ORLANDO Sometimes the simplest surgical strategy is the best choice for reconstruction of facial defects, according to a presentation at the annual meeting of the Florida Society of Dermatologic Surgeons.
Closure of facial defects requires careful planning, which can be more challenging than the surgery for some reconstructions. "Always talk to patients about their expectations. You may have to do more complex procedures for patients with higher expectations," said Dean M. Toriumi, M.D., who is professor of facial plastic and reconstructive surgery in the department of otolaryngology-head and neck surgery, University of Illinois at Chicago.
Options from simplest to more complex include granulation as secondary intention closure, primary closure, skin grafts, and local flaps.
Secondary intention can provide a good outcome with small defects, Dr. Toriumi said. However, delayed healing, daily wound care, and visible scars are possible adverse outcomes. He recalled a middle-aged male patient with a non-hair-bearing scalp defect, who proved to be a good candidate for secondary intention, he said. "On outcome, it was really hard to detect where the lesion was located."
Primary closure is also a good choice to minimize distortion of structures adjacent to a defect, Dr. Toriumi said at the meeting.
Skin grafts are an option when there is lack of available local tissue. The technique can be simple if there is abundant donor tissue. Color mismatch, contracture, depression of the graft area, and ischemia are potential concerns, Dr. Toriumi said.
A patient was referred to Dr. Toriumi to correct a poor outcome after a nasal supratip skin graft. "It left a depression. We did a transposition flap to correct this," he explained. "She was a good candidate because it lifted her nasal tipa benefit from this operation she did not expect.
When planning an excision, the ideal angle of a defect is about 30 degrees, because it yields less distortion than a wider cut, Dr. Toriumi said.
Some dermatologic surgeons use a fusiform incision, but removal of a "tremendous amount of normal tissue" can be problematic.
Instead, he suggested performing an M-plasty because it employs two 30-degree apices, instead of one, and shortens the overall incision. Once the M-shaped incision is made, advance the apex of the triangle (the center of the M) toward the center of the defect by 23 mm, Dr. Toriumi suggested.
A case where an M-plasty produced a good result was a patient with a hemangioma of the eyebrow. An M-plasty inferiorly and superiorly yielded a "reasonable reconstruction" after removal of the hemangioma. However, this technique removed the lateral brow, so hair micrografts were placed to replace the eyebrow hairs.
A more complex reconstruction might call for an advancement flap, rotation flap, or other local flap. An advancement flap is a linear configuration moved in a single direction to correct a defect. Consider wide field undermining to minimize tension on the closure, Dr. Toriumi explained.
If skin is tight, as it can be with a forehead defect, for example, consider an "H-shaped incision, to reduce pull in multiple directions," he added.
"A very important technical consideration is to preserve the blood supply to the flap," Dr. Toriumi said. "Limit the length of a flap so you don't have a problem with blood supply at the distal end."
A rotation flap may be in order for the upper or midcheek region and the scalp. "Most have some advance componentfew are 100% rotation flaps," Dr. Toriumi said. A patient with recurrent squamous cell carcinoma of the upper lip fared well with a rotation flap to correct his defect.
M-plasty produced a good result after removal of a hemangioma.
Grafts were needed to replace the eyebrow hairs after the procedure. Photos courtesy Dr. Dean M. Toriumi