Disclosures Genentech Surgical Advisory Board Advanced Facial - PowerPoint PPT Presentation

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 Beauty and Perception • 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 3 1

Facial Subunits Subunit Principle Menick, FW; Nasal Reconstruction, PRS 125: 138e, 2010 5 6 Why the subunit principle? Subunit Principle 7 8 2

Subunit Skin Graft Paramedian Forehead Flap 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 9 10 Forehead flap Internal Lining Defects Menick, FW; Nasal Reconstruction, PRS 125: 138e, 2010 11 12 3

Nasolabial Flaps Nasolabial Flaps 13 14 Internal lining 3 Stage Forehead Flap 15 16 4

3 Stage Forehead Flap 3 Stage Forehead Flap 17 18 Total Rhinectomy Recurrent Melanoma 19 20 5

Vascularized Nasal Lining Vascularized Nasal Lining 21 22 Vascularized Nasal Lining Vascularized Nasal Lining 23 24 6

What makes for a good facial Vascularized Nasal Lining 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 25 26 Skin Flaps with Similar Sun Exposure Skin Color Match 27 7

Skin Color better with skin grafts Vascularized Fascia Lata 29 30 Fascia Lata for Scalp Reconstruction 31 32 8

Vascularized Fascia Lata Contour Restoration 33 34 Adipofascial Contour Restoration Creative Scar Placement 36 9

Prese Prese ntatio ntatio Creative Scar Placement Support of Local Structures 39 40 10

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Avoidance of Contracture Support of Local Structures 45 46 Subunit Principle 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 47 48 12

Conclusion Temporalis Myoplasty • 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 49 50 Thank you for your attention 51 13