Deckung ausgedehnter Defekte des Gesichtes

Summary

Extensive perforating defects of the face can be covered in three different ways: with flaps from the forehead and skull, with the delto-pectoral flap, and with tube pedicle flaps from the trunk.

Although primary reconstruction in defects of the face is preferred in respect of mutilation and the disturbed function, it cannot be achieved in every case. Three cases of this kind are presented. In a 40 year old patient, who lost his cheek, part of the orbit, and half of the nose because of a carcinoma the forehead had already been used (Fig. 1). Cover and reconstruction was achieved with a large caterpillar flap from the head (Figs. 2 and 3), diced cartilage and a bone-graft. For the immediate cover of a large defect, involving one side of the face, as after resection of a carcinoma in an old woman (Fig. 5), a delto-pectoral flap, according to Bakamjian is favoured. This flap can be positioned in one step, and a split-skin-graft is used as a lining. In such a case the cheek should be supported by a prothesis, and with it the distorsion of the contour and shrinkage can be kept to a minimum. The pedicle of the flap can be cut after three weeks, and this allows the patient to eat and speak within a minimum of time (Fig. 7).

When the whole middle-face is lost (Fig. 8), because of a recurrent basal-cell carcinoma and radiation treatment, the delayed acromio-pectoral flap with an additional extension on to the upper-arm to form a lining, is used (Fig. 9).

Step by step, the building up is achieved; iliac-bone is implanted in the nose and an ABBE-flap with vermillion pedicles is used for the upper-lip. A prothesis has to be fashioned to support the lip so as to enable the patient to eat and to speak.

A hair-bearing caterpillar-flap from the scalp is acceptable for building up the cheek in a man, but in a woman a large defect may be treated by an acromiopectoral flap, as described by Bakamjian. As distinct to the shoulder-based flap, which was recommended by Conley for oesophagus reconstruction, the sternalbased flap has a much better blood-supply. It can be extended after some delay, as shown in Figs. 8 and 9, over the whole shoulder, and even further down the upper arm. This gives enough skin, not only for the covering layer, but also for a proper lining of the mouth and provides the good pocket required for the bone-and cartilage grafts. In contradistinction to the rather rough skin of the sternal region, the skin of the shoulder and the upper-arm is soft; it is also a better match for the face, regarding the texture and the colour.

Zusammenfassung

Ausgedehnte, perforierende Defekte des Gesichtes können primär mit einem Delto-Pectorallappen gedeckt werden. Sollte ungewöhnlich viel Haut — z. B. zusätzlich für die Innenauskleidung — erforderlich sein, ist durch Vorschneiden eine Vergrößerung dieses Stiellappens möglich. Ein Raupenlappen gestattet es, Haut aus der Stirn- und Kopfregion auch dann zu verlagern, wenn die Temporalgefäße nicht mehr intakt sind. Drei Fälle werden besprochen.