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