Tumor Resection with Histologic Control

Complete tumor removal takes precedence over all cosmetic and reconstructive concerns. Regardless of whether the tumor is a basal cell carcinoma, squamous carcinoma, or melanoma, it must be certain that adequate marginal and deep clearance has been achieved in accordance with oncologic principles. Wherever possible, we practice a modified form of histologically controlled tumor resection. This means that the tumor is first excised with a margin of healthy tissue, marked with threads to indicate...

Coverage of Defects in Specific Facial Regions

For smaller facial defects, an attempt is made to achieve coverage by means of flap advancement or local flaps (Fig. 4.1). Keep in mind that these flaps should be placed in RSTLs whenever possible (see p. 6). If flaps cannot be obtained from the immediate vicinity of the primary defect, regional flaps are used. These are larger flaps involving the movement of tissue somewhat more distant from the recipient site. The classic regional flaps from the neck and chest are no longer in common use. For...

The Lips

All operations on the lips should restore both the esthetic appearance of the lips and their function, i.e., their ability to maintain oral continence during eating and drinking. Our suture material of choice for approximating muscle stumps about the lips is 4-0 or 5-0 absorbable, and we prefer 6-0 or 7-0 monofilament for the mucosa. Fig. 6.1 Wedge-shaped defect in the vermilion of the lower lip. a The defect is excised. b Inferiorly and superiorly based mucosal triangles are cut in preparation...

Dermabrasion

Dermabrasion is surgical scraping performed with a high-speed motorized handpiece (e.g., Aesculap) that delivers speeds of 15 000 to 25 000 rpm or higher. A large carborundum or diamond abrasive wheel is used. Indications Dermabrasion is done to remove scars above skin level due to burns or trauma, to lessen the visibility of traumatic tattooing, and to treat acne scars. Procedure Local anesthesia is the rule, but general anesthesia may be used when large areas are abraded. While the skin is...

Island Flap

An island flap from the cheek is also useful for reconstructing small defects in the nasal flank area. The flap may be based on the facial artery or may be designed with a subcutaneous pedicle that has an in-ferolateral or superolateral position in relation to the Fig. 5.30a, b U-advancement flap. Burow's triangles are excised from the nasolabial fold and nasal flank. Fig. 5.31 a-c Double transposition flap with V-Y advancement. flap. The skin between the flap and the defect is undermined, and...

Sliding Flap

The sliding flap of Barron and Emmet (1965), which has a lateral subcutaneous pedicle (see p. 13 and Figs. 3.11 -3.14), has proven useful for reconstructing de Fig. 5.4a, b V-Y advancement with a Z-plasty. Fig. 5.5a, b Closure with a small transposition flap. Fig. 5.6a, b Closure with a bilobed flap. fects located more in the upper lateral portion of the nasal bridge. Besides a simple transposition flap (Fig. 5.5), a specially designed V-Y advancement flap (Fig. 5.3) or V-Y advancement with a...

Small Perforations

Small septal perforations can be managed with small unilateral or bilateral U-advancement flaps, which can be elevated in one or two layers (Fig. 5.54). Small unilateral or bilateral rotation flaps (Fig. 5.55) and bipedicled flaps (Fig. 5.56) may also be considered. We have also used anteriorly or posteriorly based mucosal flaps from the inferior nasal turbinate, in which case a small piece of turbinate bone may be transferred with the flap (Fig. 5.57a). A second operation is needed for...

Indications and advantages

- The radial forearm flap is very good for reconstructions of the oral cavity, tongue, pharynx, and neck. - The vascular pedicle has a consistent length. There is no need to reposition the patient in-traoperatively. Tumor resection and reconstruction can be performed in one operation. - Two teams can work concurrently one removes the tumor while the other harvests the flap. - When a radial forearm flap is used for tongue reconstruction, for example, sensation is restored by anastomosing the...

Foreword

As president of the European Academy of Facial Plastic Surgery I have the pleasure and privilege to write a foreword in this textbook on plastic reconstructive surgery of the face. This practical step-by-step surgical guide was written by professor Hilko Weerda, who is particularly well-known worldwide for his auricular reconstruction techniques and is also an expert in facial plastic reconstructive surgery and teaching. This book is well illustrated with bicolour drawings is easily accessible...

Allen Test

The Allen test is used to determine whether the ulnar artery will adequately supply the hand following radial artery ligation. The patient is told to make a tight fist with the affected hand. Then the examiner simultaneously compresses the radial artery and ulnar artery, the patient slowly opens the hand, and pressure on the ulnar artery is released. In an abnormal test the fingers do not show significant capillary fill (blush) within 5 seconds after ulnar artery release, and a radial forearm...

Advancement Flap of Burow 1855

Simple triangular defects can be covered by advancing the adjacent skin. A small Burow's triangle is excised at the opposite end of the flap (Fig. 3.1a) to prevent formation of a dog ear. a The ratio of defect length to flap length is approximately 1 2, and the base-to-length ratio of the flap should not exceed 1 2. The flap is advanced by excising two small Burow's triangles and mobilizing the surrounding skin. b Closure of all defects.

Reconstruction of Large Commissural Defects

Reconstruction Oral Commisure

As in the previous reconstruction, a two-layer trapezoidal flap is cut above and below the defect, and the Fig. 6.51 a, b Reconstruction of the commissure by dual V-Y advancement. (Vermilion reconstruction see Figs. 6.48-6.50.) Fig. 6.52 Large full-thickness reconstruction of the cheek and commissure by Esser's cheek rotation combined with a tongue flap (Lexer 1909 Weerda 1985). a The defect is excised and the epithelium turned inward. An Esser cheek rotation flap is outlined. An incision is...

Large Superficial Defects

Vermilion defects involving up to one-third the length of the lip can be repaired with a sliding flap (Fig. 6.2a), or the entire myomucosal stump can be mobilized as an advancement flap as described by Goldstein (1990). The natural elasticity of the lip mucosa permits good coverage of the defect (Fig. 6.2b see also Fig. 6.53). These techniques can also be combined with the methods described by Blasius (see Figs. 6.25 and 6.26). Fig. 6.1 Wedge-shaped defect in the vermilion of the lower lip. a...

Larger Middle Third Defects

As in the reconstruction of large upper third defects (see Fig. 10.15), a skin pocket is developed behind the ear (Fig. 10.19a). A carved piece of rib cartilage is sutured to the cartilage stump and inserted into the pocket (see Figs. 10.14-10.16). The skin is closed with 6-0 monofilament suture material and coapted with 5-0 monofilament bolster sutures (Fig. 10.19a). A suction drain is inserted for 6-7 days (see Fig. 10.16c). Second stage The auricle is lifted from its bed (Fig. 10.19b, c),...

Larger Contractures

A) Burn with ectropion of the lower lip (Fig. 6.32) A small contracture causing ectropion of the lower lip can be dispersed with one, two, or more Z-plasties to lengthen the lower lip and restore the everted vermilion to a normal position (Fig. 6.32b). A more severe contracture with fixation of the lower lip and destruction of the underlying skin can be managed much as in the upper lip (see Fig. 6.12) by excising the scar and then mobilizing the vermilion Fig. 6.30a, b Excision of a scar at the...

Celsus Method Combined with an Abbe Flap

(Fig. 6.21 see also Figs. 6.20 and 6.22) Large defects of the upper lip can be repaired by closing or reducing the central defect by the Celsus method (Figs. 6.20 and 6.21a) and then using a three-layered Abbe flap from the lower lip (Figs. 6.21b, c, and Fig. 6.22) to replace the central part of the upper lip (Fig. 6.22a, b). In a second stage about 3-4 weeks later, the turnover flap is detached from the lower lip and the wounds in the upper and lower vermilion are closed (Fig. 6.21c).

Neurovascular Infrahyoid Myofascial Flap of Remmert 1994

Flap type neurovascular myofascial flap of the axial pattern type (see Figs. 1.3 and 1.4). Flap components muscle (infrahyoid muscle group), fascia. Use as a neurovascular myofascial island flap or microvascular free flap with a neural pedicle (Fig. 12.3a, b). Vascular pedicle The superior thyroid artery (Fig. 12.3a, b, 4) usually arises from the external carotid artery but may also arise from the bifurcation of the common carotid artery. The thyroid vein drains chiefly into the facial vein and...

Instruments and Accessories

We generally use a 2x to 2.5x binocular loupe when operating and suturing. A high-quality instrument set (Fig. 2.7a) is needed that includes No. 11, No. 15, and No. 19 knife blades (1) and one small and one slightly larger needle holder for atraumatic needles (2). The set should include fine surgical forceps (e.g., Adson forceps), dissecting forceps (3), fine angled bipolar forceps for vascular electrocautery, two or three fine hemostatic clamps, mucosal clamps, and assorted sharp-pointed...

Semicircular Flap Closure of Beyer Machule et al 1993

Larger defects involving up to one-half of the lid margin can be closed by advancing a semicircular skin flap medially (Fig. 9.2a). The lid margin is sutured first (see also Fig. 9.1). Next the tarsus and orbicularis Fig. 9.1 Direct primary closure of an upper eyelid defect involving up to one-fourth the length of the lid margin (approximately 8 mm). a The lid margin is closed with 6-0 or 7-0 PDS sutures. The tarsus and orbicularis muscle are then approximated with interrupted 6-0 absorbable...

Obtaining Rib Cartilage

Rib cartilage is generally obtained from the same side of the thorax under general anesthesia. Small amounts of cartilage can be taken from the fourth, Fig. 11.1 Harvesting rib cartilage (generally we use the same side) a In women the incision is placed in the inframammary fold (A), aided if necessary by a small Z-shaped extension. In men the incision is made between the sixth and seventh ribs (B). The synchon-drotic region of ribs 6 and 7 will supply a sufficient block for carving the...

Vermilion Reconstruction by the Method of von Langenbeck1855

The usual treatment for actinic damage of the lower lip with premalignant changes is to remove the entire vermilion of the lower lip. The mucosa lining the oral vestibule is then mobilized and advanced to resurface the lip with an excellent cosmetic result. The skin-vermilion border is carefully restored using 6-0 or 7-0 monofilament, which is removed on the fifth or sixth day (Fig. 6.42b). In all lip reconstructions, the mucosal surface of the lip should be coated with Fig. 6.42 Vermilion...

Upper Third Defects

If insufficient skin is available above the avulsion or defect, the skin should be expanded over a 6-8-week period using a 10-mL tissue expander (see also Figs. 4.5, 5.53 and Fig. 10.16). Generally, however, there will be sufficient local skin for the reconstruction. First stage A transparent film pattern is traced from the opposite, normal ear (Fig. 10.13). Then rib car Fig. 10.11 Small defects of the upper helix. a Small inferiorly based (1) or superiorly based (2) transposition flap (the...

Small Cheek Defects

Cheek Flap

Small defects are repaired with transposition or rotation flaps, and small bilobed flaps can also be used (see pp. 6, 13-17, 22 Figs. 3.1b and 3.22). Defects in the nasal flank area can be closed by a Burow-type cheek advancement with a Burow's triangle (Fig. 8.3) or by excising a skin crescent in the nasolabial angle (see Fig. 8.4). Fig. 8.2 Cheek reconstruction combining the Esser and Imre techniques (Weerda 1980). A crescent-shaped excision in the nasolabial fold is added to the Esser...

Auricular Reconstruction Following Total Amputation

(Fig. 10.30 Weerda 1983 c, 1987, 1997, Weerda and Siegert 1998) When the entire auricle has been lost as a result of accidental trauma or tumor surgery, generally there is enough skin left to proceed with reconstruction. Otherwise the available skin should be expanded by implanting a 20-35-mL tissue expander for approximately 8 weeks (Siegert and Weerda 1994 see Figs. 4.5 and 5.53). First stage First a pattern is traced from the opposite, normal ear onto a sheet of radiographic film or other...

Thin Upper Lip and Full Lower

Spare Upper Lip And Full Lower Lip

A bipedicle flap can be used to add substance to the upper lip in a patient with a full lower lip, and viceversa (Fig. 6.7a, b). The pedicle is divided about 3 weeks after the initial transfer. Fig. 6.3 V-Y advancement for adding median fullness to a thin upper lip. Fig. 6.4 Widening the upper lip on one side. a The lip height is measured on the opposite side and drawn on the affected side. A strip of skin is excised, and the vermilion is slightly mobilized. b The incision is closed (with 6-0...

Disadvantages and complications

- The flap cannot be used in patients with extensive cervical metastasis. - If the vascular pedicle has a low origin, the arc of rotation will be insufficient to reach the oral cavity, necessitating microsurgical transplantation and elongation. Neurovascular Infrahyoid Myofascial Flap of Remmert (1994) Fig. 12.3 Neurovascular infrahyoid myofascial flap of Remmert (1994). a The infrahyoid muscles (1, 2, 3) are based on the superior thyroid artery and vein (4) and on the superior root of the ansa...

Double Rotation Flap

A double rotation flap can be used to close larger midline and paramedian defects in the forehead. Again, the scars are located principally along the eyebrow and hairline (Fig. 4.4b). a, b An elliptical forehead defect is covered by incising and rotating the forehead skin and closing all defects. Again, a Z-plasty can be used to disperse the scar. a, b An elliptical forehead defect is covered by incising and rotating the forehead skin and closing all defects. Again, a Z-plasty can be used to...

Grimm 1966 and Fries 1971

Large Estlander Flap

(Fig. 6.46 unilateral or bilateral) Bernard (1852) described an operation, repeatedly modified during the past century, for unilateral or bilateral reconstruction of the lower lip. Placing the incisions and Burow's triangles in the lines of the esthetic units yields a very good cosmetic result with acceptable mobility and width of the reconstructed lip. A turnover flap of cheek mucosa (S) is raised to restore the vermilion on the opposing de-epithelial-ized portion of the reconstruction flap...

Wound Management and Scar Revision

Eliptical Excision Suture

It is a general rule in facial plastic surgery to sacrifice as little skin as possible. Small wounds that extend obliquely into the tissue should be straightened whenever the surrounding tissue can be mobilized and the wound edges coapted without tension. A subcutaneous suture with a buried knot should always be placed to allow tension-free approximation of the wound margins (see Fig. 2.1). Because the subcutaneous tissue, epidermis, and dermis take different lengths of time to achieve adequate...

Partial and Total Nasal Reconstruction

Facial Reconstruction Surgery

Median or oblique forehead flaps (see Figs. 5.15,5.16, 5.49, and 5.53) can be effectively used for nasal reconstruction, depending on the size and location of the defect. In other cases turnover flaps can be used in conjunction with nasolabial flaps (see Figs. 5.11 and 5.40) or bilobed flaps (see Fig. 5.46), or complex flaps may be required. Various flap combinations can be used in the reconstruction of large defects. When a large forehead flap has been transferred (see Figs. 5.16 and 5.49),...

Burows Method of Reconstructing the Lateral Upper Lip 1855

Burow Triangle

Following the wedge excision of a tumor of the lateral upper lip (Fig. 6.48a), that part of the lip and the commissure can be reconstructed by a simple advancement technique following the excision of a Burow's triangle next to the lower lip. A mucosal flap raised adjacent to the lower lip (Fig. 6.48a, S) is used to resurface the de-epithelialized area (D) on the reconstruction flap. This restores an acceptable length to the oral fissure and yields a good cosmetic result (Fig. 6.48b Zisser...

Problems and Complications

- Inequality of vessel diameters (Figs. 14.14-14.16). - Early or delayed thrombosis at the anastomotic - Gaps between the vessel ends (Fig. 14.17). site (Fig. 14.18). Fig. 14.14 If the vessel calibers are nearly equal, the smaller lumen can be gently dilated with a forceps or retractor. Fig. 14.14 If the vessel calibers are nearly equal, the smaller lumen can be gently dilated with a forceps or retractor. Fig. 14.15 Vessel calibers can also be matched by cutting the smaller vessel end at an...

Earlobe Reconstruction by the Gavello Technique

We very often use the double-flap technique of Gavello for earlobe reconstructions (Fig. 10.20a). After the defect is freshened, the flap is folded over and sutured to the stump (Fig. 10.20b, c). The donor defect is closed by direct approximation, placing the lower wound margin as far behind the auricle as possible. If necessary, the reconstruction can be supported by a cartilage graft from the concha of the opposite ear or from the rib (Fig. 10.21a, b). This requires making the anterior flap...

Median Cheek Rotation of Sercer 1962

Rotating the cheek medially on a superiorly based flap results in scars at the boundary of the esthetic units. Fig. 5.19a, b Superiorly based lateral transposition flap. Fig. 5.19a, b Superiorly based lateral transposition flap. Fig. 5.20a, b Small transposition flap based inferomedially. a Wedge-shaped defect on the nasal flank. Burow's triangle is in the nasolabial fold. b Closure of all defects (see Fig. 3.1). Fig. 5.23 Superiorly based cheek rotation of Sercer (1962). Fig. 5.23 Superiorly...

Defect in the Medial Canthus

Esser Rotation Flap

A medial defect can be repaired with an Imre cheek rotation flap combined with a rotation flap from the forehead (see Figs. 5.2-5.8). Fig. 8.5 Modified Imre flap. The scar is located in the alar groove. Fig. 8.5 Modified Imre flap. The scar is located in the alar groove. Fig. 8.6 Modified Esser cheek rotation (see Fig. 8.1). It may be necessary to extend the flap incision around the mandibular angle. Burow's triangles are excised for counter-rotation and to reduce the size of the secondary...

Brown Modification of the Estlander Flap 1928

Estlander Flap

An Estlander flap can also be used for larger medial defects involving more than one-third of the lower lip. The defect created by the wedge excision (Fig. 6.44a) is covered by making a three-layer incision through the lower lip at the commissure and advancing the lip into the defect (Fig. 6.44a, b). A superior Estlander flap is then used to close the remaining lateral defect (Fig. 6.44c, d). a A mucosal flap from the anterior margin of the tongue, based on the right or left side, is swung into...

Deltopectoral Flap

Although this flap (see Fig. 12.1, 5) is credited to Bakamjian, it was first mentioned in the German literature during the 1900s and in the American literature in the early 2000s. Once commonly used, the deltopectoral flap has now been largely superseded by the pectoralis major island flap. Flap type fasciocutaneous flap of the random pattern type (see Fig. 1.2). Flap components skin, subcutaneous fat, muscular fascia. Use as a regional transposition flap. Vascular supply First through fourth...

Radial Forearm Flap

Venae Comitantes Radial

Flap type fasciocutaneous (neurovascular) flap or pure fascial flap of the axial pattern type (see Figs. 1.3 and 1.4). Flap components skin, subcutaneous fat, and fascia (may include sensory nerve). Use microvascular flap. Vascular pedicle The flap is based on the radial artery, which is a continuation of the brachial artery. Its caliber is approximately 1-2 mm. The radial artery is accompanied in its distal portion by two venae comitantes (Fig. 14.1, 2), which unite at the elbow to form one...

Wedge Shaped Defect in the Alar

Alar Groove

Wedge-shaped defects in the alar rim no larger than 1 cm can be covered with a full-thickness composite graft from the auricle (Fig. 5.41 ). These composite grafts have a success rate of 80 , and livid discoloration during the initial days after graft inset should not cause concern. The skin component should be cut slightly larger than the cartilage, and the fine monofilament sutures should not be spaced too close Fig. 5.41 Wedge-shaped alar defect reconstructed with a composite graft. a A...

Composite Grafts

Composite grafts are generally obtained from the auricle, particularly two-layer chondrocutaneous grafts and full-thickness (three-layer) grafts composed of anterior skin, cartilage, and posterior skin. They are most commonly used for nasal reconstruction but can be used in the auricle as well. Because the skin of the graft contracts slightly, it should be cut slightly larger than the defect and thus larger than the cartilage layer. Again, we use a pattern made from aluminum foil (suture...

Wedge Shaped Defects

Clinical Facial Plastic Images

Wedge-shaped midline defects that are based on the glabella (Fig. 4.2a) or frontal hairline (Fig. 4.2b) can be closed primarily by making an incision above the eyebrow or along the hairline and mobilizing the forehead skin. in the forehead with an inferior base. An incision is made above the browline, and Burow's triangles are excised just lateral to the brow (see Fig. 4.3). The forehead skin is mobilized in the direction of the arrows. A Z-plasty (red line) can be used to disperse the scar. b...

Method of Gillies and Millard 1957

A vermilion flap is outlined on the upper or lower lip (Fig. 6.58a) according to the degree of elongation required. A two-layer excision is made at the commissure, sparing the mucosa on the inner aspect of the lower lip, which is raised as a flap (Fig. 6.58b, c). That flap is sutured to a de-epithelialized area to reconstruct the vermilion of the lower lip (Fig. 6.58d). The vermilion flap is rotated laterally to restore the upper vermilion at the commissure. The mucosal flap may have to be...

Inand Out Flap of Peers 1967

This flap has an anterior superior subcutaneous pedicle (Fig. 5.45a, b) similar to the sliding flap above. The anterior portion of the flap is used for lining (Fig. 5.45b, c). The lower portion of the nasolabial flap is partially cleared of fat and inset into the alar defect for cover (Fig. 5.45c, d). from the nasolabial fold (after Barron et al. 1965 see Fig. 5.33). a The flap is based superiorly on a subcutaneous pedicle. b Closure of all defects. from the nasolabial fold (after Barron et al....

Pedicled Transposition Flaps

Clinical Facial Plastic Images

Defects of the concha and preauricular region may sometimes require a flap that does not follow the RSTLs, especially in the case of elderly patients where swift treatment and rehabilitation are a prior ity. We have repaired these cases with an inferiorly based (Fig. 8.22) or temporally based transposition flap (Fig. 8.23 1), using an anteriorly based cheek rotation to close the secondary defect (Figs. 8.22 and 8.23, 2). Fig. 8.24 Preauricular hair loss corrected with a superiorly based...

Wedge Excision

Tumors that require excising up to one-third of the lower lip can be removed by a wedge excision. The sides of the excision should curve outward (heart-shaped excision, Fig. 6.38a) this creates a slight tissue excess along the suture line that will prevent notching after the scar has matured. The wound is closed from inside to outside (Fig. 6.38b), using a special stay suture (Fig. 6.38c, A) to coapt and align the vermilion. The muscle stumps are approximated separately with absorbable sutures...

Earlobe Reduction

Earlobe Reduction

A variety of simple incision techniques can be used, as illustrated. Fig. 10.27 a Two-layer defect in the postauricular surface repaired with a transposition flap. c Closure of a three-layer defect. The anterior side is repaired with a superiorly or inferiorly subcutaneously based island flap (A), the posterior side with a transposition flap (see Figs. 10.1 and 10.2). d The completed repair. Fig. 10.26 Two-layer defect in the postauricular surface repaired with a rotation flap. a Outline of the...

Free Skin Grafts

Although our tendency is to cover facial defects with local skin flaps, sometimes it is better to use a full-thickness or split-thickness skin graft to repair a tumor resection site, especially in older patients. This is especially true if the tumor cannot be excised with the requisite safety margin or if it is uncertain that the tumor has been fully encompassed. We use skin from the postauricular or retroauricular area to cover facial defects, as it most closely matches the color and texture...

Carving an Auricular Framework

The framework should be as delicate as possible and about 3 mm smaller than the film pattern in all dimensions (see Fig. 10.13). The block from which the main framework is carved may be obtained from the ipsilateral side (Weerda, Nagata operative side, easier access) or from the contralateral side (Brent, Siegert) (Fig. 11.3a, b see also Fig. 11.1). Instruments The instruments for framework fabrication consist of No. 11 and No. 15 scalpel blades, special sharp gouges (see Fig. 2.7a, 7) 2-5 mm...

Bilobed Flap

A submental bilobed flap provides a very simple method for repairing this kind of defect. Fig. 7.1 a, b Burow's hook-shaped cheek advancement flap, used here to resurface a defect on the chin. Fig. 7.1 a, b Burow's hook-shaped cheek advancement flap, used here to resurface a defect on the chin. Fig. 7.2 a, b Defect repaired with a bilobed flap. Fig. 7.2 a, b Defect repaired with a bilobed flap.

Classic Lower Lip Reconstructions

Angle The Lip

Approximately 90 of all lip tumors occur in the lower lip. It is important, therefore, to obtain a good esthetic and functional result when repairing small and large defects of the lower lip. Fig. 6.37a, b Z-plasty used to raise the angle of the mouth. Fig. 6.37a, b Z-plasty used to raise the angle of the mouth. Fig. 6.38a Heart-shaped wedge excision from the lower lip (up to one-third). b The mucosa is closed first. c Then the muscle edges are approximated with absorbable sutures (M). A...

Replantation of the Auricular Cartilage

Analogous to auricular reconstruction with rib cartilage, the skin of the avulsed ear can be removed and the auricular cartilage implanted into a pocket developed in the area above and behind the defect (see Figs. 10.15,10.18, and 10.30). The cartilage is sutured to the auricular cartilage stump and inserted into the pocket, and the skin of the pocket is sutured to the skin of the stump (see Figs. 10.15,10.18, and 10.30). Fig. 10.28 Subtotal auricular defect with preservation of the helix and...

Ways To Correct Upper Lip Defects

Larger defects in this area are repaired with an inferiorly based bilobed flap from the cheek. The first lobe of the flap should cover the nasal floor and upper lip, and the ala should be correctly positioned without tension in the angle between the first and second lobes (Fig. 6.16b). A larger defect in the upper lip can be repaired with a full-thickness sliding flap (Fig. 6.17) or advancement flap (Fig. 6.18). In the latter case a crescent-shaped skin excision is made in the alar groove above...

Instrumentation

The instruments required for microvascular surgery are relatively few in number straight and curved microforceps (Fig. 14.3a), microscissors (Fig. 14.3b), and Fig. 14.3 Instruments for microvascular surgery. b Spring-handled microscissors, straight and curved (also spring-handled needle holder with fine jaws). c Vascular clips and clip applier. d Approximators (double micro-clamps). vascular clips and clip appliers (Fig. 14.3c). Microforceps or special spring-handled needle holders are...

Frontotemporal Flap of Schmid and Meyer

What Total Composite Flap Facelift

If the median or oblique forehead flap cannot adequately cover a defect or if larger, full-thickness defects are present, excellent results can be achieved with the somewhat difficult frontotemporal flap of Schmid (1952) as modified by Meyer (1964, 1988) (Fig. 5.17). Because of its technical complexities, however, this flap is no longer widely used. The flap is mobilized in stages approximately 16-20 days apart. In about 8 weeks the surgeon can swing the flap downward, freshen the wound edges,...

Weerda 1983

In elderly patients with a large excess of cheek skin, an anterosuperiorly based bilobed flap can be taken from the cheek to reconstruct a large alar defect. With older defects, a turnover flap above the nostril can be used for lining (Fig. 5.46a see also Fig. 5.42a, b), and an alar rim is fashioned by hinging over the lateral part of the first bilobed flap (Fig. 5.46a). The secondary defect is closed by mobilizing the surrounding skin. The cheek just below the eyelid should not be mobilized,...

Closure of Defects in the Auricular Region

If an inferiorly or superiorly based transposition flap or rotation flap is not adequate, other options include a large inferiorly based rotation flap (Fig. 10.33), bilobed flaps (similar to Fig. 10.28 Weerda 1978 a-c), or a bilobed flap (Fig. 10.34 see also Fig. 10.18). The second lobe of the bilobed flap is taken from the neck Fig. 10.34a, b Large defect in the auricular region repaired with a bilobed flap (Weerda 1978). The primary lobe is cut behind the defect, and the secondary lobe is...

Nasolabial Flap of Tipton 1975

Tipton suggested using the Nelaton flap for larger defects in 1975. The ala is detached for its full thickness, and the Nelaton flap is sutured into the defect (Fig. 5.58a). The upper edge of the flap can be deep-ithelialized prior to inset. The second side can be left to granulate. Three weeks later the flap is detached and the ala returned to its original position (see Fig. 5.47). Fig. 5.57a Posteriorly (or anteriorly) based flap from the inferior turbinate (may include a piece of bone). b...

Neurovascular Island Flaps

With some flaps, sensory or motor nerves can be mobilized in addition to nutrient vessels. For example, authors have transferred neurovascular island flaps from around the mouth for use in lip reconstruction (Karapandzic 1974 Weerda 1983 a, b Remmert et al. 1994 Figs. 6.17, 6.29, and 12.1). Fig. 1.5 Axial-pattern myocu-taneous island flap (see Figs. 12.1 and 12.2). Fig. 1.5 Axial-pattern myocu-taneous island flap (see Figs. 12.1 and 12.2).

Tumor Resection and Helical Defect Closure with a Decrease in Auricular Size

Colobomas Plasty

A) Wedge-shaped resection (Fig. 10.4) A helical defect caused by a small tumor resection or injury can be closed by extending the defect to a wedge shape (Fig. 10.4a). Small, full-thickness Fig. 10.5 Small helical resection defect repaired by the Ger-suny technique (1903) (Weerda modification). a Following tumor resection, a curved two-layer incision is made in the scapha, and a Burow's triangle is excised in the earlobe. b The entire helix is mobilized on the postauricular skin, and the wounds...

Reconstruction of Helical Defects with Preservation of Auricular Size

Crus defects are reconstructed with a superiorly based preauricular transposition flap (Fig. 10.10a, b). b) Small helical defect transposition flap and bipedicle flap (Figs. 10.11 and 10.12) First stage A small helical defect can be reconstructed with a superiorly or inferiorly based transposition flap (Fig. 1o.11 ) and a slightly longer defect with a bipedicle flap (Fig. 10.12) supported by cartilage from the ipsilateral concha or opposite ear. Fig. 10.10 Reconstruction of the crus. a...

Large Bilobed Flap from the Neck Weerda 1980b

We cover large defects of the lower lateral cheek and neck with a posteriorly based bilobed flap from the submandibular or neck-shoulder region. With exten- Fig. 8.26 Use of a posterosuperi-orly based bilobed flap to close a defect in the lower cheek. a Outline of the superiorly based bilobed flap. b The completed repair. Fig. 8.26 Use of a posterosuperi-orly based bilobed flap to close a defect in the lower cheek. a Outline of the superiorly based bilobed flap. b The completed repair. sive...

Rotation Flap

Bilobed Flap

This is a semicircular skin flap that is rotated into the defect on a pivot point. Again, the flap must be sufficiently broad, and a broad base is necessary if a backcut is needed to lengthen the flap (Fig. 3.20). If the rotation flap is too small (Fig. 3.21a), the residual defect can be covered by mobilizing the surrounding skin (Fig. 3.21b, c). a The mobilized flap is rotated into the defect (D) after the excision of a Burow's triangle (B). b Appearance after closure of the defects. a The...

ZPlasty

Multiple Plasty Technique

The Z-plasty is used to relieve tension on tissues that have been distorted by a contracted scar (Fig. 2.15). This technique can also disperse and redirect wounds that cross RSTLs at right angles, in which case a multiple Z-plasty can also be used (Fig. 2.16) (Jackson 1985 a). a The scar is excised, and the long scar is dispersed into multiple Z's that more closely follow the RSTLs. b Transposing the flaps lengthens the tissue in the direction of the scar and disperses the scar into multiple...

Total Nasal Reconstruction with the Sickle Flap Farrior 1974

As in other reconstructions following total nasal loss, the forehead skin can be augmented by soft-tissue expansion for 6-8 weeks before the flap is incised (see Fig. 4.5). Stage I The skin flap is taken from the median forehead, and its distal end is preshaped to form the alae and columella. As with the Converse scalping flap (Figs. 5.50 and 5.51 ), the flap should not be made too narrow (Fig. 5.52a). It receives its blood supply from branches of the superficial temporal artery. Nasal lining...

Weerda 1984

Posterior Auricular Flap

Larger two-layer and three-layer defects involving the anthelix and concha can be repaired with a superiorly or inferiorly based transposition flap. If necessary, the postauricular surface is covered with a rotation flap. The helical rim can be temporarily sectioned and separated (Fig. 10.3a-c). In a second stage 18-22 days later, the healed flap is divided and the helix reapproximated. The rest of the pedicle is then returned to the mastoid area (Fig. 10.3d). b Retroauricular and postauricular...

Design Bilobed Flap

Bilobed Flap Face

The nasal tip area can be reconstructed using bilobed flaps that are based inferiorly (Fig. 5.13a), laterally (Fig. 5.13c), or superiorly (Fig. 5.13e). The scars should be placed approximately in the RSTLs. If the flaps are sufficiently large and mobile, a defect in the upper columella can be repaired concurrently with the tip defect. Fig. 5.13 a-f Various designs of the bilobed flap. Fig. 5.13 a-f Various designs of the bilobed flap.

Random Pattern Flaps

Random And Axial Pattern Flap

Random pattern flaps derive their blood supply from the dermal and subdermal plexus (Fig. 1.2). The ratio Fig. 1.2 Random pattern skin flap for facial use has an approximately 2 1 ratio of length to width. A special type is the subcutaneous pedicle flap (Barron et al. 1965 Lejour 1972 see Figs. 5.44 and 5.45). Fig. 1.2 Random pattern skin flap for facial use has an approximately 2 1 ratio of length to width. A special type is the subcutaneous pedicle flap (Barron et al. 1965 Lejour 1972 see...

Of Weerda 1980 1990

Gillies Fan Flap

This flap is incised in three layers (Fig. 6.29a). The inferior labial artery and vein are dissected laterally in the cheek, then the mucosa is divided. The facial nerve branches are dissected and preserved. The three-layer skin-muscle-mucosal flap is then slid into the upper lip defect on its vascular pedicle, and the secondary wound is closed by mobilizing the surrounding skin (Fig. 6.29b, c). If part of the upper lip remains, the flap is incised downward at the commissure, portions of the...

Suture Materials and Techniques

Images Simple Continues Sutures

We use atraumatic cutting needles for the skin, and we generally use round needles for the mucosa. Our suture material of choice for the face is 6-0 or 7-0 monofilament on a very fine needle. Occasionally we use 5-0 monofilament for areas that are not visible. Prolene , PDS , P1 and P6 5-0 needle with P3 or PS 3 needle. Our subcutaneous sutures are composed of ab-sorbable or fast-dissolving braided or monofilament material. Vicryl or PDS, P1, P3 needle Ethicon, Norderstedt, Germany. A suture or...

Reconstruction of the Medial Canthus

(Figs. 9.13 and 9.14) (see also Figs. 5.2-5.7) defect repaired with a bilobed forehead flap (see Figs. 5.3-5.7 and 9.5). defect repaired with a bilobed forehead flap (see Figs. 5.3-5.7 and 9.5). Fig. 9.14a, b Use of a bilobed cheek flap with a superior and medial pedicle to repair a medial canthal defect (see Figs. 5.3-5.7, 9.5, and 9.13).

Transposition Flap

This flap must be large enough for transfer into a local defect (D). The surrounding skin can be mobilized for primary coverage of the secondary defect (S) a The transposition flap is outlined at a 90 angle to the defect (D). b The flap is swung into the defect, and the secondary defect (S) is closed by advancing the surrounding skin. c Appearance after closure of all defects. a The transposition flap is outlined at a 90 angle to the defect (D). b The flap is swung into the defect, and the...

Lip Reduction

Lip Closure

Protuberant lips can be reduced by an intraoral mucosal resection (Fig. 6.34a, b) to decrease the size of the visible vermilion and thus narrow the lips. Since the scars are intraoral, they cannot be seen (Fig. 6.34c). Fig. 6.32a, b The vermilion is stretched out to its normal Fig. 6.33a, b Small defect of the lower lip with scar contrac-length by excising the scars and performing multiple Z-plasties. tures repaired by a V-Y closure. Excess tissue should be provided in the vermilion area to...

Large Full Thickness Reconstruction of the Cheek and Commissure

Buccal Artery Myomucosal Flap

In defects that have existed for some time, turnover flaps can be used to restore inner lining. The mucosa can also be mobilized to restore partial lining. Additionally, pedicled or free mucosal flaps from the tongue or opposite cheek as well as split-thickness skin grafts can be used for internal reconstruction after the external defect has been covered. Large ex- Fig. 6.53 a Low cheek rotation combined with an Estlander flap. Fig. 6.54 Vermilion advancement of Goldstein (1984). a The...

Total Lower Lid Reconstruction

Cheek Advancement Flap

The entire lower lid can be reconstructed with a transposition flap (Fig. 9.11a, b) or a bipedicle flap (myocutaneous flap, Fig. 9.12a, b) from the upper eyelid (Tripier flap). As in other methods, a chon-dromucosal graft from the nasal septum can be used for lining (see Figs. 9.6 and 9.7). The lateral and medial pedicles are divided and inset in a later sitting. Fig. 9.7 Lower lid reconstruction using the rotation-advancement technique of Mustarde (1980). a The mucosal defect is reconstructed...

Burows UAdvancement

Pic Advancement Flap

The U-shaped skin advancement requires the excision of two Burow's triangles Fig. 3.2a . The length-to-width ratio of the standard U-flap should not exceed 2 1, and a 3 1 ratio is allowed only in exceptional cases. In the Stark modification of the U-advancement quoted in Jost et al. 1977 , the flap is widened toward its base. Cut-backs can be added to increase the flap length Fig. 3.3a . The extra small defects created by the flap are closed by mobilizing the surrounding skin Fig. 3.3b . Other...

A

Each excision angle is 30 b Closure. Fig. 2.11 a Crescent-shaped advancement flap of Jackson 1985 . Fig. 2.11 a Crescent-shaped advancement flap of Jackson 1985 . a The scar, which crosses the RSTLs -- almost at right angles, is excised and dispersed with a 45 Z-plasty. Flaps 1 and 2 are transposed, causing a slight lengthening of the tissue in the direction of the arrow. b Transposing flaps 1 and 2 in a 60 Z-plasty produces even greater tissue lengthening arrow . a...

Imres Cheek Rotation 1928

Cheek Rotation Flap

Imre developed a laterally based, wedge-shaped cheek rotation flap for reconstructing nasal flank defects that extend into the lower eyelid. Instead of a Burow's triangle, a banana-shaped incision is made Fig. 5.24a, b Burow's laterally based cheek advancement is a hook-shaped flap for repairing nasal flank defects also suitable for lower eyelid reconstruction . Fig. 5.24a, b Burow's laterally based cheek advancement is a hook-shaped flap for repairing nasal flank defects also suitable for...

Upper Eyelid Reconstruction of Fricke and Kreibig

Fricke Flap

Large portions of the upper and lower eyelid can be reconstructed with a narrow transposition flap that is raised above the eyebrow on a lateral pedicle. Thick split retroauricular skin grafts can also be used. Fig. 9.3 Mustarde's technique of upper eyelid reconstruction using a laterally based full-thickness flap from the lower lid after Beyer-Machule and Riedel 1993 . a The full-thickness lower lid flap is outlined with a lateral pedicle. b The flap is swung into the upper lid defect, and the...

VY Advancement

Advancement Flaps Tongue

Trapezoidal rotation flaps are useful for reconstructing defects of the upper nasal dorsum Fig. 5.2a and canthal area Figs. 5.3-5.6 . The flap geometry corresponds to a V-Y advancement, and the secondary defect is closed by mobilizing the surrounding skin Figs. 5.2b, 5.3, and 5.4 . Because these flaps receive a good blood supply from the supratrochlear artery on one side, the pedicle can be kept relatively thin, allowing for good mobilization and downward rotation of the flap. from the...

VY Advancement Flap of Rieger 1957

Pectoralis Advancement Flap

Larger nasal tip defects can be covered with a Rieger advancement flap based on the side of the nose Fig. 5.14a . The glabellar portion of the flap has a trapezoidal design. The flap is mobilized along the opposite nasal flank, and a V-Y advancement is performed Fig. 5.14b . A small Z-plasty may be necessary with larger defects Fig. 4.14c, d . The U-ad-vancement is another option Fig. 5.14e, f . Fig. 5.14 Various designs of advancement flaps used to reconstruct the dorsal nasal skin. a-d Long...

Fan Flap of Parietotemporal Fascia

The head is shaved on the designated side. A Doppler probe is used to locate and mark the course of the superficial temporal artery Fig. 10.32a , and the skin over the fascia is opened with a zigzag incision Fig. 10.32b . The skin should not be incised too deeply, because the parietotemporal fascia directly overlies the deep temporal fascia and is just below the hair bulbs and fat. The scalp is dissected to the left and right, directly below the plane of the hair bulbs. At this point the blood...

Burows Retroauricular UAdvancement Flap

Bolster Facial Surgery

Middle third defects of the helix Fig. 10.17 can be reconstructed with a broad, posteriorly based flap that is raised in the postauricular sulcus Fig. 10.17a and dissected toward the scalp. After raising the flap, we use a film pattern as a guide to make a supportive Fig. 10.16 Reconstruction of the upper auricle with an anteriorly based flap L . a The flap is cut along the stump in the sulcus and superiorly along the hairline. b The cartilage framework is sutured to the stump. The skin on the...

Bipedicled Flap of Schultz Coulon 1989

First the mucosa on both sides of the septal defect is undermined from the front through a transfixion incision, and the defect is freshened. The entire mucosa Fig. 5.59 Bilateral bipedicled flap technique of Schultz-Coulon 1989 . a The septal mucosa around the defect is mobilized through a hemitransfixion incision, and the entire mucosa is mobilized past the nasal floor to the inferior turbinate here on the right side . The mucosa on the left side is separated past the nasal dorsum. The mucosa...

Lateral Cheek Rotation of Weerda 1980c

Pectoralis Advancement Flap

Moderate-sized preauricular cheek defects can be repaired with a superiorly based cheek rotation flap Fig. 8.20 . A transposition flap with V-Y advancement can be used in the inferolateral cheek area Fig. 8.21 . Fig. 8.21 Low lateral cheek defect repaired with a transposition flap from the neck. a The superiorly based transposition flap is outlined in a rhomboid-like design. b All defects are closed by V-Y advancement. Fig. 8.22 Defect in the upper preauricular region D1 . a Inferiorly based...

Cheek Flap

Nasolabial Flap

If a large defect of the nasal dorsum cannot be adequately covered with a midline Rieger flap see Fig. 5.10 , it may be necessary to perform a unilateral or bilateral cheek advancement Fig. 5.12 with Burow's triangles in the nasolabial folds. A better scar is obtained by adding a Z-plasty on the nasal dorsum Fig. 5.12a, b . The median forehead flap is also useful for this type of reconstruction see p. 33, Fig. 5.15 . Fig. 5.11 Nasolabial flaps Cameron 1975 used to reconstruct b A second...

Or Binocular Loupe

Practiced on thin silicone film or surgical glove material. practiced on thin silicone film or surgical glove material. practiced in a thin silicone tube. The needle should enter and exit perpendicular to the vessel plane. Note the curved needle path. b The needle not the suture itself is grasped with the needle holder and pulled. The suture is pulled through until the short end appears in the magnified field of view. practiced in a thin silicone tube. The needle should enter and exit...

Median Forehead Flap with Soft Tissue Expansion

In this technique the median forehead skin is expanded with a 200-mL envelope for 6-8 weeks, and then a forehead flap is incised to match the nasal defect Fig. 5.53 Siegert et al. 1992, 1994 see also Fig. 5.49 and Fig. 5.16, oblique forehead flap . b The forehead flap is inset into the defect over silicone stents lining see text . Closure of the donor defects is the same as with the Converse scalping flap Figs. 5.50 and 5.51 e, f . Fig. 5.52 Sickle flap of Farrior 1974 . a The lower portion of...

Reconstruction of the Ear or Auricular Region in Patients with Skin Loss or Burns

If the skin around the ear cannot be used, the parie-totemporal fascia Fig. 10.32 on the ipsilateral side can be transferred as a fan flap to cover the auricu lar framework. Split-thickness skin is then used to cover the fascia. The preferred donor site for this skin is the posterior surface of the opposite auricle, as this will provide the best color and texture match. The entire postauricular surface and mastoid area can be utilized while leaving the perichondrium on the auricle. A large...

Median Forehead Flap

Flap Surgery

The median forehead flap is used to reconstruct larger defects of the nasal dorsum, sidewall, and tip. The flap receives its blood supply from the su-pratrochlear artery on one or both sides Fig. 5.15b . These vessels can be identified with a Doppler probe. The forehead should be high enough to permit the end of the flap to reach the nasal tip using a pattern as a guide . The width of the flap should not exceed 3-3.5 cm so that the donor defect in the forehead can be closed primarily without...

Abbe Flap 1898

Abbe Flap Surgery

Moderate-sized defects of the upper lip can be repaired by transposing a wedge-shaped flap from the lower lip based on the inferior labial artery. The Abbe Fig. 6.19 Modified cheek advancement of Weerda et al. 1981, 1990 . a The flap is cut and the cheek is mobilized, aided by a crescent-shaped excision in the area of the alar groove and lateral nose. b The completed repair. Fig. 6.20 Upper lip reconstruction by the method of Celsus ca. 25 A.D. and Bruns 1859 . a A two-layer, crescent-shaped...

Replantation by the Technique of Mladick 1971

In this technique the amputated ear part is derma-braded with a large diamond or corundum wheel, then inserted into a retroauricular skin pocket and sutured to the stump, as in the replantation of auricular cartilage. Four weeks later the skin pocket is opened, the largely epithelialized segment is taken from the pocket, and the skin of the pocket is fixed in the retroauricular sulcus. The replantation of small auricular segments by the Mladick technique has a success rate of approximately 65...

Turnover Flap and Composite Graft

Alar And Prevertebra Facial Layer

Lexer 1931, modified by Kastenbauer 1977 A bipedicled turnover flap is used for intranasal lining Fig. 5.39a, b , similar to the technique just described. Then a two-layer composite graft is used to reconstruct the alar rim. The skin of the composite Fig. 5.36 Modification of the anteriorly based alar rotation. a An incision is made around the ala, and two adjacent flaps are outlined. b The ala is brought down to the desired position, and the flaps are transposed. c Appearance after the...

Opposing Transposition Flaps

Burows Triangle

If the primary reconstruction flap can be raised in the preauricular area Fig. 8.18a , the secondary defect can be closed with an inferiorly based retroauricular flap. The tertiary defect can then be covered by mobilization Fig. 8.18 or with a thick split skin graft e.g., from the buttock . a Wedge-shaped defect with a superior base. A retroauricular Burow's triangle is excised. b The completed repair. c A circular defect is covered with a rotation flap from the upper neck. d The completed...

Latissimus Dorsi Island Flap

Latissimus Dorsi Flap

Flap type myocutaneous island flap of the axial pattern type see Figs. 1.3 and 1.4 . Flap components skin, subcutaneous fat, fascia, muscle latissimus dorsi . Use myocutaneous island flap, microvascular anastomosis. Vascular pedicle The vascular bundle supplying the muscle consists of the thoracodorsal artery and vein Fig. 12.2 , which are a continuation of the subscapu-lar artery and vein and give off the circumflex scapular artery and vein about 2-4 cm below their origin from the axillary...

Groin Flap

Flap type osteomyocutaneous flap composite or compound of the axial pattern type. Flap components skin, subcutaneous, muscle internal oblique , bone ilium . The groin flap can be transferred as a bone graft only iliac crest bone graft , as a bone graft with muscle, or as a bone graft with muscle and skin osteomyocutaneous flap . Use microvascular transfer. Vascular pedicle The osteomyocutaneous flap is supplied by the superficial and deep circumflex iliac arteries. The deep circumflex iliac...

Esthetic Units

Nasal Subunits

If portions of the face need to be reconstructed, better cosmetic results are achieved by reconstructing areas as complete units. This is not always possible, however, especially in tumor resections. b nasal subunits, anterior view, c nasal subunits, lateral view. b nasal subunits, anterior view, c nasal subunits, lateral view. Fig. 2.21 Tumor resection with histologic control. a The skin tumor is removed with a margin of healthy tissue, and the edges of the specimen are marked with threads. b...

Earlobe Reconstruction in Two Stages

Analogous to a total auricular reconstruction see Fig. 10.31 , the first stage consists of developing a pocket and inserting a cartilage graft. In a second Fig. 10.21 Reconstruction of the lower auricle by the technique of Brent 1976, modified . a Outline of a large, anteriorly based, bilobed Gavello flap. b The flap is raised, and a cartilage framework is sutured into place. c The framework is covered with the flap, and all defects are closed. Fig. 10.20 Reconstruction of the earlobe by the...

Pectoralis Major Island Flap

Images Pectoral Major Flap

Flap type myocutaneous island flap of the axial pattern type see Figs. 1.3 and 1.4 . Flap components skin, subcutaneous fat, fascia, muscle pectoralis major . Use myocutaneous island flap for reconstructing major defects in the neck and face microvascular free transfer is possible . Vascular pedicle The skin and muscle are supplied by the thoracoacromial artery, which is the second branch of the axillary artery past the scalene interval. The flap is supplied by the pectoral branches of the...

Auricular Replantation by the Technique of Baudet 1972 and Arfai 1974 Weerda 1980

Facial 1974

The replantation of ear parts is doomed to failure in most cases Weerda et al. 1986 . The overall success rate reported in the literature is approximately 30 . First stage Avulsed ear parts should be kept cool and clean by placing them in a moist paper towel or special box for delivery to the operating room. Small auricular composite grafts can be successfully replanted even after 24 hours, but necrosis increases with the size of the replanted part and the duration Fig. 10.30 Auricular...

Harvesting a Bone Graft from the Iliac Crest

Tensor Fascia Lata Graft Harvest

Autogenous bone is needed for the reconstruction of defects or to correct cosmetic deformities. Along with the tibia, fibula, scapula, and ribs, the iliac crest is among the most common donor sites for autogenous bone. It can furnish extremely large grafts, which are usually taken in the form of compound or composite flaps that include soft-tissue elements see Fig. 14.2 . Indications Cancellous bone chips are used as filling material for mandibular reconstructions and bone cysts, and composite...