Case 1

A 52-year-old man presented for excision of atypical junctional melanocytic hyperplasia of the cheek and lower eyelid. This skin abnormality is considered to be at high risk for transitioning to an invasive melanoma. Margins free of disease around the lesion were obtained by the square technique. (See discussion of the square technique in Chapter 8, Case 3.) This resulted in an area requiring resection that measured 4 × 4-cm (Fig. 16-1). The patient’s facial skin was taut and the area of skin excision large relative to the total surface area of the cheek. A rhombic flap was designed for repair of the cheek defect after resection of the lesion. Although the rhombic flap was designed correctly, when the flap was transposed to the recipient site after excision of the skin lesion, excessive wound closure tension was noted. The tension caused a downward pull on the lower eyelid skin, raising concern for retraction or even ectropion of the eyelid. For this reason, a full-thickness skin graft was used to assist with repair. The graft was harvested from the standing cutaneous deformity resulting from pivoting of the flap. The skin graft was positioned between the distal border of the flap and the lower eyelid. This completely relieved wound closure tension, and the wound healed without distorting the eyelid. The proximity of the donor site and the recipient site of the skin graft ensured the best possible skin color and textural match with adjacent facial skin.

A patient with the same disease as in Case 1 is shown in Figure 16-2. It was necessary to resect a large area of cheek skin in addition to skin of the lower eyelid. In this case, a superiorly based transposition flap was selected for repair to facilitate recruitment of skin for construction of the flap from the jowl area. The jowl region has the greatest skin redundancy of the face. The defect was too large to completely cover with a transposition flap without causing excessive wound closure tension. In this case, such tension was likely to cause lower eyelid retraction or ectropion. To prevent distortion of the lower eyelid, a full-thickness skin graft was used to cover the eyelid component of the defect after resection of the skin lesion. The skin from the standing cutaneous deformity resulting from transfer of the flap (vertical lines of flap marked in Fig. 16-2A) was excised and used as the source for the skin graft. The skin graft served the purpose of reducing overall wound closure tension. It also enabled the use of separate and different skin to reconstruct a defect involving two aesthetic regions of the face, the cheek and eyelid. This in turn facilitated a more distinct topographic separation of the eyelid from the cheek. The skin of the standing cutaneous deformity was non–hair-bearing skin. This skin was also thinner than the skin of the lower face. Both of these qualities made the standing cutaneous deformity of the transposition flap the ideal donor site for the full-thickness skin graft. In this case, the skin graft did not survive completely. As a result, the patient developed a minor ectropion of the lower eyelid. The possible partial or complete failure of the skin graft is one of the disadvantages of combining skin grafts with local flaps to repair facial defects. The other major disadvantage of the combined approach is the possible discrepancy of skin color and texture between flap and graft. However, this is uncommon when the source of the graft is the standing cutaneous deformity formed by the local flap. When skin grafts are harvested from a more distant site, skin color and texture discrepancies are more likely to be observed.

Case 2

The note flap, a transposition flap originally described by Walike and Larrabee,⁴ allows the closure of a circular defect with a triangular flap. The design of this flap consists of drawing a line tangent to a border of a circular cutaneous defect and parallel to RSTLs for a distance of 1.5 times the defect diameter. A second line the same length as the diameter of the defect is drawn at 50° to 60° to the first line to create a triangle-shaped flap. The final flap design resembles a musical eighth note when it is drawn. The surface area of the flap is typically 75% of the surface area of the defect. Although ideally the flap is used to repair skin defects smaller than 2 cm, larger defects can be closed with this design. The major disadvantage with larger note flaps, as with most large transposition flaps, is that the standing cutaneous deformity is also larger and requires removal. In addition, the major tension vector is perpendicular to the tangential border of the triangular flap, and it is this force that is magnified with larger flaps. (See discussion of note flaps in Chapter 8.)

A 74-year-old woman with a basal cell carcinoma of the right cheek underwent micrographic surgical excision. The resulting skin defect measured 4 × 2.5-cm. A 5 × 1.8-cm laterally based note flap was designed for repair (Fig. 16-3). In retrospect, the flap was not designed sufficiently large enough to close the wound without excessive wound closure tension. This was a particular problem because of the proximity of the defect to the lower eyelid in an elderly patient with lower eyelid laxity. When the flap was transposed, tension caused the lower eyelid to retract from secondary tissue movement. Thus, in addition to the flap, it was elected to use a 2.5 × 1-cm full-thickness skin graft that was placed between the flap and the inferior border of the eyelid. The skin graft was obtained from the standing cutaneous deformity marked in Figure 16-3A. Figure 16-3B shows the patient 5 days after reconstruction and immediately after the removal of a skin graft bolster dressing and sutures. The skin graft healed completely and perfectly matched the skin color and texture of the flap and adjacent facial skin. Most important, however, was the maintenance of a normal lower eyelid position and contour. This case represents an example of selecting an inappropriate local flap to repair a cutaneous defect. It was fortunate that a major complication (ectropion or eyelid retraction) was avoided. Avoidance of the likely complication of eyelid retraction was made possible by use of a full-thickness skin graft to assist the local flap in reconstruction of the defect.

Case 3

Rotation flaps are pivotal flaps with a curvilinear configuration. They are designed immediately adjacent to the defect and are best used to close triangular defects. In such instances, the triangular defect is covered by a portion of the standing cutaneous deformity, thus facilitating the pivotal movement of the flap and lessening the need to excise the deformity. The greatest wound closure tension of rotation flaps is at the advancing border of the flap. A back cut at the base of the flap shifts the position of the pivotal point and thus changes the wound closure tension vector as well as the location of the standing cutaneous deformity. There are several advantages of rotation flaps. The flap has only two sides; thus it lends itself to placement of one side in a border between aesthetic regions of the face. The flap is broad based, and therefore its vascularity tends to be reliable. There is great flexibility in the design and positioning of the flap. When possible, the flap should be designed so that it is inferiorly based, which promotes lymphatic drainage and minimizes flap edema. Rotation flaps are discussed in detail in Chapter 7.

The patient shown in Figure 16-4 developed a melanoma in situ of the right cheek. Tumor-free margins were obtained around the skin lesion by the square technique. The resulting area requiring excision measured 5 × 3.5-cm. A 7 × 3.5-cm V-Y subcutaneous tissue pedicled advancement flap was designed to reconstruct the cheek after resection of the skin lesion (Fig. 16-4A). The advancement flap proved to be of insufficient size to cover the defect because of the limited superior mobility of the flap. A 3 × 2.5-cm full-thickness skin graft was obtained from the supraclavicular fossa and used to cover the most superior portion of the defect (Fig. 16-4C). Figure 16-4D shows the results of the reconstruction 6 months postoperatively. The skin graft was moderately unsightly, and there was a depressed scar along the lateral border of the transferred flap. For these reasons, a second operation was performed in which incisions were made along the superior and lateral borders of the healed flap. The skin of the flap was widely undermined to develop a cutaneous pedicled advancement flap. The mobilized skin was advanced superomedially. Advancement was such that most of the full-thickness skin graft was removed and the resulting skin defect covered with the advancement flap (Fig. 16-4E). Figure 16-4F-I shows the patient before resection of her melanoma and 7 months after the second-stage surgical procedure.

Similar to the last case, this case represents an example of poor clinical judgment in designing a local flap. The defect was large, the facial skin was taut, and the flap did not provide sufficient skin to reach the most superior aspect of the defect. A better method for reconstruction of the patient would have been to use a large cervical facial rotation advancement flap. Such a flap may have prevented the need for use of a full-thickness skin graft. However, in repairing very large cutaneous cheek defects with a cervical facial rotation advancement flap, it is not uncommon that the flap must be combined with a skin graft to achieve wound closure.

This case demonstrates the advantage of staging reconstruction of large facial cutaneous defects. Use of two surgical stages enabled the covering of the cheek defect resulting from resection of the skin lesion with adjacent cheek skin, which provided the best possible skin color and texture match with the resected skin.

Case 4

A 71-year-old woman with lentigo maligna melanoma of the left cheek required an extensive resection for complete tumor clearance, resulting in a defect that measured 10 × 7-cm. The defect extended inferiorly from beneath the left lower eyelid to below the angle of the mandible (Fig. 16-5A). Although there was considerable skin redundancy of the patient’s neck, there was insufficient skin to construct a flap that would completely cover the defect. Wide undermining of the cervical skin in the subcutaneous plane was performed to create a large cervical facial advancement flap to assist with repair of the defect. A full-thickness skin graft measuring 9 × 5-cm was harvested from the supraclavicular fossa and used to resurface the superior portion of the defect in the region of greatest wound closure tension (Fig. 16-5B). Figure 16-5C demonstrates the 8-month postoperative result of the reconstruction. The skin graft played an important role in reconstruction of this large facial cutaneous defect that could not be repaired solely with a local flap. Regional and microsurgical flaps are the only alternatives to the method used in this case. These flaps are more complex and would not have provided as good an aesthetic result as the method selected.

Case 5

A 72-year-old man developed atypical junctional melanocytic hyperplasia of the right cheek. This is considered a pre-melanoma skin condition, and the patient underwent a square technique to identify margins around the lesion that were free of disease. An area of skin involving the cheek and temple measuring 8 × 8-cm required surgical excision (Fig. 16-6). A large cervical facial rotation advancement flap was designed to reconstruct the cheek after resection of the skin lesion. The flap was insufficient to cover the entire defect. A full-thickness skin graft was used to assist the flap in repair of the wound. The graft was harvested from the standing cutaneous deformity created by transfer of the cervical facial flap. The flap and graft survived completely and revision surgery was not necessary. Figure 16-6D shows the results of reconstruction 6 years later.

Case 6

A 52-year-old woman with basal cell carcinomas of the left temple and left upper lip was referred for wound closure after micrographic surgical excision of the tumors. The lip defect measured 2 × 1.5-cm and was closed with a V-Y subcutaneous tissue pedicled advancement flap. The left temple defect measured 5 × 5-cm (Fig. 16-7A). A large cervical facial rotation advancement flap measuring 15 × 20-cm was designed by marking an incision extending from the temple along a preauricular crease and then posteriorly to the border of the trapezius muscle, where it continued to the inferior neck. The flap was elevated in the subcutaneous tissue plane, pivoted, and advanced to cover approximately 80% of the surface area of the temple defect. A full-thickness skin graft measuring 5 × 2-cm was used to cover the distal portion of the defect (Fig. 16-7B). The graft was obtained by using the redundant skin of the flap that overlapped the earlobe after advancement of the flap. The 4-month postoperative result is demonstrated in Figure 16-7C. The majority of the scars were effectively camouflaged by positioning incisions for the flap along aesthetic boundary lines. Likewise, the skin graft placed adjacent to the temporal hairline was camouflaged by the temporal tuft of hair.

Case 7

A 62-year-old man was diagnosed with atypical junctional melanocytic hyperplasia of the right cheek. A margin free of hyperplasia was established by the square technique (Fig. 16-8A). The patient was referred for resection of the lesion and reconstruction. The skin defect created after the resection measured 8 × 7-cm and extended from above the right lateral canthus to below the level of the right oral commissure (Fig. 16-8B). A 10 × 15-cm unipedicle advancement flap was designed for repair of the defect. The advancement flap was of insufficient size to completely cover the defect (Fig. 16-8C). The two standing cutaneous deformities created by advancement of the flap were excised and used as full-thickness skin grafts to resurface a 5 × 5-cm area of the superior portion of the defect (Fig. 16-8D). The full-thickness skin grafts served the purpose of reducing wound closure tension and preventing distortion of the right ala and lower eyelid. The flap and skin grafts healed without necrosis. However, scar contracture caused mild retraction of the lower eyelid. Scar revision surgery including Z-plasty was necessary to correct the eyelid retraction. This minor revision procedure produced a satisfactory aesthetic result (Fig. 16-8E, F).

Case 8

A 67-year-old man was diagnosed with atypical junctional melanocytic hyperplasia of the left cheek and nasal sidewall. The square technique was used to ensure a tumor-free margin (Fig. 16-9A). The resection necessary to remove the entire lesion extended from the medial cheek onto the nasal sidewall and medial aspect of the lower eyelid. A 5 × 5-cm unipedicle advancement flap was designed to close the cheek component of the defect. The flap design was modified so that the two incisions typically required to create an advancement flap were positioned in facial aesthetic boundaries rather than parallel to each other. In this case, the incisions to create the flap were placed in the melolabial crease and along the infraorbital bony rim (Fig. 16-9B). This flap design enabled the inferior standing cutaneous deformity formed by advancement of the flap to be excised in the melolabial crease to camouflage the scar. To segregate the healing process and to preserve the nasofacial sulcus, the nasal sidewall defect was closed with a 3 × 1.5-cm full-thickness skin graft. The component of the defect involving the lower eyelid was also repaired with a separate full-thickness skin graft. The grafts were obtained from the excised standing cutaneous deformities that formed along the infraorbital bony rim and in the melolabial crease (Fig. 16-9C). The skin grafts served the purpose of relieving wound closure tension and maintaining aesthetic boundaries between facial aesthetic regions.

For defects of the medial cheek that cross the nasofacial sulcus, it is critical to preserve the sulcus by not advancing cheek flaps onto the lateral nasal sidewall to prevent blunting of this important aesthetic boundary line.⁵ To achieve this goal, a cheek advancement flap can be combined with a full-thickness skin graft. The cheek skin is advanced to the nasofacial sulcus and the standing cutaneous deformities are removed and used to graft the nasal sidewall. This divides the healing process into two distinct regions while maintaining a scar line in the sulcus. In the case presented, the advancement flap caused intraoperative inferior displacement of the lower eyelid margin. To eliminate the retraction, a second full-thickness skin graft was used to resurface the eyelid component of the defect and to relieve the tension on the eyelid caused by the flap.

The V-Y subcutaneous tissue pedicled island advancement flap is a unipedicle advancement flap without surrounding cutaneous attachments. The flap is designed as an inverted triangle. The base of the triangle becomes the advancing border of the flap. The flap is advanced into the defect on a mobile subcutaneous fat pedicle. The triangular secondary defect is closed by advancing skin adjacent to the donor site, creating a Y configuration of the wound closure. The island advancement flap is ideally suited for repair of defects of the superior melolabial fold (see discussion of this flap in Chapter 9). This is because the flap is dependent on ample subcutaneous fat for mobility and the medial cheek contains the greatest amount of facial fat.⁶ The flap is less effective in repairing medial cheek defects that are superior to the level of the alae. However, in these instances, a full-thickness skin graft combined with a V-Y subcutaneous tissue pedicled island advancement flap may offer an aesthetically acceptable alternative. Use of a skin graft in combination with the flap limits the required length of the flap and the necessary distance of advancement. Unlike rotation or bilobe transposition flaps, the island flap can be designed with most incisions in RSTLs. Ideally, the vertical limb of the Y is aligned in an aesthetic border, rhytid, or RSTL. Unlike with most other local cutaneous flaps, no standing cutaneous deformity is created with V-Y island advancement flaps, and thus there is no need to resect skin as when standing cutaneous deformities are removed.

Case 9

A 71-year-old woman developed a large area of atypical junctional melanocytic hyperplasia of the left cheek. Skin margins around the lesion were established by the square technique. The area requiring resection measured 4.5 × 4-cm. The resection margin encroached on the left lower eyelid and lateral canthus (Fig. 16-10A). A V-Y subcutaneous tissue pedicled island advancement flap was designed to cover a portion of the defect resulting from resection of the hyperplasia (Fig. 16-10B). It was not possible to completely close the defect with the flap because of the size and superior extent of the defect. Attempts to advance the flap to the superior margin of the defect would have caused downward traction on the eyelid. This in turn would almost certainly have caused lower eyelid retraction or ectropion. To avoid these problems, the 8 × 6-cm advancement flap was combined with a 3.5 × 2.5-cm full-thickness skin graft. The graft was used to close the superior portion of the defect near the lower eyelid (Fig. 16-10C). Because V-Y subcutaneous tissue pedicled island advancement flaps do not generate a standing cutaneous deformity, the skin graft was harvested from the supraclavicular fossa. Figure 16-10D depicts the 11-month postoperative result.

Case 10

An 81-year-old woman developed lentigo maligna melanoma of the left cheek. Tumor-free margins around the skin lesion were obtained by the square technique (Fig. 16-11). She was referred for excision of the malignant neoplasm and reconstruction of the face. The area requiring resection measured 5 × 5-cm. As in Case 9, it was not possible to completely repair the skin defect resulting from tumor excision with a single local flap because of the size and superior extent of the defect. A 12 × 5-cm subcutaneous tissue pedicled island advancement flap was designed for repair of the inferior portion of the cheek defect once the malignant neoplasm was resected. A 5 × 2.5-cm full-thickness skin graft was harvested from the supraclavicular fossa and used to cover the superior portion of the cheek defect. Both flap and skin graft healed without necrosis or excessive scarring, with an acceptable aesthetic result. In spite of the distant donor site of the skin graft, color and textural match between the skin of the flap and the skin graft was nearly ideal.

Case 11

A 69-year-old woman developed melanoma in situ of the left cheek. Tumor-free margins around the skin lesion were obtained by the square technique (Fig. 16-12). The area requiring excision measured 5 × 2.8-cm. The linear and relatively narrow configuration of the planned excision created a situation in which partial primary wound repair after excision was a reasonable approach. The standing cutaneous deformity resulting from advancement of the borders of the wound after resection of the melanoma was excised and used as a full-thickness skin graft to repair the small (1 × 1.2-cm) persistent skin defect of the lower eyelid. A cutaneous advancement flap would have been the best alternative method of wound repair. Partial primary wound closure avoided the need for incisions perpendicular to RSTLs, which would have been necessary to create an advancement flap. It also reduced the area of dead space created during wound repair compared with that necessary with use of an advancement flap. This reduced the risk for development of a postoperative hematoma or seroma.

Case 12

A 72-year-old woman presented with melanoma in situ of the left cheek. Tumor-free margins around the skin lesion were obtained by the square technique. The area requiring excision measured 6 × 2.75-cm (Fig. 16-13). Similar to Case 11, the area requiring resection had a relatively linear narrow configuration. For this reason, partial primary wound repair was planned with skin grafting of the remainder of the wound after removal of the melanoma. The advantages of selecting this surgical approach for wound repair were the same as those listed in Case 11.

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3. Baker, SR. Options for reconstruction in head and neck surgery. In: Cummings CW, Fredrickson JM, eds. Otolaryngology—head and neck surgery, Update 1. St. Louis: Mosby; 1989:192.

4. Walike, JW, Larrabee, WF, Jr. The note flap. Arch Otolaryngol. 1985; 111:430.

5. Baker, SR. Nasal cutaneous flaps. In: Baker SR, ed. Principles of nasal reconstruction. St. Louis: Mosby; 2002:103.

6. Clevens, RA, Baker, SR. Defect analysis and options for reconstruction. Otolaryngol Clin North Am. 1997; 30:495.