Local flaps are a common reconstructive technique of the head and neck. Consequently, knowledge of fundamental concepts and pitfalls to avoid will reduce surgical complications. These complications result from tension-related, ischemic, hematologic, and infectious causes. This paper seeks to address each of these causes with pearls to accomplish a successful outcome.
Key points
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Local facial flaps are commonly used to reconstruct facial defects.
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Complications of facial flaps include those of tension-related, ischemic, hematologic, and infectious etiology.
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Complication avoidance is achieved through thorough patient evaluation, thoughtful preoperative planning, and meticulous surgical technique.
Introduction
The American Cancer Society estimates an incidence of approximately 3.5 million cases of nonmelanoma skin cancer in the past year. Of these, the majority occur in the sun-exposed head and neck. From 1992 to 2006 the treatment of nonmelanoma skin cancer increased by 77%. Consequently, the number of facial reconstructions performed also increased.
Local flaps are the criterion standard for reconstruction of most cutaneous defects of the face. Complications from these procedures are readily apparent given the sensitive location of the surgical repair. Depending on the area treated, the complication may result in functional and/or aesthetic sequelae.
Complications from local flap reconstruction result from tension-related, ischemic, hematologic, and infectious causes. Such complications may arise intraoperatively or may not occur until the early or late postoperative phases. Prevention of complications is based on the surgeon’s understanding of the fundamental principles of facial reconstruction. Selection of the appropriate technique is critical to a successful outcome. The mutual goal is a balanced functional and aesthetic result that is pleasing to the patient as well as the surgeon. This result is accomplished through a systematic, comprehensive analysis of defects. The surgeon must consider the following questions when developing the reconstructive plan :
- 1.
Which surrounding landmarks must not be distorted or subject to tension by the reconstruction?
- 2.
Where is the vector of tension created during flap inset as well as throughout the normal healing process?
- 3.
What region of tissue recruitment offers maximal laxity?
- 4.
How are the relaxed skin-tension lines and borders of aesthetic subunits oriented?
- 5.
Is the blood supply of the designed flap adequate?
Introduction
The American Cancer Society estimates an incidence of approximately 3.5 million cases of nonmelanoma skin cancer in the past year. Of these, the majority occur in the sun-exposed head and neck. From 1992 to 2006 the treatment of nonmelanoma skin cancer increased by 77%. Consequently, the number of facial reconstructions performed also increased.
Local flaps are the criterion standard for reconstruction of most cutaneous defects of the face. Complications from these procedures are readily apparent given the sensitive location of the surgical repair. Depending on the area treated, the complication may result in functional and/or aesthetic sequelae.
Complications from local flap reconstruction result from tension-related, ischemic, hematologic, and infectious causes. Such complications may arise intraoperatively or may not occur until the early or late postoperative phases. Prevention of complications is based on the surgeon’s understanding of the fundamental principles of facial reconstruction. Selection of the appropriate technique is critical to a successful outcome. The mutual goal is a balanced functional and aesthetic result that is pleasing to the patient as well as the surgeon. This result is accomplished through a systematic, comprehensive analysis of defects. The surgeon must consider the following questions when developing the reconstructive plan :
- 1.
Which surrounding landmarks must not be distorted or subject to tension by the reconstruction?
- 2.
Where is the vector of tension created during flap inset as well as throughout the normal healing process?
- 3.
What region of tissue recruitment offers maximal laxity?
- 4.
How are the relaxed skin-tension lines and borders of aesthetic subunits oriented?
- 5.
Is the blood supply of the designed flap adequate?
Evaluation of the patient
Avoidance of complications begins in the preoperative period with a thorough patient history and physical examination. A standardized medical screening questionnaire is often useful in identifying pertinent medical history that may predispose a patient to otherwise unanticipated complications. Hypertension, diabetes, liver failure, immune suppression, renal failure, inherited blood dyscrasias, inflammatory skin conditions, history of hypertrophic scarring/keloids, and prior radiation exposure can all negatively affect the surgical result.
Many surgeons elicit a history on prescription medications including nonsteroidal anti-inflammatories and antiplatelet therapies, given their known effects on coagulation. However, herbal supplements are sometimes overlooked. Popular supplements, including ginkgo biloba, garlic, ginger, ginseng, feverfew, vitamin E, licorice, bilberry, German chamomile, red clover, poplar, meadowsweet, willowbark, tamarind, turmeric, danshen, dong quai, alfalfa, goldenseal, and green tea, should receive special consideration given their effects on the clotting cascade.
Use of alcohol and tobacco increases the risk of complications following surgery. Heavy alcohol use affects the hepatic system, which in turn affects both the clotting cascade and drug metabolism. Tobacco use has a well-documented detrimental effect on tissue perfusion. Nicotine adversely affects tissue perfusion while carbon monoxide lowers cutaneous oxygenation. Heavy smokers (greater than 1 pack per day) have a 3 times higher incidence of postoperative flap necrosis.
Tension-related complications
Achieving a tension-free closure is fundamental to surgical success. Excess tension may serve as the catalyst for development of ischemic, hematologic, and infectious complications. Placement of incisions parallel to relaxed skin-tension lines and along aesthetic subunit borders allows for maximal extensibility and camouflage of the resultant scar.
In addition, tension must not distort the immobile surrounding landmarks. The nose, eyelids, and lips are particularly susceptible to this distortion ( Figs. 1–3 ). With respect to the nose, the superior vector of alar retraction and tip twisting is well recognized. However, there remains an additional perpendicular tension vector requiring consideration. As the wound bed contracts, it tends to draw the flap medially or intranasally. This problem is significant for reconstructions overlying the ala or supra-alar crease, as a medial displacement in this region will tend to narrow the nasal valve and may lead to iatrogenic nasal obstruction.
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