Disclosures Genentech Surgical Advisory Board Advanced Facial - - PowerPoint PPT Presentation

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Disclosures Genentech Surgical Advisory Board Advanced Facial - - PowerPoint PPT Presentation

Oct 10, 2022 286 likes •424 views

Disclosures Genentech Surgical Advisory Board Advanced Facial Reconstruction UCSF Head and Neck Course P. Daniel Knott, MD FACS November, 2014 Director Facial Plastic and Reconstructive Surgery UCSF Medical Center 2 Overall Paradigm

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Advanced Facial Reconstruction

  • P. Daniel Knott, MD FACS

Director Facial Plastic and Reconstructive Surgery UCSF Medical Center

UCSF Head and Neck Course November, 2014

Disclosures

  • Genentech Surgical Advisory Board

2

Overall Paradigm

  • Assume that patients want to look normal
  • Normal defined by

– Regional subunits – 3-D contour – Color match – Dynamic movement – Symmetry – Scar camoflauge

  • Build on a stable platform
  • Use delay techniques to enhance vascularity
  • Let each move/operation prepare for the next
  • If your patients are sick, opt for the simple option

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Beauty and Perception

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2 Facial Subunits

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Menick, FW; Nasal Reconstruction, PRS 125: 138e, 2010

Subunit Principle

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Why the subunit principle?

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Subunit Principle

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3 Subunit Skin Graft

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Paramedian Forehead Flap

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  • Fig. 4. The vertical paramedian forehead flap is centered over the supratrochlear

vessels and is richly perfused by a random, axial, and frontalis muscle blood supply. (From Menick F. Nasal Reconstruction: Art and Practice. New York: Elsevier, 2008.) Menick, FW; Nasal Reconstruction, PRS 125: 138e, 2010

Forehead flap

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Internal Lining Defects

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Menick, FW; Nasal Reconstruction, PRS 125: 138e, 2010

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4 Nasolabial Flaps

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Nasolabial Flaps

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Internal lining

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3 Stage Forehead Flap

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5 3 Stage Forehead Flap

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3 Stage Forehead Flap

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Recurrent Melanoma

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Total Rhinectomy

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6 Vascularized Nasal Lining

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Vascularized Nasal Lining

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Vascularized Nasal Lining

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Vascularized Nasal Lining

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7 Vascularized Nasal Lining

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What makes for a good facial reconstructive outcome?

  • 1. Good skin color match
  • 2. Contour restoration
  • 3. Creative scar placement
  • 4. Support of local structures (nose, lips, orbit.

. . )

  • 5. Avoidance of contracture
  • 6. Subunit principle
  • 7. Restore movement

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Skin Color Match

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Skin Flaps with Similar Sun Exposure

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8 Skin Color better with skin grafts

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Vascularized Fascia Lata

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Fascia Lata for Scalp Reconstruction

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9 Vascularized Fascia Lata

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Contour Restoration

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Adipofascial Contour Restoration Creative Scar Placement

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Prese ntatio Prese ntatio

Creative Scar Placement

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Support of Local Structures

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12 Support of Local Structures

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Avoidance of Contracture

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Subunit Principle

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Temporalis Myoplasty

  • Significant temporal

edema for 2 weeks

  • Muscle may be

“shocked” for several weeks

  • Some degree of posterior

temporal hollowing

  • Voluntary smile may be

achieved

  • Movement usually

approaches 6 mm of upper lip excursion

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13 Temporalis Myoplasty

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Conclusion

  • Assume that your patients want to look normal
  • Accurate color and contour restoration critical

to an acceptable outcome

  • 3 stage fold over forehead flaps for internal

lining

  • Fascia lata microvascular flaps for total nasal

reconstruction and appropriate scalp/forehead reconstructions

  • Use bone and large skin paddles to avoid

contracture

  • Take advantage of subunit principle when

possible

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Thank you for your attention