Cẩm Nang Các Quy Trình Cốt Lõi Trong Phẫu Thuật Tạo Hình (Core Procedures)

89
Complications and outcomes
Figure 5.13  A 49-year-old patient with weight reduction of 50 kg with circumferential skin excess in the abdominal, flank, lateral/medial thigh and gluteal region. After
rejecting a lower bodylift, the patient underwent a fleur-de-lis abdominoplasty. Pre- and 3 months postoperative oblique and front images of a fleur-de-lis abdominoplasty
procedure with fascial tightening.
A
B
C
D
Figure 5.14  A 52-year-old patient after an open laparotomy procedure with a transverse scar. Pre- and postoperative front view following a reverse abdominoplasty
procedure.
A
B
C
D
Postoperative considerations
• The operation can be performed as outpatient or
inpatient surgery.
• Drains are left in place until discharge is less then 30 ml
in 24 h.
• The patient should rest in a relaxed position with a
flexion of approximately 30° at the hip joint.
• This position should be retained for 2–3 weeks
postoperatively in order to assure a tension free healing
of the scar.
• Sporting activities should be omitted for 6 weeks
postoperatively, and in cases of fascial reconstruction for
8 weeks.
• Patient should be advised to avoid saunas and tanning
beds.
• A compression garment should be worn for the same
period of time.
Complications and outcomes
• Patients can expect postoperative pain or soreness,
numbness of the abdominal flap, bruising, general fatigue
and discomfort due to increased abdominal tension for
many weeks.
• Local complications include hematoma, seroma, wound
infection, fat necrosis, wound dehiscence, parasthesias,
and persisting numbness.
• Seromas are the most common problem and are usually
handled with serial punctures and drainage.
• Persistent seromas may require an indwelling drain, or in
the case of a late encapsulated seroma, a secondary
surgical procedure.
• Minor wound dehiscence is common and is normally a
self-limiting problem.
• Many local problems of a cosmetic nature can result from
abdominoplasty including lateral dog ears, widened or

90
•
• Abdominoplasty
5
Dellon first published, in 1985, his approach to a vertical
and horizontal restoration of the abdominal wall through a
combined resection, the “fleur-de-lis” technique.
Huger Jr WE. The anatomic rationale for abdominal
lipectomy. Am Surg. 1979;45(9):612–617.
Hunstad JP, Repta R. Atlas of Abdominoplasty. Philadelphia:
Saunders Elsevier; 2009.
This major work on all current abdominoplasty procedures
is written by a leading authority on this subject, covering
all topics from patient selection, incision placement,
ancillary procedures up to all possible complications by
highlighting key considerations for a safe and successful
performance.
Lockwood T. High lateral-tension abdominoplasty with
superficial fascial system suspension. Plast Reconstr
Surg. 1995;96:603–608.
This article describes the principles and details of this new
approach to abdominoplasty. It offers an alternative
technique, especially in patients after massive weight loss
with limited treatment of the flanks.
Pitanguy I. Abdominolipectomy. An approach to it through
an analysis of 300 consecutive cases. Plast Reconstr
Surg. 1967;40:384.
Saldanha OR, Pinto EB, Matos WN Jr, et al.
Lipoabdominoplasty without undermining.
Aesthet Surg J. 2001;21(6):518–526.
Song AY, Jean RD, Hurwitz DJ, et al. A classification of
contour deformities after bariatric weight loss: the
Pittsburgh Rating Scale. Plast Reconstr Surg.
2005;116(5):1535–1546.
Rubin, as a currently “leading postbariatric surgeon”
has published an interesting work on the different
deformities in patients after bariatric weight loss, which
may serve as a guideline for plastic surgeons during
preoperative planning and for evaluation of their
postoperative outcomes.
hypertrophic scars, malpositioned scars, and numerous
cosmetic problems directly related to the umbilicus.
• Most of these problems can be avoided with proper
preoperative planning and attention to surgical detail.
• If liposuction has been done simultaneously, issues
pertaining to that procedure include contour irregularities
and dermal tethering.
• Systemic complications include deep vein thrombosis,
pulmonary embolism, respiratory compromise due to
increased intraabdominal pressure, and systemic
infections including toxic shock syndrome.
• All of these complications are potentially lethal and must
be dealt with expeditiously.
• Abdominoplasty, especially when combined with other
procedures such as liposuction, has a higher systemic
complication rate than any other type of routine cosmetic
surgical procedure.
Further reading
Aly AS. Body Contouring after Massive Weight Loss. St Louis:
Quality Medical; 2006.
This work is published by a currently “leading postbariatric
surgeon.” Aly has composed a unique work on all reliable
techniques for body contouring of patients after massive
weight loss.
Bozola AR. Abdominoplasty: same classification and a new
treatment concept 20 years later. Aesthet Plast Surg.
2010;34(2):181–192.
Costa-Ferreira A, Rebelo M, Vásconez LO, et al. Scarpa
fascia preservation during abdominoplasty: a
prospective study. Plast Reconstr Surg.
2010;125(4):1232–1239.
Dellon AL. Fleur-de-lis abdominoplasty. Aesthet Plast Surg.
1985;9:27.

©2014, Elsevier Inc. All rights reserved.
6 
Chapter
Facial injuries
a good result and the quality of the result are better with
early or immediate management.
• Less soft tissue stripping is required, bones are often
easily replaced into their anatomic position and easier
fracture repairs are performed.
• The definitive radiographic evaluation is the craniofacial
CT scan with axial, coronal and sagittal sections of bone
and soft tissue windows. However, the clinical
examination remains the most sensitive detection of the
character and functional implications of the facial injury.
• Access to the craniofacial skeleton can be achieved
through strategic incision placement (Fig. 6.1).
Preoperative considerations
• Management begins with an initial physical examination
and is followed by a radiologic evaluation accomplished
with computerized tomographic (CT) scanning
(Table 6.1).
• Bone injuries are suggested by soft tissue symptoms such
as contusions, abrasions, ecchymosis, edema, and
distortion of the facial proportions.
Frontal bone and sinus injury patterns
Brief introduction
• The frontal sinuses are paired structures that begin to be
detected at 3 years of age. Significant pneumatic
expansion does not begin to occur until approximately 7
years, with full sinus development complete by the age
of 18 to 20.
• The frontal sinuses are lined with respiratory epithelium,
which consists of a ciliated membrane with mucus
This chapter was created using content from
Neligan & Rodriguez, Plastic Surgery 3rd edition,
Volume 3, Craniofacial, Head and Neck Surgery,
Chapter 3, Facial fractures, Eduardo D. Rodriguez,
Amir H. Dorafshar and Paul N. Manson.
SYNOPSIS
■ The teachings of John Converse, Nicholas Georgiade and Reed
Dingman provided the benchmark for an entire generation of
surgeons in facial injury repair.
■ The treatment concepts discussed in this chapter were developed
at the University of Maryland Shock Trauma Unit and ultimately
employed at the International Center for Facial Injury
Reconstruction at Johns Hopkins.
■ The proportion of severe injuries seen at these centers is high.
■ The treatment concepts, however, may be modified for common
fractures and less significant injuries.
■ Greater emphasis has been placed on minimizing operative
techniques and limited exposures, whereas the decade of the
eighties witnessed craniofacial principles of broad exposure and
fixation at all buttresses for a particular fracture across all degrees
of severity.
■ Presently, the treatment of injuries is organized both by severity
and anatomic area to permit the smallest exposure possible to
achieve a good result. (CT based facial fracture treatment).
Brief introduction
• Bone and soft tissue injuries in the facial area should be
managed as soon as the patient’s general condition
permits.
• Classically, facial soft tissue and bone injuries are not
acute surgical emergencies, but both the ease of obtaining

92
•
• Facial injuries
6
Coronal incision
Upper
blepharoplasty
incisions
Transcon-
junctival
incisions
Intraoral
incisions
Extraoral
incisions
Extraoral
incisions
Transcon-
junctival
incisions
Figure 6.1  Cutaneous incisions (solid line) available for open reduction and
internal fixation of facial fractures. The conjunctival approach (dotted line) also
gives access to the orbital floor and anterior aspect of the maxilla, and exposure
may be extended by a lateral canthotomy. Intraoral incisions (dotted line) are also
indicated for the Le Fort 1 level of the maxilla and the anterior mandible. The lateral
limb of an upper blepharoplasty incision is preferred for isolated zygomaticofrontal
suture exposure if a coronal incision is not used. A horizontal incision directly
across the nasal radix is the one case in which a local incision can be tolerated
over the nose. In many instances, a coronal incision is preferable unless the hair is
short or the patient is balding.
secreting glands. A blanket of mucin is essential for
normal function and the cilia beat this mucin in the
direction of the nasofrontal ducts.
• When injured, they serve as a focus for infection,
especially if duct function is impaired.
• One-third of fractures involve the anterior table alone,
and 60% involve the anterior table and posterior table
and/or ducts.
• Forty percent of frontal sinus fractures have an
accompanying dural laceration.
Preoperative considerations
• Lacerations, bruises, hematomas, and contusions
constitute the most frequent signs of frontal bone or sinus
fractures.
• Occasionally, the first presentation of a frontal sinus
fracture may be an infection or symptom of frontal sinus
obstruction, such as mucocele, or abscess formation.
Infection in the frontal sinus may produce serious
complications because of its location.
Table 6.1  Key components of initial evaluation
I. ABCs
II. History
1. Mechanism of injury (was the patient restrained, mobile,
stationary)?
2. Time of injury (i.e., how much time has elapsed since injury)?
3. Penetrating vs. blunt injury?
4. What type of object involved (e.g., fist, bat, windshield, etc.)?
5. Does the patient complain of any symptoms to particular
facial area (e.g., numbness, pain)?
6. How does it feel when the patient bites down – pain? Do
teeth feel “normal”? Does bite “feel normal”?
7. Does the patient complain of visual problems, nasal
problems, hearing problems, or abnormal/painful bite?
8. Any significant PMH, meds, allergies, social history (e.g.,
diabetes, aspirin, coumadin, steroid use, ETOH, etc.)?
III. Exam
1. Inspect face/head for asymmetry, lacerations, abraisions,
hematomas, ecchymoses (especially periorbital), epistaxis
2. Document any bony irregularities, enophthalmos, proptosis,
telectanthus
3. Document visual acuity (e.g., Can you read my ID badge
from 12 inches away?)
4. Check pupils and ocular muscles
a. Is there a hyphema (blood in the anterior chamber)
b. Are extra-ocular movements intact or is there a restriction
in gaze
c. Are pupils reactive and equal
5. Inspect oral cavity – pay particular attention to dentition,
occlusion, lacerations
6. Palpate the facial bones and soft-tissue: document bony
step-offs, crepitance, mobile segments, significant pain,
and numbness
a. Palpate orbital rims
b. Palpate radix and nasal bridge for instability, crepitance
c. Check for integrity/mobility of medial canthus
d. Palpate zygoma/zygomatic arch
e. Palpate frontal bone, maxilla/maxillary sinus, cranium
f. Palpate TMJ at rest and through mandible ROM
g. Palpate mandible along its length
h. Using gloved hand, palpate teeth for instability, fractures,
etc.
i. Using gloved hand, grab maxilla/alveolus and check for
midface instability/pain
j. Inspect nasal passages and external auditory canal to
rule out septal hematoma, CSF rhinorrhea, otorrhea
7. Perform sensory exam of all branches of trigeminal nerve
(supraorbital, infraorbital, marginal mandibular)
8. Perform motor exam of facial nerve – raise eyebrows, smile,
grit teeth, close eyes tightly
IV. Imaging
1. CT face/orbits (1.5–3 mm cuts along facial bones with
coronal/sagittal/axial reconstructions)
2. CT Cspine (overall, 2–4% incidence of Cspine injury with
facial fractures)
3. Sometimes a Panorex is warranted. (Often study of choice
for mandible fracture, can miss symphyseal fractures –
requires normal Cspine)
V. Adjuncts
1. Ophthalmology consult – if any sign/concern for ocular
injury/visual disturbance

93
Frontal bone and sinus injury patterns
Figure 6.2  (A) Nasofrontal duct. (B) Bone plug for nasofrontal duct and galeal flap. (C) Bone obliteration of frontal sinus. (D) “Back table” surgery for bone replacement.
(E) Bone reconstruction and cranialization of the frontal sinus; intracranial neurosurgery. (F) Postoperative result.
D
A
B
E
F
C
• Frontal sinus fractures should be characterized by
describing both the anatomic location of the fracture,
including involvement of the anterior table, posterior
table, or both, and their degree of displacement.
• Indications for operative management include:
• Depression of the anterior table.
• Radiographic demonstration of involvement of the
nasofrontal duct with presumed future non-function.
• Obstruction of the nasofrontal duct with persistent air
fluid levels.
• Mucocele formation.
• Fractures of the posterior table that are displaced and
presumably have lacerated the dura resulting in a
cerebrospinal fluid leak.
• While some authors recommend exploration of any
posterior table fracture or any fracture in which an air
fluid level is visible, most explore posterior wall fractures
only if their displacement exceeds the width of the
posterior table.
Anatomical pearls
• The nasofrontal duct passes through the anterior
ethmoidal air cells to exit adjacent to the ethmoidal
infundibulum beneath the middle meatus.
• Blockage prevents adequate drainage of normal mucous
secretions and predisposes to the development of
mucoceles.
• The reported average interval between the primary injury
and development of frontal sinus mucocele is 7 12 years.
Key technical considerations
• The best technique of exposure is the coronal incision.
Occasionally, a laceration may be used.
• Any depressed frontal sinus fracture of the anterior wall
potentially requires exploration and wall replacement in
an anatomical position to prevent contour deformity.
• If the nasofrontal duct is compromised, obliteration of the
sinus is required and commonly involves stripping of the
mucosa, burring of the bone, and occlusion with well-
designed “formed-to-fit” calvarial bone plugs or soft
tissue (Fig. 6.2A–C).
• If most of the posterior bony wall is intact, the entire
frontal sinus cavity may be filled either with fat or
cancellous bone.
• If the posterior table is missing, or significantly displaced,
the sinus should be “cranialized”. In cranialization, the
posterior wall of the frontal sinus is removed, effectively
making the frontal sinus a part of the intracranial cavity.

94
•
• Facial injuries
6
pressure and subsequent fracture through the orbital
floor (Fig. 6.3).
• In children, the mechanism is more frequently like that of
a trapdoor, rather than the “blow-out” fracture seen in
adults (Fig. 6.4).
• As opposed to incarceration of fat adjacent to the inferior
rectus muscle, children more frequently “scissor” or
capture the muscle directly in the fracture site.
The “dead space” may be filled with cancellous bone or
left open. Any communication with the nose by the
nasofrontal duct or with the ethmoid sinuses should be
sealed.
• A galeal flap with a pedicle of the superficial temporal
artery can be a useful method for vascularized soft tissue
obliteration of frontal bone problems.
Outcomes and complications
• Complications of frontal bone and sinus fractures include:
■ CSF fluid rhinorrhea.
■ Pneumocephalus and orbital emphysema.
■ Absence of orbital roof and pulsating exophthalmos.
■ Carotid-cavernous sinus fistula.
Orbital fractures
Brief introduction
• Orbital fractures may occur as isolated fractures of the
internal orbit or may involve both the internal orbit and
the orbital rim.
• An orbital blow-out fracture is caused by the application
of a traumatic force to the rim, globe or soft tissues of the
orbit accompanied by sudden increase in intraorbital
Figure 6.3  (A) Mechanism of blow-out fracture from displacement of the globe itself into the orbital walls. The globe is displaced posteriorly, striking the orbital walls and
forcing them outward, causing a “punched out” fracture the size of the globe. (B) “Force transmission” fracture of orbital floor.
A
B
Figure 6.4  Blow-out fracture in a child produced by a snowball. Note the nearly
complete immobility of the ocular globe and the enophthalmos. Such severe loss of
motion implies actual muscle incarceration, an injury that is more frequent in
children than in adults. This fracture deserves immediate operation with release of
the incarcerated extraocular muscle system. It is often accompanied by pain on
attempted rotation of the globe and sometimes nausea and vomiting. These
symptoms are unusual in orbital floor fractures without true muscle incarceration.

95
Orbital fractures
• “Blow-in” orbital fractures that involve the medial or
lateral walls of the orbit, and severely constrict orbital
volume, creating increased intraorbital pressure.
• Goals of surgical management:
• Disengage entrapped structures and restore ocular
rotatory function.
• Replace orbital contents into the usual confines of the
normal bony orbital cavity, including restoration of both
orbital volume and shape.
• Restore orbital cavity walls which, in effect, replaces the
tissues into their proper position and dictates the shape
into which the soft tissue can scar.
Anatomical pearls
• The orbits are conceptualized in thirds progressing from
anterior to posterior.
• Anteriorly, the orbital rims consist of thick bone.
• The middle third of the orbit consists of thin bone,
while the bone structure thickens again in the posterior
third.
• The orbital bone structure is thus analogous to a “shock-
absorbing” device in which the middle portion of the
orbit breaks first, followed by the rim.
• The optic foramen is situated at the junction of the lateral
and medial walls of the orbit posteriorly and is well
above the horizontal plane of the orbital floor. The
foramen is located 40–45 mm behind the inferior orbital
rim.
Key technical considerations
• Exposure considerations:
■ Endoscopic approaches through the maxillary sinus
permit direct visualization and repair of the orbital
floor and manipulation of the soft tissues without an
eyelid incision (Fig. 6.6).
■ Lower eyelid incisions have the least incidence of
ectropion of any lid incision location but tend to be the
most noticeable.
■ Subciliary incisions near the upper margin of the lid
leave the least conspicuous cutaneous scar, although
they have the highest incidence of lid retraction.
■ Transconjunctival incisions can be performed in the
preseptal or retroseptal plane and avoid external scars.
Occasionally, a lateral canthotomy or caruncular
extension is necessary to widen exposure to the lateral
and medial orbit, respectively.
Complications and outcomes
• Diplopia: usually the result of muscle contusion, but can
be the result of incarceration of muscle, soft tissue
adjacent to the muscles, or nerve damage to cranial nerve
III, IV, and VI.
• Enophthalmos: second major complication of blow-out
fractures usually due to enlargement of the orbital
volume.
• Muscle incarceration is an urgent situation that demands
immediate release of the incarcerated muscle.
• The patient with true muscle entrapment may experience
pain on attempted eye motion as well as nausea,
vomiting, and an oculocardiac reflex (nausea,
bradycardia, and hypotension).
• The purpose of orbital floor reconstruction/replacement
in this scenario, whether a bone graft or an inorganic
implant, is to re-establish the size and the shape of
the orbital cavity. This replaces the orbital soft tissue
contents and allows scar tissue to form in an anatomic
position.
• A forced duction test is performed by grasping the orbital
conjunctiva with forceps and testing the range of motion
of the globe (Fig. 6.5).
• Limitation of forced rotation or motion is a positive test
for entrapment of extraocular muscles.
■ This test should be performed:
■ Before dissection.
■ After dissection
■ After the insertion of each material used to reconstruct
the orbital wall.
■ Just prior to closure of the incisions.
Preoperative considerations
• Indications for surgical treatment of orbital fractures:
• Diplopia caused by incarceration of muscle or the fine
ligament system, documented by forced duction
examination and suggested by CT scans.
• Radiographic evidence of extensive fracture, such that
enophthalmos would occur.
• Enophthalmos or exophthalmos produced by an orbital
volume change.
• Visual acuity deficit, increasing and not responsive to
medical dose steroids, implying that optic canal
decompression would be indicated.
Figure 6.5  The forced duction test. Clinical photograph. A drop of local anesthetic
instilled into the conjunctival sac precedes the procedure.

96
•
• Facial injuries
6
from the downward displacement of the eyeball in
enophthalmos.
• Scleral show, ectropion and entropion – vertical
shortening of the lower eyelid.
• Infraorbital nerve anesthesia.
• The “superior orbital fissure” syndrome: when a roof
fracture extends posteriorly to involve the superior
orbital fissure and its contents (CN III, IV, V, VI). Signaled
by: restricted gaze and numbness of the forehead, brow,
medial portion of upper lid, and medial upper nose.
• The “orbital apex” syndrome: when a roof fracture
extends posteriorly to involve the superior orbital fissure
and optic foramen and their contents (CN II, III, IV, V,
VI). Signaled by: all symptoms of the superior orbital
fissure syndrome with visual acuity change or blindness.
Nasal fractures
Brief introduction
• Most nasal fractures are initially reduced by closed
reduction (Fig. 6.7).
• In practice, closed reduction is frequently deferred until
the edema has partially subsided and the accuracy of the
reduction may be confirmed by visual inspection and
palpation.
• In more severe frontal impacts where loss of nasal height
and length occurs, or in nasoethmoidal orbital fractures,
the use of open reduction and primary bone or cartilage
grafting is beneficial to restore the support of the nose to
its original volume (Fig. 6.8).
• Naso-orbital ethmoid (NOE) fractures are severe fractures
of the central one-third of the upper midfacial skeleton.
They comminute the nose, the medial orbital rims and
• Retrobulbular hematoma: signaled by globe proptosis,
congestion and prolapse of the edematous conjunctiva.
Diagnosis is confirmed by a CT scan imaged with soft
tissue windows. It is usually not possible to drain
retrobulbar hematomas.
• Ocular (globe) injuries and blindness.
• Implant migration, late hemorrhage around implants and
implant fixation.
• Ptosis of the upper lid: true ptosis of the upper lid
should be differentiated from “pseudoptosis” resulting
Figure 6.6  Endoscopic approach through the maxillary sinus permits direct
visualization of the orbital floor and manipulation of the soft tissue and floor repair.
Figure 6.7  Frontal impact nasal fractures are classified by degrees of displacement, as are lateral fractures. (A) Plane I frontal impact nasal fracture. Only the distal ends of
the nasal bones and the septum are injured. (B) Plane II frontal impact nasal fracture. The injury is more extensive, involving the entire distal portion of the nasal bones and
the frontal process of the maxilla at the piriform aperture. The septum is comminuted and begins to lose height. (C) Plane III frontal impact nasal fractures involve one or
both frontal processes of the maxilla, and the fracture extends to the frontal bone. These fractures are in reality nasoethmoidal-orbital fractures because they involve the lower
two-thirds of the medial orbital rim (central fragment of the nasoethmoidal-orbital fracture) as well as the bones of the nose.
A
B
C

97
Nasal fractures
■ Directly over the medial canthal ligaments, crepitus or
movement may be palpated with external pressure.
■ Traumatic telecanthus (increase in distance between
medial canthal ligaments) and/or traumatic orbital
hypertelorism (increase in distance between the orbits
and globe) is present.
Anatomical pearls
• The diagnosis of an NOE fracture requires at a minimum
four fractures that isolate the frontal process of the
maxilla from adjacent bones:
■ Fracture of the nose.
■ Fracture of the junction of the frontal process of the
maxilla with the frontal bone.
■ Fracture of the medial orbit (ethmoidal area).
■ Fracture of the inferior orbital rim extending to involve
the piriform aperture and orbital floor.
• NOE fractures can be classified into one of three types:
■ Type I: an incomplete fracture which is displaced only
inferiorly at the infraorbital rim and piriform margin
(Fig. 6.9).
■ Type II: comminuted fracture with the fracture
remaining outside the canthal ligament insertion
(Fig. 6.10).
■ Type III: either avulsion of the canthal ligament
(uncommon) or extension of the fracture underneath
the canthal ligament insertion (Fig. 6.11).
Technical considerations
• Exposure: typically requires three incisions: (1) a coronal
(or an appropriate laceration or local incision); (2) a lower
eyelid incision; and (3) a gingival buccal sulcus incision.
• In all cases of NOE fractures, one must identify and
classify what is happening to the bone of the medial
orbital rim which bears the medial canthal attachment.
• Displacement of the medial canthal bone fragment is the
“sine qua non” of the NOE injury.
• The most essential feature of NOE reduction is the
transnasal reduction of the medial orbital rims by a wire
placed posterior and superior to the canthal ligament
insertion. It should be emphasized that the transnasal
reduction wires must be passed posterior and superior to
the lachrymal fossa in order to provide the proper
direction of force to recreate the preinjury bony position
of the central fragments.
Complications and outcomes
• Untreated hematomas of the nasal septum may result in
subperichondrial fibrosis and thickening with partial
nasal airway obstruction.
• Senechia formation usually occurs between the septum
and the turbinates.
• Nasal obstruction may occur as a result of fracture
malunion of the piriform margin, especially if displaced
medially.
the piriform aperture. NOE fractures are isolated in
one-third of cases and in two-thirds of cases extend to
involve the frontal bone, zygoma or maxilla. One-third is
unilateral and two-thirds are bilateral injuries. The central
feature is the displacement of the section of the medial
orbital rim carrying the attachment of the medial canthal
ligament.
Preoperative considerations
• The appearance of NOE fractures is typical:
■ The nose is flattened.
■ There is a loss of dorsal nasal prominence.
■ An obtuse angle is noted between the lip and
columella.
■ The medial canthal areas are swollen and distorted
with palpebral and subconjunctival hematoma.
Figure 6.8  Palpation of the columella (A) and dorsum (B) detects superior
rotation of the septum and lack of dorsal support. There is an absence of columellar
support and dorsal septal support.
A
B

98
•
• Facial injuries
6
Figure 6.9  (A,B) Lateral image of 3D craniofacial computer tomography scan of a Type 1 naso-orbital ethmoidal fracture injury pattern pre and post open reduction and
internal fixation of midface fractures using the inferior alone approach.
A
B
Figure 6.10  (A,B) Frontal 3D craniofacial computer tomography scan of a Type II naso-orbital ethmoidal fracture injury pattern in a 23-year-old female who sustained
craniofacial injuries following being struck by a motor vehicle as a pedestrian, pre and post open reduction and internal fixation of midface fractures. (C) Postoperative frontal
photograph view of patient approximately 12 months from surgery.
A
B
C
Figure 6.11  (A,B) Frontal 3D craniofacial computer tomography scan of Type III naso-orbital ethmoidal and a Le Fort II type injury pattern in a 33-year-old who sustained
craniofacial injuries following being thrown off a motorcycle without a helmet, pre and post open reduction and internal fixation of midface and mandibular fractures.
(C) Postoperative frontal photograph view of patient 6 months from surgery.
A
B
C

99
Zygoma fractures
• The direction of displacement, however, varies with the
direction of the injuring force and with the pull of the
attached muscles.
• About half of fracture dislocations of the zygoma result
in separation at the zygomaticofrontal (ZF) suture, which
is palpable through the skin over the upper lateral
margin of the orbit.
• The lateral canthal attachment is directed towards
Whitnall’s tubercle located approximately 10 mm below
the zygomaticofrontal suture.
• When the zygoma is displaced inferiorly, the lateral
attachment of the eyelids is also displaced inferiorly
giving rise to an antimongoloid slant of the palpebral
fissure.
Anatomical pearls
• The zygomatic bone has a quadrilateral shape with
several processes that extend to reach the frontal bone,
the maxilla, the temporal bone (zygomatic arch), and
orbital processes of the sphenoid and maxilla.
• Malunion.
• Special considerations for NOE fractures:
■ Frontal sinus obstruction.
■ Nasal functional impairment.
■ Nasal deformity.
■ Enophthalmos.
Zygoma fractures
Brief introduction
• The zygoma, a major buttress of the midfacial skeleton,
forms the malar eminence and the lateral and inferior
portions of the orbit (Fig. 6.12).
Preoperative considerations
• When disrupted, the zygoma is usually displaced in a
downward, medial, and posterior direction (Fig. 6.13).
Figure 6.12  The zygoma and its articulating bones.
(A) The zygoma articulates with the frontal, sphenoid, and
temporal bones and the maxilla. The orange-shaded area
shows the portion of the zygoma and maxilla occupied by
the maxillary sinus. (B) Lateral view of the zygoma. (From
Kazanjian VH, Converse J. Surgical Treatment of Facial
Injuries, 3rd ed. Baltimore, Williams & Wilkins, 1974.)
A
B
Figure 6.13  (A,B) Frontal 3D craniofacial computer
tomography scan of a right zygomaticomaxillary
fracture in a 22-year-old male who sustained
craniofacial injuries following a sports related injury,
pre and post open reduction and internal fixation of the
right zygomaticomaxillary complex and orbital floor
fractures.
A
B

100
•
• Facial injuries
6
• Malunion.
• Infraorbital nerve injury.
• Orbital complications:
■ Diplopia.
■ Visual loss.
■ Globe injury.
■ Enophthalmos or exophthalmos.
■ Lid position abnormalities.
• Ankylosis of the temporomandibular joint from impacted
arch fractures abutting the coronoid process.
• Oral–antral fistula.
• Miniplate complications.
Midface fractures
Brief introduction
• The midface is a system of sinus cavities interspersed
between skeletal buttresses which provide vertical and
horizontal structural support. If fractured or
malpositioned, the buttresses must be anatomically
reconstructed or reduced to re-establish pre-injury facial
bone architecture (Fig. 6.14).
• Vertical buttresses include the nasal septum, and the
paired nasomaxillary, zygomaticomaxillary, and
pterygoid buttresses (Fig. 6.15).
• Horizontal buttresses include the inferior orbital rims and
associated orbital floor, the paired zygomatic arches, and
the palate at the level of the maxillary alveolus.
• Le Fort fractures represent the common patterns of severe
midface fractures as characterized by Rene LeFort in
1901. The typical Le Fort fracture consists of combinations
of these patterns, rather than pure bilateral Le Fort I, Le
Fort II, or Le Fort III fractures (Fig. 6.16).
• Le Fort I fractures are those which traverse the maxilla
horizontally above the level of the apices of the maxillary
teeth. These fractures separate the entire alveolar process
of the maxilla, vault of the palate and the inferior ends of
• The bone furnishes attachments for the masseter,
temporalis, zygomaticus major and minor, and the
zygomatic head of the quadratus labii superiorus
muscles.
• The zygomaticotemporal and zygomaticofacial nerves
pass through this region to innervate the soft tissues over
the region of the zygomaticofrontal junction and malar
eminence.
Technical considerations
• If the ZF suture demonstrates significant diastasis then it
must be stabilized. Exposure of the ZF suture is most
easily accomplished through the lateral portion of an
upper blepharoplasty incision which is made directly
over the ZF suture 8–10 mm above the lateral canthus.
Alternately, it may be approached through a brow
laceration, coronal incision, or by superior dissection
from a subciliary or transconjunctival lower lid incision
with lateral canthotomy.
• Fractures with extreme posterior displacement, and those
with lateral displacement of the zygomatic arch benefit
from the addition of a coronal incision which allows
exposure of the entire zygomatic arch and roof of the
glenoid fossa as well as the ZF suture and the lateral
orbital wall.
• Medially displaced arch fractures, whether isolated or
part of a more extensive zygomatic fracture, may be
managed through a temporal/Gillies approach.
• Fractures amenable to closed reduction include medial
displaced isolated arch fractures, and simple large
segment or single piece zygoma fractures without
comminution at the buttresses or complete fracture at the
ZF suture.
Complications and outcomes
• Bleeding.
• Maxillary sinusitis.
• Nonunion.
Figure 6.14  Frontal 3D craniofacial computer
tomography scan of a Le Fort II type injury in a
33 year old who sustained craniofacial injuries
following a high speed motor vehicle collision,
pre and post open reduction and internal
fixation of the left orbital and
zygomaticomaxillary complex.
A
B

101
Midface fractures
Technical considerations
• Treatment of maxillary fractures is initially oriented
toward the establishment of an airway, control of
hemorrhage, closure of soft tissue lacerations and
placement of intermaxillary fixation (IMF). IMF reduces
the fracture, reduces movement and bleeding, and is
the single most important treatment of a maxillary
fracture.
• Simple fractures of the maxillary alveolar process can
usually be digitally repositioned and held in reduction
with arch bars. Fixation of the alveolar segment should
be maintained for at least 4–12 weeks or until clinical
immobility has been achieved.
• The goals of Le Fort fracture treatment are:
■ Restoration of midfacial height and projection through
buttress reduction and fixation.
■ Provide proper occlusion.
■ Restore the integrity of the nose and orbit.
• Management of LeFort I fractures may only require IMF.
Although in most cases the alveolus should be opened
through a gingival buccal sulcus incision with plate and
screw fixation at the nasomaxillary and
zygomaticomaxillary buttresses.
• Le Fort II fractures are managed with IMF placement,
exposure through a gingival buccal sulcus incision and
lower lid incision for reduction and fixation at the
zygomaticomaxillary and nasomaxillary buttresses and at
the inferior orbital rims. The need for opening fractures
crossing the nose must be assessed by the CT scan and
the displacement at the nasofrontal junction.
• Open reduction of Le Fort III fractures generally involves
combining procedures at the Le Fort I, Le Fort II and
zygomatic levels in a single operation.
Postoperative considerations
• Cleansing and aspiration of the nose and mouth is very
important.
• The presence of a fever in patients with facial fractures
should always prompt a sinus evaluation by radiographs
if the fever cannot be explained by other sources.
• Any foul odor to the breath necessitates inspection,
cleaning and/or a return to the operating room for
irrigation and a thorough examination.
Complications and outcomes
• Complications of maxillary/midface fractures include:
■ Airway compromise.
■ In severe cases, bleeding may require anterior–
posterior nasopharyngeal packing, manual reduction
of the displaced maxilla and intermaxillary fixation, or
in extreme circumstances angiographic embolization or
external carotid and superficial temporal artery
ligation.
■ Infection.
■ CSF rhinorrhea.
■ Blindness.
the pterygoid processes in a single block from the upper
craniofacial skeleton (Fig. 6.17).
• Le Fort II fractures are those which result in a
pyramidally shaped central maxillary segment.
This fracture begins above the level of the apices
of the maxillary teeth laterally and posteriorly in
the zygomaticomaxillary buttress and extends through
the pterygoid plates in the same fashion as the Le
Fort I fracture. The fracture lines travel medially and
superiorly to pass through the medial portion of
the inferior orbital rim and extend across the nose
(Fig. 6.18).
• Le Fort III fractures, or craniofacial dysjunction, may
occur when the fracture extends through the zygomatico-
frontal suture and the nasal frontal suture and across the
floor of the orbits to effectively separate all midfacial
structures from the cranium (Fig. 6.19).
Figure 6.15  The vertical buttresses of the midfacial skeleton. Anteriorly, the
nasofacial buttress skirts the piriform aperture inferiorly and composes the bone of
the medial orbital rim superiorly to reach the frontal bone at its internal angular
process. Laterally, the zygomaticomaxillary buttress extends from the zygomatic
process of the frontal bone through the lateral aspect of the zygoma to reach the
maxillary alveolus. A component of the zygomaticomaxillary buttress extends
laterally through the zygomatic arch to reach the temporal bone. Posteriorly, the
pterygomaxillary buttress is seen. It extends from the posterior portion of the maxilla
and the pterygoid fossa to reach the cranial base structures. The mandibular
buttress forms a strong structural support for the lower midface in fracture
treatment. This support for maxillary fracture reduction must conceptually be
achieved by placement of both jaws in intermaxillary fixation. The other “transverse”
maxillary buttresses include the palate, the inferior orbital rims, and the superior
orbital rims. The superior orbital rims and lower sections of the frontal sinus are
also known in the supraorbital regions as the frontal bar and are technically frontal
bone and not part of the maxilla. (From Manson PN. Hoopes JE, Su CT. Structural
pillars of the facial skeleton: an approach to the management of Le Fort fractures.
Plast Reconstr Surg. 1980;66:54.)
Frontal
attachment
Orbital
buttress
Nasoethmoid
region
Nasofrontal
buttress
Zygomatric
buttress
Pterygomaxillary
buttress
Cranial
base
Mandibular
buttress

102
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• Facial injuries
6
Figure 6.16  The Le Fort classification of midfacial
fractures. (A) The Le Fort I (horizontal or transverse)
fracture of the maxilla, also known as Guérin fracture.
(B) The Le Fort II (or pyramidal) fracture of the maxilla. In
this fracture, the central maxilla is separated from the
zygomatic areas. The fracture line may cross the nose
through its cartilages or through the middle nasal bone
area, or it may separate the nasal bones from the frontal
bone through the junction of the nose and frontal sinus.
(C) The Le Fort III fracture (or craniofacial disjunction). In
this fracture, the entire facial bone mass is separated from
the frontal bone by fracture lines traversing the zygoma
nasoethmoid, and nasofrontal bone junctions. (D)
Buttresses of the midface. N: nasofrontal buttress; Z:
zygomatic buttress; P: pterygomaxillary buttress; P1:
posterior height and anteroposterior projection must be
maintained in complicated fractures. This is especially true
in Le Fort fractures accompanied by bilateral subcondylar
fractures. (A–C from Kazanjian VH, Converse J. Surgical
Treatment of Facial Injuries, 3rd ed. Baltimore, Williams
&Wilkins, 1974.)
A
B
C
D
P1
Z
N
P
P1
Figure 6.17  Frontal 3D craniofacial computer
tomography scan of a Le Fort I type injury pre
and post open reduction and internal fixation.
A
B

103
Mandible fractures
• Late complications:
■ Nonunion and bone grafting.
■ Malunion.
■ Malocclusion.
■ Nasolacrimal duct injury.
Mandible fractures
Brief introduction
• Craniofacial fractures frequently involve the jaws, which
will invariably produce malocclusion.
• The mandible is a strong bone, but has several weak
areas that are prone to fracture including:
■ The subcondylar area.
■ Angle.
■ Distal body.
■ The mental foramen.
• Timely loss of teeth results in atrophic changes of the
alveolar bone and alters the structural characteristics of
the mandible.
• Fractures often occur through the edentulous areas rather
than through the areas better supported by adequate
tooth and alveolar bone structures.
• In general, a tooth in the fractured segment may be
extremely important, and should be retained, as the tooth
acts as an occlusal stop and provides some stability for
fracture alignment.
• Class I mandible fractures: fractures with teeth on either
side of the fracture site (symphysis, parasymphysis,
body) (Fig. 6.20).
• Class II fractures: fractures where teeth are present
only on one side of the fracture site (posterior body,
angle).
• Class III fractures: fractures which have no teeth on either
side of the fracture site (ramus, condyle).
Figure 6.18  Frontal 3D craniofacial computer tomography scan of a Le Fort II type
injury pre and post open reduction and internal fixation.
Figure 6.19  Frontal 3D craniofacial computer tomography scan of a Le Fort III type
injury pre and post open reduction and internal fixation.
A
B
Figure 6.20  Classification of mandibular fractures.
Alveolar process
Canine root
Mental foramen
Coronoid
Parasymphysis
Body
Third
molar
Angle
Ramus
Condyle

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• Facial injuries
6
by a premature contact in the molar dentition on the
fractured side, which produces a subtle open bite in
the contralateral occlusion.
• Absolute indications for open treatment of condylar/
subcondylar fractures are (Fig. 6.24):
■ Dislocation into the middle cranial fossa or external
auditory canal.
■ Lateral extracapsular displacement.
■ Inability to obtain adequate occlusion.
■ Open joint wound with foreign body or gross
contamination.
• Relative indications for open treatment of condylar/
subcondylar fractures include:
■ Angulation between the fractured fragments in excess
of 30°.
■ Fracture gap between the bone ends exceeding
4–5 mm.
■ Significant lateral override and lack of contact of the
ends of the fractured fragments.
Preoperative considerations
• Key diagnostic signs of mandible fractures:
■ Mobility or distraction at the fracture site with manual
manipulation.
■ Crepitation with motion.
■ Malocclusion.
■ Inability to move the jaw.
■ Pain and/or tenderness with speech or motion.
• Indications for ORIF of mandible fractures:
■ Favorable or unfavorable Class I fractures where
stability is desired (Fig. 6.21).
■ Class II and Class III fractures.
■ Comminuted fractures (Fig. 6.22).
■ Displaced fractures and those subject to rotation.
■ Edentulous fractures.
■ The desire to avoid IMF in the postoperative period.
■ Combined fractures of the upper and lower jaws.
■ Uncooperative (head injured) patients.
• Extraction of an impacted 3rd molar is recommended if it
is preventing alignment of the fracture fragments,
partially erupted and/or inflamed, or if the tooth root is
exposed.
■ It is important to note that extraction of impacted 3rd
molars may result in greater bone instability and
conversion to comminution.
• Most condylar or subcondylar fractures are generally
treated with closed reduction, with or without IMF
(Fig. 6.23).
■ In children, growth considerations create a capacity for
both regeneration and remodeling which is not present
in adults.
■ Some shortening of the ramus height is almost
inevitable with a closed approach and is first heralded
Figure 6.21  In (A) and (C), the direction and bevel of the fracture line did not
resist displacement due to muscle action. The arrows indicate the direction of
muscle pull. In (B) and (D), the bevel and direction of the fracture line resist
displacement and oppose muscle action. The direction of the muscle pull in
fractures beveled in this direction would tend to impact the fractured bone ends.
(After Fry WK, Shepherd PR, McLeod AC, Parfitt GJ. The Dental Treatment of
Maxillofacial Injuries, Oxford, Blackwell Scientific, 1942.)
A
B
C
D
Figure 6.22  (A,B) Intraoperative photograph of comminuted mandibular fracture in
a 23-year-old male following attempted homicidal gunshot wound to the face pre
and post open reduction and internal fixation via the extra-oral approach using
multiple miniplates.
A
B

105
Mandible fractures
Figure 6.23  The use of intermaxillary fixation screws for intermaxillary fixation.
These devices do not provide the stability or flexibility obtained from arch bars and
full intermaxillary fixation. Numbers of patients have been thought to be in good
occlusion with this technique when actually they were in an open bite, were
malreduced, and required osteotomy or fracture revision. Crossed wires may also be
used to buttress the screw support obtained. (Courtesy of Synthes Maxillofacial,
Paoli, Pa.)
Figure 6.24  (A,B) Lateral view of 3D craniofacial computer tomography on a 20-year-old female involved in a motor vehicle collision who sustained craniofacial injuries,
pre and post open reduction and internal fixation of a right mandibular subcondylar fracture via a retromandibular extra-oral approach. Note that the patient also had a Le Fort
II type fracture that was treated with closed reduction and interdental fixation. (C) Lateral profile view photograph of patient one year postoperatively.
A
B
C
■ Bilateral subcondylar fractures in a patient who has no
dentition and where a splint is unavailable or when
splinting is impossible because of alveolar ridge
atrophy.
■ Bilateral or unilateral subcondylar fractures when
splinting is not recommended for medical reasons or
where adequate physiotherapy is impossible.
■ Bilateral condylar fractures associated with
comminuted midfacial fractures.
■ Bilateral subcondylar fractures with associated
gnathologic problems, such as (1) retrognathia or
prognathism, (2) open bite with periodontal problems
or lack of posterior support, (3) loss of multiple teeth
and later need for elaborate reconstruction, (4) bilateral
condylar fractures with unstable occlusion due to
orthodontics, and (5) unilateral condylar fracture with
unstable fracture base.
• Edentulous mandibular fractures represent less than 5%
of the mandibular fractures and commonly occur through
the most atrophic portions where the bone is thin and
weak (typically the body) (Fig. 6.25).
• Many fractures are bilateral or multiple, and
displacement of a bilateral edentulous body fracture is
often severe and a challenging condition to treat.
• Closed fractures demonstrating minimal displacement
may be treated with a soft diet and avoidance of
dentures; however, in these cases observation is critical to
be sure that healing occurs within several weeks without
further displacement.
• Most fractures are better treated with fixation using large
reconstruction “locking” plates.
Anatomical pearls
• Unique to mandibular fractures, mandibular movements
are determined by the action of reciprocally placed
muscles attached to the bone.
■ When fractures occur, displacement of the segments is
influenced by the pull of the muscles attaching to the
segments.
• The direction of the fracture line may oppose forces
created by these muscles.
• Mandibular fractures can be classified as “favorable” or
“unfavorable” according to their direction and bevel of
displacement. In some fractures, the muscular force
would pull the fragments into a position favorable for
healing, whereas in other fractures, the muscular pull is
unfavorable resulting in separation at the fracture site
(Fig. 6.26).

106
•
• Facial injuries
6
• In symphysis and parasymphysis fractures, both a
muscular and mucosal closure of intraoral incisions is
preferred.
• Class II fractures require open reduction and fixation.
• The type and strength of plate needed to control the
non-toothbearing fragment and displacement of the
fracture will vary according to the direction and bevel of
the fracture and the position of the teeth and surrounding
muscles.
• Generally, a larger inferior border plate with a smaller
superior border plate is preferred.
• In non-displaced or favorable angle fractures, the
Champy technique may be used.
• Class III fractures that are non-displaced and immobile
may be treated by a soft diet with close follow up,
although the majority should be managed with rigid
fixation using superior and inferior border plates.
Technical considerations
• In select cases (non-displaced or favorable fractures)
management by IMF alone is possible.
• In unfavorable fractures, panfacial fractures, or those in
which early function is desired, internal fixation is
preferred.
• Dental wiring and fixation techniques include arch bars
and IMF screws.
• Arch bars are ligated to the external surface of the dental
arch by passing 24 or 26 G steel wires around the arch-
bar, and around the necks of the teeth.
• The wires are twisted tightly to individual teeth to hold
the arch bars in the form of the dental arch.
• If segments of teeth are missing, or if anterior support of
the arch bar is needed to balance the forces generated by
elastic traction anteriorly, the arch bar may be stabilized
by additional wires passed to the skeleton (skeletal
wires).
• IMF screws are a rapid method of immobilizing the teeth
in occlusion, given good dentition and uncomplicated
fracture types (see Fig. 6.23).
• The number and position of the IMF screws is based on
the fracture type, fracture location and surgeon
preference.
• Screws must be positioned superior to the maxillary
tooth roots and inferior to the mandibular tooth roots.
Operative techniques
• The general approaches to mandible fractures are:
■ Establish proper occlusion.
■ Anatomically reduce the fractured bones into their
normal position.
■ Utilize fixation techniques that hold the fractured bone
segments in occlusion and normal position until
healing has occurred. Open reduction internal fixation
(ORIF) can often permit limited function while healing
is occurring.
■ Control infection.
• Horizontally favorable: mandibular fractures that are
directed from lingual to buccal cortex in a forward
direction. In this fracture pattern, the pull of the muscles
of mastication holds the fragments together at the
fracture site.
• Horizontally unfavorable: fractures directed from lingual
to buccal cortex in a posterior direction. In this pattern,
the muscle groups displace the fracture fragments.
• Vertically unfavorable: fractures directed from superior to
inferior in a posterior direction.
• Vertically favorable: fractures directed from superior to
inferior in a forward direction.
• In general, class I fractures are broadly exposed with an
intraoral degloving technique to allow adequate exposure
for plate and screw fixation.
Figure 6.25  Lateral view of 3D craniofacial computer tomography on a 64-year-old
edentulous female with a history of oseogenesis imperfecta; who was referred for
treatment of a malunion of a left mandibular fracture postoperative open reduction
and internal fixation using a load bearing mandibular plate and iliac bone grafting
via an extra-oral approach.
Figure 6.26  Large reconstruction plate spans fractures of the entire body.
(Courtesy of Synthes Maxillofacial, Paoli, Pa.)

107
The panfacial injury
Complications and outcomes
• Malocclusion.
• Hardware infection and migration.
• Increased facial width and rotation of the mandible.
• Non-union.
• Osteomyelitis.
The panfacial injury
Brief introduction
• Conceptually, panfacial fractures involve all three areas of
the face: frontal bone, midface, and mandible.
Preoperative considerations
• Various sequences have been suggested such as “top to
bottom”, “bottom to top”, “outside to inside”, or “inside
to outside”. In reality, it does not make any difference
• General principles of reduction and fixation:
■ Superior and inferior border stabilization is the general
rule.
■ The use of the “locking plate” minimizes the
requirement for precise plate bending.
■ Comminuted fractures require larger fixation plates,
and are conceptually fractures with “bone loss”, where
the plate itself bears the entire load of fixation (see Fig.
6.26).
• Champy and miniplate fixation:
■ Speeds exposure and is more tolerant for mandibular
shape and occlusion versus more rigid plates.
■ The malleable plates minimize malreductions
from “plate bending errors” common to stiff larger
plates.
■ Does not result in the maximum rigidity achieved with
the large plates, but is generally sufficient for good
immobilization at fracture sites with minimal
movement, such as a favorable and minimally
displaced angle fracture.
• Lag screw technique (Fig. 6.27):
■ Indicated in non-comminuted parasymphysis or
symphysis fractures where a long length of screw can
be tolerated.
■ In this technique, the first cortex in the bone is
over-drilled to the major diameter of the screw
while the second segment of the screw path is
drilled to the minor diameter of the screw. This
allows the screw head to engage only the bone
in the first section and as the screw is tightened into
the second section of the fracture, the screw head
impacts the cortex toward the fracture site as it is
tightened.
■ Generally, two lag screws are recommended for
each fracture to be stable, for if one becomes loose,
the fracture would be unstable by virtue of the
rotation.
• Extraoral approach to mandible fractures:
■ The position of an external mandibular incision should
always respect the location of the marginal mandibular
branch of the facial nerve.
■ Subperiosteal dissection should be performed.
■ The fragments at the inferior border of the fracture are
aligned with clamps and occlusal reduction should be
checked.
■ A superior border plate is secured first at the
upper border of the mandible and fixed with
unicortical screws and the occlusion is again
checked.
■ The lower border plate and screws are then applied. A
larger plate may be utilized and bicortical screw
placement is preferred.
• Intraoral approach:
■ Any fracture in the horizontal or vertical mandible is
usually amenable to an intraoral approach and is the
preferred exposure for symphysis, parasymphysis, and
noncomminuted angle fractures. The body region is
also able to be reduced but may require use of a
percutaneous Trocar approach for drilling and screw
placement.
Figure 6.27  (A) Placement of two horizontal lag screws to reduce and stabilize a
parasymphysis fracture using a trocar device. (Courtesy of Synthes Maxillofacial,
Paoli, Pa.) (B) Intraoperative photograph of open reduction and internal fixation of
mandibular symphseal fracture using lag screws.
A
B

108
•
• Facial injuries
6
Figure 6.28  (A,B) Frontal photographs of a 34-year-old male following a self-inflicted gunshot wound injury to the face demonstrating severe midfacial and mandibular
fractures. (C) Intraoperative photographs following open reduction and internal fixation of mandibular fractures using a load bearing mandibular plate and a monocortical
miniplate fixation via an extra-oral approach. (D,E) Frontal 3D craniofacial computer tomography scan of the patient pre and post open reduction and internal fixation of
midfacial and mandibular fractures. (F) Postoperative photograph 1 year following surgery.
A
B
C
D
E
F
what the order is as long as the order makes sense and
leads to a reproducible, anatomically accurate bone
reconstruction.
• In our experience, it is more predictable to stabilize the
occlusion by relating the maxilla to the mandible than by
relating the inferior maxilla to the superior maxilla.
Technical considerations
• Presently, a one-stage restoration of the architecture of the
craniofacial skeleton is the preferred method of treatment
using open reduction of all fracture sites with plate and
screw fixation.
• Regional incisions such as the coronal, transconjunctival,
upper and lower gingival buccal sulcus and the
retromandibular incisions provide the complete
exposure.
• In each subunit of the face, the important dimension to
be considered first is facial width.
Complications and outcomes
• Lack of facial projection.
• Enophthalmos.
• Malocclusion.
• Increased facial width.
• Positional deformities seen in the frontal region:
■ Posterior and inferior positioning of the superior
orbital rims.
■ Flattened frontal contour.
• Soft tissue deformities, including descent, diastasis, fat
atrophy, and ectropion, thickening and rigidity.
• Temporal wasting: usually caused by lack of periosteal
closure over the zygomaticofrontal suture.

109
Further reading
Ballistics injuries to the face
Brief introduction
• Recently, immediate reconstruction and immediate soft
tissue closure with “serial-second-look” procedures has
become the standard of care.
• Ballistic injuries are classified into low, medium, and
high-energy deposit injuries.
• In formulating a treatment plan for ballistic injuries, it is
helpful to identify the entrance and exit wounds, the
presumed path of the bullet, and to appreciate the mass
and velocity of the projectile, so that the extent of internal
areas of tissue injury can be predicted.
• Conceptually, soft tissue injury and bone injury, and soft
tissue loss and bone loss must all be individually
assessed.
Technical considerations
• Low velocity gunshot wounds involve little soft tissue
and bone loss and have limited associated soft tissue
injury outside the exact path of the bullet.
• Appropriate for immediate definitive bony stabilization
and primary soft tissue closure with limited debridement
necessary.
• Intermediate and high velocity ballistic injuries to the
face are characterized by extensive soft tissue and bone
destruction (Fig. 6.28).
• These injuries must be managed with a specific treatment
plan that involves stabilization of existing bone and soft
tissue in anatomic position, maintenance of this
stabilization throughout the period of soft tissue
contracture, and eventual bone and soft tissue
reconstruction.
• “Second look” procedures, which generally occur at
48-hour intervals, are important with these injuries to
re-open the soft tissue and define additional areas of soft
tissue necrosis, drain hematomas and/or developing
fluid collections, and assure bone integrity.
• In some cases, it may be possible to plan a more complex
reconstruction of bone and soft tissue simultaneously by
loco-regional flaps and/or composite free tissue transfer.
Further reading
Champy M, Lodde JP, Schmidt R, et al. Mandibular
osteosynthesis by miniature screwed plates via a
buccal approach. J Maxillofac Surg. 1978;6:14.
Clark N, Birely B, Manson PN, et al. High-energy ballistic
and avulsive facial injuries: Classification, patterns,
and an algorithm for primary reconstruction. Plast
Reconstr Surg. 1996;98:583–601.
Dingman RO, Grabb WC. Surgical anatomy of the
mandibular ramus of the facial nerve based on the
dissection of 100 facial halves. Plast Reconstr
Surg.1962;29:2166.
Ellis 3rd E. Treatment methods for fractures of the
mandibular angle. Int J Oral Maxillofac Surg.
1999;28(4):243–252.
Gruss JS, MacKinnon SE, Kassel EE, et al. The role of
primary bone grafting in complex craniomaxillofacial
trauma. Plast Reconstr Surg. 1985;75:17.
Le Fort R. Etude experimentale sur les fractures de la
machoire superieur. Rev Chir Paris. 1901;23:208,360,479.
Original article describing the various fracture patterns
associated with traumatic craniofacial injury. We associate
the author’s name to the different types of fracture patterns
recognized.
Manson PN, Su CT, Hoopes JE. Structural pillars of the
facial skeleton. Plast Reconstr Surg. 1980;66:54.
Significant article describing the anatomical buttresses of the
craniofacial skeleton that are required for reconstruction to
maintain facial width and height.
Markowitz B, Manson P, Sargent, et al. Management of the
medial canthal tendon in nasoethmoid orbital
fractures: The importance of the central fragment in
treatment and classification. Plast Reconstr Surg.
1991;87:843–853 .
Landmark article on the classification types of
nasoethmoidorbital region. Knowledge of this fracture
pattern classification assists with the treatment of this
complex surgical condition.
Rodriguez ED, Stanwix MG, Nam AJ, et al. Twenty-six-year
experience treating frontal sinus fractures: a novel
algorithm based on anatomical fracture pattern and
failure of conventional techniques. Plast Reconstr Surg.
2008;122(6):1850–1866.
Landmark article describing the longest experience with
treating frontal sinus fractures and provides an algorithm
for its treatment based on their outcomes, to minimize
long-term complications.
Tessier P, Guiot G, Rougerie J, et al. Osteotomies cranio-
naso-orbital-facials. Hypertelorism Ann Chir Plast.
1967;12:103.
An article by the father of craniofacial surgery describing
the possibilities of an intracranial approach for orbital
reconstructive surgery.

©2014, Elsevier Inc. All rights reserved.
7 Chapter
Local flaps for facial coverage
Brief introduction
• Flaps on the face have many designs and these are
related to the area to be reconstructed and the size of the
defect. It must not be forgotten, however, that there are
only certain basic well-defined tissue manipulations;
these are based on the concepts of advancement,
transposition, and rotation (Video 7.1; Video 7.2).
• When a wound is closed tightly or a flap which seems
too small is used and yet the defect is closed, the
biomechanical properties of creep and stress relaxation
have been harnessed, and the skin elongates over time
(Table 7.1).
• For simplicity, key concepts for facial coverage will be
grouped according to anatomic area.
Forehead and scalp
• The characteristics of the forehead vary considerably with
age and nationality.
• All foreheads have a limited amount of spare skin and, as
a result, wide undermining and freeing are necessary to
deal with many skin defects.
• The forehead is surrounded by a frame with distinct
outlines, mainly of hair that should not be disturbed,
where possible.
Technical pearls
• In the forehead, vertical donor sites are preferred to
horizontal sites, which may cause an upward shift of the
eyebrows or downward repositioning the forehead
hairline (Fig. 7.1).
This chapter was created using content from
Neligan & Rodriguez, Plastic Surgery 3rd edition,
Volume 3, Craniofacial, Head and Neck Surgery,
Chapter 10, Cheek and lip reconstruction, Peter C.
Neligan, Chapter 18, Local flaps for facial coverage,
Ian T. Jackson.
SYNOPSIS
■ Always consider the defect when planning a flap.
■ Assess availability and laxity of local tissue.
■ Rob Peter to pay Paul but only if Peter can afford it.
■ Match the flap to the defect, not the defect to the flap.
■ Keep your reconstruction as simple as possible.
■ Good cosmesis is vital but function trumps cosmesis.
■ Do not burn bridges.
■ If unsure of how to proceed, for whatever reason, use a
temporizing approach.
Cheek reconstruction
■ Local tissue should be used whenever possible.
■ Local and regional flaps work well.
■ Color match is important.
■ For composite defects of lips and cheeks, each component defect
can be reconstructed as a separate unit.
Lip reconstruction
■ Accurate three layered closure of lip defects is imperative to
preserve function.
■ Local tissue should be used whenever possible.
■ Small defects can be closed by direct repair:
• Defects up to 25% the width of the upper lip can be closed.
• Defects up to 30% the width of the lower lip can be closed.
■ Intermediate defects are best reconstructed with local flaps.
■ Total or sub-total lip defects are best reconstructed with free
tissue.
Video
7.2
Video
7.1

111
Forehead and scalp
• In larger defects, a triple rhomboid may be used;
this necessitates an excision of a hexagonal design
(Fig. 7.2).
• Careful planning and assessment of the availability
of loose skin in all three areas of flap harvest is
essential.
Figure 7.1  Rhomboid flap. (A) Melanoma in situ right temple. (B,C) Lesion excised. Limberg flap designed for repair of 2 × 2 cm defect. (D,E) Dufourmentel flap designed
and transferred to defect.
A
B
C
E
D
Table 7.1  Viscoelastic properties of the skin
Creep
When a sudden load is applied and kept
constant, skin will stretch
Stress relaxation
A constant load on the skin will cause
lengthening. With time, the load required to
maintain the lengthening decreases. This
explains why white flaps will frequently
become pink with time
• In the temporal area, 3.5 cm flaps can be used, but this
requires great care in order to prevent too great a shift of
the hairline. This applies to reconstruction of any area on
the non-hair-bearing scalp in proximity to the hairline
edge (Fig. 7.3).
• Direct advancement flaps are possible but can only close
smaller defects.
• Island flaps are used only occasionally; they are
frequently based on subcutaneous tissue rather than on
definite blood vessels. This necessitates taking great care
to maintain every subcutaneous strand possible and
tension must be minimized.
• Bilobed flaps can be used, but they tend to trapdoor or
pincushion and are therefore obvious in any form of
indirect lighting.
• Large forehead reconstruction is treated by tissue
expansion; this allows reconstruction by simple

112
•
• Local flaps for facial coverage
7
burned patient in whom both eyebrows are frequently
involved.
• An alternative technique is micro-hair transplants with
frequent trimming. These, unfortunately, rarely produce
the unique anatomy and the density of the eyebrow hair.
(Fig. 7.5).
Nasal reconstruction
• Many different flaps for nasal reconstruction have been
described.
Technical pearls
• In the bridgeline region, the glabella is the preferred
donor site, and the variety of flaps can be the direct
advancement type (Fig. 7.6), transposition (Fig. 7.7),
bilobed (Fig. 7.8), rhomboid (see Fig. 7.1), or island
(Fig. 7.9).
• On the lateral aspect of the nose, bilobed (see Fig. 7.8),
rotation (Fig. 7.10), or transposition flaps (Fig. 7.11) – all
can provide excellent results. Fortunately, there is often
more skin available in this area than expected.
• To provide an acceptable nasal tip reconstruction, the
bilobed flap is ideal, though, as already mentioned, it
does have a tendency to trapdoor.
• The long advancement flap of Rintala, which looks
unreliable, usually works well but can cause some
apprehension on the part of the surgeon and the patient
due to skin color changes (see Fig. 7.11).
• Laterally, a nostril is made by dissecting a skin pocket
and lining it with a skin graft and cartilage, which will
provide the required support if necessary.
• Approximately 2–3 weeks after the initial reconstruction,
this composite is brought down to reconstruct the rim
and the alar region (see Fig. 7.11).
• A composite graft from the ear is an excellent choice
when the nostril is to be reconstructed.
• The maximal dimensions of a composite graft are
approximately 1 cm2; for defects greater than this, a
composite flap of helical root is an excellent solution.
• When a more complex reconstruction is required (e.g.,
bilateral alar rims and columella), the total central
forehead should be used.
• The key to complete survival of the flap is the position of
its base; this should be at the medial canthal level or
below. In this way, the vascular anastomosis on the side
of the nose between the cheek and forehead vessels is
used to give length to the flap.
• The reason for poor results and failures is usually due to
elevating the flap pedicle based on the brow area.
• The forehead is closed directly, but if there is tension in
the area just anterior to the hairline, it should be left to
close secondarily. The scar resulting from this rarely, if
ever, requires any reconstruction
• The pedicle is divided at 2–3 weeks, depending on
the inset, and the nasal tip is fashioned. Apart from
thinning, it is unusual to require further adjustments
(Fig. 7.12).
Figure 7.2  Triple rhomboid flap. Circular cutaneous defect conceptualized as
hexagon. Sides of hexagon are equal to radius (r) of circle. First side of flap created
by direct extension equal in length to radius at alternative corners to prevent sharing
of common sides. Second side of flap designed parallel to adjacent side of
hexagon. (From Bray DA. Rhombic flaps. In: Baker SR, Swanson NA, eds. Local
Flaps in Facial Reconstruction. St Louis: Mosby; 1995:155, Fig 6, with permission.)
r
r
r
Figure 7.3  Bilateral rhombic flaps designed for repair of large defect. Defect
divided into two adjacent rhombuses (A,B) to assist with designing rhombic flaps.
A
A
B
B
advancement or one of the expanded flaps described
previously (Fig. 7.4).
• Post-expansion size increases will decrease when the
expander is removed and this must be taken into
consideration when planning the reconstruction. Thus, a
degree of over-expansion is strongly advised.
Eyebrow reconstruction
• The eyebrow is complex and reconstruction is difficult,
this is because hair grows in a fixed pattern that is not
uniform and is difficult to reproduce exactly.
Technical pearls
• A scalp island flap based on the temporal blood supply
can be used, but the hair must be trimmed.
• The hair is often too dense and does not grow in the
correct manner; however, the reconstructed eyebrow can
be much appreciated by the patient, especially in the

113
Nasal reconstruction
Figure 7.4  Tissue expansion to achieve defect closure. (A,B) Skin graft covering temple, anterior parietal scalp, and lateral cheek. (C) Expanded forehead skin.
(D) Following tissue expansion, expanded forehead skin used to cover defect created by partial resection of skin graft. (E) Expansion provided sufficient skin to cover temple.
(F) Tissue expander beneath lateral cheek skin. (G) 6 days following removal of skin graft from cheek and reconstruction with expanded cheek advancement flap. (H) 6
months’ postoperative.
A
B
C
D
E
F
G
H

114
•
• Local flaps for facial coverage
7
Figure 7.5  Nevus of left supraorbital area involving eyebrow – hatchet flap reconstruction. (A) The planned excision has been drawn out together with bilateral hatchet flaps.
(B) Nevus has been excised. It can be seen that the flap pedicles are superior for the lateral flap and inferior for the medial flap. (C) The flaps are elevated. (D) The flaps are
transposed, and the secondary defect is closed. (E) Satisfactory end result with the eyebrow in a good position.
A
C
D
B
E

115
Nasal reconstruction
Figure 7.6  Reconstruction of nasal defect with lateral advancement flaps. (A) 0.5 × 0.5 cm skin defect of nasal tip. (B) Primary wound closure planned. Anticipated
standing cutaneous deformities (marked by horizontal lines). (C) Deformities excised and wound closed. (D) 1.5 years’ postoperatively.
A
B
C
D
Figure 7.7  Reconstruction of lateral nasal defect with forehead flap. (A,B) 1.5 × 1.5 cm skin defect of nasal tip. (C) Interpolated paramedian forehead flap used to repair
defect. (D) 9 months’ postoperative. Depressed scar surrounds lateral aspect of flap and mild trap-door deformity is present. (E) Nose marked for planned contouring
procedure. Three Z-plasties positioned along depressed scar. (F) Flap thinned and Z-plasties performed. (G,H) 4 months following Z-plasties and full face carbon dioxide
laser peel.
A
B
C
D
E
F
G
H

116
•
• Local flaps for facial coverage
7
Figure 7.8  Closure of nasal defect with bilobed flap. (A) 1 × 1 cm skin defect of tip. (B) Bilobed flap designed for repair. Anticipated standing cutaneous deformity marked
for excision in alar groove. Linear axis of each lobe designed 45° from each other with primary lobe axis positioned 45° from axis of defect. (C) Transfer of flap requires
complete undermining of entire nasal skin. (D) Flap in place. (E) 1 year postoperative. No revision surgery performed.
A
B
C
D
E

117
Eyelids
Figure 7.9  (A) 0.8 × 0.7 cm skin defect of alar groove. V–Y island subcutaneous tissue pedicle advancement flap designed for repair. (B) Flap incised and advanced on
nasalis muscle. (C) Flap in place. (D) 4 months’ postoperative.
A
B
C
D
Figure 7.10  (A) 1 × 0.8 cm skin defect of the dorsum. Transoperative flap designed for repair. Anticipated standing cutaneous deformity marked by horizontal lines. (B) Flap
transposed. (C) 6 months postoperative. No revision surgery performed.
A
B
C
• If there is any concern about vascularity, the flap base is
delayed.
• If a total nasal reconstruction is required, a larger amount
of forehead skin is harvested in the transverse dimension,
but again, the base should be positioned at or below the
medial canthal ligament.
• The septal mucosa is used for lining.
• If nasal support is needed, a cranial bone graft from the
outer table of the skull can be used.
• For closure of the midline forehead defect, the skin can
frequently be mobilized extensively and advanced. If
there is concern, a tissue expander can be inserted to
expand the whole forehead. This gives a large amount of
skin with a good blood supply.
• Noses may be prefabricated elsewhere (e.g., on the
forearm using a radial flap) and subsequently transferred
by microvascular techniques.
Eyelids
Technical pearls
Partial lower lid defects
• Lesions are frequently resected in a V fashion and the
resulting defect can be carefully closed in layers.

118
•
• Local flaps for facial coverage
7
Figure 7.11  Transverse forehead flap for composite nasal tip defect. (A) At initial elevation of the flap, a septal mucosa graft is prelaminated within the distal flap to provide
eventual nasal lining. (B) A bolster dressing is applied to the septal mucosa graft. (C) At a second stage the flap is rotated and inset.
A
B
Skin graft
C
• If this is not possible, the lower portion of the lateral
canthal ligament is divided through a small lateral
canthal incision. This allows the lid to move medially,
and closure can be obtained without tension.
• If there is too much tension, the incision and dissection
are taken further laterally on the cheek. Closure is then
obtained without difficulty. The lateral incision is closed
with a Z-plasty in order to reduce any skin tension.
• An extensive defect requires that a portion of nasal
septum, with mucosa attached on one side, be inserted
with the mucosa toward the globe in order to form an
internal lamella.
• A portion of ear cartilage, with perichondrium in place of
the mucosa, can also be used for support.
• A cheek rotation flap of the required size then provides
external cover.
• If the cheek skin is insufficient, prior expansion of the
lateral cheek skin should be performed, or a narrow
midline forehead flap can be used.
Partial upper lid defects
• Reconstruction of the upper lid is a more difficult
problem because the lid is vital for protection of the eye.
• It is best for the surgeon to sit at the head of the
operating table and think of the upper lid as the lower
lid and use the same techniques described for the
lower lid modified to the required shape and size of the
upper lid.
• Any failure of reconstruction, particularly in the vertical
dimension, may cause conjunctivitis and/or impair
vision. Without an adequate upper lid, the eye will be at
risk for exposure, scarring, and loss of vision. Experience
in eyelid surgery is essential.
Advancement flap
• For a triangular defect in the upper lid (e.g., after tumor
resection), an incision is made horizontally from the
lateral canthus, followed by division of the superior limb

119
Eyelids
Figure 7.12  Reconstruction of nasal tip and dorsum with forehead flap after resection of basal cell carcinoma. (A) 4 × 6 cm skin defect of dorsum, nasal tip, sidewall, and
ala extending into cheek. Cheek advancement flap designed to repair cheek component of defect. (B) Cheek flap advanced to nasal facial sulcus. Auricular cartilage graft
positioned for ala framework. (C) Remaining skin of dorsum and sidewall aesthetic units marked for excision. (D) Interpolated paramedian forehead flap design as covering
flap. (E,F) Forehead flap transferred to nose. Portion of donor site left to heal by secondary incision. (G–J) Preoperative and 1 year, 4 months’ postoperative. Contouring
procedure performed.
A
B
C
D
E
F
G
H
I
J

120
•
• Local flaps for facial coverage
7
Figure 7.13  Reconstruction of total upper eyelid defect with lower lid transposition. (A–D) Illustration of planned reconstruction of an upper eyelid defect with lower lid
transposition.
A
B
C
D
of the lateral canthal ligament. An incision is also made
in the conjunctiva of the superior fornix. This alone will
allow small defects to be closed.
• As in the lower lid, accurate suturing and repositioning
of the gray line, the lash line, and the rim conjunctival
junction is essential.
Lid-switch flap (Abbé flap) (Fig. 7.13)
• By using the same principles as the Abbé flap on the lip,
a similar reconstruction can be used for defects of the
upper lid.
• There are marginal vessels in the lid, and a full-thickness
V flap (the defect of which should close easily) can be
taken from the lower lid, swung up, and sutured into the
upper lid in layers.
• The lower lid defect closure requires the edges to come
together directly without tension.
• If this does not occur, a small lateral canthal incision is
made, and the inferior limb of the lateral canthal tendon
is divided.
• If this is not sufficient, a long transverse incision from the
canthus out to the temporal skin (incorporating a
Z-plasty if necessary) will suffice to obtain tensionless
closure.
Free grafts
• For larger defects, free, full-thickness lid replacements
(composite grafts) have been employed.
• A full-thickness lid replacement is used as a composite
graft if a portion of conjunctiva and subconjunctival
tissue can be preserved as described in the last
segment.
• A full-thickness graft can be taken from the lower lid,
and the conjunctiva is excised from the graft, leaving just
enough for the full-thickness defect. The full-thickness
skin portion remaining will be enough to allow the graft
to survive; however, meticulous reconstructive technique
is imperative. The lower lid defect is closed as described
previously.
Large and total upper lid defects
• For larger defects, the lower lid is used and the
significant lower lid defect is reconstructed.

121
Eyelids
of like texture, similar color, and with identical
characteristics such as dermal appendages and hair
growth.
• When there is insufficient local tissue and time is
available for staged reconstruction, tissue expansion may
be an option.
• The only indication to use distant tissue in cheek
reconstruction is in the situation where there is
insufficient local tissue.
• Older patients generally have greater skin laxity which
will often allow smaller cheek wounds to frequently be
converted to an ellipse and closed directly.
• It is important to be cognizant of the relaxed skin tension
lines and to keep all scars parallel to these lines if
possible.
Cheek rotation flap
• Because the cheek area is relatively large, rotation flaps
may be designed in many sizes, depending on the
position, shape and size of the defect to be reconstructed
(Figs 7.14, 7.15).
• Cheek flaps can be based anteriorly or posteriorly:
■ Basing the flap posteriorly allows mobilization of the
jowls so that this excess can be moved up onto the
face.
■ Basing the flap anteriorly allows for mobilization of
neck skin up onto the face.
• Extending the incision down onto the chest significantly
increases the arc of the rotation of the flap. This
incorporates a back-cut which allows for better flap
mobility of the flap as well as facilitating closure of the
secondary defect.
• The possibility of ectropion as a complication of a cheek
rotation advancement flap is a very real one.
• To avoid ectropion and pull on the lower lid, the cheek
flap should be suspended from the underlying bony
skeleton either using peri-osteal sutures or with an
anchoring device such as a Mitek anchor.
• Particular care must be exercised in female patients to
avoid advancing hair-bearing skin from the sideburn area
onto the cheek. This can be avoided by placing the
incision around the sideburn in these cases (Fig. 7.14).
Advancement flaps
• Advancement flaps can be used at any location on the
cheek. As with the rotation flap, the advancement flap
can be of any size. It is best to use natural lines, even
if they diverge away from the defect, because this will
still give a better and more natural cosmetic end result
(Fig. 7.16).
• When an advancement flap is used to close a square
defect, there are areas of excess skin related to the
Burow’s triangles, these are resected.
• Composite cheek and nose defects require composite
reconstructions. The nose is resurfaced with a full-
thickness skin graft, and an advancement flap again with
excision of Burow’s triangles is used to reconstruct the
cheek (Fig. 7.17).
• A large full-thickness portion of lower lid is moved up on
its marginal vascular pedicle.
• As the portion of lower lid is turned up, the full thickness
of the cheek is advanced medially and grafted with nasal
septum on its inner surface, as required.
• These pedicled lid reconstructions are left attached for
2–3 weeks, depending on the vascularity of the upturned
flaps.
• Once the upper lid reconstruction is in position, small
adjustments are often necessary. Rearrangements are
usually required for the lateral canthus and occasionally
to the edge of the lower lid or to provide adjustment of
lower lid height.
• When a healthy eye is present, a lid can be prefabricated
on the forehead. A pocket the size of the lid is designed
and a mucosal graft is inserted. When this reconstruction
is complete, it is brought down on a vascular pedicle to
replace the lid. The pedicle is divided at 3 weeks. This
protects the eye, but movement is minimal, unless there
is some remaining orbicularis which can be used
immediately or at a later date.
Total lower lid defects
• These result from tumor resection, from trauma, or when
the lower lid is used to reconstruct the upper lid (see Fig.
7.13). Reconstruction of the total lower lid is primarily
performed for cosmesis.
• The lower lid can be reconstructed with a cheek rotation
flap which is lined with oral mucosa or more
satisfactorily using nasal septal cartilage with its
perichondrium intact. In other instances, a forehead flap
may be necessary.
Medial canthal defects
• Generally, forehead flaps provide a reliable and
reasonably good method of reconstruction. These flaps
must be lined with mucosa; however, additional support
is not required because of the inherent flap rigidity. It is
very important to place a flap of sufficient size into the
medial canthal area. Failure to do this results in
troublesome epiphora.
Cheek
• Skin tumors are common in this area. The whole range of
flaps can be used – rotation, advancement, transposition,
and island type – with many variations required and
usually available for each type of reconstruction.
Occasionally, for extremely large defects, a free flap may
be required.
• The most important feature to consider when planning
cheek reconstruction is skin color.
• Although we think of the cheek as a separate esthetic
unit, reconstruction of the cheek will frequently impact
on nearby units.
• Whenever possible, local tissue is the first choice
in reconstructing the cheek as it provides tissue

Figure 7.14  Rotation cheek flap. (A) 4 × 3 cm medial cheek defect. Flap designed for repair. Incision for flap placed in subciliary line. Nasofacial sulcus and melolabial
creases marked. Skin between defect and nasofacial sulcus and melolabial crease removed to position advancing border of flap in aesthetic boundary. (B) Incision for flap
extended to preauricular crease and posterior auricular sulcus. Anticipated standing cutaneous deformity marked with horizontal lines on melolabial fold. (C,D) Flap in
position. Note incision lines at level of lateral canthus. Medial border of flap positioned in nasofacial sulcus and melolabial crease. (E) Postoperative result with normal
eyelid position and well-camouflaged scars.
A
B
C
D
E
Figure 7.15  Cheek rotation flap to close cheek defect. (A) 3 × 3 cm skin defect of medial cheek. (B) Rotation flap designed for repair. (C) Flap in place. Standing
cutaneous deformity excised parallel to melolabial crease. (Courtesy of Shaun R. Baker MD.)
A
B
C

123
Eyelids
Figure 7.16  (A) A medially-based cheek rotation flap. (B) A laterally-based cheek
rotation flap.
A
B
Figure 7.17  (A–C) Melanoma in situ of medial cheek; 5 × 3 cm area marked for excision using square technique to ensure tumor-free margins. (D–F) Pivotal advancement
flap designed for repair of defect following resection of lesion. Anticipated standing cutaneous deformity marked with vertical lines. Z-plasty designed at base of flap to
eliminate need for equalizing Burow’s triangle. (G,H) Melanoma excised, flap dissected. (Courtesy of Shaun R. Baker MD.)
A
B
C
D
E
F
G
H
Transposition flaps
• A transposition flap is elevated from a nearby area and
moved to close a defect while the base of the flap remains
intact. Geometric flap planning is required.
• The rhomboid flap is an ideal example.
• The lesion is resected in a rhomboid design.
• Before this reconstruction, it is necessary to determine the
location of excess skin by pinching the area between the
thumb and index finger and determining the location of a
120° angle opposite this.
• The flap can then be taken from the area with the most
available skin.
• As the flap is fitted into the defect, the donor site
becomes significantly reduced and is closed directly (see
Fig. 7.1).
Finger flap
• The finger flap is similar to the rhomboid flap with
removal of the corners, although it is usually longer
and narrower. Because the cosmetic result is not
optimal, it is not advisable to use this flap for facial
reconstruction.

124
•
• Local flaps for facial coverage
7
Figure 7.18  Schematic diagram of the vascular supply of the submental flap. Note
the separate vein draining the flap.
Facial artery
Submental branch
of facial artery
Island flap
• This technique can be used for advancement or
transposition, but it must be employed with care because
of the tendency to pincushion.
• The island flaps tend to be round or triangular.
• The triangular flap is less likely to pincushion. It is better
to keep the dermis intact, but unfortunately, this is not
always possible.
• The advantage of this variety of flap is that it is a one-
stage procedure, and it is probably more flexible than the
conventional flap.
• If care is not taken, these flaps can be devascularized
more easily than standard pedicled flaps. This can occur
by traction on or twisting of the pedicle or because of a
tunnel that is too narrow and constricts the pedicle,
compromising flap survival (see Fig. 7.9).
The submental artery flap (Fig 7.18)
• Advantages of the submental flap include similar skin
color and texture, and a conveniently hidden scar under
the chin.
• Based on the submental branch of the facial artery, this
flap can easily be tunneled up into the cheek.
• In males it is important to remember that this flap resides
in the hair-bearing portion of the chin.
• This flap is an excellent choice for small to moderate
sized defects.
• An increasing arc of rotation can be achieved in two
ways:
■ Division of the facial artery cephalad to the submental
branch allows dissection of the facial artery to its
origin off the external carotid, supplying a few extra
centimeters of pedicle length and antegrade flow.
■ Division of the facial artery caudal to the submental
branch allows pedicle elevation and flap perfusion in a
retrograde fashion which is adequate to sustain the
flap.
Free tissue transfer
• Typically employed for large defects without sufficient
local tissue, or in instances where more than soft tissue
reconstruction is required.
• Flap choice is often dependent on defect characteristics
and need for composite tissue.
Scapular and parascapular flaps
• The skin territory of the scapular and parascapular flap is
sufficiently large to allow for closure of the largest cheek
defect while at the same time closing the donor defect
directly.
• Depending on the size of defect, the flap can be folded on
itself in the case of through and through defects, to
provide lining and cover or alternatively, scapular and
parascapular flaps can be harvested on the transverse
and descending branches of the circumflex scapular
artery respectively, to provide lining and cover.
• The scapula can also be taken with bone and this can be
used effectively to reconstruct the bony contour of the
cheek.
Anterolateral thigh flap
• The anterolateral thigh flap is an alternative to the
scapular/parascapular flap.
• Color match is not as good in lighter skinned patients.
• The flap can be harvested with or without fascia
depending on need for thin or bulky flaps.
Other flap options
• The radial forearm flap.
• The rectus abdominis myocutaneous flap.
Lips
• The upper lip and lower lip must be considered
individually because the methods used for reconstruction
are not always applicable to both locations (Fig. 7.19).
• Goals of lip reconstruction:
■ Preservation of function.
■ Reconstitution of orbicularis oris.
■ Three layered closure.
■ Accurate alignment of vermillion.
■ Maintenance of relationship between upper and lower
lips.
■ Optimization of cosmesis (Fig. 7.20).

125
Lips
Table 7.2  Critical anatomy of the lips
Arterial supply of the
upper and lower lips
Sup. and Inf. labial a. (from the facial
a.)
Sensory innervation
Maxillary and mandibular divisions of
the trigeminal n. (CN V)
Important muscular
anatomy
  Orbicularis oris
Function to protrude the lips away from
the facial plane, and also approximates
the lips to the alveolar arch
  Zygomaticus major
Major lip elevator; innervated by buccal
branch of facial n. (CN VII)
  Levator anguli oris
Major lip elevator; innervated by buccal
branch of facial n. (CN VII)
  Depressor anguli oris
Major lip depressor; innervated by
mandibular branch of facial n. (CN VII)
  Platysma
Major lip depressor; innervated by
mandibular branch of facial n. (CN VII)
Modiolus
A 1 cm thick fibrovascular region where
the levator and depressor muscle fibers
intersect and attach firmly to the
dermis. It is located approximately
1.5 cm lateral to the oral commissures.
The modiolus significantly affects the
appearance of the oral commissures
with movement. Disruption can lead to
abnormal appearance of the mouth at
rest or during function.
Figure 7.19  An algorithmic approach to lip reconstruction.
Lip reconstruction
No defect
Direct repair
Small defect
Intermediate defect
Total lip defect
Upper lip <25%
Lower lip <30%
Free tissue
transfer
Local flap
e.g., lip switch
Karapandzic
Figure 7.20  Breaking up the linear scar by introducing a vertical element to an excision will allow for more precise closure as the vermillion borders can be accurately
approximated (marked with dots). Furthermore, the resulting scar will not be linear and will therefore be less likely to contract.
• Given their critical importance functionally and
aesthetically, a thorough knowledge of the lip anatomy is
imperative (Fig. 7.21, Table 7.2).
Technical pearls
• Local tissue should be used whenever possible.
• Small defects can be closed by direct repair.
• Intermediate defects are best reconstructed with local
flaps.
• Total or subtotal lip defects are best reconstructed with
free tissue (Fig. 7.22).
Operative techniques
Wedge resection (Figs 7.22, 7.23)
• Up to 25% of the upper lip can be resected and repaired
directly.
• Up to 30% of the lower lip can be resected and repaired
directly.
• Careful approximation of the muscle layer ensures a
functional repair.
• Consider a W resection for larger wedges in order to
keep the scar above the mental crease.
Lip switch flaps: Abbé (Fig. 7.24) and Estlander
flaps (Fig. 7.25)
• Width of the flap should be half the width of the defect.
• Height of the flap should be the same as height of the
defect.
• Pedicle of Abbé flap should be placed at the midpoint of
the defect.
• Pedicle division at 14–21 days.

126
•
• Local flaps for facial coverage
7
Figure 7.21  The aesthetic landmarks of the lips are seen. The curve of the upper
lip resembles a bow, known as Cupid’s bow. The central concavity of the upper lip
is the philtrum, bounded on either side by the conves philtral columns. The lateral
elements of the upper lip are bounded by the philtral ridge medially, the nasal
vestibule and alar base superiorly and the nasolabial fold laterally. The mental
crease separates the lower lip from the aesthetic unit of the chin.
Figure 7.22  (A) Schematic of palmaris/radial forearm flap reconstruction of the lower lip showing the Palmaris tendon woven through the remaining orbicularis muscle.
A
Tendon
Flap
Tendon
Flap

127
Lips
B
C
D
E
F
(B) Patient shown with a large squamous cell carcinoma of the lower lip. (C) Resection of the lower lip planned. (D) The planned radial forearm flap.
Note the different dimensions of the skin and mucosal segments of the flap. (E) Postoperative appearance. (F) Note that the patient can purse his lips and has good oral
competence.
Fig. 7.22, cont’d

128
•
• Local flaps for facial coverage
7
Figure 7.24  Schematic of an Abbé flap from the lower lip to the upper. Note that
the width of the Abbé flap is half the width of the defect, while the height of the flap
is the same as the height of the defect. The pedicle will be planned at a point
opposite the mid-portion of the defect and will end up at the medial end of the
defect following rotation of the flap.
Figure 7.23  Schematic of a step flap reconstruction. Note that the steps are excised to allow the flaps to advance. Note also that the scar remains above the mental crease.
Step removed
Width is half
the height
Ear
• The areas of the ear most often requiring
excision and reconstruction are the rim and the conchal
area.
Rim defects
• It is frequently possible to excise a rim lesion and
advance the rim by incising full thickness down to the
lobule. There is no residual defect with this method
(Fig. 7.28).
• If there is concern about the viability of the tip of this flap
or if the defect is larger, the posterior skin is dissected up
and may be included into the rim.
• A larger flap with a large base has a better blood supply
and is more likely to survive. It does not result in any ear
deformity.
• In some instances, superior and inferior rim flaps will be
used in conjunction with one another.
• Larger defects are better reconstructed by postauricular
flaps (Fig. 7.29).
• The flap is elevated and sutured to the anterior edge of
the defect.
• After 3 weeks, a large flap is incised in the postauricular
area, dissected up to provide laxity, and brought to the
ear rim to provide more tissue.
• It is trimmed as necessary and sutured in
place. Deep sutures can help in forming the shape as
required.
Large, composite or total lip defects
• Typically require large local flaps, such as the
Karapandzic, Gillies (Fig. 7.26), or Fukimori Gate Flap
(Fig. 7.27) or free tissue transfer.

129
Ear
A
B
C
D
E
F
Figure 7.25  (A) Schematic of Estlander flap designed to reconstruct a defect of the lower lip. (B) Patient with squamous cell carcinoma of the lower lip. (C) The lesion has
been excised and the flap designed. Note the dimensions of the flap. The width is half that of the defect but the height is the same as the height of the defect. (D) The flap is
being rotated into the defect. (E) Final inset of the flap and closure of the donor defect. (F) Final appearance. Note the slight blunting of the commisure.

130
•
• Local flaps for facial coverage
7
Figure 7.26  A schematic of the Gillies fan flap is shown. Note the releasing incisions on the upper lip that allow the flaps to rotate and advance.
A
B
Figure 7.27  (A) Patient with a large squamous cell carcinoma of the lower lip requiring total resection. (B) The resection is complete and bilateral Fukimori gate flaps have
been designed. (C) The flaps are rotated into the defect and the secondary defects closed. (D) Postoperative appearance showing significant deformity of the lower face.
A
B
C
D

131
Ear
Figure 7.28  (A) Helical defect following resection of a basal cell carcinoma. (B) Helical flaps are raised based on the posterior skin. (C) Flaps are dissected until
advancement and closure without tension is possible. (D) Final appearance following closure. (Courtesy of Dr David Mathes.)
A
B
C
D
Figure 7.29  (A) Defect of upper ear after resection of squamous cell carcinoma. (B) Postauricular flap is designed, (C) raised and inset into defect. (D) Appearance prior
to pedicle division and (E) following pedicle division. The intervening defect is skin grafted most easily with a post-auricular graft harvested more inferiorly than the defect
and closed directly. (F) Late appearance. (Courtesy of Dr David Mathes.)
A
B
C
D
E
F

132
•
• Local flaps for facial coverage
7
Figure 7.30  (A) A 72-year-old man with a basal cell in the upper ear, marked for excision. (B) Defect includes anterior skin and underlying cartilage. (C) Postauricular,
superiorly based flap outlined. (D) Flap raised and tunneled into anterior defect. Small segment of flap is de-epithelialized and secondary defect is closed directly. (E) Final
appearance of healed flap. (Courtesy of Dr Peter Neligan.)
A
C
B
D
E
Anterior concha
• If a lesion of significant size occurs in the anterior concha,
resurfacing will be required.
• To achieve this, the lesion is resected together
with the underlying conchal cartilage. The ear
is then distracted forward, and a flap is designed
with a central vertical pedicle based on the ear mastoid
groove.
• The skin anterior and posterior to the groove is elevated,
with some division of the subcutaneous hinge superiorly
and inferiorly, it can be rotated into the ear defect.
• The posterior edge of the postauricular island is
sutured to the posterior edge of the defect, and the
anterior edge of the island is sutured to the anterior
edge of the defect. The posterior defect is closed directly
(Fig. 7.30).
• In a large degloving of the ear, a temporal fascial flap is
used to cover the defect. The flap is then covered with a
full-thickness skin graft.
• This is a rare injury, but this technique can also be used
in reconstruction of the congenitally absent ear.
Further reading
Abbé R. A new plastic operation for the relief of deformity
due to double harelip. Plast Reconstr Surg.
1968;42(5):481–483.
Cordeiro PG, Santamaria E. Primary reconstruction of
complex midfacial defects with combined lip-switch
procedures and free flaps. Plast Reconstr Surg.
1999;103(7):1850–1856.

133
Further reading
Free flaps are generally the preferred method for
reconstructing large defects of the midface, orbit, and
maxilla that include the lip and oral commissure;
commissuroplasty is traditionally performed at a second
stage. Functional results of the oral sphincter using this
reconstructive approach are, however, limited. This article
presents a new approach to the reconstruction of massive
defects of the lip and midface using a free flap in
combination with a lip-switch flap. This was used in 10
patients. One-third to one-half of the upper lip was excised
in seven patients, one-third of the lower lip was excised in
one patient, and both the upper and lower lips were excised
(one-third each) in two patients. All patients had
maxillectomies, with or without mandibulectomies, in
addition to full-thickness resections of the cheek. A switch
flap from the opposite lip was used for reconstruction of the
oral commissure and oral sphincter, and a rectus abdominis
myocutaneous flap with two or three skin islands was used
for reconstruction of the through-and-through defect in the
midface. Free flap survival was 100%. All patients had
good-to-excellent oral competence, and they were discharged
without feeding tubes.
Curran AJ, Neligan P, Gullane PJ. Submental artery island
flap. Laryngoscope. 1997;107(11):1545–1549.
This paper describes the anatomy of the submental artery
perforator flap. The artery is a branch of the facial artery.
The perforators run alongside the anterior belly of digastric,
which is harvested with the flap. Two cases are presented of
lower face reconstruction using the submental flap.
Hofer SO, Posch NA, Smit X. The facial artery perforator
flap for reconstruction of perioral defects. Plast Reconstr
Surg. 2005;115(4):996–1003.
The concept of the facial artery perforator flap is
discussed in a study of five clinical cases. The article
concludes that this is a versatile flap due to a large arc of
rotation and an aesthetically pleasing donor site. It is an
ideal flap for one-stage reconstruction without secondary
revisions.
Jackson IT. Use of tongue flaps to resurface lip defects and
close palatal fistulae in children. Plast Reconstr Surg.
1972;49:537–541.
This paper describes the technique of using an anterior
tongue flap to reconstruct the vermillion, as well as more
extensive lip defects. It also describes the use of the tongue
flap for repair of palatal fistulae. In dentate patients, it is
particularly important to ensure that precautions are taken
to prevent the patient from biting the flap.
Jackson IT. Local Flaps in Head and Neck Reconstruction. 2nd
ed. St Louis: Quality Medical; 2007.
Jeng SF, Kuo YR, Wei FC, et al . Total lower lip
reconstruction with a composite radial forearm
palmaris longus tendon flap: a clinical series. Plast
Reconstr Surg. 2004;113(1):19–23.
Large, full-thickness lip defects after head and neck surgery
continue to be a challenge for reconstructive surgeons. The
reconstructive aims are to restore the oral lining, the
external cheek, oral competence, and function (i.e.,
articulation, speech, and mastication). These authors’
refinement of the composite radial forearm-palmaris longus
free flap technique meets these criteria and allows a
functional reconstruction of extensive lip and cheek defects
in one stage. A composite radial forearm flap including the
palmaris longus tendon was designed. The skin flap for the
reconstruction of the intraoral lining and the skin defect was
folded over the palmaris longus tendon. Both ends of the
vascularized tendon were laid through the bilateral modiolus
and anchored with adequate tension to the intact orbicularis
muscle of the upper lip. This procedure was used in 12
patients.
Karapandzic M. Reconstruction of lip defects by local
arterial flaps. Br J Plast Surg. 1974;27:93–97.
In this classic paper, Dr Karapandzic describes the procedure
which allows for preservation of the neurovascular bundles
of the orbicularis oris in order to reconstruct defects of the
lips. This classic description focuses on reconstruction of
lower lip defects.
Keskin M, Kelly CP, Yavuzer R, et al. External filling ports
in tissue expansion: confirming their safety and
convenience. Plast Reconstr Surg. 2006;117(5):1543–1551.
Kroll SS. Staged sequential flap reconstruction for large
lower lip defects. Plast Reconstr Surg.
1991;88(4):620–627.
Langstein H, Robb G. Lip and perioral reconstruction. Clin
Plast Surg. 2005;32:431–445.
Limberg AA. The planning of local plastic operations on the
body surface: theory and practice. In: Wolfe SA, ed.
trans. Planirovanie Mestnoplasticheskikh Operatsiina
Poverkhnosti Tela, 1906. Lexington MA: Collamore
Press; 1984.
McGregor IA. Eyelid reconstruction following subtotal
resection of the upper or lower lid. Br J Plast Surg.
1973;26:346–354.
McGregor JC, Soutar DS. A critical assessment of the bilobed
flap. Br J Plast Surg. 1981;34:197–205.
Mustardé JC. Eyelid repairs with costochondral grafts. Plast
Reconstr Surg. 1962;30:267–272.
Neligan PC. Strategies in lip reconstruction. Clin Plast Surg.
2009;36(3):477–485.
Injury or surgical trauma can result in significant
alterations of normal lip appearance and function that can
profoundly impact the patient’ s self-image and quality of
life. Neuromuscular injury can lead to asymmetry at rest
and during facial animation, and distressing functional
disabilities are common. Loss of labial competence may
interfere with the ability to articulate, whistle, suck, kiss,
and contain salivary secretions. For smaller defects,
reconstruction can be very effective. Reconstructing an
aesthetically pleasing and functional lip is more difficult
with larger defects.
Shestak KC, Roth AG, Jones NF, et al . The cervicopectoral
rotation flap – a valuable technique for facial
reconstruction. Br J Plast Surg.1993;46(5):375–377.
Webster J. Crescentic peri-alar cheek excision for upper lip
flap advancement with a short history of upper lip
repair. Plast Reconstr Surg. 1955;16:434–464.

©2014, Elsevier Inc. All rights reserved.
Chapter
8 
Cleft lip repair
SYNOPSIS (BIL ATERAL LIP REPAIR)
■ A child born with bilateral cleft lip should not have to suffer
because of an ill-conceived and poorly executed primary repair.
The operative principles for synchronous nasolabial repair are
established:
• Maintain symmetry.
• Secure primary muscular continuity.
• Design proper philtral size and shape.
• Construct the median tubercle from lateral labial elements.
• Position/secure the lower lateral cartilages and sculpt the nasal
tip and columella.
■ The techniques based on these principles are within the repertoire
of a well-trained surgeon whose practice is focused on children
with cleft lip. Only the philtral columns and dimple seem just
beyond the surgeon’s craft.
■ Preoperative dentofacial orthopedic manipulation of the
premaxilla is necessary to permit synchronous closure of the
primary palate. The surgeon must repair the bilateral cleft lip and
correct the nasal deformity in three-dimensions based on
knowledge of anticipated changes in the fourth-dimension.
Modifications of the techniques used in repair of the most
common complete form are needed for the less common
bilateral variants, such as, binderoid, complete with intact
secondary palate, symmetrical incomplete, and asymmetrical
complete/incomplete.
■ Outcomes can be assessed using preoperative and serial
photography and documentation of revision-rates. Direct
anthropometry is the “gold-standard” for quantification of the
changing nasolabial features; however, it requires training and
experience. Intraoperative anthropometry is used to record baseline
dimensions and is repeated as the child grows. Two-dimensional
photogrammetry is applicable for certain linear and angular
measurements if properly scaled. Computerized three-dimensional
photogrammetry is a new methodology for quantifying
nasolabial appearance. It is both accurate and reliable, and
someday could be employed in intra- and inter-institutional
comparative studies.
This chapter was created using content from
Neligan & Losee, Plastic Surgery 3rd edition,
Volume 3, Pediatric Plastic Surgery, Chapter 23
Repair of unilateral cleft lip, Philip Kuo-Ting Chen,
M. Samuel Noordhoff and Alex Kane, Chapter 24,
Repair of bilateral cleft lip, John B. Mulliken.
SYNOPSIS (UNIL ATERAL LIP REPAIR)
Principles of unilateral cleft lip repair
■ Presurgical nasoalveolar molding.
■ Modification of surgical techniques.
• Mohler’s rotation incision.
• Mucosal flaps for nasal floor reconstruction, correction of
mucosal deficiency in piriform area.
• Eliminate the perialar incision on advancement flap, limiting
scars around the ala base and nostril floor.
• Mobilization of alar base.
• Nasal floor reconstruction with complete mucosal closure.
• Muscle release and reconstruction to simulate the philtral
column.
• Anchoring of advancement flap to nasal septum for centralizing
the Cupid’s bow.
• Correction of central vermillion deficiency with triangular
vermillion flap from lateral lip.
• Semi-open rhinoplasty with a reverse U incision on the cleft
side and rim incision on the non-cleft side.
• Atraumatic dissection to release the fibrofatty tissue from lower
lateral cartilages.
• Advancement and fixation of the cleft side lower lateral cartilage
to the non-cleft side lower lateral cartilage and to the skin in an
over-corrected position.
• Definition of the ala-facial groove with alar transfixion sutures.
■ Postoperative maintenance of over-correction with silicone nasal
conformer.

135
Preoperative considerations
■ Unaffected (i.e., non-cleft) parents who have one child
with cleft lip/palate have an estimated recurrence risk
of 4%, increasing to 9% if two children are affected.
■ If one parent is affected, the risk of having a child with
cleft lip/palate is also 4%, increasing to 17% if there is
already both an affected parent and an affected child.
■ As the degree of familial relationship increases,
recurrence risk decreases: first-, second-, and third-
degree relatives have 4%, 0.7%, and 0.3% risk,
respectively.
■ Recurrence risk increases with the severity of the cleft.
Preoperative considerations
• With the assistance of ultrasound, prenatal diagnosis of
cleft lip is usually made after 16–20 weeks’ gestation.
• Three-dimensional ultrasonography has improved the
accuracy of cleft lip diagnosis and is helpful for prenatal
counseling because parents can visualize the face of the
fetus clearly.
• A genetic diagnosis and evaluation for other systemic
conditions should be done at the time when a prenatal
diagnosis of the cleft is made.
• The newborn cleft baby should have a pediatric
evaluation and parents are counseled about feeding
and given information for subsequent care and
treatment.
• Depending on surgical preference, presurgical
nasoalveolar molding may be started at 2 weeks or even
earlier.
• If utilized, it usually takes 3–4 months before the
completion of the nasoalveolar molding.
• There are several different treatment plans for surgical
correction of the cleft lip deformity (Fig. 8.1, Fig. 8.2);
however, generally timing is as follows:
■ Alveolar/nasoalveolar molding:
■ If utilized, typically begins by 2 weeks of age.
• Lip repair typically occurs around 3 months of age:
■ With presurgical nasoalveolar molding, a definitive
cheiloplasty is done at the age of 3–5 months, when
the alveolar gap is narrowed and nasal deformity is
improved.
■ When presurgical orthopedics is not available or if the
child is older than 3 months, a definitive cheiloplasty
with nasal correction is performed.
■ If there is a wide cleft (>12–15 mm) and an associated
tissue deficiency, a nasolabial adhesion cheiloplasty is
done at 3 months, followed by a definitive cheiloplasty
at about 9 months.
• If the child has an associated cleft palate, a palatoplasty is
typically performed at 9–12 months.
• Timing of alveolar bone grafting relates to the eruption of
the central incisor and canine and is frequently
determined by the orthodontist usually at the age of 7–11
years.
• Early intervention for velopharyngeal insufficiency is
done as soon as possible on the basis of speech
evaluation and nasopharyngoscopy.
Brief introduction
• The multidisciplinary approach is essential to the
satisfactory treatment of the cleft patient including:
surgeons, orthodontists, speech pathologists,
pedodontists, prosthodontists, otolaryngologists, social
workers, psychologists, as well as a photographer.
• The techniques presented for the unilateral cleft lip repair
are based on the experience of the members of the Chang
Gung Craniofacial Center over a period of 30 years in a
Chinese population. They have also been tested in other
racially diverse centers. The improved outcomes result
from an integrated approach with presurgical
management, surgical refinements and postsurgical
maintenance.
• It is generally believed that isolated cleft palate is a
genetic entity distinct from unilateral cleft lip with or
without cleft palate.
• This conclusion arises from both epidemiologic studies
and the fact that embryologic events leading to cleft lip/
palate and cleft palate occur at somewhat different times
(3–7 weeks versus 5–12 weeks).
• It has long been assumed that both genetic and epigenetic
factors play important roles in the etiology of clefts, and
this is supported by the varying incidence of clefting with
ethnicity, geographic location, and socioeconomic
conditions.
• The incidence of cleft lip/palate in white newborns is
approximately 1 in 1000 (Table 8.1); isolated cleft palate
occurs in about 0.5 in 1000.
• While there are more than 250 syndromes associated with
orofacial clefting, most cases occur as an isolated
abnormality; so-called non-syndromic cleft lip/palate.
• In a large review of their center’s experience, Rollnick
and Pruzansky identified other malformations in 35% of
cleft lip/palate patients and 54% of cleft palate patients.
• Cleft lip/palate has an unequal gender distribution,
favoring boys over girls, whereas this relationship is
reversed in cleft palate only.
• Cleft lip/palate affects the left side more often.
• A common question from parents pertains to their risk of
having another child with a cleft lip/palate:
Table 8.1  Incidence of cleft lip/palate in differing ethnic groups
Ethnicity
Incidence per 1000 births
American Indian
3.6
Japanese
2.1
Chinese
1.7
White
1.0
African-American
0.3
Data from Wyszynski DF, Beaty TH, Maestri NE. Genetics of nonsyndromic oral
clefts revisited. Cleft Palate Craniofac J. 1996;33:406–417. Vieira AR, Orioli IM.
Candidate genes for nonsyndromic cleft lip and palate. ASDC J Dent Child.
2001;68:229, 272–279.

136
•
• Cleft lip repair
8
• Secondary correction of nasal deformities and
orthognathic surgery, when indicated, are delayed until
facial growth is complete.
• Bilateral cleft lip presents in three major anatomic forms
(Fig. 8.3):
■ bilateral symmetrical complete (50%).
■ bilateral symmetrical incomplete (25%).
■ bilateral asymmetrical (complete/incomplete) (25%).
• The extent of the palatal cleft usually corresponds to the
severity of the labial clefts.
• Minor-form cleft lip extends 3–5 mm above the normal
Cupid’s bow peak, i.e., 50% or less of the normal
cutaneous labial height.
• Other features are: deficient vermillion on medial
side of the cleft; cutaneous groove and muscular
depression; hypoplastic median tubercle; and minor
nasal deformity.
Figure 8.1  Overall cleft treatment plan in the Chang Gung Craniofacial Center.
Complete cleft
lip/palate
Presurgical
nasoalveolar molding
Nasal molding
Nasolabial adhesion
width > 12–15 mm
Tissue deficiency
No presurgical
orthopedics
Definitive
cheiloplasty
Incomplete
cleft lip
Figure 8.2  Surgical algorithm for unilateral cleft lip repair in the Chang Gung
Craniofacial Center.
Prenatal diagnosis
Birth
Lip surgery
Staged or single stage
Palatal surgery
ENT
Speech evaluation
Early intervention
VPI (4 yrs)
Revision lip and nose
Alveolar bone grafting
Social workers,
pediatric evaluation
Genetic diagnosis
Prenatal counseling
Screen for other systemic conditions
1–6 weeks
Presurgical nasoalveolar molding
Post surgical nasal splinting
ENT screening for middle ear disease
Orthodontics
Final evaluation
Orthognathic surgery
(skeletal maturity)
3–4 months
9 months–1 year
2½ years
7–9 years
17 years
A
B
C
Figure 8.3  Examples of asymmetrical bilateral cleft lip. (A) Left complete and right minor-form; (B) left complete and right microform; (C) left incomplete and right
mini-microform.

137
Anatomical/technical pearls
Figure 8.4  (A) Latham appliance; (B) prior to insertion of device; (C) 6 weeks
following dentofacial orthopedic manipulation.
A
DB
DC
• Microform cleft lip is characterized by a notched
vermillion–cutaneous junction in which the Cupid’s bow
peak is elevated less than 3 mm above normal.
• Other features are the same as in a minor-form, but they
are less obvious.
• Nasal deformities include small depression of the sill,
slightly slumped alar genu and 1–2 mm lateral
displacement (and often under-rotation) of the alar base.
• Mini-microform cleft lip is distinguished by a disruption of
the white roll (vermillion–cutaneous junction) without
elevation of the Cupid’s bow peak.
• Usually there is a notch of the free mucosal margin.
Muscular depression (particularly noticeable below
the nostril sill) is variable as is the cleft nasal deformity.
• This detailed subcategorization of the contralateral side
in an asymmetrical bilateral cleft lip is important because
the extent of vermillion–cutaneous disjunction determines
the operative strategy.
• Synchronous bilateral nasolabial repair is indicated for a
contralateral incomplete cleft lip, including a minor-form.
• Correction of a contralateral microform or mini-
microform is usually deferred until closure on the greater
side.
• Alignment of the three maxillary elements sets the
skeletal stage for synchronous bilateral nasolabial repair
and minimizes the nasolabial distortions that occur
during rapid growth of early childhood.
• After retrusion and centralization of the premaxilla, the
philtral flap can be designed in proper proportions,
the nasal tip cartilages can be anatomically positioned,
and the alveolar clefts can be closed, which stabilizes
the maxillary arch and usually eliminates oronasal
fistulas.
• There are two dentofacial orthopedic strategies: passive
and active.
• Passive strategies include nasoalveolar molding (NAM)
devices.
• Active strategies include the Latham appliance
(Fig. 8.4).
Anatomical/technical pearls
• Areas of vital concern to the surgeon: the amount of
tissue medial to the base of the ala, the vertical height of
the lateral lip, the horizontal length of the lateral lip, and
the epidermal extension from the columella onto the
premaxilla.
• The discrepancy between the height from the central
point of the base of columella to the two peaks
of the Cupid’s bow is critical for leveling of the
Cupid’s bow.
• Vertical length of the lip is more important aesthetically
compared with the horizontal length.
• Therefore, vertical length is seldom sacrificed for
horizontal length columella and nasal floor skin.
The vermillion beneath the cleft-side Cupid’s bow is always
deficient compared with the counterpart vermillion width on
the non-cleft side (Fig. 8.5).