Main Reconstructive Facial Plastic Surgery: A Problem-Solving Manual

# Reconstructive Facial Plastic Surgery: A Problem-Solving Manual

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Drawing on decades of operating room and teaching experience, Dr. Weerda and his team offer a complete guide to reconstructive options for facial, head, and neck defects in this eagerly awaited second edition. Their systematic, step-by-step approach, with an emphasis on meticulous preoperative planning, evaluation of alternatives, and selection of the best procedure, ensures optimal results for all patients.

Special features of the second edition:

• Includes more than 1,500 sequential illustrations of each procedure, along with full-color intraoperative photographs and before and after surgical results
• Reviews the full range of local, regional, and free flaps used in the reconstruction of facial structures, with chapters on myocutaneous island flaps, delto-pectoral flaps, and free microvascular transplants written by well-known practitioners
• Offers new and expanded sections on dermabrasion, free flaps, removal of skull bone for modern defect reconstruction, instrument sets/trays, and more
• Covers the entire scope of the field, from basic principles, anatomy, wound healing, and scar revision to defect closings in each facial region, bone grafts, and the groundbreaking auricular reconstructive techniques developed by Dr. Weerda

Focusing on the questions, problems, and technical solutions most commonly encountered in everyday practice, this compact book will be valuable to both the novice and more experienced surgeon. It is filled with the insights, wisdom, and experience of a leading worldwide expert, and will be kept close at hand as a refresher, teaching guide, encyclopedia of facial plastic techniques, and standard operating room reference.

Year:
2014
Edition:
2nd edition
Publisher:
Thieme
Language:
english
Pages:
272
ISBN 10:
3131296429
ISBN 13:
9783131296429
File:
PDF, 61.25 MB

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```Reconstructive Facial Plastic Surgery
A Problem-Solving Manual
2nd Revised and Expanded Edition

Hilko Weerda, MD, DMD
Professor Emeritus
Department of Otorhinolaryngology—Head, Neck, and Plastic Surgery,
University Hospital Schleswig-Holstein, Campus Lübeck
Lübeck, Germany

1390 illustrations

In 2001, the first edition of this book was awarded the
George Davey Howells Memorial Prize in Otolaryngology
by the University of London and the Otology Section of the
Royal Society of Medicine, London, UK.

Thieme
Stuttgart · New York · Delhi · Rio

Library of Congress Cataloging-in-Publication Data is available from the publisher.

Illustrator: Original illustrations by Katharina Schumacher,
Munich
Fig. 5.54: Illustration by Joachim Quetz, MD, originally published in Facial Plastic Surgery 2014; 30: 300–305
Correspondence:
Prof. Hilko Weerda, MD, DMD
Freiburg, Germany
hubweerda@yahoo.de
1st English edition 2001
Reprint of 1st English edition 2007

Important note: Medicine is an ever-changing science
undergoing continual development. Research and clinical
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not involve, imply, or express any guarantee or responsibility on the part of the publishers in respect to any dosage
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Every user is requested to examine carefully the manufacturers’ leaflets accompanying each drug and to check, if necessary in consultation with a physician or specialist,
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© 2015 Georg Thieme Verlag KG
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ISBN 978-3-13-129642-9
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This applies in particular to photostat reproduction, copying, mimeographing, preparation of microfilms, and electronic data processing and storage.

V

Contents

Foreword to the 2nd Edition  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . XIII
Foreword to the 1st Edition  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . XIV

Preface to the 2nd Edition  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . XV
Contributors  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . XVI

I Anatomy, Principles of Facial Surgery, and Coverage of Defects
1 Anatomy of the Skin and Skin Flaps  .  .  .  .  .  .  .
The Skin (Fig. 1.1)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Types of Skin Flaps  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Random Pattern Flaps (Fig. 1.2) . . . . . . . . . . .
Axial Pattern Flaps (Fig. 1.3) . . . . . . . . . . . . . .
Island Flaps (Fig. 1.4) . . . . . . . . . . . . . . . . . . . . .
Myocutaneous Island Flaps
(Fig. 1.5; see also Fig. 12.1). . . . . . . . . . . . .
Neurovascular Island Flaps . . . . . . . . . . . .

2 Basic Principles of Facial Surgery  .  .  .  .  .  .  .  .  .  .
Suture Materials and Techniques  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Basic Instrument Set for Reconstructive
Facial Plastic Surgery (Fig. 2.7) . . . . . . . . . . . . . . .
The Binocular Loupe (Fig. 2.7c) . . . . . . . . . . . .
Additional instruments: . . . . . . . . . . . . . . .
Wound Management, Repair of Small
Defects, and Scar Revision . . . . . . . . . . . . . . . . . . .
Relaxed Skin Tension Lines, Vascular Supply
(Fig. 2.8i), and “Esthetic Units” (Fig. 2.20)  .  .  .  .  .  .  .
Wound Management, Repair of Small Defects,
and Scar Revision  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Management of Wounds with
Traumatic Tattooing . . . . . . . . . . . . . . . . . . . . . . . . . .
Scar Revision by W-Plasty and the
Broken-Line Technique of Webster (1969)
(Fig. 2.8a–j)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Small Excisions  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Z-Plasty (Figs. 2.15 and 2.16)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Postoperative Treatment of Scars  .  .  .  .  .  .  .  .  .  .  .
Esthetic Units of the Face (Fig. 2.20)  .  .  .  .  .  .  .  .

3
3
4
4
4
4
4
4
5
5
6
6
6
9
9
9
9

9
12
13
14
14

Tumor Resection with Histologic Control
(Fig. 2.21)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Free Skin Grafts (Fig. 2.22)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Composite Grafts (Fig. 2.23)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Cartilagenous and Composite Grafts
for Auricular and Nasal Reconstruction .
Graft Nomenclature  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .

3 Coverage of Defects  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Local Flaps  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Advancement Flaps  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
of Burow (1855) (Fig. 3.1)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
V-Y and V-Y-S Advancement of Argamaso
(1974) (Figs. 3.8–3.10)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Flaps without Continous Epithelial
Coverage (Rettinger 1996a, b) . . . . . . . . . .
Sliding Flap (Figs. 3.11–3.14)  .  .  .  .  .  .  .  .  .  .  .  .
Pedicled Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Transposition Flap (Fig. 3.15)  .  .  .  .  .  .  .  .  .  .  .  .
Rotation Flap (Fig. 3.19)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Bilobed Flap (Fig. 3.22)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Rhomboid Flap (Figs. 3.24–3.27)  .  .  .  .  .  .  .  .
Turnover Flap (Fig. 3.28)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Tubed Pedicle Flap (Bipedicle Flap)
(Fig. 3.29)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Distant Flaps  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Distant Tubed Pedicle Flap . . . . . . . . . . . . . . . . . . .
Myocutaneous and Myofascial Flaps
(see Figs. 12.1–12.3)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .

15
17
17
17
19
21
21
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21
21
22
22
22
24
24
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25
27
28
28
28
28
28

VI

Contents

Special Part
II Coverage of Defects in Specific Facial Regions
4 Forehead Region .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Median Forehead Region  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Wedge-Shaped Defects (Fig. 4.1) . . . . . . .
H-Flap (Fig. 4.2) . . . . . . . . . . . . . . . . . . . . . . . . . .
Double Rotation Flap (Fig. 4.3) . . . . . . . . .
Lateral Forehead Defects (Fig. 4.5) . . . . . .

5 Nasal Region  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Glabella and Nasal Root (Figs. 5.1–5.9) . . . . . . . .
U-Advancement Flap of Burow (Fig. 5.1) . . .
(Fig. 5.2; see also Figs. 3.8–3.10) . . . . . . . . . . .
Sliding Flap (Fig. 5.7) . . . . . . . . . . . . . . . . . . . . .
Nasal Dorsum (Figs. 5.8–5.12) . . . . . . . . . . . . . . . .
Bilobed Flap (Fig. 5.8). . . . . . . . . . . . . . . . . . . . .
Island Flap (Fig. 5.9) . . . . . . . . . . . . . . . . . . . . . .
Rieger Flap (Fig. 5.10) . . . . . . . . . . . . . . . . . . . .
Nasolabial Flap (Fig. 5.11). . . . . . . . . . . . . . . . .
Median Forehead Flap (Fig. 5.12) . . . . . . . . . .
Nasal Tip (Figs. 5.13–5.17) . . . . . . . . . . . . . . . .
Bilobed Flap (Fig. 5.13) . . . . . . . . . . . . . . . . . . .
V-Y Advancement Flap of Rieger (1957)
(Fig. 5.14) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(Fig. 5.15) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Larger Defects of the Nasal Tip and Ala  .  .  .  .  .  .  .  .
Frontotemporal Flap of Schmid and Meyer
(Figs. 5.17 and 5.18) . . . . . . . . . . . . . . . . . . . . . .
Nasal Flank  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Flap Advancement of Burow (1855) (Fig. 5.22)
Median Cheek Rotation of Sercer and
Mündich (1962) (Fig. 5.23) . . . . . . . . . . . . . . . .
Burow’s Laterally Based Cheek
(Fig. 5.24; see also Fig. 3.1) . . . . . . . . . . . . . . . .
Imre’s Cheek Rotation (1928) (Fig. 5.25) . . . .
Cheek U-Flap (Fig. 5.26) . . . . . . . . . . . . . . . . . .
Island Flap (Fig. 5.32) . . . . . . . . . . . . . . . . . . . . .
Sliding Flap (Fig. 5.33) . . . . . . . . . . . . . . . . . . . .
Nasal Ala  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Full-Thickness Reconstructions . . . . . . . . . . . . .
Z-Plasty of Denonvilliers and
Joseph (1931) (Fig. 5.34). . . . . . . . . . . . . . .
Anteriorly Based Alar Rotation
(Weerda 1984) (Fig. 5.35) . . . . . . . . . . . . . .
Modification of the Anteriorly Based
Alar Rotation . . . . . . . . . . . . . . . . . . . . . . . . .
Coverage with a Transposition Flap . . . . .

33
33
33
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34
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35
35
37
38
38
39
39
41
41
41
41
42
42
44
44
46
47
47

48
48
48
50
51
51
51
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51

Lowering the Alar Rim as a Full-Thickness
Bipedicle Flap and with a Composite Graft
(Fig. 5.38) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Turnover Flap and Composite Graft
(Lexer 1931, modified by
Kastenbauer 1977) . . . . . . . . . . . . . . . . . . . . 53
Converting a Peripheral to a Central
Defect (Haas 1991) and Reconstructing the
Alar Rim with a Transposition Flap
(Fig. 5.40) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Wedge-Shaped Defect in the Alar Rim
(Fig. 5.41) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Nelaton Flap (Nasolabial Flap) (Fig. 5.42) 55
Sliding Flap of Barron and Emmett (1965)
and Lejour (1972) from the Nasolabial
Fold (Fig. 5.44) . . . . . . . . . . . . . . . . . . . . . . . . 57
In-and-Out Flap of Peers (1967) (Fig. 5.45) 57
Median Forehead Flap (see Figs. 5.15 and
5.51). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Bilobed Flap from the Cheek
(Weerda 1983c) (Fig. 5.46) . . . . . . . . . . . . . 57
Large Defects of the Lateral Nose
(Figs. 5.47 and 5.48) . . . . . . . . . . . . . . . . . . . 57
The Columella  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 60
Nelaton Flap (Fig. 5.49) . . . . . . . . . . . . . . . . . . . 60
Frontotemporal Flap of Schmid and Meyer
(1964) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Composite Graft (Fig. 5.50). . . . . . . . . . . . . . . . 60
Partial and Total Nasal
Reconstruction  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 61
Converse Scalping Flap
(Forehead-Scalp Flap) (Fig. 5.52). . . . . . . . . . . 61
Total Nasal Reconstruction with the Sickle
Flap (Farrior 1974) (Fig. 5.53). . . . . . . . . . . . . . 65
Three-Stage Reconstruction of Total Nasal
Defects (after Burget and Menick 1994  .  .  .  .  . 66
Expansion (Fig. 5.55)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 74
Nasal Reconstruction with Distant Flaps. . . . 74
Perforations of the Septum  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 74
Small Perforations  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 74
Large Defects  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 75
Oral Mucosal Flap of Meyer (1988)
(Fig. 5.59b)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 75
Nasolabial Flap of Tipton (1975) (Fig. 5.60) 75
Bipedicle Flap of Schultz-Coulon (1989)
(Fig. 5.61)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 76

Contents

6 The Lips  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .

77
77
77
77
78
78
78
79
81
82
82
82

Mucosal Defects  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Wedge-Shaped Defects (Fig. 6.1) . . . . . . . . . .
Large Superficial Defects (Fig. 6.2). . . . . . . . .
Upper Lip  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Median Deficiency (Fig. 6.3) . . . . . . . . . . . . . .
Thin Upper Lip (Figs. 6.4–6.6) . . . . . . . . . . . . .
Thin Upper Lip and Full Lower Lip (Fig. 6.7)
Median Scars and Upper Lip Defects . . . . . . . .
Scar Revisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Small Contractures (Fig. 6.11) . . . . . . . . . .
Larger Contractures . . . . . . . . . . . . . . . . . . .
Larger Scar Contractures Causing Lip
Retraction (Figs. 6.12 and 6.13). . . . . . . . . 83
Defects in the Nasal Floor and
Upper Lip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Transposition Flap from the Nasolabial Fold
(Fig. 6.14) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Bilobed Flap (Fig. 6.15) . . . . . . . . . . . . . . . . 84
Neurovascular Island Flap from the Lower
Cheek (after Weerda 1980d Figs. 6.19 and
6.28). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Central Defects of the Upper Lip
(Fig. 6.20) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Celsus Method Combined with an Abbé Flap
Classic Reconstructive Techniques in the
Upper Lip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
Abbé Flap (1898, reprinted 1968)
(Fig. 6.22) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
Estlander Flap (1872) (Figs. 6.24; 6.40). . 90
Upper Lip Reconstruction with a Rotation
Flap (Blasius 1840) (Fig. 6.25) . . . . . . . . . . 90
Gillies Fan Flap (1976) (Fig. 6.27) . . . . . . . 92
Neurovascular Skin–Muscle–Mucosal
Flap of Weerda (1980d, 1990)
(Figs. 6.19 and 6.28) . . . . . . . . . . . . . . . . . . . 92
Combined Defect Repair of the Ala,
Columella, Cheek, and Upper Lip
(Fig. 6.29) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Lower Lip  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 94
Scar Contractures and Small Defects . . . . . . . . 94
Small Contractures (Figs. 6.30 and 6.31)
94
Larger Contractures . . . . . . . . . . . . . . . . . . . 94
Small Defects . . . . . . . . . . . . . . . . . . . . . . . . . 94
Lip Reduction. . . . . . . . . . . . . . . . . . . . . . . . . 94
Sliding Flaps in the Vermilion . . . . . . . . . . 94
Classic Lower Lip Reconstructions . . . . . . . . . . . 96
Wedge Excision . . . . . . . . . . . . . . . . . . . . . . . 96
Estlander Flap (1872) (Fig. 6.40). . . . . . . . 98

VII

Bilobed Estlander Flap (Fig. 6.41) . . . . . . . 99
Vermilion Reconstruction by the Method
of von Langenbeck (1855) (Fig. 6.42). . . . 99
Tongue Flap (Fig. 6.43). . . . . . . . . . . . . . . . . 99
Brown Modification of the Estlander Flap
(1928) (Fig. 6.44) . . . . . . . . . . . . . . . . . . . . . 102
Unilateral or Bilateral Gillies Fan Flap
(1957) (Fig. 6.45e–j). . . . . . . . . . . . . . . . . . .102
Universal Method of Bernard (1852),
Grimm (1966), and Fries (1971)
(Fig. 6.46; unilateral or bilateral) . . . . . . . 104
Reconstruction of the Lateral Lip
and Commissure  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 106
Burow’s Method of Reconstructing the
Lateral Upper Lip (1855) (Fig. 6.48) . . . . . . . . 106
Reconstruction of the Commissure by the
Method of Rehn (1933), as Modified by Fries
(1971) and Brusati (1979) (Fig. 6.50). . . . . . . . 106
Reconstruction of Large Commissural
Defects (Fig. 6.51) . . . . . . . . . . . . . . . . . . . . . . . . 107
Vermilion Defects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Goldstein (1990) (Fig. 6.52)  .  .  .  .  .  .  .  .  .  .  .  .  . 108
Combined Reconstruction of the Lower Part
of the Face (Lower Lip, Cheek, Chin, Middle
Part of the Mandible) (Fig. 6.53)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 108
Elongation of the Oral Fissure  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 110
Method of Converse (1959) (Weerda 1983)
(Fig. 6.54) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
Method of Converse (1977) (Fig. 6.55). . . . . . 110
Method of Ganzer (1921) (Fig. 6.56) . . . . . . . . 111
Method of Gillies and Millard (1957)
(Fig. 6.57) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111

7 The Chin .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 113
Coverage of Small Defects in the Chin Area  .  .  .  . 113
Advancement Flap (Fig. 7.1). . . . . . . . . . . . . . . 113
Bilobed Flap (Fig. 7.2a, b) . . . . . . . . . . . . . . . . . 113

8 The Cheek  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 115
Medial Cheek Defects .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Upper Medial Cheek . . . . . . . . . . . . . . . . . . . . . . . . . .
Esser Cheek Rotation (1918) (Fig. 8.1). . .
Cheek Reconstruction Combining the
Methods of Esser (1918) and Imre (1928)
(Weerda 1980) (Fig. 8.2) . . . . . . . . . . . . . . . . . .
Small Cheek Defects. . . . . . . . . . . . . . . . . . .
Haas and Meyer 1973, modified)
(Figs. 8.4 and 8.5) . . . . . . . . . . . . . . . . . . . . .
Defect in the Medial Canthus (Fig. 8.6) . .

115
115
115

116
117

117
117

VIII

Contents

Mid-Anterior Cheek (Fig. 8.7) . . . . . . . . . . . . . . . . 118
Pedicled Bilobed Flaps . . . . . . . . . . . . . . . . . . . . . . . . 118
Large Inferiorly/Anteriorly Based Bilobed
Flap (Fig. 8.8) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
V-Y Advancement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Upper and Posterior Cheek  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 120
Trilobed Flap of Weerda (1979) (Fig. 8.10) . . 120
Bilobed Flap (Fig. 8.11) . . . . . . . . . . . . . . . . . . . 120
Lateral Cheek Defects .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 121
Small Lateral Cheek Defects . . . . . . . . . . . . . . . . . . 121
Small Preauricular Defects . . . . . . . . . . . . . . . . . . . 122
(Burow‘s Method) (Fig. 8.17a–d). . . . . . . . . . . 122
Opposing Transposition Flaps (Fig. 8.18) . . . 122
Large Defects Involving the Auricle . . . . . . . . . 124
Lateral Cheek Rotation of Weerda (1980c)
(Figs. 8.20 and 8.21) . . . . . . . . . . . . . . . . . . . . . . 125
Pedicled Transposition Flaps
(Figs. 8.22 and 8.23) . . . . . . . . . . . . . . . . . . . . . . 125
Preauricular Hair Loss (Fig. 8.24) . . . . . . . . . . 126
Inferiorly Based Retroauricular Transposition
flap (Weerda 1978b) (Fig. 8.25) . . . . . . . . . . . . 126
Large Bilobed Flap from the Neck (Weerda
1980b) (Fig. 8.26). . . . . . . . . . . . . . . . . . . . . . . . . 127

9 The Eyelids  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 129
Upper Eyelid  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 129
Direct Closure (Fig. 9.1). . . . . . . . . . . . . . . . . . . 129
Semicircular Flap Closure of Beyer-Machule
and Riedel (1993) (Fig. 9.2) . . . . . . . . . . . . . . . . 129
Switch Flap (Fig. 9.3) . . . . . . . . . . . . . . . . . . . . . 130
Upper Eyelid Reconstruction of Fricke and
Kreibig (Fig. 9.4) . . . . . . . . . . . . . . . . . . . . . . . . . 130
Bilobed Flap (Fig. 9.5). . . . . . . . . . . . . . . . . . . . . 131
Total Upper Lid Reconstruction by the TwoStage Mustardé Technique (Beyer-Machule
and Riedel 1993) (Fig. 9.6) . . . . . . . . . . . . . . . . 131
Reconstruction of the Lower Eyelid  .  .  .  .  .  .  .  .  .  .  .  . 132
Reconstruction of Small Defects in the Lower
Eyelid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
Large Defects (Figs. 9.6 and 9.7) . . . . . . . . . . . 132
Reconstruction of the Lower Lid with
Ectropion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
Transposition Flap (Figs. 9.8 and 9.9). . . . 133
Total Lower Lid Reconstruction
(Figs. 9.11 and 9.12) . . . . . . . . . . . . . . . . . . . 133
Reconstruction of the Medial Canthus
(Figs. 9.13 and 9.14; see also Figs. 5.2–5.7) . . . . . 134

10 The Auricular Region  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 135
Classification (Table 10.1) and Esthetic Units
(Fig. 10.1)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 135
Central Defects: Recommended Defect Coverage
(Fig. 10.2)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 135
Conchal Defects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
Reconstruction with a Full-thickness
Skin Graft (Fig. 10.3) . . . . . . . . . . . . . . . . . . 137
Transposition Flap and U-shaped Advancement (Fig. 10.4) . . . . . . . . . . . . . . . . . . . . . . . 137
Reconstruction with Island Flaps
(Figs. 10.5–10.7) . . . . . . . . . . . . . . . . . . . . . . 137
Defects of the Antihelix and Combined Central
Defects (Figs. 10.8 and 10.9) . . . . . . . . . . . . . . . . . . 140
Converse and Brent’s (1977)
Three-stage Reconstruction of
Full-Thickness Defects of the Antihelix
(Fig. 10.10) . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
Superiorly or Inferiorly Based
Transposition Flap (Fig. 10.11) . . . . . . . . . 140
and Pickrell (1968) (Fig. 10.12) . . . . . . . . 142
Weerda’s Reconstruction with a
Transposition Flap and Temporary
Repositioning of the Helix (Fig. 10.13) . . 143
Weerda’s Bilobed Flap as a Transposition–
Rotation Flap (Fig. 10.14) . . . . . . . . . . . . . . 144
Weerda’s Scaphal Reconstruction with a
U-shaped Advancement Flap (Fig. 10.15) 144
Tebbetts’ (1982) Superiorly Based,
Preauricular Flap for the
Triangular Fossa (Fig. 10.16) . . . . . . . . . . . 144
Mellette’s (1991) Preauricular Flap Based
Superiorly on the Helical Crus (Fig. 10.17) 145
Subcutaneous Pedicle Flap of Barron and
Emmett (1965) (Fig. 10.18) . . . . . . . . . . . . 146
Inferiorly Based Preauricular Flap
(Fig. 10.19) . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
Peripheral Defects (Fig. 10.20) . . . . . . . . . . . . . . . 147
Helix Reconstruction with Auricular
Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Simple Wedge Excisions (Fig. 10.21) . . . . 148
Wedge Excision and
Burow’s Triangles (Fig. 10.22a–j) . . . . . . . 148
Gersuny’s (1903) Technique of Defect
Closure by Transposition of the Helix
(Fig. 10.23) . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
Modification of the Gersuny Technique by
Weerda and Zöllner (1986) (Fig. 10.24) . 150

Contents
Antia and Buch’s Modification with
Mobilization of the Helical Crus
(Fig. 10.25)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 150
Lexer’s (1933) Modification (Fig. 10.26) 150
Argamaso and Lewin’s (1968) Technique
of Ear Reduction and Defect Reconstruction
Meyer and Sieber’s (1973) (Fig. 10.27) . .
Modification of the Technique (Fig. 10.28) 150
Tenta and Keyes’ (1981) Excision of the
Triangular Fossa with Reduction of the
Auricle (Fig. 10.29) .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 150
Weerda and Zöllner’s (1986) Technique for
Defects of the Helical Crus and Preauricular
Region (Fig. 10.30)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 152
Pegram and Peterson’s (1956) Reconstruction with a Free Full-Thickness Composite
Graft from the Contralateral Ear  .  .  .  .  .  .  .  .  . 154
Helix Reconstruction without Auricular
Reduction  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 154
Superiorly Based Postauricular
Transposition Flap (Fig. 10.33)  .  .  .  .  .  .  .  .  .  . 154
Preauricular Transposition Flap
(Fig. 10.34a–c)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 154
Retroauricular Flap of Smith (1917)
(Figs. 10.35a–h)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 156
Tube-Pedicled Flap  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 156
Tube-Pedicled Flap for the Superior Helix
(Fig. 10.37) . . . . . . . . . . . . . . . . . . . . . . . . . . .157
Tubed Bipedicle Flap for Defects of the
Superior and Middle Thirds
(Figs. 10.38 and 10.39)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 158
Three-stage Reconstruction of a Defect of the
Middle Third with a Tube-Pedicled Flap
(Fig. 10.39) . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
Converse and Brent’s (1977)
Reconstruction with a Preauricular
Tube-Pedicled Flap (Fig. 10.39) . . . . . . . . . 159
Reconstruction with a Superiorly Based
Posterior Flap. . . . . . . . . . . . . . . . . . . . . . . . . 160
Inferior Helix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
Partial Reconstruction of the Auricle  .  .  .  .  .  .  .  .  .  . 160
Upper-Third Auricular Defects
(Fig. 10.40) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
Reconstruction with Auricular Reduction . . 160
Wedge Excisions . . . . . . . . . . . . . . . . . . . . . . 160
Helical Sliding Flap of Antia and Buch
(1967) (Figs. 10.42 and 10.43) . . . . . . . . . . 160
Full-thickness Composite Grafts of the
Contralateral Ear, as Described by
Pegram and Peterson (1956) . . . . . . . . . . . 160

IX

Reconstruction without Auricular
Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
Reconstruction with a Costal or Conchal
(see Fig. 10.48) Cartilage Framework and
Skin Pocket . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
Reconstruction by Insertion of an
Expander. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Crikelair’s (1956) Reconstruction using an
Anterosuperiorly Based Posterior Flap
(Figs. 10.51 and 10.52). . . . . . . . . . . . . . . . . 165
Crikelair’s Flap for Coverage of Large
Defect (Fig. 10.52). . . . . . . . . . . . . . . . . . . . . 166
Harvesting a Skin Graft from the Thorax
(Fig. 10.53) . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
Secondary Reconstruction Using a Postauricular Flap Pedicled on the Helix (Ombredanne 1931) (Fig. 10.54) . . . . . . . . . . . . . . . 166
Partial Reconstruction with a
Temporoparietal Fascial Flap (Fan Flap) . 168
Middle-Third Auricular Defects
(Fig. 10.55) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
Reconstruction with Auricular Reduction . . 168
Reconstruction of the Middle and Lower
Thirds, as Described by Templer et al.
(1981) (Fig. 10.56) . . . . . . . . . . . . . . . . . . . . 168
Reconstruction without Auricular
Reduction: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
Recommended Methods of
Reconstruction . . . . . . . . . . . . . . . . . . . . . . . 168
Retroauricular U-shaped Burow
Advancement Flap (Fig. 10.57) . . . . . . . . . 168
Inferiorly and Superiorly Based
Transposition Flap of Scott and
Klaassen (1992) (Fig. 10.58). . . . . . . . . . . . 170
Reconstruction with a Subcutaneous
Plasty (Fig. 10.59) . . . . . . . . . . . . . . . . . . . . . 170
Reconstruction with a Pocket as a
Tunneled Flap (Fig. 10.60a–h) . . . . . . . . . . 170
Reconstruction with a Rotation Flap
(Fig. 10.61) . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
Weerda’s Rotation–Transposition Flap . . 172
Posterior Auricular Flap Based on
Scar Tissue . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
Reconstruction with a Fan Flap
(Temporoparietal Fascial Flap)
(Fig. 10.62) . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
Reconstruction with Tubed Flaps . . . . . . . 173
Lower-Third Auricular Defects (Fig. 10.63) . 174

X

Contents

Recommended Methods . . . . . . . . . . . . . . . . . . . . .
Superiorly and Inferiorly Based
Transposition Flap (Fig. 10.64) . . . . . . . . .
Reconstruction of the Entire Lower
Auricle Using a Gavello Flap (Fig. 10.65)
Modified Gavello Flap (Fig. 10.66) . . . . . .
Reconstruction with a Modified
Gavello Bipedicled Flap (Fig. 10.67) . . . . .
Reconstruction of the Earlobe (Fig. 10.68) . . . .
Traumatic Earlobe Cleft . . . . . . . . . . . . . . . . . . . . . .
Reconstruction without Preservation of the
Earring Perforation . . . . . . . . . . . . . . . . . . . . . . . . . . .
Passow’s Procedure (Fig. 10.70) . . . . . . . .
Reconstruction with Preservation of
the Earring Perforation . . . . . . . . . . . . . . . . . . . . . . .
Pardue’s (1973) Method of
Reconstruction (Fig. 10.71) . . . . . . . . . . . .
Defects of the Earlobe . . . . . . . . . . . . . . . . . . . . . . . .
Loss of the Earlobe . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Gavello’s Method of Earlobe Reconstruction (1907; Figs. 10.65 and 10.66) . . . . . .
Posterior Defects  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Postauricular defects (Fig. 10.75) . . . . . . . . . .
Small Flaps (Fig. 10.76 and 10.77) . . . . . .
(Fig. 10.78) . . . . . . . . . . . . . . . . . . . . . . . . . . .
V-Y advancement (Fig. 10.79a, b) . . . . . . .
Closure of Defects Caused by
Skin Harvesting (Fig. 10.80) . . . . . . . . . . . .
Weerda’s Bilobed Flaps . . . . . . . . . . . . . . . .
Weerda’s Rotation–Transposition Flap
(Fig. 10.81a–f)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Weerda’s Double Rotation Flap
(Fig. 10.81) . . . . . . . . . . . . . . . . . . . . . . . . . . .
Retroauricular Defects (Fig. 10.82). . . . . . . . . . .
Elliptical or W-shaped Excisions and
Primary Closure (Fig. 10.83) . . . . . . . . . . .
Preauricular Transposition Flap
(Fig. 10.84) . . . . . . . . . . . . . . . . . . . . . . . . . . .
Coverage with Skin of the Postauricular
Surface and Rotation of the Cavum . . . . .
Combined Post- and Retroauricular
Defects (Fig. 10.85) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Free Skin Grafts (Fig. 10.86) . . . . . . . . . . . .

174
174
174
176
176
177
178
178
178
178
178
180
180
181
182
182
182
184
184
184
184
184
185
185
185
186
186
186
186

Subtotal Defects  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 186
Special Reconstructive Techniques . . . . . . . . . . 186
Single-stage Reconstruction with
Weerda’s Bilobed Flap as a Transposition–
Rotation Flap (Fig. 10.87)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 186
Single-stage Reconstruction of the
Anterior Surface with a Bilobed Flap
(Fig. 10.88)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 187
Loss of the Auricle  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 189
Fresh Avulsion Injuries . . . . . . . . . . . . . . . . . . . . . . . 189
Microvascular Replantation. . . . . . . . . . . . 189
Replantation of the Auricular Cartilage . 189
Replantation by the Technique of
Mladick et al. (1971)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 189
Auricular Replantation by the
Technique of Baudet (1972) and Arfai (in
Spira 1974) (Weerda 1980) (Fig. 10.89) . 189
Auricular Reconstruction Following Total
Amputation (Figs. 10.90, 10.91, and 10.92;
Weerda 1983c, 1987, 1997; Weerda
and Siegert 1998) .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 190
Reconstruction of the Ear or Auricular
Region in Patients with Skin Loss or Burns
(Fig. 10.93)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 194
Fan Flap of Parietotemporal Fascia
(Fig. 10.93)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 196
Dressing the Ear (Fig. 10.95)  .  .  .  .  .  .  .  .  .  .  .  .  . 198
Removal of Sutures  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 198
Fine-Tailoring After Operations. . . . . . . . . 198
Forming the shape of the Helical Crus,
Concha, Antitragus, and
Intertragic Notch  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 200
Reconstruction of Defects of the Auricular
Region after Partial or Total Amputation
(Figs. 10.99)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 200
Free Skin Graft (See Fig. 2.22, p. 16)  .  .  .  .  . 201
Rotation Flap of the Neck (Fig. 10.101)  .  . 202
Reconstruction with Rotation Flaps
(Fig. 10.101) and Double (Bilobed)
Flaps (Figs. 10.102 and 10.103)  .  .  .  .  .  .  .  .  .  . 202
Bone-Anchored Defect Protheses  .  .  .  .  .  .  . 202

Contents

XI

III Rib Cartilage, Myocutaneous and Free Flaps, and Microvascular Surgery
11 Rib Cartilage  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 207
Obtaining Rib Cartilage for Ear
Reconstruction (Fig. 11.1)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Operative Technique . . . . . . . . . . . . . . . . . .
Preparation of Cartilage Grafts (Fig. 11.2;
Nagata 1994)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Carving an Auricular Framework (Fig. 11.3)
Instruments . . . . . . . . . . . . . . . . . . . . . . . . . .

207
208
208
208
208

12 Myocutaneous Island Flaps  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 213
Pectoralis Major Island Flap (Fig. 12.1). . . . . . . . 213
Latissimus Dorsi Island Flap (Fig. 12.2) . . . . . . . 216
Neurovascular Infrahyoid Myofascial Flap of
Remmert et al. (1994) (Fig. 12.3)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 216
13 Deltopectoral Flap .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 219
14 Free Flaps  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 221
Radial Forearm Flap (Fig. 14.1)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Allen Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Groin Flap (Fig. 14.2)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Transplants Anastomosed Using a
Microvascular Technique
(Fig. 14.3 and 14.4) . . . . . . . . . . . . . . . . . . . . . . . . . . . .

221
223
225

226

Microvascular Surgery  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Instrumentation (Fig. 14.5)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Practicing for Microvascular Surgery . . . . . . .
Knot-Tying Practice Under a Microscope
or Binocular Loupe (Fig. 14.6–14.9)  .  .  .  .  .
Microvascular Anastomosis in an
Experimental Animal: Vascular
Dissection in the Rat (Fig. 14.10)  .  .  .  .  .  .  .  .
Problems and Complications
(Figs. 14.16–14.20)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Test for Patency (Fig. 14.21)  .  .  .  .  .  .  .  .  .  .  .  .  .

227
227
227
228

228
232
232

15 Harvesting Bone Graft from
the Iliac Crest (Figs. 15.1–15.5)  .  .  .  .  .  .  .  .  .  .  .  . 235
16 Harvesting Split Calvarian Bone Graft
(Fig. 16.1)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 239
17 Dermabrasion (Figs. 17.1)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 241
References  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 243
Further Reading  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 247
Index  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 251

XIII

Foreword to the 2nd Edition

The eagerly awaited second edition of Professor Hilko
Weerda’s beautifully concise, and influential guide to
reconstructive facial plastic surgery combines a clarity of vision that results from years of analytical
thought, with exemplary text. Almost 1,400 illustrations portray the approach and surgical planning for
a myriad of surgical defects. While students of facial
plastic surgery will find his instructions clearly
described in a stepwise manner, more senior colleagues will also benefit from his insight into more
complex problems. While there are numerous books
on similar topics, those that can in any way rival this
text in its scope and wisdom are few and far between.
In my capacity as President of the European Academy of Facial Plastic Surgery, I would urge all surgeons interested in this field to have this book close
at hand, on their work desks, and in the operating
room’s library, where it can act as a timely reminder
of the best techniques available and a valuable teaching aid.

From a practical point of view, the surgeon is initially guided through the most important principles
of facial reconstructive surgery, before being introduced to specialized sections that deal systematically with each of the major subunits of the face. Professor Weerda’s pioneering work in auricular reconstruction is also clearly reflected in the appropriate
sections in the book.
The specialty of facial plastic surgery has been
growing exponentially over the past few years. This
remarkable book will certainly act as a major leading
light for our trainees and mentors. I would like to
congratulate Professor Weerda and his team for this
impressive achievement. It has already found permanent residence on my desk.
Professor Pietro Palma
President
European Academy of Facial Plastic Surgery
University of Insubria Varese
Milano, Italy

XIV

Foreword to the First Edition

Balancing the twin needs of functional and aesthetic
facial defect reconstruction has challenged surgeons
over the centuries to develop practical and utilitarian
repair solutions. Professor Hilko Weerda, in typical
meticulous fashion, presents in this text atlas a virtual encyclopaedia of reconstructive options for the
thoughtful repair of a wide-ranging group of facial,
head, and neck defects. The multiple options and
alternatives available for defect repair and reconstruction presented in this volume have met the test
of time world-wide.
Reconstruction in the head and neck region
requires a dedication to meticulous planning. Facial
plastic and reconstructive surgery is, in it’s finest
sense, a craft best developed over time and seasoned
with experience. The thought process required in the
planning of facial repair probably supercedes the
technical skill involved in the surgical event itself.
Techniques highly useful and indicated in one region
of the face may not serve well for adjacent regions.
Skin thickness, skin mobility, the presence of hairbearing structures, and the junctions of facial landmarks must all be considered when the most appropriate surgical option is chosen. A tissue price is paid
(by the patient) whenever regional tissues are
advanced, rotated, transposed, or interposed to

reconstruct defects–scarring, distortion, and asymmetries of the donor as well as the recipient site are
everpresent possibilities. The surgeon’s critical
responsibility is to diminish the amount of that price
to be paid by employing the correct reconstructive
option. Given our present state of knowledge, the
majority of challenging facial repairs should produce
a functionally useful and aesthetically admirable outcome. As the brilliant reconstructive surgeon Gary
Burget states: “the eye does not perceive cover, lining
or support. It sees a pattern of graduated light and
shadow ... color, texture and most importantly contour create the visual image ...”.
Professor Weerda has succeeded admirably in
authoring a comprehensive compendium designed
to aid the reconstructive surgeon in assessing the
various options and alternatives for facial repair.
M. Eugene Tardy, M.D., F.A.C.S.
Professor Emeritus of Clinical Otolaryngology–
Director of Facial Plastic Surgery
Department of Otolaryngology–
University of Illinois Medical Center
Chicago, Illinois, USA

XV

Preface to the 2nd Edition

Particularly in this age of mass media, the face plays a
pivotal role in human self-identification. Malformations, defects, and bony or soft-tissue changes caused
by trauma or neoplasms can drastically alter the
patient’s appearance, frequently impacting on his or
her feeling of self-worth. Drawing on our experience
in the operating room and our many years of planning and conducting courses in plastic and reconstructive surgery, we have created an easy-to-use,
step-by-step surgical textbook for the face and neck,
based on informative illustrations and concise text.
Sequences of drawings provide both the novice and
the experienced facial surgeon with simple, reproducible solutions to many of the most commonly
encountered problems and questions in facial plastic
surgery.
In the 2nd expanded edition we were able to add
color photographs, partly taken from slides, to show

the situation before and after reconstruction. Along
with the most commonly practiced reconstructive
procedures, a number of other proposed technical
solutions are presented, largely without commentary.
I express thanks to my colleagues Stephan Remmert, Konrad Sommer, Ralf Siegert, and Joachim
Quetz for their excellent contributions. I thank Dr. S.
Storz, Tuttlingen, for letting me use the illustrations
of the basic instrument set and Mrs. Schumacher for
providing most of the drawings that consistently conformed to the author’s wishes. I also thank Mr.
Konnry, Ms. Hengst, Ms. Hollins, and Ms. KuhnGiovannini of Thieme Publishers for their outstanding work in the production of this book.
Hilko Weerda

XVI

Contributors

Joachim Quetz, MD
Supervising Physician
Department of Otorhinolaryngology, Head and Neck
Surgery
University Clinic Schleswig-Holstein, Campus
Kiel, Germany
Stephan Remmert, MD
Professor
ENT Clinic
Department of
Malteser Hospital St. Anne
Duisburg, Germany

Ralf Siegert, MD, DMD
Professor
Head of ENT Clinic, Plastic Surgery
Prosper Hospital
Recklinghausen, Germany
Professor
Marien Hospital
Osnabrück, Germany

I

Anatomy, Principles of Facial Surgery, and
Coverage of Defects

3

1

Anatomy of the Skin and Skin Flaps

The Skin
(Fig. 1.1)

The skin is composed of epithelial layers (epidermis)
and the dermis. Below the skin are the subcutaneous
tissue, fascia, and muscle (Fig. 1.1).
Fig. 1.1a, b
a Structure of the skin:
1 . Subpapillary vascular plexus
2 . Dermal vascular plexus
3 . Subdermal vascular plexus
4 . Segmental vascular plexus .
b Composition of free skin grafts.

4

1 Anatomy of the Skin and Skin Flaps

Types of Skin Flaps
Random Pattern Flaps
(Fig. 1.2)

Random pattern flaps derive their blood supply from
the dermal and subdermal plexus (Fig. 1.2). The ratio
of flap length to flap width in the face is approximately 2:1.

Axial Pattern Flaps

(Fig. 1.3)

An axial pattern flap is designed to be supplied by a
specific arterial vessel. For example, a forehead flap
can be mobilized on the frontal branch of the superficial temporal artery, and the median forehead flap
can be based on the supratrochlear artery (see Fig.
5.15). A 3:1 or 4:1 length-to-width ratio can be
achieved with these flaps.

Fig. 1.2 Random pattern skin flap for facial use has an
approximately 2:1 ratio of length to width . A special type is the
subcutaneous pedicle flap (Barron et al. 1965; Lejour 1972; see
Figs. 5.44 and 5.45) .

Island Flaps

(Fig. 1.4)

In an island flap, the skin is transposed into the defect
on a pedicle composed of only the nutrient vessels
Myocutaneous Island Flaps

Fig. 1.3 The axial pattern flap is based on a specific artery.
Examples are the forehead flap, Esser’s cheek rotation, and the
median forehead flap (see Figs. 5.51b, 6.17, 8.1) .

The myocutaneous island flap is an axial pattern flap
that generally includes skin, subcutaneous fat, muscle fascia, and muscle tissue. Familiar examples are
the myocutaneous pectoralis major island flap and
the myocutaneous latissimus dorsi island flap (see
Fig. 12.2).
Neurovascular Island Flaps
With some flaps, sensory or motor nerves can be
mobilized in addition to nutrient vessels. For example, authors have transferred neurovascular island
flaps from around the mouth for use in lip reconstruction (Karapandzic 1974; Weerda 1983a, b;
Remmert et al. 1994; see Figs. 6.19, 6.28, 12.3).

Fig. 1.4 Island flap. A variant of this flap is the neurovascular
island flap, which includes a nerve supply (Karapandzic 1974;
Weerda 1980c; Weerda and Siegert 1991; see Fig. 6.19) .

Fig. 1.5 Axial-pattern myocutaneous island flap (see Figs. 12.1
and 12.2) .

5

2

Basic Principles of Facial Surgery

Suture Materials and Techniques
We use atraumatic cutting needles for the skin, and
we generally use round needles for the mucosa. Our
suture material of choice for the face is 6-0 or 7-0
monofilament on a very fine needle. Occasionally, we
use 5-0 monofilament for areas that are not visible
(Prolene, PDS, P 1 and P 6 5-0 needle with P 3 or PS 3
needle).
Our subcutaneous sutures are composed of absorbable or fast-dissolving braided or monofilament
material (Vicryl or PDS, P 1, P 3 needle Ethicon, Norderstedt, Germany).
A suture or suture line must remain in place only
until the wound has healed to an adequate tensile
strength. Leaving sutures in for too long results in
ugly scarring of the needle tracks.
Sutures are removed as early as possible. Sutures
in the eyelid area or near the border of the lip should
be removed on the fifth postoperative day, and
sutures in other facial areas on day five or six. If
sutures have been placed under tension, we remove
them on day seven or eight. Sutures in the posterior
auricular surface are removed on day eight.
The simple interrupted suture (Fig. 2.1) is most
commonly used. Each surgical knot should be tied
with at least two, or preferably three, throws tied in
opposite directions.
We generally use continuous sutures (Fig. 2.2) for
the lid area, for long traumatic wounds, and behind
the ear in auricular reconstructions. After every
three or four stitches, we usually tie an intermediate
knot to obtain a secure coaptation.

a

b

The tightened suture should raise the wound edges
slightly, so that the scar will be at skin level following
scar contraction. With deep wounds, a subcutaneous
approximating suture is placed initially with a buried knot (Fig. 2.1a, b).
In areas where two skin incisions meet at an angle,
we generally use a Donati or Allgöwer type of vertical
mattress suture to coapt the wound edges (Fig. 2.3).
Wounds under tension are additionally reinforced
with mattress sutures tied over ointment-impregnated gauze or silicone button (Fig. 2.4). These
sutures are removed in 7 to 10 days.

Fig. 2.2 Over-and-over continuous suture, intermediate knot
after four stitches .
a

b

Fig. 2.3a, b
a Vertical mattress suture (Donati type).
b Vertical mattress suture (Allgöwer type).

c
a

Fig. 2.1a–c Simple interrupted suture .
a Subcutaneous approximating suture of absorbable material,
with a buried knot .
b The entrance and exit points are placed symmetrically .
c The suture is tightened, slightly pursing the wound margins,
and is tied on one side .

b

Fig. 2.4a, b
a Mattress sutures can be used to reinforce a suture line that is
under tension . The monofilament threads are tied over bolsters consisting of swabs, silicone tubing, etc.
b Schematic view in cross-section .

6

2 Basic Principles of Facial Surgery

a

Fig. 2.5

Continuous intracutaneous suture .

The continuous intracutaneous suture can yield a
more favorable cosmetic result in many surgical procedures (Fig. 2.5). We use 4-0 or 5-0 monofilament
material for this type of suture.
Adhesive strips can be added to the sutures, to further relieve tension on the wound edges and ensure a
cosmetically acceptable scar.
The Gillies corner suture is used in angled suture
lines and for the dispersion of scars (Fig. 2.6a). The
needle is passed subcutaneously through the wound
angle and brought out on the opposite side (Fig.
2.6b).

Basic Instrument Set for Reconstructive Facial Plastic Surgery
(Weerda 2006; Weerda and Siegert 2012)
(Fig. 2.7)

We generally use a 2× to 2.5× binocular loupe when
operating and suturing. A high-quality instrument
set (Fig. 2.7a, d, e) is needed that includes no. 11, no.
15, and no. 19 knife blades ① and one small and one
slightly larger needle holder for atraumatic needles
②. The set should include fine surgical forceps (e.g.,
Adson forceps), dissecting forceps ③, fine, angled
bipolar forceps for vascular electrocautery, two or
three fine hemostatic clamps, mucosal clamps, and
assorted sharp-pointed scissors and dissecting scissors ④. Fine, single-prong and double-prong hooks
⑤ are useful for holding and manipulating flaps. The
Weerda hook forceps (Fig. 2.7b) is a good alternative,
but care must be taken not to crush the flap margins
with the forceps. Important accessories are a millimeter rule, a caliper (Fig. 2.7a, ⑥), and sterile color
markers or methylene-blue marking pencils. Suture
materials consists of 5-0, 6-0, and 7-0 monofilament,
along with 4-0 and 5-0 absorbable braided and
monofilament sutures. For cutting the auricular cartilage and other cartilaginous structures, we use
assorted carving tools available from KARL STORZ—
ENDOSKOPE, Tuttlingen, Germany (Fig. 2.7a, ⑦ and
We also use various lengths of adhesive tape for
dressings, and emollient ointments that often contain petroleum jelly. We routinely use suction drains

Fig. 2.6a, b

b

Gillies corner suture .

and mini-suction drains to aspirate wound secretions and help contour the skin to the wound bed.

The Binocular Loupe

(Fig. 2.7c)

We have become accustomed to using a binocular
loupe (2.0 to 2.5× magnification), both when performing operations and when placing sutures.
Here we will describe only the basic instrument
set. The tray setups that we recommend for reconstructive facial plastic surgery are illustrated on p. 8.
The high-quality basic instrument set consists of
the following items (Fig. 2.7d): ①) scalpels with no.
11, no. 15, and no. 19 blades; ②needle holders—one
small and one slightly larger, for atraumatic needles;
③ fine tissue forceps (e.g., Adson forceps); ④ fine,
angled bipolar forceps for vascular electrocautery; ⑤
two or three small hemostatic clamps; ⑥ mucosa
clamps; ⑦ assorted pointed scissors; and ⑧ dissecting scissors.
We additionally use ⑨ fine, single- and doubleprong hooks for holding and manipulating the flaps.
A good alternative is the Weerda hook forceps ⑩ (Fig.
2.7e). Ordinary forceps should not be used, as they
are liable to crush the flap margins. Other important
accessories are a millimeter rule ⑪ and a caliper ⑫
(Fig. 2.7f) and sterile skin markers or methylene blue
marking pencils. We use an assortment of craft
knives for carving and sculpturing cartilaginous
frameworks (e.g., for an auricular reconstruction;
see Fig. 2.7a ⑦ and g).
• Dermatome
• Mucotome
• Assorted needle holders
• Special clamp (or needle holder) for twisting the
suture ends
• Wire cutters
• A Luniatschek gauze packer for burying wire
sutures

Basic Instrument Set for Reconstructive Facial Plastic Surgery

7

1

4

2

5

6

20

15

5

3

0

7
a

Fig. 2.7a–g
a Instruments for facial surgery (see text; from KARL STORZ—
ENDOSKOPE, Tuttlingen, Germany).
b Weerda hook forceps (KARL STORZ—ENDOSKOPE, Tuttlingen, Germany) see Fig. 2.7e .
b

(Continued on next page)

▶

8

2 Basic Principles of Facial Surgery

g

Fig. 2.7a–g (Continued)
c
Binocular loupe (from Weerda 2007, K. Storz Endo-Press).
d
Basic instrument set for reconstructive facial plastic surgery (from Weerda 2007).

e–g Basic instrument set for reconstructive facial plastic surgery (from Weerda 2007). A summary of instruments will
be found in the appendix; see text, p. 6.
With kind premission of Karl Storz-Endoskope, Tuttlingen, Germany (Weerda 2006, Weerda and Siegert 2012).

Wound Management and Scar Revision

9

Wound Management, Repair of Small
Defects, and Scar Revision

Management of Wounds with
Traumatic Tattooing

Surgical procedures of up to 2.5 hours can be conducted under local anesthesia. More extensive operations and scar revisions call for general anesthesia.
Care should be taken that the tape-secured endotracheal tube does not distort the face. The face should
not be taped over during operations in the facial
nerve area. We use a transparent film drape for this
purpose (to allow facial nerve monitoring).

If a wound contains embedded grit and dirt, it should
first be scrubbed with a sterile toothbrush or hand
brush and antiseptic soap, until all dirt residues have
been removed. It can be extremely tedious to remove
these particles after the wound has healed.

Relaxed Skin Tension Lines,
Vascular Supply (Fig. 2.8i), and
“Esthetic Units” (Fig. 2.20)
The facial surgeon must be familiar with the location
and distribution of the relaxed skin tension lines
(RSTLs) in the face, the facial “esthetic units” (see Fig.
2.20a–d), and the vascular supply of the face (Fig.
2.8i). Besides the RSTLs, attention should also be
given to wrinkle lines in the aging face.
Incisions or small excisions and sutures placed in
the RSTLs will heal with fine, unobtrusive scars. Incisions and excisions made at right angles to these
the plastic surgeon should always try to place the
cuts used for incisions, excisions, and scar revisions
in these lines, to achieve good cosmetic results.
The term “esthetic units” (see Fig. 2.20a–d) refers
to circumscribed facial regions that should each be
reconstructed as a separate unit whenever possible.
The radical excision of tumors takes precedence over
reconstructive concept in the sections that deal with
specific facial regions.

Wound Management and
Scar Revision
It is a general rule in facial plastic surgery to sacrifice
as little skin as possible. Small wounds that extend
obliquely into the tissue should be straightened
whenever the surrounding tissue can be mobilized
and the wound edges coapted without tension. A
subcutaneous suture with a buried knot should
always be placed to allow tension-free approximation of the wound margins (see Fig. 2.1). Because the
subcutaneous tissue, epidermis, and dermis take different lengths of time to achieve adequate wound
strength, early removal of the skin sutures from a
wound without subcutaneous sutures would result

Scar Revision by W-Plasty and the
Broken-Line Technique of Webster
(1969)
(Fig. 2.8a–j)

If time permits in trauma cases, the wound should be
dispersed with a W-plasty, broken-line excision, or
Z-plasty that conforms to the RSTLs. If this is not possible, scar revision should be postponed for at least 6
months to 1 year. Long scars are very conspicuous,
especially when they cross RSTLs at right angles. Scar
revision therefore has two goals:
• Dispersing a long scar into smaller individual
scars
• Positioning the smaller scars in RSTLs.
Revision techniques involve excising the scar and
dispersing the wound line into multiple segments.
The W-plasty consists of segments 4 to 5 mm long
arranged in a zigzag pattern (Fig. 2.8a2, c, e–j). The
new scars run in alternating directions and are barely
perceptible after the wound has healed. In the broken-line technique, the segments are placed in an
irregular pattern (Fig. 2.8a3, c). In both the W-plasty
and broken-line techniques, the margins of the excision are fashioned so that they will fit together precisely like a lock and key. Generally, this is done with
a no. 11 blade that is held perpendicular to the skin
surface when the cuts are made. The wound edges
are then undermined with a no. 15 blade or pointed
scissors (Webster 1969; Borges 1973; Haas 1991).
Fine scars can also be managed by dermabrasion (see
Chapter 17). The suture material of choice is 6-0 or
7-0 monofilament, and subcutaneous sutures should
be placed whenever possible. Corners and triangles
are secured with Gillies corner sutures (Fig. 2.6).

10

2 Basic Principles of Facial Surgery

a1

b

2

3

4
1

4

a3

a2

a4

RSTL

c

d

Fig. 2.8a–j Relaxed skin tension lines (RSTL) and scar revision (see p. 11) in the face.

Wound Management and Scar Revision

e

f

g

h

11

Fig. 2.8a–j (Continued) Relaxed skin tension lines (RSTL) and scar revision in the faces
b Side view .
a1 Elliptical excision in the RSTLs, front view.
c Scar revision with w-plasty and broken-line technique .
a2 Scar excision by W-plasty . The W-plasty is an interdigitad Result .
ting, zig-zag-shaped excision with segment lengths of 3 to
e Large temporal scar and auricular loss with additional facial
4 mm .
palsy . Scar revision with W-techniques and with broken-line
a3 Scar excision by the broken-line technique creates skin
technique . The ear was reconstructed 2 years previously: scar
tags of varying shape with an edge length of 3 to 5 mm.
incision .
The edges interdigitate and should follow the RSTLs as
f Scar excision following the RSTL (see a2, a3) .
closely as possible .
g Closure of the wounds and face lift .
a4 Z-plasty following scar excision in the face . The new scar is
h 5 months after revision.
orientated along the RSTLs (see Fig. 2.15, 2.16) .

(Continued on next page)

▶

12

2 Basic Principles of Facial Surgery

j

i

8 7

51

52

6

23

3

22
21

5

4

4

9

5

3

6

2

3

2

1

2

22

1

Fig. 2.8a–j (Continued) Relaxed skin tension lines (RSTL) and scar revision in the face.
j The facial nerve and its distribution in the face:
i The face derives its arterial blood supply from the external
1 Trunk from the stylomastoid foramen
carotid artery and anastomotic areas:
2 Marginal mandibular branch
1 External carotid artery
2+3: cervicofacial
22 Cervical branch
2 Facial artery
branch
21 Inferior labial artery
3 Buccal branches
4 Zygomatic branches
22 Superior labial artery
5 Temporal branches
23 Angular artery
 4+5: temporofacial
branch
6 Posterior auricular branch.
3 Transverse facial artery (from 5)
4 Zygomatico-orbital artery (from 5)
5 Superficial temporal artery
51 Frontal branch
52 Parietal branch
6 Occipital artery
7 Supraorbital artery (see Figs. 5.51b; 5.52b, d, e; 5.53, and
5.54o)
8 Supratrochlear artery (see Figs. 5.51b, 5.53, and 5.54o)
9 Dorsal nasal artery (see Fig. 5.8a) .



a

b

Fig. 2.9a–c
a Elliptical excision in the RSTLs.
The excision angle is ~30°.
b Crescent-shaped excision .
c Suture .

c

300

a

b
300

300

RSTL

Fig. 2.10a, b
a Double M-plasty. Each excision angle is 30°.
b Closure .

Small Excisions
When an elliptical excision is made in the RSTLs, the
wound angle should not exceed 30° (Figs. 2.8a and
2.9). Various excision techniques can be used (Figs.
2.10–2.14).

13

Wound Management and Scar Revision

a

b

Fig. 2.11a, b
a Crescent-shaped advancement flap of Jackson (1985).
b Closure of the defects .
a

b

Fig. 2.13a, b
a Small flap advancement for an elliptical excision .
b Closure .

Z-Plasty

a

b

Fig. 2.12a, b
a Rhomboid excision .
b Closure .
a

b

Fig. 2.14a, b
a Triangular excision .
b Closure .

a

b

RSTL

(Figs. 2.15 and 2.16)
The Z-plasty is used to relieve tension on tissues that
have been distorted by a contracted scar (Fig. 2.15).
This technique can also disperse and redirect wounds
that cross RSTLs at right angles, in which case a multiple Z-plasty can also be used (Fig. 2.16) (Jackson
1985a).
Numerous variations of the Z-plasty are available
for repairing defects of varying size (Fig. 2.8d and
Figs. 2.17 and 2.18). These techniques require a high
degree of flap mobility (Cummings et al. 1986).

1

2

2

1

45°

60°

Fig. 2.15a, b Simple Z-plasty .
a The scar, which crosses the RSTLs (– –) almost at right angles, is excised and dispersed with a 45° Z-plasty. Flaps 1 and 2
are transposed, causing a slight lengthening of the tissue in
the direction of the arrow .
b Transposing flaps 1 and 2 in a 60° Z-plasty produces even
greater tissue lengthening (arrow).
a
1
3
5
7

2
4
6
8

b
2
1
4
3
6
5
8
7

RSTL

Fig. 2.16a, b Multiple Z-plasty .
a The scar is excised, and the long scar is dispersed into multiple Zs that more closely follow the RSTLs.
b Transposing the flaps lengthens the tissue in the direction of
the scar and disperses the scar into multiple smaller flaps
(see Wound Management and Scar Revision, p. 9).

14

2 Basic Principles of Facial Surgery
Fig. 2.17a–d
a Rhomboid defect repaired
by a Z-plasty, using the
technique of Pate and Wilkinson (1991).
b Defect, a Z-plasty is
incised, with a Burow’s triangle at the end of the
incision .
c, d Closure of the defect .

b

a

60°
120°

60°

c

d

a

b

2
1

1
2

Fig. 2.18a, b Z-plasty for the closure of small circular defects .

Postoperative Treatment of Scars
We use microscissors (Fig. 2.19) for cutting and
removing the sutures on postoperative day five, six,
or seven. A cortisone ointment is massaged into the
scar for 15 minutes in the morning and evening, for 2
weeks. If the patient is prone to hypertrophic scarring, we inject a 1:2 dilution of Volon A crystal suspension (10 mg Volon A diluted with 2 mL of physiologic saline).

Fig. 2.19 Weerda suture microscissors with micro-cutting
edge (KARL STORZ—ENDOSKOPE, Tuttlingen, Germany).

Esthetic Units of the Face

(Fig. 2.20)

If portions of the face need to be reconstructed, better cosmetic results are achieved by reconstructing
areas as complete units (see Fig. 5.54). This is not
always possible, however, especially in tumor resections.

Wound Management and Scar Revision

Orbital
rim

Hairline

15

Lateral

Dorsum

Inferior
orbital rim

Sidewall
Tip
b

Preauricular
crease

Soft
triangle
Nasolabial
fold

a

Labiomental
sulcus

Inferior
border of
the
zygomatic
arch

Nasolabial
fold
Ala
Columella

c

Fig. 2.20a–d Esthetic units of the face .
a In the face.
b Nasal subunits, anterior view.
c nasal subunits, lateral view.
d Esthetic subunits of the cheek (Sherris and Larrabee 2009).

Tumor Resection with Histologic
Control
(Fig. 2.21)

Complete tumor removal takes precedence over all
cosmetic and reconstructive concerns. Regardless of
whether the tumor is a basal cell carcinoma, squamous carcinoma, or melanoma, it must be certain
that adequate marginal and deep clearance has been
achieved in accordance with oncologic principles.
Wherever possible, we practice a modified form of
histologically controlled tumor resection. This
means that the tumor is first excised with a margin
of healthy tissue, marked with threads to indicate its
position in the face or neck, and outlined on paper
(Fig. 2.21a). The specimen is sent to pathology, and
additional samples are taken from the margins and
base of the tumor bed (Fig. 2.21b), marked on a sheet
of paper (e.g., glove paper), and sent to pathology for
separate evaluation. The defect is not reconstructed
until the histologic results are known (secondary or
delayed coverage). This can minimize the recurrence
rate, and the cosmetic results are as good as with a
primary reconstruction. This procedure is followed
even if re-excision is necessary, owing to positive
margins.
Small tumors are elliptically excised in the RSTLs,
and the wound margins are sparingly undermined
and closed in two layers (see Figs. 2.8a and 2.9a). Various skin flaps can be used to cover larger defects.

Anterior
border of the
masseter

d

a

b

6
5

7
14
4

13

8
15

9

12

16
11

3

2

10
1

Fig. 2.21a, b Tumor resection with histologic control .
a The skin tumor is removed with a margin of healthy tissue,
and the edges of the specimen are marked with threads .
b The margins and base of the tumor bed are resected in a
clockwise direction and checked histologically to verify complete tumor clearance .

16

2 Basic Principles of Facial Surgery

a

b

c

d

e

f

Fig. 2.22a–g Free skin grafts .
a Following meticulous hemostasis, the split-thickness or fullthickness skin graft (see Fig. 1.1b) is sutured to the wound
margin on one side. A thin film of fibrin glue (Tissucol, Baxter
Germany, Heidelberg) is applied to the base of the wound,
and the graft is pressed firmly against the wound bed for 30
seconds .
b A light pressure dressing is particularly recommended in
more mobile facial areas . The graft-fixation sutures are left
long, and additional 4-0 sutures may be placed 1 cm from
the wound margin . We cover the graft with a 1- to 2-mm

g

c
d
e
f
g

thickness of petrolatum foam, followed by a foam or gauze
bolster over which the suture tails are tied, exerting gentle
pressure on the grafted site .
The tie-over dressing remains in place for at least 6 to 8 days.
Full-thickness skin graft from retroauricular .
Colors match after healing .
Split-thickness skin graft after tumor resection (see Fig.
10.86). The skin is glued and sutured, the sutures are left
long (b, c) .
Result 1 year after covering the defect .

Wound Management and Scar Revision

Free Skin Grafts
(Fig. 2.22)

Although our tendency is to cover facial defects with
local skin flaps, sometimes it is better to use a fullthickness or split-thickness skin graft to repair a
tumor resection site, especially in older patients.
This is especially true if the tumor cannot be excised
with the requisite safety margin, or if it is uncertain
that the tumor has been fully encompassed. We use
skin from the postauricular or retroauricular area to
cover facial defects, as it most closely matches the
color and texture of the facial skin. Other acceptable
donor sites are the supraclavicular area and the
medial surface of the upper arm. Groin skin can be
used in less conspicuous areas. We have found the
scalp above the ear to be a good donor region. When
this skin is used for split-thickness grafts that are no
more than 0.3 mm thick, the hair is cut very short
and the skin is harvested above the level of the hair
bulbs with a dermatome or mucotome. The regrowth
of hair will conceal the donor scars.
Large split-thickness grafts can be obtained from
the buttock, from the abdominal skin, or, as a last
resort, from the thigh. They are harvested using various types of dermatomes, which are set to the
desired thickness of the graft. Thin split-thickness
skin grafts are harvested with a thickness of 0.2 to
0.3 mm; thick split-thickness skin grafts are in the
range of 0.35 to 0.50 mm, and full-thickness skin
grafts are over 0.5 mm thick (see Fig. 1.1b).
The wound bed to be grafted must be free of bleeding sites and clotted blood, otherwise the graft will
not adhere to the wound bed and will be lost to
necrosis. Harvesting the graft from the groin area
leaves an unobtrusive, streaklike scar. The free graft
should be slightly larger than the primary defect. We
use a pattern made from aluminum foil (suture
wrapping material) or glove paper to outline a graft
of sufficient size.
Generally, the graft is sutured into the wound bed
with 5-0 or 6-0 monofilament (Fig. 2.22a). Fibrin
glue (Baxter Germany, Heidelberg) is additionally
used to support hemostasis and ensure adequate
fixation of the graft in the recipient bed. The grafted
site is covered with a layer of foam coated with a
mixture of Betadine and petrolatum. This is covered
with a petrolatum gauze bolster, over which the
suture tails are tied to create a light pressure dressing
(Fig. 2.22b). The tie-over dressing remains in place
for 6 to 8 days (Fig. 2.22c). The dressing can also be
A successful graft requires a well-perfused recipient bed. A graft placed on bare bone, for example,
will not survive. If bone is exposed, or if the level of
the graft does not match that of the surrounding
skin, special measures must be taken. When cortical
bone has been exposed, drilling multiple holes down
to cancellous bone will promote the formation of

17

granulation tissue. The soft granulations are periodically removed and light pressure dressings applied to
condition the graft bed. When the level of the bed
has reached that of the surrounding skin, graft inset
can be performed (see Figs. 5.52j, l and 10.100).

Composite Grafts
(Fig. 2.23)

Grafts from the auricle can be harvested from the
posterior (Fig. 2.23c–f) or anterior region (Fig. 2.23g–
l) as particularly, two-layer chondrocutaneous grafts
(Fig. 2.23g–l) and full-thickness (three-layer) grafts
composed of anterior skin, cartilage, and posterior
skin. They are most commonly used for nasal reconstruction (Fig. 2.24) and (Fig. 5.54) but can be used in
the auricle as well (Fig. 2.23m–o). Because the skin of
the graft contracts slightly, it should be cut slightly
larger than the defect and thus larger than the cartilage layer. Again, we use a pattern made from aluminum foil (Fig. 2.23c) (suture material wrapper) or
glove paper as a guide. The skin on the anterior side
is more firmly adherent to the perichondrium and
cartilage than the posterior skin. If the retroauricular
skin is included in the graft, it should be tacked to the
cartilage with a few simple interrupted sutures, to
prevent separation.
The donor defect may be closed by direct suture or
covered with a retroauricular island flap (see Figs.
10.2–10.5). When the composite graft is handled,
care must be taken not to crush its edges with the
forceps, and the fixation sutures should not be placed
too close together. Dark discoloration of the graft
during the first few days is no cause for alarm, but
more than 20% of these grafts do not survive (Fig.
2.23b–d) (Walter 1997). The dressing over the composite graft should keep it immobile for 6 to 7 days if
possible, to avoid tearing the capillary buds that
revascularize the graft (Weerda 2007, p. 42, Table
3.11; Fig. 2.23b–d).
Cartilagenous and Composite Grafts for Auricular
and Nasal Reconstruction
(Figs. 2.23 and 2.24; rib cartilage see pp. 207–211
For partial (Fig. 5.48d, e) or total reconstruction
(Fig. 5.54), we need cartilaginous grafts of different
sizes, commonly harvested from the cavum conchae
and cymba (Fig. 2.24). These grafts can be taken from
the posterior (Fig. 2.24a–d) or from the anterior
aspect of the auricle (Fig. 2.24e–g). For the nasal dorsum, we use a compound septal rotation flap (see
Fig. 5.54a–h) and usually a rib cartilage strut (see
Fig. 11.1).

18

2 Basic Principles of Facial Surgery
c

b

a

P

d

f

e

Sulcus

g

h

j

i
h

Composite
graft

Conchal
cartilage

k

l

Fig. 2.23a–o
a Donor sites where two-layer and three-layer composite grafts
or conchal cartilage can be obtained with primary closure of the
defects. A fat–dermis graft can be harvested from the earlobe.
b Situation after harvesting a three-layered wedge-shaped composite graft and closure of the wound in the upper part of the
auricle (see Fig. 5.41) .
c Harvesting conchal cartilage from postauricular region, using a
pattern (P) of aluminum foil, the graft is outlined with needles
from the anterior aspect .
d, e Incision in the sulcus, preparation of the skin.
f Outline of the cartilage .
g, h Harvesting a conchal two-layered composite graft from the
anterior aspect .
g The composite graft is outlined with a pattern (see c) .
h Incision through skin and cartilage with a no. 11 or 15 blade.
i–l Preparation of the graft and excision of the composite graft
(j, k) .
l A full-thickness or split-thickness skin graft is sutured and glued
into the defect. The free graft has taken (see Fig. 10.3) .

Wound Management and Scar Revision

n

m

19

o

Fig. 2.23a–o (Continued)
m Replantation of a small part of the helical rim after a dogbite .
n Healing with a small central defect after 3 months (Weerda
2007, p. 36).

o Replantation of a medium-sized composite graft, a necrosis
resulted .

Dorsal nasal strut
from rib cartilage

Lateral sidewall graft

Alar batten graft
(rib or conchal cartilage)
Tip graft
Columellar graft

Fig. 2.24 Grafts commonly used in nasal reconstruction (Sherris and Larrabee 2009). For nasal reconstruction we use rib cartilage
(see Fig. 5.54, p. 68) and cartilage from one or both conchae (see Fig. 5.54w–y) .

Graft Nomenclature
Autologous:
The donor and recipient are the same (autograft).

Xenogeneic:
The donor and recipient are of different species (e.g.,
bovine cartilage; xenograft or heterograft).

Isogeneic:
The donor and recipient are genetically identical
(e.g., monozygotic twins, animals of a single inbred
strain; isograft or syngraft).

Prosthetic:
Lost tissues are replaced with synthetic materials
such as metal, plastic, or ceramic (prosthetic
implants).

Allogeneic:
The donor and recipient are of the same species
(human–human, dog–dog; allograft).

21

3

Coverage of Defects

Local Flaps

a

b

2

Local flaps are flaps that are raised from tissues in
the immediate vicinity of the defect.

1

2

(Fig. 3.1)
Simple triangular defects can be covered by advancing the adjacent skin. A small Burow's triangle is
excised at the opposite end of the flap (Fig. 3.1a) to
prevent formation of a dog ear.
(Figs. 3.2–3.7)

a

1

Fig. 3.2a, b U-advancement of Burow.
a The ratio of defect (D) length to flap length is ~1:2, and the
base-to-length ratio of the flap should not exceed 1:2 . The
flap is advanced by excising two small Burow‘s triangles and
mobilizing the surrounding skin.
b Closure of all defects (see Figs. 5.14, 5.26, 10.17) .
a

The U-shaped skin advancement requires the excision of two Burow’s triangles (Fig. 3.2a). The lengthto-width ratio of the standard U-flap should not
exceed 2:1, and a 3:1 ratio is allowed only in exceptional cases.
In the Stark modification of the U-advancement
(quoted in Jost et al. 1977), the flap is widened
toward its base. Cut-backs can be added to increase
the flap length (Fig. 3.3a). The extra small defects
created by the flap are closed by mobilizing the surrounding skin (Fig. 3.3b). Other modifications are
shown in Figs. 3.4–3.7.

D

Cut−back

Fig. 3.3a, b
triangles.

a

b

Modifications of defect closure using Burow’s

b

b

D

Fig. 3.4a, b
triangles.
Fig. 3.1a, b Advancement flap of Burow (1855).
a The flap is incised along the base of the wedge-shaped
defect, and a small Burow‘s triangle (arrow) is excised on the
opposite side. The skin is mobilized and shifted in the direction of the arrow to close the defect . Excising the small
Burow‘s triangle eliminates a dog ear at the base of the flap.
b Appearance after coverage of the defect (see Figs. 5.1 and
5.24) .

a

Fig. 3.5a, b
triangles.

Modifications of defect closure using Burow’s

b

Modifications of defect closure using Burow’s

22

3 Coverage of Defects

a

Fig. 3.6a, b
triangles.

a

b

Modifications of defect closure using Burow’s

V-Y and V-Y-S Advancement of Argamaso (1974)
(Figs. 3.8–3.10)

b

Fig. 3.7a, b Modifications of defect closure using Burow’s
triangles.

a

b

c

The V-Y advancement and double V-Y-S advancement of Argamaso (1974) are special designs used
for releasing contracted scars, for columellar reconstruction from the upper lip, and for lengthening the
frenulum (Fig. 3.8).
a

b

c

Fig. 3.9a–c Modification of the V-Y plasty (see Figs. 5.2 and
5.10) .
a

Fig. 3.8a–c V-Y advancement (see Fig. 5.4) .
a A contracted scar or the frenulum can be lengthened by
making a V-shaped incision, mobilizing the flap, and advancing it in the direction of the arrow .
b The skin is mobilized.
c Closure of the defects .

Flaps without Continuous Epithelial
Coverage (Rettinger 1996a, b)
Sliding Flap
(Figs. 3.11–3.14)
Another interesting type of advancement flap is the
sliding flap, which is based entirely on subcutaneous
tissue. Barron and Emmett (1965) devised a flap with
Figs. 5.33, 5.44, 6.16). The skin flap is outlined, and
the pedicle is mobilized on one side. The flap is slid
into the defect on the subcutaneous pedicle. Lejour
(1975) described a similar flap based on subcutaneous tissue (Figs. 3.12–3.14; see also Fig. 5.7). We have
used this type of flap to repair defects in the tongue
(Weerda 1985; Fig. 3.14).

b

Fig. 3.10a, b V-Y-S advancement of Argamaso (1974).

a

b

Fig. 3.11a, b Sliding flap of Barron and Emmett (1965, see
Fig. 5.7, p. 37).
a Flap with a lateral subcutaneous pedicle .
b Closure of the defects .
a

b

Fig. 3.12a, b Sliding flap of Lejour (1975), based on the subcutaneous tissue below the flap. (see Fig. 3.13; see also Fig.
5.7) .

Local Flaps

23

Fig. 3.13 Examples and modifications of sliding flaps for facial
plastic surgery (see Figs. 5.33,
5.44, 5.45, 6.16) .

a

b

Fig. 3.14a, b Myomucosal sliding flap of Weerda (1985b).
a The sliding flaps have been outlined .
b The flaps are slid into the defects on a lateral muscle pedicle,
and the defects are closed .

24

3 Coverage of Defects

Pedicled Flaps

nutrition (Weerda 1978b; Haas 1991); see Figs. 5.12,
10.16, 10.64.

Transposition Flap
(Fig. 3.15)
This flap must be large enough for transfer into a
local defect (D). The surrounding skin can be mobilized for primary coverage of the secondary defect (S)
(Fig. 3.15b, c; Figs. 3.16 and 3.17). The flap may be
swung through an acute angle (Fig. 3.17), a 90° angle,
or even more than 90°, depending on the mobility of
the surrounding skin. If the transposition flap is too
short but has a broad enough base, the flap can be
lengthened by adding a back-cut (Fig. 3.18). Care is
taken that the residual base is still adequate for flap

a

b

Rotation Flap
(Fig. 3.19)
This is a semicircular skin flap that is rotated into the
defect on a pivot point. Again, the flap must be sufficiently broad, and a broad base is necessary if a backcut is needed to lengthen the flap (Fig. 3.20; see also
Figs. 6.25, 8.1, 8.17). If the rotation flap is too small
(Fig. 3.21a), the residual defect can be covered by
mobilizing the surrounding skin (Fig. 3.21b, c; see
also Fig. 6.14).

c
S

D

a

c

b

Fig. 3.15a–c Transposition flap
(see Figs. 5.6; 5.29b, c; 10.16) .
a The transposition flap is outlined
at a 90° angle to the defect (D).
b The flap is swung into the defect,
and the secondary defect (S) is
closed by advancing the surrounding skin .
c Appearance after closure of all
defects .
Fig. 3.16a–c Other options for
closing the secondary defect (S).
D = defect .

S
D

a

b

c

S

D

a

b

c
S

D

D

Fig. 3.17a–c Other options for
transposition and mobilization
(see Fig. 5.19) .
a Transposition flap . D = defect .
b Additional skin is excised to allow
closure of the secondary defect
(S).
c Closure .

Fig. 3.18a–c The surrounding
skin is mobilized and advanced in
the direction of the arrow .
a The transposition flap is too
short . D = defect .
b A back cut is made to lengthen
the flap (while preserving an
adequate base) . S = secondary
defect .
c Closure of all defects .

Local Flaps

Fig. 3.19a, b Rotation flap (see
Figs. 8.1; 8.17c, d; 10.49) .
a The mobilized flap is rotated into
the defect (D) after excision of a
Burow’s triangle (B).
b Appearance after closure of the
defects .

b

a

D

B

a

b

S

Fig. 3.20a–c Transfer of a toosmall rotation flap aided by a cutback (see Fig. 3.18) .
a The flap is lengthened by making
a cut-back .
b The defect (D) is closed, and the
secondary defect (S) is mobilized
in the area of the cut-back .
c Closure of all defects .

c

D
D

S

cut−back

a

b

c

S
D

D

a

b

1

2

D

S1

L1

L1

L2
L2

c

3

25

S2

Fig. 3.21a–c Transfer of a toosmall rotation flap aided by mobilizing the surrounding skin (see Fig.
8.17c–g) .
a Flap .
b The flap is rotated, and the surrounding skin is mobilized to
close the residual defect (D) and
secondary defect (S). If necessary,
a skin triangle is excised over the
secondary defect (——) .
c Closure of all defects .

Fig. 3.22a–d Bilobed flap (Esser 1918) (see Figs. 5.6, 5.8,
5.13, 5.29, 5.46, 6.15, 8.8, 8.19, 10.65, 10.87) .
a The angle between the defect (D) and the first lobe L1 equals
the angle between L1 and lobe L2. If the skin is mobile, lobe 1
is approximately two thirds of the size of the defect, and
lobe 2 is approximately two thirds of the size of lobe 1 .
b The flaps and surrounding skin are mobilized, and lobe L1 is
swung into the defect. Lobe L2 is swung into the secondary
defect S1 .
c The surrounding skin is mobilized, and all secondary defects
are closed .
d Appearance after closure of all defects .

d

Bilobed Flap
(Fig. 3.22)

S2

An interesting flap design is the “bilobed flap,”
described by Esser (1918). The two flaps have a common base and form an angle between 45° and 180°.
Smaller angles make it easier to rotate the two
attached transposition flaps (Fig. 3.23), while larger
angles require longer flaps and cause greater skin
bunching. Other combinations of such flaps are possible (see Fig. 5.29).
These flaps are used in areas where the surrounding skin is not mobile enough to close the secondary
defect, such as the nasal flank, the junction of the

26

3 Coverage of Defects

a

scalp and neck, the cheek, and the nasal tip area
(Zimany 1953; Elliot 1969; Weerda 1978c, d, 1980d,
e) (see Figs. 5.6, 5.8, 5.13, 5.28, 5.46, 8.19, 9.5, 10.87).

b
D

c

d

D

Fig. 3.23a–c

a

Modifications of the bilobed flap. D = defect .

b

C

B

D

D
G

A

c

E
F´

F

d

C

B

C

D

G

E

B

E

G

D

F
A
e

F

A
f

Fig. 3.24a–f Rhomboid flap of Limberg (1967).
a The first flap incision is an extension of the axis
B–D, and the second incision (E–F) is made parallel
to G–A.
b Outline of tumor excision and rhomboid flap .
c The flap is mobilized.
d, e Appearance after closure of all defects .
f Result (see Fig. 10.42) .

Local Flaps
a

27

Fig. 3.25a, b Two opposing Limberg flaps are mobilized
(arrows) (a), and all the defects (D) are closed (b) .

b

D

a

b

c

e

f

Fig. 3.26a–f Rhomboid flap
of Dufourmentel (1962).
a, b Pattern of the flap incision. The tumor is incised, the
flap outlined .
c Mobilization and flap transfer .
d, e Closure of all defects .
f Result .

D

d

a

Fig. 3.27a–c Defect covered with
two modified rhomboid flaps corresponding to a Z-plasty. D = defect.

b

4
3

3

D
1

1

2

4

2

c

4
2

3

1

Rhomboid Flap
(Figs. 3.24–3.27)
The rhomboid flap described by Limberg (1967) is
useful for reconstructing temporal or cheek defects
(Fig. 3.24b, c and Fig. 3.25; see also Fig. 8.13). A simi-

lar flap was described by Dufourmentel (1962)
(Figs. 3.26 and 3.27).

28

3 Coverage of Defects

a

b

c

Turnover Flap
(Fig. 3.28)
Turnover flaps can be used for nasal reconstruction,
especially in the alar area (see Figs. 5.37, 5.39, 5.46).
They can also be designed as island flaps (see Fig. 5.45)
and are useful for closing a tracheostoma (Fig. 3.28).
Tubed Pedicle Flap (Bipedicle Flap)
(Fig. 3.29)
The tubed flap or tubed pedicle flap is generally
designed as a delayed bipedicle flap (Fig. 3.29a).
Transfer is delayed for ~3 to 4 weeks, to promote the
development of a central vascular supply. First the
flap is cut with a 5:1 or 6:1 length-to-width ratio
(Fig. 3.29a) and tubed, preferably by sewing epithelium to epithelium. The proximal end of the flap is
preserved as a nutrient pedicle for the “long flap.”
The defect below the tube can be mobilized and
closed by direct suture (Fig. 3.29b). After 3 to 4
weeks, the distal end of the bridge segment is
clamped off with a thin rubber tube (Nelaton catheter). If livid discoloration occurs, the catheter is

a

b

c

d

RSTL

Fig. 3.28a–c Turnover flaps are
used for tracheostoma closure,
closing a tracheal groove, or reconstructing alar defects (see Fig.
5.39) .
a A flap of appropriate size is outlined lateral to the tracheostoma
and dissected to its margin . Skin
triangles are excised above and
below the defect and are discarded . The tracheostoma margin
on the opposite side is freshened .
b The flap is hinged over and sutured to the freshened epithelial
border . The long laryngeal muscles are mobilized to cover the turnover flap (middle layer →).
c A Z-plasty is performed to close
the wound and place the scar in
the RSTLs (dashed red line).

applied only briefly as a tourniquet (Fig. 3.29c). The
tourniquet times are then gradually lengthened each
day until the entire flap receives its blood supply
from the proximal end. Finally, the other end is
detached (Fig. 3.29d) and sutured into the defect.
This process is repeated, and in about 3 weeks the
residual tube flap is removed and insetting is completed (see Figs. 5.17, 5.18, 10.37, 38).

Distant Flaps
Distant Tubed Pedicle Flap
As noted above, tubed pedicle flaps can be transferred to the face from the upper arm or abdominal
skin, if necessary by using a jump-flap technique.
With the development of myocutaneous flaps and
free tissue transfers, however, this technique is rarely
used today.

Myocutaneous and Myofascial Flaps
(see Figs. 12.1–12.3)

D

Fig. 3.29a–d Delayed transfer of a
tubed bipedicle flap (see text).
a The bipedicle flap is raised and its
bridge segment is tubed . The
donor defect is closed .
b Appearance after closure of the
defects .
c About 3 weeks later, the distal
end of the bridge segment is
clamped off with a Nelaton catheter and clamp .
d The distal end of the flap is detached and inset into the defect. In
a second operation 3 weeks later,
the residual tube is divided, insetting at the recipient site is completed, and the unused portion of
the flap is returned or discarded
(see Fig. 10.37) .

Special Part

31

II Coverage of Defects in Specific Facial
Regions
For smaller facial defects, an attempt is made to
achieve coverage by means of flap advancement or
local flaps (Plate 1). Keep in mind that these flaps
should be placed in RSTLs whenever possible (see p.
9).
If flaps cannot be obtained from the immediate
vicinity of the primary defect, regional flaps are used.
These are larger flaps involving the movement of tissue somewhat more distant from the recipient site.
The classic “regional flaps” from the neck and chest
are no longer in common use. For the most part they
have been replaced by myocutaneous island flaps
(see p. 213) and free flaps. Even the classic “distant
flaps,” transferred as tubed flaps from the chest or
abdomen over a period of weeks or months, are very
rarely used today and have been replaced by myocutaneous flaps and free tissue transfers with microvascular anastomosis (see pp. 221 and 227).
Small facial defects can be excised and reconstructed with small flaps using a technique that will
place the scars as close to the RSTLs as possible (see
Fig. 2.8a and Plate 1).

Plate 1 Various small flaps in the face and forehead (dashed red lines: RSTLs) (see Fig. 5.2).

33

4

The RSTLs run along the forehead and are perpendicular to the frown lines in the glabellar area (see Fig.
2.8a). Forehead defects up to 3.5 cm in size, especially
when near the midline, can be closed by mobilizing
the surrounding tissue. Primary closure can be facilitated by making parallel or perpendicular incisions in
the galea. Small defects can be managed with various
advancement, rotation, and transposition flaps (see
Figs. 3.1–3.27) and Z-plasties (see Figs. 2.15–2.18).
Wedge-Shaped Defects
(Fig. 4.1)
Wedge-shaped midline defects that are based on the
glabella (Fig. 4.1a) or frontal hairline (Fig. 4.1b) can
a

b

a

b

a

b

be closed primarily by making an incision above the
eyebrow or along the hairline and mobilizing the

H-Flap

(Fig. 4.2)
The H-flap is suitable for defects ~4 cm wide. Incisions
are made along the eyebrow and hairline, extending
through all layers in their lateral portions. The inferior
Burow’s triangles are placed near the eyebrow to preserve the frontal branch of the superficial temporal
artery. The brow portion of the flap should be
anchored to the periosteum, to avoid eyebrow distortion. As a rule, scars are no longer visible by 6 months
to 1 year after surgery. A visible midline scar can be
revised with the broken-line technique, or dispersed
Fig. 4.1a, b
a Wedge-shaped defect in the
forehead with an inferior base . An
incision is made above the browline, and Burow‘s triangles are
excised just lateral to the brow
(see Fig. 4.2) . The forehead skin is
mobilized in the direction of the
arrows. A Z-plasty (red line) can
be used to disperse the scar .
b For a superiorly based defect, an
incision is made ~1 to 1.5 cm
behind the hairline. Lateral
Burow‘s triangles are excised.
Fig. 4.2a, b H-flap (bilateral
a For a midline forehead defect over
4 cm wide, an incision is made
above the eyebrow and below the
hairline. Lateral Burow‘s triangles
are excised on the hairline and
just behind the eyebrow, to avoid
cutting the frontal branch of the
superficial temporal artery . The
midline scar can be dispersed
with a Z-plasty (red line).
b All defects are closed .
Fig. 4.3a, b Double rotation flap.
An elliptical forehead defect is covered by incising and rotating the
forehead skin and closing all defects .
Again, a Z-plasty can be used to disperse the scar .

34

V

Double Rotation Flap
(Fig. 4.3)
A double rotation flap can be used to close larger
midline and paramedian defects in the forehead.
Again, the scars are located principally along the eyebrow and hairline (Fig. 4.3b).
Soft-tissue expansion can also be used for the primary closure of large midline defects (Fig. 4.4).
(Fig. 4.5)

Fig. 4.4 Use of a tissue expander with a volume of ~100 cm3 .
V = valve for injecting sterile saline solution into the expander.

and 2.15). Smaller defects can be managed with a
Burow's U-advancement on one side (Fig. 4.2a).
a

a

A wedge-shaped lateral forehead defect can be closed
by making a long incision behind the frontal hairline,
widely mobilizing the forehead skin, and rotating the
skin into the defect. A dog ear is excised at the pivot
point in the central forehead, and the wound is closed
(Fig. 4.5b).
Similarly, wedge-shaped defects in the lateral forehead can be covered by a modification of the Esser
cheek rotation flap (Fig. 4.6). Burow's triangles are
excised below the earlobe and on the neck, to close the
secondary defect. In the area of the zygomatic arch, the
flap should be carefully dissected on the subcutaneous
plane, to avoid damaging the temporal branch of the
facial nerve, which is very superficial in that area.
Other options for covering lateral forehead defects
are described in the section on reconstructing cheek
defects (Chapter 8, see Figs. 8.10, 8.16, 8.19, 8.22, 8.24).
defect closed with a rotation flap .
a The flap incision is placed ~3 to
4 cm behind the hairline (see Fig.
5.48a, b) .
b The primary defect is closed . A
Burow‘s triangle is excised at the
pivot point (this may be postponed, owing to risk of flap
necrosis) .

b

b

defect closed with an Esser cheek
rotation flap .
a Cheek rotation with Burow’s triangles .
b Closure of all defects. Z-plasty
(red line) can be added to disperse the scar (see Fig. 2.8, Fig.
8.1) .

35

5

Nasal Region

esthetic units of the nose (see p. 15 and Fig. 2.20b, c).

Glabella and Nasal Root
(Figs. 5.1–5.9)

(Fig. 5.1)

A simple U-shaped advancement flap can be used to
cover smaller defects in the area of the glabella and
upper nasal dorsum (see p. 21). Burow’s triangles are
excised just above the eyebrow, resulting in unobtrusive scars.

Trapezoidal rotation flaps are useful for reconstructing defects of the upper nasal dorsum (Fig. 5.2a, b)
and canthal area (Figs. 5.3–5.6). The flap geometry
corresponds to a V-Y advancement, and the secondary defect is closed by mobilizing the surrounding
skin (Figs. 5.2b, 5.3, 5.4). Because these flaps receive
a good blood supply from the supratrochlear artery
on one side, the pedicle can be kept relatively thin,
allowing for good mobilization and downward rotation of the flap.

from the glabella, used to reconstruct a defect in the superior nasal
dorsum .
a Burow’s triangles are located just
above the eyebrows .
b Appearance after closure of all
defects (see Fig. 3.2) .

a

b

a

b

Fig. 5.2a, b Trapezoidal V-Y
5.4) .

a

b

Figs. 5.3a, b Modification of the
V-Y advancement (see Fig. 5.4) .

36

5 Nasal Region

b

a

c

with a Z-plasty .
a, b Outline, large tumor at the
nasal root .
c, d Closure of the defect after
tumor excision . An incision
near the eyebrow and mobilization of the skin of the forehead allows primary closure .
e, f Result 1 year after reconstruction .

d

f

e

a

b

Fig. 5.5a, b Closure with a
small transposition flap .

a

b

Fig. 5.6a, b Closure with a
bilobed flap (see Fig. 5.8) .

Glabella and Nasal Root
a

37

Fig. 5.7a–f Sliding flap with a
lateral subcutaneous pedicle (see
p . 22) .
a Outline of the flap on the left
side .
b Closure of all defects .
c Superiorly and inferiorly merged
sliding flap to close the defect at
the right lateral nasal root .
d Upper sliding flap on the left
side .
e Results after reconstruction .
f One year after reconstruction .

c

b

d

f

e

Sliding Flap

(Fig. 5.7)

The sliding flap of Barron and Emmet (1965), which
has a lateral subcutaneous pedicle (see p. 22 and
Figs. 3.11–3.14), has proven useful for reconstructing
defects located more in the upper lateral portion of
the nasal bridge. Besides a simple transposition flap
(Fig. 5.5), a specially designed V-Y advancement flap
(Fig. 5.3) or V-Y advancement with a Z-plasty (Fig.
5.4) can be used.

38

5 Nasal Region

a

b

d

e

f

g

Nasal Dorsum
(Figs. 5.8–5.12)
Because the skin of the nasal dorsum is very tight,
only relatively small defects extending across the
dorsum can be closed by mobilizing the surrounding
skin. A great many defects in this area can be closed
with local tissue transferred from above or from the
side. It should be noted, however, that the skin of the

c

Fig. 5.8a–g
Different bilobed
flaps, superiorly or
inferiorly based .
a, b Superiorly
based bilobed
flaps for the reconstruction of the
dorsum and the
lateral nose .
c The flaps are rotated into the
defect .
d Result after 1 year .
e Superiorly based
bilobed flaps on
the right side . The
defect is closed .
f Result .
g Inferiorly based
bilobed flap to
recover a defect
on the dorsum
(distortion of the
lower eyelid
should be avoided!) .

cheek and forehead is considerably thicker than the
dorsal nasal skin.

Bilobed Flap

(Fig. 5.8)

Superiorly or inferiorly based bilobed flaps have
proven excellent for the reconstruction of defects in
the nasal dorsum and sidewall (Fig. 5.8; see pp. 25,

Nasal Dorsum

a

b

39

c

Fig. 5.9a–c Island flap based on the supratrochlear artery (Converse 1977).
a The flap is outlined, and subcutaneous dissection is perforb The bridge of skin between the flap and defect is undermimed without vascular injury.
ned, and the island flap is pulled through.
c Closure of all defects .
a

b

Fig. 5.10 Trapezoidal V-Y
reach the nasal tip; see Fig. 5.14) .

26 and Fig. 3.23). Both small and larger defects can be
managed in this way. The first lobe of the flap is
moved into the primary defect, the second lobe is
moved into the defect created by the first lobe, and
the other secondary defect is closed by cheek mobilization (Fig. 5.8a, b). The angle between the primary
defect and first lobe should approximately equal the
angle between the first and second lobes, and all the
angles should be 90° or less if possible. Larger angles
lead to greater torsion and a bulkier dog ear at the
pivot point of the flap (see pp. 25, 26 and Figs. 3.22
and 3.23). If the transfer creates a relatively large
cheek defect, care should be taken that the closure
does not distort the lower eyelid. For this reason, the
subcutaneous tissue of the lower wound margin is
usually attached to the periosteum of the upper
wound margin after the cheek has been mobilized.

Island Flap

(Fig. 5.9)

The island flap described by Converse (1977), based
on one or both trochlear arteries, is also useful for
reconstructing defects in the nasal dorsum (Fig. 5.9).
The bridge of skin between the island flap and the primary defect can be partially or completely divided if
the flap shows livid discoloration because of excessive
pressure on the pedicle. This flap can also been taken
more laterally based on one supratrochlear artery.

Rieger Flap

(Fig. 5.10)

The trapezoidal Rieger flap (Fig. 5.10) is another
option for reconstructing dorsal nasal defects (see
also Figs. 5.2, 5.3).

40

a

5 Nasal Region

b

c

Fig. 5.11a–c Nasolabial flaps (Cameron 1975) used to reconstruct a full-thickness defect.
a One nasolabial flap (left side) is de-epithelialized in the septal
b A second nasolabial flap (right) is used for cover.
area to reconstruct the lining .
c Closure of all defects .

a

b

d

e

c

Fig. 5.12a–e Reconstruction of a
defect of the lateral nose and dorsum
with a median forehead flap inner lining
(with a full-thickness free skin graft).
a, b Outline .
c, d Closure of the defects .
e Results after 2 years .

Nasal Dorsum

a

d

Fig. 5.13a–h Various designs of the
bilobed flap .
a, b Inferiorly based bilobed flaps.
c, d Closure .
e–h Various designs of the bilobed flap (see
Figs. 3.22 and 3.23) .

b

41

c

e

f

g

h

Nasolabial Flap

Nasal Tip

Cameron (1975) suggested using two nasolabial flaps
to reconstruct full-thickness nasal defects. The first flap
(Fig. 5.11a, b) is swung into the defect with the epithelial side inward, after first removing the epithelium
from the area that will overlie the septum. The second
flap is then used for cover (Fig. 5.11c). One nasolabial
flap is sufficient for reconstructing a two-layer defect.

While small defects in the nasal tip area can be
reconstructed with local flap transfers, larger defects
that extend to the ala and columella require the use
of median forehead flaps or the relatively difficult
frontotemporal flap described by Schmid and Meyer
(1962)(see Figs. 5.17 and 5.18).

(Fig. 5.13)

If a large defect of the nasal flank cannot be adequately covered with a bilobed flap (see Fig. 5.8), the

The nasal tip area can be reconstructed using bilobed
flaps that are based inferiorly (Fig. 5.13a), laterally
(Fig. 5.13e), or superiorly (Fig. 5.13g). The scars
should be placed approximately in the RSTLs. If the
flaps are sufficiently large and mobile, a defect in the

(Fig. 5.11)

(Fig. 5.12)

(Figs. 5.13–5.17)

Bilobed Flap

42

5 Nasal Region

a

b

c

d

2

1

Fig. 5.14a–f Various designs of
advancement flaps used to reconstruct the dorsal nasal skin (see
Figs. 3.9, 5.10) .
a–d Long Rieger flap
(see Fig. 5.10) .