However, the term, Unipedicle advancement flaps are created by parallel incisions that allow a sliding movement of skin in a single vector toward the defect. Superficial or full-thickness defects involving the lower two-thirds of the nose (including the columella) requiring skin, volume, and/or infrastructural support can, in theory, be rehabilitated with primary or staged suprabrow, midline or paramedian forehead, or melolabial flaps (, For smaller defects (<2 cm diameter) of the inferior aspect of the nose, local nasal flaps such as transposition or bilobe are a notably better and less invasive option. FIGURE 12-3 Melolabial subcutaneous tissue pedicle island advancement flaps are particularly suited for repair of skin defects adjacent to alar base. The pivotal movement, although limited, eliminates the need to make the second incision parallel to the first incision to create and to move the flap. Because of proximity, the color, texture, and thickness of the skin of the melolabial fold closely match those of the lips and the caudal lateral nose. Texture, due to the relative similarity of the melolabial flap surface to potential reconstructed sites, is typically not an issue, except when considering the prospect of mismatching hair-bearing and non-hair-bearing regions. The framework in the form of a cartilage graft must be used at the time of the initial reconstructive procedure and requires vascularized tissue superficial and deep to the graft, totally enveloping the cartilage. The template is positioned so that the medial border of the designed flap lies in the melolabial crease. In the author’s practice, local flaps in the form of rotation are rarely designed in the area of the melolabial fold because their curvilinear incision frequently creates a scar that crosses the melolabial crease perpendicular to relaxed skin tension lines (RSTLs). Choosing a flap for facial reconstruction is invariably determined after weighing the options and figuring out what will give you the best possible result at the recipient site with minimal donor site morbidity. In some cases, they may be used in associa- ... transposition of the interpolated melolabial flap to the nasal defect and primary closure of resulting 12-2). Melolabial flap selection follows the elimination of other flap choices and usually is an easier choice if the patient is perhaps more senior with an already present melolabial crease. The flap donor site is closed in a V-Y fashion, with care taken to compensate for any differences in the length of the opposing margins of the donor site by suturing on a bias (see. In contrast, the skin of the nasal dorsum and cephalic portion of the nasal sidewall is thin and tends to have less sebaceous glandularity than the skin of the melolabial fold. Melolabial advancement flaps are not frequently designed with two parallel incisions. Melolabial transposition flaps have frequently been used for reconstruction of the ala and nasal sidewall. Any reconstructive ladder dealing with defects of the face should in theory mention the possibility of allowing either secondary intention controlled granulation closure of the defect or employing some form of skin or composite graft reconstruction. [2][3][4] Nasolabial (Melolabial) Transposition Flap Dieffenbach originally described the nasolabial flap in 1830 when he used superiorly based nasolabial flaps to reconstruct the nasal ala. This has the effect of pulling the pedicle upward toward the ala without the need to place additional traction on the subcutaneous tissue pedicle. Transposition flaps are pivotal flaps, and the greater the arc of pivotal movement, the greater will be the size of the standing cutaneous deformity and the less will be the effective length of the flap (see discussion in, Advancement flaps have a linear configuration and are moved by sliding toward the defect. A linear closure of cutaneous defects of the temple often results in elevation of the lateral brow or webbing of the lateral canthus. C, Superior and lateral portions of wound closure suture lines are in aesthetic boundaries. For sizeable (2-3 cm) lip skin defects adjacent to the inferior border of the ala, it may be beneficial to excise the small peninsula of skin between the ala and melolabial fold in the process of enlarging the defect so that it extends to an aesthetic boundary. Transposition flaps are the most common type of melolabial flaps used in facial reconstruction. An appropriate donor site is selected within the melolabial fold area of the medial part of the cheek. Melolabial transposition flaps have frequently been used for reconstruction of the ala and nasal sidewall. This involves stretching the skin of the flap. This approach also avoids the technically challenging requirements of integrating the flap into the nasal sill at the time of flap inset. This is especially true if the border has a concave topography, like that of the alar-facial sulcus. 12-4). They have the advantage of maintaining a lymphatic drainage route through the pedicle of the flap, which remains in continuity with cheek skin. The all-important blood supply to the melolabial flap is not actually based on a specific vessel found in the flap, but rather on a directionally oriented subdermal plexus that courses parallel to the melolabial crease, giving the flap a certain degree of axiality. The melolabial V-Y subcutaneous tissue pedicle island advancement flap is an option for repair of medial cheek skin defects at or below the level of the nasal alae.7 The flap is particularly well suited for skin defects located immediately adjacent to the alae (Fig. Whenever possible, local flaps should be designed so that they do not cross borders that separate aesthetic regions. The fashioned template is placed on the melolabial fold so that the center of the flap is positioned 1 cm above the horizontal plane of the oral commissure. Sizeable (3 cm) skin defects of the medial cheek can be closed this way by advancing skin from the melolabial region in such a fashion that the resulting standing cutaneous deformities can be excised parallel to the melolabial crease. 12-3). Although the flap is rarely elevated as a true axial flap incorporating the angular artery, many small peripheral branches of the artery are probably included in the base of melolabial flaps. The flap design is analogous to that of a 1-step nasolabial transposition flap (see Nasolabial Transposition Flap). This is especially true if the border has a concave topography, like that of the alar-facial sulcus.9 Too often, this sulcus has been violated by transposition flaps harvested from the cheek to reconstruct lower lateral nasal defects. transposition of the interpolated. The only requirement is that the base of the flap be contiguous with the defect the flap is designed to repair. The nasal-alar unit is highly contoured, has a free margin, and functions as the external nasal valve. The cheek skin in this region of the face has a rich blood supply from perforating branches of the facial artery and is drained by the facial angular vein. They also avoid a circumferential scar, which in part accounts for trap-door deformity. In older patients, this redundancy can provide a source for a large flap and still enable primary closure of the donor site. Variations of this flap may be used to reconstruct small- to medium-sized defects involving the chin, upper and lower lip, cheek, nose, and lower eyelid. In addition to repair of medial cheek defects as discussed, subcutaneous tissue pedicle island advancement flaps are ideally suited for repair of skin defects of the lateral upper lip. The flap is designed to pivot 90° toward the midline in a clockwise direction when it is harvested from the left cheek and counterclockwise when it is harvested from the right cheek.
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