Reconstruction of Acquired Lip and Cheek Deformities Flashcards
(139 cards)
1
Q
Three considerations are essential in choosing a reconstructive method and orientation of a flap for cheek defects
A
where laxity exists
where resulting scars will lie
the need for excision of residual
cutaneous deformities after flap transfer
2
Q
The normal intercommissural distance in an adult at rest is 5 to 6 cm,
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T
3
Q
Oral commissures end at the medial limbus
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T
4
Q
he pars peripheralis, which lies deep to the
pars marginalis
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T
5
Q
The deepest layer of facial muscle
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deepest layer of
muscles, which includes the mentalis, levator anguli oris, and buccinator muscles
6
Q
The muscles responsible for lip elevation include
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the paired
levator anguli oris, levator labii superioris, levator labii superioris
alaeque nasi, zygomaticus major, and zygomaticus minor muscles
7
Q
The mentalis muscles are primary elevators of the
lower lip
A
T
8
Q
The venous drainage mirror
the well-formed arterial supply
A
F The venous drainage does not mirror
the well-formed arterial supply
9
Q
Sensation to the upper and lower lips is provided by the infraorbital
(V2) and mental (V3) branches of the trigeminal nerve
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10
Q
Over 90%
of lip cancer cases involve the lower lip
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11
Q
Basal cell carcinoma is the most common
malignancy involving the upper lip, and squamous cell carcinoma is
the most common in the lower lip
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12
Q
partial-thickness defects around the vermilion border are generally best managed
by converting defects into full-thickness wedge excisions.
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T
13
Q
motor supply to the lips
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fascial nerve -buccal branches -orbicularis +elevators
Marginal mandibular - deppresser
14
Q
Sensory of the lips
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Maxillary- infraorbital - upper lips
Mandibular- inferior elevolus-mental nerve
15
Q
Skin grafts are
generally not required for superficial skin defects because adjacent soft
tissuelaxity permits the use oflocal flaps for primaryclosure
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16
Q
the best area that ca treated by skin graft is defects of the central lip involving large portions of
the philtral groove
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17
Q
Philtral groove can treated only wih skin graft
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F For
smaller defects within the philtral groove healing by secondary intention
generally provides good results and avoids the patch-like appearance of
a skin graft
18
Q
The nasolabial
flap is a particularly good option for recreating a hair-bearing upper lip
in male patients
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19
Q
Option for large superficial vermilion defect
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Mucosal sliding flap or Kawamoto vermilion switch flap
20
Q
Vermioln defect up to one third
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Myomucosal advancement flap,, goldstien flap
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Q
Vermilion defect more than one thrid
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Tongue flap
22
Q
Total vermilionectomy defects
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Mucosa of oral vestibule mobilized - advanced over raw surface & sutured.
May cause thinning of lip, inward pulling of hair bearing skin, tense free lip margin.
23
Q
Small defects confined to the vermilion can be managed
with musculomucosal V-Y advancement flaps designed horizontally
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24
Q
Lesions closer to the vermilion border are preferentially excised perpendicular to the white roll to facilitate alignment of this landmark
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The major disadvantages of a mucocutaneous flap
these techniques are inward retraction and thinning of the lower lip due
to mucosa retraction as well as decreased mucosa! sensation
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The FAMM flap is an axial flap
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Utilizing the lateral or ventral surfaces of the tongue
avoids transferring the dorsal tongue papillae
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The biggest drawback of any oral mucosa) or tongue flap for lip
reconstruction is the tendency for the tissue to desiccate.
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Wound edge eversion is critical to prevent notching in full thickness defect
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What is teh webster tech ?
Webster's technique of crescentic perialar cheek excisions move the upper lip without disturbing lateral muscle function
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Bengt-Johansson staircase technique
is a useful, one-stage repair for central lower lip defects of intermediate width. In this technique, neither the orbicularis oris muscle, opposite lip, nor the labiodental crease are violated
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the best option for full-thickness lip defects
of intermediate width is webster tech
F , lip-switch flaps are arguably the best method for reconstructing full-thickness lip defects
of intermediate width
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lip-switch flaps are axial flaps based on the labial arteries to reconstruct skin, subcutaneous tissue, muscle, and mucosa of
one lip
T
34
In abbe flap one third of the donor site can used to reconstruct on the third in recipient lip
F one-third of the donor lip can be used to reconstruct up
to two-thirds of the recipient lip
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ABBE flap Is effective at recreating the philtral columns without flattening the upper lip contour
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Reverse abbe flap can centrally placed
F a flap from the junction of the middle and lateral thirds of the upper lip should be used
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The Estlander flap
The Estlander flap is a full-thickness, medially based triangular
flap from the upper lip used to reconstruct lateral lower lip defects
when the oral commissure is involved
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Draw back of Estlander flap
F a rounded commissure and causes distortion
of the modiolus. Therefore, secondary commissuroplasty is often
required
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Gillies fan flap
The Gillies fan flap is a modification of the cross-lip technique.
It rotates tissue around the commissure similar to an Estlander flap,
but it includes additional tissue from the nasolabial region
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Nasolabial flap superiorly based for female
F Inferiorly base for hairless flap
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Gillies fan flap A quadrangular-shaped flap , Estlander flap triangular
flap
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microstomia and oral incompetence due to denervation ofthe orbicularis oris muscle.can occur in bilateral gullies flap
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The Karapandzic flap similar to gullies flap that required denervation of the orbicularis oris
F ith the Karapandzic
flap, incisions are limited to the skin and subcutaneous and the neurovascular bundles are carefully dissected and preserved to maintain
muscle function and lip sensation
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Karapandizic flaps can
be used for large central defects up to 80%; however, blunting of the
commissures and microstomia may occur
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Flap that used to reconstruct up to 80 % lip defect
Karpandizk flap and gullies
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Reconstraction of more than 80% of the lip defect
Bernard cheiloplasty / Webster's modification of the BernardBurow technique.
Fujimori's gate flap design, which rotates two nasolabial island flaps
90° for reconstruction of lower lip defects
Von Brun interiorly based nasolabial flaps for reconstructing upper lip defects
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Advantage of webster modification ?
Benefits of this technique are the ability to
produce good contour of the commissure, place scars within natural
skin creases, and preserve the aesthetic region of the chin
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The drawback of the Webster?
incomplete recovery of sensation, vermilion color
mismatch, and poor oral competence.
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Fujimori's gate flap need skin grafting to line the inner surface
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Fujimori's gate &Von Brun should design with the flap larger than the defect
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Fujimori's gate &Von Brun are two stage
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Regional flaps options?
The submental flap based on the submental
branch of the facial artery can be transferred as an island
The temporoparietal scalp flap
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free flap options?
radial forearm free flap
the free gracilis muscle flap
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The use
of a reinnervated gracilis muscle free flap has also been described
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Vertical incisions placed medial
to a line drawn from the lateral canthus remain obvious on frontal
view and ideally should be replaced by incisions along the nasolabial
fold or by blepharoplasty incisions
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The principles for subunit reconstruction (e.g., discarding remaining tissues of a subunit) are applicable to cheek reconstruction
F are less applicable to cheek reconstruction
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Options of hair bearing flap for the lip
Temporla ,submental, check advancment , cervical skin flap
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In gullies flap can possibly maintained neurovascular pedicles
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The central cheek has more complex and subtle contours compared to the lateral cheek
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Sensory
innervation for the check
provided by the maxillary (V2) and mandibular (V3)
divisions of the trigeminal nerve and from small contributions from
the anterior cutaneous nerve of the neck and great auricular nerve
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The facial
nerve is located deep to superficial lobe of parotid
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superficial temporal artery and the transverse facial artery supply the
superior aspect of the cheek
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The lymphatic drainage of the check?
is via lymphatic
channels within the parotid nodes and those along the facial vessels
to the submandibular nodes
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The zygomatic ligaments (McGregor patch) anchor the skin of the
cheek to the inferior border ofthe zygoma just posterior to the origin
of the zygomaticus major muscle
F zygomaticus minor muscle
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Concave
areas heal exceedingly better with secondary intention than areas of convexity
T
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Scars are not well
hidden in structures such as the nasolabial or preauricular crease and
instead obliterate these natural landmarks
T Placing incisions/scars
immediately adjacent to them ( 1 mm away and parallel) is best
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Transposition flaps of the check used to closed medium an large defect
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Bilobed flaps are modified banner flaps
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Scarring from bilobed flaps is simple
F Scarring from bilobed flaps is complex
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bilobed flaps are generally not a first choice in cheek
reconstruction
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Rhomboid flaps are another modification of the bilobed flap that are commonly used for coverage of lateral lower cheek only
F Rhomboid flaps are another modification of the banner flap that is commonly used for coverage of lateral lower cheek and temporal area
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Drawbacks with the rhomboid flap
are that they have a tendency to pincushion and the need for multiple incisions creates one or more scars that lie perpendicular to lines of relaxed skin tension
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V-Y flaps have
more recently become a workhorse flap for cheek reconstruction
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V-Y flaps preferred to use in which region
They are useful for defects of the medial cheek, alar base, and along
the nasolabial fold superior cheek/lower eyelid defects
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V-Y flaps
less undermining required and improved rates of ectropion compared to Mustarde-type cheek flaps
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medially or laterally based cheek rotation
advancement flaps. Complication
. Ischemia of the distal
flap is the most common complication and is more likely in smokers
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What is the best approach in those patients at risk of flap necrosis
A deep plane approach with composite elevation of the skin, subcutaneous tissue, superficial muscular aponeurotic system, and platysma
improves flap vascularity and is useful in those at risk for distal flap
ischemia; however, facial nerve injury is a significant risk
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the limit of
Cervicopectoral flaps
to the imaginary line drawn from the tragus to the lateral commissure
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Anteriorly based flaps depend on wich blood supply
internal mammary perforators
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Indication and contents of Anteriorly based flaps
raised deep to the platysma muscle and include deltoid and pectoral fascia and are used for reconstructing large defects of the posterior
and lower cheek
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Posteriorly based flaps are based on blood supply
From the superficial temporal, occipital, transverse cervical, and thoracoacromial vessels and are used for large anterior cheek defects.
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Skin grafting of the donor site is always required to minimize tension on the closure
F Skin grafting of the donor site is occasionally required to minimize tension on the closure
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submental artery
flap for lateral check defect
F submental artery
flap for central cheek defects
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pectoralis major, trapezius, and supraclavicular flaps, which are
useful for lower lateral cheek defects
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Tissue expansion in the head and neck
region is associated with high complication rates
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free flaps are the first choice for complex defects involving multiple tissue layers in check
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Limitations of free flap coverage
include the inability to provide color- and texture-matched skin and
the propensity for bulky reconstructions
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motor supply to the lips
fascial nerve -buccal branches -orbicularis +elevators
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Gillies; distorts the commissure.
Karapandzic; intact neurovascular pedicle, oral apperture narrowed
* McGregior: pivots around commissure, less distorting, new vermillion & changed direction of fibres.
* Nakajima: similar to McGregor's but facial vessels are spared.
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In fugimorigate flap the facial vessels remain intact
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DEltopectoral flap can be ised for total lowe lip reconstraction
T based on 2nd and 3 rd intercostal
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The FAMM flap is an axial flap that includes part
of the buccinator muscle and can be based inferiorly (antegrade)
or superiorly (retrograde) on the facial vessels
t
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The labial
arteries arise from the facial artery approximately 1.5 cm lateral to the
oral commissure and lie either
t
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The lymphaticdrainage of the upper lip is primarily to thesubmandibularnodes
with some drainage from the commissure to the ipsilateral preauricular nodes.
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The lower lip also drains to the ipsilateral submandibular
nodes;
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The superior aspect of the philtrum
is occasionally innervated by a branch ofthe nasopalatine and requires
direct infiltration at the base ofthe columella
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The primary etiology of acquired lip defects is truma
F The primary etiology of acquired lip defects is malignancy
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An exception for the area of the upper lip that better treated with skin graft
defects ofthe central lip involving large portions of
the philtral groove
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For
smaller defectswithin the philtralgroove, healing bysecondaryintention
generally provides good results and avoids the patch-like appearance of
a skin graft
T
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The nasolabial
flap gives an natural hair appearance for the upper lip becaue of horizontal hair orientation
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For larger defects that do not involve the white rol staged bipedicle mucosa
flap, or the cross-lip mucosa] flap (lip switch
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buccal mucosa! flaps or, more reliably, a facial artery musculomucosal
(FAMM) flap can be rotated from intraorally to reconstruct defects
of the vermilion
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The FAMM flap is an axial flap that includes part
of the buccinator muscle and can be based inferiorly (antegrade)
or superiorly (retrograde) on the facial vessels
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tongue flaps can provide significant bulk
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In the lower lip,
40% of the width can generally be reapproximated using layered closure,
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Lower lip tolerated primary closure only 25%
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Defects should
generally be converted into a shield excision design so that layered
closure at the vermilion border is perpendicular to white roll for precise alignment. in primery repair of the lips
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For larger defects, one is able to keep the scar above
the labiomental crease using a W-plasty design
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Larg-sized full-thickness defects represent the most complex
decision-making challenge
F Intermediate-sized full-thickness defects represent the most complex
decision-making challenge
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For defects involving slightly greater than
two -third the width of the lip, primary closure is possible if combined
with perioral skin excisions.
F For defects involving slightly greater than
one-third the width of the lip, primary closure is possible if combined
with perioral skin excisions.
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The Schuchardt procedure
a sliding-lip
reconstruction that combines medial advancement of the lower lip
tissue with bilateral labiomental crease excisions
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The Abbe rotated
180° on its pedicle (labial artery) and remains for about 3 weeks
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The height of the flap should match that
of the defect and the width of the flap and should be about half the
width of the defect
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The Estlander flap Similar to the
Abbe flap, it is designed so that its width equals half the width of the
defect
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Modifications of The Gillies fan flap technique
include the incorporation of a Z-plasty, which allows better turning
of the pedicle around the commissure
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Bilateral Gillies flaps
are often required for large defects approaching up to 80% of the lip
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undesirable sequelae of reconstructing such large defects
include significant microstomia and oral incompetence due to the denervation ofthe orbicularis oris muscle (GIILIIES)
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blunting of the
commissures and microstomia may occur occures with The Karapandzic flap
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Webster's modification of the BernardBurow drawbacks
T Include incomplete recovery of sensation, vermilion color
mismatch, and poor oral competence
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oral competence and sensation can be preserved in Webster modification
T To overcome these limitations, current techniques excise the skin and subcutaneous only and
preserve the neurovascular structures to maximize oral competence
and sensation.
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Fujimori's gate flap and Von Brun interiorly based nasolabial flaps blood supply
angular artery
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flaps should be made larger than the lip
defect (fujimori and von brun )
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Reconstruction of the vermilion occurs at a second stage after fujimori and von brun flap )
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nasolabial
flaps generally produce optimal oral competence and aesthetics
F nasolabial
flaps generally produce suboptimal oral competence and aesthetics and the use of multiple local flaps is typically more effective
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The most
commonly used free flap for total or near-total defects of the lower lip
is the radial forearm free flap.
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a palmaris longus tendon graft is incorporated with the radial forearm free flap. and either attached to
the modiolus or anchored to the malar eminence to act as a sling for
oral competence.
T
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The radial forarm flap can be sensate flap for lower lip reconstruction
T by coaptating the
lateral antebrachial cutaneous nerve to the mental or inferior alveolar nerve
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prelaminating the
gracilis by incorporating a long strip of fascia lata tendon for lower
lip support and placing a silicone sheet along the deep site of the
muscle to create a neomucosal lining before final transfer
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The use
of a reinnervated gracilis muscle free flap has also been described.33
Symmetrical spontaneous and voluntary lower lip control was
restored by coaptating the motor branch of the gracilis muscle to the
marginal branch of the facial nerve.
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Motor innervation of the mimetic facial muscles is provided by the
facial nerve and its main branches
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the masseter and temporalis muscles are innervated by the trigeminal nerve
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The arterial supply of the cheek is predominantly provided by the
facial artery, which gives off the angular artery that anastomoses
with the infraorbital artery and infratrochlear artery distally
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the temple or preauricular region is beast treated with secondary intension for the superficial wounds
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bilobed flaps are generally not a first choice in cheek
reconstruction
T
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Rhomboid flaps have
more recently become a workhorse flap for cheek reconstruction
F V-Y flaps have
more recently become a workhorse flap for cheek reconstruction
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V-Y flaps have been shown to provide excellent
outcomes in even large, superior cheek/lower eyelid defects, with
less undermining required and improved rates of ectropion compared to Mustarde-type cheek flaps
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These flaps are designed by extending the cervicofacial incision inferiorly along the sternum, then laterally down across the chest above
the nipple-areola complex ( Cervicopectoral flaps)
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free flaps are the first choice for complex defects involving multiple tissue layers. in check reconstruction
T
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Limitations of free flap coverage
include the inability to provide color- and texture-matched skin and
the propensity for bulky reconstructions.
T
