Combination Flaps

Abstract

Sometimes one flap is not sufficient, and two or more flaps may be required to reconstruct a defect. This is particularly a requirement on the face near important landmarks such as the nose and perioral regions. Forward thinking and consideration of options require the most experience and clinical judgement. The goals should always be, first, adequate tumour clearance and, second, aesthetic reconstruction to avoid disfigurement and the stigma of disease and surgery. In this chapter some challenging defects are considered, where the combination of traditional local flaps or traditional and modern local flaps such as the keystone are useful.

Keystone Advancement + Chin Rotation Flaps

Fig. 14.1

Keratoacanthoma on the lower lip/chin junction of a 55-year-old man. Excision completed with 5 mm margins and the defect repaired with a perioral keystone perforator island local flap from the right side and an inferiorly based chin rotation flap from the left (a, b). Wedge resection of right lower lip dog-ear required. Result at 9 months (c)

Notes

Oral competence is the key function to preserve in this reconstruction of the lower lip and respect for the resting skin tension lines. Balance of the vermillion lip contours is also important, and sometimes a mucosal revision is required to remove excess mucosal tissue.

Cervicofacial Rotation + Glabellar Transposition Flaps

Fig. 14.2

A right nasojugal tumour of uncertain origin (ruptured dermoid cyst), in this 67-year-old woman (a) widely excised and reconstruction delayed for 24 h, awaiting urgent histology (b). The defect involving the right nasojugal and lateral nasal subunits, was repaired with a cervicofacial rotation flap, combined with a glabellar transposition flap (c). The result at 3 months (d)

Notes

Extra length can be added to the cheek rotation flap with the addition of a Z-plasty at the jawline as illustrated in Figs. 14.2b and 14.2c.

Forehead Interpolated Flap + Cheek Rotation Flap + Lip Switch Flap

Fig. 14.3

(a–c): An extensive ulcerated BCC in a young woman treated elsewhere with antibiotics for some months. The infiltrating BCC involved the right upper lip, alar base and medial cheek (a). Staged reconstruction was performed after wide and complete margin-controlled excision with a right lower lip-switch flap and inferiorly based cheek rotation flap to provide a platform for the paramedian forehead flap alar reconstruction (b). The result after three stages at 1 year (c)

Combination Keystone Flaps from Cervical and Cheek Regions

Fig. 14.4

This 45-year-old clergyman presented to our Interplast team in Port Moresby, Papua-New Guinea with an extensive fungating SCC of his mouth, secondary to chronic betel nut chewing (a–c). Transfer to New Zealand or Australia for care was not an option. A wide excision was undertaken with the local surgical team, and two keystone flaps (right cervicomental and left cheek) for cover plus a potential total forehead flap for lining were planned (a–c). The forehead flap was ultimately not required as the large cervicomental keystone flap based on right sternomastoid perforators was folded to provide upper lip lining. The secondary neck defect was repaired with split skin graft but in hindsight could have been reconstructed with the supraclavicular flap of Lamberty. Immediate result shown (d, e). Long-term results are unavailable