Reconstructive facial plastic surgery : A problem- solving manual.

276 Pages·2015·52.352 MB·English

Reconstructive Facial Plastic Surgery
A Problem-Solving Manual
2ndRevisedandExpandedEdition
HilkoWeerda,MD,DMD
ProfessorEmeritus
DepartmentofOtorhinolaryngology—Head,Neck,andPlasticSurgery,
UniversityHospitalSchleswig-Holstein,CampusLübeck
Lübeck,Germany
1390illustrations
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V
Contents
Forewordtothe2ndEdition . . . . . . . . . . . . . . . . . . . XIII Prefacetothe2ndEdition . . . . . . . . . . . . . . . . . . . . . XV
Forewordtothe1stEdition . . . . . . . . . . . . . . . . . . . XIV Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XVI
I Anatomy,PrinciplesofFacialSurgery,andCoverageofDefects
1 AnatomyoftheSkinandSkinFlaps . . . . . . . 3 TumorResectionwithHistologicControl
TheSkin(Fig.1.1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 (Fig.2.21) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
TypesofSkinFlaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 FreeSkinGrafts(Fig.2.22) . . . . . . . . . . . . . . . . . . 17
RandomPatternFlaps(Fig.1.2) ........... 4 CompositeGrafts(Fig.2.23) . . . . . . . . . . . . . . . . 17
AxialPatternFlaps(Fig.1.3) .............. 4 CartilagenousandCompositeGrafts
IslandFlaps(Fig.1.4)..................... 4 forAuricularandNasalReconstruction . 17
MyocutaneousIslandFlaps GraftNomenclature . . . . . . . . . . . . . . . . . . . . . 19
(Fig.1.5;seealsoFig.12.1)............. 4
3 CoverageofDefects . . . . . . . . . . . . . . . . . . . . . . . . 21
NeurovascularIslandFlaps ............ 4
LocalFlaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
2 BasicPrinciplesofFacialSurgery . . . . . . . . . . 5 AdvancementFlaps . . . . . . . . . . . . . . . . . . . . . . . . . 21
SutureMaterialsandTechniques . . . . . . . . . . . . . . 5 AdvancementFlap
BasicInstrumentSetforReconstructive ofBurow(1855)(Fig.3.1) . . . . . . . . . . . . . . . 21
FacialPlasticSurgery(Fig.2.7)............... 6 Burow’sU-Advancement(Figs.3.2–3.7) 21
TheBinocularLoupe(Fig.2.7c)............ 6 V-YandV-Y-SAdvancementofArgamaso
Additionalinstruments:............... 6 (1974)(Figs.3.8–3.10) . . . . . . . . . . . . . . . . . . . 22
WoundManagement,RepairofSmall FlapswithoutContinousEpithelial
Defects,andScarRevision ................... 9 Coverage(Rettinger1996a,b).......... 22
RelaxedSkinTensionLines,VascularSupply SlidingFlap(Figs.3.11–3.14) . . . . . . . . . . . . 22
(Fig.2.8i),and“EstheticUnits”(Fig.2.20) . . . . . . . 9 PedicledFlaps................................. 24
WoundManagement,RepairofSmallDefects, TranspositionFlap(Fig.3.15) . . . . . . . . . . . . 24
andScarRevision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 RotationFlap(Fig.3.19) . . . . . . . . . . . . . . . . . 24
ManagementofWoundswith BilobedFlap(Fig.3.22) . . . . . . . . . . . . . . . . . . 25
TraumaticTattooing.......................... 9 RhomboidFlap(Figs.3.24–3.27) . . . . . . . . 27
ScarRevisionbyW-Plastyandthe TurnoverFlap(Fig.3.28) . . . . . . . . . . . . . . . . . 28
Broken-LineTechniqueofWebster(1969) TubedPedicleFlap(BipedicleFlap)
(Fig.2.8a–j) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 (Fig.3.29) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
SmallExcisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 DistantFlaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Z-Plasty(Figs.2.15and2.16) . . . . . . . . . . . . . . . . 13 DistantTubedPedicleFlap................... 28
PostoperativeTreatmentofScars . . . . . . . . . . . 14 MyocutaneousandMyofascialFlaps
EstheticUnitsoftheFace(Fig.2.20) . . . . . . . . 14 (seeFigs.12.1–12.3) . . . . . . . . . . . . . . . . . . . . . . . . . 28
VI Contents
SpecialPart
II CoverageofDefectsinSpecificFacialRegions
4 ForeheadRegion . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 LoweringtheAlarRimasaFull-Thickness
MedianForeheadRegion . . . . . . . . . . . . . . . . . . . . . . . 33 BipedicleFlapandwithaCompositeGraft
Wedge-ShapedDefects(Fig.4.1) ....... 33 (Fig.5.38)............................ 51
H-Flap(Fig.4.2).......................... 33 TurnoverFlapandCompositeGraft
(Lexer1931,modifiedby
DoubleRotationFlap(Fig.4.3) ......... 34
Kastenbauer1977).................... 53
LateralForeheadDefects(Fig.4.5)...... 34
ConvertingaPeripheraltoaCentral
5 NasalRegion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Defect(Haas1991)andReconstructingthe
GlabellaandNasalRoot(Figs.5.1–5.9)........ 35 AlarRimwithaTranspositionFlap
U-AdvancementFlapofBurow(Fig.5.1) ... 35 (Fig.5.40)............................ 53
V-YAdvancement Wedge-ShapedDefectintheAlarRim
(Fig.5.2;seealsoFigs.3.8–3.10)........... 35 (Fig.5.41)............................ 55
SlidingFlap(Fig.5.7)..................... 37 NelatonFlap(NasolabialFlap)(Fig.5.42) 55
NasalDorsum(Figs.5.8–5.12)................ 38 SlidingFlapofBarronandEmmett(1965)
BilobedFlap(Fig.5.8)..................... 38 andLejour(1972)fromtheNasolabial
IslandFlap(Fig.5.9)...................... 39 Fold(Fig.5.44)........................ 57
RiegerFlap(Fig.5.10) .................... 39 In-and-OutFlapofPeers(1967)(Fig.5.45) 57
NasolabialFlap(Fig.5.11)................. 41 MedianForeheadFlap(seeFigs.5.15and
5.51)................................. 57
MedianForeheadFlap(Fig.5.12).......... 41
BilobedFlapfromtheCheek
NasalTip(Figs.5.13–5.17) ................ 41
(Weerda1983c)(Fig.5.46)............. 57
BilobedFlap(Fig.5.13) ................... 41
LargeDefectsoftheLateralNose
V-YAdvancementFlapofRieger(1957)
(Figs.5.47and5.48)................... 57
(Fig.5.14) ............................... 42
MedianandParamedianForeheadFlap TheColumella . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
(Fig.5.15)............................... 42 NelatonFlap(Fig.5.49)................... 60
LargerDefectsoftheNasalTipandAla . . . . . . . . 44 FrontotemporalFlapofSchmidandMeyer
FrontotemporalFlapofSchmidandMeyer (1964).......................................... 60
(Figs.5.17and5.18)...................... 44 CompositeGraft(Fig.5.50)................ 60
NasalFlank . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 PartialandTotalNasal
FlapAdvancementofBurow(1855)(Fig.5.22) 47 Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
MedianCheekRotationofSercerand ConverseScalpingFlap
Mündich(1962)(Fig.5.23)................ 47 (Forehead-ScalpFlap)(Fig.5.52)........... 61
Burow’sLaterallyBasedCheek TotalNasalReconstructionwiththeSickle
AdvancementFlap Flap(Farrior1974)(Fig.5.53).............. 65
(Fig.5.24;seealsoFig.3.1)................ 48 Three-StageReconstructionofTotalNasal
Imre’sCheekRotation(1928)(Fig.5.25).... 48 Defects(afterBurgetandMenick1994 . . . . . 66
CheekU-Flap(Fig.5.26) .................. 48 MedianForeheadFlapwithSoft-Tissue
IslandFlap(Fig.5.32)..................... 50 Expansion(Fig.5.55) . . . . . . . . . . . . . . . . . . . . . . . . 74
SlidingFlap(Fig.5.33).................... 51 NasalReconstructionwithDistantFlaps.... 74
NasalAla . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 PerforationsoftheSeptum . . . . . . . . . . . . . . . . . . . . 74
Full-ThicknessReconstructions ............. 51 SmallPerforations . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Z-PlastyofDenonvilliersand LargeDefects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Joseph(1931)(Fig.5.34)............... 51 OralMucosalFlapofMeyer(1988)
AnteriorlyBasedAlarRotation (Fig.5.59b) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
(Weerda1984)(Fig.5.35).............. 51 NasolabialFlapofTipton(1975)(Fig.5.60) 75
ModificationoftheAnteriorlyBased BipedicleFlapofSchultz-Coulon(1989)
AlarRotation......................... 51 (Fig.5.61) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
CoveragewithaTranspositionFlap..... 51
Contents VII
6 TheLips . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 BilobedEstlanderFlap(Fig.6.41)....... 99
MucosalDefects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 VermilionReconstructionbytheMethod
Wedge-ShapedDefects(Fig.6.1).......... 77 ofvonLangenbeck(1855)(Fig.6.42).... 99
LargeSuperficialDefects(Fig.6.2)......... 77 TongueFlap(Fig.6.43)................. 99
UpperLip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 BrownModificationoftheEstlanderFlap
MedianDeficiency(Fig.6.3) .............. 78 (1928)(Fig.6.44) ..................... 102
ThinUpperLip(Figs.6.4–6.6) ............. 78 UnilateralorBilateralGilliesFanFlap
ThinUpperLipandFullLowerLip(Fig.6.7) 79 (1957)(Fig.6.45e–j)...................102
MedianScarsandUpperLipDefects ........ 81 UniversalMethodofBernard(1852),
ScarRevisions................................. 82 Grimm(1966),andFries(1971)
SmallContractures(Fig.6.11).......... 82 (Fig.6.46;unilateralorbilateral) ....... 104
LargerContractures................... 82 ReconstructionoftheLateralLip
LargerScarContracturesCausingLip andCommissure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Retraction(Figs.6.12and6.13)......... 83 Burow’sMethodofReconstructingthe
DefectsintheNasalFloorand LateralUpperLip(1855)(Fig.6.48) ........ 106
UpperLip...................................... 83 ReconstructionoftheCommissurebythe
TranspositionFlapfromtheNasolabialFold MethodofRehn(1933),asModifiedbyFries
(Fig.6.14)............................ 83 (1971)andBrusati(1979)(Fig.6.50)........ 106
BilobedFlap(Fig.6.15)................ 84 ReconstructionofLargeCommissural
NeurovascularIslandFlapfromtheLower Defects(Fig.6.51)........................ 107
Cheek(afterWeerda1980dFigs.6.19and VermilionDefects............................. 108
6.28)................................. 87 VermilionAdvancementof
CentralDefectsoftheUpperLip Goldstein(1990)(Fig.6.52) . . . . . . . . . . . . . 108
(Fig.6.20)............................ 87 CombinedReconstructionoftheLowerPart
CelsusMethodCombinedwithanAbbéFlap oftheFace(LowerLip,Cheek,Chin,Middle
(Fig.6.21;seealsoFigs.6.20and6.22).. 87
PartoftheMandible)(Fig.6.53) . . . . . . . . . . . . . . . 108
ClassicReconstructiveTechniquesinthe
ElongationoftheOralFissure . . . . . . . . . . . . . . . . . . 110
UpperLip...................................... 88 MethodofConverse(1959)(Weerda1983)
AbbéFlap(1898,reprinted1968) (Fig.6.54) ............................... 110
(Fig.6.22)............................ 88 MethodofConverse(1977)(Fig.6.55)...... 110
EstlanderFlap(1872)(Figs.6.24;6.40).. 90 MethodofGanzer(1921)(Fig.6.56)........ 111
UpperLipReconstructionwithaRotation MethodofGilliesandMillard(1957)
Flap(Blasius1840)(Fig.6.25).......... 90 (Fig.6.57) ............................... 111
GilliesFanFlap(1976)(Fig.6.27)....... 92
7 TheChin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
NeurovascularSkin–Muscle–Mucosal
CoverageofSmallDefectsintheChinArea . . . . 113
FlapofWeerda(1980d,1990)
AdvancementFlap(Fig.7.1)............... 113
(Figs.6.19and6.28)................... 92
BilobedFlap(Fig.7.2a,b) ................. 113
CombinedDefectRepairoftheAla,
Columella,Cheek,andUpperLip 8 TheCheek . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
(Fig.6.29)............................ 93 MedialCheekDefects . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
LowerLip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 UpperMedialCheek.......................... 115
ScarContracturesandSmallDefects........ 94 EsserCheekRotation(1918)(Fig.8.1)... 115
SmallContractures(Figs.6.30and6.31) 94 CheekReconstructionCombiningthe
LargerContractures................... 94 MethodsofEsser(1918)andImre(1928)
SmallDefects......................... 94 (Weerda1980)(Fig.8.2).................. 116
LipReduction......................... 94 SmallCheekDefects................... 117
SlidingFlapsintheVermilion.......... 94 ImreCheekAdvancementFlap(After
ClassicLowerLipReconstructions........... 96 HaasandMeyer1973,modified)
WedgeExcision....................... 96 (Figs.8.4and8.5) ..................... 117
EstlanderFlap(1872)(Fig.6.40)........ 98 DefectintheMedialCanthus(Fig.8.6).. 117
VIII Contents
Mid-AnteriorCheek(Fig.8.7) ................ 118 10 TheAuricularRegion . . . . . . . . . . . . . . . . . . . . . . . 135
PedicledBilobedFlaps........................ 118 Classification(Table10.1)andEstheticUnits
LargeInferiorly/AnteriorlyBasedBilobed (Fig.10.1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
Flap(Fig.8.8)............................ 118 CentralDefects:RecommendedDefectCoverage
V-YAdvancement............................. 119 (Fig.10.2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
UpperandPosteriorCheek . . . . . . . . . . . . . . . . . . . . . 120 ConchalDefects............................... 137
TrilobedFlapofWeerda(1979)(Fig.8.10).. 120 ReconstructionwithaFull-thickness
BilobedFlap(Fig.8.11) ................... 120 SkinGraft(Fig.10.3) .................. 137
LateralCheekDefects . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 TranspositionFlapandU-shapedAdvance-
SmallLateralCheekDefects.................. 121 ment(Fig.10.4)....................... 137
SmallPreauricularDefects................... 122 ReconstructionwithIslandFlaps
SimpleSkinAdvancementandRotation (Figs.10.5–10.7)...................... 137
(Burow‘sMethod)(Fig.8.17a–d)........... 122 DefectsoftheAntihelixandCombinedCentral
OpposingTranspositionFlaps(Fig.8.18)... 122 Defects(Figs.10.8and10.9).................. 140
LargeDefectsInvolvingtheAuricle ......... 124 ConverseandBrent’s(1977)
LateralCheekRotationofWeerda(1980c) Three-stageReconstructionof
(Figs.8.20and8.21)...................... 125 Full-ThicknessDefectsoftheAntihelix
PedicledTranspositionFlaps (Fig.10.10)........................... 140
(Figs.8.22and8.23)...................... 125 SuperiorlyorInferiorlyBased
PreauricularHairLoss(Fig.8.24).......... 126 TranspositionFlap(Fig.10.11) ......... 140
InferiorlyBasedRetroauricularTransposition U-shapedAdvancementFlapofGingrass
flap(Weerda1978b)(Fig.8.25)............ 126 andPickrell(1968)(Fig.10.12) ........ 142
LargeBilobedFlapfromtheNeck(Weerda Weerda’sReconstructionwitha
1980b)(Fig.8.26)......................... 127 TranspositionFlapandTemporary
RepositioningoftheHelix(Fig.10.13) .. 143
9 TheEyelids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Weerda’sBilobedFlapasaTransposition–
UpperEyelid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
RotationFlap(Fig.10.14).............. 144
DirectClosure(Fig.9.1)................... 129
Weerda’sScaphalReconstructionwitha
SemicircularFlapClosureofBeyer-Machule
U-shapedAdvancementFlap(Fig.10.15) 144
andRiedel(1993)(Fig.9.2)................ 129
Tebbetts’(1982)SuperiorlyBased,
SwitchFlap(Fig.9.3) ..................... 130
PreauricularFlapforthe
UpperEyelidReconstructionofFrickeand
TriangularFossa(Fig.10.16) ........... 144
Kreibig(Fig.9.4) ......................... 130
Mellette’s(1991)PreauricularFlapBased
BilobedFlap(Fig.9.5)..................... 131
SuperiorlyontheHelicalCrus(Fig.10.17)145
TotalUpperLidReconstructionbytheTwo-
SubcutaneousPedicleFlapofBarronand
StageMustardéTechnique(Beyer-Machule
Emmett(1965)(Fig.10.18) ............ 146
andRiedel1993)(Fig.9.6) ................ 131
InferiorlyBasedPreauricularFlap
ReconstructionoftheLowerEyelid . . . . . . . . . . . . 132
(Fig.10.19)........................... 146
ReconstructionofSmallDefectsintheLower
PeripheralDefects(Fig.10.20) ............... 147
Eyelid.......................................... 132
HelixReconstructionwithAuricular
LargeDefects(Figs.9.6and9.7)........... 132
Reduction ..................................... 147
ReconstructionoftheLowerLidwith
SimpleWedgeExcisions(Fig.10.21).... 148
Ectropion......................................
WedgeExcisionand
............................................133
Burow’sTriangles(Fig.10.22a–j) ....... 148
TranspositionFlap(Figs.9.8and9.9).... 133
Gersuny’s(1903)TechniqueofDefect
TotalLowerLidReconstruction
ClosurebyTranspositionoftheHelix
(Figs.9.11and9.12)................... 133
(Fig.10.23)........................... 148
ReconstructionoftheMedialCanthus
(Figs.9.13and9.14;seealsoFigs.5.2–5.7)..... 134 ModificationoftheGersunyTechniqueby
WeerdaandZöllner(1986)(Fig.10.24) . 150