Making decisions and avoiding complications in skin flaps

247 Pages·2012·743.681 MB·English

by  Friedman, David H(Editor);Saadat, Payam(Editor)

Making Decisions and
Avoiding Complications in
Skin Flaps
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Making Decisions and
Avoiding Complications in
Skin Flaps
David H. Friedman, M.D.
Clinical Professor of Dermatology, Keck School of Medicine of USC
and Private Practice in Northridge, California
Payam Saadat, M.D.
Clinical Professor of Dermatology, Keck School of Medicine of USC
and Private Practice in Los Angeles, California
CRC Press
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Version Date: 20130624
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Dedication
To my ever-patient, loving, and generous wife Laura Schwimmer
David H. Friedman, M.D.
To my mother Giti, father Sion, and siblings Daryoush, Peyman, and Dalia
for their continued love and support
Payam Saadat, M.D.
Contents
Preface viii
1 Repairs by location 1
A Scalp 1
B Temple 2
C Forehead 10
D Eyelids 19
E Bridge of nose 28
F Dorsum of nose 31
G Nasal sidewall 35
H Nasal tip 50
I Nasal ala 73
J Cheek 93
K Lip 105
L Chin 116
M Ear 118
N Non-facial 127
2 Repairs by fl ap 132
A Advancement 132
1 Single 132
2 Double advancement 137
3 Island pedicle 138
4 A-to-T 148
5 Perialar crescentic 152
6 East west 154
7 Jigsaw puzzle 155
8 Helical rim advancement 155
9 Other 157
B Rotation 158
1 Simple 158
2 O-to-Z and Square-to-Z 167
CONTENTS VII
3 Helical rim 169
4 Dorsi-nasal flap 170
5 Other 172
C Transposition 173
1 Rhombic 173
2 Bilobed 195
3 Meilolabial 198
4 Peng 199
5 Other 200
D Interpolation 202
1 Meilolabial 202
2 Paramedian forehead 203
3 Ear 206
E Wedge excision 207
F Complex closures 213
3 Suboptimal results: Avoiding complications 215
4 Surgical pearls 230
5 References 235
Index 237
Preface
Most skin surgery textbooks focus on the fundamentals with lengthy discussions and illustrations on tech-
nique, but are limited on demonstrative clinical photographs. We have found that when we are pondering
the options on how to repair a defect in a particular anatomical location that an atlas with a large number of
clinical photographs showing how various fl aps would look in repairing that particular defect would be
extremely helpful in our decision-making process. The purpose of this atlas is to fi ll that gap. This atlas is
intended for the surgeon who already has a grasp of the fundamentals and mechanics of fl ap repair, but may
need additional ideas on selecting an appropriate fl ap for a given defect. Each example will have a photo-
graph showing the defect and a second showing the repair. When available and/or of educational value,
illustrations of the fl ap or long-term follow-up photos may be used. Throughout the text, we’ve highlighted
in bold text surgical pearls which can help optimize a particular fl ap’s success rate and/or aesthetic outcome
and have also compiled these pearls into an addendum at the end of the book. We have elected to publish
clinical photographs of fl aps only and leave those of primary closure, secondary intention closure, and graft
closure to other sources.
This atlas is divided into three sections. The fi rst section contains repairs organized by location. There-
fore, if the surgeon has a defect on the nasal tip, lip, or eyelid, etc. he/she can go to that chapter and review
the various options that can be used for repairing the defect. Our atlas does not contain an exhaustive list of
all fl aps ever used, but the ones we have successfully used on a routine basis. In some instances we may
express a preference for a particular fl ap in a particular location, but we have found over the years that excel-
lent aesthetic results depend not only on the fl ap chosen, but also the surgeon’s technique. Where one sur-
geon may obtain superb results with a bilobed fl ap another surgeon may not be able to obtain such excellent
results with the same fl ap, but obtain equally excellent aesthetic results with a different fl ap such as an island
pedicle fl ap for the same type of defect. We all seem to have our favorite or workhorse fl aps, but another
purpose of this atlas is to help expand the surgeon’s armamentarium so that he/she does not force the fl ap
they are most familiar with to work in a given defect, but is able to choose a different fl ap that will give
a better aesthetic result.
The second section contains repairs organized by fl ap type. We suspect most of us have seen or read
about a fl ap we have never used and are excited to try it out. In that case the surgeon can choose the fl ap they
would like to try and then see clinical photographs of how it has been used successfully in various types of
defects. For simplicity’s sake we do not differentiate between the various types of rhombic fl aps. We just call
them all rhombic fl aps.
For those of us who teach it is tempting to show only our best results. Our best results show how fl aps
can be put to best use. However, over the years we have found that discussing and showing suboptimal
results may be equally or even more helpful. Therefore, the third section contains clinical photographs of
suboptimal results with a discussion of what we think went wrong and what could have been done differ-
ently to obtain a better result.
Some defects are complex and involve several cosmetic units making them diffi cult to categorize by
anatomic location. In such instances, instead of repeating these photos in multiple chapters (e.g.: tip, ala, and
sidewall), we’ve placed them in the chapter which contains the cosmetic unit that posed the greatest chal-
lenge in closing the defect.
Lastly, the intention of this text is not to showcase results but to present fl ap options for different
defects and anatomic sites. Most of our photos are taken by medical assistants who do not have any photog-
raphy experience and neither of us has a photo studio or professional equipment. As such, the quality and
reproducibility of the photos can vary from picture to picture. In addition, follow-up dates are approximate.
1 Repairs by location
1A Scalp
1A.1 1A.2
1A.3 1A.4
1A.5 1A.6
Figure 1A.1 Post-Mohs micrographic surgery (MMS) defect with an advancement fl ap drawn. Although the repair takes a little
longer to pick out the hairs if the surgical site is left unshaved, the patients are very appreciative that the hair
covers the site postoperatively.
Figure 1A.2 Repair in place. If you don’t shave the area be sure to use a suture color that is easily seen and leave the tails longer
than usual for easy removal.
Figure 1A.3 Post-MMS defect with an O-to-Z fl ap drawn.
Figure 1A.4 Repair in place.
Figure 1A.5 Post-MMS defect with a spiral rotation fl ap drawn. An excellent choice for the scalp vertex.
Figure 1A.6 Repair in place.