of staging
reconstruction of large facial cutaneous defects. Use of
two surgical stages enabled the covering of the cheek
defect resulting from resection of the skin lesion with
adjacent cheek skin, which provided the best possible skin
color and texture match with the resected skin.
F
G
I
H
F-I, Before excision of melanoma and 7 months after second surgical stage. No revision surgery performed.
FIGURE 16-4, cont’d  ■

16  THE USE OF SKIN GRAFTS WITH LOCAL FLAPS
375
Case 4
A 71-year-old woman with lentigo maligna melanoma of
the left cheek required an extensive resection for com­
plete tumor clearance, resulting in a defect that measured
10 × 7-cm. The defect extended inferiorly from beneath
the left lower eyelid to below the angle of the mandible
(Fig. 16-5A). Although there was considerable skin
redundancy of the patient’s neck, there was insufficient
skin to construct a flap that would completely cover the
defect. Wide undermining of the cervical skin in the
subcutaneous plane was performed to create a large cervi­
cal facial advancement flap to assist with repair of the
defect. A full-thickness skin graft measuring 9 × 5-cm was
harvested from the supraclavicular fossa and used to
resurface the superior portion of the defect in the region
of greatest wound closure tension (Fig. 16-5B). Figure
16-5C demonstrates the 8-month postoperative result of
the reconstruction. The skin graft played an important
role in reconstruction of this large facial cutaneous defect
that could not be repaired solely with a local flap. Regional
and microsurgical flaps are the only alternatives to the
method used in this case. These flaps are more complex
and would not have provided as good an aesthetic result
as the method selected.
Case 5
A 72-year-old man developed atypical junctional melano­
cytic hyperplasia of the right cheek. This is considered a
pre-melanoma skin condition, and the patient underwent
a square technique to identify margins around the lesion
that were free of disease. An area of skin involving the
cheek and temple measuring 8 × 8-cm required surgical
excision (Fig. 16-6). A large cervical facial rotation
the size and location of the defect, there may be a signifi­
cant component of flap advancement that increases
wound closure tension. Cervical facial rotation advance­
ment flaps are particularly useful for repair of large facial
defects when a rotation flap without advancement would
cause excessive wound closure tension or distortion of
facial features. For very large cutaneous defects, even
large cervical facial flaps may not entirely resurface the
defect without causing significant distortion of surround­
ing structures. For these unique cases, a full-thickness
skin graft can provide an excellent adjunct to local flap
repair.
A cervical facial rotation advancement flap is fre­
quently used to repair large posterior cutaneous cheek
defects. The flap is designed with a portion of the incision
along the preauricular crease extending inferiorly and
posteriorly around the ear and along the postauricular
hairline to the anterior border of the trapezius muscle.
This design enables the recruitment of cervical skin in
the construction of the flap. The location of the incision
to create the flap provides an acceptable scar because it
is positioned in aesthetic boundaries even though it does
not typically fall within RSTLs. When full-thickness skin
grafts are combined with cervical facial rotation advance­
ment flaps, the graft is typically used to cover the portion
of the defect most distal from the base of the flap (loca­
tion of greatest wound closure tension). The graft is
usually obtained from the standing cutaneous deformity
that is created as the flap is pivoted and advanced. The
flap is always designed with an inferior base to recruit
skin from the upper neck and to facilitate lymphatic and
venous drainage. The following are three examples in
which cervical facial flaps were combined with full-
thickness skin grafts to repair large cutaneous defects of
the cheek.
FIGURE 16-5  ■  Cervical facial rotation advancement flap and full-thickness skin graft. A, A 10 × 7-cm skin defect of left cheek resulting
from removal of lentigo maligna melanoma. An 8 × 7-cm cervical facial rotation advancement flap designed to close inferior portion
of defect. B, Transferred flap combined with full-thickness skin graft used to cover superior portion of defect. C, Postoperative view
at 8 months. No revision surgery performed.
A
B
FTSG
C

376
SECTION I  FUNDAMENTALS
FIGURE 16-6  ■  Cervical facial rotation advancement flap and full-thickness skin graft. A, B, An 8 × 8-cm area of atypical junctional
melanocytic hyperplasia of cheek. Tumor-free margins around lesion determined by square technique. A 15 × 12-cm cervical facial
rotation advancement flap with Z-plasty at base designed to repair cheek after resection. Horizontal lines indicate anticipated stand­
ing cutaneous deformity. C, Flap transferred. Bolster dressing is covering full-thickness skin graft harvested from standing cutaneous
deformity formed by transfer of flap. D, Postoperative view at 6 years. No revision surgery performed.
A
B
C
D

16  THE USE OF SKIN GRAFTS WITH LOCAL FLAPS
377
Likewise, the skin graft placed adjacent to the temporal
hairline was camouflaged by the temporal tuft of hair.
ADVANCEMENT FLAPS WITH SKIN GRAFTS
There are three types of advancement flaps: unipedicle,
bipedicle, and island subcutaneous tissue pedicle. Biped­
icle advancement flaps are rarely used for repair of facial
cutaneous defects. Unipedicle advancement flaps are the
most common type of advancement flaps used for facial
reconstruction. However, island advancement flaps based
on a subcutaneous tissue pedicle are very useful for
reconstruction of cutaneous defects of the medial cheek.
Advancement flaps are designed with a linear orientation
such that the advancing edge of the flap is also a border
of the defect. The flap is advanced across the defect by
stretching the skin and “sliding” the flap into the defect.
The greatest vector of wound closure tension is perpen­
dicular to the distal border of the flap. For large skin
defects, significant undermining of skin surrounding the
defect to facilitate closure of the wound may have a sub­
optimal aesthetic and functional result from secondary
tissue movement. Secondary tissue movement that occurs
concomitantly with flap advancement may cause distor­
tion of facial structures, such as the vermilion, nostril
margin, eyelid, and eyebrow. At times it is preferable to
limit the extent of skin undermining to prevent distortion
of adjacent facial structures and to use a full-thickness
skin graft to cover a portion of the defect to complete the
wound closure. The standing cutaneous deformities that
are created by unipedicle advancement flaps can often be
excised and used as skin grafts.
advancement flap was designed to reconstruct the cheek
after resection of the skin lesion. The flap was insufficient
to cover the entire defect. A full-thickness skin graft was
used to assist the flap in repair of the wound. The graft
was harvested from the standing cutaneous deformity
created by transfer of the cervical facial flap. The flap and
graft survived completely and revision surgery was not
necessary. Figure 16-6D shows the results of reconstruc­
tion 6 years later.
Case 6
A 52-year-old woman with basal cell carcinomas of the
left temple and left upper lip was referred for wound
closure after micrographic surgical excision of the tumors.
The lip defect measured 2 × 1.5-cm and was closed with
a V-Y subcutaneous tissue pedicled advancement flap.
The left temple defect measured 5 × 5-cm (Fig. 16-7A).
A large cervical facial rotation advancement flap measur­
ing 15 × 20-cm was designed by marking an incision
extending from the temple along a preauricular crease
and then posteriorly to the border of the trapezius muscle,
where it continued to the inferior neck. The flap was
elevated in the subcutaneous tissue plane, pivoted, and
advanced to cover approximately 80% of the surface area
of the temple defect. A full-thickness skin graft measur­
ing 5 × 2-cm was used to cover the distal portion of the
defect (Fig. 16-7B). The graft was obtained by using the
redundant skin of the flap that overlapped the earlobe
after advancement of the flap. The 4-month postopera­
tive result is demonstrated in Figure 16-7C. The majority
of the scars were effectively camouflaged by positioning
incisions for the flap along aesthetic boundary lines.
FIGURE 16-7  ■  Cervical facial rotation advancement flap and full-thickness skin graft. A, A 5 × 5-cm left temple skin defect after exci­
sion of basal cell carcinoma. A 15 × 20-cm cervical facial rotation advancement flap designed to close defect. B, Flap transferred.
A 5 × 2-cm full-thickness skin graft used to cover superior portion of defect. C, Postoperative view at 4 months. No revision surgery
performed.
A
B
C

378
SECTION I  FUNDAMENTALS
vermilion and in some instances be instrumental in pres­
ervation of facial aesthetic borders.
Case 7
A 62-year-old man was diagnosed with atypical junctional
melanocytic hyperplasia of the right cheek. A margin free
of hyperplasia was established by the square technique
(Fig. 16-8A). The patient was referred for resection of
the lesion and reconstruction. The skin defect created
after the resection measured 8 × 7-cm and extended from
above the right lateral canthus to below the level of the
Unipedicle cheek advancement flaps typically depend
on the relative mobility and elasticity of the skin and soft
tissue of the lower face for movement of the flap. Unlike
pivotal flaps that generate only one standing cutaneous
deformity, unipedicle advancement flaps form two defor­
mities, one on either side of the advancing flap. For large
defects of the cheek repaired with an advancement flap
that is insufficient to cover the entire defect, the two
standing cutaneous deformities formed by skin advance­
ment can be excised and used as full-thickness skin grafts
to assist the flap with closure of the defect. This com­
bined approach may prevent distortion of the eyelid or
FIGURE 16-8  ■  Cheek advancement flap and full-thickness skin grafts. A, Atypical junctional melanocytic hyperplasia of cheek measur­
ing 8 × 7-cm. Tumor-free margins around lesion determined by square technique. B, Cutaneous defect after excision of lesion. Cheek
flap reflected inferiorly. C, A 10 × 15-cm advancement flap mobilized to resurface lower portion of defect. D, Superior portion of
defect (5 × 5-cm) covered with two full-thickness skin grafts (FTSG) obtained from excised standing cutaneous deformities resulting
from flap advancement. E, F, Postoperative views at 3 years. Scar revisions in form of Z-plasties performed after initial procedure.
A
B
FTSG
C
D
E
F

16  THE USE OF SKIN GRAFTS WITH LOCAL FLAPS
379
eyelid. Scar revision surgery including Z-plasty was nec­
essary to correct the eyelid retraction. This minor revi­
sion procedure produced a satisfactory aesthetic result
(Fig. 16-8E, F).
Case 8
A 67-year-old man was diagnosed with atypical junctional
melanocytic hyperplasia of the left cheek and nasal side­
wall. The square technique was used to ensure a tumor-
free margin (Fig. 16-9A). The resection necessary to
remove the entire lesion extended from the medial cheek
right oral commissure (Fig. 16-8B). A 10 × 15-cm uni­
pedicle advancement flap was designed for repair of the
defect. The advancement flap was of insufficient size to
completely cover the defect (Fig. 16-8C). The two stand­
ing cutaneous deformities created by advancement of the
flap were excised and used as full-thickness skin grafts to
resurface a 5 × 5-cm area of the superior portion of the
defect (Fig. 16-8D). The full-thickness skin grafts served
the purpose of reducing wound closure tension and pre­
venting distortion of the right ala and lower eyelid. The
flap and skin grafts healed without necrosis. However,
scar contracture caused mild retraction of the lower
FIGURE 16-9  ■  Cheek advancement flap and full-thickness skin grafts. A, A 3 × 3-cm lentigo maligna melanoma of nose, cheek, and
lower eyelid. Tumor-free margins around lesion determined by square technique. B, A 5 × 5-cm advancement flap designed to close
cheek component of defect after resection of lesion. C, Flap transferred. Nasal sidewall and lower eyelid components of defect
repaired with full-thickness skin grafts. D, E, Postoperative views at 7 months. No revision surgery performed.
A
B
C
D
E

380
SECTION I  FUNDAMENTALS
RSTL. Unlike with most other local cutaneous flaps, no
standing cutaneous deformity is created with V-Y island
advancement flaps, and thus there is no need to resect
skin as when standing cutaneous deformities are removed.
Case 9
A 71-year-old woman developed a large area of atypical
junctional melanocytic hyperplasia of the left cheek. Skin
margins around the lesion were established by the square
technique. The area requiring resection measured 4.5 ×
4-cm. The resection margin encroached on the left lower
eyelid and lateral canthus (Fig. 16-10A). A V-Y subcuta­
neous tissue pedicled island advancement flap was
designed to cover a portion of the defect resulting from
resection of the hyperplasia (Fig. 16-10B). It was not
possible to completely close the defect with the flap
because of the size and superior extent of the defect.
Attempts to advance the flap to the superior margin of
the defect would have caused downward traction on the
eyelid. This in turn would almost certainly have caused
lower eyelid retraction or ectropion. To avoid these prob­
lems, the 8 × 6-cm advancement flap was combined with
a 3.5 × 2.5-cm full-thickness skin graft. The graft was
used to close the superior portion of the defect near the
lower eyelid (Fig. 16-10C). Because V-Y subcutaneous
tissue pedicled island advancement flaps do not generate
a standing cutaneous deformity, the skin graft was har­
vested from the supraclavicular fossa. Figure 16-10D
depicts the 11-month postoperative result.
Case 10
An 81-year-old woman developed lentigo maligna mela­
noma of the left cheek. Tumor-free margins around the
skin lesion were obtained by the square technique (Fig.
16-11). She was referred for excision of the malignant
neoplasm and reconstruction of the face. The area requir­
ing resection measured 5 × 5-cm. As in Case 9, it was not
possible to completely repair the skin defect resulting
from tumor excision with a single local flap because of
the size and superior extent of the defect. A 12 × 5-cm
subcutaneous tissue pedicled island advancement flap was
designed for repair of the inferior portion of the cheek
defect once the malignant neoplasm was resected. A 5 ×
2.5-cm full-thickness skin graft was harvested from the
supraclavicular fossa and used to cover the superior
portion of the cheek defect. Both flap and skin graft
healed without necrosis or excessive scarring, with an
acceptable aesthetic result. In spite of the distant donor
site of the skin graft, color and textural match between
the skin of the flap and the skin graft was nearly ideal.
PRIMARY WOUND CLOSURE
WITH SKIN GRAFT
On occasion, cutaneous defects that are large in one
dimension and small in the other dimension present a
situation in which partial primary wound closure is pos­
sible without making incisions other than to excise the
onto the nasal sidewall and medial aspect of the lower
eyelid. A 5 × 5-cm unipedicle advancement flap was
designed to close the cheek component of the defect. The
flap design was modified so that the two incisions typi­
cally required to create an advancement flap were posi­
tioned in facial aesthetic boundaries rather than parallel
to each other. In this case, the incisions to create the flap
were placed in the melolabial crease and along the infra­
orbital bony rim (Fig. 16-9B). This flap design enabled
the inferior standing cutaneous deformity formed by
advancement of the flap to be excised in the melolabial
crease to camouflage the scar. To segregate the healing
process and to preserve the nasofacial sulcus, the nasal
sidewall defect was closed with a 3 × 1.5-cm full-thickness
skin graft. The component of the defect involving the
lower eyelid was also repaired with a separate full-
thickness skin graft. The grafts were obtained from the
excised standing cutaneous deformities that formed along
the infraorbital bony rim and in the melolabial crease
(Fig. 16-9C). The skin grafts served the purpose of reliev­
ing wound closure tension and maintaining aesthetic
boundaries between facial aesthetic regions.
For defects of the medial cheek that cross the nasofa­
cial sulcus, it is critical to preserve the sulcus by not
advancing cheek flaps onto the lateral nasal sidewall to
prevent blunting of this important aesthetic boundary
line.5 To achieve this goal, a cheek advancement flap can
be combined with a full-thickness skin graft. The cheek
skin is advanced to the nasofacial sulcus and the standing
cutaneous deformities are removed and used to graft the
nasal sidewall. This divides the healing process into two
distinct regions while maintaining a scar line in the
sulcus. In the case presented, the advancement flap caused
intraoperative inferior displacement of the lower eyelid
margin. To eliminate the retraction, a second full-
thickness skin graft was used to resurface the eyelid com­
ponent of the defect and to relieve the tension on the
eyelid caused by the flap.
The V-Y subcutaneous tissue pedicled island advance­
ment flap is a unipedicle advancement flap without sur­
rounding cutaneous attachments. The flap is designed as
an inverted triangle. The base of the triangle becomes
the advancing border of the flap. The flap is advanced
into the defect on a mobile subcutaneous fat pedicle. The
triangular secondary defect is closed by advancing skin
adjacent to the donor site, creating a Y configuration of
the wound closure. The island advancement flap is ideally
suited for repair of defects of the superior melolabial fold
(see discussion of this flap in Chapter 9). This is because
the flap is dependent on ample subcutaneous fat for
mobility and the medial cheek contains the greatest
amount of facial fat.6 The flap is less effective in repairing
medial cheek defects that are superior to the level of the
alae. However, in these instances, a full-thickness skin
graft combined with a V-Y subcutaneous tissue pedicled
island advancement flap may offer an aesthetically accept­
able alternative. Use of a skin graft in combination with
the flap limits the required length of the flap and the
necessary distance of advancement. Unlike rotation or
bilobe transposition flaps, the island flap can be designed
with most incisions in RSTLs. Ideally, the vertical limb
of the Y is aligned in an aesthetic border, rhytid, or

16  THE USE OF SKIN GRAFTS WITH LOCAL FLAPS
381
FIGURE 16-10  ■  V-Y subcutaneous tissue pedicled island advancement flap and full-thickness skin graft. A, Atypical junctional mela­
nocytic hyperplasia measuring 4.5 × 4-cm. Tumor-free margins around lesion determined by square technique. B, An 8 × 6-cm V-Y
subcutaneous tissue pedicled island advancement flap designed to close inferior portion of defect after resection of lesion. C, Lesion
excised, flap advanced. A 3.5 × 2.5-cm full-thickness skin graft used to resurface superior portion of defect covered by bolster dress­
ing. D, Postoperative view at 11 months. No revision surgery performed.
A
B
C
D

382
SECTION I  FUNDAMENTALS
FIGURE 16-11  ■  V-Y subcutaneous tissue pedicled island advancement flap and full-thickness skin graft. A, Lentigo maligna melanoma
measuring 5 × 5-cm. Tumor-free margins around lesion determined by square technique. A 12 × 5-cm V-Y subcutaneous tissue
pedicled island advancement flap designed to close inferior portion of defect after resection of lesion. B, Tumor excised. Island flap
mobilized on subcutaneous tissue. C, Flap in place. Superior portion of defect covered with full-thickness skin graft. D, E, Postopera­
tive views at 6 months. No revision surgery performed.
A
B
C
E
D

16  THE USE OF SKIN GRAFTS WITH LOCAL FLAPS
383
resulting from advancement of the borders of the wound
after resection of the melanoma was excised and used as
a full-thickness skin graft to repair the small (1 × 1.2-cm)
persistent skin defect of the lower eyelid. A cutaneous
advancement flap would have been the best alternative
method of wound repair. Partial primary wound closure
avoided the need for incisions perpendicular to RSTLs,
which would have been necessary to create an advance­
ment flap. It also reduced the area of dead space
created during wound repair compared with that neces­
sary with use of an advancement flap. This reduced the
risk for development of a postoperative hematoma or
seroma.
standing cutaneous deformities that form as a result of
primary wound repair.
Case 11
A 69-year-old woman developed melanoma in situ of
the left cheek. Tumor-free margins around the skin
lesion were obtained by the square technique (Fig.
16-12). The area requiring excision measured 5 ×
2.8-cm. The linear and relatively narrow configuration
of the planned excision created a situation in which
partial primary wound repair after excision was a rea­
sonable approach. The standing cutaneous deformity
FIGURE 16-12  ■  Partial primary wound closure and full-thickness skin graft. A, A 5 × 2.8-cm melanoma in situ marked for excision.
Anticipated standing cutaneous deformity (SCD) marked at inferior border of skin lesion. B, Melanoma excised. C, SCD excised.
Partial primary wound repair completed. Excised SCD used as full-thickness skin graft (FTSG) to repair persistent 1 × 1.2-cm skin
defect of lower eyelid. D, Gauze bolster in place over FTSG. E, F, Postoperative views at 4 months. No revision surgery
performed.
A
B
C
E
SCD excised here
FTSG
F
D

384
SECTION I  FUNDAMENTALS
flap and the most distal portion of the defect to relieve
wound closure tension. Skin grafts can also be used in
conjunction with local flaps to preserve aesthetic borders
or to assist with closure of the flap donor defect. Aesthetic
and functional outcomes are frequently enhanced with
this dual treatment approach. Skin grafts can subse­
quently be removed with serial excisions if it is deemed
necessary for improved aesthetic results.
REFERENCES
1. Baker SR. Reconstruction of facial defects. In: Cummings CW,
Fredrickson JM, Harker LA, et al, editors. Otolaryngology—head
and neck surgery. 3rd ed. Philadelphia: Mosby; 1998. p. 527.
2. Baker SR. Local cutaneous flaps in soft tissue augmentation and
reconstruction in the head and neck. Otolaryngol Clin North Am
1994;27:139.
3. Baker SR. Options for reconstruction in head and neck surgery. In:
Cummings CW, Fredrickson JM, editors. Otolaryngology—head
and neck surgery, Update 1. St. Louis: Mosby; 1989. p. 192.
4. Walike JW, Larrabee WF Jr. The note flap. Arch Otolaryngol
1985;111:430.
5. Baker SR. Nasal cutaneous flaps. In: Baker SR, editor. Principles of
nasal reconstruction. St. Louis: Mosby; 2002. p. 103.
6. Clevens RA, Baker SR. Defect analysis and options for reconstruc­
tion. Otolaryngol Clin North Am 1997;30:495.
Case 12
A 72-year-old woman presented with melanoma in situ
of the left cheek. Tumor-free margins around the skin
lesion were obtained by the square technique. The area
requiring excision measured 6 × 2.75-cm (Fig. 16-13).
Similar to Case 11, the area requiring resection had a
relatively linear narrow configuration. For this reason,
partial primary wound repair was planned with skin graft­
ing of the remainder of the wound after removal of the
melanoma. The advantages of selecting this surgical
approach for wound repair were the same as those listed
in Case 11.
CONCLUSION
Full-thickness skin grafts can be useful adjuncts to local
flaps in reconstruction of large facial cutaneous defects.
Repair of such defects with a single local flap may occa­
sionally result in undesirable secondary tissue movement,
which in turn causes distortion of adjacent facial features.
Skin grafts can be used to prevent undesired secondary
tissue movement. The graft is positioned between the
FIGURE 16-13  ■  Partial primary wound closure and full-thickness skin graft. A, A 6 × 2.75-cm melanoma in situ marked for excision.
B, After excision of melanoma, wound repaired by partial primary closure. Standing cutaneous deformity excised at inferior aspect
of wound used as full-thickness skin graft (FTSG) to repair superior portion of wound. C, Postoperative view at 3 years. No revision
surgery performed.
A
B
C
F
T
S
G

387
C H A P T E R 1 7 
RECONSTRUCTION OF THE EYELIDS
Robert G. Fante  •  Michael John Hawes
INTRODUCTION
During the past two centuries, hundreds of surgical pro­
cedures have been described for the purpose of eyelid
reconstruction, perhaps because of the great value
attached to the eyes and vision by our culture. The list
of eponymous flaps and techniques is daunting for any
student in this field, but rather than overwhelm the
reader with their diversity, the goal of this chapter is to
present a small number of reliably effective techniques
that will address the majority of common clinical situa­
tions likely to be encountered. Given the wide audience
for this book, this chapter concentrates on those proce­
dures found to be most reproducibly useful among sur­
geons of different disciplines. Mastery of the concepts
and surgical methods herein will also serve as a solid
foundation for additional study of advanced procedures
that may be best suited for unusual cases.
PHYSIOLOGY OF THE OCULAR
ANTERIOR SEGMENT
The mobile nature of the eyelids in ordinary use of the
eyes, together with the importance of their supportive
role in maintaining the air-tear interface at the cornea for
crisp vision and their central role in conveying facial
beauty and expression, creates substantial challenges for
the reconstructive surgeon. Detailed understanding of
the anatomy of the eyelids and ocular adnexa will aid the
surgeon in selecting reconstructive approaches that will
best restore ocular function while optimizing aesthetic
outcome.
The normal adult eyelids frame an elliptical palpebral
fissure measuring 8- to 11-mm vertically at the pupillary
meridian by 30- to 33-mm horizontally. Inside the fissure,
the ocular anterior segment composed primarily of con­
junctiva, cornea, and iris is visible. The lower eyelid has
a smoothly elliptical contour, but the upper eyelid contour
is characterized by a tighter medial curvature culminating
in an apogee at the medial border of the pupil. The pal­
pebral fissure most commonly slopes upward from medial
to lateral so that the lateral canthus is 2-mm higher
than the medial canthus. Phenotypic variations exist, and
senescence typically causes inferior dystopia of the lateral
canthus; the position of the medial canthus is stable
throughout adulthood. Minor aberrations in the size of
the palpebral fissures, the contour of the eyelids, and the
relative positions of the canthi dramatically affect the
appearance of the eyes to an onlooker, and asymmetry is
immediately apparent.
The upper and lower eyelids rest snugly on the ocular
surface in all locations except medially, where the car­
uncle, composed of sebaceous glands, is interposed and
partly covered. Conjunctiva on the surface of the globe
is continuous with the conjunctiva lining the inner surface
of the eyelids by means of a redundant fornix, most
prominently superiorly and inferiorly, where it is sup­
ported by attachments to the eyelid retractor muscles and
associated fascia. These relationships must be maintained
or restored during reconstruction to preserve blink effi­
ciency for corneal wetting and normal tear flow.
Tears are composed of three layers: an outer lipid
layer from the meibomian glands in each eyelid; a middle
aqueous layer from the main and accessory lacrimal
glands located in the superolateral orbit and conjunctival
fornices, respectively; and an inner mucin layer from
goblet cells in the conjunctiva. Basal tear production is
measured by Schirmer paper strips and topical anesthetic.
Inadequate production is commonly augmented with
artificial tears in older adults. Tear drainage occurs
through the lacrimal outflow system in each medial
canthus, and purposeful occlusion of outflow with sili­
cone plugs in the lacrimal puncta is also useful to improve
the tear film in patients with dry eyes. Minor ocular
irritation related to eyelid malpositions after reconstruc­
tion can often be improved with these strategies for tear
film enhancement.
Excessive tearing or epiphora can be a common
problem after eyelid reconstruction, resulting in blurred
reading vision and patient annoyance. A balance between
tear production and outflow is normally regulated by
reflex response to corneal sensation through a complex
neural arc involving cranial nerves V and VII. Primary
excess tear production is rare, but reflex overproduction
in response to corneal irritation (known as exposure
keratopathy) from eyelid malposition is common. Treat­
ment is aimed at resolving the exposure by improving
eyelid position and movement or by augmenting the
tear film as discussed before. Prolonged exposure kera­
topathy results in corneal scarring or infection with loss
of vision.
Interruption of tear drainage from damage to the lac­
rimal outflow system is common after eyelid reconstruc­
tion. The lacrimal puncta are normally in contact with
the ocular surface and eversion or ectropion may occur,
especially with lower eyelid reconstruction. The lacrimal
canaliculi connect the puncta with the lacrimal sac,
  Videos available online

388
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
The eyelid protractor is the orbicularis oculi muscle,
concentrically arranged around the palpebral fissure. It
is commonly divided into three sections. The pretarsal
segment overlies the tarsal plates and attaches to the
posterior lacrimal crest, deep to the lacrimal sac, together
with the posterior limb of the medial canthal tendon. The
gray line of the eyelid margin is formed by the innermost
fibers of the pretarsal orbicularis. The preseptal segment
overlies the orbital septum and attaches to the lacrimal
sac itself and also to the anterior limb of the medial
canthal tendon. Laterally, the pretarsal orbicularis con­
tributes to the lateral canthal tendon, together with ten­
dinous fibers from the tarsal plates. The pretarsal and
preseptal orbicularis fibers together form the lateral
canthal raphe. Finally, the orbital outermost segment of
the orbicularis overlies the orbital rim and interdigitates
with the frontalis muscle superiorly and the superficial
musculoaponeurotic system inferiorly. Superiorly, there
is a sub-brow fat pad between the orbital orbicularis
muscle and the frontal periosteum of the superolateral
orbital rim. Inferiorly, an analogous fat pad, the subor­
bicularis oculi fat, is between the orbital orbicularis and
the maxillary periosteum.
The lateral canthal tendon anchors the tarsal plates
posteriorly and superolaterally to Whitnall’s tubercle
inside the orbital rim. The lateral eyelids are thus kept
snugly against the globe in all positions of gaze. Medially,
the medial canthal tendon is the centerpiece of medial
canthal anatomy. The medial canthal tendon has an
elastic lateral portion that supports the lacrimal canaliculi
and then splits into anterior, superior, and posterior
limbs, all of which blend with the lacrimal sac fascia.1 The
thick anterior limb inserts on the maxillary bone, and the
superficial preseptal orbicularis muscle fibers insert on
the anterior limb (Fig. 17-3). The superior branch extends
to the lacrimal sac apex and covers the anterosuperior
portion of the lacrimal sac.2 The thin posterior limb
forms the anterior fascia of the pretarsal orbicularis
muscle and inserts on the posterior lacrimal crest formed
by the lacrimal bone. It acts as a horizontal supporting
band that posteriorly directs forces generated by the pre­
tarsal muscle fibers. The lateral portion of the medial
canthal tendon invests the fragile lacrimal canaliculi.
Reconstruction at either canthus must re-create the deep
attachments of the canthal tendons inside the orbit to
avoid symptomatic eyelid malpositions.
Posterior to the orbicularis oculi muscle is the orbital
septum, a multilayer fascia separating the superficial
eyelid and skin adnexa from the orbit. It extends from the
arcus marginalis of the orbital rim to the levator aponeu­
rosis and capsulopalpebral fascia before their insertion on
the tarsal plates. It is nondistensible and avascular, making
it an excellent surgical landmark.
The tarsal plates are composed of dense connective
tissue and house the meibomian glands that produce oil
for the tears. The upper eyelid tarsus is 10- to 12-mm in
height and tapers medially and laterally. It is 16- to
20-mm in length and approximately 1-mm thick. The
lower eyelid tarsus is 4- to 5-mm in height but similar
in length and thickness to the upper tarsus. Both
are anchored medially and laterally to the orbital rim
by the canthal tendons, as described before. The
located posterior to the palpable anterior limb of the
medial canthal tendon. The upper and lower canaliculi
are encased in fibers of the orbicularis oculi muscle,
which insert onto the lateral wall of the lacrimal sac.
Contraction of the orbicularis oculi during blinking
pumps the tears into the lacrimal sac. From there, the
tears drain to the inferior nasal meatus via the nasolacri­
mal duct through the maxilla. Surgery in the region of
the medial canthus frequently results in epiphora caused
by injury to the canaliculi, the lacrimal sac, or the orbi­
cularis oculi fibers that form the lacrimal pump. Primary
repair of the canaliculi is obligatory when trauma or
tumor excision results in their interruption.
SURGICAL ANATOMY OF THE EYELIDS
With a clearer understanding of the physiologic role of
the eyelids in maintaining vision from the foregoing,
more detailed review of eyelid anatomy is necessary to
grasp the methodology of surgical eyelid reconstruction.
Vertically, the palpebral fissure measures 8- to 12-mm,
such that the upper eyelid rests 3- to 4-mm above the
center of the pupil and the lower eyelid rests at the infe­
rior limbus. The peak of the upper eyelid contour is
medial to the pupil, whereas the lowest point of the lower
eyelid contour is lateral to the pupil. Measurement of
eyelid position is accomplished with the patient looking
in primary gaze (straight ahead) and should be docu­
mented preoperatively and postoperatively. The upper
eyelid crease is 6- to 12-mm above the eyelashes in blacks
and whites (0-6-mm above the eyelashes in Asians) and
is formed by the cutaneous insertion of the aponeurosis
of the levator palpebrae superioris muscle. The lower
eyelid crease is inconsistently present at approximately
3- to 5-mm below the eyelid margin. Additional useful
measurements include the range of upper eyelid excur­
sion, typically 10- to 15-mm, obtained by measuring
movement of the upper eyelid margin from extreme
downward gaze to extreme upward gaze, with the eyebrow
fixed with digital pressure from the examiner. The pres­
ence and degree of failure of eyelid closure or lagophthal­
mos is also routinely measured, with notation if gentle or
forced contraction of the orbicularis oculi is necessary for
eyelid competence.
The multilaminar structure of the eyelids varies
according to distance from the palpebral fissure. For the
upper eyelid below the lid crease, the layers include the
epidermal skin with minimal dermis, orbicularis oculi
muscle, levator aponeurosis, tarsus, and conjunctiva.
Above the lid crease, the layers include skin, orbicularis
oculi, orbital septum, orbital fat, levator aponeurosis,
Müller’s muscle, and conjunctiva (Fig. 17-1).
The lower eyelid has similar structures, except that the
retractor (analogous to the levator muscle) is the capsulo­
palpebral fascia. This fascia is an extension of the inferior
rectus muscle sheath that inserts at the inferior border of
the lower eyelid tarsus and causes passive downward
movement of the lower eyelid in downward gaze. A
sympathetically innervated inferior tarsal muscle analogous
to Müller’s muscle is also present in most individuals
(Fig. 17-2).

17  RECONSTRUCTION OF THE EYELIDS
389
FIGURE 17-1  ■  Anatomy of the upper eyelid.
Fat
Orbital septum
Müller’s muscle
Conjunctiva
Levator aponeurosis
Tarsal plate
Meibomian glands
Gray line
Skin
Eyelid crease
Orbicularis muscle

390
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 17-3  ■  Anatomy of the medial canthus. MCT, medial canthal tendon.
Superior preseptal m.
Superior branch of MCT
Superior deep pretarsal m.
Inferior deep pretarsal m.
Medial canthal tendon
enclosing canaliculi
Inferior superficial
pretarsal m.
Inferior deep
preseptal m.
Inferior superficial
preseptal m.
Superior superficial
pretarsal m.
FIGURE 17-2  ■  Anatomy of the lower eyelid.
Orbital septum
Inferior tarsal muscle
Capsulopalpebral fascia
Conjunctiva
Tarsal plate
Meibomian glands
Gray line
Skin
Orbicularis oculi muscle

17  RECONSTRUCTION OF THE EYELIDS
391
and Müller’s muscle to the upper lid tarsus causes ptosis,
loss of the attachments of the capsulopalpebral fascia and
inferior tarsal muscle to the lower lid tarsus commonly
causes rotational instability of the lower eyelid and
entropion.
The vascular supply to the region comes from the
internal and external carotid systems. Branches from the
ophthalmic artery in the posterior orbit pass forward as
the anterior ciliary arteries and contribute to the superior
and inferior tarsal arcades in the eyelids (Fig. 17-4).
Branches from the facial artery supply the medial and
lateral canthus and also contribute to the eyelid vascular
arcades. Risk of eyelid vascular compromise exists if the
arteries are interrupted both medially and laterally.
For the purposes of eyelid reconstruction, the ana­
tomic layers can be divided into anterior and posterior
lamellae. The anterior lamella is composed of the skin
and eyelid protractor, the orbicularis muscle; the poste­
rior lamella is composed of the conjunctiva, tarsus, and
eyelid retractors. The orbital septum can be considered
a middle lamella and is not typically reconstructed;
however, prevention of contracture and tension in the
orbital septum can avoid severe compromise to eyelid
excursion postoperatively.
ANESTHESIA
Topical tetracaine 1% or proparacaine 0.5% eye drops
are used to anesthetize the ocular surface and are repeated
as needed for patient comfort. Frequent lubrication of
posterior surface in each case is lined with densely adher­
ent conjunctiva.
In the upper eyelid, the levator muscle originates pos­
teriorly in the orbit and is redirected by Whitnall’s liga­
ment to insert on the anterior surface of the tarsus as a
broad aponeurosis. Whitnall’s ligament runs horizontally
from the trochlea to Whitnall’s tubercle and acts as a
pulley for the levator. The levator muscle and aponeuro­
sis are invested loosely by orbital fat anteriorly until the
aponeurosis fuses with the orbital septum at or above its
insertion at the tarsus. It is innervated by the oculomotor
nerve (cranial nerve III).
The sympathetically innervated Müller’s muscle arises
from the posterior surface of the levator at the junction
of the muscle and aponeurosis and inserts onto the supe­
rior border of the tarsus. The insertion is associated with
a rich vascular plexus. Loosely adherent conjunctiva lines
the posterior surface of Müller’s muscle. Suspensory liga­
ments from the levator support the superior conjunctival
fornix.
In the lower eyelid, the capsulopalpebral fascia arises
from the inferior rectus, splits to envelope the inferior
oblique muscle, and then inserts at the anterior inferior
border of the tarsal plate. It has few attachments to the
skin and so the lower lid crease is poorly formed. The
capsulopalpebral fascia is loosely attached to the inferior
forniceal conjunctiva posteriorly and the orbital fat ante­
riorly. The sympathetically innervated inferior tarsal
muscle arises from the posterior surface of the capsulo­
palpebral fascia and inserts at the inferior tarsal border.
Whereas loss of the normal attachments of the levator
FIGURE 17-4  ■  Vascular supply to the eyelids.
Superior lateral
palpebral a.
Inferior lateral
palpebral a.
Transverse facial a.
Infraorbital a.
Supraorbital a.
Supratrochlear a.
Dorsal nasal a.
Superior medial
palpebral a.
Angular a.
Inferior medial
palpebral a.
Superior and inferior
palpebral arterial arches
Facial a.

392
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
the cornea with ophthalmic petrolatum ointment or
hydroxypropyl cellulose eye drops will also improve
patient comfort during and after surgery.
Local anesthesia with monitored sedation is usually
preferred, although reconstruction of the lacrimal drain­
age system or very large defects may require general
anesthesia. Lidocaine 1% with 1 : 100,000 concentration
of epinephrine is mixed 1 : 1 with bupivacaine 0.75% for
most cases. The addition of 150 units of hyaluronidase
per 10 mL of local anesthetic greatly facilitates more
rapid distribution and also enhances regional vasocon­
striction from epinephrine. A 27- or 30-gauge needle is
preferred for superficial infiltration, and injection tech­
nique should steer clear of subcutaneous vessels and the
orbicularis muscle to avoid ecchymosis. Injection of
small aliquots deeply inside the lateral orbital rim is
helpful for lateral canthal tendon reconstruction, and
subconjunctival infiltration with 1 to 2 mL is also gen­
erally useful in full-thickness eyelid reconstruction. An
infratrochlear block may be used for surgery in the
medial canthus, and cocaine 4% topically is expedient
for intranasal anesthesia needed for passage of lacrimal
stents.
RECONSTRUCTIVE OBJECTIVES
The primary objective of eyelid reconstruction is to rees­
tablish functional eyelids that protect the eye and permit
normal vision. Normal tear film maintenance necessary
for corneal clarity and patient comfort is a corollary pre­
requisite. The most important secondary goal is normal
or improved appearance because the periocular region is
critical in interpersonal relations. Loss of eyelid tissue is
caused most commonly by surgical excision of neoplasms
but also by burns, trauma, necrotic infections, congenital
colobomas, and medical interventions (such as steroid
injections, cryotherapy, and irradiation). Surgical objec­
tives include the following:
1. Nonkeratinizing mucosal epithelium to line the
inside of the reconstructed eyelid to protect and
to wet the cornea
2. Rotationally stable eyelid margin with a mucocu­
taneous junction to protect the eye from skin,
lanugo hairs, and lashes
3. Posterior apposition to the globe in all areas of the
reconstructed eyelid
4. Moderately flexible, firm connective tissue frame
to provide support and shape for the eyelid
5. Adequate protractor muscle to close the eyelids,
to provide a normal blink, and to assist in poste­
rior apposition of the eyelid to the eye
6. Lack of orbital septal contracture or attachments
that restrict eyelid excursion
7. Supple, thin skin that permits normal eyelid
excursion
8. Adequate levator muscle function to provide
upper lid clearance of the pupil
9. Appropriate height and shape of the reconstructed
eyelid and the medial and lateral canthi to main­
tain symmetry with the contralateral side
10. Minimally visible scars
TABLE 17-1  Algorithm for Full-Thickness
Lower Eyelid Reconstruction
Size of Eyelid
Margin Defect
(eyelid width)
Repair
<25%
Direct closure
25%-50%
Direct closure with lateral cantholysis
25%-80%
Tarsoconjunctival graft and skin-
muscle flap
33%-66%
Semicircular flap
50%-75%
Semicircular flap with periosteal flap
50%-100%
Tarsoconjunctival flap and skin graft
TABLE 17-2  Algorithm for Full-Thickness
Upper Eyelid Reconstruction
Size of Eyelid
Margin Defect
(eyelid width)
Repair
<25%
Direct closure
25%-50%
Direct closure with lateral cantholysis
25%-50%
Tarsal rotation flap and skin-muscle flap
or skin graft
25%-75%
Tarsoconjunctival graft and skin-muscle
flap
33%-66%
Semicircular flap with periosteal flap
50%-100%
Cutler-Beard flap
The single most useful reconstructive strategy to achieve
most of these objectives is conversion of vertical surgical
tension to horizontal tension in the eyelids whenever
possible.
Surgical planning is facilitated by conceptually divid­
ing the eyelids into anterior and posterior lamellae. The
anterior lamella is composed of the skin and the
orbicularis muscle; the posterior lamella is composed of
the conjunctiva, tarsus, and eyelid retractors. For full-
thickness defects, both lamellae usually require recon­
struction. In these cases, at least one of the reconstructed
lamellae typically must include a blood supply. Com­
monly used, reliable surgical techniques are listed in
Tables 17-1 and 17-2 and involve various flaps and grafts.
Selection will depend on the size, location, depth, and
configuration of the defect. Some superficial defects may
require only reconstruction of the anterior lamella, and
choice of flap or graft is primarily dependent on the need
to restore a mobile, cosmetically satisfactory eyelid or to
restore normal canthal position. When necessary, recon­
struction of the lacrimal tear drainage system is accom­
plished concomitantly.
RELAXED SKIN TENSION LINES
Relaxed skin tension lines (RSTLs) are a generally useful
guide for the reconstructive surgeon in the attempt to
minimize cutaneous scars.3 Around the eyes, these lines
follow the lines of facial expression (Fig. 17-5) and are
oriented horizontally in the upper and lower eyelid skin.

17  RECONSTRUCTION OF THE EYELIDS
393
Unfortunately, vertical tension created by closure of
elliptical defects oriented along RSTLs in the eyelids has
a substantial risk of creating iatrogenic cicatricial eyelid
malpositions, including retraction and ectropion. Asymp­
tomatic laxity in the medial and lateral canthal tendons,
commonly present in the elderly, will permit downward
migration of the lower lids. Similarly, ineffective
FIGURE 17-5  ■  Periorbital wrinkle and relaxed
skin tension lines.
FIGURE 17-6  ■  Orientation of elliptical excisions in the periorbital region to minimize wound closure tension and to prevent retraction
of the upper or lower eyelid.
senescent or neuropathic orbicularis muscle tone will
predispose patients to lower eyelid ectropion or upper
eyelid retraction and lagophthalmos. For these reasons,
horizontal tension is usually preferred for closure of
eyelid wounds, and the long axis of any ellipse will be
perpendicular to the eyelid margin (Fig. 17-6). Excessive
dermatochalasis in the upper eyelid that would otherwise

394
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
require blepharoplasty may permit the use of horizontally
oriented ellipses in the lid crease for some individuals.
Conversely, for the glabella, medial canthus, eyebrows,
and lateral canthus, use of RSTLs for wound orientation
will produce satisfactory outcomes (see Fig. 17-6).
LOCAL SKIN FLAPS FOR
SUPERFICIAL DEFECTS
The simple ellipse is often used for excision of small facial
lesions, including those in the periocular area. Whereas
the long axis of such an ellipse is usually oriented parallel
to RSTLs, ellipses are oriented perpendicular to RSTLs
in the eyelids to minimize vertical tension and the risk of
cicatricial ectropion. Because the ellipse sacrifices up to
160% of the surface area of the excised lesion of interest,
modified ellipses such as the double S ellipse and O-Z
plasty can be used to conserve normal tissue (Fig. 17-7).
Local skin flaps are preferred to free skin grafts for
reconstruction of anterior lamellar defects in the periocu­
lar region for many reasons.4 Adjacent skin usually pro­
vides a better texture and color match than with grafts
from distant sites, and flaps undergo substantially less
contraction during healing. In addition, the rich vascular
supply in the region permits the use of flaps that would
be more tenuous in other parts of the body. Furthermore,
the ample vascular supply of local flaps can be used to
support free grafts for posterior lamellar reconstruction.
Prior irradiation or multiple prior surgeries may reduce
local circulation.
Rhomboid transposition flaps are the most useful adja­
cent skin flap in the periocular area, especially for medial5
and lateral canthal defects. The principles of design can
be found in Chapter 11 of this text. Specific to this region
is the need to avoid distortion of the eyebrow, eyelid
crease, eyelid margin, and canthal angles. Common flap
designs are shown in Figure 17-8. The vector of maximal
wound closure tension must be parallel to the lid margin
in the lower lid and most commonly in the upper lid as
well. Maximal tension may be vertical in the lateral and
medial canthal regions, provided the canthal position is
not changed.
Other advancement and transposition flaps can be
used to repair certain anterior lamellar defects (Figs. 17-9
to 17-12). Among those commonly used are the standard
unipedicle and bipedicle rectangle-shaped advancement
flaps and V-Y and Y-V advancement flaps. The unipedicle
rectangular advancement flap is well suited to the region
and can be used to close defects up to 25 cm2. Cutaneous
defects of the eyebrow or the anterior lamella of the
medial upper and lower eyelids can be repaired with this
flap. The resulting scars fall into or parallel to the lid
creases and avoid injury to the lid margin. V-Y advance­
ment flaps can be used to lengthen the palpebral fissure
or to close donor sites.6 Y-V advancement flaps are useful
in the management of epicanthal folds7 and scar
contractures.
Healing by second intention is generally not an
accepted strategy for eyelid wounds because the inci­
dence of cicatricial ectropion is substantial. However, in
the medial canthus, healing by second intention (or
laissez-faire) is more often successful,8,9 especially if the
defect is 1 cm or less in diameter and centered between
the upper and lower eyelids.
During surgery to reconstruct superficial lower
eyelid defects, if significant lower eyelid retraction or
ectropion occurs, it is advisable to perform concomitant
lateral canthoplasty to avoid postoperative eyelid malpo­
sition. Many canthoplasty methods have been described;
however, simple horizontal tightening of the lateral
canthal tendon with the lateral tarsal strip procedure10 is
reliable and should be mastered by reconstructive sur­
geons working in this area.
PRIMARY CLOSURE OF
FULL-THICKNESS DEFECTS
Excision of eyelid scars and neoplasia as well as repair of
colobomas frequently requires reconstruction of a full-
thickness defect. In the simplest case, horizontal laxity of
the eyelid and canthal tendons will permit direct closure
under reasonable tension. This is usually possible with
defects that involve 33% or less of the horizontal length
of the eyelid, although some authors find it useful in up
to 50% of the horizontal length.11 A few additional mil­
limeters can be gained with concomitant lateral canthot­
omy, although this may result in inferior displacement of
the reconstructed lower eyelid. The advantage of primary
wound closure is preservation of the eyelid margin and
lashes in a single-stage procedure. As with repair of other
multilaminar structures, the primary strategy is to restore
tissue integrity by matching corresponding layers. Cre­
ation of (or conversion to) a pentagonal defect greatly
eases this repair by eliminating standing cutaneous defor­
mities. Establishing clean tarsal edges perpendicular to
the lid margin ensures re-creation of reasonably normal
eyelid contour without notching or misalignment.
Meticulous surgical technique is necessary and may
require the use of loupes or an operating microscope.
Avoidance of injury to the cornea is also obviously impor­
tant and is eased with use of a corneal shield and topical
anesthetic. Small Guthrie double hooks or Castroviejo
0.5-mm forceps can be used intraoperatively to assess the
suitability of direct closure for a particular defect. If nec­
essary, cantholysis is performed by first making a small
lateral canthotomy incision with scissors or protected
electrosurgical tip (e.g., Colorado needle) and next
cutting the involved crus of the lateral canthal tendon. If
medial tension is maintained on the eyelid segment,
immediate release will be palpated and visually observed
once cantholysis is complete. The canthotomy incision is
typically left unclosed.
The first suture must establish perfect vertical align­
ment of the eyelid margin and should be replaced unless
it is ideal. It is placed to approximate the tarsal edges just
peripheral to the eyelid margin, at 90% depth, using a
trapezoidal passage that places the knot farther from the
margin than the deep suture pass (Fig. 17-13). A 5-0 or
6-0 polyglactin suture on an S-14 spatula needle is pre­
ferred, although Monocryl and polydioxanone sutures
may also be used. Chromic and plain gut sutures dissolve
too quickly to be useful for this deep closure. After the