More About Full Thickness Skin Grafts
 

    

Facial flaps can be divided into two types:  Axial and Random.  An axial flap has a named artery supplying it.  The surviving length of an axial flap will remain constant regardless of the width of the flap.  A random flap has smaller unnamed vessels and is not as stable.  It's surviving length is in direct proportion to the width.  A random flap's surviving length can be lengthened by "delaying" the flap.  Examples of axial flaps are abbe estlander flaps, forehead flap and some Nasolabial Flaps.   For skin and nasal reconstruction, nasolabial flaps are usually to thin to incorporate the underlying artery.  

To delay a flap, one elevates it but leaves it in the donor site as a bipedicle flap.  Two weeks later it is raised as a unipedicle flap and placed into position to close the defect.  Interpolation flaps traverse skin in order to reach the defect.  If placed over the skin, they will have a pedicle.  The pedicle can be divided in 3 to 6 weeks depending upon the type of flap and the condition of the patient.  Flaps may be "trained" by occluding the blood supply in the pedicle for progressive lengths of time.  This allows for an earlier transection of the pedicle.   An example of an interpolation flap is a forehead flap used in nasal reconstruction. 

Care of the flap during surgery should include, not grasping the skin with forceps but instead using skin hooks attached to the underlying fibrous tissue to move the flap in position--see advancement flap.  Post-op care should include the use of antibiotic ointment three times a day.  The flap may get wet after 24 hours after the wound seals.  The patient should be followed closely and if the flap starts to die, sutures should be released to relieve flap tension and improve flap blood supply --see flap necrosis. 

• Axial Flaps:  

Forehead Flap  This is a commonly used flap with a good blood supply.  The end cosmetic result is usually good.  The biggest disadvantage is that two operations are required and the patient must live for several weeks with a flap pedicle over his face.  The blood supply to the forehead flap is by the supraorbital and supratrochlear artery, both are branches of the opthalmic artery and are of the internal carotid artery system.  This flap may have a very large length to width ratio.  The surgeon must be careful not to create a defect which is too wide and prevents closure of the forehead donor site.  Flaps wider than 2.5 cm will often create donor sites which cannot be closed primarily.
View Flash Presentation - Nose Reconstruction:  May not be suitable for all viewers.
View Pictures - Nose Reconstruction:  May not be suitable for all viewers.
View Pictures - Nose Reconstruction:  May not be suitable for all viewers.
View Pictures - Nose Reconstruction:  May not be suitable for all viewers.

Abbe Estlander Flap  This flap also has a named artery and an excellent blood supply.  The pedicle of the flap is very small.  The biggest disadvantage is that two operations are required and the patient must have his lips sewn together for 4 to 6 weeks.  The blood supply to this flap is from the superior labial or inferior labial artery, both are branches of the facial artery and are of the external carotid artery system.     Lip Reconstructions: 
View Pictures-Superiorly Based Flap:  May not be suitable for all viewers.
View Pictures-Superiorly Based Flap:  May not be suitable for all viewers.
--This patient had reinervation of the flap with constriction of the lip.  He was even able to whistle. -- Hear Patient Whistle.
View Pictures-Inferiorly Based Flap:  May not be suitable for all viewers.

• Random Flaps:

Rotation Advancement Flap  This flap can be used to close large and small defects.   As a general rule the length of the flap's arc should be twice the width of the flap's base.  It is often used on the scalp where there tissues have little stretch and a large flap is required to close even a relatively small defect.  
View Pictures - Cheek Reconstruction:  May not be suitable for all viewers.
View Pictures - Scalp Reconstruction:  May not be suitable for all viewers.
View Pictures - Scalp Reconstruction:  May not be suitable for all viewers.
View Pictures - Forehead Reconstruction:  May not be suitable for all viewers.

A rotation advancement flap can also be used to close small defects.  Shown here is the use of a flap to close a lip defect.
View Pictures - Lip Reconstruction:  May not be suitable for all viewers.

A rotation advancement flap can also be used to close large defects.  Shown here is the use of this flap to close cheek and neck defects.
View Pictures - Cheek Reconstruction:  May not be suitable for all viewers.
View Pictures - Neck Reconstruction:  May not be suitable for all viewers.
View Pictures - Cheek Reconstruction:  May not be suitable for all viewers.
View Pictures - Cheek Reconstruction:  May not be suitable for all viewers.
View Pictures - Neck Reconstruction:  May not be suitable for all viewers.
View Pictures - Neck Reconstruction:  May not be suitable for all viewers.

Rhomboid (Limberg) Flap  This flap is easy to construct and rotate into position.  It consists of two corners at 60 deg and two corners at 120 degrees.  The flap is outlined and then rotated into position.   An understanding of the direction of skin pull once the flap is placed into position is needed to prevent distortion of tissues.  View More on Flap
View Pictures:  May not be suitable for all viewers.
View Pictures:  May not be suitable for all viewers.
View Pictures:  May not be suitable for all viewers.
View Pictures:  May not be suitable for all viewers.
View Pictures:  May not be suitable for all viewers.
View Pictures:  May not be suitable for all viewers.

Bilobed Flap  This flap is a combination between a rotation advancement and nasal labial flap.  The flap is comprised of two lobes, each positioned at an angle of 45 to 60 degrees, which are rotated to fill corresponding defects.  Each lobe is slightly smaller than the defect it fills.  The prominent "dog ear" and distortion of the nostrils, which can occur with a nasal labial flap are less likely to occur with a bilobed flap.  The bilobed flap is useful in reconstructing nasal alar defects of 1.5 cm or less.   Keeping the angle of the lobes at 45 degrees minimizes tissue protrusions.  The final lobe should be positioned on the border of the facial aesthetic subunit, between the nose and the cheek.   View Abstract 

View Flash Presentation:  May not be suitable for all viewers.
View Flash Presentation:  May not be suitable for all viewers.

Nasolabial Flap  This flap is difficult to achieve a good cosmetic result in a single stage.  Due to both swelling and the thickness of the flap most patients will require a second-stage reduction rhinoplasty.  With wide flaps the closure of the secondary defect can also distort the nose.  With superiorly based flaps, the defect is next to the nasal ala and closure under tension may spread the nasal opening laterally.  With inferiorly based flaps, the defect is superiorly, and this can result is notching or wrinkling of the nasal ala as the superior nasal skin is pulled laterally. 
 
Indications for use of this flap is the loss of the nasal rim, loss of the nasal supporting cartilages (only nasal mucosa lines the depths of the resection), and a through and through defect.   If the resection is not deep, a skin graft, if possible a full thickness graft,  may be the better option since nasal distortion and flap swelling are then avoided.  Full thickness skin grafts give a better cosmetic result than a nasal labial flap but should only be used for small superficial defects.  See Nasal Skin Grafts

This flap is often classified as an axial flap because there is a named artery which runs deep to the flap (angular artery).  However, when used for nasal reconstruction the flap is thinned and does not contain the artery which is much deeper in the tissues.  In general, random flaps should not have a length to width ratio greater that 2.5 to 1.  Flaps wider than 1.5 cm may create a donor site which is difficult to close primarily.  In one patient, a width to length ratio of 3 to 1 was used, which resulted in partial loss of the tip of the flap.  ( See Flap Necrosis Page )  The angular artery, a branch of the facial artery (external carotid artery system) runs deep to this flap.

Superiorly based nasolabial flaps can reconstruct a wide range of defects.  If possible, they should be constructed so the base is high up along the nose so the angle of rotation is small.  This will result in smaller dog-ear formation.  In addition, the patient must be warned not to wear eyeglasses which rest on the pedicle base, otherwise flap loss and edema may occur.  Flap swelling may occur even months after the operation from wearing eyeglasses.  Thus, the nasal rest of eyeglasses may have to be modified and in the short term, the eyeglasses should be taped to the forehead to relieve any nasal pressure.    Most superiorly based nasal flaps will need a second stage reduction rhinoplasty to obtain a good cosmetic result.
View Pictures-Superiorly Based Flap:  May not be suitable for all viewers   
View Pictures-Superiorly Based Flap:  May not be suitable for all viewers
View Pictures-Superiorly Based Flap:  May not be suitable for all viewers
View Pictures-Superiorly Based Flap With Partial Necrosis:  May not be suitable for all viewers

Inferiorly based nasolabial flaps can be used to reconstruct lower nasal defects.  Because of the larger angle of rotation, dog-ear formation is more likely to occur.  However,  when an inferiorly based nasolabial flap is used to reconstruct nasal alar defects this dog ear tends to blend into the contour of the nasal ala. 
View Pictures-Inferiorly Based Flap:  May not be suitable for all viewers.
View Pictures-Inferiorly Based Flap:  May not be suitable for all viewers.
View Pictures-Inferiorly Based Flap:  May not be suitable for all viewers.
View Pictures-Inferiorly Based Flap and Closure of a Nasal Cutaneous Fistula:  May not be suitable for all viewers.

• Nasal Reconstruction :

This section shows how to reconstruct a large 75% nasal defect and cheek defect using three local facial flaps: 

1. Right Cheek Advancement Flap (random)
2. Left Nasal Labial Flap (random)
3. Forehead Flap (axial)

View Pictures:  May not be suitable for all viewers.

• Ear Reconstruction :

This section shows how to reconstruct an ear defect of the helix using a local scalp flap.  The patient was 89 years old so the scalp flap was kept as small as possible do not to create a secondary defect requiring a closure with a second scalp flap.
View Flash Presentation:  May not be suitable for all viewers.
View Pictures:  May not be suitable for all viewers.
View Pictures:  May not be suitable for all viewers.
View Pictures:  May not be suitable for all viewers.
View Pictures:  May not be suitable for all viewers.
  

•   Lip Reconstruction:
  
  This patient had 1/3 of the vermillion of her lip removed.  The defect could be divided into three parts:  A central 1/3 very deep defect and lateral 1/3 shallower defects.  The lateral 1/3 defects were reconstructed by advancing vermillion and underlining muscle from the lateral lip.  The middle third was removed with a "V" resection and three layer closure.
  View Pictures:  May not be suitable for all viewers.
   
•   Flap Necrosis :

Unfortunately, not all flaps survive.  Presented are two cases.  The first is a nasal labial flap with a length to base ratio greater that 2.5 to 1.  The second is a nasal-dorsal flap with a length to base ratio of 1.5 to 1.  Both of these flaps had partial necrosis.  Treatment was conservative with the release of sutures and administration of Pentoxifylline.  The patient did not desire revision, after healing with secondary intension.
View Pictures:  May not be suitable for all viewers.

•   Full Thickness Skin Graft:
   
  View the technique for nasal and ear reconstruction using a Full Thickness Skin Graft:
  --  Go To Full Thickness Skin Graft Web Page --