Phẫu Thuật Tái Tạo Khuôn Mặt Sau Phẫu Thuật Mohs

first lobe in width and situated 90 degrees away from the first
lobe. This allows the closure scar to fall within, or in close prox-
imity to, the horizontal glabellar fold. Dissection of the flaps is
in the subcutaneous fat plane to prevent excessively thin flaps
which can be lost, and also to avoid injury to the deeper struc-
tures, particularly the corrugator and procerus muscles in this
region.
Larger and more inferiorly positioned medial canthal defects
can be addressed with cheek advancement flaps, utilizing a lat-
eral rhinotomy incision coupled with an incision hidden in the
orbital rim ligament depression which can recruit significant
thick skin for medial canthal reconstruction ( Fig. 15.9a). Dis-
section once again is in the subcutaneous fat plane to maintain
a thick viable flap, yet avoid damage to the underlying facial
mimetic muscles (Fig. 15.10b). The depth of the medial can-
thus is often best left to heal by secondary intention which, as
noted earlier, often results in an excellent final aesthetic result
(Fig. 15.9c-e).
Full-thickness skin grafting or dermal matrix substitutes (e.g.,
Integra) followed by partial- or full-thickness grafting after
integration are good options when very large defects less ame-
nable to advancement flaps are present or in patients in whom
large flaps are less desirable, such as smokers ( Fig. 15.10).
Fig. 15.5 Algorithm for closure of defects
involving the canthi.
Fig. 15.6 (a) Large medial canthal defect in the
region of concern for lacrimal outflow apparatus
injury. (b) Lacrimal probing confirms injury of the
lower lacrimal canaliculus. (c,d) Placement of a
silicone monocanalicular stent to bridge the
compromised canalicular segment.
Fig. 15.7 5–0 Vicryl pericanalicular sutures (anterior and posterior to
the canaliculus) ensure reapproximation and repair of the medial
canthal tendon, as the canaliculi run through the middle of the medial
canthal tendon.2 (Used with permission from Chen WP. Ocuplastic
Surgery: the Essentials. Thieme, New York, 2001.)
Techniques for Specific Anatomic Location
134

15.3.2 Lateral Canthal Defects
The lateral canthus houses the lateral canthal tendon which sta-
bilizes the upper and lower eyelids ( Fig. 15.3). Defects in the
lateral canthus can involve the lateral canthal tendon and desta-
bilize the eyelids. Small defects that involve the upper or lower
eyelid canthal tendons can be repaired by creating a lateral tar-
sal strip from the remaining eyelid if adequate mobility is
present for the tarsal strip to be attached to the periosteum of
the inner aspect of the lateral orbital rim; typically this can be
achieved for defects less than or equal to one-fourth of the hori-
zontal eyelid length ( Fig. 15.11). Fig. 15.12 demonstrates
use of the technique in a patient with approximately one-fourth
of the eyelid defect involving the tarsus and lateral canthus.
Defects involving the lateral canthal tendon and full-
thickness eyelid greater than one-fourth of the eyelid length are
not amenable to the tarsal strip procedure due to the inability to
adequately mobilize the eyelid laterally to allow attachment in
the lateral canthus. A periosteal flap of varying length (typically
for defects up to half of the eyelid horizontal length) can be
developed from the lateral orbital rim to reconstruct an upper
and/or lower lateral canthal tendon and serves as an adequate
posterior lamella substitute in this region as well (Fig. 15.13).
Local advancement flaps or even full-thickness skin grafts can
then be used to reconstruct the anterior lamellar deficiency.
15.4 Defects Not Involving the
Canthus ( Fig. 15.14)
15.4.1 Upper and Lower Eyelid: Partial-
Thickness Defects
Partial-thickness defects, those involving the anterior lamella
(skin +/- orbicularis), of the upper and lower eyelids can be
closed in a variety of ways including full-thickness skin grafting
or local advancement flaps.
Full-thickness skin grafts of the upper and lower eyelids heal
well with good care and cosmesis if appropriate grafting sour-
ces are utilized to provide like tissue. The ideal source of full-
thickness skin graft tissue to the eyelids is eyelid donor itself.
Older patients with redundant dermatochalasis of the upper
eyelids provide an excellent source of tissue for grafting. If eye-
lid skin is unavailable or insu cient for reconstruction, retro-
auricular skin grafts thinned appropriately provide an excellent
donor site. Supraclavicular, preauricular, or other non–hair-
bearing donor sites provide an adequate, though less favorable,
donor site if eyelid or retroauricular sources are unavailable. It
is important to adequately thin this thicker donor skin and
ensure the harvest site is truly non–hair-bearing.
Graft size can often be minimized, particularly in lower eyelid
defects with preexisting horizontal laxity and a high likelihood
for development of ectropion, by converting a portion of the
defect to full thickness. This is particularly useful in defects
which partially violate the integrity of the tarsus (Fig. 15.15).
Bolstering of full-thickness skin grafts can be very di cult and
uncomfortable for the patient in the periocular region. Use of a
“cyanoacrylate cast” can be very helpful in this area to stabilize,
immobilize, and prevent graft corrugation during the first week
of healing, often obviating the need for a bolster for small grafts
in this area ( Fig. 15.16).
A variety of flaps are useful in the periocular region for par-
tial-thickness defect reconstruction (Fig. 15.17). The single
most important tenet which must be obeyed in this region
regardless of the choice of advancement flap is that defect clo-
sure tension must be directed parallel to the eyelid margin
which is most readily achieved with defect closure oriented 90
degrees perpendicular to the eyelid margin. Closure in this
manner disobeys relaxed skin tension lines in this area; more
importantly, however, closure in this manner does not place
vertical tension on the eyelid that can result in ectropion and or
eyelid retraction. O-T plasty is particularly useful in this area
and allows for closure with tension directed parallel to the
eyelid margin (Fig. 15.18).
Fig. 15.8 (a) Medial canthal defect with planned bilobed flap closure.
See 15.17a as well. (b) Conservative flap thinning, avoiding excess
thinning and potential loss of viability. (c) One-week post-op with
healing incisions oriented in the vertical and horizontal glabellar folds.
(d) Two years post-op.
Eyelid Reconstruction
135

15.4.2 Upper and Lower Eyelid:
Full-Thickness Defects
Full-thickness defects of the upper and lower eyelids require
reconstruction of both the anterior and posterior lamellae. The
underlying degree of preexisting eyelid laxity determines the
method of closure that can be used. In general, approximation
in younger patients with minimal eyelid and canthal tendon
laxity defects up to one-fourth of the eyelid margin can be
closed directly; defects up to one-third of the eyelid margin can
be closed directly after release of the lateral canthal tendon with
or without a semicircular advancement flap; and defects more
than one-third of the eyelid margin typically require a lid-
sharing–type procedure to allow adequate closure. In older
patients with significant eyelid and canthal tendon, laxity
defects up to one-third of the eyelid margin can be closed
directly; defects up to half of the eyelid margin can be closed
directly after release of the lateral canthal tendon with or with-
out a semicircular advancement flap; and defects more than
half of the eyelid margin typically require a lid-sharing–type
procedure to allow adequate closure. The use of two forceps to
attempt tissue reapproximation without undue tension can con-
firm or contradict the above approximations on an individual
basis (Fig. 15.21c). When direct closure is an option, with or
without canthal manipulation, closure involves stepwise lamella
reapproximation (Fig. 15.19, Fig. 15.20, Fig. 15.21).
When direct closure is not an option for large full-thickness
defects, lid-sharing procedures can be utilized. For large lower
eyelid defects, posterior lamellar reconstruction can be
achieved with a Hughes tarsoconjunctival flap ( Fig. 15.22).
Fig. 15.9 (a) A lateral rhinotomy incision coupled with a lateral incision along the tear trough for planned reconstruction. (b) Dissection of a thick flap
in the subcutaneous plane. (c) Closure with a small area in the depth of the medial canthus left to heal by secondary intention. (d,e) Six weeks with
almost full epithelialization of the area of secondary intention healing.
Fig. 15.10 A 68-year-old smoker with a large deep Mohs defect of the
cheek down to the facial mimetic muscles. A large advancement flap in
this area would result in significant tissue loss if the flap failed. Integra
was utilized to build volume and allow the patient to cease smoking for
1 month at which time full-thickness skin grafting was performed from
a supraclavicular donor site with full take.
Techniques for Specific Anatomic Location
136

Fig. 15.11 Lateral tarsal strip procedure. (a) The
procedure involves conservative exposure of a
small strip of tarsus (2–3 mm is sufficient) of the
remaining eyelid by denuding the eyelid margin
epithelium and recessing the anterior lamella to
expose a strip of tarsus. (b) The tarsal strip is then
secured to the inner aspect of the arcus
marginalis with a horizontal mattress suture to
provide horizontal stability to the eyelid and
recreate the lateral canthus.
Fig. 15.12 (a,b) A 58-year-old woman with
approximately one-fourth of eyelid margin defect
involving the lateral canthus and partially
violating the tarsus. The violated region of lateral
canthus and tarsus was excised and a lateral
tarsal strip fashioned for reconstruction.
(c,d) Six months post-op.
Eyelid Reconstruction
137

Fig. 15.14 Algorithm for closure of defects not
involving the canthi.
Fig. 15.13 (a) A large lateral canthal defect
which involves the upper and lower eyelid lateral
canthal tendon and approximately 50% of full-
thickness lower eyelid and 25% of full-thickness
upper eyelid. (b,c) A periosteal flap is developed
from the lateral orbital rim periosteum for lower
eyelid posterior lamellar and lateral canthal
tendon reconstruction at which point anterior
lamellar reconstruction can commence with
either local adjacent tissue flaps or full-thickness
skin grafting. (d) A 52-year-old patient with a
large upper and lower eyelid and canthal defect.
A periosteal flap was used for both upper and
lower eyelid posterior lamellar and canthal
reconstruction at which point a modified
Mustarde flap was used for anterior lamellar
reconstruction. (e) Post-op 2 years.
Techniques for Specific Anatomic Location
138

Fig. 15.15 (a) A 70-year-old patient with a large
partial-thickness defect of the right lower eyelid.
There is partial violation of the tarsus in one area
and the patient has underlying lower eyelid
involutional laxity predisposing to ectropion.
(b-d) A full-thickness wedge removed from the
area of tarsal violation achieves several goals in
addition to the simple removal of this relatively
weakened area: horizontal tightening in an eyelid
at risk of developing ectropion and minimizing
the size of the full-thickness graft needed for
reconstruction. (e, f) The patient 3 months after
reconstruction.
Fig. 15.16 Cyanoacrylate glue with or without
pressure patching can be used for stabilizing and
immobilizing small skin grafts in the periocular
region often obviating the need for suturing in a
formal bolster. (a,b) Glue is placed at the
periphery of the graft on normal tissue with the
goal of immobilizing the surrounding normal
eyelid tissue to prevent graft corrugation during
healing. (c) The glue can be removed along with
sutures at 1 week post-op.3
Fig. 15.17 (a) In the periocular region, bilobed
flaps are particularly useful in the medial canthus
(see Fig. 15.8). (b) O-T plasty is particularly
useful when the defect is situated close to the
eyelid margin ( Fig. 15.18). (c) Conversion to an
elliptical shape can be utilized in the periocular
region; however, as noted above, orientation
should be perpendicular to the eyelid margin to
prevent tension perpendicular to the eyelid
margin and possible ectropion. (d) Defects too
close to the eyelid margin to be closed with a
simple ellipse can be closed by converting to an
M-plasty for the portion close to the eyelid
margin which in effect will reduce by 50% of half
of the ellipse. (e) O-Z plasty provides another
useful tool for partial-thickness closure in the
periocular region.
Eyelid Reconstruction
139

Fig. 15.18 (a) A 65-year-old female with a
partial-thickness defect close to the eyelid
margin. O-T plasty allows closure with tension
directed parallel to the eyelid margin.
(b, c) Post-op 6 months.
Fig. 15.19 Full-thickness defect closure. The tarsus is closed with
partial-thickness lamellar bites followed by skin closure. A vertical
mattress suture through the eyelid margin allows for wound eversion
and minimizes the risk of eyelid notch formation with healing.2
(Reused with permission from Chen WP. Ocuplastic Surgery: the
Essentials. Thieme, New York, 2001.)
Fig. 15.20 (a) A 48-year-old female with minimal eyelid laxity and one-
third full-thickness eyelid margin defect. (b) A canthotomy and inferior
cantholysis without semicircular flap allow adequate mobilization to
allow full-thickness closure without undue tension. (c,d) Post-op
2 years.
Techniques for Specific Anatomic Location
140

Fig. 15.21 (a) A 65-year-old male with moderate
involutional eyelid laxity and approximately one-
third full-thickness lower eyelid margin defect.
Canthotomy and inferior cantholysis with a
(b) small semicircular advancement flap allow
adequate mobilization for direct closure,
(c) demonstrate adequate mobilization without
undue tension confirmed with forceps prior to
closure. (d) Post-op 30 months.
Fig. 15.22 (a) A 70-year-old male with
approximately 60% full-thickness lower eyelid
defect. The defect is reconstructed with a
tarsoconjunctival flap from the upper eyelid to
reconstruct the posterior lamella and an
advancement skin flap to reconstruct the anterior
lamella. (b) Surgery commences with
measurement of the defect to be repaired.
(c) The planned tarsoconjunctival flap is drawn
on the posterior upper eyelid donor tissues. It is
important to leave adequate upper eyelid tarsus
in situ to prevent upper eyelid destabilization,
typically 4–5 mm left in situ throughout the
length of the eyelid is adequate. (d, e) After tarsal
dissection, a conjunctival flap is then dissected to
the superior fornix to allow mobilization of the
tarsoconjunctival flap which is sutured in place to
reconstitute the posterior lamella. The anterior
lamella is then reconstructed with an
advancement flap in this case from the (f) upper
eyelid; however, the tarsoconjunctival flap
provides a vascularized bed which can allow
full-thickness skin grafting as well. The flap is
transected typically at 2–4 weeks. (g) Post-op
1 year.
Eyelid Reconstruction
141

The anterior lamella is then reconstructed typically with a full-
thickness skin graft or local advancement flap.
Large upper eyelid defects pose a particular challenge,
given the strict requirem ent of a structurally functional
upper eyelid for ocular surface health. Large upper eyelid
defects can be repaired with a Cutler-Beard procedure to
allow sim ultaneous anterior and posterior lamellar recon-
struction ( Fig. 15.23).
References
[1] Schuenke M, Schulte E, Schumacher U. Head, Neck, and Neuroanatomy
(Thieme Atlas of Anatomy). New York: Thieme; 2016
[2] Chen WP. Oculoplastic Surgery: The Essentials. New York: Thieme; 2001
[3] Jackson CM, Nguyen M, Mancini R. Use of cyanoacrylate glue casting for sta-
bilization of periocular skin grafts and flaps. Ophthal Plast Reconstr Surg.
2017; 33(3):218–220
Fig. 15.23 (a) Total upper eyelid loss
reconstructed with a Cutler-Beard flap. An
infratarsal incision is created in the lower eyelid
approximately 4 mm inferior to the lash line on
the anterior lamellar surface for the entire lower
eyelid length. (b–d) Full-thickness lower eyelid is
then dissected into the inferior fornix posteriorly
and the upper cheek anteriorly which can then be
elevated and mobilized under the lower eyelid
intact tissue bridge and sutured to the remaining
upper eyelid tissues lamella to lamella. (e) Patient
1 week post-op with vital lower eyelid margin
tissue bridge and intact flap. The flap is divided
typically at 1 month resulting in the newly
constructed upper eyelid and the lower eyelid
then reestablished by freshening the lower
portion of the bridge and resuturing to the flap
cut edge. (f, g) Patient 1 year post-op with viable
upper and lower eyelid with a healthy ocular
surface and full closure.
Techniques for Specific Anatomic Location
142

16 Cheek Reconstruction
James F. Thornton and Jourdan A. Carboy
Sum m ary
This chapter discusses cheek reconstruction including the iden-
tification of the three anatomic zones of the cheek, as well as a
number of surgical techniques for closure corresponding to the
three anatomic zones. The avoidance of lower eyelid and lip
complications as well as closure techniques ranging from
simple linear closure to cervicofacial advancement flaps are
covered.
Keywords: cheek, suborbital, preauricular, buccomandibular,
primary closure, advancement flap, malar, perialar crescentic
advancement flap, cervicofacial advancement flap
Summary
● There are three anatomic zones, the suborbital, preauricular,
and buccomandibular (zones 1, 2 and 3, respectively), to
consider when reconstructing the cheek.
● Direct closure, even for large defects, often provides the
most ideal result.
● Cervicofacial advancement flaps can be performed under
intravenous sedation with very low complication rate.1
● Lower eyelid complications can be avoided by appropriate
flap design that includes the cheek–lid junction incision and
lateral placement of vertical flap tension vector.
● Full-thickness grafting can be preferable for medial cheek
defects but should be used with caution for larger central
defects.
16.1 Algorithm for Closure
( Fig. 16.1 and Fig. 16.2)
16.1.1 General Considerations
In evaluating the cheek, there are important functional consid-
erations and it is useful to consider the anatomic zones defined
as follows: zone 1—the suborbital and premolar medial cheek
from eyelid to below malar eminence; zone 2—the temporal/
preauricular; and zone 3—the buccomandibular from below
malar eminence to mandibular rim ( Fig. 16.1 and
Fig. 16.2).2 The primary factor of zone 1 is the functional
integrity of the lower lid and a successful cheek reconstruction
is a failure if there is extrinsic ectropion, which is the most
common complication of these procedures and is entirely
avoidable with appropriate techniques. Also, zone 1 contains
the malar eminence, or the malar prominence, and this is often
quite a di cult area to reconstruct due to convexity with lim-
ited tissue laxity from anterior to posterior plane. Additionally,
it is the most prominent anatomic location on the cheek.
Zone 2 is reasonably featureless. It is limited posteriorly by
the ear and therefore there is functional significance to main-
tain the patency and configuration of the external auditory
canal. What is most challenging on zone 2 is that it is a zone of
adhesion and, despite being relatively flat and featureless, has
relatively little laxity in the anteroposterior plane and this must
be a consideration for reconstructive planning.2,3 Importantly,
zone 2 is somewhat posterior and hidden from frontal viewing
Fig. 16.1 Algorithm for cheek closure.
Cheek Reconstruction
143

and more liberty can be taken with incision placement and
secondary healing.
Zone 3 has functional importance with regard to the lower
lip, and it must remain in its anatomical position to maintain
oral competence. Additionally, zone 3 includes the convexity of
the chin and it has little inherent laxity to recruit for
reconstruction.
16.1.2 Commonly Applied Methods of
Closure
● Primary closure utilizing the laxity of the cheek and oriented
in the vertical plane to reduce risk of lower eyelid ectropion.
● Combined chin and cheek defects (zone 3) may tolerate pri-
mary closure with avoidance of lower vermilion ectropion;
however, in the elderly patients with significant lower face
laxity, a bilobed flap advanced from the neck may be a
preferable postoperative result.
● V-Yadvancement flap is often an excellent choice for either
lateral or medial chin defects as well as defects found on the
upper cutaneous lip. These may be especially useful for small
defects in males restoring hair bearing coverage.
● Defects of the upper cutaneous lip may ideally be managed
with a perialar crescentic advancement flap; care must be
taken to avoid eversion of the upper lip.
● For patients that may not tolerate a cervicofacial advance-
ment flap, color-matched full-thickness skin grafting is a safe
and viable option.
16.2 Primary Closure
The algorithm for cheek reconstruction begins with attempts at
primary closure. A single tacking suture is placed sequentially
in two orientations at 180 degrees from each other and the
wound is tailor tack closed. Even large linear scars on the cheek
heal tremendously well and this is considered a first choice
reconstruction.2 Linear closures on the midportion in zones 1
and 2 of the cheek are vertically oriented to prevent ectropion.
The resulting dog-ear or standing cone can be extended into
the cheek–lid junction. This often involves the lower eyelid and
as long as meticulous attention is paid to elimination of redun-
dant skin on the final inset, excellent results can be obtained.
Rarely any attempt is made at undermining given there is more
than su cient laxity for the vast majority of defects to a ect a
Fig. 16.2 The three anatomic zones of the cheek:
zone 1, suborbital and premolar; zone 2, the
temporal/preauricular; and zone 3, the central
cheek to mandibular rim.
Techniques for Specific Anatomic Location
144

mild tension closure. Vigorous postoperative scar management,
including early use of silicone sheeting, adjunctive laser treat-
ment, and dermabrasion as required are critical to obtain ideal
postoperative results.4,5,6 The clinical examples illustrated show
both short- and long-term results for linear closures. These
were female patients without ideal skin tone or type for opti-
mal linear closure; however, with closure even under moderate
tension, the final results with minimal postoperative adjunctive
methods are superior to any other technique. The consideration
or institutional avoidance of transposition flaps for the cheek is
based on the fact that even the most properly done transposi-
tion flap will, by definition, have surgical incisions placed coun-
ter to ideal relaxed skin tension lines. The very premise of a
transposition flap is to recruit laxity from an area of relative
laxity to an area of a paucity of laxity and on the cheek we con-
sider the entire anatomical subunit to have essentially equal
laxity.7 Therefore, there is simply no surgical advantage of
transposition flaps on the cheek and additionally they lead to
suboptimal scarring patterns. Clinical example 3 shows the
poor postoperative result from an adequately designed and exe-
cuted rhomboid transposition flap for cheek reconstruction
(Fig. 16.3, Fig. 16.4, Fig. 16.5).
16.3 V-YAdvancement Flap
A V-Y advancement flap has been defined for both central and
lateral cheek defects and is e ective for very large and complete
defects. Several technical points on this is that once a single
Fig. 16.3 A 62-year-old female with an appropriately designed and executed rhomboid flap for cheek closure. This illustrates the postoperative
deformity inherent in geometric flap closure of cheek defects.
Fig. 16.4 A 48-year-old female status post 2 × 3 cm Mohs excision for basal cell carcinoma at right malar cheek. Defect was closed primarily with
standing cone excision. Postoperative results shown at 1 and 3 months from left to right. Note that lip eversion seen immediately postoperatively
settled by 3 weeks.
Fig. 16.5 A 54-year-old female status post 1 × 1 cm Mohs excision for basal cell carcinoma on the left malar cheek. Wound was treated with primary
vertical closure and standing cone excision. Postoperative results shown at 1 week, 1 month, and 6 months, from left to right.
Cheek Reconstruction
145

perforator vessel is identified with Doppler, generous soft-
tissue advancement can be performed if this single vessel is
maintained.8 Very wide dissection is then possible. When
these have been performed and appropriately inset, the final
results on these flaps are quite good, with provision for re-
advancement if needed ( Fig. 16.6).
16.4 Perialar Crescentic
Advancement Flap
For defects that abut the upper lip, a perialar crescentic advance-
ment flap is an e ective option. These are essentially “reversed
facelift flap” with a planned standing cone excision along the
nasolabial fold both superior and inferior to the defect.1,9 A mod-
erate amount of tension can be placed on the upper lip at inset
with the expectation that this will resolve secondary to the
action of the orbicularis oris muscle.1 These flaps provide a very
nice color-matched soft-tissue inset and easy postoperative ma-
nagement. Great care must be taken on inset, however, to ensure
there is no vermillion e acement as it will rarely resolve sponta-
neously (Fig. 16.7).
16.5 Cervicofacial Advancement
Flaps
For defects larger than 3 cm that are not amenable to primary clo-
sure, a cervicofacial advancement flap is designed. Cervicofacial
flaps are actually very simple procedures and can be done safely
under intravenous (IV) sedation. Part of the confusion lies in the
multiple descriptions of flap design (Fig. 16.8). These include the
Esser, the Mustarde, Blascowicz, Ferris Smith, Converse, Stark and
Kaplan, and Juri and Juri, as illustrated in Fig. 16.9.
This can create significant confusion as to correct flap selec-
tion and execution. A better approach is to look at a cervicofa-
cial flap on a continuum, a “cut-as-you-go” type flap with iden-
tical incision planning but with varied extent of the incisions.
Another point of confusion is the plane of dissection. Subcuta-
neous, sub-SMAS (submuscular aponeurotic system), and sub-
muscular flap dissection are all championed as the ideal option;
however, at the University of Texas Southwestern Medical Cen-
ter’s clinical practice of over 500 sequential cheek reconstruc-
tions, subcutaneous-only flap elevation resulted in only a 3%
partial flap loss.1 There are several principles that should be
practiced in regard to cervicofacial flaps: (1) IV sedation anes-
thesia is appropriate for the majority; (2) wide infiltration of
local anesthetic containing epinephrine on flap dissection can
be used; (3) subcutaneous dissection can be performed, even
for large flaps; (4) the understanding that the laxity from the
flap is negligible in the anteroposterior direction and the
majority of the flap laxity comes from the lax neck with a supe-
rior advancement; (5) subciliary incision is not used, but rather
an incision made at the cheek–lid junction is preferable; and (6)
no attempt is made to secure the flap along the orbital rim,
rather the vector is posterior to the lateral canthus where ten-
sion of the flap is supported entirely on the lateral brow, allow-
ing redundant skin to fall along the lower eyelid and support
the lower eyelid with prevention of late ectropion.10 These flaps
are performed as follows. The maximal extent of the incision is
designed and drawn with no postauricular component, only a
component that extends down to the neck. The incision starts
medially and follows the cheek–lid junction, extending into the
temporal brow hairline and then to an immediate preauricular
Fig. 16.6 A 68-year-old white male status post 4 × 3 cm Mohs excision for melanoma in situ on right nasomalar region. Wound was closed with a V-Y
advancement flap and full-thickness skin graft at the alar base. Postoperative results shown intraoperatively at 1 and 10 months, from left to right.
Fig. 16.7 A 39-year-old white male status post 2 × 2 cm Mohs excision of basal cell carcinoma at the right cheek–upper cutaneous lip junction. Wound
was treated with perialar advancement flap. Postoperative results shown intraoperatively at 2 and 4 months, from left to right.
Techniques for Specific Anatomic Location
146

Fig. 16.8 (a) Blascowicz. (b) Converse. (c) Esser. (d) Ferris-Smith. (e) Juri and Juri. (f) Mustarde. (g) Stark and Kaplan.
Fig. 16.9 (a–e) Schematic showing importance of lateral tacking sutures to the periosteum to allow redundant free infraorbital cheek flap inset.
Cheek Reconstruction
147

location that stays preauricular with extension onto the neck.
At this point, the flap is dissected sharply without electrocau-
tery to the level of the maximal extent, and a planned standing
cone excision is outlined on the cheek. The flap is tailor tacked
inset to ensure adequate support of the lower eyelid, and at this
point, the standing cone excision on the cheek is performed.
The flap is then released from its tailor tacking sutures and
hemostasis is achieved on the cheek portion with electrocau-
tery. Any actively bleeding vessels are cauterized again with
electrocautery on the flap itself and then fibrillar collagen is
placed along the flap elevation junction and on any areas of
previous active bleeding. The flap is then re-inset and great care
is taken to provide deep periosteal tacking sutures posterior to
the lateral canthus even to the point of an exaggerated upward
vector with redundant flap skin. The redundant skin is then
very carefully inset on the cheek–lid junction with excision of
any nonviable skin that resulted from handling during the flap
elevation. At this point, the incision extending onto the anterior
cheek is closed ( Fig. 16.9b) and the remaining flap inset is
performed. Vicryl 3–0 pop-o sutures are utilized for the
majority of the flap inset, Monocryl for superficial wound
closure, and then 5–0 fast-absorbing gut is placed underneath
the eye with 5–0 or 6–0 nylon for the remainder. The patient is
cautioned postoperatively that there will be significant post-
operative swelling even to the point of complete eyelid swelling.
Sutures are removed at 5 days, and early postoperative scar care
is utilized. Nitropaste is applied to the majority of these flaps
intraoperatively as a single application to increase venous
return. Illustrations shown here demonstrate that excellent
final aesthetic results can be maintained by placement of the
surgical incision in the cheek–lid junction, both early and late in
the postoperative period. No lid tightening procedure is
required providing that laxity is maintained in the superior
direction, posterior to the lateral canthus ( Fig. 16.9,
Fig. 16.10, Fig. 16.11, Fig. 16.12, Fig. 16.13, Fig. 16.14).
16.6 Full-Thickness Skin Grafts
Full-thickness skin grafting is ideal for zone 1 medial canthal
and lower lid defects. There is relatively little laxity in this area
to allow linear closure and on patients, particularly in male
patients with thick sun-damaged skin that does not lend itself
Fig. 16.10 (a,b) Cervicofacial advancement flap plan is drawn on skin to its maximal extent and dog-ear excision is outlined on the cheek. (c) Flap is
elevated and dog-ear is excised from cheek. (d) Flap is advanced and inset into defect. (e) Postoperative results shown at 8 years.
Fig. 16.11 A 61-year-old female status post 3 × 3 cm Mohs excision at the right temple for squamous cell carcinoma. Wound was treated with
cervicofacial advancement flap. Postoperative results shown intraoperatively at 2 and at 10 months, from left to right.
Fig. 16.12 A 72-year-old white female status post
3 × 4 cm Mohs excision for melanoma in situ at
the lateral right eyebrow. Wound was closed
primarily taking advantage of vertical neck and
cheek laxity. One-month postoperative view is
shown.
Techniques for Specific Anatomic Location
148

Fig. 16.14 A 65-year-old male status post-Mohs excision of right ear lobule and preauricular region of cheek. Lobule was reconstructed with small
advancement flap of remaining soft tissue and a small color-matched full-thickness skin graft to maintain external auditory canal patency. Cheek
defect was repaired with a cervicofacial advancement flap in the deep subcutaneous plane and elevated to the level of mid-neck. Postoperative results
shown intraoperatively at 1 week and 2 months, from left to right.
Fig. 16.15 A 42-year-old male status post 3 × 2 cm Mohs defect for basal cell carcinoma at right medial canthus. Wound was treated with color-
matched full-thickness skin graft. Postoperative results shown intraoperatively at 3 and at 6 months.
Fig. 16.13 A 68-year-old female status post 4 × 2 cm Mohs excision for basal cell carcinoma on the right malar cheek. Wound was closed with
cervicofacial advancement flap. Incision was placed at the cheek–lid junction. Postoperative results shown intraoperatively at 1 and 2 months.
Fig. 16.16 A 52-year-old female status post 1 × 1 cm Mohs excision of basal cell carcinoma at left nasomalar region. Wound was treated with color-
matched full-thickness skin graft. Postoperative results shown at 5 months.
Cheek Reconstruction
149

to easy transposition, a full-thickness graft placed here with
appropriate bolstering provides a final wound appearance that
is superior to any other technique11 ( Fig. 16.15, Fig. 16.16,
Fig. 16.17, Fig. 16.18).
Final considerations are given to large cheek defects in patients
that are not able to tolerate formal cervicofacial advancement
flap. These can be reconstructed with full-thickness grafting and,
despite common dismissal of full-thickness grafting as a poor
reconstructive modality for the cheek and although it is not our
primary modality, oftentimes it o ers the best surgical result.
The use of color-matched skin is preferable, but non–color-
matched skin can provide adequate soft-tissue coverage at the
expense of final wound appearance.11
16.7 Postoperative Management
Full-thickness skin grafting often requires initial dermabrasion
and may benefit from late (3 months) fat grafting to improve
contour deformities.12
Cervicofacial advancement flaps done under IV sedation can
be managed without drain placement with a predictably low
postoperative hematoma rate.1
V-Y advancement flaps require early enthusiastic scar
management with silicone sheeting and often adjunctive
pulsed-dye laser to provide satisfactory incisional scars.5
References
[1] Rapstine ED, Knaus WJ, II, Thornton JF. Simplifying cheek reconstruction: a
review of over 400 cases. Plast Reconstr Surg. 2012; 129(6):1291–1299
[2] Pantalena L, Bordeaux JS. Reconstruction of a multi-subunit defect on the lip,
nose, and cheek. Dermatol Surg. 2017; 43(2):293–296
[3] Barakat K, Ali A. Thermoplastic vestibuloplasty: a novel technique for treat-
ment of lip and cheek adhesion. Craniomaxillofac Trauma Reconstr. 2014; 7
(4):258–262
[4] Kim JS, Hong JP, Choi JW, Seo DK, Lee ES, Lee HS. The e cacy of a silicone
sheet in postoperative scar management. Adv Skin Wound Care. 2016; 29(9):
414–420
[5] Khatri KA, Mahoney DL, McCartney MJ. Laser scar revision: a review. J Cosmet
Laser Ther. 2011; 13(2):54–62
[6] Commander SJ, Chamata E, Cox J, Dickey RM, Lee EI. Update on postsurgical
scar management. Semin Plast Surg. 2016; 30(3):122–128
[7] Goldstein SA, Goldstein SM. Anatomic and aesthetic considerations in midfa-
cial rejuvenation. Facial Plast Surg. 2006; 22(2):105–111
[8] Stone JP, Webb C, McKinnon JG, Dawes JC, McKenzie CD, Temple-Oberle CF.
Avoiding skin grafts: the keystone flap in cutaneous defects. Plast Reconstr
Surg. 2015; 136(2):404–408
[9] Wang SQ, Behroozan DS, Goldberg LH. Perialar crescentic advancement flap for
upper cutaneous lip defects. Dermatol Surg. 2005; 31(11, Pt 1):1445–1447
[10] Bartella AK, Ghassemi M, Hölzle F, Ghassemi A. Reconstruction of facial soft
tissue: comparison between conventional procedures and the facelift techni-
que. Br J Oral Maxillofac Surg. 2016; 54(9):1006–1011
[11] Ebrahimi A, Ashayeri M, Rasouli HR. Comparison of local flaps and skin grafts
to repair cheek skin defects. J Cutan Aesthet Surg. 2015; 8(2):92–96
[12] Jaspers ME, Brouwer KM, van Trier AJ, Groot ML, Middelkoop E, van Zuijlen
PP. E ectiveness of autologous fat grafting in adherent scars: results obtained
by a comprehensive scar evaluation protocol. Plast Reconstr Surg. 2016
Fig. 16.17 A 31-year-old male status post 4 × 5 cm Mohs excision for melanoma in situ. Mohs defects were closed with color-matched full-thickness
skin graft. Skin graft was chosen over a flap closure due to patient’s hemophilia. Postoperative results shown at 2 years.
Fig. 16.18 A 66-year-old male status post-Mohs resection for basal cell carcinoma. Wound was treated with non–color-matched full-thickness skin
graft, which provided suboptimal cosmetic results, as shown postoperatively at 6 months.
Techniques for Specific Anatomic Location
150

17 Chin Reconstruction
James F. Thornton and Jourdan A. Carboy
Sum m ary
This chapter discusses soft-tissue reconstruction of the chin
including the complexities involved in the anatomic location
and functional importance of the chin. A number of di erent
techniques including primary closure, bilobed flap, V-Y
advancement flap, as well as full-thickness skin grafts utilizing
cheek reconstruction are covered.
Keywords: chin, primary closure, bilobed flap, V-Yadvancement
flap, skin graft
Summary
● The chin is a prominent aesthetic subunit.
● Its reconstruction is complicated by the fact that it is a
prominent convexity with little inherent laxity and little
surrounding laxity.
● It has functional significance supporting the lower lip,
meaning poor reconstruction will result in oral
incompetence.
17.1 Algorithm for Closure
The chin is quite frequently involved with Mohs resection for
skin cancer ( Fig. 17.1). It is a prominent aesthetic unit with
somewhat thick and oily skin that does not lend itself to graft-
ing. Additionally, the convexity acts much like the vertex of the
scalp with little surrounding laxity. The soft-tissue components
of the chin are deeply adherent to the underlying mandible and
there is little inherent tissue laxity for closure. The natural
reservoir of laxity unfortunately comes from the lower lip and
any excessive recruitment of lower lip tissue to reconstruct the
chin will provide both a jarring postoperative appearance and
external ectropion and subsequent oral incompetence. Fortu-
nately, the chin tolerates tension on closure very well and the
vast majority of chin defects can be managed appropriately by
primary closure.
17.2 Commonly Applied Methods
of Closure
● Primary closure with meticulous care for standing cones to
avoid contour deformity and to avoid lower lip ectropion.
● Bilobed flap reconstruction with recruitment from laxity of
the neck and avoidance of excessive tension on the lower lip.
● V-Yadvancement flap.
● Full-thickness skin grafts.
17.2.1 Primary Closure
Primary closure involving the chin can be determined intrao-
peratively with a 2–0 Vicryl tacking suture placed vertically
with planned dog-ear excisions superiorly and inferiorly. Even
with significant tension on closure, with a sequential layered
closure of 2–0 and 3–0 Vicryl, followed by interrupted 5–0
nylon sutures, the final aesthetic result is nearly always uni-
formly good to excellent. There is little need for undermining as
simple advancement and closure under slight tension is more
than adequate. At the time of closure, dog-ears need to be
meticulously managed so that there is no contour deformity as
this will rarely settle.
Fig. 17.1 Algorithm for chin defect closure.
Chin Reconstruction
151

Early postoperative management including silicone sheeting
and dermabrasion at 6-week intervals helps optimize the final
scar1,2 (Fig. 17.2 and Fig. 17.3).
17.2.2 Bilobed Flaps
In elderly patients, there is often limited laxity of the chin and
little resting tone of lower lip. This can complicate reconstruc-
tion of larger chin defects due to enhanced risk of lower lip
eversion. Therefore, a bilobed flap can be recruited from sub-
mental laxity. A large two-limbed bilobed flap with a generous
second limb that is essentially as large as can be closed, that is,
65 to 70% of the initial limb, can be easily rotated into position.
With simple and meticulous dog-ear excision and contour inset,
adequate closure can be achieved. The only di culty in this is
the dissection is performed in the deep subcutaneous layer,
remaining above the platysma.3 In patients with platysmal
banding, it is di cult to maintain a symmetric bilateral con-
tour.4 However, revisionary procedures, which in fact are rarely
indicated given this patient population, can restore neck
contour to near normal (Fig. 17.4).
17.3 V-YAdvancement Flap
A V-Y advancement flap has been well described for both cen-
tral and lateral chin defects.5
Although the technique is
described here, it should be considered inferior to both direct
closure and bilobed flap reconstruction. A submental pedicled
V-Y advancement flap is quite di cult to raise and essentially
an entire V-Y perforator needs to be developed with removal
from the submental attachments and despite wide mobiliza-
tion, there is often little minimal soft tissue available to
advance.6 However, the supplied clinical photographs do sup-
port their use in large central cases with good final results given
the initial size of the soft-tissue deficit ( Fig. 17.5 and
Fig. 17.6).
17.4 Full-Thickness Skin Grafts
For patients whose comorbid disease would not support the in-
traoperative requirements of either a bilobed or submental flap,
color-matched full-thickness grafting from the clavicle can be
performed with the understanding that ultimately this is an
Fig. 17.2 A 45-year-old
female status post Mohs
excision for basal cell
carcinoma. Wound was
closed with primary closure.
Postoperative results shown
at 4 months.
Fig. 17.3 A 52-year-old female status post 4 × 2 cm Mohs excision of recurrent melanoma in situ at left chin. Wound was closed with vertical primary
adjacent tissue transfer with dog-ear excision. Postoperative results shown at 6 months.
Fig. 17.4 An 86-year-old female status post Mohs excision of squamous cell carcinoma on the left chin. Wound was treated with bilobed flap that
recruited the patient’s skin redundancy on her neck to avoid recruitment of lower lip laxity and avoid lower lip ectropion. Postoperative results shown
at 6 months.
Techniques for Specific Anatomic Location
152

inferior aesthetic result. With that in mind, there is no attempt
made to perform subunit-only grafting reconstruction.
17.5 Postoperative Management
For direct closure, early postoperative silicone sheeting for all
patients and steroid injection of hypertrophic scars are often
required.7
For bilobed flap reconstruction, revision of asymmetrical
neck donor site is often required.
References
[1] Kim JS, Hong JP, Choi JW, Seo DK, Lee ES, Lee HS. The e cacy of a silicone
sheet in postoperative scar management. Adv Skin Wound Care. 2016; 29(9):
414–420
[2] Commander SJ, Chamata E, Cox J, Dickey RM, Lee EI. Update on postsurgical
scar management. Semin Plast Surg. 2016; 30(3):122–128
[3] Perkins SW, Waters HH. The extended SMAS approach to neck rejuvenation.
Facial Plast Surg Clin North Am. 2014; 22(2):253–268
[4] Dibernardo BE. The aging neck: a diagnostic approach to surgical and nonsur-
gical options. J Cosmet Laser Ther. 2013; 15(2):56–64
[5] Khan HA, Niranjan NS. Four V-Y islanded flap reconstruction of full thickness
defect of chin and labial sulcus. Br J Plast Surg. 2004; 57(3):278–281
[6] Thornton JF, Reece EM. Submental pedicled perforator flap: V-Yadvancement
for chin reconstruction. J Oral Maxillofac Surg. 2008; 66(12):2633–2637
[7] Kelemen O, Hegedus G, Kollár L, Menyhei G, Seress L. Morphological analysis
of the connective tissue reaction in linear hypertrophic scars treated with
intralesional steroid or silicone-gel sheeting. A light and electron microscopic
study. Acta Biol Hung. 2008; 59(2):129–145
Fig. 17.5 An 80-year-old white male status post 5 × 3 cm Mohs excision of basal cell carcinoma on lower right vermilion. Wound was repaired with V-Y
lip advancement. Postoperative results shown at 2 weeks, 2 months, and 12 months from left to right.
Fig. 17.6 A 54-year-old white male status post 5 × 4 cm Mohs excision of basal cell carcinoma on the left chin. Wound was repaired with V-Y
advancement flap. Postoperative results shown at 5 months.
Chin Reconstruction
153

18 Lip Reconstruction
James F. Thornton and Jourdan A. Carboy
Sum m ary
This chapter will discuss the functional and aesthetic di eren-
ces, as well as di erences in reconstructive approaches to the
upper and lower lips. A wide variety of reconstruction techni-
ques based on the anatomic deformity including skin, mucosal-
only, and combined defects are covered. The closure techniques
include delayed healing, acellular dermal products, buccal
advancement flap, direct closure, ergotrid, V-Y advancement
flaps, and full-thickness skin grafts. Larger defects requiring
Abbe and Karapandzic flaps are also discussed.
Keywords: lip, vermilion, microstomia, buccal advancement,
direct closure, ergotrid, V-Y advancement, Abbe flaps, rotation
flaps
Summary
● The lip has significant functional and aesthetic requirements.
● The upper and lower lips are di erent in both function and
anatomy.
● The lower lip is somewhat featureless, while the upper lip
has significant anatomic components including the philtral
columns and Cupid’s bow.
● Vermillion alignment is critical, as well as maintenance of the
oral commissures.
18.1 Algorithm for Closure
18.1.1 Anatomy
There are significant functional and aesthetic issues in lip
reconstruction ( Fig. 18.1 and Fig. 18.2). It is important to
understand the functional significance of the upper and lower
lips. It is also necessary to realize that the upper and lower lips
have very di erent functional and aesthetic requirements. The
lower lip is most important in maintaining a “dam” e ect to
maintain oral competence, and reconstruction techniques that
maintain the muscle integrity of the lower lip are more useful
than simply reconstruction with atonic tissue (e.g., free radial
forearm flap). The lower lip is actually easier to reconstruct as it
is somewhat featureless and tension on closure results in less
deformity than tension on closure in the upper lip. Conversely,
the upper lip has significant anatomic features that must be
maintained or re-created for a successful reconstructive
outcome. These anatomic features include the white roll, the
philtral column, and Cupid’s bow.1
Generally, reconstruction of the lips should allow for reten-
tion of oral competence, preservation of oral commissures,
maintenance of vermilion alignment, and prevention of micro-
stomia. These considerations are critical to a functional aes-
thetic reconstruction. Wounds of the lip are classified into three
separate types of defects that include mucosal-only defects,
skin-only defects, and then combined skin and mucosal defects.
These are each managed quite di erently.
18.2 Commonly Applied Methods
of Closure
● Mucosa-only defects: Delayed healing/secondary intention
with or without wound healing agents (i.e., acellular dermal
products) and buccal advancement flaps.
● Skin-only defects: Direct closure, ergotrid, and V-Y
advancement flaps, perialar crescentic advancement flap, and
full-thickness skin grafts.
● Combined skin and mucosa defects: Direct closure with or
without wedge resection, Abbe and rotation flaps,
advancement closure, the innervated mucosal advancement
flaps, and Karapandzic flap.
18.2.1 Mucosal-Only Defects
Delayed Healing/Acellular Adjuncts
For mucosal-only defects, if primary closure for small-sized
defects without lip distortion is a possibility, this should be
how the wound is treated; however, the vast majority of these
are now managed with secondary intention healing, either with
or without acellular matrix or simple porcine acellular dermal
matrix (ADM) coverage.2 There are textbook chapters written
on vermilion-only lower lip reconstruction that really ignore
the tremendous ability of the lower lip to spontaneously heal
without scarring and it is very rare for a vermilion-only defect
to heal with a contracture that will distort the lip.3 Primary ma-
nagement for even large defects of the lower lip are to place
ACell matrix powder and then sew in an overlying acellular der-
mis sheet and then send the patient home with instructions to
just keep the surface wet with three to four times daily applica-
tions of Surgilube water-based surgical ointment. Gratifyingly,
these will uniformly heal well with no late contracture3
(Fig. 18.3).
Buccal Advancement Flap
There is a role for buccal advancement flaps in cases when
patients are unable to provide local wound care or endure the
3 to 5 weeks required for secondary healing. A buccal advance-
ment flap is particularly useful on the lower lip and takes
advantage of the laxity present in this region.4 Great caution
must be utilized that the buccal space is not shortened to the
point that oral incompetence results. It is also important to
understand that a buccal advancement flap that advances the
wet mucosa to replace the dry mucosa will never result in a
“perfect” lip reconstruction.4 Secondary intention healing for
these cases is preferable ( Fig. 18.4 and Fig. 18.5).
Techniques for Specific Anatomic Location
154

Fig. 18.1 Algorithm for lip reconstruction.
Fig. 18.2 Side lip anatomy.
Lip Reconstruction
155

18.3 Skin-Only Defects
18.3.1 Direct Closure
When approaching skin-only defects, the option of primary clo-
sure should strongly be considered first. This approach has sig-
nificantly changed over the course of the author’s practice,
when previously every vermillion-only defect or combined ver-
million- and skin-only defect was treated as a wedge excision
with excision including the buccal mucosa and then oriented
and re-closed. These uniformly resulted in very fine postopera-
tive results as seen in Fig. 18.5; however, the healing time
could often be significant, secondary to the time it takes for the
divided orbicularis oris musculature to reapproximate and rein-
nervate.5 A much more graded approach with simple linear clo-
sure following relaxed skin tension lines is much less invasive
and has equal, if not superior, cosmetic results, as seen in
Fig. 18.6. If closure without a significant superior/inferior
dog-ear or bunching of the soft tissue is not possible, perform
partial debulking of the resultant orbicularis oris muscle to the
point of complete excision; however, every e ort should be
made to maintain the oral mucosa. By providing a watertight
seal, it reduces late infection risk and allows for quicker recov-
ery with similar ideal aesthetic appearances6 (Fig. 18.6 and
Fig. 18.7).
Fig. 18.3 A 73-year-old white male status post-Mohs excision for basal
cell carcinoma at lower lip. Wound was allowed to heal secondarily.
Results shown at 2 months.
Fig. 18.4 (a) Flap is designed with the leading edge slightly larger than the defect. (b) Flap is elevated and the current wet mucosa is advanced to
cover the vermillion defect. (c) Final inset with 4–0 and 5–0 chromic gut sutures.
Fig. 18.5 An 86-year-old female status post complete vermilion excision for multifocal squamous cell carcinoma. Mohs defect closed buccal
advancement flap. Postoperative results shown at 4 months.
Techniques for Specific Anatomic Location
156

Ergotrid and V-YAdvancement Flaps
(a Continuum)
Ergotrid flaps, described by Becker, are essentially a rotation
advancement flap that takes advantage of the ability to hide the
longer advancement limb incision within the nasolabial fold.7
These can be extended quite far provided patients do have visi-
ble nasolabial folds. Their utility in younger patients without
well-defined nasolabial folds is significantly less. Every e ort
should be made to orient the flap to avoid crossing the vermil-
lion border. The ergotrid flap should be considered on a contin-
uum with a V-Y advancement flap for larger, skin-only defects
of the upper or lower lip. The incision for the lower limb of the
V-Y advancement is outlined and a Doppler is utilized to cap-
ture a single perforator, which is su cient to keep the entire
flap alive.8 First, the ergotrid portion of the superior limb is
designed and performed. If there is insu cient advancement,
then the lower limb along the white roll is performed and the
flap advanced into position for final wound closure, as depicted
in Fig. 18.7. By considering the V-Y advancement flap as a
continuum of the ergotrid flap, the surgeon should never be
“caught short” on a unilateral upper lip defect as the V-Y
advancement flap can repair the entire subunit8,9 (Fig. 18.8,
Fig. 18.9, Fig. 18.10, Fig. 18.11).
Perialar Crescentic Advancement Flap
The remaining flap choice for upper lip skin-only defects is the
perialar crescentic advancement flap, which is simply an
advancement flap taking advantage of the laxity of the superior
cheek with planned dog-ear excisions along the perialar and
nasolabial fold.10 These flaps are useful, but great caution
should be utilized to prevent telltale e acement of the upper
lip, eversion, and a long-term deformity (Fig. 18.12 and
Fig. 18.13).
Full-Thickness Skin Grafts
The use of full-thickness graft on the upper lip is with caution
only.11 For whatever reason, even color-matched full-thickness
skin grafts performed as a defect-only reconstruction yield
uniformly poor results, as shown in Fig. 18.10. The caveat to
this is reconstruction of the entire subunit can yield uniformly
excellent results. With extensive skin-only defects of the upper
lip, satisfactory full-thickness grafting results can be performed
as a subunit with color-matched supraclavicular skin.12
Successful graft take requires meticulous bolstering. A surgical
sponge with through-and-through 3–0 Prolene sutures tied on
the exterior bolster yields consistently good results
(Fig. 18.14, Fig. 18.15, Fig. 18.16).
Fig. 18.6 A 38-year-old white female status post-Mohs excision of basal cell carcinoma. Resultant 3 × 4 cm defect was repaired with a complete wedge
excision including mucosa and primary closure. Although postoperative results shown at 3 months are good, healing course is significant and current
management minimizes tissue resection.
Fig. 18.7 A 47-year-old white female status post 1 × 1 cm Mohs excision of basal cell carcinoma on right upper cutaneous lip. Wound was closed with
small dog-ear excision and primary closure. Postoperative results shown at 1 week, 1 month, and 5 months.
Lip Reconstruction
157

Fig. 18.8 (a) Initial surgical plan is ergotrid flap. Note standing cone excision planned along white roll of lip. (b) Ergotrid flap will not fully cover defect.
(c) Incision planned along lower portion of ergot rid to complete V-Y advancement. (d) Ergotrid is converted to V-Y advancement flap. (e) Final
postoperative appearance.
Fig. 18.9 A 62-year-old female status post 2 × 1 cm Mohs excision of left upper cutaneous lip for basal cell carcinoma. Wound was closed with small
ergotrid flap. Postoperative results shown at 1 week, 2 months, and 9 months, from left to right.
Fig. 18.10 A 70-year-old white male status post 3 × 2 cm Mohs excision of melanoma in situ of left upper cutaneous lip. Wound was closed with V-Y
advancement flap. Postoperative results shown intraoperatively at 1 and 5 months, from left to right.
Techniques for Specific Anatomic Location
158

Fig. 18.11 A 60-year-old white female status post 2 × 1 cm Mohs excision at right nasolabial crease for basal cell carcinoma. Wound was closed
with V-Y advancement flap. Postoperative results shown intraoperatively at 1 and 18 months, from left to right.
Fig. 18.12 A 63-year-old female status post 2 × 2 cm Mohs excision of basal cell carcinoma at right upper cutaneous lip. Wound was closed with
perialar cervicofacial advancement flap. Postoperative results shown intraoperatively at 1 and 2 months, from left to right.
Fig. 18.13 A 66-year-old male status post wide
local excision of malignant melanoma at left
mouth. Wound was closed with combined
rotation and advancement flaps. Postoperative
results shown at 3 months.
Fig. 18.14 A 16-year-old female, (active smoker) status post-Mohs excision for basal cell carcinoma. Mohs defect was closed with color-matched full-
thickness skin graft as a defect-only reconstruction with expected unacceptable postoperative results despite vigorous scar management.
Lip Reconstruction
159

18.4 Combined Skin and Mucosal
Defects
For combined skin and vermillion defects, our reconstructive
algorithm essentially centers on wedge excision and primary
closure. Essentially, every e ort is made to close the lip accu-
rately in approximation. Accurate identification of the vermil-
lion border is paramount and understand patients seen on
single-day Mohs resection and repair may present with com-
promised anatomy due to infiltration of local anesthetic and
subsequent smudging of the anatomic border. If it is not clearly
identified, patients should be rescheduled for the next day to
allow the epinephrine to wear o prior to closure. Conversely,
adequate preoperative communication with the referring Mohs
surgeon to allow him or her to mark the vermillion border prior
to infiltration will also su ce. Preoperative markings of the
vermillion border, as well as a white roll, used to be a somewhat
involved a air with methylene blue and a 27-gauge needle
used to temporarily tattoo both adjuncts to the border. This has
been replaced by what is a more accurate, and certainly easier,
placement of a single 5–0 silk both at the vermillion border and
at the wet–dry junction in the mucosa prior to infiltration of
local anesthetic. The suture is left in place during the surgical
preparation. Vermillion alignment cannot be overemphasized
as its importance in successful reconstruction of the upper or
lower lip. Even a small step-o is visible and will require post-
operative correction (Fig. 18.17 and Fig. 18.18).
18.4.1 Direct Closure with or without
Wedge Resection
The di erential ability to close the upper and lower lips is
essentially based on their laxity. In elderly patients with signifi-
cant laxity, defects greater than 60% of the lower lip can be
closed primarily with maintenance of the oral competence.
Even if initial microstomia is encountered with closure of the
lower lip, this can be managed with postoperative physical
therapy including manual physician-directed lip stretching to
restore the normal architecture of the lip.15 The previous
descriptions of free tissue reconstruction, particularly free
radial forearm coverage of the lower lip, have not been demon-
strated institutionally at the University of Texas Southwestern
to provide reliable long-term postoperative results because an
active muscular structure is essentially being replaced with an
atonic wedge of soft tissue that has no solid anchoring and will
relax over time, losing the dam e ect for the lower lip.16 With
large 50 to 60% excision and advancements of the lower lip, it is
often necessary to perform transverse wedge incision in the
mucosa to accurately match the mucosal sides on inset.17
The technical details of the lower lip closure include closing the
Fig. 18.15 A 28-year-old female with severe facial burns following aviation accident. Burn scars were excised and grafted with color-matched skin as
full subunits. Final postoperative results shown at 9 months. This illustrates the need to skin graft lips in subunits. Additionally, the philtrum is
preferentially reconstructed as a subunit with full-thickness skin grafting rather than attempts at local flaps.13,14
Fig. 18.16 A 56-year-old female status post-Mohs excision of basal cell carcinoma at the philtrum. Defect was treated by subunit reconstruction with
color-matched full-thickness skin graft from postauricular donor site. Postoperative results shown at 1 month.
Techniques for Specific Anatomic Location
160

mucosa first to the level of the white roll, and this is performed
with running as well as supplementary simple sutures of 4–0 or
5–0 chromic gut to provide a watertight seat and then the orbi-
cularis oris muscle is reapproximated with Vicryl or PDS suture.
When this has been performed, the skin is closed over it. At this
point, the vermillion is precisely reapproximated using the pre-
placed suture and the remainder of the lip is closed. Upper lip
defects are not able to tolerate as tight or as significant closure
because the lateral retraction on the philtral columns will result
in a telltale long-term deformity. The size is limited on these to
40% or less. Understand that there is a moderate amount of
retraction that is allowed and the philtral columns will often
return to their normal anatomic position even with moderate
retraction; however, overestimating the ability to return to
position will result in a long-term deformity that is very
di cult to correct (Fig. 18.19 and Fig. 18.20).
18.4.2 Central Defects of the Upper Lip:
Abbe and Rotation Flaps
Abbe or rotation flap closures are restricted to significant
defects of the upper lip and in the author’s 10 years of practice,
no instance of an Abbe flap from the upper to the lower lip has
been performed.18 The Abbe flap is done under intravenous (IV)
sedation or general anesthetic depending on the patient’s pref-
erence with provisions for extubation with a limited mouth
opening. The flap is designed undersized to the defect and
works best on central lip defects.18,19 It is rotated into position
and inset with permanent and nonpermanent suture. No suture
is placed between the upper and lower lip.
These patients are admitted and kept overnight for observa-
tion. The flap is then divided between the late second or the
third week. These have uniformly provided very safe and reli-
able reconstructive results.18 Under very rare circumstances
should an Estlander flap be considered for lip reconstruction as
when the commissure is violated, there is very little opportu-
nity to reconstruct it19 (Fig. 18.21 and Fig. 18.22).
Fig. 18.17 Vermillion border is marked suture prior to injection of local
anesthetic.
Fig. 18.18 A 72-year-old white female status post 5 × 1 cm Mohs excision of squamous cell carcinoma at lower lip. Wound was closed with V wedge
excision that extended through chin with mucosa left intact. Cutaneous lip was then advanced and inset with complex primary closure. The remaining
vermillion was then realigned and primary closure was completed. Postoperative results shown at 1 week, 1 month, and 9 months, from left to right.
Fig. 18.19 An 80-year-old female status post 1.5 ×1.5 cm Mohs excision of lower left vermillion for basal cell carcinoma. Wound was closed primarily
with adjacent tissue advancement and dog-ear excision. Postoperative results shown intraoperatively at 1 week and 6 months, from left to right.
Lip Reconstruction
161

18.4.3 Lateral Commissure Defects:
Advancement Closure
Lateral commissure defects are important to recreate, under-
standing that the anatomic location of the commissure is
the midpoint of the patient’s pupils bilaterally and compared to
the contralateral side. Many combined cheek and lip defects can
be successfully reconstructed with simple advancement closure
taking great care to reapproximate the damaged commissure at
the anatomic location determined by the contralateral side
(Fig. 18.23 and Fig. 18.24).
18.4.4 Large Defects of the Upper or
Lower Lip: Karapandzic Flap
For large defects of the upper or lower lip, where the lower lip
is not able to be approximated primarily, a Karapandzic flap is
our last option. This can be utilized for even 90% nearly com-
missure-to-commissure defects of the lower lip, and it is essen-
tially a circumoral innervated myocutaneous flap maintaining
both the intact nerves and mucosa with advances bilaterally.19,
20 Microstomia is expected primarily; however, using the same
principles as postoperative physical therapy and stretching on
the primary closures of large lip defects, this can eventually be
resolved ( Fig. 18.25).
Fig. 18.20 A 62-year-old female status post 2 × 5 cm Mohs excision of squamous cell carcinoma at midline lower vermillion, cutaneous lip, and
extending into her chin. Wound was closed with simple linear closure. Postoperative results shown intraoperatively at 1 week and 7 months, from left
to right.
Fig. 18.21 (a) A 56-year-old female status post Mohs excision of squamous cell carcinoma at the left upper lip. Full-thickness defect with cutaneous
and mucosal involvement was treated with Abbe flap. Intraoperative planning and execution of Abbe flap. (b) Postoperative results shown at 1 week, 2
months, and 6 months.
Techniques for Specific Anatomic Location
162

18.4.5 Upper and Lower Lip Mismatch:
AlloDerm Placement
For repairs that result in a significant vermillion volume mis-
match between the upper and lower lip, AlloDerm can be used
as a volumizer for the under volume lip. This is performed as an
operative procedure. Rolled thick AlloDerm is placed in the
mucosa lip with a tendon passer and this has been well
described for aesthetic volume reconstruction of the upper or
lower lip21 (Fig. 18.26).
18.5 Postoperative Management
● Postoperatively, these patients are allowed to eat and speak
the day of surgery with no limitations.
● Patients are just given intraoperative antibiotics and routinely
do not continue postoperative antibiotics.
● Patients are then instructed to utilize either a non–alcohol-
based mouthwash or to brush their teeth four to five times a
day. Anecdotally, this reduces the bacteria flora count and
infection risk.
Fig. 18.22 A 76-year-old white female status post 4.5 × 4 cm Mohs excision of right upper vermillion and cutaneous lip. Wound was closed with 3-cm
Abbe flap. The Abbe flap was then created from the right lower cutaneous lip and rotated medially to the upper lip. Postoperative results shown at
1 week and 4 months, from left to right.
Fig. 18.23 When dealing with commissural defects, one should keep in
mind that traditional facial symmetry aligns the pupils with the
commissures.
Lip Reconstruction
163

Fig. 18.24 A 78-year-old female status post Mohs excision of squamous cell carcinoma of upper and lower right lips including commissure. Mohs
defect closed with layered closure and anatomic alignment of the commissure to the mid-pupillary line. Postoperative results shown at 3 months.
Fig. 18.25 (a) Karapandzic flap design. (b) Final postoperative appearance.
Fig. 18.26 A 78-year-old male with central lip defect status post Mohs defect closure of 40% lower lip defect resulting in lower lip incompetence.
Surgical correction with AlloDerm placement restored lower lip volume and corrected central incompetence.
Techniques for Specific Anatomic Location
164

References
[1] Weinberg T, Solish M, Fayez I, Murray C. Surface anatomy of the lip for the
dermatologist. J Cutan Med Surg. 2014; 18(3):200–202
[2] Baum CL. Commentary: use of porcine xenografts on partial-thickness vermi-
lion border and mucosal lower lip Mohs defects. Dermatol Surg. 2013; 39(6):
951
[3] Leonard AL, Hanke CW. Second intention healing for intermediate and large
postsurgical defects of the lip. J Am Acad Dermatol. 2007; 57(5):832–835
[4] Glenn CJ, Adelson RT, Flowers FP. Split myomucosal advancement flap for
reconstruction of a lower lip defect. Dermatol Surg. 2012; 38(10):1725–1728
[5] Kermer C, Millesi W, Paternostro T, Nuhr M. Muscle-nerve-muscle neurotiza-
tion of the orbicularis oris muscle. J Craniomaxillofac Surg. 2001; 29(5):302–
306
[6] Barry RB, McKenzie J, Berg D, Langtry JA. Direct primary closure without
undermining in the repair of vermilionectomy defects of the lower lip. Br J
Dermatol. 2012; 167(5):1092–1097
[7] Becker S, Lee MR, Thornton JF. Ergotrid flap: a local flap for cutaneous defects
of the upper lateral lip. Plast Reconstr Surg. 2011; 128(5):460e–464e
[8] Carvalho LM, Ramos RR, Santos ID, Brunstein F, Lima AH, Ferreira LM. V-Y
advancement flap for the reconstruction of partial and full thickness defects
of the upper lip. Scand J Plast Reconstr Surg Hand Surg. 2002; 36(1):28–33
[9] Harris L, Higgins K, Enepekides D. Local flap reconstruction of acquired lip
defects. Curr Opin Otolaryngol Head Neck Surg. 2012; 20(4):254–261
[10] Wang SQ, Behroozan DS, Goldberg LH. Perialar crescentic advancement flap
for upper cutaneous lip defects. Dermatol Surg. 2005; 31(11, Pt 1):1445–1447
[11] Ibrahim AM, Rabie AN, Borud L, Tobias AM, Lee BT, Lin SJ. Common patterns
of reconstruction for Mohs defects in the head and neck. J Craniofac Surg.
2014; 25(1):87–92
[12] Seavolt MB, McCall MW. Repair of partial-thickness Mohs defects of the ver-
milion lip with a combination of full-thickness graft and mucosal advance-
ment. Dermatol Surg. 2005; 31(10):1333–1335
[13] Housman TS, Berg D, Most SP, Odland PB, Stoddard E. Repair of the philtrum:
an illustrative case series. J Cutan Med Surg. 2008; 12(6):288–294
[14] Fernández-Casado A, Toll A, Pujol RM. Reconstruction of defects in parame-
dian upper lip. Dermatol Surg. 2009; 35(10):1541–1544
[15] Clayton NA, Ledgard JP, Haertsch PA, Kennedy PJ, Maitz PK. Rehabilitation of
speech and swallowing after burns reconstructive surgery of the lips and
nose. J Burn Care Res. 2009; 30(6):1039–1045
[16] Cook JL. The reconstruction of two large full-thickness wounds of the upper
lip with di erent operative techniques: when possible, a local flap repair is
preferable to reconstruction with free tissue transfer. Dermatol Surg. 2013;
39(2):281–289
[17] Sclafani AP, Sclafani JA, Sclafani AM. Successes, revisions, and postoperative com-
plications in 446 Mohs defect repairs. Facial Plast Surg. 2012; 28(3):358–366
[18] Nyame TT, Pathak A, Talbot SG. The abbe flap for upper lip reconstruction.
Eplasty. 2014; 14:ic30
[19] Ebrahimi A, Kalantar Motamedi MH, Ebrahimi A, Kazemi M, Shams A,
Hashemzadeh H. Lip reconstruction after tumor ablation. World J Plast Surg.
2016; 5(1):15–25
[20] Khan AA, Kulkarni JV. Karapandzic flap. Indian J Dent. 2014; 5(2):107–109
[21] Brown C, Watson D. Lip augmentation utilizing allogenic acellular derm al
graft. Facial Plast Surg. 2011; 27(6):550–554
Lip Reconstruction
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19 Ear Reconstruction
James F. Thornton, Jourdan A. Carboy, and Christopher A. Derderian
Sum m ary
This chapter discusses the issues regarding soft-tissue recon-
struction of the ear including the functional and anatomic
considerations in ear reconstruction, the management of ear
defects, as well as a spectrum of surgical repair options for ear
defects including secondary healing, full-thickness skin
grafting, wedge excision and closure, a two-stage folded post-
auricular flap (Die enbach flap), as well as the management of
near-total auricular defects including prosthetic ears.
Keywords: ear, auricle, cartilage, full-thickness skin graft, Antia–
Buch flap, Die enbach flap, Medpor, total ear reconstruction
Summary
● Do not let exposed cartilage become an issue, almost all
cartilage defects with intact perichondrium will heal well
secondarily.
● The majority of ear reconstruction cases can be done with
simple full-thickness skin grafting.
● Use caution with primary closure or Antia–Buch flaps to not
distort the repaired ear compared to the contralateral side.
● Leave the normal contralateral ear alone.
● For large defects in elderly patients, consider a prosthetic ear
reconstruction.
19.1 Algorithm for Ear
Reconstruction
19.1.1 Anatomical Considerations
Anatom ical considerations of ear reconstruction encompass
both aesthetic as well as functional issues ( Fig. 19.1 and
Fig. 19.2). Functionally, it is important to maintain the
vertical height of the ear in relation to the normal contrala-
teral side as this is the platform for eyeglass wearing and
m aintenance of sym m etry is important. Also, the accompany-
ing e ect of the ear to wide binaural localization, and there-
fore prevention of external auditory canal stenosis, is
important.1,2 From an aesthetic standpoint, it is quite impor-
tant to m aintain the continuity of the helical rim as any step-
o , even sm all, w ill draw the viewer’s attention m uch as a
vermilion border step-o on the lip. Additionally, the ear has
limited laxity and does not tolerate significant soft-tissue
closure, and any attempt at this w ithout cartilage resection
often results in forward buckling of the ear. Conversely, the
presence of cartilage throughout the ear provides an excel-
lent framework for full-thickness grafting and with successful
full-thickness grafting, the antihelix and helix shape and
contour can be successfully re-created.
Fig. 19.1 Algorithm for ear reconstruction.
Techniques for Specific Anatomic Location
166

19.2 Commonly Applied Methods
of Closure
● Allow wound to heal in secondarily.
● Full-thickness skin grafting.
● Local wedge or flap closure.
● Folded postauricular flap two-stage reconstruction.
● Prosthetic ear.
19.2.1 Secondary Closure
Large areas of the ear can heal secondarily with no secondary
contraction as long as the perichondrium is intact.3,4 Careful
monitoring and wound care is required for uneventful wound
healing. Traditionally, we provide just a simple topical antibiotic
ointment that is converted to Vaseline ointment after approxi-
mately 10 days. We allow the patient to shower on the second
postoperative day and then a nonstick dressing (Xeroform) is
applied at night. We will dress the ear with a simple stockinette
dressing if the patient desires.5 Tape is avoided at all times. The
presence of exposed cartilage with absent perichondrium is not
a contraindication to secondary healing, given this can be
simply resected and the remaining area be allowed to heal.3
The use of assistive wound healing devices including acellular
dermis can provide faster healing with reduced requirements
for dressing changes by the patient (Fig. 19.3).
19.2.2 Full-Thickness Skin Grafting
Full-thickness grafting constitutes the majority of our ear
reconstruction cases.6 It is a very safe and highly reliable tech-
nique. The full-thickness skin is harvested from the ipsilateral
neck and significantly thinned to match the thickness of the
skin native to the host site on the ear. The key to ensure com-
plete graft take is careful bolster placement on the graft, which
frequently requires the majority of operative time.7 The graft
itself is sewn in place with 5–0 plain gut suture and then multi-
ple mattress sutures of through-and-through 4–0 plain gut
with a straight Keith needle are utilized to adhere the full-
thickness graft to the underlying graft contours. If the graft area
is large (>20% of the ear), we will use a surgical foam bolster
that is secured with through-and-through 3–0 double-armed
Prolene suture. This is kept dry and removed on the fifth post-
operative day. Postoperative or oral antibiotics are not given;
however, ciprofloxacin otic solution is given and the patient is
instructed to liberally coat the sponge and healing graft for the
first 3 postoperative days (Fig. 19.4 and Fig. 19.5).
19.2.3 Local Flap Wedge or Local Flap
Closure
We consider a simple wedge closure to a Antia–Buch type clo-
sure as techniques on a continuum that are performed from
simple closure and alignment of the auricular rim to near-com-
plete undermining, degloving of the ear, and advancement of
bilateral chondrocutaneous flaps.8,9,10 These can provide ideal
postoperative results when executed for appropriately sized
defects; however, it is important to proceed with caution. It is
not uncommon to be able to get the two edges of the auricular
Fig. 19.2 Anatomy of external ear.
Fig. 19.4 Illustration of bolster placement following inset of full-
thickness skin graft.
Fig. 19.3 A 67-year-old male status post 3.5 × 2 cm Mohs excision of
basal cell carcinoma at right tragus. Wound was allowed to heal
secondarily. Results shown 2 months after resection.
Ear Reconstruction
167

rim approximated, but the resulting ear will have a significantly
di erent shape and height than the una ected ear on the
contralateral side (Fig. 19.6 and Fig. 19.7).
19.2.4 Folded Postauricular Two-Stage
Ear Flap Reconstruction
(Die enbach Flap)
For large segmental defects of usually the middle ear—although
it can be applied to upper third defects also—the folded post-
auricular flap is exceedingly useful.11,12 This flap utilizes the
non–hair-bearing postauricular skin that is elevated to the
insertion of the ear into the scalp. It is also thickly elevated into
the hair-bearing scalp in a slight wedge pattern to allow tucking
of the ear and then the ear is simply tethered to the scalp with
the skin overlying it. Vicryl 3–0 pop-o sutures are utilized to
tether the cartilage portion of the ear to the scalp and then the
remaining flap is simply inset with 5–0 either gut, or this is one
Fig. 19.5 A 60-year-old male status post 4 × 4 cm Mohs excision of melanoma in situ at left upper ear. Wound was repaired with color-matched full-
thickness skin graft. Postoperative results shown at 2 months.
Fig. 19.6 Primary closure following wedge resection.
Fig. 19.7 A 49-year-old male status post 1 × 1 cm Mohs excision of basal cell carcinoma at right superior helical rim. Wound was closed with modified
Antia–Buch advancement flap.
Techniques for Specific Anatomic Location
168

instance where we will use chromic sutures on the ear. Non-
stick dressings and antibiotic ointment are placed on the ear,
which are removed on the second postoperative day. After
4 days, the patient may be allowed to shower and continue
their daily activities, the only care required being a simple anti-
biotic dressing placed over the ear by the patient.13 Understand
that there have been numerous descriptions of complicated
dressing techniques requiring nonstick dressings or red rubber
catheters to maintain the separation on the ear, but in our
experience with over 40 of these flaps, there have been no post-
operative infections with simple antibiotic ointment and show-
ering.13 Since these are so well tolerated by the patient, and
there is not that significant of an aesthetic deformity, the flaps
are able to be left at a minimum of 3 and oftentimes up to 6 to
7 weeks for development of maximum vascularity. Understand
that on division and inset, the skin can be simply folded on itself
and sutured with through-and-through 4–0 double-armed
Prolene sutures to restore the normal contour of the helical rim.
No cartilage is required ( Fig. 19.8, Fig. 19.9, Fig. 19.10).
Fig. 19.8 Folded postauricular two-stage flap during initial flap
elevation and inset.
Fig. 19.9 A 62-year-old male with middle third auricular rim skin and cartilage defect after Mohs resection. The third picture in the series shows flap
after division and inset. Flap is folded on itself to recreate auricular rim with no additional cartilage support required. Scalp donor site is repaired with
color-matched full-thickness skin graft.
Fig. 19.10 A 73-year-old male status post 4 × 3 cm Mohs excision of melanoma in situ at left antihelical rim. The lobe was then reconstructed with an
anteriorly based transposition flap. Postoperative results shown at 10 months.
Ear Reconstruction
169

19.2.5 Postoperative Care
● The patient is placed in a stockinette cap with bulky cotton
ear dressing over the first.
● Postoperative night, no surgical tape is used. The surgical
stockinette cap is removed on day 1.
● If the patient does not have a bolster in place, the patient may
be allowed to shower.
● Postoperative enteric antibiotics are not given. Topical ofloxa-
cin is applied to full thinness.
● Skin grafts and local flaps for 3 days and the graft bolsters are
removed on day 5 or 6.
● No special care is given to the postauricular flap wound care;
just simple antibiotic ointment is placed over the flap portion
of the ear, as well as the donor site. The flap is divided from 4
to 7 weeks postoperatively.
19.3 Total Ear Reconstruction
Christopher A. Derderian
The primary surgical means of reconstructing a total or subtotal
loss of the ear rely upon techniques used for treating microtia. For
those patients who are not good surgical candidates, an osseointe-
grated implant-based prosthesis is an excellent option.14,15
The two main treatment options for ear reconstruction uti-
lize either a costochondral or a porous polyethylene (Medpor)
construct (Fig. 19.11).14,15,16,17 The traditional approach to ear
reconstruction uses a costochondral construct.15 In the first
stage, the rib cartilage is harvested and the construct is fash-
ioned and placed in a skin pocket at the desired location. In a
second procedure, the ear is elevated, projected, and the poste-
rior surface is skin grafted. The lobule and tragus are typically
created during the first stage or in a third stage. The primary
advantage of this approach is the use of autologous tissue.
Given that most patients requiring Mohs reconstruction of the
ear are in the middle-age years or older, there is a high likeli-
hood of calcifications being present in their costal cartilage.
These calcifications and decreasing pliability of the costal carti-
lage with increasing age complicate the carving and assembly
of a costal cartilage construct.18 The morbidity of harvesting the
cartilage is also a drawback.18
Use of a Medpor construct requires coverage with a temporo-
parietal fascia (TPF) flap even if there is skin of good quality in
the recipient site.14,16,17 This approach provides a well-projected
ear framework with lobule transposition in a single stage. Using
porous polyethylene constructs avoids dealing with donor site
morbidity in the chest, and calcifications and/or fracture of cos-
tal cartilage during construct fabrication.14,16,17 The Medpor
approach also has drawbacks. Medpor is a foreign body predis-
posing it to infection and it can fracture with trauma.19 The
procedure for harvesting a large enough TPF flap to provide a
well-projected ear is a lengthier single-stage procedure of 6- to
8-hour duration in experienced hands. This may be prohibitive
in patients with significant comorbidities. Careful patient selec-
tion with regard to patient health, expected patient compliance
in the perioperative period, duration of recovery, and prepara-
tion of the patient for possible short- and long-term complica-
tions are all important considerations when deciding between
autologous cartilage, implant, and prosthetic options for ear
reconstruction.19
19.3.1 Medpor Technique
I employ the Medpor and TPF flap approach to ear reconstruc-
tion pioneered by Dr. John Reinisch.17 I learned this approach
by observing him operate on multiple occasions and continued
correspondence with him. It is the many small technical points
that make the di erence between achieving a good and a poor
result. Anyone considering this approach to ear reconstruction
Fig. 19.11 (a) Typical costochondral framework in the method of Nagata. (b) Assembled Medpor framework.
Techniques for Specific Anatomic Location
170

would be well served by watching Dr. Reinisch or another sur-
geon experienced with this technique execute the procedure
before attempting it.
Reinisch uses a clear plastic eye shield from a surgical mask
to create a template of the dimensions, features, and location of
the patient’s normal ear. Landmarks including the sideburn, lat-
eral eyebrow, the lateral canthus, palpebral fissure, and ala are
marked to triangulate the position and axis of the ear
(Fig. 19.12a, b). The distance from the lateral canthus to the
helical root is also measured to aid in verifying appropriate
anteroposterior (AP) positioning of the construct during inset.
The plastic sheet is flipped over and the position of the new ear
is transposed onto the a ected side. The construct will predict-
ably have some inferior descent during the healing process, so
it is best to place the ear 5 to 8 mm more superior with a
slightly more vertical axis than the mirror image position of the
una ected ear ( Fig. 19.12c).
The location of the superficial temporal artery (STA) can be
palpated and/or traced using Doppler as necessary. The TPF flap
is outlined on the scalp (Fig. 19.12d). The typical dimensions
are 11 to 12 cm vertical by 10 to 11 cm AP attempting to include
both the anterior and posterior branches of the STA (the most
common branching pattern) when possible. The vertical dimen-
sion of the flap is proportionate to the size of the desired ear.
The standard flap dimensions cross the line of temporal fusion
(marked LTF in Fig. 19.12d); therefore, the distal portion of
the flap is comprised of the galea aponeurotica, which is contig-
uous with the TPF. The vascularity to this portion of the flap is
reliable. In addition to the incision in the mastoid skin, I employ
a transverse counter incision, typically located midway along
the vertical axis of the flap, to facilitate dissection and elevation
of the flap. The counter-incision is oriented perpendicular to
the direction of the temporal hair growth to hide the scar.
19.3.2 General Operative Setup
For males, the entire surgical site is shaved. For females, the 2
to 3 cm of the hairline abutting the new ear position and a 1-
cm strip of hair at the transverse counter-incision are shaved.
The entire head and face are prepped into the field. Isolating
the eyes and the oral and nasal cavities is achieved using
occlusive dressings (Tegaderm).
19.3.3 Procedure Details
An anteriorly based skin flap is raised in the subcutaneous
plane using scissors. If present, any residual ear cartilage and
soft-tissue bulk posterior to the STA pedicle that may interfere
with the positioning of the construct or that adds excess bulk to
the conchal bowl should be removed.
The scalp is elevated in the subcutaneous plane using electro-
cautery. The cut function is set at 20 on blend and the coagula-
tion is set at 15. There should be a thin layer of fat covering the
hair follicles. Exposing the hair follicles increases the chance of
temporary or permanent alopecia. Even when the fat on the
hair follicles is preserved, it is common to have some temporary
alopecia in the area of the dissection.
The anterior limit of dissection should be the anterior border
of the temporal and frontal hairline to avoid injury to the tem-
poral branch of the facial nerve. If the anterior branch of the
STA crosses anterior to the hairline, it should be ligated where it
crosses the hairline. The collaterals between the anterior and
posterior branches are typically su cient to perfuse the ante-
rior portion of the flap.
When the entire superficial surface of the flap is exposed, the
anterior, posterior, and superior limits of the flap are incised
with cautery and the flap is raised from superior to inferior
using a gauze peanut. The loose areolar tissue between the flap
and the periosteum and deep temporal fascia should be
included on the flap by sweeping it up with the peanut. The
skin grafts will sit on this loose areolar tissue, which will func-
tion as a glide plane akin to the normal thin layer of subcutane-
ous fat along the posterior edge of the helical rim. Once the flap
is elevated, it is placed back into the donor site to allow any
vasospasm from manipulation to resolve.
Skin grafts are harvested from the groin and the posterior
surface of the contralateral ear (if available). The groin graft size
is typically 8- to 9-cm long and 4-cm wide to resurface the pos-
terior surface of the ear. The skin graft from the contralateral
ear is one-third postauricular skin and two-thirds mastoid skin
(Fig. 19.13). This skin is used to line the anterior surface of
the ear. The grafts are thoroughly defatted down to the dermis.
Preparation of the Medpor Implant
The Medpor implant comes in two pieces: a helical rim piece
and a base piece, each specific for the right or left ear, as appro-
priate. Open both pieces and soak in antibiotics with saline. The
package insert indicates suturing the construct together is the
recommended technique. Reinisch uses a high-temperature
ophthalmic cautery to solder together the base and helical rim
pieces. A smoke evacuator is necessary for this approach
because the smoke emitted is unsafe to inhale.
Remove the tragus and lobule extension from the construct
using a no. 15 blade and retain for soldering. The helical rim seg-
ment is manipulated to produce an ear with the desired size.
The contribution of the lobule to the total ear height should be
subtracted from the construct height. Failure to account for the
lobule contribution will result in too large an ear. While deter-
mining how much of the helical rim component is needed to cre-
ate the desired dimensions, a nonpenetrating towel clamp can be
used to hold the helical rim piece to the inferior aspect of the
base piece (Fig. 19.14). Once the ear is sized, the helical rim
and base pieces are soldered together at all points of contact on
the anterior and posterior surfaces of the construct. The tragus,
lobule, and excess helical rim pieces of the construct are used to
solder. When the construct assembly is complete, the implant is
placed in a bowl and soaked with antibiotic-containing saline.
Insertion of the Implant
Two 4-mm flat drains are inserted under the mastoid fascia
through the occipital hairline. One drain sits in the expected
position of the construct and the other is placed in the flap
donor site. The implant is positioned in the footprint and
axis as marked preoperatively with the suction deep to the
construct. The flap is transposed to cover the implant
(Fig. 19.15a, b) and suction is applied to the drain. Digital
manipulation of the flap edges creates a seal that allows the flap
to essentially shrink-wrap the flap around the implant. The
Ear Reconstruction
171

Fig. 19.12 (a) Normal landmarks are placed to triangulate the appropriate position of the on the affected side. (b,c) Vertical overcorrection is marked
in anticipation of slight downward migration of the construct with healing. (d) The flap dimensions are marked in blue. The red marking indicates the
course of the superficial temporal artery (STA). The line of temporal fusion is estimated with LTF to demonstrate that the distal portion of the flap
consists of galea. Mastoid skin to be used as full-thickness skin graft and scalp to be excised to accommodate implant placement are marked in black.
Techniques for Specific Anatomic Location
172

position and axis of the ear are confirmed. Once the ear posi-
tion and flap distribution are confirmed to be in the desired
position, the flap and implant are hinged upward onto a sterile
towel on the surface of the scalp and the TPF flap is wrapped
around the inferior pole of the construct and sutured to itself
with 5–0 PDS. Only two to three sutures should be required.
The flap and implant are then hinged back down to the final
position. The drain is placed to continuous suction. Digital
manipulation of the flap edges creates a seal due to the suction
and adherence of the TPF to the implant. It is critical at this
point to ensure that the construct is well projected. The flap
surface area should be distributed to ensure that the construct
sits well projected before committing to the inset. The posterior
TPF flap is sutured to the mastoid fascia with a 5–0 PDS
suture to maintain the suction and adherence of the flap to the
construct.
The anteriorly based skin flap is defatted to allow the skin to
drape over the TPF flap and reveal the contour of the construct.
The scalp posterior to the construct is undermined and advanced
to minimize the postauricular skin defect by anchoring the skin
to the mastoid fascia with a 4–0 PDS suture. If present, the lobule
is split at the margin of the incised surface to allow it to be
draped at the inferior pole of the construct and sutured to the
anterior and posterior skin flaps and grafts, respectively.
When insetting the skin grafts and anterior skin flap, no
sutures are placed from the skin to the TPF flap. Once the
skin distribution is determined, the skin grafts are sutured
together with interrupted 5–0 and 6–0 chromic to create an air-
tight as the skin grafts adhere to the flap and construct through
the forces of cohesion only ( Fig. 19.16a). It is critical to ensure
the projection is adequate before applying the dressing
(Fig. 19.16b).
Fig. 19.13 The amount and location of contralateral postauricular skin
harvested to line the anterior portion of the ear is marked.
Fig. 19.14 Sizing of the ear with a nonpenetrating towel clamp and the
soldering of the polyethylene components with a high temperature
ophthalmic cautery are shown.
Fig. 19.15 (a) The harvested temporoparietal fascia flap is shown. (b) The flap is placed over the construct and suction is transmitted to the flap to
shrink-wrap the flap to the Medpor implant.
Ear Reconstruction
173

19.3.4 Dressings
Bacitracin is applied to all suture lines. Any areas of concavity
including the concha and posterior surface of the construct are
gently packed with Kaltostat. A silicone splint is made from
orthodontic impression material (A-ZOFT). The purpose of the
splint is to maintain the position and projection of the ear and
bolster the skin grafts in place. The splint is sutured to the scalp
with 2–0 Prolene horizontal mattress sutures with care to avoid
the drains and pedicle of the flap. Once the splint is secured,
the drains are placed on bulb suction. The drains are removed
postoperative day 1. One week of oral antibiotic prophylaxis is
prescribed. At 2 weeks, the patient returns for splint removal
(Fig. 19.17).
Fig. 19.16 (a) The harvested grafts and anteriorly based skin flap are distributed to provide adequate coverage. Note the small rim of conchal bowl
retained for orientation. (b) The projection of the ear is appreciable with the groin skin graft inset on the posterior aspect of the construct. (c) Typical
appearance of the ear prior to applying the dressing.
Fig. 19.17 (a–c) The patient from the surgical photos had a conchal-type microtia that may approximate a loss of the superior half of the normal ear.
The photos show the patient 6 months after reconstruction.
Techniques for Specific Anatomic Location
174

References
[1] Bast F, Chadha P, Shelly J, Collier JM. Prevention of postoperative ear canal
stenosis using stents made of dental impression material: a rapid, cost-e ec-
tive solution. Clin Otolaryngol. 2015
[2] Bajin MD, Yılmaz T, Günaydın RO, Kuşçu O, Sözen T, Jafarov S. Management of
acquired atresia of the external auditory canal. J Int Adv Otol. 2015; 11(2):
147–150
[3] van der Eerden PA, Verdam FJ, Dennis SC, Vuyk H. Free cartilage grafts and
healing by secondary intention: a viable reconstructive combination after
excision of nonmelanoma skin cancer in the nasal alar region. Arch Facial
Plast Surg. 2009; 11(1):18–23
[4] Levin BC, Adams LA, Becker GD. Healing by secondary intention of auricular
defects after Mohs surgery. Arch Otolaryngol Head Neck Surg. 1996; 122(1):
59–66, discussion 67
[5] Orabi AA, Chintamani BH, Timms MS. Is a head bandage useful after oto-
plasty? A quasi-randomized controlled study of complications and patient
satisfaction. Ear Nose Throat J. 2009; 88(10):E17–E22
[6] Trufant JW, Marzolf S, Leach BC, Cook J. The utility of full-thickness skin grafts
(FTSGs) for auricular reconstruction. J Am Acad Dermatol. 2016; 75(1):169–
176
[7] Travelute CR, Cartee TV. Straight suture needle for full-thickness skin graft
fixation on the ear. J Drugs Dermatol. 2013; 12(1):104–105
[8] Varas-Meis E, Perez-Paredes MG, Rodríguez-Prieto MA. Superior Antia-Buch
flap for reconstruction of helical rim defects. J Am Acad Dermatol. 2016; 74
(4):e67–e68
[9] Joshi R, Sclafani AP. The Antia-Buch chondrocutaneous advancement flap for
auricular reconstruction. Ear Nose Throat J. 2016; 95(6):216–217
[10] de Schipper HJ, van Rappard JH, Dumont EA. Modified Antia Buch repair for
full-thickness middle auricular defect. Dermatol Surg. 2012; 38(1):124–127
[11] Malone CH, Wagner RF, Jr. Partially de-epithelialized postauricular flap for
ear reconstruction. J Am Acad Dermatol. 2015; 73(6):e219–e220
[12] Bayramicli M, Tuncer FB, Certel F. Postauricular conchal chondrocutaneous
sandwich flap for partial ear reconstruction. J Plast Reconstr Aesthet Surg.
2015; 68(11):1617–1620
[13] Park C, Yoo YS, Park HJ, Park YS. An analysis of the bacterial flora found in the
external auditory canals of microtia patients: results and clinical applications.
Ann Plast Surg. 2010; 65(2):197–200
[14] Wilkes GH, Wong J, Guilfoyle R. Microtia reconstruction. Plast Reconstr Surg.
2014; 134(3):464e–479e
[15] Nagata S. A new method of total reconstruction of the auricle for microtia.
Plast Reconstr Surg. 1993; 92(2):187–201
[16] Braun T, Gratza S, Becker S, et al. Auricular reconstruction with porous poly-
ethylene frameworks: outcome and patient benefit in 65 children and adults.
Plast Reconstr Surg. 2010; 126(4):1201–1212
[17] Reinisch JF, Lewin S. Ear reconstruction using a porous polyethylene frame-
work and temporoparietal fascia flap. Facial Plast Surg. 2009; 25(3):181–189
[18] Korus LJ, Wong JN, Wilkes GH. Long-term follow-up of osseointegrated auric-
ular reconstruction. Plast Reconstr Surg. 2011; 127(2):630–636
[19] Lewin S. Complications after total porous implant ear reconstruction and
their management. Facial Plast Surg. 2015; 31(6):617–625
Ear Reconstruction
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(Trang không có chữ)

3
Part 3
Management of Complications
and Revisions
20 Intraoperative Complications and Initial
Management

179
21 Management of Complications in the
Acute Healing Stage

182
22 Management of Complications in the
Late Healing Stage

188
23 Skin Graft Revisions

192
24 Local Flap Revisions

195
25 Pedicled Flap Revisions

200

(Trang không có chữ)

20 Intraoperative Complications and Initial Management
James F. Thornton and Jourdan A. Carboy
Sum m ary
This chapter discusses philosophical as well as surgical
approaches to the management of complications in soft-tissue
facial reconstruction. Techniques of “extreme ownership” with
regard to patient care are discussed. The identification and
management of intraoperative complications including fire,
bronchospasm, anaphylaxis, corneal injuries, and nerve injuries
are discussed with regard to both management and prevention.
Keywords: Jocko Willink, extreme ownership, complication,
intraoperative fire, Bovie cautery, bronchospasm, bronchocon-
striction, anaphylaxis, corneal injuries, nerve injuries
20.1 General Principles
Avoidance and management of complications begins prior to
making the first incision. “Extreme ownership,” initially coined
by Navy SEAL Jocko Willink, is a concept in leadership that
defines a true leader as an individual who takes responsibility
of not just their own actions and behaviors, but also the people
and the environment around them. A successful surgeon must
embody this notion of leadership, taking ownership of both the
positive outcomes of the procedure and the negative outcomes
and possible complications.1 A true surgeon understands that
the negative outcomes of a surgical procedure cannot be attrib-
uted to a patient’s level of compliance or shortcomings, anes-
thesia care, or factors “outside their control.” But instead, he or
she takes responsibility as the surgeon and accepts negative
outcomes with self critique, such as being due to a lack of
maturity and/or attention to detail. Success is dependent on the
surgeon’s ability to be self-aware and cognizant of all the varia-
bles influencing his patients care, all the while evaluating his
own standards of care for quality improvement. He must prac-
tice “extreme ownership” in order to ensure patient-centered
care throughout the entirety of the clinician–patient interaction
from preoperative assessment to postoperative care. Although
seemingly impossible, maintaining this mindset and developing
a practice around these principles will, without question,
improve the doctor–patient relationship, improve outcomes,
and ultimately lead to a reduction in complication rates. It
entirely becomes the surgeon’s responsibility to reduce rates of
complications and substandard results, and in doing this, there
are no longer factors outside the surgeon’s control given these
factors will have been foreseen and optimized for surgery from
the beginning.
E ective conduct of the operation begins with very accu-
rate patient assessm ent in conjunction with the anesthesia
provider and accurate assessment of what the patient is able
to contribute to his own care. This includes not just the
patient’s health, but also their ability to understand the
operative process and to comply w ith postoperative instruc-
tions including even simple social issues such as transporta-
tion or home nursing issues.
Optimizing the next steps in the operative process, including
anesthesia and supplies, comes with repetition and attention to
detail. Dedicated anesthesia sta , dedicated surgical instru-
ments, and disposables eliminate variability and distractions.
Properly done, the only variables become the patient and
their Mohs defects, and operating can become a seamless “flow
state” that is both safe and enjoyable for all involved.
20.1.1 A Note on Patient Consent
Undertaking a complex multistage Mohs repair is somewhat
similar to accompanying the patient on a journey through a
hostile land. The surgeon can serve as the experienced guide
and prevent pitfalls along the journey to a successful repair.
The consent process should not be an opportunity to discuss
every possible outcome and it is foolish of a surgeon to discuss
fatalities from an operative procedure for Mohs repair. Yes,
fatalities can result, but one does not sign an equivalent consent
on fatalities from a domestic airline flight when the safety rate
for both are very similar.2 It is unnerving for the patient and
legally unnecessary. It is incumbent upon the surgeon to dis-
cuss possible adverse outcomes and briefly consider all options
including doing nothing. The first or second postoperative visit
is also an ideal time to discuss long-term outcomes with regard
to finer results and to discuss in much greater detail the need
for possible revisions. At this time, it is also an opportunity to
review the procedure performed in depth and with the use of
postoperative photos, discuss the initial appearance, that is,
where we are now and what the expected outcome is, as well
as the time course of this surgery. Patients will find this very
reassuring and in many cases they can make travel and work
plans based on the physician’s illustration. Understand that the
patient, on the initial postoperative visit, is looking up to the
doctor for “how they are supposed to look” and oftentimes they
consider the physician as a guide on an extended journey or
travel toward their final outcome.
20.2 Intraoperative Complications
Summary
● Intraoperative complications experienced in Mohs repair
have included fire, bronchospasm, preoperative anaphylaxis,
eye injuries, and nerve injuries.
20.2.1 Fire
Unfortunately, the incidence of intraoperative fire is not zero. It
is an entirely avoidable event. The use of awake intravenous
(IV) sedation, which provides multiple benefits to the patient, is
often accompanied by the concurrent use of oxygen by nasal
cannula and if inappropriately managed, it can lead to flash
fires on the table. The current standards on oxygen administra-
tion—during the use of Bovie cautery—is to simply not use oxy-
gen at no greater than 30% FiO2 at all during the case.3,4 If
patient conditions mandate higher oxygen concentrations, then
Intraoperative Complications and Initial Management
179

very accurate communication between the surgeon and the
anesthesiologist allows for its safe e ective use. Consistent
draping with four towel drapes where the entire head is left
exposed and no tenting for possible oxygen containment is
mandatory, and the removal of the Bovie tip while the oxygen
is in use will prevent the inadvertent ignition source. The
removal of all surgical prep solution is mandatory as well as
ensuring availability of damp surgical laps on the surgical field
(Fig. 20.1 and Fig. 20.2).
20.2.2 Bronchospasm
Bronchospasm or bronchial hypersensitivity describes intense
bronchoconstriction following a low level of airway stimulus.5,6
This presents a challenge to the anesthetist to maintain airway
control and oxygenation during awake IV sedation. Most com-
mon presenting etiology can almost always be determined on
the preoperative evaluation and include bronchial asthma,
chronic bronchitis, emphysema, and upper/lower respiratory
tract infections.5,6 Proceeding with awake IV sedation on a pa-
tient with poorly controlled asthma or active respiratory tract
infections is inadvisable and the procedure is best postponed
until respiratory mechanics are optimized.
20.2.3 Perioperative Anaphylaxis
Perioperative anaphylaxis occurs in 1 out of 5,000 to 10,000
anesthesias and involves a 3 to 9% mortality rate.6,7 The most
common etiologic agents in decreasing order are neuromuscu-
lar blocking agents, latex, antibiotics, rarely local anesthetics,
chlorhexidine, and heparin.6,7 The initial treatment is essen-
tially circulatory support, which includes oxygen, crystalloid IV
fluids, and epinephrine. Identification of the likely agent often
requires referral to an allergist and is essential to prevent
repeated exposures.
20.2.4 Corneal Injuries
Corneal injuries are prevented with protection throughout the
operative course. The routine use of ophthalmic ointment on all
cases prior to surgical prep and then the covering of the eyes
with a sterile “Swiss Therapy” eye mask that the patient is
allowed to take home postoperatively provides some degree of
protection, but will not protect against dropping of sharp
instruments.8 Additionally, many corneal injuries occur in the
postoperative recovery if the semiconscious patient tries to rub
his or her eyes with the tape and/or pulse oximetry probe on
his or her hands.
Fig. 20.1 A 62-year-old male with nasal sidewall defect repaired by single-stage island nasolabial flap. Repair complicated with intraoperative fire from
electrocautery igniting oxygen delivered by nasal cannula. Wounds healed without long-term sequelae. Incident resulted in policy change of
discontinuing oxygen delivery by nasal cannula during intravenous anesthetic sedation.
Management of Complications and Revisions
180

20.2.5 Nerve Injury
Nerve injury, particularly facial nerve injury, is avoided with
meticulous knowledge of anatomy and surgical technique, but
if it occurs the decision to immediately repair the nerve is based
on the surgeon’s expertise as well as identification of the
injury.9,10 A pessimistic approach to full recovery is unfortu-
nately realistic in an elderly patient population, and there is lit-
tle justification for intraoperative nerve repair for injuries
medial to the canthus.8,9 Additionally, with the injection of local
anesthetic during the Mohs procedure and repair, it is di cult
to determine the functional defect at the time of surgery.11 The
most common facial motor nerve injury in Mohs surgery that
results in long-term disability is injury of the frontal nerve. Lit-
tle actual functional return is expected from cross-innervation
and the functional deficit includes ptosis from the overhanging
eyebrow. Direct functional eyebrow-pexy done as a secondary
procedure provides the most reliable surgical correction.
References
[1] Willink J, Babin L. Extreme Ownership: How the U.S. Navy SEALs Lead and
Win [spoken word]. New York, NY: Macmillan Audio; 2015
[2] Adams AM, Smith AF. Risk perception and communication: recent develop-
ments and implications for anaesthesia. Anaesthesia. 2001; 56(8):745–755
[3] Hart SR, Yajnik A, Ashford J, Springer R, Harvey S. Operating room fire safety.
Ochsner J. 2011; 11(1):37–42
[4] Stewart MW, Bartley GB. Fires in the operating room: prepare and prevent.
Ophthalmology. 2015; 122(3):445–447
[5] Lawal I, Bakari AG. Reactive airway and anaesthesia: challenge to the anaes-
thetist and the way forward. Afr Health Sci. 2009; 9(3):167–169
[6] Volcheck GW, Mertes PM. Local and general anesthetics immediate hypersen-
sitivity reactions. Immunol Allergy Clin North Am. 2014; 34(3):525–546, viii
[7] Galvão VR, Giavina-Bianchi P, Castells M. Perioperative anaphylaxis. Curr
Allergy Asthma Rep. 2014; 14(8):452
[8] Malafa MM, Coleman JE, Bowman RW, Rohrich RJ. Perioperative corneal abra-
sion: updated guidelines for prevention and management. Plast Reconstr
Surg. 2016; 137(5):790e–798e
[9] Gordin E, Lee TS, Ducic Y, Arnaoutakis D. Facial nerve trauma: evaluation and
considerations in management. Craniomaxillofac Trauma Reconstr. 2015; 8
(1):1–13
[10] Roostaeian J, Rohrich RJ, Stuzin JM. Anatomical considerations to prevent
facial nerve injury. Plast Reconstr Surg. 2015; 135(5):1318–1327
[11] Yawn RJ, Wright HV, Francis DO, Stephan S, Bennett ML. Facial nerve repair
after operative injury: impact of tim ing on hypoglossal-facial nerve graft out-
comes. Am J Otolaryngol. 2016; 37(6):493–496
Fig. 20.2 (a) Incorrect “keyhole” draping for awake surgical procedure. This draping procedure does not allow evaluation of the contralateral normal
side for symmetry, puts the patient’s eyes at risk for corneal abrasion, and puts patient at risk for oxygen accumulation, which increases fire risk. (b)
Full-face draping that can be done for every facial reconstruction case and diminishes the aforementioned risks.
Intraoperative Complications and Initial Management
181

21 Management of Complications in the
Acute Healing Stage
James F. Thornton and Jourdan A. Carboy
Sum m ary
This chapter discusses complications in the acute healing stage,
including hematoma, soft-tissue infection, dermatitis, chondri-
tis, wound disruption, and flap failure. Techniques for both
prevention and management are covered.
Keywords: postoperative complications, dermatitis, hematoma,
infection, corneal injuries, chondritis, flap failure, wound
disruption
Summary
● Postoperative bleeding and hematoma are an ever-present
risk given the current preference to perform Mohs excisions
and repairs with no regard to patient’s anticoagulation
status.
● Although gratifyingly rare, appropriate treatment of soft-
tissue infections on the face requires accurate identification
of the involved pathogen.
● Although nearly universal in use, prolonged application of
topical antibiotic ointment results in a very high incidence of
dermatitis.
● The early identification and e ective treatment of chondritis
is necessary to prevent long-term ear deformity.
21.1 General Principles
Management of complications in the early healing stage
requires a degree of diligence and enthusiasm than the initial
procedure requires.1,2,3 So often, early wound complications
that can put the entire procedure at risk are attempted to be
managed in a clinic setting when they require an operating
room or are not approached with appropriate diligence in what
could have been an easy return to the operating room and pro-
cession to final healing turns into a late complication requiring
revision and reoperation anyway.
21.1.1 Hematoma
Currently, the standard of care is for dermatologists to not alter
the coagulation status of patients undergoing Mohs resection.
In this patient population, hematomas can be a frequent com-
plication. The reconstructive surgeon needs to be adept at iden-
tifying which patients and procedures can be managed with
anticoagulation. Additionally, the surgeon should be well versed
with the use of a wide range of intraoperative techniques for
safe hemostasis during awake anesthesia, including wide infil-
tration with epinephrine containing local anesthetics, and the
use of topical oxidized cellulose.4,5
Again, most hematomas can be prevented by attention to in-
traoperative hemostasis and awake anesthesia. If a hematoma
occurs in the initial postoperative period, there can be little
downside to immediately returning to the operating room,
identifying the bleeding source, and evacuating the hematoma.
If a hematoma occurs in the immediate perioperative period
but after patient discharge, the criteria for returning to the
operating room for evacuation is similar but not as urgent. Few
hematomas will resolve completely and spontaneously. There is
almost always some negative impact on the final repair appear-
ance whether it is a color mismatch or contour irregularity, but
it always carries with it an increased risk of postoperative infec-
tion if left undrained.6
The routine use of compressive dressings are surgeon
dependent and in a series of over 200 cheek reconstructions, no
compressive dressings were used with no increase in bleeding
complications. It seems prudent to place a drain routinely on
take backs for bleeding. This can be removed in the initial post-
operative period.
21.1.2 Infection
Fortunately due to the favorable vascularity of the face, soft-tis-
sue infections in facial reconstruction are gratifyingly rare even
in the patient population with frequent comorbid disease
including diabetes and steroid dependence ( Fig. 21.1).7 With
soft-tissue infections in the face, management can be based on
the general classification of purulent and nonpurulent infec-
tions and each can be categorized as mild, moderate, or
severe.7,8,9,10 Mild nonpurulent skin infections include impetigo
and cellulitis.7,8,9,10 Impetigo is most frequently caused by
Staphylococcus aureus or Streptococcus pyogenes and can be
managed with topical antibiotics and oral cephalexin if
required.7,8,9,10 For purulent skin soft-tissue infections, wound
culture is mandatory for appropriate antibiotics selection and
therapy. Antibiotic therapy for mild to moderate cases can be
initiated with trimethoprim/sulfamethoxazole or doxycycline
pending culture results, while severe purulent and moderate to
severe nonpurulent cellulitis requires admission with intrave-
nous antibiotics.7,8,9,10 All cases of purulent skin soft-tissue
infections require wound debridement and washout with con-
comitant culture for appropriate antibiotic selection.7,8,9,10
Severe purulent and moderate to severe nonpurulent cellulitis
requires admission with intravenous antibiotics.7,8,9,10 In all
cases, outpatient management requires careful and frequent
postoperative visits to ascertain the e ectiveness of the chosen
antibiotic therapy. There should be no hesitation regarding
repeated surgical debridement until clear signs of improvement
are seen ( Fig. 21.2 and Fig. 21.3).
21.1.3 Dermatitis
Dermatitis in soft-tissue facial reconstruction is frequent and
can be easily confused with infection and can result from the
surgical prep, the postoperative antibiotic ointment, or simply
from the trauma of surgery.11,12,13 Prompt identification and
Management of Complications and Revisions
182