Surgical delays e. The surgeon should develop a schematic progression of reconstructive possibilities. This progression begins by mentally trying to close any wound by direct advancement of tissue in or near resting skin tension lines if possible. Repositioning of end triangles and harnessing tissue creep modifications may be necessary. After the advancement flap has been considered, possible rotational flaps are evaluated.
Finally, transposition and interpolation flaps are assessed. Obviously, there are locations on the face e. The fundamental concepts of local flap reconstruction are listed in Box Consider flap mobility blood supply. Consider allowable wound tension at closure and where any technical maneuvers may be reasonable.
Consider flap incisions near topographic borders within relaxed skin tension lines RSTLs or hidden from obvious frontal views. The most superficial layer of the skin is the epidermis. Beneath the epidermis, the dermis is subdivided into the superficial papillary and the deeper reticular layers. There is both a superficial and deep intradermal vascular plexus, which typically runs parallel to the surface of the skin and provides nutrients to a large surface area.
These vascular networks are extensive but by themselves cannot support tissue viability alone after significant tissue undermining is performed.
The deeper, subdermal plexus lies beneath the dermis within the superficial subcutaneous tissue and plays a critical role in flap physiology. These vessels are often preserved in an advancing flap edge through the retention of a trace layer of fat on the undersurface of the tissue.
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Axial vessels lie deep to the subcutaneous fat on the surface of the superficial fascia, roughly parallel to the skin surface. These vessels within the flap dramatically enhance vascularity, thus offering options for lengthening the flap without compromising viability e.
Deeper interconnecting vessels, which are perpendicular to the skin surface, are musculocutaneous arteries. These vessels exit the muscle and enter the subcutaneous tissue to supply a smaller region of the skin. Collectively, the septocutaneous and musculocutaneous arteries contribute to a diffuse interconnecting vascular network of dermal and subdermal arteries that create some vascular redundancy in the skin Figure A primary defect is any defect created by trauma or tumor.
Direct advancement flaps close a primary defect by stretching the adjacent skin over the defect. When the elliptical advancement flap is ineffective, tissue must still be otherwise mobilized to fill the primary defect without undue tension.
Reconstruction of facial defects with local flaps – a training model for medical students?
The use of additional incisions and maneuvers e. A secondary defect is the defect that occurs as a result of movement of the flap and develops behind the advancing flap edge. Flap design compensates for the secondary defect by allowing the surgeon to close this defect as well. Sometimes the secondary defect is closed by dissipation of forces elsewhere or by grafting in an inconspicuous location.
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Adequate skin mobility is partially attributable to skin extensibility stretching of the elastic fibers. Low-tension closure minimizes scar widening, wound dehiscence, tissue ischemia, and anatomic distortion. On the face, tense closures can break down. This is less of a problem on the more forgiving forehead and scalp.
Flap Definition, History, and Classification
There is generally more extensibility among older patients. Overstretching on the face will produce tears or striae, which can be permanent Figure Mechanical creep is the tendency for any solid material to move slowly or deform under the influence of stress. Skin responds no differently. Skin held at a constant tension may require less tension over time.
A common characteristic of mechanical creep can be observed following a tightly closed avulsive forehead wound. After a few days, the tissue relaxes. Three principles of mechanical creep may be functionally garnered to help close tight flaps: presuturing, cyclic loading, and deep scoring of tense tissues:.
Presuturing pulls tissues together and can be employed from days to only minutes prior to attempting wound closure. This technique can gain millimeters to centimeters of additional length. Commercially available instrumentation is available, but the use of sutures can achieve the same result.
Cyclic loading performs the same purpose at surgery. The surgeon cyclically loads the tissue with skin hooks or by inflating a catheter balloon to stretch it. Each cycle extracts additional stretch or creep from the tissue, yielding greater overall length. Deep tissue scoring, particularly of the galea, can also augment mechanical creep.
Biologic creep is a slow, methodic stretching of the skin, producing new skin. This physiologic property is reflected in severe obesity, pregnancy, and skin expansion. Blood supply to the terminal portion of a random flap flaps dependent on the subdermal plexus is not as much a function of width, but rather one of length. Flap length can be limited by vascular compromising factors such as the small veins of diabetes or vasoconstriction from nicotine. The tissue perfusion pressure decreases as the length of the flap increases from its base.
When this pressure falls below a critical closing pressure of the arterioles, flap necrosis occurs beyond that point. On the face, the original studies based the actual length on angiosomal units of vascularity Figure Augmenting the viable length of a flap may be critical to success. The delay technique for a local flap involves circumferential incision alone, subcutaneous undermining alone through small incisions, or circumferential and subcutaneous undermining without mobilization.
Two weeks after the delay procedure, the flap may be transferred to the recipient site. This delay results in enhanced circulation to the flap through the closure of arteriovenous shunts and the realignment of the vasculature within the subdermal plexus. The angiosomal unit is the three-dimensional territory supplied by source arteries and veins. Identification of the anatomic territory of an individual perforator can help the surgeon define an area that may be safely lifted for a reconstructive effort with or without flap delay. There is a wide variance of structural differences of the face depending on the location.
These differences are often described and categorized as the facial units , examples of which are the eyelids, cheeks, nose, lips, mentum, and auricles. Some of these units can be further divided into subunits based on visible creases and differences in skin quality.
When designing an ideal flap for reconstruction, the most favorable result will be one that respects the facial subunits and their boundaries. Scars that lie directly along the borders of these units will be naturally camouflaged. Therefore, the surgeon who encounters a defect encompassing over half of a subunit such as the nasal tip or lip philtrum may consider removal of the entire subunit prior to reconstruction. The surgeon may consider independent repair of adjacent unit s so that large reconstructions do not flow nonanatomically from one unit to another Figure Elasticity of the dermis determines how easily the ellipse can be closed.
What to do with the excess tissue or bunching dog ears, which form as tissue moves into a defect Box Do nothing works well on the scalp where bunched tissue lies down over time. Depending upon the jurisdiction, maxillofacial surgeons may require training in dentistry, surgery , and general medicine ; training and qualification in medicine may be undertaken optionally even if not required. Oral and maxillofacial surgery is widely recognized as one of the specialties of dentistry.
In many countries, however, maxillofacial surgery is a medical specialty requiring both medical and dental degrees, culminating in an appropriate qualification e. All oral and maxillofacial surgeons, however, must obtain a university degree in dentistry before beginning residency training in oral and maxillofacial surgery. In the United States oral and maxillofacial residency programs are either four or six years in duration. Programs that grant the MD degree are six years in duration. They also may choose to undergo further training in a one or two year subspecialty Oral and Maxillofacial Surgery Fellowship Training in the following areas:.
The popularity of oral and maxillofacial surgery as a career for persons whose first degree was medicine, not dentistry, seems to be increasing in a few EU countries [ clarification needed ]. However, the public funds spent for 14 years of training are of a major concern for governments. Integrated programs are becoming more available to medical graduates allowing them to complete the dental degree requirement in about three years in order for them to advance to subsequently complete oral and maxillofacial surgical training.
Treatments may be performed on the craniomaxillofacial complex : mouth, jaws, face, neck, and skull, and include:.
Alternative to suturing reduces surgical time for dental procedures
In the United States, oral and maxillofacial surgeons are required to undergo five months of intensive general anesthesia training. The American Society of Anesthesiologists published a Statement on the Anesthesia Care Team which specifies qualified anesthesia personnel and practitioners as anesthesiologists, anesthesiology fellows, anesthesiology residents, oral and maxillofacial surgery residents, anesthesiologist assistants, and nurse anesthetists.
Oral and maxillofacial surgery requires four to six years of further formal university training after dental school i. In the United States , four-year residency programs grant a certificate of specialty training in oral and maxillofacial surgery. Six-year residency programs grant the specialty certificate in addition to a degree such as a medical degree e.
Both four— and six—year graduates are designated US "Board Eligible" and those who earn "Certification" are Diplomats. In addition, graduates of oral and maxillofacial surgery training programs can pursue fellowships, typically 1—2 years in length, in the following areas:.
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