Pedicled Skin Flaps of the Face: What to Keep in Mind

This article refers to:

Reconstruction of Alar-Perialar Defects with a Combined Subcutaneous and Cutaneous Pedicled Rotation-Advancement Nasolabial Flap

Skin tumors of the face involve the alar region of the nose in 33% of cases [1]. After removal of facial skin cancer, patients of 10 experience loss of substance, which can be treated with a skin graft, local flaps, or secondary wound healing. However, tissue rearrangement in local flaps may have an adverse impact in cases of cancer recurrence or if a sentinel lymph node biopsy is required [2]. The National Comprehensive Cancer Network suggests that wounds after skin cancer surgery be treated by second intention healing, linear suture, or through the use grafts. They also underline the importance of Mohs’ technique to obtain free margins [3]. When it is not possible to perform a linear suture, the surgeon can close the defects with flaps or grafts.

The use of local flaps is often justified to obtain better esthetic outcomes in low-risk tumors, such as basal cell carcinoma, which represents about 50% of all skin cancers. The use of skin grafts is linked to dyschromia, skin retraction, scarring around the graft (i.e., “frame effect”), and in cases of necrosis, ugly scars. Numerous local flaps have been described for treatment of loss of substance of the face, and they are classified according to the type (rotation, translation, interpolation, etc.) and anatomical region (cheek, forehead, nose).

When performing a local flap, the first thing to keep in mind is radicality. The Mohs’ technique can be very useful for performing a good excision while obtaining free margins. With free margins, the surgeon can freely choose the reconstructive technique that he or she prefers. The second aspect to keep in mind is referred to as “esthetic contiguity.” The human body (and the face) can be divided into esthetic units, and each esthetic unit has distinct characteristics including skin thickness, sebaceous quality, elastic propriety, and resistance to mechanical stress. In addition, some esthetic units can be divided into even smaller subunits, and close esthetic units have similar characteristics. Therefore, when we perform local flaps, we try (when possible) to use adjacent esthetic units for a correct reconstruction while keeping in mind several factors. The alar region of the nose is involved in about 1/3 of the cases of skin cancer of the face, and these cases involve the possibility of noticeable deformities as well as functional disturbances of the external nasal cavity.

The alar region, in particular, has low mobility and a rigid structure, while perialar tissues are more elastic. The preservation of natural alar contours is very important for preserving respiratory function and symmetry with the contralateral portion. Direct closure is preferable only for small defects to avoid alar rim distortion. Bigger defects may be left to heal by secondary intention, but when possible the surgeon should avoid this.

One of the most frequently used techniques to reconstruct this area is an interpolated flap [1,4]. In their recent study, Mohos et al. described the use of a new technique to reconstruct extended alar defects that combines an interpolated and rotational flap. They examined perfusion with laser Doppler flowmetry [1] and investigated patient satisfaction with a questionnaire in the 6th post-operative month. Statistical analysis was performed with Friedman analysis of variance (for Doppler flowmetry) and Dunn’s method for time-dependent differences from the baseline. With this procedure, the authors were able to obtain good esthetic results without submitting patients to multiple corrective procedures.

During the tissue transfer from the cheek to the nose, the surgeon must keep in mind that the superior aspect of the alar-facial sulcus is an important topographic junction between the esthetic region of nose, cheek, and upper lip. To obtain a good esthetic outcome, flaps should not cross the borders that divide these esthetic units. This should be avoided in the perialar region in particular because the nasolabial junction is composed of the sulcus, and a flap across the sulcus interrupts its concave topography, which makes it difficult to restore the sulcus and the natural contour of the face [5].

In addition to the typical anatomical aspects, the surgeon performing a local flap must consider the cutaneous anisotropy, which is directly related to the direction of the collagen fibers, as well as the age and the comorbidities of patients such as hypotension, anemia, and other pathologies that compromise microcirculation [1].

Cutaneous anisotropy is a highly important aspect, as skin can be more easily stretched in one direction than another depending on the arrangement of the collagen fibers in the dermis. For flaps with larger peduncles or for the use of methods to improve the survival of the flaps such as carboxytherapy [6] and new molecules such as morroniside [7,8], or oxygen [9], the age and the comorbidities of the patient, instead, can determine the choice of technique.

The use of local flaps for loss of substance arising after skin cancer surgery of the face has some important advantages over skin grafts. The flap shrinks less than the graft and does not result in altered pigmentation. Flaps are useful when the surgeon hopes to obtain a more esthetic outcome, but they should be used cautiously in cases of high recurrence tumors with capacity to metastasize and should always be avoided if the surgeon is not able to remove the cancer with safe margins (e.g., if use of Mohs’ technique is not possible).

Declaration of interests

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.