CONTRAINDICATIONS

There are no absolute contraindications to the use of this flap. The surgeon should be cautious in patients with a history of poor wound healing and smoking.

PREOPERATIVE PLANNING

A thorough medical history, in particular, a history of prior radiation to the face and neck, diabetes, malnutrition, autoimmune disease, and smoking should be obtained. Physical examination should make note of any facial nerve deficits, prior facial or neck incisions, cervical or parotid lymph adenopathy, extent of the tumor to be resected or defect to be reconstructed, and actinic changes of the skin. If the defect is being created for the treatment of malignancy, such as cancer of the skin, a delayed reconstruction may be of benefit so as to ensure that final tumor margins are negative. It is also important to know if other procedures such as parotidectomy or neck dissection will be required as this will also influence the timing of the reconstruction as well as the placement of incisions.

SURGICAL TECHNIQUE

The patient is placed in the supine position on the operating room table. Depending on the extent of resection and reconstruction as well as surgeon and patient preference, the procedure may be performed under general anesthesia or monitored anesthesia care.

A number of factors will determine the best reconstructive approach including the size, location and depth of the defect, the involved layers in the defect, the relationship between the defect and aesthetic units and subunits, as well as patient factors such as a history of smoking, autoimmune disease, or radiation therapy. The general principles of flap design and elevation are such that the flap to be inset should be under minimal tension and should require the least amount of resection of normal skin (i.e., for management of dog ears). The incisions should be made in a stepwise fashion, reassessing the extent of tissue rotation and suture line tension prior to each subsequent incision. Depending upon the size and location of the defect, an anteriorly based or posteriorly based flap may be elevated.

Anteriorly Based Flap

This flap is also referred to as the forward cervicofacial advancement flap or the inferiorly based cervicofacial advancement flap. A horizontal incision is made at the posterior–superior aspect of the defect along the inferior orbital rim, carried superiorly to the lateral canthus and then inferiorly into the preauricular crease. The incision is then carried inferiorly behind the earlobe and into the neck along the hairline. A back cutting incision may be required, and this may be placed in a crease in the neck. For larger defects, a cervicothoracic or cervicopectoral flap may be used. In this case, the incision along the hairline is carried inferiorly into the lower neck, staying 1 to 2 cm posterior to the anterior border of the trapezius, then creating a curvilinear incision that runs lateral to the acromioclavicular joint, stays along the lateral edge of the pectoralis muscle and then extends medially on the chest, parallel to the clavicle. The medial incision is usually placed at the level of the third intercostal space (or just above the areola in males) although it may be carried down to the costal margin if needed.

The flap is elevated superficial to the SMAS layer and parotideomasseteric fascia in the subcutaneous plane thereby avoiding the branches of the facial nerve. If the flap elevation is carried inferiorly, it can be elevated superficial or deep to the platysma. With elevation deep to the platysma, dissection should be kept in the subplatysmal plane to minimize the risk of injury to the marginal mandibular branch of the facial nerve. If dissection is carried onto the chest, elevation is in the plane deep to the deltoid and pectoralis fascia. Care should be taken to avoid injury to the internal mammary perforators, which arise about 2 cm lateral to the lateral border of the sternum.

As the flap is advanced into the defect in question, the edges are trimmed accordingly. A standing cone deformity will normally occur at the medial–inferior incision line usually in the melolabial groove; the greater the rotation of the flap, the larger the deformity. This can be addressed primarily once the flap is inset. Closure of the donor site is usually achieved primarily and occasionally by V-Y advancement or with skin grafting. Placement of a suction drain will minimize hematoma or seroma formation especially when more extensive dissection is carried out.

Posteriorly Based Flap

Stay updated, free articles. Join our Telegram channel

Join