Facial Reconstruction The Sublime Beauty of Normal P. Daniel - PDF document

Facial Reconstruction The Sublime Beauty of Normal P. Daniel Knott, MD FACS Facial Plastic and Reconstructive Surgery Disclosures • Genentech Surgical Advisory Board 2 1

Introduction • Scale of the problem • Mohs Technique and outcomes • Review standard reconstructive techniques • New pearls for reconstruction 3 What do you do? 4 2

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7 Mohs Micrographic Surgery 8 4

5 Year Recurrence rates: Primary BCC 1989 meta-analysis of studies performed since 1945 Treatment Modality 5 Year Recurrence Rate Mohs Micrographic Surgery 1.0% Surgical Excision 10.1% Radiation Therapy 8.7% ED&C 7.7% Cryosurgery 7.5% J Dermatol Surg Oncol. 1989 Mar;15(3):315-28. Long-term recurrence rates in previously untreated (primary) basal cell carcinoma: implications for patient follow-up. Rowe DE, Carroll RJ, Day CL Jr. 9 5 Year Recurrence rates: Recurrent BCC 1989 meta-analysis since 1945 Treatment Modality 5 Year Recurrence Rate Mohs Micrographic Surgery 5.6% Surgical Excision 17.4% Radiation Therapy 9.8% ED&C 40.0% Cryotherapy 13.0% J Dermatol Surg Oncol. 1989 Mar;15(4):424-31. Mohs surgery is the treatment of choice for recurrent (previously treated) basal cell carcinoma. Rowe DE, Carroll RJ, Day CL Jr. 10 5

11 Vismodegib: Effectiveness 12 6

Vismodegib: Adverse Reactions 13 Anatomic distribution 14 7

Feeling The Heat 15 Sun Exposure 16 8

Facial Subunits Menick, FW; Nasal Reconstruction, PRS 125: 138e, 2010 17 Paramedian Forehead Flap Menick, FW; Nasal Reconstruction, PRS 125: 138e, 2010 18 9

Paramedian Forehead Flap Kishi K, et al. Alternative 1-Step Nasal Reconstruction Technique, Arch Facial Plast Surg. 2012;14(2):116-121 19 Paramedian Forehead Flap Kishi K, et al. Alternative 1-Step Nasal Reconstruction Technique, Arch Facial Plast Surg. 2012;14(2):116-121 20 10

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23 Forehead Flaps 24 12

Internal Lining Defects Menick, FW; Nasal Reconstruction, PRS 125: 138e, 2010 25 3 Stage Forehead Flap 26 13

Cervicofacial Flaps • Subplatysmal elevation • Back-cut made as low as necessary for adequate rotation • Very useful for color-matched skin • Careful patient selection for 27 Cervicofacial Flaps 28 14

Cervicofacial Advancements 29 Cervicofacial Flaps 30 15

31 Nasolabial Flaps • Used primarily when defect is limited to the ala • Scar is well hidden in nasolabial fold • Preference for females • Preference for inferiorly based • Usually performed in 2 stages 32 16

Nasolabial Flaps 33 Nasolabial Flaps 34 17

35 Lip Reconstruction • Maintain neural input • Maintain red lip, vermillion border, and cutaneous contour and color match • Maintain symmetry of upper and lower lip relative lengths • Subunit principle with reconstructive incision planning • Maintenance or reconstruction of the commissure • Absolute preservation of lip material 18

Choices Less than 50% without commissure involvement = Abbe Less than 50% with commissure involvement = Estlander More than 50% of lip absent = Karapandzic More than 75% absent = Free tissue Lip R Lip R 19

Lip R Lip R 20

V-Y Island Flaps 41 Lip R 21

Lip R Lip R 22

Lip R 46 23

Lip R Lip R 24

Lip R Lip R 25

Lip R Commissure reconstruction Lip R 26

Lip R Lip R 27

Lip R Lip R 28

Lip R Lip R 29

Thank you for your attention 59 30