B, Auricular cartilage graft used for structural support of ala. Interpolated melolabial flap designed for covering of cartilage graft. The majority of melolabial transposition flaps are designed as a rectangle, parabola, or rhombus. Melolabial transposition flaps used to repair small (2 cm or less) cutaneous defects of the medial cheek may be based superiorly or inferiorly. The width of the skin island should equal the width of the defect at its widest point. To limit this restricting factor, whenever possible, melolabial transposition flaps should be designed to pivot no more than 90°. The subcutaneous pedicle advancement flap in the melolabial region of the face is robust, simple to imple-ment, and accomplished in a single stage. Flap pivots toward midline. Lateral to the crease, the skin of the cheek is loosely attached to the deep muscular fascia and there is an abundance of subcutaneous fat. III. The depth of the incision is carried to the level of the superficial surface of the zygomatic major and levator labii muscles. They also avoid a circumferential scar, which in part accounts for trap-door deformity. A, Defect enlarged to remove peninsula of skin between ala and melolabial fold. 12-3). The nasal-alar unit is highly contoured, has a free margin, and functions as the external nasal valve. The template is positioned so that the medial border of the designed flap lies in the melolabial crease. This movement is in one direction, and the flap advances directly over the defect. When they are used to repair skin defects of the superomedial cheek, melolabial advancement flaps are usually designed by making only one long incision in the melolabial crease and undermining the skin of the fold lateral to the incision (Fig. Current technology with hair epilation lasers allows us to sometimes place a hair-bearing flap into a non-hair-bearing area, but ideally, this can be avoided with judicious planning. 12-4). Adequate function of the nose requires a thin internal layer most appropriately supplied by vascularized mucosa. 12-4). By use of this classification, melolabial flaps may be categorized as pivotal, advancement, and hinge. The fashioned template is placed on the melolabial fold so that the center of the flap is positioned 1 cm above the horizontal plane of the oral commissure. Full-thickness alar »defects are ideally reconstructed with a superiorly based flap as a one-stage proce- c dure using the twisted melolabial flap (24) (Figs. Further subcutaneous undermining of the skin adjacent to the flap is required if puckering of the peripheral facial skin occurs with flap mobilization (see, tissue so that scars will be positioned along aesthetic boundary lines and the defect will more appropriately accommodate the thickness of the advancement flap. This frees the elastic subcutaneous tissue pedicle from its medial and lateral fibrous attachments to the surrounding cheek fat while preserving its vascular supply, which is derived from its deep attachments. The melolabial (nasolabial) flap is a random-pattern local flap based either superiorly or inferiorly along the melolabial sulcus and cheek-nasal sidewall. The superior triangle of skin is minimized to reduce loss of tissue from the upper melolabial fold where the fold is well developed. Blunt and sharp dissection is then carried through the subcutaneous tissue surrounding the skin island, beveling slightly away from the skin island down to the level of the fascia overlying the facial muscles. Texture, due to the relative similarity of the melolabial flap surface to potential reconstructed sites, is typically not an issue, except when considering the prospect of mismatching hair-bearing and non-hair-bearing regions. Melolabial transposition flaps used to repair small (2 cm or less) cutaneous defects of the medial cheek may be based superiorly or inferiorly. This in turn causes the inferior border of the in situ flap to join the anterior border of the defect. As the flap is pivoted and transferred to the recipient site, the medial border of the in situ flap is sutured to the cephalic border of the nasal defect. When this happens, it is extremely difficult to restore the valley to a completely natural contour. Crossing over rather than through the sulcus maintains a perfectly natural alar-facial sulcus, an important facial aesthetic boundary. This movement is in one direction, and the flap advances directly over the defect. Transposition (Figures 5-7) Rhombic (Duformental and Webster modifications) - Bilobed (Zitelli modification) - Z-plasty - Note - Melolabial - Nasofacial IV. Removal of skin from the upper portion of the fold may result in considerable asymmetry of the medial cheeks. The pedicle of fat is freed from the surrounding cheek fat by incising through the borders of the pedicle perpendicular to the surface of the skin. Rotation flaps are pivotal flaps with a curvilinear configuration. The nasal-alar unit is highly contoured, has a free margin, and functions as the external nasal valve. for deep nasal defects, providing thick subcutaneous skin and fat for rebuilding tissue lost in surgery. This hair variation can be used to advantage occasionally, depending upon whether there is a need to bring hair-bearing or hairless skin into a specific defect. As a consequence, the flap must be developed adjacent to the defect, and one border of the defect becomes the leading border of the flap. Since flap design, volume, and size are limited to the redundancy of available anatomy, medial and superior based flaps are limited not only in width (1 to 5 cm, depending on the laxity of the facial skin) but also in length (1 to 12 cm, depending on the vertical height of the face). The flap may be lengthy relative to its width, which facilitates closure of the donor defect without excessive wound closure tension. Interpolated (Figure 8) - Paramedian forehead - Melolabial - Nasofacial V. Free flap Patel and Sykes Local Flap Design and Classification 15 Therefore, there is less risk for development of a hematoma compared with use of other types of flaps. FIGURE 12-4 A, Skin defect of ala. Island flap designed to replace skin peninsula. Split-thickness skin grafts not only are a poor color and volume match usually but also can contractually distort some of the fragile anatomy of the lip, eyelid, or nose. Choosing a flap for facial reconstruction is invariably determined after weighing the options and figuring out what will give you the best possible result at the recipient site with minimal donor site morbidity. Melolabial advancement flaps are not frequently designed with two parallel incisions. Further thinning of the subcutaneous tissue of the undermined leading border of the flap may be performed to create an appropriate thickness match between the border of the flap and the recipient site. As a consequence, the flap must be developed adjacent to the defect, and one border of the defect becomes the leading border of the flap.
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