Phẫu Thuật Tạo Hình (Tập 3): Sọ Mặt, Đầu Cổ Và Nhi Khoa – Neligan (Ấn bản 4)

419
Salivary gland neoplasms
extension to the parapharyngeal space or invasion of skin,
subcutaneous tissues, or underlying muscle should all be
specifically examined for (Fig. 16.25). The availability and cost
of CT scanning has made it the modality of choice in many
centers. MRI does have a number of inherent benefits when
assessing salivary gland neoplasms. The superior soft tissue
definition enables improved delineation of the margins of a
lesion, and the signal intensities may aid diagnosis. High-
grade malignancies tend to have low to intermediate signal
intensities on all imaging sequences, whereas low-grade
malignancies and benign tumors typically have low T1 signal
and high T2 signal.57 Gadolinium enhanced sequences are
critical in assessing perineural invasion and cervical lymph
node metastasis.
Fine needle aspiration (FNA) plays a key role in the preop­
erative work-up of a patient with a salivary gland tumor.
While the decision to operate does not solely depend on the
findings of a needle biopsy, it does have a number of benefits.
Firstly, it may identify inflammatory causes as well as lym­
phoma, which do not require surgery. Secondly, the preopera­
tive identification of a high-grade malignancy enables the
surgeon to determine surgical urgency and to counsel the
patient with respect to the need for neck dissection, possible
sacrifice of the facial nerve, and the need for postoperative
adjuvant therapy. It is critical for the clinician to also under­
stand the potential pitfalls in its use.58 FNA cytology is highly
dependent on the experience of the reporting pathologist and
yields a non-diagnostic sample more frequently than FNA of
other head and neck masses. Finally, and most importantly,
the sensitivity and specificity of this test even for differentiat­
ing benign from malignant pathology is not 100%. A meta-
analysis of the diagnostic accuracy of FNA cytology for
parotid lesions examined 64 studies, including 6169 cases, and
concluded the sensitivity of this test was 79% and its specific­
ity 97% when attempting to differentiate malignant from
Table 16.7  Complications of neck dissection
General
Specific
Hematoma
Neural injury- CN XI, CN XII, marginal
mandibular branch of CN VII,
lingual nerve, brachial plexus,
phrenic nerve, vagus nerve
Infection
Vascular injury: carotid artery, internal
jugular vein
Wound dehiscence
Chyle leak
Seroma
Air embolism
Atelectasis, PE, UTI, DVT
Epidemiology
The incidence of salivary gland tumors in the US is in the
range of 1–3 per 100 000 population.55 The distribution of
frequency and malignancy amongst the salivary glands is of
particular note (Table 16.8). In terms of frequency, the propor­
tion of tumors found in the parotid gland compared to the
submandibular gland and sublingual gland is 100 : 10 : 1.56
Interestingly, however, 80% of parotid tumors are benign, in
contrast to 60% of submandibular, 40% of sublingual gland,
and 20% of minor salivary gland tumors, making the risk of
malignancy inversely proportional to the size of the gland
(Table 16.8).
Work-up of a salivary gland neoplasm
The first consideration in assessment of an enlarged salivary
gland is to differentiate neoplastic and non-neoplastic causes.
Sialadenosis, sialadenitis (viral, bacterial), and sialolithiasis
along with autoimmune conditions (Sjögren’s syndrome,
sarcoidosis) are all non-neoplastic causes that need to be
excluded. Once a neoplastic cause is considered most likely,
the history is important in aiding differentiation of benign
from malignant tumors. Features such as pain, rapid growth,
and cranial nerve neuropathies are all warning signs for
malignancy. On examination, the presence of fixation to skin
or the deeper structures such as muscle and bone, as well as
cervical lymphadenopathy, should also alert the clinician to
the potential for malignancy.
While ultrasound is a rapid, non-invasive, and relatively
cheap test, cross-sectional imaging is preferred for preopera­
tive planning. The size and location of the mass as well as its
relationship to surrounding structures, in particular any
Table 16.8  Tumors of the salivary glands
Gland
Benign (%)
Malignant (%)
Parotid
80
20
Submandibular
60
40
Sublingual
40
60
Minor salivary glands
20
80
Note the inverse relationship between size of salivary gland and risk of
malignancy
Fig. 16.25  Extension of a deep lobe parotid tumor to the parapharyngeal space.

420
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CHAPTER 16 • Overview of head and neck tumors
benign tumors.59 A study by the same authors examining
ultrasound-guided core biopsy found the sensitivity to be 92%
and specificity 100% when analyzing the data from 277 cases
reported in five studies.60 Interestingly, a two-step procedure
of FNA followed by core biopsy, if the FNA was non-diagnostic,
yielded a sensitivity of 99% and a specificity of 96%. Thus, in
a clinical sense, the addition of core biopsy to FNA can reduce
the false negative rate from 21% to just 1%.
In the event of a malignant diagnosis, the combination of
clinical examination and radiologic imaging enables accurate
staging using current AJCC TNM staging for major salivary
gland cancer (Table 16.9), which assists in guiding treatment
decisions. Minor salivary gland cancers are staged according
to their anatomic site of origin.
Pathology of salivary gland neoplasms
Salivary gland neoplasms are a particularly diverse group of
tumors. Their clinical behavior reflects this diversity and is
often driven by histologic grade. Thus, a detailed understand­
ing of salivary gland pathology is essential in order to guide
appropriate treatment for patients (Box 16.3).
Pleomorphic adenoma is the most common benign salivary
gland neoplasm, and it demonstrates some unique clinical
and pathological features (Fig. 16.26). Despite being an encap­
sulated tumor, it does often contain pseudopodia that project
from its surface.61 It is thought that these can contribute to
post-surgical recurrence and hence why parotidectomy in
Table 16.9  AJCC TNM staging for major salivary gland cancer
Note N stage and M stage are as for the upper aerodigestive
mucosal sites
T stage
Salivary gland
Tx
Primary tumor cannot be assessed
T0
No evidence of primary tumor
Tis
Carcinoma in situ
T1
Tumor 2 cm or less in greatest dimension without
extraparenchymal extension
T2
Tumor larger than 2 cm but 4 cm or less in greatest
dimension without extraparenchymal extension
T3
Tumor larger than 4 cm in greatest dimension and/
or has extraparenchymal extension
T4a
Tumor invades skin, mandible, ear canal, and/or
facial nerve
T4b
Tumor invades pterygoid plates or skull base or
encases internal carotid artery
BOX 16.3  World Health Organization (WHO) classification of parotid neoplasms
Malignant epithelial tumors
Squamous cell carcinoma 8070/3
Verrucous carcinoma 8051/3
Papillary squamous cell carcinoma 8052/3
Basaloid squamous cell carcinoma 8083/3
Spindle cell carcinoma 8074/3
Adenosquamous carcinoma 8560/3
Acantholytic squamous cell carcinoma 8075/3
Lymphoepithelial carcinoma 8082/3
Sinonasal undifferentiated carcinoma 8020/3
Adenocarcinoma
Intestinal-type adenocarcinoma 8144/3
Non-intestinal-type adenocarcinoma 8140/3
Salivary gland-type carcinomas
Adenoid cystic carcinoma 8200/3
Acinic cell carcinoma 8550/3
Mucoepidermoid carcinoma 8430/3
Epithelial-myoepithelial carcinoma 8562/3
Clear cell carcinoma N.O.S. 8310/3
Myoepithelial carcinoma 8982/3
Carcinoma ex pleomorphic adenoma 8941/3
Polymorphous low-grade adenocarcinoma 8525/3
Neuroendocrine tumors
Typical carcinoid 8240/3
Atypical carcinoid 8249/3
Small cell carcinoma, neuroendocrine type 8041/3
Benign epithelial tumors
Sinonasal papillomas
Inverted papilloma
(Schneiderian papilloma, inverted type) 8121/1
Oncocytic papilloma
(Schneiderian papilloma, oncocytic type) 8121/1
Exophytic papilloma
(Schneiderian papilloma, exophytic type) 8121/0
Salivary gland-type adenomas
Pleomorphic adenoma 8940/0
Myoepithelioma 8982/0
Oncocytoma 8290/0
Soft tissue tumors
Malignant tumors
Fibrosarcoma 8810/3
Malignant fibrous histiocytoma 8830/3
some form, rather than enucleation, is recommended for
these lesions.62 This reduces the recurrence rate from 4%
to less than 1% (Fig. 16.27).63 It also has a known risk of
malignant transformation.64,65 One large study highlighted
the importance of disease duration in assessing malignant

421
Salivary gland neoplasms
risk when their review found the risk to be 1.5% at 5 years,
increasing to 10% at 15 years.66 Carcinoma ex pleomorphic
adenoma is an aggressive malignancy that is histologically
high-grade and demonstrates an overtly infiltrative growth
pattern. Avoidance of this entity is a good reason to recom­
mend surgery for pleomorphic adenoma despite its otherwise
benign nature.
Warthin’s tumor is the second most common benign
salivary gland tumor and is found almost exclusively in
the parotid gland. In contrast to pleomorphic adenoma, it
demonstrates no risk of malignant transformation and may
potentially be observed. It is pathologically represented by its
former name – papillary cystadenoma lymphomatosum.
Bilayer epithelium grows in papillary fronds projecting into
cystic spaces, surrounded by lymphoid follicles with germinal
centers. Its unique clinical features include its predilection for
older males, an association with smoking, and its unique
ability to concentrate Technetium-99.67,68 It is bilateral in 10%
of cases and multicentric within the ipsilateral gland in a
further 10%.69
The diagnosis of salivary gland malignancies has evolved
considerably in recent years with the World Health Organiza­
tion (WHO) now recognizing 24 distinct pathological entities
(Box 16.3).70 These tumors demonstrate a broad range of
morphological diversity and, coupled with the relative rarity
of many of these, can make accurate diagnosis difficult.
Pathologists continue to rely on microscopic appearance as
the immunocytochemical profiles are rarely useful in aiding
diagnosis.71,72 Clinically, it is most useful to consider these
malignancies as either low-grade or high-grade.73 High-grade
Leiomyosarcoma 8890/3
Rhabdomyosarcoma 8900/3
Angiosarcoma 9120/3
Malignant peripheral nerve sheath tumor 9540/3
Borderline and low malignant potential tumors
Desmoid-type fibromatosis 8821/1
Inflammatory myofibroblastic tumor 8825/1
Glomangiopericytoma
(Sinonasal-type hemangiopericytoma) 9150/1
Extrapleural solitary fibrous tumor 8815/1
Benign tumors
Myxoma 8840/0
Leiomyoma 8890/0
Hemangioma 9120/0
Schwannoma 9560/0
Neurofibroma 9540/0
Meningioma 9530/0
Tumors of bone and cartilage
Malignant tumors
Chondrosarcoma 9220/3
Mesenchymal chondrosarcoma 9240/3
Osteosarcoma 9180/3
Chordoma 9370/3
Benign tumors
Giant cell lesion
Giant cell tumor 9250/1
Chondroma 9220/0
Osteoma 9180/0
Chondroblastoma 9230/0
Chondromyxoid fibroma 9241/0
Osteochondroma (exostosis) 9210/0
Osteoid osteoma 9191/0
Osteoblastoma 9200/0
Ameloblastoma 9310/0
Nasal chondromesenchymal hamartoma
Hematolymphoid tumors
Extranodal NK/T cell lymphoma 9719/3
Diffuse large B-cell lymphoma 9680/3
Extramedullary plasmacytoma 9734/3
Extramedullary myeloid sarcoma 9930/3
Histiocytic sarcoma 9755/3
Langerhans cell histiocytosis 9751/1
Neuroectodermal
Ewing sarcoma 9260/3
Primitive neuroectodermal tumor 9364/3
Olfactory neuroblastoma 9522/3
Melanotic neuroectodermal tumor of infancy 9363/0
Mucosal malignant melanoma 8720/3
Germ cell tumors
Immature teratoma 9080/3
Teratoma with malignant transformation 9084/3
Sinonasal yolk sac tumor (endodermal sinus tumor) 9071/3
Sinonasal teratocarcinosarcoma
Mature teratoma 9080/0
Dermoid cyst 9084/0
Secondary tumors
1 Morphology code of the International Classification of Diseases for Oncology
(ICD-O) {821} and the Systematized Nomenclature of Medicine (http://
snomed.org).
Behavior is coded /0 for benign tumors, /3 for malignant tumors, and /1 for
borderline or uncertain behavior.
(From Barnes L, World Health Organization, International Agency for Research on
Cancer. Pathology and Genetics of Head and Neck Tumors. Lyon: IARC; 2005:1.)
BOX 16.3  World Health Organization (WHO) classification of parotid neoplasms—cont’d

422
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CHAPTER 16 • Overview of head and neck tumors
survival is 1–10% with many of these late failures being
lung metastases.
Squamous cell carcinoma warrants special discussion in
parotid surgery. While primary SCC of the parotid gland is
rare, metastatic cutaneous SCC is the most common malig­
nant parotid gland tumor, particularly in countries with high
sunlight exposure such as Australia.75 The parotid gland
contains approximately 15–20 lymph nodes within the
parotid gland, mostly within the superficial lobe, and these
are the first echelon nodes for an extensive area of the face
and scalp anterior to a vertical line through the external
auditory meatus.76 These tumors are aggressive, with a pro­
pensity for extracapsular extension, neck nodal metastasis,
and perineural spread of disease.77 Hence, they most often
require multi-modality treatment with surgery targeted to
extent of disease (Fig. 16.30) and adjuvant therapy based on
disease extent and the features of the surgical pathology
report (Fig. 16.31).76,78, 79
Fig. 16.26  Pleomorphic adenoma pathology. Pleomorphic adenoma contains three
components histologically: epithelial, myoepithelial, and stromal components. The
stroma may be myxoid, chondroid, osteoid, fibroid, or vascular.
Fig. 16.27  (A) MRI of recurrent pleomorphic adenoma demonstrating multifocal
disease through the superficial and deep lobes. (B) Extensive multifocal disease.
Recurrent pleomorphic adenoma represents a difficult management problem for the
head and neck surgeon. Pleomorphic adenoma recurrence is often multifocal as
demonstrated in these images. Operation in a previously operated field places the
facial nerve at significant risk during these procedures.
A
B
malignancies include high-grade mucoepidermoid carcinoma,
adenocarcinoma, squamous cell carcinoma, salivary ductal
carcinoma, and carcinoma ex pleomorphic adenoma. Low-
grade malignancies include low-grade mucoepidermoid car­
cinoma, acinic cell carcinoma, basal cell adenocarcinoma, and
low-grade polymorphous adenocarcinoma. Adenoid cystic
carcinoma (ACC) is an intermediate grade malignancy that
can span either end of the histologic grading spectrum. In any
case, however, it is a high-risk tumor in terms of disease
recurrence.73 This differentiation helps to guide treatment (see
below).
Mucoepidermoid carcinoma is the most common salivary
gland malignancy with the majority occurring in the major
salivary glands although oral cavity minor salivary glands
are not infrequently involved.74 Various histologic grading
systems have been developed, but in essence high-grade
lesions are those with increased epidermoid cells, whereas
low-grade lesions tend to have a greater mucinous com­
ponent with less cytologic atypia and a lower mitotic rate
(Fig. 16.28). Grading correlates strongly with clinical behav­
ior of these tumors. ACC is a salivary gland malignancy
that demonstrates unique clinical features. Pathologically,
it demonstrates three distinct growth patterns that may
overlap within the same tumor – tubular, cribriform, and
solid (Fig. 16.29). The solid lesions are more aggressive
with a higher tendency to nodal metastasis, whereas the
cribriform pattern is the most common and most easily
recognized with its “Swiss cheese” appearance histologi­
cally. ACC is a relentless disease with a propensity for peri­
neural spread and late recurrences. While 5-year survival
approaches 80%, 10-year survival is 10–30% and 15-year

423
Salivary gland neoplasms
Decision-making in salivary gland neoplasms
The management of salivary gland neoplasms is predomi­
nantly surgical. The decision to operate rather than observe
most salivary gland neoplasms is based on four consider­
ations. Firstly, the lack of certainty in differentiating benign
from malignant pathology using preoperative FNA behests
the surgeon to seek diagnostic certainty via surgical removal.
Secondly, pleomorphic adenomas have a potential for malig­
nant transformation that has already been discussed. Thirdly,
the surgical procedure may become more difficult as the
tumor increases in size, potentially increasing the risk to the
facial nerve in parotid surgery. Finally, many patients have
cosmetic concern with a salivary gland neoplasm that can
only be reconciled with surgical excision.
Effective management of salivary gland malignancies
requires an understanding of the pathologic considerations
Fig. 16.28  Mucoepidermoid carcinoma. (A) High grade. (B) Low grade
A
B
Fig. 16.29  Adenoid cystic carcinoma. (A) Tubular; (B) cribriform; (C) solid.
A
B
C
discussed above. Application of these principles enables clini­
cians to target appropriate therapy to individual patients
based on tumor histology, grade, and stage. Division to high-
grade and low-grade malignancy enables the surgeon to tailor
their surgical intervention. Parotidectomy alone is adequate
therapy for low-grade malignancies. With a preoperative
diagnosis of a high-grade salivary gland malignancy, consid­
eration should be given to elective neck dissection because of
an increased risk of occult regional metastatic disease.80 Obvi­
ously, the presence of clinical or radiological evidence of
neck nodal disease necessitates therapeutic neck dissection.

424
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CHAPTER 16 • Overview of head and neck tumors
Furthermore, high-grade malignancies, advanced stage
tumors, or those with local invasion as well as low-grade
malignancies with positive surgical margins should be con­
sidered for postoperative radiation therapy.81
Surgical management of salivary
gland neoplasms
Multiple surgical procedures have been described for manag­
ing tumors of the parotid gland. The classical approach to
benign tumors has been a superficial parotidectomy, which
extirpates the entire parotid gland superficial to the plane of
the facial nerve (Fig. 16.32). With improved understanding of
the biology of salivary gland disease, partial parotidectomy is
more commonly performed currently. This involves identifi­
cation of the facial nerve trunk and dissection tailored to
enable removal of the tumor with a cuff of normal tissue. This
often does not equate to a full superficial parotidectomy,
reducing dissection of distal facial nerve branches and mini­
mizing cosmetic deformity. For malignant tumors, a total
Fig. 16.30  Management of the parotid and neck in metastatic
squamous cell carcinoma. (From D’Souza J, Clark J. Management of
the neck in metastatic cutaneous squamous cell carcinoma of the head
and neck. Curr Opin Otolaryngol Head Neck Surg. 2011;19(2):99–105.)
NECK
Posive
Negave
PAROTID
Posive
Parod + CND
PORT: parod + neck
Parod + Staging Neck:
Ant 1°- I-III SND
Post 1°- II-V SND
Unknown 1°- CND
PORT: parod + neck (if SND +ve,
otherwise don’t include neck)
Negave
CND
PORT: parod + neck
No evidence for SND
?? SNB
Watch + wait
Fig. 16.31  Management algorithm for postoperative adjuvant therapy in metastatic SCC to the parotid gland. (Adapted from D’Souza J, Clark J. Management of the neck in
metastatic cutaneous squamous cell carcinoma of the head and neck. Curr Opin Otolaryngol Head Neck Surg. 2011;19(2):99–105).
conservative parotidectomy is recommended in which all
parotid tissue is removed while sparing the facial nerve. The
deep lobe is removed in piecemeal fashion between nerve
branches. Finally, parotid tumors presenting with preopera­
tive facial nerve palsy should undergo radical parotidectomy
in which the entire parotid tissue is removed en bloc with facial
nerve sacrifice. In these cases, preoperative Gadolinium-
enhanced MRI is essential to determine the proximal extent
of facial nerve involvement, which may be within the parotid
gland or may extend through the stylomastoid foramen and
up the fallopian canal of the temporal bone. In the latter case
temporal bone surgery, mostly commonly lateral temporal
bone resection, is indicated.
Management of submandibular gland neoplasms should
take into consideration the greater risk of malignancy. Tumors
either suspected or proven to be malignant should be removed
along with the overlying fascia, as opposed to subfascial dis­
section that characterizes a submandibular gland excision for
inflammatory disease or sialolithiasis. Furthermore, the same
principles that guide elective neck dissection in parotid

425
Conclusions
A
B
Fig. 16.32  Superficial parotidectomy. (A) Identification of the greater auricular nerve and preservation where possible. (B) Raising the parotid fascia off the sternomastoid
muscle. (C) Identification of posterior belly of digastric, a useful landmark for the depth of the facial nerve. (D) Dissecting tumor off the main trunk of the facial nerve.
C
D
surgery hold true for the submandibular gland also. Sublin­
gual and minor salivary gland tumors are removed transorally
as a wide local excision.
Postoperative adjuvant treatment
The addition of radiotherapy in the postoperative period after
resection of salivary gland malignancy is thought to improve
locoregional disease control.81 As already discussed, postop­
erative radiotherapy is indicated in patients with high grade
histologic types, advanced stage disease, positive surgical
margins, or local invasion including perineural spread or
bone involvement. Primary radiotherapy may be considered
for patients not fit for surgery. The role of chemotherapy has
been limited. In contrast to mucosal sites of the head and neck,
platinum-based chemotherapy has not been employed in
combination with radiotherapy. However, a recent trial from
the Trans-Tasman Radiation Oncology group (TROG) has
completed recruitment to compare radiation alone with con­
current chemoradiotherapy for high-risk metastatic cutaneous
SCC (TROG 05.01). The results of this trial have not yet been
analyzed.
There is some enthusiasm for targeted therapies for selected
salivary gland malignancies. Case reports have reported
success in the use of Trastuzumab in the adjuvant setting for
management of salivary ductal carcinoma, a cancer with an
otherwise dismal outcome.82,83 Similarly, targeted therapy for
adenoid cystic carcinoma has also been reported with c-KIT
tyrosine kinase inhibitors.84,85 None of these would be consid­
ered standard practice at this time, however.
Conclusions
Head and neck tumors represent a diverse group of diseases
that require the treating physician to have an in depth under­
standing of in order to provide evidence-based care plans. The
treatment of these cancers has evolved significantly in recent
years with technological advances and large-scale clinical
trials. Ablative treatment of head and neck cancer has signifi­
cant functional and cosmetic consequences for the patient and
the post-treatment defects represent some of the most
challenging scenarios that the reconstructive surgeon will
encounter.

426
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CHAPTER 16 • Overview of head and neck tumors
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SECTION II • Head and Neck Reconstruction
17 
Local flaps for facial coverage
David W. Mathes
SYNOPSIS
■ After careful and complete evaluation of the defect, the surgeon
should formulate a reconstructive plan that is tailored to the patient’s
needs
■ Always assess the availability and laxity of local tissue
■ Keep the reconstruction as simple as possible
■ Always consider the next flap that might need to be performed (do not
burn bridges)
■ Local tissue is far superior to free flap reconstruction of the face as it
provides like tissue and should be the first thought when
reconstructing facial defects
■ Choose a flap that will both restore function and achieve a good
cosmetic result
Introduction
The face is the most common location for neoplasms of skin,
and the incidence of these tumors is increasing due the aging
of our population and increasing exposure to ultraviolet light.
These patients often present to the plastic surgeon for recon­
struction more than once for treatment. The face is a very
cosmetically sensitive location on the body, and the recon­
struction can be challenging for the surgeon as we seek to
preserve form and function. The reconstruction must begin
with careful evaluation of the defect. The surgeon must con­
sider the location, regional skin laxity, size, shape, and depth
of the defect.
The principles of reconstruction are the same as in other
areas of the body. After careful and complete evaluation of the
defect, the surgeon should formulate a reconstructive plan
that is tailored to the patient’s needs. This planning should, if
possible, include several reconstructive options. A simple
reconstructive plan can often yield superior results to the
more complex options. The viable options for coverage are
dictated primarily by the vascular supply in the area. The
excision of a malignant lesion must be based on current
guidelines and should not be designed to fit in with the chosen
method of reconstruction. In situations where there is concern
as to the pathology, a temporary dressing is applied until a
definitive diagnosis becomes available. The best reconstruc­
tive plans include consideration of secondary procedures and
the future needs of the patient.
The design of flaps on the face is based on the fundamental
concepts in plastic surgery of advancement, transposition,
and rotation. However, the reconstructive design should not
be limited by these basic concepts. Often it is necessary to
modify the flap into an island flap. When this technique is
combined with appropriate pedicle dissection, it yields a
mobile flap that is relatively free of tension and reduces the
incidence of congestion of the flap. In those cases where the
defect is beyond your reconstructive abilities, the use of a full-
thickness skin graft is acceptable provided the skin color and
texture match. Once healing is complete, a more satisfactory
resection and a well-designed local flap reconstruction can
be performed. The other technique that can be employed at
the time of skin graft placement is the use of tissue expan­
sion. This technique can provide the ideal skin cover and
allow for the transfer of like tissue to close large defects.
Alternatively, the surgeon can take advantage of the fact that
the skin will undergo stress relaxation (skin elongates over
time) when a closure is tight or a flap appears smaller than
the defect. There is a limit to the utilization of stress relax­
ation in facial reconstruction dictated by the tissue’s blood
supply.
The success of flap reconstruction of the face is dependent
on making the correct defect analysis. Understanding what
is missing allows for the surgeon to design a reconstruction
that addresses all of the layers. After selection of the flap,
the next step is to tailor the design to hide the incisions
in the borders of well-known aesthetic units. Local tissue
is far superior to free flap reconstruction of the face as it
provides like tissue and should be the first thought when
reconstructing facial defects. Only when the defect is too large
or complex should the surgeon turn to more distant flap for
reconstruction.
Access video and video lecture content for this chapter online at expertconsult.com

428
SECTION II
CHAPTER 17 • Local flaps for facial coverage
Forehead and scalp
The scalp often requires flap closure, except for very small
lesions, due to its relative inelasticity. Most often, single or
paired large rotation flaps are reliable local workhorses.
Numerous variations exist, such as Juri flaps and Orticochea
flaps, but the principles of scalp rotation flaps are the same.
These flaps are best elevated in the subgaleal plane to preserve
vascularity.1–3 Care must be taken if subcutaneous undermin­
ing is performed to avoid damaging the blood supply and
causing alopecia by traumatizing hair follicles. The impor­
tance of designing large (often in a 9 : 1 ratio) flaps cannot be
overemphasized. Unlike other body areas, the scalp is inelas­
tic. For this reason, small flaps have limited success for any­
thing other than a small defect. Galeal scoring expands scalp
flaps, but should be performed in no smaller than 1-cm inter­
vals, to avoid disrupting the blood supply.
The forehead generally offers a limited amount of spare
skin. In addition, asymmetrical movement on one side of the
forehead can raise the position of the patient’s brow, giving
them a quizzical appearance. In reconstructing the central
forehead, the options are limited. The best local flaps move
skin on the horizontal access and thereby avoid raising the
brow.
Bilateral horizontal advancement flaps can be designed to
take advantage of the naturally occurring rhytids (Fig. 17.1).
The flaps should be designed equal to size of the defect. Small
Burrow’s triangles can be added to allow reduce the occur­
rence of dog-ears.
Hatchet flap reconstruction can also be designed for recon­
struction of the forehead. It generally requires the use of two
flaps.4 One flap should be based superiorly and one inferiorly
(Fig. 17.2). These flaps are then elevated and transposed into
the defect, again, avoiding the superior elevation of the brow.
The use of patterned flaps should be avoided in the fore­
head; one exception is the use of a rhomboid flap to reconstruct
defects in the temple (Fig. 17.3). Provided that the flap does
not shift the hairline significantly, this can provide an excel­
lent result with the scars hidden in the rhytids of the temporal
area.
The optimal treatment of large forehead defects is through
the application of tissue expansion (Fig. 17.4). Once the fore­
head skin is expanded the reconstruction can be achieved
with the use of a simple advancement of the skin. The critical
part of this surgery is the planning of the type of tissue
expander used and the need for overexpansion to ensure
tension-free closure.
Eyebrow reconstruction
The eyebrow is complex and reconstruction is difficult; this is
because hair grows in a fixed pattern that is not uniform and
is difficult to reproduce exactly. A scalp island flap based on
the temporal blood supply can be used, but the hair must be
trimmed. The hair is often too dense and does not grow in the
correct manner. An alternative technique is micro-hair trans­
plants with frequent trimming. These, unfortunately, rarely
produce the unique anatomy and the density of the eyebrow
hair. Eyebrow flaps must be designed with care to maintain
the correct anatomic relationship. Unfortunately, there may be
a shortage of material available, and it may not be possible to
A
B
Fig. 17.1  (A–C) Bilateral horizontal advancement flaps can be designed to take
advantage of the naturally occurring rhytids.
C

429
Eyelids
A
B
C
Fig. 17.2  Nevus of left supraorbital area involving eyebrow – hatchet flap
reconstruction. (A) The planned excision has been drawn out together with bilateral
hatchet flaps. (B) Nevus has been excised. It can be seen that the flap pedicles are
superior for the lateral flap and inferior for the medial flap. (C) The flaps are elevated.
(D) The flaps are transposed, and the secondary defect is closed. (E) Satisfactory
end result with the eyebrow in a good position.
D
E
have the eyebrow in the exact desired anatomical position
or size.
Eyelids
Partial upper lid defects
The reconstruction of the upper lid is critical as it is vital for
the protection of the eye. Failure to adequately reconstruct the
upper lid, especially in the vertical component, may cause
conjunctivitis and/or impaired vision. Without an adequate
upper lid, the eye will be at risk for exposure, scarring, and
loss of vision. Often, some of the same techniques used in
reconstruction of the lower eyelid are used in upper eyelid
surgery.
An advancement flap can be designed with an incision
made horizontally from the lateral canthus (Fig. 17.5). This is
followed by the division of the superior limb of the lateral
canthal ligament and an incision in the conjunctiva of the
superior fornix. The addition of a Z-plasty can be performed

430
SECTION II
CHAPTER 17 • Local flaps for facial coverage
anesthetized with drops or, rarely, general anesthesia. In
adults, infraorbital nerve blocks can be used
Large and total upper lid defects
For larger defects, the lower lid is used and the significant
lower lid defect is reconstructed. A large full-thickness portion
of lower lid is moved up on its marginal vascular pedicle. A
partial lower lid reconstruction is necessary. As the portion of
lower lid is turned up, the full-thickness of the cheek is
advanced medially and grafted with nasal septum on its inner
surface, as required (Fig. 17.7).
To reconstruct the upper lid, the whole lower lid can
be turned up. The lower lid reconstruction is based on an
advancement cheek flap lined with nasal septum, cartilage,
and mucosa as above. These pedicled lid reconstructions are
left attached for 2–3 weeks, depending on the vascularity of the
upturned flaps. Once the upper lid reconstruction is in posi­
tion, small adjustments are often necessary. Rearrangements
to deal with the dog-ear. Best results depend on accurate
suturing and repositioning of the gray line, the lash line, and
the rim conjunctival junction.
Defect of the upper lid can also be addressed by using a
lid-switch flap (Abbé flap) (Fig. 17.6). In much the same way
one would use an Abbé flap to reconstruct the lip, this can be
applied to the upper eyelid with the flap based on the mar­
ginal vessels in the lid, and a full-thickness V flap (the defect
of which should close easily) can be taken from the lower lid,
swung up, and sutured into the upper lid in layers.
The lower lid defect closure requires the edges to come
together directly without tension. If this does not occur, a
small lateral canthal incision is made, and the inferior limb of
the lateral canthal tendon is divided. If this is not sufficient, a
long transverse incision from the canthus out to the temporal
skin (incorporating a Z-plasty if necessary) will suffice to
obtain tensionless closure. It is important that a preoperative
examination of the mobility of the lower lid is carefully
assessed. If necessary (e.g., in children), the conjunctiva is
Fig. 17.3  Rhomboid flap. (A) Melanoma in situ right
temple. (B,C) Lesion excised. Limberg flap designed
for repair of 2 × 2 cm defect. (D,E) Dufourmentel flap
designed and transferred to defect. (Reproduced from
Baker SR. Local Flaps in Facial Reconstruction, 2nd
ed. St. Louis: Mosby, 2007.)
A
B
C
D
E

431
Eyelids
a mucosal graft is inserted. When this reconstruction is com­
plete, it is brought down on a vascular pedicle to replace the
lid. The pedicle is divided at 3 weeks. This protects the eye,
but movement is minimal, unless there is some remaining
orbicularis which can be used immediately or at a later date
(Fig. 17.8).
are usually required for the lateral canthus and occasionally
to the edge of the lower lid or to provide adjustment of lower
lid height. With meticulous technique, a good cosmetic and
functional result can be obtained.
When a healthy eye is present, a lid can be prefabricated
on the forehead. A pocket the size of the lid is designed and
Fig. 17.4  Tissue expansion to achieve left defect closure. (A,B) Skin graft covering temple, anterior parietal scalp, and lateral cheek. (C) Expanded forehead skin.
(D) Following tissue expansion, expanded forehead skin used to cover defect created by partial resection of skin graft. (E) Expansion provided sufficient skin to cover
temple. (F) Tissue expander beneath lateral cheek skin. (G) Six days following removal of skin graft from cheek and reconstruction with expanded cheek advancement flap.
(H) Six months postoperative. (Reproduced from Baker SR. Local Flaps in Facial Reconstruction 2nd ed. St. Louis: Mosby, 2007.)
A
B
C
D
E
F
G
H

432
SECTION II
CHAPTER 17 • Local flaps for facial coverage
for cosmesis. The lower lid can be reconstructed with a cheek
rotation flap which is lined with oral mucosa or more satis­
factorily using nasal septal cartilage with its perichondrium
intact as shown in Fig. 17.7. In other instances, a forehead
flap may be necessary. This has the disadvantage of bulk,
which can result in poor aesthetics. With time, however, the
latter can be improved upon by debulking. With experience,
there is no longer so much concern about ischemia resulting
in skin or lid loss.
Lid-switch flap (Abbé flap)
By using the same principles as the Abbé flap on the lip, a
similar reconstruction can be used for defects of the upper
lid (Fig. 17.7A–D) There are marginal vessels in the lid, and a
full-thickness V flap (the defect of which should close easily)
can be taken from the lower lid, swung up, and sutured into
the upper lid in layers. The lower lid defect closure requires
the edges to come together directly without tension. If this
does not occur, a small lateral canthal incision is made, and
the inferior limb of the lateral canthal tendon is divided.
If this is not sufficient, a long transverse incision from the
canthus out to the temporal skin (incorporating a Z-plasty
if necessary) will suffice to obtain tensionless closure. It is
important that a preoperative examination of the mobility
of the lower lid is carefully assessed. If necessary (e.g., in
children), the conjunctiva is anesthetized with drops or, rarely,
general anesthesia. In adults, infraorbital nerve blocks can
be used.
Partial lower lid defects
Lesions are frequently resected in a V fashion and the result­
ing defect can be carefully closed in layers. If this is not pos­
sible, the lower portion of the lateral canthal ligament is
divided through a small lateral canthal incision. This allows
the lid to move medially, and closure can be obtained without
tension. If there is too much tension, the incision and dissec­
tion are taken further laterally on the cheek. Closure is then
obtained without difficulty. The lateral incision is closed with
a Z-plasty in order to reduce any skin tension.
An extensive defect requires that a portion of nasal septum,
with mucosa attached on one side, be inserted with the
mucosa toward the globe in order to form an internal lamella.
A portion of ear cartilage, with perichondrium in place of the
mucosa, can also be used for support. Mucosalization of the
inner surface occurs fairly rapidly. A cheek rotation flap of
the required size then provides external cover. If the cheek
skin is insufficient, prior expansion of the lateral cheek skin
should be performed, or a narrow midline forehead flap can
be used. The latter has the advantage of being a little more
rigid. This, however, requires accurate sizing in all dimen­
sions; also there will be a forehead scar.
Total lower lid defects
These result from tumor resection, from trauma, or when
the lower lid is used to reconstruct the upper lid (Fig. 17.7).
Reconstruction of the total lower lid is primarily performed
Fig. 17.5  Coloboma of the upper eyelid – Abbé flap. (A–C) The defect can be seen, and the planned Abbé flap from the lower to the upper eyelid is outlined and shown in
diagrammatic form. (D) The flap is in position. (E) The patient can close his eyelid satisfactorily.
A
B
C
D
E

433
Nasal reconstruction
A
B
Fig. 17.6  Reconstruction of partial upper eyelid defect with advancement flap. (A) Basal cell carcinoma involving medial end of upper eyelid. (B) Operative plan of
excision and rotation and advancement of the upper lid. (C) Excision of upper lid basal cell carcinoma. Note spoon to protect eye and the use of sharp pointed scissors to
resect the lid. (D) Defect after excision of medial portion of the upper eyelid. (E) Lateral canthotomy performed superiorly. The lid is advanced with lateral Z-plasty in the
temporal region. (F) End result.
C
D
E
F
Medial canthal defects
Generally, forehead flaps provide a reliable and reasonably
good method of reconstruction. These flaps must be lined
with mucosa; however, additional support is not required
because of the inherent flap rigidity. It is very important to
place a flap of sufficient size into the medial canthal area.
Failure to do this results in troublesome epiphora.
Nasal reconstruction
The nose is a complex structure comprised of three critical
layers (skin, bone, and cartilage) and lined by mucoperichon­
drium. The outer layer of skin has different properties
depending on location. The skin of the dorsum and the side­
walls are thin and smooth while the skin of the tip and ala is

434
SECTION II
CHAPTER 17 • Local flaps for facial coverage
A
B
C
D
E
F
Fig. 17.7  (A–D) Reconstruction of total upper eyelid defect with lower lid transposition. (E) Preoperative markings indicate the upper eyelid area to be resected. (F) The
total upper eyelid is resected; the lower eyelid will be rotated up to reconstruct the upper eyelid with use of a medial pedicle.
thick and stiff and contains sebaceous glands. The nasal bones
and cartilage provide the structural integrity and projection
of the nose. Finally, the lining of the nose consists of special­
ized tissue that is thin and well vascularized with dry, hair-
bearing skin at the vestibule and moist mucosa in the nasal
vault. The surgeon must identify and define the defect in
terms of size, depth, orientation, and location on the nose. The
reconstruction is based on the analysis of what is missing and
the plan to provide suitable replacement of these tissues to
restore the nose to its premorbid condition.
The outer skin of the nose has been divided into aesthetic
subunits based on adjacent areas of characteristic skin quality,
contour, and border outline. These subunits are the dorsum,
tip, columella, and paired sidewalls, alae, and soft triangles.5

435
Nasal reconstruction
G
H
I
(G) The medial pedicle is divided, and the medial end of the
lower lid is inset into the defect of the medial side of the upper lid. (H) A nasal
septal chondromucosal graft is placed in position, and the cartilage is scored to
make it bend as favorably as possible. A lateral cheek rotation flap is performed.
Note the lateral Z-plasty to give as much medial movement as possible. This will
give a good end result. (I) A nasal septal chondromucosal graft is placed in
position, and the cartilage is scored to make it bend as favorably as possible.
Fig. 17.7, cont’d
According to the subunit principle, if greater than 50% of a
subunit is involved, excision of the entire subunit before
reconstruction is recommended. However, this is not univer­
sally applicable, as enlarging small defects may result in
increased use of the forehead flap for defects where smaller
local flaps may suffice. The subunit principle is a tool, not a
rigid rule, and should be modified to fit the individual needs
of the patient.6,7
Flap section in nasal reconstruction is based on defect loca­
tion and orientation (Table 17.1), with the nose divided
transversely into three zones (proximal third, middle third,
and distal third). Many of these reconstructions can be per­
formed under local anesthesia in an outpatient setting.
However, once defects exceed the 2 cm in size, it can become
difficult to rotate local tissue.
Proximal third
Defects most often encountered in the proximal third of the
nose can be centrally located on the dorsum or radix area
or laterally on the upper sidewalls. These defects often
have exposed periosteum or bone but rarely require bone
reconstruction.
Defects in the upper third are often reconstructed with a
glabella flap (Fig. 17.9) transposed from the midforehead or
glabella region.8 If the lesion is centrally located, it can often
be reconstructed with a dorsal nasal advancement flap (Fig.
17.9). Lateral defects that are horizontally orientated can be
reconstructed with the glabellar flap, whereas those defects
that are vertically orientated can be treated with a V–Y flap
from the dorsum of the nose (Fig. 17.10). Larger combined
defects are best treated with a forehead flap but can be ame­
nable to an extended glabella flap or modified glabella-bilobed
flap (Fig. 17.11).9
Medial third
The middle third of the nose is divided into central and lateral
zones, and includes the nasal bones and upper lateral carti­
lages. The medial third is an excellent place to apply the
dorsal nasal flap. The lateral defects encountered in the medial
third can be closed with a V–Y flap, nasolabial flap, bilobed
flap, or a dorsal nasal flap. A very useful flap is a V–Y flap
based on perforators from the facial artery (Fig. 17.12).10,11
Larger defects will most often require a forehead flap.
Distal third
The distal third zone of the nose is the most common location
for nasal defects after cancer excision. Alar defects can be
reconstructed with a staged nasolabial flap (Fig. 17.13).
However, for alar defects sparing the rim, a V–Y advancement
flap may used.12 Any remaining alar rim will need a cartilage
graft for support to prevent collapse of the rim. Small alar rim

436
SECTION II
CHAPTER 17 • Local flaps for facial coverage
A
B
C
D
E
F
Fig. 17.8  Total reconstruction of upper eyelid by
a prefabricated composite forehead flap. (A) The
preoperative appearance with no upper eyelid
whatsoever. The lower eyelid is intact. (B) An
upper eyelid is delayed vertically on the forehead
with a bucket being designed under the forehead
skin and subcutaneous tissue. (C) A mucosal
graft is harvested, and holes are made in it to
stretch it. (D) The mucosal graft is placed,
mucosal side down, into the pocket in the center
of the forehead with a small pack. Sutures are
holding the mucosa in position. (E) Upper eyelid
is released as much as possible. (F) Upper
eyelid reconstruction being brought down to
reconstruct the upper lid. Note the mucosa on the
undersurface of the flap.

437
Nasal reconstruction
G
H
(G) The lid is inset. (H) The lid reconstruction is complete and ready for levator muscle
repositioning.
Fig. 17.8, cont’d
Table 17.1  Flap selection for nasal reconstruction with local and
regional flaps based on location
Proximal third of the nose
Central
Horizontal defect: dorsal nasal flap
Round defect: glabella flap
Vertical defect: V-Y flap
Lateral
Horizontal defect: glabella flap, first choice; dorsal
nasal flap, second choice
Vertical defect: V-Y flap
Combined defect: gorehead flap
Middle third of the nose
Central
Horizontal and round defect: dorsal nasal flap
Vertical defect: V-Y flap
Lateral
Horizontal defect: dorsal nasal flap
Vertical defect: V-Y flap, first choice; nasolabial
flap second choice
Combined defect: forehead flap
Distal third of the nose
Alar defect: nasolabial flap, first choice; V-Y flap,
second choice
Domal-alar groove defect — nasolabial flap, first
choice; V-Y flap, second choice
Dome defect: bilobed flap
Central tip defect — bilobed flap
Columella defect: composite graft, skin graft,
ascending helical free flap
Nasal sill defect: nasolabial flap
Combined defect forehead flap, first choice;
nasolabial or extended V-Y flap, second choice
defects (up to 8 mm) can be reconstructed with a composite
graft of skin and cartilage from the root of the ear helix. If the
defect is full-thickness, then lining can be provided by turn­
over flaps or skin graft, cartilage from the nasal septum or ear
concha (placed along the alar edge), and skin from nasolabial
flap or forehead flap.
Defects located in the domal-alar groove can be recon­
structed with a nasolabial flap but, more recently, these defects
are often reconstructed with the V–Y flap advanced laterally
to cover the defect in a single stage. Those defects confined to
the dome of the nose are usually best reconstructed with a
forehead flap. Alternative options include the use of the dorsal
nasal flap or the use of a bilobed flap.13,14 Cartilage tip grafts
may need to be placed if there is deficient or weakened carti­
lage. Lining can be reconstructed with a mucoperichondrial
flap or full-thickness skin graft (FTSG).
If the defect involves only the columella and is small then
a composite graft from the antihelix of the ear can be used. If
no cartilage is deficient and there is intact periosteum, an
FTSG may be placed. If the columella defect is large or encom­
passes the entire columella, a multi-staged nasolabial flap
may be required.15 When a more complex reconstruction is
required (e.g., bilateral alar rims and columella), the total
central forehead flap should be used (Fig. 17.14). The best
approach to the more complex lower third defect is to use the
three-stage technique described by Menick (Fig. 17.15).16
The key to complete survival of the flap is the position of
its base; this should be at the medial canthal level or below.
In this way, the vascular anastomosis on the side of the nose
between the cheek and forehead vessels can provide a satis­
factory flap to close the defect. With the base correctly posi­
tioned, the midline flap will comfortably reconstruct the nasal
tip and the columella without tension. The forehead is closed

438
SECTION II
CHAPTER 17 • Local flaps for facial coverage
Fig. 17.10  (A–D) This defect is closed with a V-Y flap based on the underlying Nasalis.
A
B
C
D
Fig. 17.9  (A–D) Forehead flap for Medial canthus.
A
B
C
D
directly, but if there is tension in the area just anterior to the
hairline, it should be left to close spontaneously. The scar
resulting from this rarely, if ever, requires any reconstruction
The pedicle is divided at 3 weeks, depending on the inset, and
the nasal tip is fashioned. Apart from thinning, it is unusual
to require further adjustments. If there is any concern about
vascularity, the flap base is delayed.
If a total nasal reconstruction is required, a larger amount
of forehead skin is harvested in the transverse dimension, but
again, the base should be positioned at or below the medial

439
Cheek
Fig. 17.11  (A–H) This lesion on the nasal dorsum is reconstructed with a forehead flap.
A
B
C
D
E
F
G
H
canthal ligament. The septal mucosa is used for lining. For
closure of the midline forehead defect, the skin can frequently
be mobilized extensively and advanced. If there is concern,
a tissue expander can be inserted to expand the whole
forehead.
This gives a large amount of skin with a good blood supply.
If nasal support is needed, a cranial bone graft from the outer
table of the skull is taken from an area where the curvature is
similar to that required for the defect reconstruction, and the
shape can be chosen to some extent. This may be done at the
same time as secure screw stabilization of the bone graft in
the forehead/nose junction. It may be safer to delay grafting
to the time of flap division or to a third procedure. Noses
may be prefabricated elsewhere (e.g., on the forearm using
a radial flap) and subsequently transferred by microvascular
techniques.
Cheek
The cheek is the largest aesthetic subunit of the face. The
cheek is broad and has a smooth convex contour that makes
A
Fig. 17.12  (A,B) V–Y flap
from the dorsum of the nose.
B

440
SECTION II
CHAPTER 17 • Local flaps for facial coverage
Fig. 17.13  (A–D) Dorsal nasal flap. This is a V-Y flap based on
perforators from the facial artery system.
A
B
C
D
A
Fig. 17.14  (A,B) Modified
glabellar-bilobed flap.
B

441
Nasal reconstruction
A
B
C
D
Fig. 17.15  (A–E) Three stage technique described by Menick.
E

442
SECTION II
CHAPTER 17 • Local flaps for facial coverage
A
B
Fig. 17.16  (A–D) Cheek rotation flap.
C
D
it difficult to hide incisions in this region. For this reason, it is
important to limit the use of geometric flaps such as bilobed
or rhomboid flaps on the cheek. However, when reconstruct­
ing the cheek, the surgeon must consider the effect on the
adjacent structures such as the lower eyelid, nasal ala, and the
lip. The boundaries of the cheek include the infraorbital rim
and zygomatic arch, superiorly, the nasofacial junction, naso­
labial fold, and labiomandibular crease, medially, the border
of the mandible, inferiorly, and the preauricular crease, later­
ally. Whenever possible, the incisions of the flap used should
be placed in these boundaries to minimize the visibility of the
scars.17 There are four main subdivisions of the lateral cheek.
These include the medial, zygomatic, buccal, and lateral units.
Each of these areas has unique characteristics that the surgeon
must account for while planning the reconstruction. The
whole range of flaps can be used (Table 17.2) – rotation,
advancement, transposition, and island type – with many
variations required and usually available for each type of
reconstruction.18
Rotation and advancement flaps
for cheek closure
The cheek area is large and, therefore, rotation flaps can be
designed to close the skin defect (Fig. 17.16). The design of
rotation can be calculated by placing one end of a thread on
the angle apex and the other at the edge of the defect. By
rotating the outer end of the flap on the skin, the required
circumference can be marked. Often, flap closure of the cheek
is best achieved with a combination of rotation and advance­
ment. This is especially true in the medial cheek subunit. The
incisions for these flaps should be placed in the borders of the
aesthetic subunits (Video 17.2
).
The defects that are encountered in the medial subunit can
be closed with a large anteriorly based cheek flap. The inci­
sions of this flap extend laterally along the zygomatic arch,
up into the temple and then inferiorly in the preauricular skin
fold and can be extended into the neck when more skin is
needed. The soft tissues are raised in the subcutaneous plane
and rotated anteriorly to close the defect.
Another option for a large defect in the medial subunit
includes a posteriorly based check flap. The incision is carried
along the nasolabial fold and then down into the cervical
skin (if necessary). The skin is then rotated superiorly to fill
the defect and the standing cone deformity is created over
the zygomatic arch is excised (Fig. 17.17). If the defect is
located laterally then a flap can be designed that recruits
skin from anterior and inferior to the defect. The tissue is
rotated superiorly and an anterior standing cone deformity is
then excised.

443
Lips
These flaps should be suspended to the underlying perios­
teum with suture support of 4-0 or 3-0 polyglycolic suture at
multiple sites along the flap. This is especially true in those
medial defects and this technique will minimize the chance of
ectropion of the lower lid or distortion of the nose or lip.
V–Y island advancement flap
The V–Y island advancement flap can be used in cheek recon­
struction.19 The best places to design this flap are the nasolabial
and perialar area. The V–Y flap can be modified with a curvi­
linear incision and this provides some element of rotation
when the flap is advanced into place (Fig. 17.18). The donor
site is then closed, primarily creating base of the Y. The V–Y
island advancement flap requires preservation of at least one
third of the subcutaneous tissue beneath the skin. However,
depending on the vascular anatomy, this can also be harvested
as a perforator flap. The closure of the Y limb pushes the flap
into the defect. There is a higher incidence of pin cushioning
of the flap in the early postoperative period that resolves over
time.
Transposition
A transposition flap is elevated from a nearby area with excess
laxity and moved to close a defect while the base of the flap
remains intact. These flaps may be used for defects in the
buccal and lateral subunits; however, the patterns of these
flaps can create challenges during reconstruction of cheek
defects. These flaps are based on geometric patterns such as
the rhomboid flap. The lesion is resected in a rhomboid design
and then the location of the excess skin is determined with a
pinch test. The flap can then be taken from the area with the
most available skin. The flap is rhomboid and should fit
perfectly into the defect. As the flap is fitted into the defect,
the donor site becomes significantly reduced. Because the
design has corners, pin cushioning rarely, if ever, occurs. The
donor site can be closed directly. Any excess skin is resected.
These flaps maybe used for small- to medium-sized defects in
the mid portion of the cheek although in the authors’ practice,
rhombic flaps are used primarily in the temple area. Bilobed
flaps may be used to close small preauricular defects and
small- to medium-sized defects located in the central cheek.
A large bilobed cheek flap can be created, recruiting tissue
from the preauricular area for the first flap and the postauricu­
lar skin for the second flap.20 The cervical skin is then advanced
for closure of the second flap donor site.
Large cheek defects
When large areas of the cheek require resection, it is possible
to elevate the inferior skin of the cheek and neck. This large
amount of skin can be moved upward and medially, a com­
bination of advancement and rotation. Such a flap will allow
significant defects to be closed with the correct skin match
and, more importantly, it is tension-free. The scar can be
hidden in the pre-auricular and pre-hairline area. The results
from this technique can be excellent. It may be necessary to
remove a lateral triangle of excess skin that results from the
rotation. Care must also be taken when reconstructing defects
in the male face. If possible, hair-bearing skin should not be
placed in the non-hair-bearing areas of the face.
Lips
The upper and lower lips are each made up of a red portion
and a white portion with the vermilion border serving as the
demarcation between the two. The upper lip consists of a
medial and two lateral subunits, demarcated by the philtral
ridges and the nasolabial folds. The philtral ridges are the
elevated ridges of white lip extending vertically from the
highest point of the vermilion on either side to the base of
the columella. The common lip reconstruction paradigm is
based on the amount of horizontal lip involved in the defect.
The upper lip and lower lip must be considered individually
because the methods used for reconstruction are not always
applicable to both locations.
Upper lip
The Cupid’s bow, the central mucosal excess, the position of
the base of the nose, and the oral commissure are the areas to
be considered in upper lip reconstruction. Any method that
compromises the symmetry of these areas is not satisfactory.
Unfortunately, when the defect is large, an optimal result may
not be obtainable.
Direct closure
Direct closure is used whenever possible, but care should be
taken to realign the mucocutaneous margin and the white
roll. In some instances, to prevent a notch on the free margin,
a mucosal Z-plasty may be employed. This must be done
with care. Dry (external) mucosa should be extraoral, and
Table 17.2  Flap considerations based on size and location
of cheek defect
Location
Size of defect
Reconstructive choice
Lateral
Small
Primary closure
Medium
Cheek advancement
Large
Cervicofacial rotation flap
Zygomatic
Small
Primary closure
Medium
Transposition flap
Large
Cervicofacial rotation flap/large
bilobed flap
Medial
Small
Primary Closure/V–Y island
advancement flap
Medium
V–Y island advancement flap/
cheek advancement flap
Large
Cervicofacial rotation flap
(anterior/posterior based)
Buccal
Small
Primary closure
Medium
Primary closure/transposition flap
Large
Cervicofacial rotation flap/large
bi-lobe flap

444
SECTION II
CHAPTER 17 • Local flaps for facial coverage
wet (internal) mucosa should be intraoral. If wet mucosa is
exposed, it will be obvious because it is red and shiny and
tends to crust when dry. The Cupid’s bow is an important
aesthetic area and should always be managed with great
care. Its symmetry should not be compromised unless this
is unavoidable. In full-thickness defects, accurate muscle
reconstruction is critical to ensure symmetrical upper
lip function.
Lateral and central defects can be closed directly, but judg­
ment must be used. Any degree of asymmetry should be
minimal. The muscle must be dissected out from the mucosa
and the skin and reconstructed with accuracy. Magnification
helps greatly and should always be used. In lip repair, there
should be equal emphasis on aesthetics and function.
Larger defects
In the lateral and central areas of the upper lip, the perialar
crescentic flap can be used. To allow the lip to advance without
tension, a crescent of skin and deep subcutaneous tissue is
removed from around the lateral area of the alar base by
careful layered closure. It is important to construct the lower
part of the crescent end at the alar base. This maintains the
correct vertical height of the lip. In addition, the mucosa is
incised transversely in the upper buccal sulcus. A fringe of
mucosa should be left on the alveolus for accurate closure.
This allows the whole lip segment to move medially, and large
closure can be performed without tension. When there are
large midline defects, these can sometimes be closed with
bilateral perialar crescentic advancement flaps. The problem
with this reconstruction is that it may result in a tight lip. In
addition, the Cupid’s bow may more than likely be compro­
mised, but this is unavoidable and further surgery may be
required, as indicated.
Abbé flap
Traditionally, the Abbé flap was a full-thickness V-shaped
portion of the lower lip, which was taken up to expand the
Fig. 17.17  (A–C) Posteriorly based cheek flap.
A
B
C

445
Lips
A
B
Fig. 17.18  (A–D) V–Y island advancement flap.
C
D
upper lip transversely.21 The labial vessels provide the blood
supply. The upper lip is released by a vertical incision and the
V-shaped defect of the upper lip is reconstructed using the
Abbé flap. The lower lip vessel is then divided at 2–3 weeks.
Although this gives nice release of the upper lip and provides
bulk, there is a tendency to have a convexity bilaterally on
either side of the flap and there tends also to be more move­
ment in the lateral segments of the upper lip, with little or no
movement of the flap.
In order to prevent these problems and to create a mobile
upper lip that would give a more satisfactory result aestheti­
cally and functionally, Jackson changed the design of the Abbé
flap.22 He advocated that the flap be incised anteriorly on the
lower lip skin and posteriorly on the mucosa. On one side
of the flap, the incision is taken from the buccal sulcus over
the lip mucosa and on to the skin. The lower lip muscles are
dissected out, leaving the mucosa and skin free of attach­
ments. At this point, the muscles of the lower lip are intact
and the mucosa and skin are sutured. In the upper lip, an
incision is made and the orbicularis muscles are dissected
out so that they can be freed and joined in the midline. This
muscle dissection is extensive so that the muscles can be
interdigitated in the midline. Care is taken not to disturb
any nerves. This having been done, the lip dimensions are
now satisfactory in terms of lip height and muscle bulk.
The lower lip segment is now swung up into the upper lip
defect and is sutured in position. Because of the very narrow
pedicle, it is possible to have the flap placed in exactly the
required position. This is almost like a full-thickness graft of
the skin and mucosa and, therefore, the division of the sup­
plying vessel can be carried out in 2–5 days, although five is
most frequent.
At the second-stage procedure, it is necessary to rearrange
the mucocutaneous junction with additional trimming of the
flap. If the flap described above can be used, the lower lip
muscle is left intact and the upper lip muscle is reconstructed.
This results in good function of both lips in most cases.
Fan flaps
Fan flaps can be used for hemi-lip or total upper lip defects.
These defects may be skin only or a full-thickness lip defect.

446
SECTION II
CHAPTER 17 • Local flaps for facial coverage
Fan flaps can be standard or full-thickness and are based on
the perioral vasculature. The commissures are maintained
and the flaps are rotated around them; thus, the anatomy of
the mouth is maintained. However, fan flaps yield a much
better result on the lower lip. This type of reconstruction has
largely been overtaken by the perialar crescentic advance­
ment flap.
Lower lip
In the lower lip, skin defects can be reconstructed with naso­
labial flaps. These can be transferred as a two-stage procedure
or in one stage, as island flaps. Pin cushioning is a problem
regardless of whether the flaps are round or square.
Full-thickness defects
In the lower lip, as opposed to the upper lip, larger defects
can be closed directly because of the greater lip laxity. The
closure should be performed in a careful, layered fashion in
the following order: mucosa, muscle, and skin.
Karapandzic technique
By use of the Karapandzic technique, three-quarters of the
lower lip can be reconstructed without difficulty (Fig. 17.19).23
It has some resemblance to the perialar crescentic advance­
ment flap, but it is a superior method. The reconstruction
should replace the full-thickness and depth of the lip. The skin
is incised in a transverse direction to just beyond the nasola­
bial fold. Laterally, the vessels and nerves are dissected out
and carefully preserved. The orbicularis muscle fibers are
spread apart as far laterally as necessary. After this, it should
be possible to move the leading edge to the midline or beyond,
if necessary. It is best to use bilateral flaps and to perform a
layered closure where they meet. In this way, a loose and
symmetric lip is obtained, and the blood and nerve supply are
maintained. Also, a properly functioning lip with a virtually
normal anatomy is formed. The scars settle well and are
acceptable from a cosmetic viewpoint.
Gillies fan flap
Until the Karapandzic procedure was published, the Gillies
fan flap was considered to be the method of choice. Full-
thickness nasolabial flaps based on the labial vessels are
swung around the commissure into the lower lip defect. These
flaps can be unilateral or bilateral.
Comparison between Karapandzic and
Gillies techniques
In the Karapandzic technique, the commissures are main­
tained and the width of the commissure is satisfactory.23
There is no need to supply lower lip mucosa. The flaps
are neurotized and results in good lower lid function and
sensation. In the Gillies reconstruction, the mouth is nar­
rowed, and there is no mucosal cover of the flaps at the lip
margin. Mucosal cover is supplied by advancing intraoral
mucosa. Unfortunately, mucosa from this area is always
red and shiny, and frequently has a tendency to crust when
exposed to the air. The nerves are not kept intact, thus lip
function and sensation are compromised. In spite of this, the
function may be better than expected, especially in hemi-lip
reconstruction.
Tongue flaps
Tongue flaps can be used to replace the lip red margin in
reconstructions that do not supply the required amount
of mucosa.24 Tongue flaps are also used in patients with
advanced and extensive leukoplakial involvement of the lip
mucosa. The traditional method is to use the dorsum of the
tongue, but its color and surface irregularity make it aestheti­
cally unsuitable as a lip mucosal substitute. The undersurface
of the tongue mucosa is smooth, may have good color, and
can easily be transferred in a staged procedure. The flap
is based anteriorly. It should be of a sufficient length and
width. It is sutured into the lip defect. In 10 days, under local
anesthesia, the flap is divided and inset. The tongue defect
is closed directly. The mucosa tends to be a deeper shade of
red and shinier than normal tongue mucosa. Crusting may
occur and may require frequent application of petroleum
jelly. Sensation is reduced as with any free transplant on
the lip.
Total lower lip reconstruction
The Karapandzic technique can be used for total lower lip
reconstruction, but the reconstructed lip is frequently too
tight. The method of choice is bilateral fan flaps with resurfac­
ing of the red lip with a flap from the undersurface of the
tongue.25 The Webster advancement technique, in which
bilateral full-thickness horizontal advancement cheek flaps
can be brought into place by excision of bilateral upper and
lower vertical triangles at their bases, is another possibility.
The mucosa is again supplied from the undersurface of the
tongue. The scars in the nasolabial lines and around the chin
heal well. The main problem is that the reconstructed lip is
flat and tight and tends to trap-door. On occasion, two Abbé
flaps from either side of the prolabial segment of the lip can
be turned down to increase lip volume, but the end result is
not particularly satisfactory from a cosmetic point of view.
Function (e.g., drooling) may be improved to a variable
degree. Not infrequently, free tissue transfer will be required
to reconstruct a total lip defect.
Commissure reconstruction
The commissure mucosa occasionally requires reconstruction.
When analyzed, this can be divided into two rhomboids, one
for each lip. Rhomboid flaps from the intraoral cheek area can
resurface the defects without difficulty, and the donor sites
can be closed directly. However, this is wet mucosa and is
redder than the normal lip. Another method for larger defects
(e.g., electrical burns) is to develop a large triangular mucosal
island flap, advance its base to the commissure, and then use
the considerable amount of tissue obtained as required. The
donor site is closed directly. Later rearrangement of the
mucosa is always required but, fortunately, a sufficient supply
is available after the procedure. Finally, in some instances,
lateral tongue flaps can be used to cover the upper and lower
lip region at the commissure. These are divided after 10 days.
These flaps are not widely used because anteriorly-based
mucosal flaps have proved to be more satisfactory in terms of
position and patient comfort.

447
Lips
A
B
Fig. 17.19  Reconstruction of partial defect of lower lip with Karapandzic rotation-advancement flaps. (A) Full-thickness defect of the lower lip. Bilateral Karapandzic flaps
incised. (B) Demonstration of vessels preserved with “Karapandzic” technique of dissection. Compared to central lip, identification of peripheral margin of orbicularis
muscle in the vicinity of commissures is more difficult. Releasing facial muscular attachments to orbicularis muscle may be performed lateral to actual peripheral margin of
orbicularis muscle near commissures to insure consistency of thickness of muscular layer of flaps. (C) Flaps approximated. (D,E) Six months postoperative. For proper lip
height, flaps are designed with uniform width throughout length of flaps. For this reason, it is necessary to design flaps lateral to melolabial crease near commissure.
(F) One year postoperative. Reconstructed lip has tightened, resulting from scar contraction. Such long-term changes are common. (From Renner G. Reconstruction of the
lip. In: Baker SR, Swanson NA (eds). Local flaps in facial reconstruction. St. Louis: Mosby, 1995:368, with permission.)
C
D
E
F

448
SECTION II
CHAPTER 17 • Local flaps for facial coverage
Ear
The areas of the ear most often requiring excision and recon­
struction are the rim and the conchal area.
Rim defects
It is frequently possible to excise a rim lesion and advance the
rim by incising full-thickness down to the lobule. There is no
residual defect with this method (Fig. 17.20).26 If there is
concern about the viability of the tip of this flap or if the defect
is larger, the posterior skin is dissected up and may be included
into the rim. A larger flap with a large base has a better blood
supply and is more likely to survive. It does not result in any
ear deformity. In some instances, superior and inferior rim
flaps will be used in conjunction with one another. Even larger
defects are better reconstructed by postauricular flaps (Fig.
17.21). The flap is elevated and sutured to the anterior edge
of the defect. After 3 weeks, a large flap is incised in the
postauricular area, dissected up to provide laxity, and brought
to the ear rim to provide more tissue. It is trimmed as neces­
sary and sutured in place. Deep sutures can help in forming
the shape as required. Further adjustments will most likely be
necessary following on healing.
Anterior concha
If a lesion of significant size occurs in the anterior concha,
resurfacing will be required.27 To achieve this, the lesion is
resected together with the underlying conchal cartilage. The
ear is then distracted forward, and a flap is designed with
a central vertical pedicle based on the ear mastoid groove.
The skin anterior and posterior to the groove is elevated, and
with some division of the subcutaneous hinge superiorly and
inferiorly, it can be rotated into the ear defect. The posterior
edge of the postauricular island is sutured to the posterior
edge of the defect, and the anterior edge of the island is
sutured to the anterior edge of the defect. The posterior defect
is closed directly. This will give an excellent result both on the
anterior aspect of the concha and in the postauricular groove
(Fig. 17.22).28 In a large degloving of the ear, a temporal fascial
flap is used to cover the defect. The flap is then covered with a
full-thickness skin graft. This is a rare injury, but this technique
can also be used in reconstruction of the congenitally absent
ear. The end result is suboptimal because of the poor color of
the skin graft. It may also have a shiny surface, especially if a
split-thickness graft is used.
Perforator flaps in the face
Facial artery perforator flap (Video 17.1 )
The facial artery flap is a relatively new addition to the flap
options in facial reconstruction.29 It can be designed with an
aesthetic donor site and due to the reliability of the presence
of perforators these flaps can have a large arc of rotation. They
are commonly used as a V–Y flap or as a propeller flap (Fig.
17.18).30,31 For clinical application, the identification of the
facial artery and its perforators can be identified with the use
of a hand-held Doppler. The facial artery travels from the
midpoint of the mandibular edge towards the nasal alar
margin medical to the labial crease. There are generally four
to five cutaneous perforators of greater than 0.5 mm that arise
along the course of the artery.
Submental flap
The submental flap is very useful perforator flap for recon­
struction of the lower face. It can be used both intraorally as
well as for cutaneous reconstruction.32,33 It is based on the
submental artery (a well-defined branch of the facial artery).
This vessel arises deep to the submandibular gland and
passing forward and medially across the mylohyoid muscle
and can be either superficial or deep to the digastric muscle
and terminates behind the mandibular symphysis on the
anterior belly of digastric. It gives off several cutaneous
branches that pierce the platysma and this allows a large flap
to be raised, from mandibular angle to mandibular angle,
with width determined by the flaccidity of the neck skin
allowing direct closure (up to 18 × 7 cm). This flap has a
pedicle length of 8 cm and an arc that allows it to reach the
lower two-thirds of the face.34 It provides excellent donor
tissue with a well-hidden donor site (Fig. 17.23).
Fig. 17.20  (A) Helical defect following resection of a basal cell carcinoma. (B) Helical flaps are raised based on the posterior skin. (C) Flaps are dissected until
advancement and closure without tension is possible. (D) Final appearance following closure. (Courtesy of Dr. David Mathes.)
A
B
C
D

449
Perforator flaps in the face
A
B
C
Fig. 17.21  (A) Defect of upper ear after resection of squamous cell carcinoma. (B) Post-auricular flap is designed, (C) raised and inset into defect. (D) Appearance prior
to pedicle division and (E) following pedicle division. The intervening defect is skin grafted most easily with a post-auricular graft harvested more inferiorly than the defect
and closed directly. (F) Late appearance. (Courtesy of Dr. David Mathes.)
D
E
F
A
B
C
Fig. 17.22  (A) A 72-year-old man with a basal cell in the upper ear, marked for excision. (B) Defect includes anterior skin and underlying cartilage. (C) Postauricular,
superiorly based flap outlined.
Continued

450
SECTION II
CHAPTER 17 • Local flaps for facial coverage
Fig. 17.23  (A–D) This patient is reconstructed with a submental
flap based on the submental branch of the facial artery.
A
B
C
D
(D) Flap raised and tunneled into
anterior defect. Small segment of flap is de-epithelialized
and secondary defect is closed directly. (E) Final
appearance of healed flap. (Courtesy of Dr. Peter Neligan.)
D
E
Fig. 17.22, cont’d

451
Perforator flaps in the face
18. Garrett WS Jr, Giblin TR, Hoffman GW. Closure of skin defects of
the face and neck by rotation and advancement of cervicopectoral
flaps. Plast Reconstr Surg. 1966;38(4):342–346.
19. Pribaz JJ, Chester CH, Barrall DT. The extended V–Y flap. Plast
Reconstr Surg. 1992;90(2):275–280.
20. McGregor JC, Soutar DS. A critical assessment of the bilobed flap.
Br J Plast Surg. 1981;34(2):197–205.
21. Abbé R. A new plastic operation for the relief of deformity due to
double harelip. Plast Reconstr Surg. 1968;42(5):481–483.
22. Jackson IT, Soutar DS. The sandwich Abbé flap in sceondary cleft
lip deformity. Plast Reconstr Surg. 1980;66(1):38–45.
23. Karapandzic M. Reconstruction of lip defects by local arterial flaps.
Br J Plast Surg. 1974;27(1):93–97.
24. Rees TD, Tabbal N, Aston SJ. Tongue-flap reconstruction of the lip
vermilion in hemifacial atrophy. Plast Reconstr Surg. 1983;72(5):643–
647.
25. Jackson IT. Use of tongue flaps to resurface lip defects and close
palatal fistulae in children. Plast Reconstr Surg. 1972;49(5):537–541.
26. Antia NH, Buch VI. Chondrocutaneous advancement flap for the
marginal defect of the ear. Plast Reconstr Surg. 1967;39(5):472–477.
27. Brent B. The acquired auricular deformity. A systematic approach to
its analysis and reconstruction. Plast Reconstr Surg. 1977;59(4):475–
485.
28. Masson JK. A simple island flap for reconstruction of concha-helix
defects. Br J Plast Surg. 1972;25(4):399–403.
29. Hofer SO, Posch NA, Smit X. The facial artery perforator flap for
reconstruction of perioral defects. Plast Reconstr Surg. 2005;115(4):
996–1003, discussion 1004–1005.
30. Kannan RY, Mathur BS. Perforator flaps of the facial artery
angiosome. J Plast Reconstr Aesthet Surg. 2013;66(4):483–488.
31. Camuzard O, Foissac R, Georgiou C, et al. Facial artery perforator
flap for reconstruction of perinasal defects: An anatomical study
and clinical application. J Craniomaxillofac Surg. 2015;43(10):2057–
2065.
32. Ishihara T, Igata T, Masuguchi S, et al. Submental perforator flap:
location and number of submental perforating vessels. Scand J Plast
Reconstr Surg Hand Surg. 2008;42(3):127–131.
33. Curran AJ, Neligan P, Gullane PJ. Submental artery island flap.
Laryngoscope. 1997;107(11 Pt 1):1545–1549.
34. Faltaous AA, Yetman RJ. The submental artery flap: an anatomic
study. Plast Reconstr Surg. 1996;97(1):56–60, discussion 61–52.
References
1. Juri J, Juri C, Arufe HN. Use of rotation scalp flaps for treatment of
occipital baldness. Plast Reconstr Surg. 1978;61(1):23–26.
2. Orticochea M. Four flap scalp reconstruction technique. Br J Plast
Surg. 1967;20(2):159–171.
3. Orticochea M. New three-flap reconstruction technique. Br J Plast
Surg. 1971;24(2):184–188.
4. Zilinsky I, Farber N, Haik J, et al. The hatchet and bilobed flaps
revisited: shedding new light on traditional concepts. J Drugs
Dermatol. 2012;11(1):99–102.
5. Burget GC, Menick FJ. The subunit principle in nasal
reconstruction. Plast Reconstr Surg. 1985;76(2):239–247.
6. Parrett BM, Pribaz JJ. An algorithm for treatment of nasal defects.
Clin Plast Surg. 2009;36(3):407–420.
7. Rohrich RJ, Griffin JR, Ansari M, Beran SJ, Potter JK. Nasal
reconstruction–beyond aesthetic subunits: a 15-year review of 1334
cases. Plast Reconstr Surg. 2004;114(6):1405–1416, discussion
1417–1409.
8. Koch CA, Archibald DJ, Friedman O. Glabellar flaps in nasal
reconstruction. Facial Plast Surg Clin North Am. 2011;19(1):113–122.
9. Panizzo N, Colavitti G, Papa G, et al. Reconstruction after wide
excision in medial canthal region: the extended bilobed glabellar-
palpebral flap. J Plast Reconstr Aesthet Surg. 2015;68(1):131–132.
10. Staahl TE. Nasalis myocutaneous flap for nasal reconstruction. Arch
Otolaryngol Head Neck Surg. 1986;112(3):302–305.
11. Wee SS, Hruza GJ, Mustoe TA. Refinements of nasalis
myocutaneous flap. Ann Plast Surg. 1990;25(4):271–278.
12. Constantine VS. Nasalis myocutaneous sliding flap: repair of nasal
supratip defects. J Dermatol Surg Oncol. 1991;17(5):439–444.
13. Zitelli JA. Design aspect of the bilobed flap. Arch Facial Plast Surg.
2008;10(3):186.
14. Zimany A. The bi-lobed flap. Plast Reconstr Surg (1946). 1953;11(6):
424–434.
15. Menick FJ. Aesthetic refinements in use of forehead for nasal
reconstruction: the paramedian forehead flap. Clin Plast Surg.
1990;17(4):607–622.
16. Menick FJ. A 10-year experience in nasal reconstruction with the
three-stage forehead flap. Plast Reconstr Surg. 2002;109(6):1839–1855,
discussion 1856–1861.
17. Jowett N, Mlynarek AM. Reconstruction of cheek defects: a review
of current techniques. Curr Opin Otolaryngol Head Neck Surg.
2010;18(4):244–254.

SECTION II • Head and Neck Reconstruction
18 
Secondary facial reconstruction
Julian J. Pribaz and Rodney K. Chan
SYNOPSIS
■ Secondary revision is an inevitable and indispensable part of facial
reconstruction.
■ An accurate diagnosis of the missing parts is as important in
secondary reconstructions as during the primary reconstruction.
■ A comprehensive reconstructive plan is needed from the start,
including bailout strategies.
Introduction
The goal of any reconstruction is to restore to normal – or
close to normal – form and function. This could only be
completely achieved by replantation or, in the future, trans­
plantation. All of our current reconstructive methods will
always fall short of the ideal due to specific tissue character­
istics. Hence the need for secondary, tertiary, or in fact mul­
tiple revisional procedures to achieve the best possible
functional and aesthetic result. Indeed, the meaning of the
word plastic, which is derived from the Greek plastikos,
means to make or mold.
This chapter will address the principles and techniques
utilized to enhance the final result of the initial primary
reconstructive procedure. The sequence of reconstruction
and timing in the application of these different techniques
should be guided by basic principles. A well-thought-
out reconstructive path is needed from the start so as not
to “burn any bridges”. Secondary facial reconstructions can
be broadly separated into (1) those that were part of the
initial reconstructive plan and (2) those that were unplanned
and which may present to a different surgeon as a
challenging case.
Access the Historical Perspective section online at

Basic science/disease process
Secondary facial reconstruction assumes a previous operative
procedure, the cause of which in the head and neck may have
a wide range of etiologies, from congenital malformations to
various types of trauma, including burns, ballistic injuries,
motor vehicle accidents, and animal bites. Tumors involving
both bone and soft tissues and infections may also have been
the culprit. Each one of these etiologies has its own unique
consequences.
Tissues may have been lost, displaced, or distorted. Both
bone and soft tissues may have been involved. A common
feature of all these etiologies is that, along the way, wounds
were created and treated. These may have been simple and
superficial but, more likely, deep and complex. Healing may
have been facilitated by primary or secondary closure, or
involved a prior operative procedure utilizing tissue locally
or afar. It should be remembered that there is renewed swell­
ing and scarring at each interface, and that this occurs with
each operative procedure, which in turn makes the outcome
after each procedure somewhat unpredictable. It is usual and
safe practice to allow the patient and the involved tissue to
heal, the swelling to subside, and the scarring to mature
before embarking on secondary and tertiary operative
procedures.
Diagnosis/patient presentation
An accurate diagnosis of the deformity and an appraisal of
the missing parts are essential. The deformity is compared
with what is considered to be the “perceived normal”. If the
deficit is unilateral, the best guide is a comparison with the
opposite side. With more extensive defects where both sides
are involved, a consideration of baseline appearance as seen
on an old photograph may serve as a guide to reconstruction.
However, realistic goals must be set from the start as to what
might be achievable with reconstruction.

452.e1
Historical perspective
Historical perspective
Much has been written about the principles of reconstruction
by the giants and early pioneers of plastic surgery, including
Tagliacozzi, Paré, Gillies, and Millard, among others. The
aims are always to restore to normal. Over the last century,
many techniques of increasing sophistication have been
described. Our armamentarium continues to expand, so that
today the reconstructive surgeon has many options to con­
sider for achieving the best possible result. To maximize the
end result in complex reconstruction, it is in fact not uncom­
mon to utilize every rung of the reconstructive ladder, or as
Bennett and Choudhary have described, the “reconstructive
elevator”, which takes the reconstructive surgeon directly to
the best method of reconstruction based on the patient’s needs
and within the surgeon’s realm of experiences.1

453
Treatment and surgical technique
a correct sequence of procedures so to avoid “burning future
bridges”.
Treatment and surgical technique
Meticulous technique and planning should be emphasized at
every step of a multistage facial reconstruction, as this makes
subsequent operations more predictable. Planning and initial
flap tailoring are critical first steps. Radiographs are useful to
visualize the missing bony elements. We recommend the
liberal use of preoperative and intraoperative models to simu­
late the missing soft tissues and/or bone in developing the
plan.3 This maneuver at the commencement of an operative
procedure allows for tailored flaps to be designed at the most
ideal donor site.
In general, the principles that are observed in secondary
facial reconstructions are:
1. Restore uninjured or partially injured anatomical
features to their normal location.
2. Repair scar contracture and, if possible, place the scars
along the natural crease lines.
3. Restore the contour, which may involve debulking or
augmenting soft facial parts with dermis fat grafts or
autogenous fat grafting.4,5
4. Restoration of contour is more important than the
presence of scars.
5. Replace “like with like”, thus, soft tissues should be
replaced with soft tissues, and bony tissues with bone
or bone substitutes.
6. Use local flap options with better color and texture
match as advancement or transposition flaps to provide
better cutaneous coverage of de-epithelialized,
previously placed distant free flaps that may have been
used.
7. Local specialized flaps, for example, hair-bearing flaps,
to reconstruct specific subunits previously covered by
large distant flaps are also used to help break up the
scars and create an illusion of a more normal
appearance.
8. If local flaps are not available to improve the color
mismatch of distant flaps, consider the use of thin
split-thickness skin grafts harvested from the scalp as
overgrafts to resurface these areas after
de-epithelialization of the existing flap.6
9. Carry out functional restoration of absent muscles of
facial expression, especially for restitution of a smile and
adequate closure of the eyelids and mouth. The options
of free muscle transfer, with and without nerve grafts or
local or regional muscle transfers of functioning muscle,
can all be considered.
10. Restore adequate bony platform to repair bony contour
deformities, or allow for dental rehabilitation with
osseointegrated implants.
11. Carry out supplemental prosthetic reconstruction of
non-reconstructible parts, for example, orbital and ear
prostheses.
A few recurrent themes encountered in complex facial recon­
structions are worthy of mention: (1) reconstruction of defi­
cient intraoral and intranasal lining; (2) reconstruction of
An evaluation for secondary facial reconstruction begins
with a thorough investigation into the history of the patient,
in particular the operations and flaps that were previously
utilized, paying close attention to the remaining donor vessels
in the head and neck.2 Next, an accurate diagnosis of the
missing parts has to be made. While it is generally obvious
what the missing parts are for a primary reconstruction that
immediately follows extirpation, it is less obvious in second­
ary reconstructions where tissues have been pulled closed or
healed secondarily. It takes an astute plastic surgeon to visual­
ize what constitutes adequate contracture release and the
resulting defect. This attention to making the correct compre­
hensive diagnosis is especially important when evaluating a
patient whose primary reconstruction was performed else­
where. Subsequent revisions are individualized and dictated
by the area and underlying cause that required reconstruc­
tion. Therefore, a surgeon who specializes in secondary facial
reconstructions needs to be well versed in all rungs of the
reconstructive ladder, especially when many first-line options
have already been utilized.
Patient selection
Facial defects and deformities should be evaluated in a sys­
tematic manner, starting from:
1. Overall magnitude and extent of the deformity and its
anatomical location.
2. Displacement of major facial subunits; for example, the
eyebrows, eyelids, nose, ears, and lips.
3. The extent of contour distortion.
4. Location and quality of the scarring that is present.
5. The color, texture, and quality of the skin.
6. The presence, absence, and distortion of specialized
cutaneous features; for example, the hairline, sideburn,
and beard area.
7. The quality of the subcutaneous tissues, volume, and
distribution.
8. The function or lack thereof of the underlying
musculature.
9. The integrity or deformity of the underlying bony or
cartilaginous support structures.
10. The status and quality of tissues lining the oral and
nasal cavity.
11. The loss of other specialized components such as the
lacrimal apparatus, teeth, and an adequate and mobile
tongue.
The status of all these elements should first be appraised and
a decision made regarding the best method of restoration.
In consideration of secondary reconstruction it is under­
stood that a primary procedure has already been performed.
The effectiveness of the first reconstruction has to be evalu­
ated and sometimes it is necessary to advise the complete
removal of an inadequate first reconstructive effort, to recreate
the defect, and start again from scratch. For complex recon­
struction, it is ideal to have an expert evaluate the initial
presenting problem and develop an appropriate and often-
staged treatment plan. No complex facial defect or deformity
can be expected to be adequately repaired in a single stage
and thus if a staged repair is required, it is necessary to plan

454
SECTION II
CHAPTER 18 • Secondary facial reconstruction
sideburn and beard areas in order to maintain symmetry.
However, few sites are available as hair-bearing donors. The
temporal scalp, frontal scalp, and the submental region can
all give satisfactory results.10 The frontal scalp can be trans­
ferred using the supratrochlear artery and the submental
region can be transferred on the submental branch of the facial
artery, though these areas may not be available. Temporal
scalp skin contains an abundance of hair follicles and needs
implantation of a heterotopic vessel as a first-stage reconstruc­
tion (see prefabrication, below).
Prefabrication
Prefabrication refers to the pretransfer implantation of a non­
native vascular pedicle into the tissue desired for reconstruc­
tion. It is used when the tissue desired for reconstruction
cannot be practically transferred by alternate means. To opti­
mize aesthetics in facial reconstruction, prefabrication is typi­
cally used to hand-pick thin tissues with cutaneous qualities
most similar to the pre-disfigured part. The donor vessel can
be any good length of vessel, including its surrounding fatty
tissue.11,12 The radial forearm fascial flap, the temporal parietal
fascial flap, and the descending branch of the lateral femoral
circumflex pedicles are all reliable donor vessels of good
hair-bearing regions; as well as the use of (3) prefabrication
and (4) prelamination as adjunctive techniques.
Intraoral and intranasal lining
Deficiency in intraoral and intranasal lining must be suspected
in cases of internal or external perioral contractures, or when
the lining is known to have been excised or irradiated. Defi­
ciency in intraoral lining can manifest as dry mouth, lack of
facial movement, or lack of oral competence. Therefore, prior
to commencement of any perioral reconstruction, intraoral
scars must be fully released and the lining reconstructed.
Otherwise, any attempts at external skin replacement will be
suboptimal. Replacements of intraoral lining include skin
grafts, regional flaps, and distant flaps. While skin graft might
appear to be most appealing because of its availability and
simplicity, we have not found it to be durable, especially in
scarred or irradiated beds. Distant flaps such as anterolateral
thigh flaps and radial forearm free flaps are certainly reliable
methods of replacing lining. However, in cases of multiple
prior operations, those flaps may have already been utilized
or may be needed elsewhere. Furthermore, donor vessels are
usually scarce. The facial artery musculomucosal (FAMM)
flap, a composite flap with mucosa and muscle taken from the
lateral cheek, should be considered as an option. This is best
done at the first operation when wide exposure and easy
access to supple mucosa are available. When harvested with
the overlying buccinator muscle, this is a robust flap that can
cover widths of 2–2.5 cm. It can be based either superiorly
(retrograde flow) or inferiorly (antegrade flow) to cover a
variety of oronasal mucosal defects, including defects of the
palate, alveolus, nasal septum, antrum, upper and lower lips,
floor of the mouth, and soft palate (Fig. 18.1).7
With larger mucosal defects involving the floor of the
mouth, the submental flap based on the submental branch of
the facial artery is another useful regional option. Our experi­
ence indicates that this flap is generally very reliable with
minimal donor site morbidity but should be used with caution
if there was prior irradiation. Further, it can be easily com­
bined with the need for a neck dissection, though it is impera­
tive to raise the flap and preserve its blood supply prior to
commencement of the extirpative procedure.8
While vermilion is not strictly intraoral lining, it is a spe­
cialized type of tissue that is impossible to reproduce. When
vermilion is missing and cannot be borrowed from its neigh­
boring areas, its appearance is much better matched with the
use of non-keratinized mucosa than the use of keratinized
skin. In the early days of vermilion reconstruction, jejunal and
gastric mucosa were attempted but were fraught with prob­
lems. The use of gastric mucosa in particular can be hyperse­
cretory and its acidic contents ulcerogenic. FAMM flap, based
superiorly for the upper lip and inferiorly for the lower lip,
can give a good match for this specialized tissue.9 Alterna­
tively, the use of lingual mucosa or tattooing of keratinized
skin can also be acceptable.
Hair-bearing flaps
Successful facial reconstructions, especially in males, need to
recognize the pattern of hair growth particularly in the
Fig. 18.1  (A) Superiorly based facial artery musculomucosal (FAMM) flap may be
used for defects of the anterior palate, alveolus, maxillary antrum, nose, upper lip,
and orbit. (B) Inferiorly based FAMM flap may be used for defects of the posterior
palate, tonsillar fossa, alveolus, floor of mouth, and lower lip.7
A
B
1
1
2
2
3
3

455
Prelamination
Each of the selected cases of secondary facial reconstruc­
tions below demonstrates many of the basic dictums previ­
ously described. While secondary reconstructions can be
broadly separated into two categories: (1) those that were part
of the initial reconstructive plan and (2) those that were
unplanned and usually followed multiple other unsatisfac­
tory reconstructions done elsewhere, it is on the second cat­
egory that we want to focus. In the cases of secondary
reconstructions that follow, we will first demonstrate our
diagnosis of the missing elements and then the principles
used to arrive at the reconstructive plan.
Case example 1
This patient is a 16-year-old girl with severe facial burns from
a hot-oil spill as a baby. She underwent initial reconstruction
with staged tube pedicle flap from her groin for nose and chin
reconstruction which unfortunately was totally inadequate
(Fig. 18.2).
caliber. This is placed under the desired area of transfer and,
if needed, can be placed over a tissue expander. This is an
especially useful adjunct in cases of secondary facial recon­
structions as first-line donor options are exhausted and new
donor options need to be explored. This technique essentially
creates a limitless number of donor sites.
Prelamination
Flap prelamination is a term first coined by Pribaz and Fine
in 1994, referring to the pretransfer implantation of anything
other than a vascular pedicle in the territory of an existing
axial vascular bed.13,14 In aesthetic facial reconstruction,
prelamination is often used to assemble composite flaps that
can be transferred as a unit that more closely approximates
the pre-disfigured part.11 Prelamination is a useful adjunct in
both primary and secondary facial reconstructions of complex
multifaceted defects.
A
B
C
D
E
F
Fig. 18.2  A 16-year-old girl with severe facial burns from a hot-oil spill as a baby. (A,B) Her initial
reconstruction with staged tube pedicle flap from her groin for nose and chin reconstruction was unfortunately
inadequate to give her oral competence and facial expression. (C,D) At the first stage, right neck skin is
prefabricated using pedicled temporal parietal fascia flap over a tissue expander for upper lip reconstruction.
(E,F) Lower lip and chin were reconstructed with free folded radial forearm flap and bilateral facial artery
musculomucosal flaps.
Continued

456
SECTION II
CHAPTER 18 • Secondary facial reconstruction
G
H
I
J
K
L
(G) Her interim appearance with diminished lower incisor show is already evident. Tissue expander was placed under forehead flap for nasal
reconstruction. At the second stage, her upper lip was reconstructed with the prefabricated expanded pedicle neck flap. (H,I) Template of the upper lip defect is seen and
the course of the transposed pedicle outlined. (J) Her nose was reconstructed with the expanded forehead flap over lining flaps and cartilage grafts. (K) She was seen 3
months postoperatively with lower lip sagging. Dynamic temporalis muscle slings were designed to support her lower face and lips (not shown). (L) A satisfactory outcome
is achieved 2 years following initial presentation. She has achieved oral competence and improved nasal aesthetics.2
Fig. 18.2, cont’d
Diagnosis
1. Full-thickness upper and lower lip loss and consequent
lack of oral competence manifested as frequent oral
caries and lack of facial expressions.
2. Nasal deformity with lack of tip projection and ill-
defined facial-alar groove.
Reconstructive plan
Additional oral lining and external skin are needed to correct
her upper and lower lip deficiencies. No local options are
available. A radial forearm free flap is planned for lower lip
reconstruction and a prefabricated neck flap is planned for
upper lip reconstruction. Forehead flap and cartilage grafts
will increase nasal projection and nasal skin quality. At the
first stage, right neck skin was prefabricated using a pedicled
temporal parietal fascia flap over a tissue expander for upper
lip reconstruction. A tissue expander was also placed under
forehead flap for nasal reconstruction. The lower lip and chin
were reconstructed with free folded radial forearm flap. A
three-dimensional template of the defect was made following
contracture release which was then converted into a two-
dimensional pattern before transposing on to the radial forearm.

457
Prelamination
4. Use of FAMM flap for vermilion reconstruction.
5. Delayed use of forehead flap for resurfacing after
previous distant flap.
6. Restoration of contour following free tissue transfer
through debulking and placement of scars along natural
creases.
7. Functional reconstruction of the lower lip with bilateral
temporalis muscle flaps.
Case example 2
This patient is a 23-year-old female with a history of extensive
burns and multiple facial skin grafts and releases who now
desires better texture and uniformity (Fig. 18.3).
Diagnosis
The skin is irregular and noncompliant with no subcutaneous
fat throughout her face and neck. She suffers from loss of
normal nasal and facial contours from contractures of the face
and nose.
She was seen immediately following lower lip free folded
radial forearm flap and bilateral FAMM flap for vermilion
reconstruction. At the second stage, her upper lip was recon­
structed with the prefabricated expanded pedicle neck flap.
Template of the upper lip defect is seen and the course of the
transposed pedicle outlined. Her nose was reconstructed with
a forehead flap over lining flaps and cartilage grafts. Sculpting
of the supramental crease was also done at this time.
She was seen 3 months postoperatively with lower lip
sagging. Bilateral dynamic temporalis muscle slings were
designed to support her lower face and lips. She is seen
immediately after her lower lip revision as well as sculpting
of her nose. The mouth closes when the patient bites down.
A satisfactory outcome is achieved 2 years following initial
presentation. She has achieved oral competence and improved
nasal aesthetics.2
This case illustrates multiple principles of secondary facial
reconstruction:
1. Comprehensive diagnosis from the outset.
2. Use of templates for planning.
3. Prefabrication to bring in additional tissue, saving her
from an additional free tissue transfer.
A
B
C
D
E
F
G
Fig. 18.3  A 23-year-old female with a history of extensive burns and multiple facial skin grafts and releases who now desires better texture and uniformity. (A,B) She
suffers from loss of normal nasal and facial contours from contractures of the face and nose. (C,D) Facial resurfacing using an expanded free scapular/parascapular free flap
was designed and outlined. (E) Following expansion, hypertrophic burn scar was excised from her face and neck. (F) She is seen immediately following free tissue transfer.
(G) Expanded forehead flap was used for nasal resurfacing.
Continued

458
SECTION II
CHAPTER 18 • Secondary facial reconstruction
H
I
J
(H) She is seen following healing of her free flap which still lacks normal facial and nasal contours. (I) Facial aesthetic units were recreated through
debulking and placement of scars in lines of natural creases to recreate lines of the cheek, the philtrum, the upper lip, and chin. (J) Resurfacing of unstable skin has
achieved a more uniform appearance of her face and neck.
Fig. 18.3, cont’d
Reconstructive plan
The intention was to carry out facial resurfacing using an
expanded free scapular/parascapular free flap. She has few
unburned donor sites large enough to resurface this area.
Following expansion, hypertrophic burn scar was excised
from her face and neck. Templating over the back was per­
formed. She is seen immediately following free tissue transfer.
Expanded forehead flap was used for nasal resurfacing. She
is seen following healing of her free flap, which still lacks
normal facial and nasal contours. Facial aesthetic subunits
were recreated through debulking and placement of scars in
lines of natural creases to recreate separation between the
cheeks, the philtrum, the upper lip, and chin. Resurfacing of
unstable skin has achieved a more uniform appearance of her
face and neck. Attempts at further improving facial skin tone
with laser resurfacing were partially successful, and the
patient is satisfied with her appearance with use of additional
makeup.
This case illustrates multiple principles of secondary facial
reconstruction:
1. Comprehensive diagnosis from the outset.
2. Use of templates for planning.
3. Delayed use of forehead flap for resurfacing.
4. Uniform resurfacing of the face and neck with expanded
free flap.
5. Restoration of contour following free tissue transfer
through debulking and placement of scars along natural
creases.
Case example 3
The patient is a 17-year-old male (see preinjury in Fig. 18.4B)
following self-inflicted gunshot wound to the central
one-third of his face with loss of bony support and left
mandible. Reconstruction was first done elsewhere including
open reduction, internal fixation of multiple bony fractures,
rib grafts, and radial forearm free flap to separate the oro- and
nasopharynx. Cantilever bone graft and forehead flap were
performed for nasal reconstruction and subsequent Abbé flap
for upper lip deficiency. The patient presented for secondary
facial reconstruction 24 months after initial injury.
Diagnosis
1. Midface retrusion with lack of bony support.
2. Lack of nasal projection and ill-defined facial alar
groove, deficient left alar.
3. Asymmetric lip with upper lip contracture and intraoral
contracture.
Reconstructive plan
The intention was to carry out release of all intraoral con­
tracture and reconstruct bony platform using free fibula flap.
The contralateral facial artery is outlined in anticipation of
extensive lining deficits. Midfibula osteotomy was performed
to give support to both the maxilla and the mandible as a
single free osteocutaneous flap. A large lining deficit is
indeed seen following release. Both the fibular skin paddle
as well as a superiorly based right FAMM flap can be seen
during inset.
At a second stage, deficient left alar is reconstructed with
free auricular flap of ascending helix and root of helix. Sixty-
three months postinjury, after healing and edema subsided, a
second forehead flap was done for nasal resurfacing. He is
seen 8 years after the initial injury with symmetric lips lacking
any external or internal oral contractures, improved midface,
nasal projection, and nasal appearance.
This case illustrates multiple principles of secondary facial
reconstruction:

Fig. 18.4  (A) A 17-year-old male following self-inflicted gunshot wound to the central one-third of his face with loss of bony support and left mandible. (B) Preinjury
appearance from an old photograph used as reference. Reconstruction first performed elsewhere included open reduction, internal fixation of multiple bony fractures, rib
grafts, and radial forearm free flap to separate the oro- and nasopharynx. Cantilever bone graft and forehead flap were performed for nasal reconstruction and subsequent
Abbé flap for upper lip deficiency. (C,D) The patient presented for secondary facial reconstruction 24 months after initial injury, lacking mid facial bony support, nasal
projection, and asymmetric lip with upper lip and intraoral contractures. (E) The contralateral facial artery is outlined in anticipation of extensive lining deficits.
(F) Reconstructive plan included release of all intraoral contracture and reconstruction of bony platform using free fibula flap. (G) A large lining deficit is indeed seen
following release. (H) Midfibula osteotomy was performed to give support to both the maxilla and the mandible. (I) Both the fibular skin paddle, as well as a superiorly
based right facial artery musculomucosal flap, are used for coverage. (J–L) At a second stage, deficient left alar is reconstructed with free auricular flap of ascending helix
and root of helix. (M,N) Sixty-three months postinjury, after healing and edema subsided, a second forehead flap was done for nasal resurfacing. (O,P) He is seen 8 years
after the initial injury with symmetric lips lacking any external or internal oral contractures, improved midface, nasal projection, and nasal appearance.
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P

460
SECTION II
CHAPTER 18 • Secondary facial reconstruction
reconstruction of the maxillary platform was performed using
a free fibula flap with osseointegrated implant for future
dental rehabilitation. This was complicated by dehiscence of
the radial forearm flap from the lateral alar with exposed
plate. An extended forehead flap including a hair-bearing
segment which was initially planned for mustache reconstruc­
tion was also able to cover the cheek defect. He was seen at 6
months postoperatively with excellent cheek projection and a
symmetric mustache. At the time, he was still lacking all the
facial mimetic muscles and thus had an asymmetric smile. A
functional platysma-submental flap based on the submental
branch of the facial artery and the cervical branch of the facial
nerve was used for cheek reconstruction. One week later,
muscle function was evident; 2 years later, he achieved a
symmetric smile and symmetric hair growth.
This case illustrates many principles of secondary facial
reconstruction:
1. Comprehensive diagnosis from the outset.
2. Planning for a multiple-stage reconstruction from the
start.
3. Use of alginate to model a three-dimensional volume
loss and then converted to a two-dimensional defect on
the donor site that can later be folded.
4. Use of FAMM flap for vermilion reconstruction.
1. Comprehensive diagnosis from the outset, starting
reconstruction from “scratch”.
2. Adequate release of intraoral contracture a must, using
FAMM flap and cutaneous portion of the free flap.
3. Reconstruction of stable bony platform.
4. Delayed use of second forehead flap for resurfacing.
Case example 4
A 39-year-old male presents with extensive left facial arterio­
venous malformation (Fig. 18.5).
Diagnosis
He has a large deficit involving his cheek, upper and lower
lip, intraoral lining, muscles of facial expression, and bony
maxillary platform.
Reconstructive plan
This is a case of a planned multiple-stage reconstruction. He
was primarily reconstructed using a tailored radial forearm
folded flap, customized to defect with an alginate model. The
folded portion was used for intraoral lining. Palmaris longus
slings were used to suspend the lip and a contralateral FAMM
flap was used for vermilion reconstruction. A planned delayed
A
B
C
D
E
F
G
H
Fig. 18.5  (A) A 39-year-old male presents with extensive left facial arteriovenous malformation. (B) He has a large deficit involving his cheek, upper and lower lip,
intraoral lining, muscles of facial expression, and bony maxillary platform. (C,D) He was primarily reconstructed using a tailored radial forearm folded flap, customized to
the size, shape, and volume of the defect with an alginate model. (E,F) The folded portion was used for intraoral lining. (G,H) Palmaris longus slings were used to suspend
the lip and a contralateral facial artery musculomucosal flap was used for vermilion reconstruction.

I
J
K
L
M
N
O
P
Q
R
(I–L) A planned delayed reconstruction of his maxillary platform was performed using a free fibula flap with osseointegrated implant for future dental
rehabilitation. This was complicated by dehiscence of the radial forearm flap from the lateral alar with exposed plate. (M,N) An extended forehead flap, including a
hair-bearing segment which was initially planned for mustache reconstruction, was also used to cover the cheek defect. (O) He was seen at 6 months postoperatively with
excellent cheek project and symmetric mustache, though he still was missing all the facial mimetic muscles and had an asymmetric smile. (P) A functional platysma flap
based on the submental branch of the facial artery and the cervical branch of the facial nerve was planned for cheek reconstruction. (Q) One week later, muscle twitching
was evident. (R) Two years later, he achieved a symmetric smile and symmetric hair growth.
Fig. 18.5, cont’d

462
SECTION II
CHAPTER 18 • Secondary facial reconstruction
3. Pribaz JJ, Morris DJ, Mulliken JB. Three-dimensional folded
free-flap reconstruction of complex facial defects using
intraoperative modeling. Plast Reconstr Surg. 1994;93:285–293.
Multifaceted free flaps are often needed in the reconstruction of complex
facial defects. The article describes a simple technique to determine both
the volume of tissue required and the localization of the various epithelial
surfaces, thereby simplifying these complex reconstructions using an
intraoperative alginate moulage.
7. Pribaz J, Stephens W, Crespo L, et al. A new intraoral flap: facial
artery musculomucosal (FAMM) flap. Plast Reconstr Surg.
1992;90:421–429. First description of the FAMM flap by Pribaz et al.
combining the principles of nasolabial and buccal mucosal flaps. The flap
has proven to be reliable based either superiorly (retrograde flow) or
inferiorly (antegrade flow) to reconstruct a wide variety of difficult
oronasal mucosal defects, including defects of the palate, alveolus, nasal
septum, antrum, upper and lower lips, floor of the mouth, and soft palate.
8. Taghinia AH, Movassaghi K, Wang AX, et al. Reconstruction of the
upper aerodigestive tract with the submental artery flap. Plast
Reconstr Surg. 2009;123:562–570. The article demonstrates the versatility
of FAMM flaps specifically in lip and vermilion reconstruction. While lip
and vermilion are specialized tissues that cannot be easily reproduced,
FAMM flap has features similar to those of lip tissue that makes it an
option when such losses are encountered. In this article, the anatomy,
dissection, and clinical applications for the use of the FAMM flap in lip
and vermilion reconstruction are discussed.
11. Mathy JA, Pribaz JJ. Prefabrication and prelamination applications
in current aesthetic facial reconstruction. Clin Plast Surg.
2009;36:493–505. A review of prefabrication and prelamination techniques
in facial reconstruction. Some of their unique abilities are presented, and
their advantages, limitations, and technical pointers are provided.
Relevant features and interdependencies among these procedures as they
relate to aesthetic facial reconstruction are discussed.
13. Pribaz JJ, Fine NA. Prelamination: defining the prefabricated flap
– a case report and review. Microsurgery. 1994;15:618–623. First paper
to coin the term “prelamination” as modification of flaps prior to local or
distant transfer were gaining wide acceptance. This article also clarifies
the use of the term “prefabrication” which, until then, was used to
describe all possible modifications. In this article, the term
“prelamination” is used to refer to the implantation of tissue or other
devices into a flap prior to transfer and suggests that prefabrication be
restricted to the implantation of vascular pedicles.
Access the complete reference list online at

5. Reconstruction of stable bony platform with dental
implants in place.
6. Delayed use of forehead flap for resurfacing both the
cheek and mustache reconstruction.
7. Use of local flaps secondarily to provide better color
match and hair-bearing segments.
As evident from the patients presented, each case of second­
ary reconstruction is unique. While thinking “outside the box”
is no doubt necessary at times, adherence to the basic principles
demonstrated above will help guide the reconstruction.
Postoperative care
Postoperative care for each patient is unique and depends on
the specific procedure performed. In the early postoperative
period, this uniformly involves flap monitoring, perioperative
antibiotics, and appropriate scar management. It is usual and
safe practice to allow the patient and the involved tissue to
heal, the swelling to subside, and the scar to mature before
embarking on another tertiary procedure.
Outcomes, prognosis,
and complications
Multiple operations are often required to achieve a finally
acceptable outcome. This is discussed in detail with the
patient from the start and the plan modified on an “as
needed” basis. Realistic goals need to be communicated.
Depending on the complexity of reconstruction, the number
of secondary revisions necessary ranges from 2–3 for
relatively simple defects to exceeding 20–30 for more
complex defects. Once composite tissue allotransplanta­
tion becomes more widely available, patients with certain
defects, especially those involving the central triangle of
the face, should be pursued as transplant candidates. As
such, local and regional flap options might actually become
“lifeboats”.
On assessing our own outcomes, it is of foremost impor­
tance as reconstructive surgeons to listen to our patients as
they serve as our best teachers. Persistent complaints follow­
ing reconstruction can be a hint as to what we can do better.
To that end, we must strive to reintegrate the patient back to
normalcy through our reconstructive means.
Complications are, unfortunately, a part of performing
any complex reconstruction. Especially in areas of previous
irradiation and severe scarring, blood supply is suboptimal
and donor vessels are lacking. As Millard preached in
his writings, each reconstructive plan must have a life­
boat, preferably even a lifesaver in a lifeboat.15 For this
reason, when first approaching a problem, the surgeon
should go through the mental exercise of considering all
the different options before deciding on the best one. The
other options, hence, will serve as lifeboats when they
become needed.

462.e1
References
References
1. Bennett N, Choudhary S. Why climb a ladder when you can take
the elevator? Plast Reconstr Surg. 2000;105:2266.
2. Parrett BM, Pomahac B, Orgill DP, et al. The role of free-tissue
transfer for head and neck burn reconstruction. Plast Reconstr Surg.
2007;120:1871–1878.
3. Pribaz JJ, Morris DJ, Mulliken JB. Three-dimensional folded
free-flap reconstruction of complex facial defects using
intraoperative modeling. Plast Reconstr Surg. 1994;93:285–293.
Multifaceted free flaps are often needed in the reconstruction of complex
facial defects. The article describes a simple technique to determine both
the volume of tissue required and the localization of the various epithelial
surfaces, thereby simplifying these complex reconstructions using an
intraoperative alginate moulage.
4. Erol OO. Facial autologous soft-tissue contouring by adjunction of
tissue cocktail injection (micrograft and minigraft mixture of
dermis, fascia, and fat). Plast Reconstr Surg. 2000;106:1375–1387,
discussion 1388–1379.
5. Moseley TA, Zhu M, Hedrick MH. Adipose-derived stem and
progenitor cells as fillers in plastic and reconstructive surgery. Plast
Reconstr Surg. 2006;118:121S–128S.
6. Walton RL, Cohn AB, Beahm EK. Epidermal overgrafting improves
coloration in remote flaps and grafts applied to the face for
reconstruction. Plast Reconstr Surg. 2008;121:1606–1613.
7. Pribaz J, Stephens W, Crespo L, et al. A new intraoral flap: facial
artery musculomucosal (FAMM) flap. Plast Reconstr Surg.
1992;90:421–429. First description of the FAMM flap by Pribaz et al.
combining the principles of nasolabial and buccal mucosal flaps. The flap
has proven to be reliable based either superiorly (retrograde flow) or
inferiorly (antegrade flow) to reconstruct a wide variety of difficult
oronasal mucosal defects, including defects of the palate, alveolus, nasal
septum, antrum, upper and lower lips, floor of the mouth, and soft palate.
8. Taghinia AH, Movassaghi K, Wang AX, et al. Reconstruction of the
upper aerodigestive tract with the submental artery flap. Plast
Reconstr Surg. 2009;123:562–570. The article demonstrates the versatility
of FAMM flaps specifically in lip and vermilion reconstruction. While lip
and vermilion are specialized tissues that cannot be easily reproduced,
FAMM flap has features similar to those of lip tissue that makes it an
option when such losses are encountered. In this article, the anatomy,
dissection, and clinical applications for the use of the FAMM flap in lip
and vermilion reconstruction are discussed.
9. Pribaz JJ, Meara JG, Wright S, et al. Lip and vermilion
reconstruction with the facial artery musculomucosal flap. Plast
Reconstr Surg. 2000;105:864–872.
10. Ridgway E, Pribaz J. Reconstruction of male hair bearing facial
regions. Plast Reconstr Surg. 2011;127:131–141.
11. Mathy JA, Pribaz JJ. Prefabrication and prelamination applications
in current aesthetic facial reconstruction. Clin Plast Surg.
2009;36:493–505. A review of prefabrication and prelamination techniques
in facial reconstruction. Some of their unique abilities are presented, and
their advantages, limitations, and technical pointers are provided.
Relevant features and interdependencies among these procedures as they
relate to aesthetic facial reconstruction are discussed.
12. Guo L, Pribaz JJ. Clinical flap prefabrication. Plast Reconstr Surg.
2009;124:e340–e350.
13. Pribaz JJ, Fine NA. Prelamination: defining the prefabricated flap
– a case report and review. Microsurgery. 1994;15:618–623. First paper
to coin the term “prelamination” as modification of flaps prior to local or
distant transfer were gaining wide acceptance. This article also clarifies
the use of the term “prefabrication” which, until then, was used to
describe all possible modifications. In this article, the term
“prelamination” is used to refer to the implantation of tissue or other
devices into a flap prior to transfer and suggests that prefabrication be
restricted to the implantation of vascular pedicles.
14. Pribaz JJ, Weiss DD, Mulliken JB, et al. Prelaminated free flap
reconstruction of complex central facial defects. Plast Reconstr Surg.
1999;104:357–365, discussion 366–367.
15. Millard DR. Principalization of Plastic Surgery. Boston: Little, Brown;
1986.

SECTION II • Head and Neck Reconstruction
19 
Facial transplant
Michael Sosin and Eduardo D. Rodriguez
SYNOPSIS
■ Feasibility of face transplantation is well-established, and an extensive
vetting process for candidate selection using a multidisciplinary team
is recommended and likely to optimize patient outcomes.
■ Most facial defects will not warrant face transplantation, but those
patients considered for face transplantation should meet the
established indications and avoid contraindications and relative
contraindications described from the current experience.
■ Face transplantation requires meticulous technical planning and
practice using cadaveric and translational models. Computer aided
techniques increase the precision of technical outcomes.
■ Each facial defect and facial allograft is different; a combination of
craniofacial, microsurgical, and aesthetic principles of plastic surgery
should guide allograft design.
■ Face transplantation improves patient’s quality of life, but is not
considered lifesaving.
■ Allograft acute rejection is a phenomenon that must be recognized
clinically and initiation of treatment should not be delayed.
■ Standard maintenance immunosuppression includes orally
administered tacrolimus, mycophenolate mofetil, and corticosteroids.
Patients may deviate from the regimen based on co-morbidities and
the side-effect profiles of immunosuppressive agents.
■ Sensory and motor functions have a predictable pattern of restoration
ranging from days to months, and months to years, respectively.
Introduction
Clinical face transplantation has entered its 12th year in
existence and, as of June 2017 there have reportedly been 38
face transplants performed worldwide.1 This constantly
evolving surgical discipline is categorized as a specialty
within a broader field known as vascularized composite tissue
allotransplantation (VCA), defined as the transplantation of
multiple tissue types including bones, cartilage, tendons, liga­
ments, muscles, nerves, blood vessels, and skin. Facial trans­
plantation is reserved for a specific group of patients that have
suffered devastating facial deformity which is unable to be
adequately reconstructed using traditional reconstructive
techniques. Advances have been predicated on prior advances
including techniques and experience gained in reconstructive
microsurgery, innovation in new pharmacological agents
in solid organ transplantation, and pioneering surgical
approaches dedicated to improving their patients’ quality of
life, autonomy, and ability to socially integrate back into
society. Although the burgeoning field continues to expand at
a rapid pace, the broader application of face transplantation
for patients in need has yet to occur. Understanding the fun­
damental principles of facial transplantation is crucial to
interpreting outcomes and propelling future breakthroughs in
the field. This chapter specifically focuses on providing the
reader with a historical overview of facial VCA, ethical dilem­
mas, the process by which patients are evaluated for facial
VCA candidacy, allograft design within anatomical and tech­
nological contexts, an overview of outcomes, immunology of
face transplantation, and the future of the specialty.
Access the Historical Perspective section online at

Selection of patients
To consider a patient for face transplantation, a multidisci­
plinary team of specialists must evaluate multiple patient
factors.
Commonly,
patients
have
sustained
severely
deforming facial injury and may have undergone multiple
reconstructive procedures. The results of prior surgery often
fail to meet patient and surgeon expectations. Consequently,
patients will have lived with a facial deformity for years,
often relegating them to psychological, social, and daily
challenges. Aside from patients understanding the technical
obstacles of performing such complex surgery, other purposes
of the evaluation is to determine whether the patient fully
Access video lecture content for this chapter online at expertconsult.com