Ординатура / Офтальмология / Английские материалы / Reconstructive Facial Plastic Surgery A Problem-Solving Manual_Weerda_2001

Fig. 6.57 Elongation of the oral fissure by the Ganzer method.

aAn epithelial triangle is excised following measurement of lip length. An incision is made around the vermilion without dividing it.

bThe entire vermilion is advanced laterally and sutured into the defect.

Fig. 6.58 Elongation of the oral fissure by the method of Gillies and Millard (1957).

aAfter the necessary elongation is determined, a triangular segment of skin is excised lateral to the rounded commissure, and a vermilion flap is raised from the lower (or upper)

lip.

bThe vermilion flap is rotated laterally, and the remaining tissue is excised down to the oral mucosa.

cThe mucosal flap is mobilized to form the vermilion of the lower lip.

dBoth flaps are sutured into the upper and lower lip defects (using 6−0 or 7−0 monofilament).

e Two-part mucosal flap from the cheek.

Coverage of Small Defects in the

Chin Area

(See also Scar Revision pp. 6, 7, 8, 68, 69)

a Burow’s triangle is excised at the mandibular angle for closure of the secondary defect.

Bilobed Flap

(Fig. 7.2a, b)

Advancement Flap

(Fig. 7.1)

Small defects in the chin area can be covered by advancement of the lateral inferior cheek (Fig. 7.1). The incision is placed below the mandibular border, and

A submental bilobed flap provides a very simple method for repairing this kind of defect.

Fig. 7.1 a, b Burow’s hookshaped cheek advancement flap, used here to resurface a defect on the chin.

Fig. 7.2 a, b Defect repaired with a bilobed flap.

Medial Cheek Defects

Upper Medial Cheek

Esser Cheek Rotation (1918)

(Fig. 8.1)

The Esser cheek rotation can be used to reconstruct portions of the nose as well as the medial cheek (see also Fig. 5.50a). From the defect, the incision extends along the lower eyelid and up into the temporal area, then curves down in front of the ear, where it may run a short distance back below the earlobe if necessary. It then proceeds downward and forward behind the mandibular angle (Fig. 8.1). The circumscribed flap is mobilized in the fat plane and rotated forward. Ectropion is prevented by fixing the flap to the periosteum of the infraorbital region. Burow’s triangles are excised to close the secondary defect. If greater rotation is needed, the submandibular limb of the incision can be extended. The surgeon should not dissect too deeply in the fat, especially in the temporal area, as this could damage intact facial nerve branches.

Cheek Reconstruction Combining the

Methods of Esser (1918) and Imre (1928)

(Weerda 1980)

(Fig. 8.2)

For defects of the medial cheek and lower eyelid area, it may be necessary to combine the Esser flap with a nasolabial advancement. We have obtained good overall cheek mobility by combining the Esser rotation with a two-layer crescent-shaped excision in the nasolabial fold.

Small Cheek Defects

Small defects are repaired with transposition or rotation flaps, and small bilobed flaps can also be used (see pp. 6, 13−17, 22; Figs. 3.1b and 3.22). Defects in the nasal flank area can be closed by a Burow-type cheek advancement with a Burow’s triangle (Fig. 8.3) or by excising a skin crescent in the nasolabial angle (see Fig. 8.4).

Fig. 8.1 Esser cheek rotation (1918). The flap is cut somewhat higher in the temporal area to provide excess tissue at the lower lid (to prevent ectropion). It is fixed to the periosteum of the orbital rim, and the cheek skin is mobilized (sparing the branches of the facial nerve).

Fig. 8.2 Cheek reconstruction combining the Esser and Imre techniques (Weerda 1980). A crescent-shaped excision in the nasolabial fold is added to the Esser rotation (see Fig. 8.1). The flap is mobilized in the fat plane to avoid facial nerve injury (see Fig. 9.10).

Imre Cheek Advancement Flap

(After Haas 1973, Modified)

(Figs. 8.4 and 8.5)

Modified Esser Cheek Rotation For Nasal

Flank Defects

(Fig. 8.6)

This rotation flap is developed somewhat higher into the temporal area, and a cut is made around the earlobe, where a second Burow’s triangle is placed. If the flap is not sufficiently mobile, the incision can be extended (see p. 84 and Fig. 8.1).

Defect in the Medial Canthus

(Fig. 8.7)

A medial defect can be repaired with an Imre cheek rotation flap combined with a rotation flap from the forehead (see Figs. 5.2−5.8).

Fig. 8.5 Modified Imre flap. The scar is located in the alar groove.

Fig. 8.7 a, b Imre cheek rotation combined with a small forehead flap to repair a defect involving the cheek and medial canthal area (see Figs. 5.2−5.8; see also Fig. 8.2).

Inferiorly based bilobed flaps are particularly suitable for elderly patients (Dean et al. 1975; Weerda

1983). The secondary lobe may be placed behind the ear or in the upper neck (Fig. 8.8a, b).

Fig. 8.8 a, b Inferiorly based bilobed flap. c Modified bilobed flap for larger defects.

V-Y Advancement

(Fig. 8.9)

Upper and Posterior Cheek

Trilobed Flap of Weerda (1979)

(Fig. 8.10)

Occasionally a bilobed flap is insufficient for repairing a cheek defect, which requires one lobe between the ear and defect (Fig. 8.10a), a second lobe behind the ear, and a third lobe in the lateral neck.

As in an Esser cheek rotation, the lower limb of the third lobe may be extended below the mandible. Closure of the secondary defects may require the excision of Burow’s triangles (Fig. 8.10b).

Fig. 8.10 Trilobed flap of Weerda (1979).

a Trilobed flap for a defect in the temporal region consists of a preauricular lobe (1), a retroauricular lobe (2), and a neck lobe (3).

bThe completed repair. All defects can be closed by excising Burow’s triangles and mobilizing the surrounding skin.

Bilobed Flap

(Fig. 8.11)

A defect involving the lateral cheek or earlobe area can be repaired with a retroauricular bilobed flap (Fig. 8.11a). The somewhat smaller secondary lobe is raised from the side of the neck (Fig. 8.11b).

Lateral Cheek Defects

Small Lateral Cheek Defects

These defects can be repaired with various flaps, such as transposition flaps (Fig. 8.12), the trapezoidal flaps described by Limberg or Dufourmentel (Fig. 8.13; see Figs. 3.24−3.27), by flap advancement, or by Z-plasties (Figs. 8.14 and 8.15).

Fig. 8.12 a, b Small preauricular transposition flap (can be cut slightly smaller than the defect). Scar revision may be necessary as a secondary procedure.

Fig. 8.14 a, b Double advancement flap (see Fig. 3.1).

Fig. 8.15 a, b Small cheek defect repaired by a Z-plasty (see Figs. 2.15 and 4.1).

Small Preauricular Defects

Small preauricular defects can be covered by advancing tissue from the retroauricular neck area (Fig. 8.16).

Simple Skin Advancement

and Rotation (Burow’s Method)

(Fig. 8.17a−d)

Wedge-shaped defects of the lower lateral cheek can be repaired by a simple Burow skin advancement (Fig. 8.17a, b). For a round or oval defect, we use rotation flaps from the upper neck (Fig. 8.17c, d).

Opposing Transposition Flaps

(Fig. 8.18)

If the primary reconstruction flap can be raised in the preauricular area (Fig. 8.18a), the secondary defect can be closed with an inferiorly based retroauricular flap. The tertiary defect can then be covered by mobilization (Fig. 8.18) or with a thick split skin graft (e.g., from the buttock).

Fig. 8.16 a, b Skin advancement from the retroauricular area.

Fig. 8.17 Burow’s flap advancement.

a Wedge-shaped defect with a superior base. A retroauricular Burow’s triangle is excised.

b The completed repair.

cA circular defect is covered with a rotation flap from the

upper neck.

d The completed repair.

Large Defects Involving

the Auricle

A large defect involving the auricle can be repaired by transposing a posterosuperiorly based bilobed flap with a submandibular secondary lobe (Fig. 8.19).

Lateral Cheek Rotation of Weerda

(1980c)

(Figs. 8.20 and 8.21)

Moderate-sized preauricular cheek defects can be repaired with a superiorly based cheek rotation flap (Fig. 8.20). A transposition flap with V-Y advancement can be used in the inferolateral cheek area (Fig. 8.21).