Kevin T.

Kavanagh, MD
Axial
Based upon a named artery.
Survival length depends upon the artery not the
width of the flap.
Random
Has random unnamed vessels supplying it.
Survival length is directly proportional to the width
of the flap.
Survival length maybe increased by delaying the
flap.
To delay a flap, elevate as a bipedical flap and
return it to the flaps bed. Two weeks later,
elevate as a unipedical flap.
Interpolation flap is a two-staged flap where
a pedicle traverses intact skin.
The flaps pedicle maybe divided in three to
six weeks. Early division requires training of
the flap.
Examples of this type of flap are the forehead
flap, the Abbe-Estlander flap and some
nasolabial flaps.
This flap can be used to close large defects.
The flap is planned so as not to violate
cosmetic units of the face.
The arc of the flap should be no greater than
twice the base.
A back-cut can be made to increase the flaps
rotation.
This patient had a melanoma.
A 1 cm margin is outlined
around the melanoma. The
melanoma had less than 1
mm of invasion.
The melanoma was
resected. The
adipose tissue of the
cheek and orbicularis
oculi muscle was
exposed. A deep
margin of the muscle
and adipose tissue
was negative.
The length of the flap should be 4:1 to
the defect. A wedge of tissue may be
taken inferiorly to prevent a dog ear.
The flap is designed to not cross facial
sub-units. This incision arches
superiorly around the orbital rim,
across the temple area where crows
feet wrinkles are common, then down
the pre-auricular area into the neck.
A very small dog-ear remained
which was resected under local
anesthesia in the office.
This patient had a melanoma
of the forehead. A 1 cm
margin is outlined.
Closure of forehead defects
must be done carefully so the
eyebrow is not raised. If the
width is over 2.5 cm it is very
hard to close primarily.
The scalp is even less
forgiving, since the tissues do
not stretch. Relatively large
flaps are needed to close
small defects.
A small back cut can be made and the drain
placed through the opening.
The six week postop result is shown on
the left. The eyebrow is not raised and
the dog ear has regressed.
At two weeks postop, a prominent
dog ear was present.
A rhomboid flap uses a
geometric design and
measurements to close defects.
All sides are of equal length.
The defect can be varied from a
square to a 60-120-60-120 deg
rhomboid.
A square defect will produce the
smallest defect but the largest
dog ear.
The rhomboid defect will produce
the largest defect but the
smallest dog ear.
Shown above is a 60-
120-60-120 degree
defect (red) which will
produce the smallest dog
ears.
Two defects are presented that
were reconstructed with a
rhomboid flap.
In the first and younger patient,
there is very little stretching of
the tissue and a dog ear was
created with a square shaped
flap.
The dog ear can be excised in the
office under local anesthesia.
The square shaped flap has the
advantage of creating a smaller
defect and less facial scaring.
Shown above is a 60-
120-60-120 degree
defect (red) which will
produce the smallest dog
ears.
This patient had a resected
basal cell carcinoma of the
cheek with positive margins.
The surgical site needed
excision and had to be closed
without placing tension on the
lower eyelid.
A rhomboid flap uses a
geometric design and
measurements to close
defects. All sides are of
equal length.
At one week post op the patient
had a small dog-ear. There was
no tension on the lid. The
patient was lost to followup.
One Week Postop Result Surgical Closure
One Month Post
Operative Result
Can be both Axial and Random.
The artery is relatively deep so Nasolabial
Flaps for facial reconstruction are usually
random.
The flap can also be inverted and placed
through the cheek for floor of mouth
reconstruction. This is a thicker flap and can
incorporate the artery.
Flaps wider than 1.5 cm can create a defect
which is difficult to close. In addition, closure
of a large defect can result in widening of the
nasal ala (superiorly based flaps) or notching
of the nasal ala (inferiorly based flaps).
Flaps longer than 2.5 times the width are at
risk of tip necrosis.
Thus, the maximum length should be around
3.75 cm.
Superiorly Based
Can easily reach most nasal defects.
Because of poor lymphatic flow (uphill) they tend to
swell. Look good right after the operation but
become hypertrophic at one month, with some
resolution of the swelling by six months postop.
Glasses rest on the flaps base which increases
swelling and chances of necrosis.
The higher the base of the pedicle the less the flap
has to rotate and the less of a dog ear will form.
Need to plan for a second stage to thin the flap.
Basal cell carcinoma of the
left nasal ala.
Three Month Postop Result Note Flap Swelling
Five Month Postop Result Note Flap Swelling
Flap Length to Width Ratio Was 2.5 to 2.75 To 1
Immediate Postop Result Five Days Tip Necrosis
Three Week Postop, Note the Flaps Swelling
Nine Month Postop Result
Inferiorly Based
Can be used to reconstruct some inferior or nasal
alar defects.
Rotation is very acute and a dog ear forms, but this
tends to blend into the nasal alar defect.
Note the crease in the
midportion of the flap
and the purplish hue of
the distal of the flap
At one week postop, the distal of flap is
viable but is dusky and NOT healthy.
Used to reconstruct defects
between 1/3 to 2/3 of the lip.
Axial flap based medially. A
portion of the opposite lip equal to
the defect is rotated into the
defect.
If you base the flap laterally more
likely to cut artery and may not
have enough room to rotate flap
into position.
Lip is divided and the vermillion
portion of the lips are rotated into
position.
The three month postoperative result is shown above. Note that the flap has
reinnervated and the patient is even able to whistle.
The flap is a paramedian
axial flap based upon the
supratrochlear artery.
If the flaps pedicle is
wider than 2.5 cm,
closure may be difficult.
Nasal reconstruction with the forehead flap was
believed to originated in India in 700 BCE
Note that the flaps
pedicle is narrower
than the tip. This is
to aid in closure of
the forehead. The
tip will be used for
the nasal
reconstruction.
If necessary, the
artery can be found
using a doppler.
This patient underwent
Mohs surgery for a
basal cell carcinoma.
Two small lesions are
seen.
10 Days Postop Immediately After Surgery
The patient was a 40 year old whose ear was
bitten by a police dog.
The patient lost part of his ear cartilage and a
significant amount of ear skin. A flap to cover
the ear is outlined on the patient's scalp.
The flaps donor site is sewn to the
undersurface of the ear.
The flap is then placed over the anterior
surface of the auricle and sewn into position.
The one month result is
shown to the left. Tragically,
the patient died of an
unrelated event.
This patient had a large portion of his ear
resected to remove a melanoma.
Four Days Postop Six Weeks Postop
The flap used for the reconstruction
is outlined, The donor site is closed
with a superior rotation
advancement flap and inferior
advancement flap.
Note, this flap is grasped at its tip, which
will be resected. Never CLAMP a flap.
The flap is elevated.
The flap is trimmed and sewn into
position.
The rotation advancement flap is
elevated.
The flaps are sewn into position.
Two week postop result.
One Year Post Operative Result.
Nasal Dorsal Flap which is
based on the left side.
When flaps are folded,
creased, or cross the midline
there is a risk of necrosis.
Cheek advancement flaps
which cross the nasal-labial
fold onto the nose also have
an increased risk of necrosis.
Random flaps that are too long
have an increased risk of necrosis.
To improve chances of survival:
-- No Smoking
-- Use pentoxifylline (Trental)
-- Leeches
Immediate Postop Two Month Result
Treated with pentoxifylline (Trental) 400 mg T.I.D.
Two Week Result