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Use of the double tubed pedicle graft in reconstruction of large facial defects
Use of the Double Tubed Reconstruction of Large GEORGE WARREN PIERCE,
M.D.,
Pedicle Graft in Facial Defects
E. HORACE KLABUNDE, M.D. San Francisco, CaliJornia
From The Plastic and Reconstructive Surgery Center of tbe St. Francis Memorial Hospital, San Francisco, Calijornia.
WILLIAM SHADISH, M.D.,
based high on the neck to facilitate a one-step transfer. This positioning of the pedicIe bases aIIows movement of the central materia1 to the IeveI of the maIar region or any point beIow. The amount of materia1 for repair can be large. In addition the tubed pedicIes can be utilized after the centra1 portion of the graft has been seated and blood suppIy has been obtained. The versatiIity of the method thus is great and considerabIe tissue losses can be restored. If the central mass is Iarge, the donor area may be skin grafted. Of importance is the augmented Huid exchange provided by two instead of onIy one pedicIe. As experience has taught us, problems of diminished or fauIty venous return cause more failures than do those of Iessened arteria1 suppIy. The doubled suppIy and drainage system make for freedom from that dreaded vicious circIe of edema, venous stasis and final venous thrombosis which is so final. Further variations may be had in the seIection of materia1, such as the hairIess Iower neck donor skin for the reconstruction of a complete lip. This provides not only covering but aIso Iining, as shown in the accompanying case history. We have reconstructed a number of chin areas by using the skin of the upper chest, furnishing sufficient skin not onIy for the chin but aIso the throat Iine. Most of these patients had suffered severe burns of the Iower face and upper neck, with marked contractures.
HE bipedicIed chest flap has numerous advantages in the repair of Iarge facia1 deformities and is of such vaIue that we think its use has been overIooked too often. Review of the Iiterature has revealed onIy sparse mention of the method [I-J]. At this point it is onIy fitting to pause to pay tribute to that great surgeon whose name is synonymous with tubed pedicIes. It was the great priviIege of one of the authors (G. W. P.) to have served under Sir HaroId GiIIies at Queens HospitaI at Sidcup, Kent. In those earIy days of modern pIastic surgery he was a surgeon of briIIiant imagination and accurate decisions, generous in teaching and sparing himseIf never-and so he is today. His sptendid new book, “The PrincipIes and Art of PIastic Surgery” (written with MiIIard), with its weaIth of wisdom and its sparkIing styIe is, when read, Iike sitting with him for a deIightfu1 and rewarding visit. May he Iong continue to do and to teach that we may profit as aIways. Integument Iosses about the face demand repIacement of the highest order as the visage is subject to constant scrutiny. The perennia1 argument of spIit skin graft versus fIap of skin and subcutaneous tissue is aIways with us. Split graft enthusiasts pIead speed of repair pIus saving of pain, suffering and expense. We have never seen a spIit graft which possessed norma coIor, texture and softness of contour. AI1 our patients with ffap repairs have stated that the resuIts were worth the time and expense. Skin of the upper chest or Iower neck is a cIose match with facia1 skin. We transport this tissue to the face by two tubed pedicIes usuaIIy
T
American Journal of Surgery, Volume 99, February, 1958
AND
CASE REPORT This patient suffered the Ioss of almost the entire upper lip, the lower part of the nose, in&ding part of the right and a11of the Ieft aIa, the coIumeIIa and lower septum and burned tissue of the contiguous Ieft cheek. (Fig. I.) On September 6, rg5 I, biIatera1 tubed pedicIes from the chest to the neck were constructed. I94
DoubIe Tubed PedicIe Graft for Facial Defects
FIG. I. Loss of practicaIIy all the tissue of the upper Iip, left aIa, columeIIa and part of the left cheek. Tubed pedicIes can be seen at the base of the neck. FIG. 2. Transposed
pedicIe in position
to restore upper lip.
FIG. 3. One pedicle aIready has been swung to repair the left ala. The other pedicle has been swung into the tip of the nose to reconstruct the coIumeIIa. FIG. 4. Finished Iip, ala and part of cheek, which was Iater smoothed out. this pedicIe was severed and impIanted in the lip to compIete the coIumeIIa. (Fig. 4.) A number of smaller revisions were carried out later. No Iengthy periods of hospitalization were needed and the patient was able to pursue the practice of his speciaIty of roentgenoIogy with onIy short interruptions. He speaks we11with the reconstrutted Iip, and the color and appearance of the grafted areas are very satisfactory.
(Fig. I .) The chest Aap was delayed twice and then shifted to the Iip region on February 14, 1952. (Fig. 2.) At that time the useless remainder of the upper Iip was sacrificed to avoid patching and the central Aap was so folded that covering and Iining were provided. On JuIy 24th the Ieft pedicIe was detached at its base and swung in to form the Ieft ala. On October I 6th the other end of the Ieft pedicIe was detached, opened and spread to repIace the scarred area of the Ieft cheek. On December 8th the right pedicIe was detached and swung into the right aIar region, and on February 12, 1953, the other end was detached and swung to the tip of the nose for a coIumeIIar reconstruction. (Fig. 3.) On April 2nd
SUMMARY I. The bipedicIed chest or Iower neck flap is a quick and reIiabIe method of transporting
‘95
Pierce, KIabunde and Shadish skin and subcutaneous tissue to repair faciaI scars and deformities. 2. The two pedicIes insure a more efEcient circulation of the bIood, both arteria1 and venous. 3. The color match and texture of the skin of the donor area is acceptabIe for transferra1 to the recipient site. 4. The donor site can be secIuded from view by cIothing. 5. The tubed pedicIes may be used to repair additiona defects of the face, after having
served their supporting roIe to the grafted centraI fIap. 6. HairIess or hair-bearing skin may be seIected as desired. REFERENCES
I. MILLARD, D. R., JR. OrientaI peregrinations. Pk. 2.
196
Ed Reconstruct. Surg., 16: 3 19-336, 1955. GILLIES, H. and MILLARD, D. R., JR. The Principks and Art of PIastic Surgery, vol. I. chapt. I, pp. 33-34. Boston, 1957. Little, Brown & Co. PIERCE, G. W., KLABUNDE, E. H. and BROBST, H. T. SurgicaI reconstruction of Iarge lip Iosses. Pk. @ Reconstruct. Surg., 9: 68-83, 1952.
M.D.,
Pedicle Graft in Facial Defects
E. HORACE KLABUNDE, M.D. San Francisco, CaliJornia
From The Plastic and Reconstructive Surgery Center of tbe St. Francis Memorial Hospital, San Francisco, Calijornia.
WILLIAM SHADISH, M.D.,
based high on the neck to facilitate a one-step transfer. This positioning of the pedicIe bases aIIows movement of the central materia1 to the IeveI of the maIar region or any point beIow. The amount of materia1 for repair can be large. In addition the tubed pedicIes can be utilized after the centra1 portion of the graft has been seated and blood suppIy has been obtained. The versatiIity of the method thus is great and considerabIe tissue losses can be restored. If the central mass is Iarge, the donor area may be skin grafted. Of importance is the augmented Huid exchange provided by two instead of onIy one pedicIe. As experience has taught us, problems of diminished or fauIty venous return cause more failures than do those of Iessened arteria1 suppIy. The doubled suppIy and drainage system make for freedom from that dreaded vicious circIe of edema, venous stasis and final venous thrombosis which is so final. Further variations may be had in the seIection of materia1, such as the hairIess Iower neck donor skin for the reconstruction of a complete lip. This provides not only covering but aIso Iining, as shown in the accompanying case history. We have reconstructed a number of chin areas by using the skin of the upper chest, furnishing sufficient skin not onIy for the chin but aIso the throat Iine. Most of these patients had suffered severe burns of the Iower face and upper neck, with marked contractures.
HE bipedicIed chest flap has numerous advantages in the repair of Iarge facia1 deformities and is of such vaIue that we think its use has been overIooked too often. Review of the Iiterature has revealed onIy sparse mention of the method [I-J]. At this point it is onIy fitting to pause to pay tribute to that great surgeon whose name is synonymous with tubed pedicIes. It was the great priviIege of one of the authors (G. W. P.) to have served under Sir HaroId GiIIies at Queens HospitaI at Sidcup, Kent. In those earIy days of modern pIastic surgery he was a surgeon of briIIiant imagination and accurate decisions, generous in teaching and sparing himseIf never-and so he is today. His sptendid new book, “The PrincipIes and Art of PIastic Surgery” (written with MiIIard), with its weaIth of wisdom and its sparkIing styIe is, when read, Iike sitting with him for a deIightfu1 and rewarding visit. May he Iong continue to do and to teach that we may profit as aIways. Integument Iosses about the face demand repIacement of the highest order as the visage is subject to constant scrutiny. The perennia1 argument of spIit skin graft versus fIap of skin and subcutaneous tissue is aIways with us. Split graft enthusiasts pIead speed of repair pIus saving of pain, suffering and expense. We have never seen a spIit graft which possessed norma coIor, texture and softness of contour. AI1 our patients with ffap repairs have stated that the resuIts were worth the time and expense. Skin of the upper chest or Iower neck is a cIose match with facia1 skin. We transport this tissue to the face by two tubed pedicIes usuaIIy
T
American Journal of Surgery, Volume 99, February, 1958
AND
CASE REPORT This patient suffered the Ioss of almost the entire upper lip, the lower part of the nose, in&ding part of the right and a11of the Ieft aIa, the coIumeIIa and lower septum and burned tissue of the contiguous Ieft cheek. (Fig. I.) On September 6, rg5 I, biIatera1 tubed pedicIes from the chest to the neck were constructed. I94
DoubIe Tubed PedicIe Graft for Facial Defects
FIG. I. Loss of practicaIIy all the tissue of the upper Iip, left aIa, columeIIa and part of the left cheek. Tubed pedicIes can be seen at the base of the neck. FIG. 2. Transposed
pedicIe in position
to restore upper lip.
FIG. 3. One pedicle aIready has been swung to repair the left ala. The other pedicle has been swung into the tip of the nose to reconstruct the coIumeIIa. FIG. 4. Finished Iip, ala and part of cheek, which was Iater smoothed out. this pedicIe was severed and impIanted in the lip to compIete the coIumeIIa. (Fig. 4.) A number of smaller revisions were carried out later. No Iengthy periods of hospitalization were needed and the patient was able to pursue the practice of his speciaIty of roentgenoIogy with onIy short interruptions. He speaks we11with the reconstrutted Iip, and the color and appearance of the grafted areas are very satisfactory.
(Fig. I .) The chest Aap was delayed twice and then shifted to the Iip region on February 14, 1952. (Fig. 2.) At that time the useless remainder of the upper Iip was sacrificed to avoid patching and the central Aap was so folded that covering and Iining were provided. On JuIy 24th the Ieft pedicIe was detached at its base and swung in to form the Ieft ala. On October I 6th the other end of the Ieft pedicIe was detached, opened and spread to repIace the scarred area of the Ieft cheek. On December 8th the right pedicIe was detached and swung into the right aIar region, and on February 12, 1953, the other end was detached and swung to the tip of the nose for a coIumeIIar reconstruction. (Fig. 3.) On April 2nd
SUMMARY I. The bipedicIed chest or Iower neck flap is a quick and reIiabIe method of transporting
‘95
Pierce, KIabunde and Shadish skin and subcutaneous tissue to repair faciaI scars and deformities. 2. The two pedicIes insure a more efEcient circulation of the bIood, both arteria1 and venous. 3. The color match and texture of the skin of the donor area is acceptabIe for transferra1 to the recipient site. 4. The donor site can be secIuded from view by cIothing. 5. The tubed pedicIes may be used to repair additiona defects of the face, after having
served their supporting roIe to the grafted centraI fIap. 6. HairIess or hair-bearing skin may be seIected as desired. REFERENCES
I. MILLARD, D. R., JR. OrientaI peregrinations. Pk. 2.
196
Ed Reconstruct. Surg., 16: 3 19-336, 1955. GILLIES, H. and MILLARD, D. R., JR. The Principks and Art of PIastic Surgery, vol. I. chapt. I, pp. 33-34. Boston, 1957. Little, Brown & Co. PIERCE, G. W., KLABUNDE, E. H. and BROBST, H. T. SurgicaI reconstruction of Iarge lip Iosses. Pk. @ Reconstruct. Surg., 9: 68-83, 1952.