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Local Flaps I: Bilobed, Rhombic, and Cervicofacial
Local Flaps I : Bilobed, Rhombic, and Cervicofacial Eugene A. Chu, MDa, Patrick J. Byrne, MD, FACSb,* KEYWORDS Local flaps Bilobed Rhombic Cervicofacial Rotational flap Advancement flap Transposition flap Skin cancer
blood supply, minimal morbidity, and excellent cosmesis. The bilobed, rhombic, and cervicofacial advancement flaps are all local flaps that have a long history of success in the reconstruction of facial defects after resection of skin cancers, and represent an important addition to the armamentarium of any surgeon interested in facial reconstructive surgery. This article reviews the indications, surgical techniques, and complications of each.
BILOBED FLAP The bilobed flap is a random-pattern cutaneous transposition flap consisting of two lobes based on a single pedicle. Although the bilobed flap has been used in sites as disparate as the face, eyelids, trunk, foot, scalp, and hand, its greatest use is in nasal reconstruction. It has the advantages of being a single-stage flap of simple design that has excellent color and texture match with adjacent tissues and predictable flap viability. The particular advantage of the bilobed flap is that it allows surgeons to recruit tissue from a distant site—one not really adjacent to the defect but somewhat removed—to close a defect. Thus, if the tissue adjacent to the defect lacks distensibility, but tissue a bit further away is easily
a Facial Plastic and Reconstructive Surgery, Anterior Skull Base Surgery, Department of Otolaryngology Head and Neck Surgery, University of California, Irvine School of Medicine, Irvine, CA, USA b Facial Plastic and Reconstructive Surgery, Departments of Otolaryngology-Head and Neck Surgery and Dermatology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA * Corresponding author. JHOC 6210 - Johns Hopkins Department of Otolaryngology-Head and Neck Surgery, 601 North Caroline Street, Baltimore, MD 21287. E-mail address: [email protected] (P.J. Byrne).
Facial Plast Surg Clin N Am 17 (2009) 349–360 doi:10.1016/j.fsc.2009.05.003 1064-7406/09/$ – see front matter ª 2009 Elsevier Inc. All rights reserved.
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This article is the first in a series focusing on the reconstruction of defects of the face, head, and neck created by the resection of a skin cancer. This series begins with a detailed description of specific types of local flaps, and is followed by articles emphasizing the options for reconstruction by anatomic site. The surgical technique for three workhorse flaps of the face are described: the bilobed flap, rhombic flap, and cervicofacial flaps. Reconstruction of facial defects after excision of skin cancers can be challenging. Optimal results rely on a sound understanding of skin anatomy and flap physiology, careful analysis of the defect and recipient site, familiarity with multiple reconstructive options, and meticulous techniques for handing soft tissue. The concept of the reconstructive ladder, in which each rung of the ladder represents a successively more complex surgical plan (ie, healing through secondary intention to the use of microvascular free flaps), provides a framework for organizing the myriad surgical options (Fig. 1). Most facial defects that cannot be treated with primary closure are amenable to local flaps. Local flaps by definition use tissue adjacent to the defect and therefore have favorable skin color– and texture-match characteristics. When designed and executed properly, they allow for rapid and reliable reconstruction of defects with a reliable
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Chu & Byrne Esser’s design, and incorporated an excision of a dog ear redundancy near the base of the flap. The combination of these changes eliminated the dog ear and decreased the incidence of pincushioning. This article describes the bilobed flap design and execution, with several suggestions to enable its effective use. The description focuses on its use on the nose, only because the repair of nasal tip defects has some unique challenges. However, the design is applicable to other areas of the face, head, and neck.
Indications for Bilobed Flap
Fig. 1. Reconstructive ladder. Each higher rung of the ladder represents increasingly more complex surgical procedures.
stretched to close, the bilobed flap may be a great choice. The nasal tip is obviously the typical site of its use, although other areas are useful. Among the disadvantages are that it has complex incision lines, cannot follow the principle of nasal subunit reconstruction, is limited to closure of small nasal defects, and has a dramatic ability to distort the symmetry of the distal nose if not planned appropriately. Esser1 first described the bilobed flap for the repair of nasal defects in 1918 in the German literature. Subsequent authors described minor variations of the flap but not until Zitelli’s2 modifications in 1989 were the problems of tissue protrusion (dog ears) and pincushioning minimized. Zitelli transposed each flap 45 , instead of 90 as in
The bilobed flap is designed to recruit adjacent skin and soft tissue from areas of laxity to areas of deficiency. This technique is ideally suited for reconstructing relatively small defects (<1.5 cm in diameter) of the distal nose where the thick, sebaceous, relatively immobile skin overlying the supratip, tip, and alae can be repaired with the thin, loose, relatively nonsebaceous skin of the nasal dorsum and side walls. Use of a second lobe allows recruitment of tissue from a more distant site, and distributes tension across a greater area. Although generally defects of 1.5 cm or less may be adequately addressed with the bilobed flap, it may be influenced by the presence of previous scars and patient skin type. Patients who have thin, dry, loose skin often have an abundance of available skin for transposition, and larger defects may be closed favorably. However, favorable results may be difficult to achieve in patients who have thick sebaceous skin that extends superiorly beyond the tip subunit, even for defects smaller than 1.5 cm.
Preoperative Assessment Before designing the flap, three important characteristics seen on physical examination must be considered: location of defect, nature of the nasal skin, and nasal anatomy. Defects of the nasal ala are generally approached with medially based bilobed flaps, whereas tip defects are treated with a laterally based flap. Patients who have thick and sebaceous skin of the nasal tip require special consideration. The thick sebaceous skin, when used as part of the flap, limits the amount of skin available for transposition and has a tendency to ‘‘bulldoze’’ the ipsilateral alar margin inferiorly. The nose must be examined carefully with the supportive structure in mind. Surgeons must anticipate the inevitable effects of the repair, which entail some degree of soft tissue contracture in
Bilobed, Rhombic, and Cervicofacial Flaps the future. Some patients may be at greater risk for nasal tip distortion, depending on the amount of inherent tip support. Depending on the location of the defect, postoperative internal or external nasal valve collapse may cause functional nasal obstruction. Thus, the nasal airway, tip, and internal and external nasal valve support must be assessed. The quality of the tip cartilages, septal anatomy, and presence or absence of cephalic malposition of the lower lateral cartilages are all determined, particularly for defects involving the tissue overlying the internal nasal valve. The primary goal of any oncologic surgical resection is complete extirpation of tumor. If any concern exists regarding the adequacy of the resection or if the tumor is highly aggressive, allowing the site to heal through secondary intention or using a skin graft to facilitate monitoring for tumor recurrence may be preferable.
Surgical Technique for Bilobed Flap The entire face is prepped so that any nasal asymmetry introduced by the flap design can be recognized. The diameter of the defect (D) is measured with calipers and then the pivot point is selected (Fig. 2A). The pivot point should extend to an angle of 30 and is placed at least 0.5 D from the edge of the defect (Fig. 2B) and may be drawn much longer. Longer pivot points may protrude less, and limit some of the bulldozing effect on the ipsilateral ala, in which the alar margin is displaced inferiorly. Lines drawn from the pivot point to the edges of the circle delineate the Burrow’s triangle that will be excised to prevent dog ear formation. As described by Baker (Dr. Shan Baker, Professor of Facial Plastic and Reconstructive Surgery, University of Michigan Medical Center, Ann Arbor, MI, personal communication), a 3-0 silk suture on a needle with a knot tied at the end is passed though the nasal cavity, exiting through the pivot point (Fig. 2C). This suture is draped across the defect and a clamp placed where the suture crosses the edge of the defect (Fig. 2D). This technique more accurately measures the defect diameter by taking into account the surface topography of the wound. The outer edge of the flap’s design is then determined through rotating this length of suture around the pivot point (Fig. 2E). Next, an inner arc of curvature is marked, a distance of precisely 0.5 D inside the outer arc (Fig. 2F). The primary lobe is demarcated with a diameter equal to that of the defect (Fig. 2F). Lengthening the flap decreases tension as the primary lobe is inset and decreases the need for secondary movement (ie, alar displacement).
Next, the secondary lobe is marked, centered anywhere from 90 to 180 from the line bisecting the pivot point with the midpoint of the defect (ie, a line bisecting the dog ear excision) (Fig. 2G). It is best placed with its closure aligned vertically at the subunit border (dorsal subunit with lateral wall subunit, or nasofacial junction). Placement of the secondary lobe line of closure perpendicular to the long axis of the nasal alae minimizes the chance for alar displacement secondary to surgical tension. The width of the secondary lobe is between one half the diameter of the primary lobe up to the same size as the primary lobe. Determining the size of the secondary lobe is a delicate balance between being small to allow easy closure of the tertiary defect and being large enough to close the primary defect site without secondary motion and subsequent tip or alar displacement. The marked incisions are incised and flaps are elevated just above the perichondrium or periosteum (similar to rhinoplasty) to include the nasal musculature, thus creating a robust flap (Fig. 2H). Ideally, the donor flap should be slightly thinner than the depth of the defect to account for the expected elevation of the flap that occurs with healing. In general, wide undermining of the periphery of both the donor and defect site should be performed. The planned Burrow’s triangle is excised before flap transposition to minimize depression of the ipsilateral ala from impeded distal flap movement. Closure of the tertiary defect before insetting the flaps facilitates precise placement with minimum tension. The primary flap is inset first. Before placement, the soft tissue deep to the rotation point of the primary and secondary flaps is excavated to create a tissue void to reduce the likelihood of a standing cone deformity. Tacking sutures (5-0 Vicryl, Ethicon Inc, Johnson & Johnson, Somerville, New Jersey) are placed into the bed of the defect and then into the primary flap. The secondary flap tip is trimmed to precisely fit the remaining defect and inset in a similar fashion. Finally, interrupted vertical mattress sutures (6-0 nylon or Prolene, Ethicon Inc, Johnson & Johnson, Somerville, New Jersey) are used to reapproximate the superficial skin edges; Fig. 3 shows typical postoperative results. The patient, a 69-year-old man, underwent bilobed reconstruction of a 1-cm nasal tip defect. Fig. 3C shows his appearance 12 months postoperatively. Placement of cartilage grafts For improved cosmesis and nasal function, occasionally cartilage grafts should be placed
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Fig. 2. Bilobed flap for nasal tip defect. (A, B) The diameter of the defect (D) is measured with calipers and the pivot point placed at least 0.5 D from the edge of the defect. (C) A 3–0 silk ligature is passed through the pivot point and (D) clamped at the edge of the defect. (E) The outer edge of the flap’s design is determined by rotating the length of suture around the pivot point. (F) An inner arc of curvature is marked a distance 0.5 D inside the outer arc. (G) Finally, the primary lobe is demarcated with a diameter equal to that of the defect, and the secondary lobe is marked out with a width 0.5 D up to the same size as the primary lobe. (H) Flaps are elevated just above the perichondrium or periosteum.
Bilobed, Rhombic, and Cervicofacial Flaps
Fig. 3. Post–bilobed flap reconstruction of a 1-cm nasal tip defect in a 69-year-old man. (A) Preoperative markings. (B) Appearance immediately after closure. (C) Appearance 12 months postoperatively.
concurrently with bilobed flap repairs of nasal defects. Placement of a cartilage graft may be beneficial (1) as a brace against contracture along a free margin (ie, near alar margin), (2) as an alar batten graft, which should be considered prophylactically in patients at risk for nasal valve collapse3 (eg, defects over nasal valve, preexisting nasal valve collapse, cephalic malposition of the lower lateral cartilages, narrow nostrils), or (3) as a columellar strut (eg, soft/pliable tip cartilages, tip defects/caudal septal defects). Cartilage can be harvested from the ear or septum if a septoplasty is planned. Fig. 4 shows placement of a septal cartilage strut in a 60-yearold man who underwent bilobed reconstruction of a 1.1-cm full-thickness defect through the nasal valve region.
RHOMBIC FLAP Similar to the bilobed flap, the rhombic flap is considered a transpositional flap. Rhombic flaps move relatively lax donor tissue adjacent to the defect (typically on the cheek) over stationary skin and into the surgical defect using a combination of rotation and advancement. This technique redistributes and redirects wound closure tension. Another advantage of the rhombic flap is that it can be designed in several directions, allowing surgeons to select the orientation that produces the most ideal would closure and scar tension. Similar to the bilobed flap, using adjacent donor tissue ensures excellent color and texture match. Although technically easy to execute, the rhombic flap requires careful geometric planning because some incisions cannot be placed within relaxed skin tension lines. One disadvantage of the classic rhombic flap design is the significant tension at the closure point of the secondary defect
and the amount of tissue discarded when a circular defect is converted into a rhombic defect. Since 1946 and Limberg’s original description of the rhombic flap in Russia,4 many modifications have been described. This article describes several of the more commonly used modifications, but focuses on the Limberg design in the ‘‘Surgical Technique’’ section. In the classic Limberg design, a rhombic defect is created (equilateral parallelogram) with 60 and 120 angles, and the flap is designed off the short axis of the defect to minimize the size of the secondary defect. The flap can be constructed in four possible orientations based off the short axis (Fig. 5), with the following considerations in mind: (1) orientation along a relaxed skin tension line or at the junction of two facial aesthetic subunits, (2) optimal use of tissue laxity so as not to distort adjacent tissue free margins, and (3) areas of tension (ie, closure of secondary defect [area of maximal tension, Fig. 5] and leading tip). The typical defect after Mohs surgical excision is circular rather than rhombic. Rather than converting the defect into a rhombic defect, a modified rhombic flap has been designed to allow closure of circular defects.5 Essentially, a rhombus is mentally superimposed or drawn over the circular defect. Because the defect is circular, an infinite number of flap positions are possible. The first incision bisects the circular defect and has a length slightly shorter than the diameter of the defect (Fig. 6). The second incision is equal in length to the first incision and forms a 60 angle with the end point of the first line. A Burow’s triangle may be excised from the base of the flap to prevent a standing cone deformity with flap transposition. Closure may also be facilitated by squaring off the circular defect at the site of the distal-most flap closure before inset of the flap.
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Fig. 4. Bilobed flap reconstruction of a 1.1-cm full-thickness defect through the region of the nasal valve in a 60-year-old man. (A) Defect. (B) Preoperative markings. (C) Placement of septal cartilage as an alar batten graft. (D) Appearance 4 months postoperatively.
Bilobed, Rhombic, and Cervicofacial Flaps
Fig. 5. Design of the classic Limberg rhombic flap. (A–D) Four possible arrangements of the flap. The arrow indicates the vector and point of maximal tension. Dotted lines indicate planned incisions.
The Dufourmental flap, a modification of the Limberg design, has angles varying from 60 to 90 and a shorter arc of rotation than the Limberg flap, and produces a more obtuse leading angle.6 This technique relieves pivotal restraint but results in more lateral tip tension while decreasing vertical tip tension. Thus, the Dufourmental flap is ideal when lateral tension is acceptable and a vertical tension vector is not. The Dufourmental flap is initiated by drawing a line of the short angle of the rhombus as for a Limberg flap. However, the first incision bisects the angle formed from extending one side of the rhombus and the first line of the Limberg flap (Fig. 7). The incision is equal to the length of one side of the rhombus. The second incision is equal in length to the first and extends down from the
Fig. 6. Modified version of the rhombic flap allowing closure of circular defects. Dotted lines indicate planned incisions. Shaded areas indicate potential additional areas of skin excision.
Fig. 7. Design of the Dufourmental flap. Thick dotted lines indicate planned incisions.
end point of the first incision parallel to the long axis of the rhombus, forming a 60 angle with the first incision. This angle may be varied as needed to account for variability in skin elasticity. Furthermore, an M-plasty may be used to help relieve rotational forces at the base of the flap. The Webster flap provides even greater tension sharing between the primary and secondary defects than the Dufourmental flap.7 The flap tip angle is decreased from 60 to 30 , making the base of the flap equal to half the length of the recipient defect. The small donor site decreases the amount of tension needed to close the defect. Fig. 8 shows the design of the Webster flap. Although the initial incision is similar to that of the Dufourmental flap, the second incision extending from the end point of the first incision forms
Fig. 8. Design of the Webster flap. Dotted lines indicate planned incisions.
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Chu & Byrne a 30 angle with the first incision, rather than the 60 angle seen with the Dufourmental flap. Adding an M-plasty at the base of the defect minimizes the risk for a standing cone deformity and shortens the scar length. These modifications are especially useful when two flaps are used to each close one half of a defect. Proper application of the Webster flap relies on a fair amount of skin laxity around the primary defect, because half of this defect is filled with adjacent tissue rather than the flap. Undue tension could distort the anatomy around the primary defect, which could be deleterious around critical structures with a free margin, such as the nasal ala and eyelids.
Indications for Rhombic Flaps Rhombic flaps are most commonly used for small to medium-sized cutaneous cheek defects. However, they have been successfully used in reconstruction of scalp, neck, temple, nose, chin, and eyelid defects.6,8,9 Preoperative assessment A complete head and neck examination should be performed, with special attention to the location of the defect and nature of the skin. Special attention also must be paid to lesions near critical structures with free margins, such as the nasal ala and eyelids. Incisions must be planned carefully to limit distortion of these structures from wound tension. The quality and laxity of the skin also influence which rhombic flap design is used.
Surgical Technique for Rhombic Flaps Typically, the initial design of the flap is demarcated in the preoperative area with the patient in
the upright position so the normal forces of gravity on the face can be visualized properly. Previous scars, relaxed skin tension lines, facial subunits, and lines of facial expression should be noted both in repose and with movement. The flap is designed so that the closure of greatest tension (donor-site closure) is aligned to take advantage of the area of maximal laxity (Fig. 9A). Typically the lines of maximal extensibility run perpendicular to the relaxed skin tension lines. Once a rhombic defect is created using the classic Limberg rhombic flap design, four flap choices are possible, only one of which will result in closure of the secondary defect with the corresponding vector of greatest laxity. Therefore, all design options and orientations must be considered carefully before incision. The entire face is prepped, especially in lesions near the eyelid or nasal ala, to ensure that any secondary movement caused by the flap is noted. A rhombic defect is created with 60 and 120 angles and a slight outward bevel of the incisions. The first incision extends off the selected short axis and is equal in length to one side of the rhombus (Fig. 9A). The second incision is equal in length to the first and extends from the end point of the first incision to form a 60 angle (second incision is parallel to the nearest rhombus edge). The flap should be raised at the desired depth based on the depth of the defect. The periphery of the primary and secondary defect is widely undermined to reduce would tension. After obtaining hemostasis with bipolar forceps or needle-point cautery, the flap is transposed into the primary defect. Before the flap is secured, it should be thinned to match the level of the donor site. To minimize tissue trauma, the flap and
Fig. 9. Classic Limberg rhombic flap. (A) Flap is designed so the closure of the region of greatest tension (donorsite closure) is aligned to take advantage of the area of maximal laxity. (B) Final appearance after closure of all incisions.
Bilobed, Rhombic, and Cervicofacial Flaps surrounding tissue should be manipulated as little as possible. Skin hooks and toothed forceps help to minimize soft tissue trauma. The secondary defect is closed in layers with deep dermal sutures (5-0 Vicryl) and the superficial layer is closed with interrupted vertical mattress sutures (6-0 nylon or Prolene) for maximal eversion of the wound edges. The flap is then sutured into the primary defect in a similar fashion (Fig. 9B). Tacking sutures, typically 5-0 absorbable suture, may be useful, especially in primary defects in an area of facial concavity. Excellent results depend on meticulous handling of soft tissue and placement of sutures. Fig. 10A shows the preoperative appearance of a 58-year-old man who underwent rhomboid flap reconstruction of a 2-cm left cheek defect caused by wide local excision and sentinel lymph node mapping for a Clark level 3 melanoma. Fig. 10B shows excellent cosmetic results at 4 months.
CERVICOFACIAL FLAP The cervicofacial flap is a combination rotation and advancement flap that provides a single-stage, dependable, and cosmetically acceptable reconstruction of moderate to large defects of the cheek. It takes advantage of the usually abundant tissue laxity in the adjacent cheek and jowl areas. Although it requires long incisions and a moderate of amount of skin undermining and elevation, the strategic placement of incisions makes the resulting scar relatively inconspicuous. The disadvantages of the cervicofacial flap relate to the amount of skin mobilization needed for adequate coverage. Some patients experience cheek asymmetry, with the appearance of a unilateral facial rhytidectomy. Furthermore, improper planning of incisions can cause distortion of
important landmarks, such as the lower eyelid, upper lip, and nasal ala. Another drawback of extensively mobilized cervicofacial flaps is the unpredictable blood supply. The deep plane cervicofacial flap (DPCFF) is a significant modification of the traditional flap.10 Based on the superficial musculoaponeurotic system (SMAS) deep plane facelift technique, the DPCFF is a musculo-fascio-cutaneous flap with an axial blood supply from branches of the facial artery or superficial temporal vessels. Cervicofacial flaps are often used to reconstruct cheek defects, which can often encroach on or involve the lower eyelid. Therefore, perhaps the greatest concern about these flaps is the risk for postoperative ectropion, and careful attention must be given to eliminating tension of the closure. The flap must be suspended to the periosteum of the orbital rim or zygoma to prevent this complication. This article describes both anteriorly based and the less commonly used posteriorly based rotation advancement designs. The design of the anteriorly based cervicofacial flap is described in detail in the ‘‘Surgical Technique’’ section. Posteriorly based flaps have the advantage of preserving the transverse branches of the facial and superficial temporal arteries. The flap transfers the excess skin of the inferior face, jowl, and submental areas along an incision that follows the nasolabial fold to the oral commissure and can continue to or across the jawline and anteriorly in the submental crease, ending with a back-cut.
Indications The cervicofacial advancement flap is ideally suited for moderate (1.5 cm) to large (>3.0 cm) cutaneous defects of the cheek, periorbital, periauricular, and neck regions. Although frequently
Fig.10. (A) Preoperative appearance of a 58-year-old man who underwent rhomboid flap reconstruction of a 2-cm left cheek defect after wide local excision and sentinel lymph node mapping for a Clark level 3 melanoma. (B) Appearance 4 months postoperatively.
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Chu & Byrne described as separate flaps in the literature, the cervicothoracic flap simply represents a more inferior extension of the same flap and allows recruitment of additional tissue for large defects of the neck. Anteriorly based flap designs are useful for posterior and large anterior defects, whereas posterior based flaps are well suited for small and moderate-sized defects of the anterior cheek.11 Preoperative assessment Again, a complete head and neck examination should be performed, with special attention to the location of the defect; depth of the wound and layers involved; size; relationship of the defect to recognized aesthetic units and facial subunits; function of local and surrounding tissue; and properties of the adjacent tissue. A history of smoking or previous radiation therapy should be noted because the risk for flap necrosis is especially high in large wounds closed under tension, in smokers, and in patients who have undergone radiation.
Surgical Technique The entire face is prepped and draped to allow comparison to the contralateral side. For an anteriorly or anterior-inferiorly–based flap, the incision begins from the posterolateral aspect of the resection margins and extends superiorly and laterally along a subciliary crease, or at that lid–cheek junction near the orbital rim, then out the lateral canthal and temporal area before entering the preauricular crease. The incision may then continue inferiorly into a crease in the neck, similar to the standard parotidectomy incision with a horizontal limb. For additional skin recruitment, the incision may extend behind the lobule and onto the mastoid before follow the posterior hairline to the anterior edge of the trapezius muscle. This additional tissue can be transposed over the ear in a bilobed fashion. The medial incision should be made along the nasal facial groove and continued into the nasolabial fold. Standing cone deformities, frequently seen around the melolabial fold, can be excised directly. Fig. 11 shows the incisions and potential areas for backcuts within cervical creases. Generally, the incision is performed in a staged, as-needed manner, with continual reassessment of the arc of rotation and the ability of the flap to close the defect in a tension-free manner. On the face, the flap is elevated superficial to the SMAS and parotideomasseteric fascia to protect branches of the facial nerve. Elevation continues in a subplatysmal manner in the neck, with care taken to stay just below the platysma to minimize risk for injury to the marginal mandibular branch of the facial nerve. The donor site may be closed
Fig. 11. Design of an anterior-inferiorly–based cervicofacial flap. Dotted lines indicate planned incisions. The incisions are tailored based on the extent of the lesion and are performed in a staged fashion, with continual reassessment of the arc of rotation and the ability of the flap to fill the defect in a tensionfree manner. The arrows indicate potential back-cuts within a cervical crease.
primarily after wide undermining of the posterior skin flap. No tension should be placed on the lower eyelid, nasal ala, or upper lip after closure. The flap must be suspended in a superior medial direction using long-lasting absorbable suture (2-0, 3-0, or 4-0 PDS, Ethicon, Johnson & Johnson, Somerville, New Jersey) to anchor the flap to the periosteum of the zygoma, infraorbital rim, lateral orbital rim, or nasal facial groove. If the subciliary incision is chosen, the portion of the flap over the lower eyelid should be aggressively thinned to match the thickness of the native eyelid skin. The authors generally prefer to make the incision along the lower lid–cheek junction, however, to lesson the risk for postoperative ectropion. Maintaining an acute angle of the superior medial tip of the flap helps ensure a precise fit into the borders of the cheek, eye, and nasal aesthetic unit and minimizes tension on the lower eyelid with scar contracture. The remaining incisions are closed in layers, with buried interrupted absorbable sutures for the deep dermal layer and a fine permanent suture for the skin. Depending on the amount of dissection, a Jackson Pratt drain may be left in place for 24 to 48 hours. Fig. 12 presents intraoperative
Bilobed, Rhombic, and Cervicofacial Flaps
Fig. 12. Left lower eyelid/cheek melanoma in situ in an 85-year-old man (A) after excision of the lesion, (B) showing elevation of an anterior-inferiorly–based cervicofacial flap, and (C) after inset of the flap.
photographs showing an anterior-inferior–based cervicofacial flap used for reconstructing a left cheek/eyelid defect after excision of melanoma in situ involving the junction of the cheek, eyelid, and nasal aesthetic units.
COMPLICATIONS WITH LOCAL FLAPS Major complications after local flap reconstruction are extremely rare.6,12,13 All flaps are subject to postoperative wound infection, hemorrhage, and the formation of hematomas or seromas. Flap necrosis may occur from excessive tension on would edges, ischemia from cigarette smoking, or shortening of the flap base when removing the Burrow’s triangle (bilobed and rhombic flaps). Partial flap necrosis is best treated with wound debridement and local wound care. Partialthickness injuries may not affect the long-term aesthetic outcome; however, full-thickness necrosis may result in a depressed scar that is best left to heal through secondary intention. It is prudent to resist the temptation for immediate revision and delay any secondary procedures until after the wound has adequately healed. Standing cone deformities and pincushioning are potential complications common among bilobed, rhombic, and cervicofacial flaps. Standing cone deformities are best avoided through proper planning of incisions and the excision of Burrow’s triangles as necessary. Although the exact pathogenesis of pincushioning or the trapdoor deformity is unclear, several theories have been advanced, including lymphatic obstruction, rounded flap edges, excess subcutaneous tissue in the flap, and asymmetric scar contracture
between the base of the flap and surrounding tissues.12 Pincushioning, or bulging elevation of tissue occurring within a scar, is more common in bilobed transposition flaps, or other flaps with curved designs, but may occur with rhombic or cervicofacial flaps. Wide undermining and using straight lines and angles when possible minimizes the risk for circumferential contraction and pincushioning. If pincushioning occurs, treatment options include daily patient passage, intralesional corticosteroids, dermabrasion, and flap revision. Other complications related to flap design include secondary movement of critical adjacent structures caused by edema, gravity, or flap tension. In the case of bilobed or rhombic flaps used for nasal reconstruction, alar collapse can lead to nasal obstruction. Poorly planned rhombic or cervicofacial flaps used in the periocular and perioral regions can lead to ectropion, scleral show, and distortion of the upper lip. Finally, unique to the cervicofacial flap is the potential for abnormal hair distribution. Glabrous skin should not exist within the male beard pattern, nor should sideburns or the male beard pattern be displaced anteriorly in an abnormal position. These complications are best avoided during the preoperative planning phase. Laser hair removal or directed hair transplantation can be used when more conservative measures fail.
SUMMARY The bilobed, rhombic, and cervicofacial flaps are reliable flaps that provide vascularized tissue with excellent texture and color match for
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Chu & Byrne reconstructing facial defects after excision of skin cancers. These flaps have multiple applications in the head and neck region; however, the bilobed flap is particularly useful for small defects of the nasal tip, whereas the rhombic and cervicofacial flaps are well suited for small to medium and medium to large defects of the cheek, respectively. The ultimate success of the flaps relies on careful preoperative assessment of patient characteristics and defect analysis, along with appropriate flap design and meticulous surgical technique.
REFERENCES 1. Esser JFS. Gestielite lokale Nasenplastik mit zweizipfligem Lappen, Deckung des sekundaren Defektes vom ersten Zipfel durch den zweiten [in German]. Deutsch Zeitsch Chir 1918;143:385–90. 2. Zitelli JA. The bilobed flap for nasal reconstruction. Arch Dermatol 1989;125(7):957–9. 3. Robinson JK, Burget GC. Nasal valve malfunction resulting from resection of cancer. Arch Otolaryngol Head Neck Surg 1990;116(12):1419–24. 4. Limberg AA. Mathematical principles of local plastics procedures on the surface of the human body. Leningrad (Russia): Medgis; 1946.
5. Quaba AA, Sommerlad BC. ‘‘A square peg into a round hole’’: a modified rhomboid flap and its clinical application. Br J Plast Surg 1987;40(2): 163–70. 6. Bray DA. Clinical applications of the rhomboid flap. Arch Otolaryngol 1983;109:37–42. 7. Fee WE Jr, Gunter JP, Carder HM. Rhomboid flap principles and common variations. Laryngoscope 1976;86(11):1706–11. 8. Pletcher SD, Kim DW. Current concepts in cheek reconstruction. Facial Plast Surg Clin North Am 2005;13:267–81. 9. Roth DA, Longaker MT, Zide BM. Cheek surface reconstruction: best choices according to zones. Operat Tech Plast Reconstr Surg 1998;5(1):26–36. 10. Tan ST, MacKinnon CA. Deep plane cervicofacial flap: a useful and versatile technique in head and neck surgery. Head Neck 2006;28(1):46–55. 11. Menick FJ. Reconstruction of the cheek. Plast Reconstr Surg 2001;108(2):496–505. 12. Cook JL. Reconstructive utility of the bilobed flap: lessons from flap successes and failures. Dermatol Surg 2005;31(8 Pt 2):1024–33. 13. Cook TA, Israel JM, Wang TD, et al. Cervical rotation flaps for midface resurfacing. Arch Otolaryngol Head Neck Surg 1991;117(1):77–82.
blood supply, minimal morbidity, and excellent cosmesis. The bilobed, rhombic, and cervicofacial advancement flaps are all local flaps that have a long history of success in the reconstruction of facial defects after resection of skin cancers, and represent an important addition to the armamentarium of any surgeon interested in facial reconstructive surgery. This article reviews the indications, surgical techniques, and complications of each.
BILOBED FLAP The bilobed flap is a random-pattern cutaneous transposition flap consisting of two lobes based on a single pedicle. Although the bilobed flap has been used in sites as disparate as the face, eyelids, trunk, foot, scalp, and hand, its greatest use is in nasal reconstruction. It has the advantages of being a single-stage flap of simple design that has excellent color and texture match with adjacent tissues and predictable flap viability. The particular advantage of the bilobed flap is that it allows surgeons to recruit tissue from a distant site—one not really adjacent to the defect but somewhat removed—to close a defect. Thus, if the tissue adjacent to the defect lacks distensibility, but tissue a bit further away is easily
a Facial Plastic and Reconstructive Surgery, Anterior Skull Base Surgery, Department of Otolaryngology Head and Neck Surgery, University of California, Irvine School of Medicine, Irvine, CA, USA b Facial Plastic and Reconstructive Surgery, Departments of Otolaryngology-Head and Neck Surgery and Dermatology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA * Corresponding author. JHOC 6210 - Johns Hopkins Department of Otolaryngology-Head and Neck Surgery, 601 North Caroline Street, Baltimore, MD 21287. E-mail address: [email protected] (P.J. Byrne).
Facial Plast Surg Clin N Am 17 (2009) 349–360 doi:10.1016/j.fsc.2009.05.003 1064-7406/09/$ – see front matter ª 2009 Elsevier Inc. All rights reserved.
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This article is the first in a series focusing on the reconstruction of defects of the face, head, and neck created by the resection of a skin cancer. This series begins with a detailed description of specific types of local flaps, and is followed by articles emphasizing the options for reconstruction by anatomic site. The surgical technique for three workhorse flaps of the face are described: the bilobed flap, rhombic flap, and cervicofacial flaps. Reconstruction of facial defects after excision of skin cancers can be challenging. Optimal results rely on a sound understanding of skin anatomy and flap physiology, careful analysis of the defect and recipient site, familiarity with multiple reconstructive options, and meticulous techniques for handing soft tissue. The concept of the reconstructive ladder, in which each rung of the ladder represents a successively more complex surgical plan (ie, healing through secondary intention to the use of microvascular free flaps), provides a framework for organizing the myriad surgical options (Fig. 1). Most facial defects that cannot be treated with primary closure are amenable to local flaps. Local flaps by definition use tissue adjacent to the defect and therefore have favorable skin color– and texture-match characteristics. When designed and executed properly, they allow for rapid and reliable reconstruction of defects with a reliable
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Chu & Byrne Esser’s design, and incorporated an excision of a dog ear redundancy near the base of the flap. The combination of these changes eliminated the dog ear and decreased the incidence of pincushioning. This article describes the bilobed flap design and execution, with several suggestions to enable its effective use. The description focuses on its use on the nose, only because the repair of nasal tip defects has some unique challenges. However, the design is applicable to other areas of the face, head, and neck.
Indications for Bilobed Flap
Fig. 1. Reconstructive ladder. Each higher rung of the ladder represents increasingly more complex surgical procedures.
stretched to close, the bilobed flap may be a great choice. The nasal tip is obviously the typical site of its use, although other areas are useful. Among the disadvantages are that it has complex incision lines, cannot follow the principle of nasal subunit reconstruction, is limited to closure of small nasal defects, and has a dramatic ability to distort the symmetry of the distal nose if not planned appropriately. Esser1 first described the bilobed flap for the repair of nasal defects in 1918 in the German literature. Subsequent authors described minor variations of the flap but not until Zitelli’s2 modifications in 1989 were the problems of tissue protrusion (dog ears) and pincushioning minimized. Zitelli transposed each flap 45 , instead of 90 as in
The bilobed flap is designed to recruit adjacent skin and soft tissue from areas of laxity to areas of deficiency. This technique is ideally suited for reconstructing relatively small defects (<1.5 cm in diameter) of the distal nose where the thick, sebaceous, relatively immobile skin overlying the supratip, tip, and alae can be repaired with the thin, loose, relatively nonsebaceous skin of the nasal dorsum and side walls. Use of a second lobe allows recruitment of tissue from a more distant site, and distributes tension across a greater area. Although generally defects of 1.5 cm or less may be adequately addressed with the bilobed flap, it may be influenced by the presence of previous scars and patient skin type. Patients who have thin, dry, loose skin often have an abundance of available skin for transposition, and larger defects may be closed favorably. However, favorable results may be difficult to achieve in patients who have thick sebaceous skin that extends superiorly beyond the tip subunit, even for defects smaller than 1.5 cm.
Preoperative Assessment Before designing the flap, three important characteristics seen on physical examination must be considered: location of defect, nature of the nasal skin, and nasal anatomy. Defects of the nasal ala are generally approached with medially based bilobed flaps, whereas tip defects are treated with a laterally based flap. Patients who have thick and sebaceous skin of the nasal tip require special consideration. The thick sebaceous skin, when used as part of the flap, limits the amount of skin available for transposition and has a tendency to ‘‘bulldoze’’ the ipsilateral alar margin inferiorly. The nose must be examined carefully with the supportive structure in mind. Surgeons must anticipate the inevitable effects of the repair, which entail some degree of soft tissue contracture in
Bilobed, Rhombic, and Cervicofacial Flaps the future. Some patients may be at greater risk for nasal tip distortion, depending on the amount of inherent tip support. Depending on the location of the defect, postoperative internal or external nasal valve collapse may cause functional nasal obstruction. Thus, the nasal airway, tip, and internal and external nasal valve support must be assessed. The quality of the tip cartilages, septal anatomy, and presence or absence of cephalic malposition of the lower lateral cartilages are all determined, particularly for defects involving the tissue overlying the internal nasal valve. The primary goal of any oncologic surgical resection is complete extirpation of tumor. If any concern exists regarding the adequacy of the resection or if the tumor is highly aggressive, allowing the site to heal through secondary intention or using a skin graft to facilitate monitoring for tumor recurrence may be preferable.
Surgical Technique for Bilobed Flap The entire face is prepped so that any nasal asymmetry introduced by the flap design can be recognized. The diameter of the defect (D) is measured with calipers and then the pivot point is selected (Fig. 2A). The pivot point should extend to an angle of 30 and is placed at least 0.5 D from the edge of the defect (Fig. 2B) and may be drawn much longer. Longer pivot points may protrude less, and limit some of the bulldozing effect on the ipsilateral ala, in which the alar margin is displaced inferiorly. Lines drawn from the pivot point to the edges of the circle delineate the Burrow’s triangle that will be excised to prevent dog ear formation. As described by Baker (Dr. Shan Baker, Professor of Facial Plastic and Reconstructive Surgery, University of Michigan Medical Center, Ann Arbor, MI, personal communication), a 3-0 silk suture on a needle with a knot tied at the end is passed though the nasal cavity, exiting through the pivot point (Fig. 2C). This suture is draped across the defect and a clamp placed where the suture crosses the edge of the defect (Fig. 2D). This technique more accurately measures the defect diameter by taking into account the surface topography of the wound. The outer edge of the flap’s design is then determined through rotating this length of suture around the pivot point (Fig. 2E). Next, an inner arc of curvature is marked, a distance of precisely 0.5 D inside the outer arc (Fig. 2F). The primary lobe is demarcated with a diameter equal to that of the defect (Fig. 2F). Lengthening the flap decreases tension as the primary lobe is inset and decreases the need for secondary movement (ie, alar displacement).
Next, the secondary lobe is marked, centered anywhere from 90 to 180 from the line bisecting the pivot point with the midpoint of the defect (ie, a line bisecting the dog ear excision) (Fig. 2G). It is best placed with its closure aligned vertically at the subunit border (dorsal subunit with lateral wall subunit, or nasofacial junction). Placement of the secondary lobe line of closure perpendicular to the long axis of the nasal alae minimizes the chance for alar displacement secondary to surgical tension. The width of the secondary lobe is between one half the diameter of the primary lobe up to the same size as the primary lobe. Determining the size of the secondary lobe is a delicate balance between being small to allow easy closure of the tertiary defect and being large enough to close the primary defect site without secondary motion and subsequent tip or alar displacement. The marked incisions are incised and flaps are elevated just above the perichondrium or periosteum (similar to rhinoplasty) to include the nasal musculature, thus creating a robust flap (Fig. 2H). Ideally, the donor flap should be slightly thinner than the depth of the defect to account for the expected elevation of the flap that occurs with healing. In general, wide undermining of the periphery of both the donor and defect site should be performed. The planned Burrow’s triangle is excised before flap transposition to minimize depression of the ipsilateral ala from impeded distal flap movement. Closure of the tertiary defect before insetting the flaps facilitates precise placement with minimum tension. The primary flap is inset first. Before placement, the soft tissue deep to the rotation point of the primary and secondary flaps is excavated to create a tissue void to reduce the likelihood of a standing cone deformity. Tacking sutures (5-0 Vicryl, Ethicon Inc, Johnson & Johnson, Somerville, New Jersey) are placed into the bed of the defect and then into the primary flap. The secondary flap tip is trimmed to precisely fit the remaining defect and inset in a similar fashion. Finally, interrupted vertical mattress sutures (6-0 nylon or Prolene, Ethicon Inc, Johnson & Johnson, Somerville, New Jersey) are used to reapproximate the superficial skin edges; Fig. 3 shows typical postoperative results. The patient, a 69-year-old man, underwent bilobed reconstruction of a 1-cm nasal tip defect. Fig. 3C shows his appearance 12 months postoperatively. Placement of cartilage grafts For improved cosmesis and nasal function, occasionally cartilage grafts should be placed
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Fig. 2. Bilobed flap for nasal tip defect. (A, B) The diameter of the defect (D) is measured with calipers and the pivot point placed at least 0.5 D from the edge of the defect. (C) A 3–0 silk ligature is passed through the pivot point and (D) clamped at the edge of the defect. (E) The outer edge of the flap’s design is determined by rotating the length of suture around the pivot point. (F) An inner arc of curvature is marked a distance 0.5 D inside the outer arc. (G) Finally, the primary lobe is demarcated with a diameter equal to that of the defect, and the secondary lobe is marked out with a width 0.5 D up to the same size as the primary lobe. (H) Flaps are elevated just above the perichondrium or periosteum.
Bilobed, Rhombic, and Cervicofacial Flaps
Fig. 3. Post–bilobed flap reconstruction of a 1-cm nasal tip defect in a 69-year-old man. (A) Preoperative markings. (B) Appearance immediately after closure. (C) Appearance 12 months postoperatively.
concurrently with bilobed flap repairs of nasal defects. Placement of a cartilage graft may be beneficial (1) as a brace against contracture along a free margin (ie, near alar margin), (2) as an alar batten graft, which should be considered prophylactically in patients at risk for nasal valve collapse3 (eg, defects over nasal valve, preexisting nasal valve collapse, cephalic malposition of the lower lateral cartilages, narrow nostrils), or (3) as a columellar strut (eg, soft/pliable tip cartilages, tip defects/caudal septal defects). Cartilage can be harvested from the ear or septum if a septoplasty is planned. Fig. 4 shows placement of a septal cartilage strut in a 60-yearold man who underwent bilobed reconstruction of a 1.1-cm full-thickness defect through the nasal valve region.
RHOMBIC FLAP Similar to the bilobed flap, the rhombic flap is considered a transpositional flap. Rhombic flaps move relatively lax donor tissue adjacent to the defect (typically on the cheek) over stationary skin and into the surgical defect using a combination of rotation and advancement. This technique redistributes and redirects wound closure tension. Another advantage of the rhombic flap is that it can be designed in several directions, allowing surgeons to select the orientation that produces the most ideal would closure and scar tension. Similar to the bilobed flap, using adjacent donor tissue ensures excellent color and texture match. Although technically easy to execute, the rhombic flap requires careful geometric planning because some incisions cannot be placed within relaxed skin tension lines. One disadvantage of the classic rhombic flap design is the significant tension at the closure point of the secondary defect
and the amount of tissue discarded when a circular defect is converted into a rhombic defect. Since 1946 and Limberg’s original description of the rhombic flap in Russia,4 many modifications have been described. This article describes several of the more commonly used modifications, but focuses on the Limberg design in the ‘‘Surgical Technique’’ section. In the classic Limberg design, a rhombic defect is created (equilateral parallelogram) with 60 and 120 angles, and the flap is designed off the short axis of the defect to minimize the size of the secondary defect. The flap can be constructed in four possible orientations based off the short axis (Fig. 5), with the following considerations in mind: (1) orientation along a relaxed skin tension line or at the junction of two facial aesthetic subunits, (2) optimal use of tissue laxity so as not to distort adjacent tissue free margins, and (3) areas of tension (ie, closure of secondary defect [area of maximal tension, Fig. 5] and leading tip). The typical defect after Mohs surgical excision is circular rather than rhombic. Rather than converting the defect into a rhombic defect, a modified rhombic flap has been designed to allow closure of circular defects.5 Essentially, a rhombus is mentally superimposed or drawn over the circular defect. Because the defect is circular, an infinite number of flap positions are possible. The first incision bisects the circular defect and has a length slightly shorter than the diameter of the defect (Fig. 6). The second incision is equal in length to the first incision and forms a 60 angle with the end point of the first line. A Burow’s triangle may be excised from the base of the flap to prevent a standing cone deformity with flap transposition. Closure may also be facilitated by squaring off the circular defect at the site of the distal-most flap closure before inset of the flap.
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Fig. 4. Bilobed flap reconstruction of a 1.1-cm full-thickness defect through the region of the nasal valve in a 60-year-old man. (A) Defect. (B) Preoperative markings. (C) Placement of septal cartilage as an alar batten graft. (D) Appearance 4 months postoperatively.
Bilobed, Rhombic, and Cervicofacial Flaps
Fig. 5. Design of the classic Limberg rhombic flap. (A–D) Four possible arrangements of the flap. The arrow indicates the vector and point of maximal tension. Dotted lines indicate planned incisions.
The Dufourmental flap, a modification of the Limberg design, has angles varying from 60 to 90 and a shorter arc of rotation than the Limberg flap, and produces a more obtuse leading angle.6 This technique relieves pivotal restraint but results in more lateral tip tension while decreasing vertical tip tension. Thus, the Dufourmental flap is ideal when lateral tension is acceptable and a vertical tension vector is not. The Dufourmental flap is initiated by drawing a line of the short angle of the rhombus as for a Limberg flap. However, the first incision bisects the angle formed from extending one side of the rhombus and the first line of the Limberg flap (Fig. 7). The incision is equal to the length of one side of the rhombus. The second incision is equal in length to the first and extends down from the
Fig. 6. Modified version of the rhombic flap allowing closure of circular defects. Dotted lines indicate planned incisions. Shaded areas indicate potential additional areas of skin excision.
Fig. 7. Design of the Dufourmental flap. Thick dotted lines indicate planned incisions.
end point of the first incision parallel to the long axis of the rhombus, forming a 60 angle with the first incision. This angle may be varied as needed to account for variability in skin elasticity. Furthermore, an M-plasty may be used to help relieve rotational forces at the base of the flap. The Webster flap provides even greater tension sharing between the primary and secondary defects than the Dufourmental flap.7 The flap tip angle is decreased from 60 to 30 , making the base of the flap equal to half the length of the recipient defect. The small donor site decreases the amount of tension needed to close the defect. Fig. 8 shows the design of the Webster flap. Although the initial incision is similar to that of the Dufourmental flap, the second incision extending from the end point of the first incision forms
Fig. 8. Design of the Webster flap. Dotted lines indicate planned incisions.
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Chu & Byrne a 30 angle with the first incision, rather than the 60 angle seen with the Dufourmental flap. Adding an M-plasty at the base of the defect minimizes the risk for a standing cone deformity and shortens the scar length. These modifications are especially useful when two flaps are used to each close one half of a defect. Proper application of the Webster flap relies on a fair amount of skin laxity around the primary defect, because half of this defect is filled with adjacent tissue rather than the flap. Undue tension could distort the anatomy around the primary defect, which could be deleterious around critical structures with a free margin, such as the nasal ala and eyelids.
Indications for Rhombic Flaps Rhombic flaps are most commonly used for small to medium-sized cutaneous cheek defects. However, they have been successfully used in reconstruction of scalp, neck, temple, nose, chin, and eyelid defects.6,8,9 Preoperative assessment A complete head and neck examination should be performed, with special attention to the location of the defect and nature of the skin. Special attention also must be paid to lesions near critical structures with free margins, such as the nasal ala and eyelids. Incisions must be planned carefully to limit distortion of these structures from wound tension. The quality and laxity of the skin also influence which rhombic flap design is used.
Surgical Technique for Rhombic Flaps Typically, the initial design of the flap is demarcated in the preoperative area with the patient in
the upright position so the normal forces of gravity on the face can be visualized properly. Previous scars, relaxed skin tension lines, facial subunits, and lines of facial expression should be noted both in repose and with movement. The flap is designed so that the closure of greatest tension (donor-site closure) is aligned to take advantage of the area of maximal laxity (Fig. 9A). Typically the lines of maximal extensibility run perpendicular to the relaxed skin tension lines. Once a rhombic defect is created using the classic Limberg rhombic flap design, four flap choices are possible, only one of which will result in closure of the secondary defect with the corresponding vector of greatest laxity. Therefore, all design options and orientations must be considered carefully before incision. The entire face is prepped, especially in lesions near the eyelid or nasal ala, to ensure that any secondary movement caused by the flap is noted. A rhombic defect is created with 60 and 120 angles and a slight outward bevel of the incisions. The first incision extends off the selected short axis and is equal in length to one side of the rhombus (Fig. 9A). The second incision is equal in length to the first and extends from the end point of the first incision to form a 60 angle (second incision is parallel to the nearest rhombus edge). The flap should be raised at the desired depth based on the depth of the defect. The periphery of the primary and secondary defect is widely undermined to reduce would tension. After obtaining hemostasis with bipolar forceps or needle-point cautery, the flap is transposed into the primary defect. Before the flap is secured, it should be thinned to match the level of the donor site. To minimize tissue trauma, the flap and
Fig. 9. Classic Limberg rhombic flap. (A) Flap is designed so the closure of the region of greatest tension (donorsite closure) is aligned to take advantage of the area of maximal laxity. (B) Final appearance after closure of all incisions.
Bilobed, Rhombic, and Cervicofacial Flaps surrounding tissue should be manipulated as little as possible. Skin hooks and toothed forceps help to minimize soft tissue trauma. The secondary defect is closed in layers with deep dermal sutures (5-0 Vicryl) and the superficial layer is closed with interrupted vertical mattress sutures (6-0 nylon or Prolene) for maximal eversion of the wound edges. The flap is then sutured into the primary defect in a similar fashion (Fig. 9B). Tacking sutures, typically 5-0 absorbable suture, may be useful, especially in primary defects in an area of facial concavity. Excellent results depend on meticulous handling of soft tissue and placement of sutures. Fig. 10A shows the preoperative appearance of a 58-year-old man who underwent rhomboid flap reconstruction of a 2-cm left cheek defect caused by wide local excision and sentinel lymph node mapping for a Clark level 3 melanoma. Fig. 10B shows excellent cosmetic results at 4 months.
CERVICOFACIAL FLAP The cervicofacial flap is a combination rotation and advancement flap that provides a single-stage, dependable, and cosmetically acceptable reconstruction of moderate to large defects of the cheek. It takes advantage of the usually abundant tissue laxity in the adjacent cheek and jowl areas. Although it requires long incisions and a moderate of amount of skin undermining and elevation, the strategic placement of incisions makes the resulting scar relatively inconspicuous. The disadvantages of the cervicofacial flap relate to the amount of skin mobilization needed for adequate coverage. Some patients experience cheek asymmetry, with the appearance of a unilateral facial rhytidectomy. Furthermore, improper planning of incisions can cause distortion of
important landmarks, such as the lower eyelid, upper lip, and nasal ala. Another drawback of extensively mobilized cervicofacial flaps is the unpredictable blood supply. The deep plane cervicofacial flap (DPCFF) is a significant modification of the traditional flap.10 Based on the superficial musculoaponeurotic system (SMAS) deep plane facelift technique, the DPCFF is a musculo-fascio-cutaneous flap with an axial blood supply from branches of the facial artery or superficial temporal vessels. Cervicofacial flaps are often used to reconstruct cheek defects, which can often encroach on or involve the lower eyelid. Therefore, perhaps the greatest concern about these flaps is the risk for postoperative ectropion, and careful attention must be given to eliminating tension of the closure. The flap must be suspended to the periosteum of the orbital rim or zygoma to prevent this complication. This article describes both anteriorly based and the less commonly used posteriorly based rotation advancement designs. The design of the anteriorly based cervicofacial flap is described in detail in the ‘‘Surgical Technique’’ section. Posteriorly based flaps have the advantage of preserving the transverse branches of the facial and superficial temporal arteries. The flap transfers the excess skin of the inferior face, jowl, and submental areas along an incision that follows the nasolabial fold to the oral commissure and can continue to or across the jawline and anteriorly in the submental crease, ending with a back-cut.
Indications The cervicofacial advancement flap is ideally suited for moderate (1.5 cm) to large (>3.0 cm) cutaneous defects of the cheek, periorbital, periauricular, and neck regions. Although frequently
Fig.10. (A) Preoperative appearance of a 58-year-old man who underwent rhomboid flap reconstruction of a 2-cm left cheek defect after wide local excision and sentinel lymph node mapping for a Clark level 3 melanoma. (B) Appearance 4 months postoperatively.
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Chu & Byrne described as separate flaps in the literature, the cervicothoracic flap simply represents a more inferior extension of the same flap and allows recruitment of additional tissue for large defects of the neck. Anteriorly based flap designs are useful for posterior and large anterior defects, whereas posterior based flaps are well suited for small and moderate-sized defects of the anterior cheek.11 Preoperative assessment Again, a complete head and neck examination should be performed, with special attention to the location of the defect; depth of the wound and layers involved; size; relationship of the defect to recognized aesthetic units and facial subunits; function of local and surrounding tissue; and properties of the adjacent tissue. A history of smoking or previous radiation therapy should be noted because the risk for flap necrosis is especially high in large wounds closed under tension, in smokers, and in patients who have undergone radiation.
Surgical Technique The entire face is prepped and draped to allow comparison to the contralateral side. For an anteriorly or anterior-inferiorly–based flap, the incision begins from the posterolateral aspect of the resection margins and extends superiorly and laterally along a subciliary crease, or at that lid–cheek junction near the orbital rim, then out the lateral canthal and temporal area before entering the preauricular crease. The incision may then continue inferiorly into a crease in the neck, similar to the standard parotidectomy incision with a horizontal limb. For additional skin recruitment, the incision may extend behind the lobule and onto the mastoid before follow the posterior hairline to the anterior edge of the trapezius muscle. This additional tissue can be transposed over the ear in a bilobed fashion. The medial incision should be made along the nasal facial groove and continued into the nasolabial fold. Standing cone deformities, frequently seen around the melolabial fold, can be excised directly. Fig. 11 shows the incisions and potential areas for backcuts within cervical creases. Generally, the incision is performed in a staged, as-needed manner, with continual reassessment of the arc of rotation and the ability of the flap to close the defect in a tension-free manner. On the face, the flap is elevated superficial to the SMAS and parotideomasseteric fascia to protect branches of the facial nerve. Elevation continues in a subplatysmal manner in the neck, with care taken to stay just below the platysma to minimize risk for injury to the marginal mandibular branch of the facial nerve. The donor site may be closed
Fig. 11. Design of an anterior-inferiorly–based cervicofacial flap. Dotted lines indicate planned incisions. The incisions are tailored based on the extent of the lesion and are performed in a staged fashion, with continual reassessment of the arc of rotation and the ability of the flap to fill the defect in a tensionfree manner. The arrows indicate potential back-cuts within a cervical crease.
primarily after wide undermining of the posterior skin flap. No tension should be placed on the lower eyelid, nasal ala, or upper lip after closure. The flap must be suspended in a superior medial direction using long-lasting absorbable suture (2-0, 3-0, or 4-0 PDS, Ethicon, Johnson & Johnson, Somerville, New Jersey) to anchor the flap to the periosteum of the zygoma, infraorbital rim, lateral orbital rim, or nasal facial groove. If the subciliary incision is chosen, the portion of the flap over the lower eyelid should be aggressively thinned to match the thickness of the native eyelid skin. The authors generally prefer to make the incision along the lower lid–cheek junction, however, to lesson the risk for postoperative ectropion. Maintaining an acute angle of the superior medial tip of the flap helps ensure a precise fit into the borders of the cheek, eye, and nasal aesthetic unit and minimizes tension on the lower eyelid with scar contracture. The remaining incisions are closed in layers, with buried interrupted absorbable sutures for the deep dermal layer and a fine permanent suture for the skin. Depending on the amount of dissection, a Jackson Pratt drain may be left in place for 24 to 48 hours. Fig. 12 presents intraoperative
Bilobed, Rhombic, and Cervicofacial Flaps
Fig. 12. Left lower eyelid/cheek melanoma in situ in an 85-year-old man (A) after excision of the lesion, (B) showing elevation of an anterior-inferiorly–based cervicofacial flap, and (C) after inset of the flap.
photographs showing an anterior-inferior–based cervicofacial flap used for reconstructing a left cheek/eyelid defect after excision of melanoma in situ involving the junction of the cheek, eyelid, and nasal aesthetic units.
COMPLICATIONS WITH LOCAL FLAPS Major complications after local flap reconstruction are extremely rare.6,12,13 All flaps are subject to postoperative wound infection, hemorrhage, and the formation of hematomas or seromas. Flap necrosis may occur from excessive tension on would edges, ischemia from cigarette smoking, or shortening of the flap base when removing the Burrow’s triangle (bilobed and rhombic flaps). Partial flap necrosis is best treated with wound debridement and local wound care. Partialthickness injuries may not affect the long-term aesthetic outcome; however, full-thickness necrosis may result in a depressed scar that is best left to heal through secondary intention. It is prudent to resist the temptation for immediate revision and delay any secondary procedures until after the wound has adequately healed. Standing cone deformities and pincushioning are potential complications common among bilobed, rhombic, and cervicofacial flaps. Standing cone deformities are best avoided through proper planning of incisions and the excision of Burrow’s triangles as necessary. Although the exact pathogenesis of pincushioning or the trapdoor deformity is unclear, several theories have been advanced, including lymphatic obstruction, rounded flap edges, excess subcutaneous tissue in the flap, and asymmetric scar contracture
between the base of the flap and surrounding tissues.12 Pincushioning, or bulging elevation of tissue occurring within a scar, is more common in bilobed transposition flaps, or other flaps with curved designs, but may occur with rhombic or cervicofacial flaps. Wide undermining and using straight lines and angles when possible minimizes the risk for circumferential contraction and pincushioning. If pincushioning occurs, treatment options include daily patient passage, intralesional corticosteroids, dermabrasion, and flap revision. Other complications related to flap design include secondary movement of critical adjacent structures caused by edema, gravity, or flap tension. In the case of bilobed or rhombic flaps used for nasal reconstruction, alar collapse can lead to nasal obstruction. Poorly planned rhombic or cervicofacial flaps used in the periocular and perioral regions can lead to ectropion, scleral show, and distortion of the upper lip. Finally, unique to the cervicofacial flap is the potential for abnormal hair distribution. Glabrous skin should not exist within the male beard pattern, nor should sideburns or the male beard pattern be displaced anteriorly in an abnormal position. These complications are best avoided during the preoperative planning phase. Laser hair removal or directed hair transplantation can be used when more conservative measures fail.
SUMMARY The bilobed, rhombic, and cervicofacial flaps are reliable flaps that provide vascularized tissue with excellent texture and color match for
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Chu & Byrne reconstructing facial defects after excision of skin cancers. These flaps have multiple applications in the head and neck region; however, the bilobed flap is particularly useful for small defects of the nasal tip, whereas the rhombic and cervicofacial flaps are well suited for small to medium and medium to large defects of the cheek, respectively. The ultimate success of the flaps relies on careful preoperative assessment of patient characteristics and defect analysis, along with appropriate flap design and meticulous surgical technique.
REFERENCES 1. Esser JFS. Gestielite lokale Nasenplastik mit zweizipfligem Lappen, Deckung des sekundaren Defektes vom ersten Zipfel durch den zweiten [in German]. Deutsch Zeitsch Chir 1918;143:385–90. 2. Zitelli JA. The bilobed flap for nasal reconstruction. Arch Dermatol 1989;125(7):957–9. 3. Robinson JK, Burget GC. Nasal valve malfunction resulting from resection of cancer. Arch Otolaryngol Head Neck Surg 1990;116(12):1419–24. 4. Limberg AA. Mathematical principles of local plastics procedures on the surface of the human body. Leningrad (Russia): Medgis; 1946.
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