Facial Flaps

Facial flaps are of two types: Axial and Random. An axial flap has an 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 it is not stable. Its surviving length is directly proportional to the flap. Random flap’s surviving length can be lengthened by “delaying” the flap. To delay a flap, it is elevated but left in position as a bipedicle flap. Two weeks after the procedure, it is raised as an unipedicle flap and placed into position to close the defect. Interpolation flaps traverse the skin before reaching the defect. When placed over the skin, they will have a pedicle. The pedicle can be divided in about 3 to 6 weeks depending upon the type of flap and the patient’s condition. Flaps can be trained by occluding the blood supply in the pedicle for progressive lengths of time. This allows for an earlier transection of the pedicle.

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. After the surgery, antibiotic ointment must be taken three times a day. The flap can get wet after a day passes and 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.

• Axial Flaps

Forehead Flaps - These are some of the most common flaps that give an excellent blood supply. The cosmetic results are most of the time, very good. The biggest disadvantage is that two operations are required and the patient must live for a period with a flap pedicle over his face. The blood supply to the forehead flap is by supraorbital and supratrochlear artery, both are branches of the ophthalmic artery and are part of the internal carotid artery system. This flap can have a very large length to width ratio. The surgeon must handle it with care so he will not create a defect that is too wide and prevents closure of the forehead donor site. Flaps wider than 2.5 cm will often create donor sites that cannot be closed primarily.

Abbe Estlander Flap - This flap has also a named artery and a good 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 the flap is directed from the superior labial or inferior labial artery, bot being branches of the facial artery and is of the external carotid artery system.

• Random Flaps

Rotation advancement flap – This is a flap that can be used to close large and small defects. As a 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 small insignificant defects.

Nasolabial Flap - This flap is difficult to achieve a good cosmetic result in a single stage. Due to swelling and thickness of the flap, most patients will require a second-stage reduction rhinoplasty. With wide flaps, the closure of the secondary defect can also modify the noses appearance. 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 in notching or wrinkling of the nasal ala as the superior nasal skin is pulled laterally.

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.

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