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September 30, 2013 | Ken Deem, MD, MPH

Otolaryngology – Head and Neck Surgery

Group Health Cooperative

Tacoma, Washington

Principles of

Facial Reconstruction

After Mohs Surgery

Objectives

• Identify important functional anatomy and aesthetic units of the face.

• Describe techniques used in facial reconstruction.

• Discuss postoperative care and complications.

• Participate in an interactive discussion on caring for patients with skin cancer of the face.

Mohs Micrographic Surgery Resources

Sherris & Larrabee. Priciples of Facial Reconstruction. New York: Thieme, 2010.

Objectives

• Identify important functional anatomy and aesthetic units of the face.

Functional Anatomy

Anatomical Unit Function

Eyelids Corneal Protection

Lacrimal System Lubrication and Drainage

External Nose Nasal Airway

Lips Speech and Swallowing

External Ear Sound Conduction

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Functional Anatomy

Eyelids & Lacrimal System

medfriendly.com/images/lacrimal.gif

Functional Anatomy

External Nose and Septum

Chan & Most. Op Tech OHNS. 2008;19(4):263.

Functional Anatomy

Lips and Facial Musculature

Functional Anatomy

External Ear

Cosmetic Units and Subunits

Aesthetic Unit

Scalp

Forehead

Eyes

Ears

Nose

Cheek

Lips

Chin

Border

Hairline

Preauricular Crease

Orbital Rim

Nasofacial Groove

Melolabial Fold

Labiomental Crease

Border of Mandible

Sherris & Larrabee. Priciples of Facial Reconstruction


Forehead Subunits

Central Forehead

Lateral (Temporal) Forehead

Eyebrows


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Eye Subunits

Upper Eyelid

Lower Eyelid

Medial Canthus

Lateral Canthus



Nasal Subunits

Dorsum

Sidewall

Tip

Ala

Columella

Facet/Soft Triangle



Cheek Subunits

Medial

Zygomatic

Buccal

Lateral



Ear Subunits

Helix

Antihelix

Scapha

Triangular Fossa

Concha

Lobe



Lip and Chin Subunits

Lateral Upper Lip

Philtrum

Vermillion

Lower Lp

Chin




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Objectives

• Describe techniques used in facial reconstruction.

Reconstructive Techniques

Reconstructive Ladder

Free Flaps

Regional Tissue Flaps

Local Tissue Flaps

Tissue Expansion

Skin Grafting

Primary Closure

Secondary Intention


Secondary Intention

pathol.med.stu.edu.cn


Secondary Intention



Primary Closure


Relaxed Skin

Tension Lines

Lines of Maximal

Extensibility


Primary Closure


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Primary Closure



Primary Closure



Primary Closure



Primary Closure



Grafting

Skin Cartilage Bone



Local Tissue Flap


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Local Tissue Flap



Local Tissue Flap



Local Tissue Flap



Local Pedicled Flap



Local Pedicled Flap


Objectives

• Discuss postoperative care and complications.

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Postoperative Care and Complications

Reconstructive Ladder

Free Flaps

Regional Tissue Flaps

Local Tissue Flaps

Tissue Expansion

Skin Grafting

Primary Closure

Secondary Intention


Secondary Intention

Antibiotic Ointment

Non-adherent Dressing

Peroxide



Secondary Intention

• Extended Healing Time

• Scar Contracture

• Distortion of Anatomy



Primary Closure

• Excessive Tension

• Scarring

• Wound Separation




Skin Graft

Split Thickness – Scalp

Full Thickness – Facial Units

Revascularization ~ 1 Week

• Minimize Shearing Forces

• Bolster Dressing x 1 Week



Skin Graft

Complications

• Seroma / Hematoma

• Graft Failure

• Contraction

• Pin-cushioning

• Poor color match


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Local Tissue Flaps

Dermal Blood Supply

• Incision Care

• Avoid Tension



Local Tissue Flaps

Complications

• “Dog-ear” Deformity

• Inadequate Blood Supply

• Graft Necrosis

• Healing by Secondary

Intention



Pedicled Flaps

Staged Procedure

1.Flap Raised & Transferred

2.Pedicle Divided & Flap Inset

• Revascularization ~ 3 Weeks

• Pedicle Kept Clean

• Avoid Shearing Forces

• Avoid TensionSherris & Larrabee. Priciples of Facial Reconstruction


Pedicled Flaps

Complications

• Donor Site Reconstruction


• Graft Failure


Objectives

• Participate in an interactive discussion on caring for patients with skin cancer of the face.

Discussion

How can we best care for patients with skin cancer of the face?

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Discussion

Multidisciplinary Team:

• What roles do nurses play in the care of these patients?

• How can nurses lead improved care for these patients?

September 28, 2013 | Ken Deem, MD, MPH

Otolaryngology – Head and Neck Surgery

Group Health Cooperative

Tacoma, Washington

Thank You

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