Direct closure
(Soliman, Plast Reconstr Surg 2011; Rapstine, Plast Reconstr Surg 2012)
- Usually not an option for larger defects
- Minimize vertical tension when near the eyelid.
- Close the deep layer with buried absorbable sutures, typically 4-0 or 5-0 polyglactin (Vicryl) or poliglecaprone 25 (Monocryl) suture.
- Skin can be closed with 5-0 or 6-0 polypropylene, nylon, or plain gut absorbable suture.
- Conservatively excise Burow's triangles at the end of the closure if a standing "dog-ear" deformity is present.
Local flaps
Advancement
(Patrinely, Surv Ophthalmol 1987; Hayano, J Skin Cancer 2012; Patel, Op Techniq Otolaryngol 2012; Lee, OPRS 2012)
- Meticulous dissection in the appropriate plane is crucial to avoid damage to the facial nerve.
- Involves the advancement of surrounding tissue along a linear axis to close the defect.
- Length-to-width typically a ratio of 3:1 to avoid tip necrosis. Longer flaps of 4:1 can be created if based along a named larger artery.
- Often creates "dog ear" deformities, which must be addressed as part of the reconstruction plan. Dog ear deformity occurs when one side of an incision has more tissue than the other side. To correct the problem, excess skin must be excised from the side with excess skin. Options to repair these iatrogenic deformities include
- Use of Burow's triangle (triangular wedge of tissue excised from side with excess skin)
- Use of a hockey stick or elliptical incision
- Lengthening the defect to ensure similar tissue quantity on both sides of the incision
- A to T, V to Y, and island pedicle flaps are examples of advancement flaps. Island flaps maintain a subcutaneous pedicle from the original flap, which is transferred to the defect.
- A to T/O to T (T-plasty):
- Transforms an A- or O-shaped defect into a T-shaped scar by advancing 2 flaps on opposite sides of the defect toward each other
- Useful for the forehead, lip, and chin
- V to Y:
- V-shaped flap is moved into the defect and the secondary triangular defect is closed by approximating the 2 wound edges, creating a Y-shaped scar.
- Useful for the medial canthus, forehead, and nose
- Can be used in the cheek, but care should be taken to avoid vertical tension and resulting ectropion of the lower lid
- Island pedicle flap:
- Recruits skin and subcutaneous tissues with a reliable vascular supply
- Allows for larger flaps with good viability
- Useful for the cheek, eyebrow, nose, and medial canthus (Figures 1–3)
Figure 1. Left cheek and lower eyelid defect measuring 7.5 cm x 5 cm after excision of melanoma in situ.
Figure 2. One week after reconstruction with cervicofacial advancement flap, canthoplasty, and full-thickness skin grafts to left lower eyelid and temple area to cover secondary defects. Note the standing cutaneous deformity near the left oral commissure.
Figure 3. Two months after second stage procedure with removal of the standing cutaneous deformity.
Rotational
(Patel, Op Techniq Otolaryngol 2012; Ebrahimi, J Craniofac Surg 2013)
- Good tissue match
- Require preoperative planning to minimize secondary deformities
- Pivoted around a fixed point at the base of the flap, and rotated on an arc toward the defect
- Rotated on an arc of 30º or less with the radius 2–3 times the diameter of the defect, and the arc length approximately four to five times the width of the defect
- To minimize standing cutaneous deformity, closure of a triangular defect should have 2:1 height to width ratio.
- Examples include O to Z, cervicofacial, and glabellar flaps (Figures 4–6). O to Z:
- Double rotational flap at opposing sides of a circular or oval defect
- Pedicles are created 180º from each other.
- Each flap is advanced, rotated, and fixed 90º from its incision point.
- Flaps can be equal or unequal length depending on surrounding tissue, but closure tension is least with equal flap lengths and angle.
- Converts a circular defect into a Z shaped closure
- Useful for defects of the forehead, scalp, eyelid, and cheek — where tissue is available on both sides of the defect
- Cervicofacial:
- Extended form of the Mustarde flap
- Facial skin lateral and inferior to the defect is rotated in to allow closure.
- Incision begins at lateral superior edge of defect, proceeds down the preauricular skin, and then inferiorly into the neck.
- Due to the size of the flap, helpful to include platysma in the flap for improved vascularity
- Useful for large defects of the cheek, temple, and lower eyelid
- When used in the cheek and lower lid, often requires concurrent stabilization of the lower lid with canthoplasty
- Glabellar:
- Transfers skin from the glabellar region to cover defects of the side of the nose and medial canthal region
- Taken from hairless area between eyebrows and adjacent forehead, pivoting around the superior orbital foramen on the opposite side from the defect
- Triangular flap with apex pointing upwards, secondary triangular defect is closed by approximating wound edges.
Figure 4.
Figure 5.
Figure 6.
Transpositional
(Patel, Op Techniq Otolaryngol 2012; Ibrahim, J Craniofac Surg 2012)
- Versatile flaps that create a secondary defect
- Flap is raised from a donor site over an incomplete bridge of skin to be placed into the defect site.
- The donor site must also be closed as part of the design.
- Examples include rhombic, bilobed, and Z-plasty.
- Rhombic:
- Square flap tilted toward one side, used to repair defects with rhombus or diamond shape
- Transfer involves advancement of tissue with a pivot point.
- Classic description by Limberg has two 60º angles and two 120º angles: 2 equilateral triangles placed base to base.
- Can be modified as needed to fit size of defect
- Most tension is at closure of donor site.
- Up to 4 rhombic flaps can be designed for a defect.
- Tissue extensibility and surrounding mobile structures should be taken into account when designing flap.
- Useful for the cheek and temple
- More difficult to hide this scar in relaxed tension lines
- Bilobed:
- Double transposition flaps that share a common base
- The greater the arc of rotation, the greater the standing cutaneous deformity
- Linear axis of each lobe should not be more than 45º from each other.
- The central lobe is moved in to fill the primary defect, then the second smaller lobe is moved in to fill the secondary defect.
- Advantage is recruitment of redundant skin from area that is not adjacent to the defect.
- Useful for the nose and the cheek
- Z-plasty:
- Double transposition of triangular flaps with independent pivot points
- 3 arms of Z should be same length.
- 60º angles are adequate for most repairs.
- Useful for scar revision with the scar positioned in the central limb of the Z
- Useful on forehead, cheek, lids, and for medial canthal webbing
- Multiple adjacent z-plasties can be used for larger scars.
Interpolated
(Patel, Op Techniq Otolaryngol 2012; Kim, Arch Plast Surg 2013)
- Pedicled flap that cross over or under intervening intact tissue
- The flap must be divided in a second stage of reconstruction.
- In contrast to transposition flaps, the base of interpolated flaps is not contiguous with the defect base.
- Examples include paramedian forehead and melolabial flaps, although the paramedian flap can be modified by removing the epidermis from the segment that passes under the bridge thereby making it a one-stage reconstruction without the need for later separation.
Free skin graft
(Patel, Op Techniq Otolaryngol 2012; Angelos, Fac Plast Surg Clin North Am 2013)
- Match like-tissue to like-tissue.
- If possible, avoid placing hair-baring skin in locations that do not usually have hair.
- May cause color mismatch and skin surface irregularity.
- Frequent graft contracture may occur. When placed on the lower lid, a temporary Frost tarsorrhaphy to elevate the lower lid and graft upwards may be useful in minimizing contracture.
- Small venting incisions within the graft to allow egress of serosanguinous fluid can help prevent graft failure if bleeding occurs.
Microvascular free flap
(Patel, Op Techniq Otolaryngol 2012; Thorwath, Oral Maxillofac Surg, 2008; Angelos, Fac Plast Surg Clin North Am 2013)
- Time and resource intensive
- Requires advanced techniques. Must have anastomosis donor arterial and venous supply to host site vasculature.
- Typically taken from the radial forearm (radial artery) or anterolateral thigh (descending branch of the lateral circumflex femoral artery)
- Often a poor match in skin color and texture
Tissue expansion
(Cannon, OPRS 2011)
- Primarily used in breast and burn reconstruction
- By increasing the surface area of tissue adjacent to a defect, tissue expanders enable repair by local tissue transfer.
- Once tissue expander is placed, saline is used to inflate the expander. Typically inject 1–2 cc of saline each 1–2 weeks. May take 3–4 months to achieve adequate expansion. Be careful not to overinflate, or may cause overlying skin necrosis.
- 35–60% increased skin surface area created.
- Once adequate expansion is created, the defect can be closed with rotational or transposition flap.
- Requires multiple surgical procedures and clinic visits
Acellular human dermal matrix
(AlloDerm, LifeCell, Bridgewater, NJ) (Levin, OPRS 2011)
- Useful adjunct for large periocular defects in patients who are not good candidates for skin grafts or local flaps due to comorbid conditions
- Allows for epithelium to grow over the dermal matrix
Negative pressure wound therapy
(Semlacher, OPRS 2012)
- NPWT at 75 mm Hg can expedite wound healing and improve skin graft survival.
- Has been shown in case report to be safe in the periocular area, with no long-term effect on vision or intraocular pressure (IOP). IOP should be monitored while on NPWT.