Locoregional Flaps for the Reconstruction of Midface Skin Defects: A Collection of Key Surgical Techniques

Abstract

Background: The reconstruction of midface skin defects represents a challenge for the head and neck surgeon due to the midface's significant role in defining important facial traits. Due to the high complexity of the midface region, there is no possibility to use one definitive flap for all purposes. For moderate defects, the most common reconstructive techniques are represented by regional flaps. These flaps can be defined as donor tissue with a pedunculated axial blood supply not necessarily adjacent to the defect. The aim of this study is to highlight the more common surgical techniques adopted for midface reconstruction, providing a focus on each technique with its description and indications.

Methods: A literature review was conducted using PubMed, an international database. The target of the research was to collect at least 10 different surgical techniques.

Results: Twelve different techniques were selected and cataloged. The flaps included were the bilobed flap, rhomboid flap, facial-artery-based flaps (nasolabial flap, island composite nasal flap, retroangular flap), cervicofacial flap, paramedian forehead flap, frontal hairline island flap, keystone flap, Karapandzic flap, Abbè flap, and Mustardè flap.

Conclusions: The study of the facial subunits, the location and size of the defect, the choice of the appropriate flap, and respect for the vascular pedicles are the key elements for optimal outcomes.

Keywords: head and neck reconstruction; midface locoregional flaps; midface skin defects; pedunculated flaps.

Figure 1

The bilobed flap with its geometrical drawing. Red zone indicate the skin defect, dotted lines indicate cuts, blue lines are geometric landmarks, and yellow arrows indicate flap shifts.

Figure 2

Rhomboid flap with angles and incision lines.

Figure 3

Facial-artery-based flap: (A), nasolabial flap, with evidence of the facial artery as the pedicle; (B), retroangular flap, with evidence of angular artery as the pedicle, the grey shade indicates the subcutaneous tunneling; (C), island composite nasal flap, with exposure of the procerus muscle.

Figure 4

Cervicofacial flap. Part of the incision is hidden behind the ear lobe. During the dissection, a deep-plane incision is needed to permit the advancement of the flap. The skin has been marked with points A and B to show the incision’s advancement.

Figure 5

Paramedian forehead flap. The A’ point represents the pivotal point for the flap rotation. The supratrochlear artery is shown as the pedicle of the flap.

Figure 6

The frontal hairline island flap, with evidence of the vascular pedicle; the grey shade indicates the subcutaneous tunneling.

Figure 7

The keystone flap.

Figure 8

The Karapandzic flap: two Burow triangles are shown. The labial artery pedicle is indicated.

Figure 9

The Abbè flap: point A’ is rotated and inserted in the upper lip, becoming point A”. The branches of the labial artery are indicated.

Figure 10

The Mustardè flap: the A’ point is rotated to fill the skin gap till the A” point is reached.

Figure 11

Gonzales-Ulloa aesthetic subunits of the face. From top to bottom: frontal, temple, periorbital, nasal, zygomatic, infraorbital, upper lip, lower lip, mandibular, and chin [4].