Zygomatic Flap for Reconstruction of The Lip and Nose

EDITORIAL COMMENT

The editors have no experience with this relatively new flap. Nonetheless, the good anatomic studies would make it an appropriate flap for reconstruction of soft-tissue defects of the upper lip and the nose.

Reconstruction of soft-tissue defects of the upper lip and the nose, especially of the tip and the columella, is still one of the most difficult tasks for a plastic surgeon. Numerous possibilities, such as a composite graft, transposition flaps, and local flaps, have been described in the literature.

INDICATIONS

Although full-thickness skin grafts or transposition flaps may satisfy the requirements of the reconstruction, their aesthetic outcome is often not quite satisfactory. Color match and contour irregularity may be problems in grafts; also, conventional transposition flaps, such as the nasolabial flap, often retain a “bulky” appearance, even many years later (1). However, in many cases, a primary reconstruction with a final good result is not always possible because of the limited advancement. For these reasons, we consider the zygomatic flap as a new and promising approach for a one-stage procedure (2). The donor defect is quite similar to the nasolabial flap and therefore cosmetically inconspicuous. As an island flap, the zygomatic flap offers a big arc of rotation. Usually, there is no destruction of muscle and nerve tissue, and because of the central vessel, the arc of rotation is essentially larger.

ANATOMY

The zygomatic flap is supplied by the cutaneous zygomatic branch, a branch of the facial artery (3). It runs upward over the buccinator muscle and divides into two branches at the major zygomatic muscle’s inferior border. One ascends laterally and branches out in the subcutaneous fatty tissue. The second one continues through the major zygomatic muscle and penetrates the subcutaneous tissue above the muscle, similar to the first branch.

FLAP DESIGN AND DIMENSIONS

The zygomatic flap is an island axial pattern flap, and when properly designed, it can follow naturally existing contour lines, thus respecting and preserving the normal facial topography and leaving the patient with minimal surgical deformity. For the design of the flap, it is very important to mark the origin of the cutaneous zygomatic branch. The measurements based on the auxiliary lines proposed by the authors make the dissection of the vessel’s origin relatively easy (Fig. 41.1).

The point of origin from the facial artery is defined by using the mean-distance calculation of 10 mm lateral from the vertical line and 28 mm below the transverse line. The flap has to be designed directly over the origin of the cutaneous zygomatic branch. The size of the flap has been demonstrated by selective injection of the cutaneous zygomatic branch, indicating the supplied skin territory. The length of the flap is extended from 1 to 1.5 cm distal to the vessel’s origin until the transverse line, for a total length of 4 cm. However, the width of the flap is extended strictly from the nasolabial fold, its medial border, until 2 cm toward the cheek area. The width especially should not be designed too large, to ensure a tension-free wound closure. Because of the presented anastomosis with other cutaneous branches from the facial artery and the infraorbital artery, the maximum potential length reaches to 6 cm (2, 3). In this way, an enlargement of the axial skin flap is possible, and the arc of rotation can be extended by orthograde and retrograde pedicles (Fig. 41.1). Thus, the flap can be designed to abut the ala of the nose, and reconstruction of nasal defects can be achieved without conspicuous scars.

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