advanced facial reconstruction - ucsf cme
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Advanced Facial Reconstruction
P. Daniel Knott, MD FACSDirectorFacial Plastic and Reconstructive SurgeryUCSF Medical Center
UCSF Head and Neck CourseNovember, 2014
Disclosures
• Genentech Surgical Advisory Board
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Overall Paradigm
• Assume that patients want to look normal
• Normal defined by
– Regional subunits
– 3-D contour
– Color match
– Dynamic movement
– Symmetry
– Scar camoflauge
• Build on a stable platform
• Use delay techniques to enhance vascularity
• Let each move/operation prepare for the next
• If your patients are sick, opt for the simple optio n3
Beauty and Perception
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Facial Subunits
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Menick, FW; Nasal Reconstruction, PRS 125: 138e, 2010
Subunit Principle
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Why the subunit principle?
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Subunit Principle
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Subunit Skin Graft
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Paramedian Forehead Flap
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Fig. 4. The vertical paramedian forehead flap is centered over the supratrochlear vessels and is richly perfused by a random, axial, and frontalis muscle blood supply. (From Menick F. Nasal Reconstruction: Art and Practice. New York: Elsevier, 2008.)
Menick, FW; Nasal Reconstruction, PRS 125: 138e, 2010
Forehead flap
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Internal Lining Defects
12Menick, FW; Nasal Reconstruction, PRS 125: 138e, 2010
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Nasolabial Flaps
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Nasolabial Flaps
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Internal lining
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3 Stage Forehead Flap
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3 Stage Forehead Flap
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3 Stage Forehead Flap
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Recurrent Melanoma
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Total Rhinectomy
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Vascularized Nasal Lining
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Vascularized Nasal Lining
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Vascularized Nasal Lining
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Vascularized Nasal Lining
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Vascularized Nasal Lining
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What makes for a good facial reconstructive outcome?
1. Good skin color match
2. Contour restoration
3. Creative scar placement
4. Support of local structures (nose, lips, orbit. . . )
5. Avoidance of contracture
6. Subunit principle
7. Restore movement
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Skin Color Match
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Skin Flaps with Similar Sun Exposure
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Skin Color better with skin grafts
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Vascularized Fascia Lata
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Fascia Lata for Scalp Reconstruction
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Vascularized Fascia Lata
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Contour Restoration
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Adipofascial Contour Restoration Creative Scar Placement
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Presentatio
Presentatio
Creative Scar Placement
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Support of Local Structures
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Support of Local Structures
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Avoidance of Contracture
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Subunit Principle
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Temporalis Myoplasty
• Significant temporal edema for 2 weeks
• Muscle may be “shocked” for several weeks
• Some degree of posterior temporal hollowing
• Voluntary smile may be achieved
• Movement usually approaches 6 mm of upper lip excursion
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Temporalis Myoplasty
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Conclusion
• Assume that your patients want to look normal
• Accurate color and contour restoration critical to an acceptable outcome
• 3 stage fold over forehead flaps for internal lining
• Fascia lata microvascular flaps for total nasal reconstruction and appropriate scalp/forehead reconstructions
• Use bone and large skin paddles to avoid contracture
• Take advantage of subunit principle when possible
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Thank you for your attention