Sam Naficy and Shan R. Baker

Preparation of the Patient

Surgical restoration of the face may require a multistage procedure with a potentially protracted healing period before the final aesthetic outcome is evident. The initial reconstructive procedure is usually the most influential in predicting the aesthetic and functional result. Mucosa, cartilage, and facial skin are limited commodities. If the initial reconstructive effort squanders these resources through poor planning or surgical execution, subsequent options for surgical restoration are more limited. The surgeon must carefully analyze the facial defect and develop a cohesive surgical plan.

For many patients, the diagnosis of facial skin cancer and the perceived potential for unsightly scarring and distortion of facial features are traumatizing and create a great deal of anxiety. The patient must be prepared, emotionally and medically, through detailed explanation of the surgical plan. A thorough discussion of the required reconstructive procedure is helpful in creating a trusting relationship between patient and surgeon.

Preoperative Consultation

Most of our patients undergo micrographic (Mohs) surgery for a cutaneous malignant neoplasm. We work with the referring dermatologic surgeon to provide an efficient and convenient coordination of care. Every attempt is made to schedule reconstruction on the day after micrographic surgery. To enable a smooth transition between the two procedures, all patients are seen preoperatively by the dermatologic surgeon and the facial plastic surgeon. The consultation provides the opportunity to anticipate the extent of the defect to be repaired, to assess the aesthetic demands of the patient, and to discuss the reconstructive options. Depending on the location and anticipated size of the defect, patients may be provided with several reconstructive options.

Consideration is given to the patient’s age, occupation, and aesthetic demands. As a general rule, younger patients have the highest aesthetic concerns and are more willing to tolerate a complex, multistage operation to obtain an optimal aesthetic result. Many older patients also have high aesthetic standards, but some are willing to compromise the outcome in return for a single-stage operation with a more rapid recovery. The occupation of the patient may influence the choice of reconstructive procedures. For example, patients having occupations that require considerable public interaction are unable to perform their duties during the initial stage of reconstruction in which an interpolated forehead flap is used. The interpolated cheek flap, however, may be covered with a surgical bandage and allow the patient an earlier return to his or her occupation. Occupational use of corrective or protective eyewear or protective headwear should be considered when an interpolated paramedian forehead flap is required because the patient may not be able to use these items during the interval between flap transfer and pedicle detachment.

Factors are considered that may influence the extent of the facial defect. These include tumor size and depth, histologic features, and whether the tumor represents a recurrence. Recurrent tumors or those with aggressive histologic features often require significantly larger excisions of tissue than may be anticipated.

Most patients have a difficult time visualizing flaps used in facial reconstruction. This is especially true in the case of interpolated cheek and paramedian forehead flaps. To prepare patients, they are shown a photograph album displaying representative preoperative and postoperative photographs of their anticipated operation. For staged repairs, such as with interpolated flaps, photographs are shown that display an individual at each stage of the reconstruction. We have found this to be especially useful for younger patients, for whom the shock of the initial deformity caused by an interpolated flap, without prior visual preparation, can be devastating and may create in the patient a feeling of hostility or resentment toward the surgeon. Photographs also allow patients to view the outcome of representative examples of different reconstructive techniques. The scar and differences in skin color and texture in the area of reconstruction are pointed out, particularly to those patients with the greatest aesthetic concerns. For realistic expectations to be developed of the outcome, patients with fair to average surgical results are included in the photograph album. A realistic estimate of when the patient may return to work and social activities is discussed, aided by photographs of representative reconstructive sequences.

The average number of surgical procedures and length of time required to complete all stages of the reconstruction are discussed with the patient (Table 5-1). In cases of repair of the nose, when an interpolated covering flap is planned, the reconstructive sequence includes initial flap transfer, pedicle division 3 weeks later, a contouring procedure 2 or 3 months after pedicle division, and possibly dermabrasion in the office 2 months after contouring of the flap. We therefore advise patients that up to 6 months may be necessary for the restoration to be completed.

Preoperative consultation with the patient is ideally scheduled 4 to 6 weeks before surgery, allowing adequate time for the patient to stop anticoagulant agents. Medications to be avoided beginning up to 3 weeks before surgery include all nonsteroidal anti-inflammatory drugs and vitamin E supplements (Table 5-2). Coumadin should be discontinued 3 to 5 days before surgery. A number of herbal supplements also possess anticoagulant properties and should be avoided.

A medical history is obtained from the patient, and a physical examination is performed as part of the consultation. The general health of the patient is noted, with special attention given to hypertension, symptomatic coronary artery disease, and smoking history. Smokers are strongly encouraged to quit and are instructed on the higher risk of complications for users of tobacco products. An electrocardiogram is obtained for all men older than 40 years and women older than 50 years. All patients older than 60 years are tested for hematocrit and blood levels of urea nitrogen, creatinine, and glucose (Table 5-3). During the physical examination, note is made of prior facial cutaneous surgery or ear surgery involving the cartilage. The patient is examined for scars on the face that may potentially influence the design of flaps. The redundancy of the facial skin is assessed, particularly in the area of the anticipated cutaneous defect. The position of the anterior hairline is noted when a paramedian forehead flap for nasal reconstruction is anticipated. Patients with low hairlines are informed about the possibility of the flap’s extending to hair-bearing scalp and the need for subsequent depilation procedures on the nose.

We provide patients with prescriptions for medications at the time of preoperative consultation (Table 5-4). Oral diazepam (5 to 10 mg) is prescribed for patients younger than 70 years with instructions to take it the evening before and 1 hour before the operation. Benzodiazepines help reduce preoperative anxiety and counteract the toxic effects of local anesthetics used during the procedure. In instances in which skin or composite grafting is planned or cartilage and bone grafting is anticipated, patients are given a postoperative course of an oral antistaphylococcal antibiotic for 5 to 7 days. A tapering dose pack of prednisone is prescribed for those patients undergoing composite grafting. An analgesic of choice is prescribed in appropriate quantity. In addition to the standard medications, those patients requiring a forehead flap are prescribed a 2-day supply of antiemetic suppositories.

Patients are encouraged to visit the office on the day of their micrographic surgery after completion of tumor resection. This visit enables the surgeon to examine and photograph the defect and to confirm or modify the surgical plan. This visit is often reassuring to the patient and allows the surgeon sufficient time to make adjustments and alterations of the surgical plan and the operative schedule.

Photography

The senior author’s technique for photography has been consistent during the past 12 years. Most photographs in the chapters he has authored in this book were obtained by the following setup. For in-office photographs, the system uses two Canon EOS Digital Rebel XT camera bodies, each outfitted with Canon zoom 18-55mm f/3.5-5.6 lenses. Two ceiling-mounted strobe flashes are aimed at an angle of 25° to 30°, 6 feet from the subject. The strobe flashes are hard-wired to the camera bodies for synchronization. A backlight illuminates a blue background to eliminate shadow. Blue is chosen as the background color as it provides an excellent contrast to the color of flesh and hair.

Photography in the operating room is accomplished with a Nikon D90 12.3-megapixel digital camera body attached to a Nikkor AF-S Micro 60mm f/2.8G ED lens. The camera is equipped with a built-in flash for close-up photography. The operating room lights are turned away from the subject because they give an undesirable yellow color to the photograph. In the operating room, a blue or green surgical towel often serves as an adequate substitute for the photographic background.

Photographic documentation includes those views that illustrate the facial defect. These typically consist of a full-face frontal view, with oblique and lateral views on the side of the defect. If the defect involves the nose, a base view is also obtained. Close-up views of the defect may be obtained when it is appropriate. For nasal cutaneous malignant neoplasms, we have found it helpful to obtain photographs of the lesion at the time of initial consultation, before surgery. Photographs of the defect are obtained in the office photography suite if the patient is seen on the day before repair. Otherwise, photographs are obtained in the holding area or operating suite with proper regard for light and background.

Anesthesia

Monitored anesthesia care is appropriate for the majority of facial reconstructive procedures, including all skin grafts, local or regional flaps, and cartilage grafts. The patient is placed on a head/neck surgery stretcher with the head of the stretcher turned 90° to 120° from the anesthetist but near enough to the anesthetist to allow manipulation of the airway if necessary (Fig. 5-1). The patient is positioned supine without a special headrest. A doughnut-shaped foam pillow is placed under the patient’s head, and a towel roll supports the shoulders. A standard-sized pillow is placed under the knees to provide flexion and to reduce back strain. The stretcher is placed in an appropriate degree of reverse Trendelenburg’s position to reduce venous pooling in the face. Oxygen is administered at the rate of 2 to 4 L/min by nasal cannula tubing either nasally or orally. Preoxygenation reduces the toxic effects of local anesthetics and accommodates brief periods of apnea caused by intravenous sedation. To prevent the risk of fire, it is important to reduce or to stop the flow of oxygen when cautery is performed in the area of the nasal cannula openings.

After adequate oxygenation, the patient is given a bolus of intravenous sedatives and narcotics, achieving an adequate depth of anesthesia to enable the surgeon to infiltrate the local anesthetic. It is not uncommon for the patient to require a chin thrust at this point to prevent transient apnea. After infiltration of the local anesthetic, the patient is maintained at an appropriate level of intravenous sedation for the duration of the procedure.

General anesthesia is used when cranial bone grafting is performed or when large septal mucoperichondrial flaps are required to repair full-thickness nasal defects. An oral RAE tube taped in the midline to only the lower lip and chin offers the least amount of obstruction and distortion of the surgical field. An alternative is the use of laryngeal mask ventilation. The nose and face are painted with iodine, and a surgical drape is wrapped around the head in a turban fashion, exposing the entire face and donor sites if applicable. The eyelids are taped closed, and moistened eye pads are placed over the eyes to protect them from the intense overhead light and accidental injury. A preoperative intravenous dose of an antistaphylococcal antibiotic is administered when grafting is performed.

Local Anesthesia

The four methods of local anesthesia applicable to local flap surgery are topical, local infiltration, field block (ring block), and peripheral nerve block. Topical anesthesia and vasoconstriction of nasal mucosa are performed for all procedures in which the inside of the nose is manipulated. In such instances, × 3-inch surgical cottonoids moistened with an equal mixture of topical lidocaine 4% and oxymetazoline hydrochloride are used to apply the mixture to nasal mucosa. The topical medicine is left in contact with the nasal mucosa for a few minutes before injection of the mucosa with local anesthetic. The septum is injected in the subperichondrial plane with a 27-gauge needle and a 3-mL syringe for adequate hydraulic force.

It may be useful to perform nerve blocks before local infiltration of the face (Fig. 5-2). An anesthetic block of the midface can be obtained by infiltrating the infraorbital (V2) nerve as it exits the maxilla. The nerve exits the infraorbital foramen 1 cm below the level of the inferior orbital rim, vertically aligned with the pupil. The nerve is blocked by injecting 1 mL of lidocaine (1% with 1 : 100,000 concentration of epinephrine) just above the periosteum around the site of exit of the nerve from the foramen. The injection may be performed percutaneously with a 30-gauge needle or through the gingivobuccal sulcus with a 27-gauge needle. The external nasal branch of the anterior ethmoidal nerve supplies the skin of the caudal half of the nasal dorsum and most of the tip. This nerve is blocked by injection of anesthetic in the subfascial plane of the nasal sidewall at the junction of nasal bone and upper lateral cartilage approximately 1 cm lateral to the midline. The infratrochlear nerve supplies the skin of the upper nasal vault. This nerve is blocked by infiltration of anesthetic under the thin skin of the lateral bony nasal sidewall, medial to the medial canthus. Bilateral blocks of all of the nerves discussed will result in anesthesia of the majority of the skin and soft tissue of the nose, medial cheek, and upper lip. The forehead can be anesthetized by a nerve block of the supraorbital and supratrochlear nerves. The supraorbital nerve exits its foramen and extends superiorly toward the scalp in a line that is directly vertical to the pupil. The supratrochlear nerve ascends toward the scalp in a line that is a vertical tangent to the medial limits of the eyebrow. This line is 1.5 cm lateral to the midline. The skin of the lower lip and chin can be anesthetized by blocking the mental nerve. This nerve exits the mental foramen, which is located at the midpupillary line.

In addition to any specific nerve block, local anesthetic solution is injected in the planned plane of dissection and more superficially to the level of the subdermis by multiple punctures with a 30-gauge needle. A longer, 27-gauge needle is used for injection of the septum and turbinates and for infraorbital nerve blocks.

Choice of local anesthetic depends on the length of the procedure and the desired amount of postoperative analgesia. Procedures lasting less than 1.5 hours are performed with lidocaine (1% with 1 : 100,000 concentration of epinephrine). Longer anesthesia of up to 2.5 hours may be obtained by use of lidocaine (2% with 1 : 100,000 concentration of epinephrine). One of our preferred local anesthetic formulations prepared just before injection is an equal (1 : 1) mixture of lidocaine (1% with 1 : 100,000 concentration of epinephrine) and bupivacaine (0.25% to 0.5% without epinephrine). The lidocaine provides immediate anesthesia and vasoconstriction, whereas the longer acting bupivacaine provides an additional 3 to 6 hours of anesthesia. The lidocaine compensates for the longer onset of action of bupivacaine. The diluted epinephrine in the mixture is just as effective for hemostasis because there is no additional vasoconstrictive benefit with concentrations of epinephrine greater than 1 : 200,000.

Postoperative Care

Written postoperative instructions that cover general wound care (Table 5-5) are provided. Patients are provided with an adequate supply of cotton-tipped applicators, hydrogen peroxide, and antibiotic ointment. Patients are instructed to avoid heavy lifting, bending, straining, and nose blowing if nasal reconstruction has been performed. There are other postoperative instructions specific to each procedure.

Hospitalization

The majority of cases of facial reconstruction are performed on an outpatient basis. There are two categories of patients who are admitted overnight after the procedure. Patients requiring hinged septal mucoperichondrial flaps are often admitted for observation and to decrease risk of early postoperative bleeding. Patients requiring cranial bone or rib grafting are admitted for pain control and because of the prolonged duration of such operations. Patients requiring interpolated paramedian forehead flaps are occasionally admitted for control of pain and nausea. Nausea and vomiting are not uncommon after use of wide (3 cm or greater) forehead flaps and are presumably due to tension on the galea aponeurotica.