11Combination Reconstruction

Stanislav N. Tolkachjov

11.1 Introduction

Patients with cutaneous malignancies often have multiple lesions requiring treatment. Single-site surgery is most common; however, the following reasons may lead to treatment of several tumors in a single day: patient preference, difficulty traveling for treatment, and multiple tumors in one cosmetic subunit or anatomic area which would encroach on a potential reconstruction. Treating more than one tumor at a surgical visit allows “cleaning up” the tumor burden on a patient analogous to field therapy treating actinic keratoses. To spare normal tissue, a combination reconstruction or using one reconstruction for multiple defects may be chosen.^1,2,3

Inaccurate estimation of tissue laxity and reservoir can hinder a planned reconstruction and create aesthetically or functionally unsuitable results. This is often seen when overestimating the mobility of inherently tight forehead tissue, working in a scar, or approaching a free margin. Sometimes, a well-designed flap fails to close the defect. Even seasoned surgeons have elevated a large flap and realized it just won’t reach. In these cases, a comfort level with combination reconstructive techniques may improve outcomes.

11.2 Combination of Primary and Graft Reconstruction

As primary or linear repairs are commonly used reconstructive options, they should be the first reconstructive consideration after second intention. While the 3:1 length-to-width ratio of elliptical excisions with 30-degree angles of the standing tissue cones is frequently used, certain anatomic sites allow for lengthening or shortening of this ratio and widening or “cheating” the vertex angle of the standing tissue cones. For example, the hairless triangle of the lip, the medial canthus, and the back often allows for shortening of the excision and widening the vertex angle. However, ellipses on the nasal dorsum and columella, the scalp, the vermilion lip, and the helical rim are often extended past the 3:1 ratio, with angles that are even more acute, in order to lengthen the incision over a curved surface for a smooth transition and avoid a pucker.

In combination reconstruction, this extension of an ellipse allows for harvesting a graft without creating a new incision. Burow’s grafts are full-thickness skin grafts (FTSG) obtained from adjacent tissue from a standing cone of a primary repair, allowing for a better color, thickness, and texture match when used for adjacent tissue reconstruction.^4–7 Traditionally, they are used on the nasal dorsum or tip with the proximal nose closed primarily providing the grafted tissue distally.^8,​9 However, they can be used in almost any location. In addition, FTSG from other locations can be used in combination with primary repairs.

The key points of using Burow’s grafts or FTSG in combination with primary reconstructions are:

1.Determine the appropriate tissue properties for the graft site.

2.Determine if the reservoir available in the standing tissue cone is sufficient for the defect after accounting for partial closure of the defect with a primary reconstruction.

3.If a unilateral or bilateral Burow’s grafts do not allow for sufficient tissue, FTSG may be harvested from a matching tissue reservoir (retroauricular, preauricular, conchal bowl, supraclavicular, inner arm, and femoral canal) depending on the amount of tissue needed.

4.Don’t discard tissue until the reconstruction is finished.

5.Don’t harvest the graft until you determine the area needed to be grafted.

6.Extend the primary repair from which a Burow’s graft may be harvested where an extended incision may best heal (inferior curvature of the cheek as opposed to zygoma, proximal nasal dorsum as opposed to distal nose).^8,​9

7.Consider tissue match (thickness, color, texture, hair density, pore density).

8.Suturing from graft to the surrounding base and “setting in” the graft helps limit pincushioning.

Anatomic examples will be discussed in the following text.

11.2.1 Arm/Hand

The dorsal hand or large forearm defects are great for FTSG/primary repair combinations. While granulation, purse string repairs, single arm rotation flaps, O-Z double rotation flaps, and the “Mercedes” flap are used in these locations, Burow’s grafts offer an acceptable reconstruction, especially on tight and often atrophic skin.¹⁰ If the defect is too large to use a Burow’s graft without significant tension, it may be prudent to repair much of the defect primarily and use a supraclavicular or axillary upper arm FTSG to close the remaining part of the defect.

11.2.2 Temple

Horizontally and vertically oriented primary repairs, rotation flaps, and advancement flaps are typically used to reconstruct the temple. While FTSG of the forehead often lead to an atrophic appearance, Burow’s grafts of the temple and lateral suprabrow offer an acceptable repair option (Fig. 11.1a–c).

Fig. 11.1 Combinations of full-thickness skin graft (FTSG) and primary linear repairs of the forehead/temple. (a) Defect involving the lateral eyebrow, lateral forehead, and lower temple. (b) Burow’s graft and primary repairs bilaterally and superiorly causing slight elevation of the brow. This is often called a “Mercedes” flap when a Burow’s graft isn’t used. The brow elevation settles back to baseline within weeks to months of the repair. (c) Four-month follow-up with settling of the eyebrow and continued fading of the FTSG.

11.2.3 Cheek

Primary curvilinear reconstruction or flaps are used on the cheek. In instances when a primary repair may not close the defect without significant tension on the oral commissure or a flap is unnecessary, a Burow’s graft may be used.

The bilobed transposition and rotation flaps, such as the Mustarde cheek rotation flap, are used to close large infraocular defects. However, this cheek rotation flap is difficult to execute with the goal of avoiding any tension on the lower eyelid and preventing an ectropion. Keys to this flap include oversizing the flap (especially in the temple area), tacking the flap superolaterally from the lateral canthus with sutures to the taught temporal skin in the vertical vector or the orbital rim, and tacking the anterior edge of the flap in a horizontal direction to the medial portion of the defect or the nasal sidewall in order to avoid tension to the eyelid itself. However, if the cheek defect is large and too lateral to allow the secondary defect of the flap to be sewn out, other modifications must be made (Fig. 11.2a). Even with a maximum amount of tissue rotated starting immediately preauricularly and stretching superiorly to the lateral temple, the secondary defect may be too large. An FTSG may be taken out inferiorly from the flap standing tissue cone and purposely sized to close the secondary defect. The keys to the flap are similar to those previously discussed; however, an inferior tissue cone should not be removed until the secondary defect is maximally closed without giving too much pull to the flap or the lower eyelid. Subsequently, a template may be made of the remaining secondary defect and used to outline the area of the inferior standing tissue cone (Fig. 11.2b). This can then be sewn in to close the secondary defect without greatly changing the tissue vectors of the flap (Fig. 11.2c–e). In the case of medial or extremely large defects, a wider rotational arc maximizing the preauricular cheek availability and additional FTSGs may be needed (Fig. 11.2f–n).

Fig. 11.2 Combination of a cheek rotation flap and a back graft. (a) Medium-to-large defect after a melanoma resection involving the infraocular cheek. This defect poses difficulty as the defect is wider than the preauricular cheek reservoir, the area of undermining is at risk for damaging the temporal and zygomatic branches of the facial nerve, and the proximity to the lax lower eyelid puts the patient at high risk for an ectropion. (b) Cheek rotation flap fully undermined bluntly in the mid fat in order to avoid the temporal branch of the facial nerve. A bilobed flap from the retroauricular area may also be used transposing tissue over the ear. (c) Combination of a cheek rotation flap and a full-thickness skin graft (FTSG) (back graft) from the inferior standing tissue cone. Periocular swelling is expected due to numbing and oozing in the thin eyelid skin. The patient was also on an anticoagulant. Drains may be placed in large cheek rotation flaps to allow drainage. Some authors advocate tacking sutures of the cheek flap to prevent hematomas by avoiding dead space; however, this must be done with caution in order to avoid cutting off any blood supply of the flap or collaterals. (d) Anterior view of the patient 4 months from surgery. No ectropion is noted and the eyelid swelling is back to his contralateral baseline. (e) Lateral view at 4 months. Note contraction of the graft site as well as anterior and inferior edges of the flap. An infection caused some unwanted eschar to develop, leaving some areas to granulate. (f) Larger melanoma defect involving the medical buccal and infraocular cheek. Of note, the patient has had a previous Mustarde cheek rotation flap after a melanoma resection by an oculoplastic surgeon with significant scarring at the eyelid causing lid retraction and mild ectropion.

Fig. 11.2 (contiuned) (g) Cheek rotation flap planned. Note the inferomedial standing cone designed in the melolabial fold and the marionette lines. The superior temporal arc is designed higher than the eyelid margin in order to avoid excessive tension and the previous scar. (h) Flap undermined down to the superior platysmal bands with great care taken to avoid injury to the marginal mandibular nerve, parotid duct, or other facial nerve branches. Of note, when prior surgery has been done, it’s important to be extra careful as normal anatomy may be distorted. (i) Key stitches are placed superiorly to the taught temporal skin creating a vertical vector prior to involving the eyelid skin. Tacking to the orbital rim was not done in this case and rarely done by the author. The second set of key sutures is toward the medial portion of the defect with a slight raise to the horizontal vector allowing the eyelid skin to be free of tension and creating a buttress holding up the lower lid. In her case, the left lateral canthal scar was extremely thick, and caution was taken to avoid causing any extra damage. (j) Lateral view of the final repair showing suture lines placed in the nasofacial sulcus extending down to the melolabial fold and the marionette line. A back graft from the inferior standing tissue cone is used; however, a supraclavicular graft was also harvested to close the secondary defect. Dissolving tacking sutures were used at the depth of the grafts. The author prefers to use nylon top sutures in larger facial flaps. No drains were used in this case. (k) Two-month follow-up comparison showing improvement of her previous ectropion. Scar lines are expected to fade over time, especially further out from the contraction phase of the scars. (l) Frontal view of the final repair showing placement of the final suture lines. Note the left oral commissure is drooping due to the lidocaine. (m) Frontal view at 2 months for comparison demonstrating preservation of the melolabial fold, nasal symmetry, and the oral commissure. Slight ectropion from previous surgeries is present; however, the patient thought it was improved from her baseline. (n) Closer view at 2 months demonstrating scar fading and lower lid margin preservation.

Fig. 11.2 (contiuned (m) Frontal view at 2 months for comparison demonstrating preservation of the melolabial fold, nasal symmetry, and the oral commissure. Slight ectropion from previous surgeries is present; however, the patient thought it was improved from her baseline. (n) Closer view at 2 months demonstrating scar fading and lower lid margin preservation.

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