Facial Landmark Reconstruction with a Combination of Local Flaps: A Novel Technique for Landmark Destruction

Abstract

Background:

Various methods of landmark reconstruction have been discussed in medical literature, but few describe defects involving the rim of the landmark. For landmark malposition, such as eyelid ectropion, borders are abnormally elongated by scar contracture. The reconstruction should thus restore both the cutaneous defect and the anatomical structure. We suggest the combination of local flaps via end-to-end connection and transposition for facial landmark reconstruction.

Patients:

Ten patients who had facial landmark malpositions caused by scar contractions, and 5 patients who had landmark defects, were successfully treated using this combination flap technique. Among the 15 patients, landmark malposition repairs of the nasal ala, nasal columella, eyelid margin, Cupid’s bow, and eyebrow were performed.

Results:

Most flaps survived without complications; one procedure resulted in the cutaneous tip developing necrosis, which was successfully healed within 2 weeks of conservative treatment. The landmark was reconstructed with aesthetics in mind, and no subsequent scar contracture was observed. After a 6- to 14-month follow-up period, successful landmark reconstruction had been achieved in all 15 patients via a single-stage procedure.

Conclusion:

A combination of local flaps is a viable option for facial landmark reconstruction in selected patients having landmark rim destruction.

Introduction

The face is a complex topographic structure, and facial organs separated by landmarks. Landmark defect and malposition caused by scar contracture can influence both facial aesthetic and function, potentially having a negative effect on the affected person’s quality of life. ¹ For landmark malpositions such as eyelid ectropion, the tissue is stretched and borders are abnormally elongated. Few of the various methods in medical literature describing landmark reconstruction have discussed defects involving the landmark rim. Thus, in this article, we explore a novel technique describing how to combine local flaps using end-to-end connection and transposition of the flaps, for correction of contracture in scar tissue around the nasal ala, nasal columella, eyelid margin, Cupid’s bow, or eyebrow.

Methods

Ethical Statements

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008. Informed consent was obtained from all patients for study inclusion. The international review board of the First Hospital of Shanxi Medical University approved this study.

Surgical Technique

The contracted scar tissue was resected, and 2 opposite flaps were designed along the deformed landmark rim (Figure 1). Development of these 2 flaps released the contracted border, returning it to its anatomical position. If the border had been abnormally stretched, a wedge was resected to restore anatomical length (Figure 2). The distal ends of these 2 opposite flaps were then trimmed and rotated to meet the repositioned border and advanced via end-to-end connection with little tension (Figure 3); a transposition flap was used to correct the resulting defect (Figure 4). The donor area was closed by undermining both borders and reapproximating the tissue in a fashion similar to that seen in a V-Y advancement flap (Figure 5).

Figure 1.

Scar tissue was resected, and the deformed, contracted tissue was released.

Figure 2.

The extended borders were cutoff and shortened when necessary.

Figure 3.

The dislocated tissue was developed along the border of the defect as tissue blocks and rotated in the form of local flaps.

Figure 4.

The flaps were combined in an end-to-end manner to restore the border, and another local flap was used to restore the residual defect and minimize vertical tension.

Figure 5.

The donor area was primarily closed by undermining both borders.

The length and shape of the flaps were designed and trimmed based on the area of the defect. After harvesting, flap perfusion was evaluated based on dermal bleeding from the flap edges. We used 5-0 absorbable thread sutures (Vicryl, Ethicon) for subcutaneous suturing, and 6-0 polypropylene thread sutures (Prolene, Ethicon) to ensure adequate eversion of the skin edges.

The occurrence of necrosis, patient satisfaction, requirement of secondary procedures, and complications was assessed by an independent surgeon. Necrosis was subdivided into superficial necrosis and full-thickness necrosis; wounds resulting from superficial necrosis were able to reepithelialize within 2 weeks, whereas leaving unhealed wounds resulting from full-thickness necrosis would inevitably cause adverse consequences. Patient satisfaction was categorized as dissatisfactory, good, satisfactory, or excellent by the patient. Complications observed included wound infection, erythema, pincushioning, scar contracture, and ectropion.

Results

This particular technique of facial reconstruction was performed on 15 patients with facial landmark deformities or defects. The deformed landmarks included 9 nasal ala, 2 nasal columellae, 5 Cupid’s bows, 3 eyebrows, and 1 eyelid margin. The patient summaries are included in Table 1. Patient age varied, with patients as young as 1, and as old as 63. The average follow-up period was 8.87 months (range: 6-14 months).

Table 1.

Summary of the Cases.

Case no.	Sex/age (years)	Deformed landmarks	Etiology	Elements of reconstruction	No. of local flaps	Flap necrosis	Complications/secondary procedure	Follow-up (months)	Outcome
1	M/57	Rt lower lid	Scar contracture	End-to-end connective flap and a nasolabial flap	3	None	None	12	Good
2	M/63	Cupid’s bow Nasal columella	Scar contracture	End-to-end connective flap	2	None	None	6	Satisfactory
3	M/43	Rt nasal ala	Scar contracture deformity	End-to-end connective flap with conchal cartilage	2	None	None	14	Good
4	F/23	Lt nasal ala	Scar contracture	End-to-end connective flap	2	None	None	6	Good
5	M/13	Cupid’s bow	Scar contracture after cleft lip surgery	End-to-end connective flap	2	1 flap tip superficial necrosis	None	12	Good
6	F/30	Lt eyebrow	Defect after tumor excision	End-to-end connective flap	2	None	None	6	Satisfactory
7	M/62	Rt nasal ala, Nasal columella	Defect after tumor excision	End-to-end connective flap	2	None	None	12	Excellent
8	M/29	Lt nasal ala, Cupid’s bow	Scar contracture	2 sets of end-to-end connective flaps and a nasolabial flap	5	None	None	6	Excellent
9	F/6	Rt nasal ala Cupid’s bow	Traumatic defect	End-to-end connective flap	2	None	None	6	Satisfactory
10	M/25	Rt nasal ala	Scar contracture deformity	End-to-end connective flap	2	None	None	6	Excellent
11	M/1	Rt nasal ala	Natural deformity	Connective flaps	2	None	None	1	Excellent
12	F/20	Rt nasal ala	Scar fissure deformity	Connective flap a with conchal cartilage	4	None	None	6	Excellent
13	F/28	Cupid’s bow	Scar contracture	End-to-end connective flaps	2	None	None	9	Satisfactory
14	M/26	Rt nasal ala	Scar contracture	End-to-end connective flap	2	None	None	14	Excellent
15	F/28	Rt eyebrow	Defect after tumor excision	Connective flaps	2	None	None	6	Excellent

Abbreviations: F, female; Lt, left; M, male; no., number; Rt, right.

Postoperative recovery was uneventful, and a complication was observed in a single patient; superficial necrosis developed at the flap tip, which was healed with 2 weeks of conservative treatment. Primary closures were performed at all donor sites without any complications during healing. No case of hematoma, seroma, wound infection, or dehiscence was observed during the postoperative follow-up period, as well as no serious late-term complications, such as scar contracture or structural collapse. Thus, the flaps provided both tension-free coverage and anatomical structure, without the need to perform a secondary procedure. No patient was unsatisfied with the aesthetic contour, color match, and tissue elasticity of the repair.

Representative Cases

Case 1: Scar Contracture

A 57-year-old man presented with eyelid margin ectropion (Figure 6). We applied the combination flap technique, and the contracted scar was excised. The conjunctival-side tissue was replaced along the eyeball, and the extended eyelid margin was shortened via wedge resection to restore anatomical length (Figure 7). Two advancement flaps were developed along the eyelid margin, and advanced to meet end-to-end with little tension. More resection and shortening of the distal borders of the 2 cutaneous flaps were necessary to prevent ectropion. A superiorly positioned nasolabial flap was developed and transposed to prevent ectropion and replace the residual cutaneous defect. The donor defect along the nasolabial groove was closed directly (Figure 8). The lower eyelid structure was preserved with a combination of 3 local flaps (Figure 9), and although the patient’s postoperative period was uneventful and recontracture did not occur within a year, pincushioning was observed on the medially based flaps.

Figure 6.

Preoperative appearance.

Figure 7.

Two flaps along the margin were developed after scar resection, while the extended lower eyelid margin was cut to the anatomical length.

Figure 8.

The 2 flaps along the margin were connected in an end-to-end manner, and a nasolabial transposition flap was used to replace the cutaneous defect below the eye. The donor defect was closed directly.

Figure 9.

The photograph shows a very pleasing postoperative result at the 12-month follow-up in accordance with the tenets of aesthetic subunit reconstruction.

Case 8: Scar Contracture

A 21-year-old man presented with scar contracture across the rim of the right ala and upper vermilion border, resulting in deformation of the right ala, shortening of the upper lip, and lip ectropion (Figure 10). We designed 2 sets of end-to-end flaps along the alar base and vermilion lip border (Figure 11). An inferiorly positioned nasolabial flap was developed and transposed between the 2 sets of end-to-end combination flaps, and the donor defect was closed directly. The combined use of 5 local flaps improved the appearance of the defect with a satisfactory lengthening of the lip, preserving the critical alar-facial sulcus (Figure 12). No subsequent scar contraction or ectropion was observed at the 6-month follow-up consultation (Figure 13).

Figure 10.

Preoperative appearance.

Figure 11.

After the scar was resected and contracture was released, 2 sets of flaps were connected in an end-to-end manner to reconstruct the alar rim and vermilion cutaneous border. a nasolabial transposition flap was used to restore the tissue defect between them.

Figure 12.

Immediate postoperative appearance.

Figure 13.

Postoperative appearance at the 12-month follow-up.

Case 12: Tissue Defect

A 20-year-old female patient received radiotherapy for nasal lymphoma at the age of 6, leaving a scar fissure through the right nasal ala (Figure 14). Two local flaps were designed along the defect border for reconstruction of the nostril rim via end-to-end connection of the flaps. Conchal cartilage was used to reconstruct the continuity of the lower lateral cartilage in order to prevent retraction of the alar edge (Figure 15). A transposition flap was created and interdigitated above the end-to-end combination flap to reconstruct the alar groove (Figure 16).

Figure 14.

Preoperation appearance.

Figure 15.

After scar resection, 2 flaps along the alar margin were developed and connected in an end-to-end manner to maintain alar continuity, and the transposition flap above was developed to reconstruct the alar groove. Conchal cartilage was used to reconstruct continuity of the lower lateral cartilage.

Figure 16.

Postoperative appearance at the 6-month follow-up.

Diabetes Case (Not Involved in the Study)

A 63-year-old man presented with scar contracture across the nasal columella and Cupid’s bow, causing malposition of the columella and lip (Figure 17). We designed end-to-end flaps along the nasal base, and an anteriorly positioned transposition flap along the upper lip. This, however, led to complications, as the distal section of the combined flap on the upper lip developed necrosis (Figure 18).

Figure 17.

Preoperative appearance.

Figure 18.

Postoperative appearance 14 days after surgery (the distal part of the combination flap had necrosis on the upper lip).

Discussion

Repair of a landmark defect is often challenging because of complicated anatomy and the lack of available donor skin; free margins are easily contracted, resulting in ectropion or malposition. Reconstruction of these landmarks, therefore, presents a challenge to plastic surgeons. Although the complete replacement of a cutaneous defect is often necessary, the decrease in vertical tension across the landmark must still be considered to prevent secondary distortion as the tissue around the defect is stretched and landmark borders are elongated. Plastic surgeons must, therefore, perform in-depth analyses of the individual defects and consider contour variations, tissue availability, laxity, and cartilage support.

Multiple options are available for the repair of facial landmark defects ^{2 -8} ; however, very few are described for defects involving the landmark rim. ^4,5 Small defects of the alar rim could be repaired with a full-thickness skin graft. ⁹ However, the viability of the composite grafts for ala defects is significantly less predictable than that of random pattern cutaneous flaps. ¹⁰ Defects of the ala can be covered using small rotation and transposition flaps, or a subcutaneous island pedicle flap. A transposition flap from the nasal dorsum and side wall was used to preserve the size, contour, and function of the ala. ¹¹ Small eyelid defects may be repaired using an advancement flap, which primarily involves the undermining and direct advancement of tissue side-to-side to close the defect. ¹² For a small defect of the eyelid margin less than one-third of the eyelid, a simple linear layered closure or transposition flap could close the defect primarily. ¹³ This closure/flap was appropriate for use as a cover, but likely cannot be used for full-layer contracted malposition. For vertical malformation of the rim, the surrounding tissue is always stretched, and the landmark border is elongated. The surgery should include 3 steps: surgical release, horizontal tightening, and vertical lengthening of the anterior tissue. ¹⁴

Herein, we described a novel technique for reconstructing scars that deform facial margins and borders. It combines an end-to-end advancement flap along the margin of the aesthetic unit to tighten the border horizontally, and a local transposition flap to vertically lengthen the contractured tissue. The combination flap was used for the repair of scar contractures and skin defects in 15 patients; none were dissatisfied with the resulting aesthetic appearance. As contracture of the scar and malformation of the tissue can lead to stretched and abnormally elongated borders, reconstruction is more complicated than for facial landmark cutaneous defects. Use of combination flaps involves recruitment of tissue from separate areas, resulting in less wound closure tension than that achieved with the use of a single flap. ¹⁵ Jayarajan ¹⁶ found that the combination of a nasolabial flap and a laterally based cheek advancement flap is a simple and effective single-stage procedure for the reconstruction of nasal, heminasal, and lateral wall defects. Baker ¹⁷ suggested that alar defects that extend into the cheek or upper lip require independent flaps to repair each aesthetic region. Our design consisted of 2 rotational flaps and an advancement flap (shown in case 8). The alar sulcus was purposefully reconstructed using combination flaps along the contracted alar margin, while a second set of combination flaps was used to reconstruct the vermilion margin, making the construction more accurate. The transposition flap served as a strut to prevent retraction of the combination flap and lengthening of the upper lip.

Limitations of the aforementioned design concern the complications associated with healing. In our study, the majority of procedures were successfully performed without complications. A single procedure resulted in superficial necrosis of the tip of the flap; however, healing was achieved within 2 weeks with conservative treatment. This case of necrosis likely occurred as a result of the distal part of the elevated flap being too thin. When the distal portion was thin or narrow, the tip of the flap was trimmed, and an end-to-end type of flap was preferred; no necrosis was observed thereafter. When creating this flap, preservation of the vascular integrity at the base of the flap is of paramount importance. The vascularization of local flaps is ensured by the dermal network, and careful undermining in a deeper subcutaneous plane will preserve this vascular pedicle. ¹⁸ Abundant vascularity of the facial region near the eye and the ala promotes good survival of the combined local flaps, although for patients with an existing infection or wound healing disorders, such as diabetes or rheumatism, combination flaps were not suggested.

Surgical scars are another concern; an increased risk of scar complications correlates with high closure tensions. ¹⁹ The combined use of multiple local flaps decreases closure tension and might therefore be beneficial for the prevention of surgical scar complications. This technique does however leave a vertical/perpendicular scar at the margin and is therefore not recommended for patients with hyperpigmented or hypertrophic surgical scars.

Conclusions

This study described a single-stage procedure for the reconstruction of landmark defects, a technique especially useful for the repair of rim malformations. The appearance achieved is natural, and no touch-up procedures are required. Thus, the combined use of local flaps may serve as a viable option for repairing landmark defects, and the preferred therapeutic tool for landmark rim destruction caused by scar contracture.