Comparing Rates of Distal Edge Necrosis in Deep-Plane Vs Subcutaneous Cervicofacial Rotation-Advancement Flaps for Facial Cutaneous Mohs Defects

Research

Original Investigation Comparing Rates of Distal Edge Necrosis in Deep-Plane vs Subcutaneous Cervicofacial Rotation-Advancement Flaps for Facial Cutaneous Mohs Defects

Andrew A. Jacono, MD; Joseph J. Rousso, MD; Thomas J. Lavin

IMPORTANCE The cervicofacial rotation-advancement flap is commonly used for facial defects. Decreasing the rate of distal edge necrosis (DEN) encountered with this flap would help prevent complications in sensitive areas such as the eyelid, lip, and nose.

OBJECTIVE To compare the untoward occurrence of DEN between 2 surgical dissection methods for reconstructive cervicofacial rotation-advancement flaps.

DESIGN, SETTING, PARTICIPANTS, AND EXPOSURE A review was conducted of 88 patients who underwent cervicofacial flap reconstruction for Mohs ablative surgery between January 1, 2003, and June 30, 2012, by the senior author (A.A.J.). All patients had periorbital, midfacial, Author Affiliations: New York Center cervical, and/or lateral temporal/forehead defects following Mohs surgical ablation. Patients for Facial Plastic and Laser Surgery, Great Neck (Jacono, Lavin); The were categorized into 1 of 2 groups on the basis of the surgical technique used: subcutaneous New York Eye and Ear Infirmary, (SC) cervicofacial elevation or deep-plane (DP) cervicofacial elevation. Subcategories of New York (Jacono); Division of Facial smokers and nonsmokers within each group were further reviewed. Statistical analysis of Plastic and Reconstructive Surgery, Department of Otolaryngology–Head DEN between categories and subcategories was performed. & Neck Surgery, Albert Einstein College of Medicine, Bronx, New York RESULTS Sixty-nine patients were in the SC group and 19 were in the DP group. The mean (Jacono); Section of Facial Plastic and defect size among both groups was 14.3 cm2. The rate of active or recent smokers was 23% in Reconstructive Surgery, North Shore University Hospital, Manhasset, the SC group and 11% in the DP group. The rate of DEN among nonsmokers in the SC group New York (Jacono); Division of Facial was 23% (n = 53) compared with 0% in the 17 DP nonsmokers (P = .03). The rate of smokers Plastic and Reconstructive Surgery, with DEN in the SC group was 75% and 0% in the DP group (P = .09). The mean area of DEN Department of Otolaryngology–Head and Neck Surgery, Long Island Jewish in the SC group was 0.8 cm2. Medical Center, New Hyde Park, New York (Jacono); Division of Facial CONCLUSIONS AND RELEVANCE Our statistically significant data indicate that DP dissection is Plastic and Reconstructive Surgery, a superior technique for avoiding DEN in nonsmokers. We found better outcomes in smokers New York Eye and Ear Infirmary, New York (Rousso); currently a as well. Thus, we strongly advocate the use of the DP approach as the criterion standard in medical student, Hofstra University cervicofacial flap elevation. School of Health Sciences and Human Services, Hempstead, New York (Lavin). LEVEL OF EVIDENCE 3. Corresponding Author: Andrew A. Jacono, MD, New York Center for JAMA Facial Plast Surg. 2014;16(1):31-35. doi:10.1001/jamafacial.2013.20 Facial Plastic and Laser Surgery, 440 Published online October 10, 2013. Northern Blvd, Great Neck, NY 11021 ([email protected]).

he midface, periorbital, and temporal/forehead zones thetically unforgiving areas. Distal edge necrosis is a result of can present very complex cutaneous defects after Mohs inadequate blood flow from the random-pattern blood sup- T surgical ablation. The reconstruction of larger-sized de- ply of the subdermal plexus of an SC flap. Even a small amount fects is traditionally based on Mustardé’s1 description of a ro- of DEN near important anatomic borders, such as the eyelids, tation-advancement flap elevated in the subcutaneous (SC) nose, or lip, can result in ectropion, alar asymmetry, or com- plane. This elegant reconstructive technique is useful and has missure distortion, respectively. These problems require a sec- withstood the test of time as a “workhorse” for facial defects. ondary surgery. However, one of the major complications that occur with this In recent years, descriptions of cervicofacial rotation- reconstructive method is distal edge necrosis (DEN), espe- advancement flaps with dissection in the subsuperficial mus- cially in smokers and patients with a history of radiotherapy.2 culoaponeurotic system (SMAS), or deep plane (DP), have been This is a particularly troublesome complication in reconstruc- advocated with the skin and SMAS elevated as a composite tion of any facial subunit because distal edges can lie in aes- flap.3-6 The advantage of this modification is its reliance on an

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crosis was defined as grossly visible eschar formation of any Figure 1. Subcutaneous Flap Elevation size on any distal suture line area; DEN did not include failed skin graft sites when performed concurrently with a cervicofacial flap because it was considered an unrelated occurrence. Smoking status was based on a patient actively smoking within 1 week of reconstructive surgery. Independent statistical analysis of DEN between the 2 groups was performed using the Fisher exact 2-tailed test determined using a scientific calculator (GraphPad; GraphPad Software, Inc). Rates of facial nerve injury, ectropion, and need for further surgery were recorded and analyzed.

Surgical Technique All surgical procedures were performed by one surgeon (A.A.J.). Elevation is shown along the zygomatico-temporal region and continuing onto All defects were documented by photography. Preoperative the preauricular and postauricular regions. skin markings were made following subunit principles. Both SC and DP reconstructive techniques require excising a tri- axial blood supply rather than a random pattern. The prem- angle of skin adjacent to the defect within corresponding me- ise of this technique is that described by Hamra7 for rhytidec- lolabial crease or relaxed skin tension lines to avoid a stand- tomy, whereby a DP dissection allows added perfusion to the ing cutaneous deformity. overlying skin flap and improves release of the flap for in- The SC dissection technique continues by creating an increased movement. Previous rhytidectomy studies8,9 have cision with a No. 15 blade along subunit borders. In cases in- shown that the most significant arterial supply is from the volving eyelid and midface defects, this follows along infra- transverse facial artery perforator, and comparisons of dissec- orbital rim and zygomatic arch skin and then inferiorly along tion techniques have indicated that its preservation is best the preauricular skin. The incision is then continued postau- maintained with a composite lift. ricularly, if necessary, for increased mobility and size. The ro- In our practice both methods of dissection have been used, tation-advancement flap is then widely undermined in all di- with most DP dissection having been performed in recent years. rections in the SC supra-SMAS plane (Figure 1). This allows for Anecdotally, we noted a significant decrease in DEN when using movement in the inferolateral to anteromedial direction. Care DP dissection and as such decided to compare our results ob- is taken to maintain a large base to ensure adequate flap per- jectively. Accordingly, the purpose of this study was to com- fusion. Additionally, the remaining viable medial cheek skin pare the occurrence of DEN between 2 different surgical tech- is undermined widely and brought out laterally as far as pos- niques for reconstructive cervicofacial rotation-advancement sible. Two 4-0 nylon sutures are then used to tack the flap me- flaps. dially and superiorly to the periosteum along the superior edge of the zygomatic arch and the infraorbital rim, respectively. Care is taken to not overstretch the flap so as to limit tension Methods that can reduce flap perfusion. Subsequently, 4-0 polyglactin 910 sutures are used to close the SC tissues, and 6-0 nylon su- Data tures are used for skin closure as interrupted vertical mat- A review of the medical records of all patients requiring Mohs tress sutures. reconstruction was performed in the private practice of one The DP surgical technique is performed by marking the DP of us (A.A.J.). Medical records with operative notes indicat- entry point by drawing a line connecting the lateral canthus ing that a cervicofacial rotation-advancement flap was per- and the angle of the mandible (Figure 2A). Incisions are made formed between January 1, 2003, and June 30, 2012, were ana- as described in the SC technique, and limited SC undermin- lyzed. Patients of all age ranges, sex, smoking status, general ing is performed until the DP entry point. The DP is entered medical health, ambulatory or inpatient setting, and dissec- inferiorly at the level of the mandibular angle using a No. 10 tion method were included. An exclusion criterion was post- blade and continued to the lateral canthus. Once the correct operative hematoma formation because this could serve as an plane is identified, the tissue should separate with relative ease. independent cause of necrosis regardless of technique. Pa- At this point, face-lift scissors and a lighted retractor are used tients whose records showed no follow-up or were incom- to continue the DP dissection inferiorly below the platysma plete were excluded. All included patients had surgical treat- with blunt separation of tissue to protect branches of the fa- ment prior to this retrospective analysis. Because treatment cial nerve (Figure 3). In the superior portion of the DP entry decisions were not being made proactively, no institutional re- point, the orbicularis oculi and zygomaticus fibers are identi- view board approval was necessary. However, informed con- fied and the flap is elevated superior to the mimetic muscu- sent was obtained from all patients. lature. It is necessary to ensure that the muscle fibers are not Analysis of age, sex, defect size, and location was per- incorporated into the flap. The zygomatico-cutaneous liga- formed. Additionally, DEN and smoking status were re- ments are released with blunt dissection to increase the flap’s viewed and compared between the 2 groups. Distal edge ne- mobility and arc of rotation. The skin and SMAS can now be

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Figure 2. Depiction of a Patient With a Deep-Plane Flap Figure 3. Deep-Plane Entry

A B

A, Preoperative defect. Cervicofacial flap markings depicting the deep-plane entry point as a line extending from the angle of the mandible to the lateral canthal region. Additionally, the Pitanguy line is marked to estimate the course of the frontal branch of the facial nerve. B, A 74-year-old man 1 year after receiving a deep-plane cervicofacial flap with medial full-thickness skin graft. After sharp entry into the deep plane, blunt dissection can be used to elevate This patient had no distal edge necrosis. the subsuperficial musculoaponeurotic system and skin as a composite flap.

elevated en bloc. The flap is rotated medially, and tacking su- Figure 4. Immediate Postoperative Deep-Plane Cervicofacial Flap tures are placed in the same manner as in the SC technique. Closure is performed with 4-0 polyglactin 910 sutures for SMAS/ muscle approximation, as well as SC closure. Final skin closure is via interrupted vertical mattress 6-0 nylon sutures. The dramatic movement can be seen by observing the starting and ending points of the skin markings for the DP entry point (Figure 4). Full-thickness skin grafts may be required on the most medial aspects of wounds when the elevated flaps do not easily cover them without tension (Figure 4). Both techniques may require the incorporation of full-thickness skin grafts, which are harvested from the standing cutaneous deformity of the defect at the beginning of the operation.

Results

Ninety-five patients who had undergone a cervicofacial ad- The highlighted area marks the deep-plane portion of the flap. This patient vancement flap were identified. Four were excluded because required a full-thickness skin graft to cover the most medial portion of the defect. of postoperative hematoma formation (3 in the SC group and 1 in the DP group). One patient was excluded because of in- complete medical records and another because of inability to fied: 16 in the SC group (23%) and 2 in the DP group (11%). contact for follow-up. Twenty-four cases (27%) of DEN were identified. The mean size A total of 88 patients met the inclusion criteria. Sixty- of necrotic area was 0.8 cm2 (range, 0.25-3.5 cm2). nine patients (78%) were identified as part of the SC group and There were 2 smokers in the DP group (11%), neither of 19 patients (22%) as part of the DP group. Forty-six were women whom had DEN, and 16 smokers (23%) in the SC group, 12 of (52%) and 42 were men (48%) (male to female ratios, 33:36 in whom had DEN (75%). Because of the disproportionate per- the SC group and 11:8 in the DP group). The mean (SD) patient centage of smokers in the SC group, subcategories of non- age at the time of the procedure was 65 (15) years. The mean smokers between the 2 groups were compared. Among non- patient age in the DP group was 70 years and in the SC group, smokers in the SC group, the DEN rate was 23% (n = 12) 64 years. The mean defect size was 14.3 (8.1) cm2. Notably, the compared with 0% in the DP group (P = .03). When compar- SC group mean defect size was 12.9 cm2 and the size in the DP ing subcategories of smokers between the groups, 75% (n = 12) group was 18.8 cm2, but this difference was not statistically in the SC group had DEN compared with 0% in the DP group significant. Sites of the defects included the cheek, lower eye- (P = .09) (Table). Direct comparison of DEN between the 2 lid, lateral temporal forehead, and anterior cervico/ groups, inclusive of all categories of smoking, showed a rate mandibular regions. Eighteen smokers (20%) were identi- of DEN of 35% in the SC group vs 0% in the DP group (P = .001).

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Table. Rates of Distal Edge Necrosis Among Subgroups and Resultant Figure 6. Distal Edge Necrosis Area of Secondary Defect A B C Necrosis No. of Distal Area, Characteristic Patients Edge, % cm2 Nonsmokers Subcutaneous dissection 53 23 0.4 Deep-plane dissection 17 0 0 Smokers Subcutaneous dissection 16 75 1.2 Deep-plane dissection 2 0 0 A, Preoperative infraorbital, temporal, and lateral cheek defect in a 79-year-old woman. B, One-month postoperative image showing secondary wound healing Figure 5. Depiction of Patient With Subcutaneous Flap due to distal edge necrosis; further surgery was not required. C, Six-month postoperative image demonstrating slight hypertrophy of a scar in the area of prior distal edge necrosis. A C

Figure 7. Another Depiction of a Patient With a Deep-Plane Flap

A B C

A, Preoperative defect involving perioral and midcheek region in a 69-year-old man. B, Incision lines drawn before deep-plane cervicofacial flap. C, Six-month B postoperative image; this patient had no distal edge necrosis.

Discussion

Mohs facial reconstructive surgery can be a difficult process for a patient to undergo. The stress and fear of a cancer diag- nosis is compounded by the resultant facial defect. The goal of facial reconstruction is to restore contour and aesthetics while minimizing morbidity. The impact of DEN is more far- reaching than the simple wound care that it requires; it can cre- A, Preoperative infraorbital and cheek defect on a 68-year-old man. ate an unsatisfactory scar. Even a small amount of DEN near B, Intraoperative elevation of a subcutaneous cervicofacial flap. C, One-month postoperative image showing secondary wound healing due to distal edge important anatomic borders, such as the eyelids, nose, or lip, necrosis. This patient subsequently required a full-thickness skin graft for can result in ectropion, alar asymmetry, or commissure dis- ectropion repair. tortion, respectively. These problems require a secondary surgery. Examples of DEN with an SC flap approach are seen in Figure 5 and Figure 6. In our practice, we were not satisfied with the results of The rate of complications was small. There were no facial SC cervicofacial rotation-advancement flaps and decided to ap- nerve injuries in any group. Five patients required a second- ply the same surgical principles that we have been practicing ary surgical intervention because of DEN, all of whom were in in our standard rhytidectomy. Our results show statistically sig- the SC flap group. Two required scar revision surgery be- nificant distal flap survival rates with the DP approach com- cause of poor secondary healing and hypertrophic scar for- pared with the SC approach; this significance was verified in mation. Three developed ectropion because of secondary heal- independent analysis of nonsmokers. Although mean defect ing and contracture pulling the lower eyelid down, requiring sizes were larger in the DP group, there were no episodes of a full-thickness skin graft. DEN (Figures 2, 7, and 8). Because our cohort had a dispropor-

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cohort, none of the patients who had DP surgery developed Figure 8. Complex Defect Treated With Deep Plane Flap ectropion, and 3 patients who had SC flaps developed small

A B areas of DEN resulting in ectropion requiring a secondary full- thickness skin graft. As for the discrepancy between our higher rate of DEN of 23% among nonsmokers, we acknowledge a low threshold for documenting DEN because we included areas of epidermolysis as small as 0.25 cm2. This gave us a higher rate of necrosis than that of Austen et al.10 As such, we concede that not every case of DEN leads to poor scarring and healing. None- theless, even small areas of epidermolysis and contracture can lead to problems, such as ectropion. The 5 patients who required a secondary procedure included 3 skin grafts for ectropion repair and 2 scar revisions for poor healing results. The rest of our DEN cases responded to conservative local debride- ment and wound care. The best-case scenario is one free of DEN, and our study indicates that this is most achievable via A, Large, complicated defect in a 73-year-old man involving the nose, cheek, a DP approach. and perioral region. B, Postoperative results at 6 months after a deep-plane The sample size of our DP group was smaller than that of cervicofacial flap combined with a paramedian forehead flap; this patient had no distal edge necrosis. our SC group on account of our relatively recent change in technique. Accordingly,there were few smokers in the DP group, and statistical significance was not achieved in comparing DEN tionate number of smokers in the SC group, we eliminated the among smokers. However, there was a strong correlation be- confounding factor of smoking by looking at nonsmokers tween DEN and smokers when approached via the SC tech- independently. nique, which was not seen with the DP approach. We therefore To our knowledge, this is the first published comparison propose that smokers, in particular, should undergo DP dissec- of both techniques of cervicofacial rotation-advancement flaps tion. In a study11 of rhytidectomies, a 0% rate of skin edge ne- and the largest published sample size of the DP technique. Kroll crosis was found with DP procedures in 18 patients who were et al3 advocated the DP as the “level of choice” on the basis of active smokers. These results were attributed to the thickness their results with 7 patients. However, in a study of 32 pa- of the DP flap and the resultant lack of perforator disturbance. tients undergoing SC flaps, Austen et al10 promoted the supe- The increase in operative time and technical difficulty riority of the SC approach. They concluded that the SC method make DP unappealing to a surgeon with limited experience. had an acceptable tip necrosis rate of 9% and advocated its use However, the merit of significantly less necrosis makes the DP because they postulated that it would “likely” have a lower ec- technique an excellent choice for dissection of cervicofacial tropion rate. We did not find this to be the case. In our study rotation-advancement flaps.

ARTICLE INFORMATION REFERENCES blepharoplasty. Plast Reconstr Surg. Accepted for Publication: January 7, 2013. 1. Mustardé JC. The use of flaps in the orbital 1997;99(1):16-21. Published Online: October 10, 2013. region. Plast Reconstr Surg. 1970;45(2):146-150. 7. Hamra ST. Composite Rhytidectomy. St Louis, doi:10.1001/jamafacial.2013.20. 2. Cook TA, Israel JM, Wang TD, Murakami CS, MO: Quality Medical Publishing; 1993:80-88. Author Contributions: Drs Jacono and Rousso had Brownrigg PJ. Cervical rotation flaps for midface 8. Whetzel TP, Mathes SJ. The arterial supply of the full access to all the data in the study and take resurfacing. Arch Otolaryngol Head Neck Surg. face lift flap. Plast Reconstr Surg. 1997;100(2): responsibility for the integrity of the data and the 1991;117(1):77-82. 480-488. accuracy of the data analysis. 3. Kroll SS, Reece GP, Robb G, Black J. Deep-plane 9. Schuster RH, Gamble WB, Hamra ST, Manson Study concept and design: Jacono, Rousso. cervicofacial rotation-advancement flap for PN. A comparison of flap vascular anatomy in three Acquisition of data: All authors. reconstruction of large cheek defects. Plast rhytidectomy techniques. Plast Reconstr Surg. Analysis and interpretation of data: All authors. Reconstr Surg. 1994;94(1):88-93. 1995;95(4):683-690. Drafting of the manuscript: Rousso, Lavin. 4. Becker FF, Langford FPJ. Deep-plane 10. Austen WG Jr, Parrett BM, Taghinia A, Wolfort Critical revision of the manuscript for important cervicofacial flap for reconstruction of large cheek SF, Upton J. The subcutaneous cervicofacial flap intellectual content: Jacono. defects. Arch Otolaryngol Head Neck Surg. revisited. Ann Plast Surg. 2009;62(2):149-153. Statistical analysis: Rousso. 1996;122(9):997-999. Administrative, technical, or material support: 11. Parikh SS, Jacono AA. Deep-plane face-lift as an Jacono. 5. Tan ST, MacKinnon CA. Deep plane cervicofacial alternative in the smoking patient. Arch Facial Plast Study supervision: Jacono. flap: a useful and versatile technique in head and Surg. 2011;13(4):283-285. neck surgery. Head Neck. 2006;28(1):46-55. Conflict of Interest Disclosures: None reported. 6. Longaker MT, Glat PM, Zide BM. Deep-plane cervicofacial “hike”: anatomic basis with dog-ear

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