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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, MD1,2,3,4,5; Joseph J. Rousso, MD6; Thomas J. Lavin1,7
[+] Author Affiliations
1New York Center for Facial Plastic and Laser Surgery, Great Neck
2The New York Eye and Ear Infirmary, New York
3Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head & Neck Surgery, Albert Einstein College of Medicine, Bronx, New York
4Section of Facial Plastic and Reconstructive Surgery, North Shore University Hospital, Manhasset, New York
5Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery, Long Island Jewish Medical Center, New Hyde Park, New York
6Division of Facial Plastic and Reconstructive Surgery, New York Eye and Ear Infirmary, New York
7currently a medical student, Hofstra University School of Health Sciences and Human Services, Hempstead, New York
JAMA Facial Plast Surg. 2014;16(1):31-35. doi:10.1001/jamafacial.2013.20.
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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, cervical, and/or lateral temporal/forehead defects following Mohs surgical ablation. Patients were categorized into 1 of 2 groups on the basis of the surgical technique used: subcutaneous (SC) cervicofacial elevation or deep-plane (DP) cervicofacial elevation. Subcategories of smokers and nonsmokers within each group were further reviewed. Statistical analysis of DEN between categories and subcategories was performed.

Results  Sixty-nine patients were in the SC group and 19 were in the DP group. The mean defect size among both groups was 14.3 cm2. The rate of active or recent smokers was 23% in the SC group and 11% in the DP group. The rate of DEN among nonsmokers in the SC group was 23% (n = 53) compared with 0% in the 17 DP nonsmokers (P = .03). The rate of smokers with DEN in the SC group was 75% and 0% in the DP group (P = .09). The mean area of DEN in the SC group was 0.8 cm2.

Conclusions and Relevance  Our statistically significant data indicate that DP dissection is a superior technique for avoiding DEN in nonsmokers. We found better outcomes in smokers as well. Thus, we strongly advocate the use of the DP approach as the criterion standard in cervicofacial flap elevation.

Level of Evidence  3.

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Figures

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Figure 1.
Subcutaneous Flap Elevation

Elevation is shown along the zygomatico-temporal region and continuing onto the preauricular and postauricular regions.

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

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. This patient had no distal edge necrosis.

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Figure 3.
Deep-Plane Entry

After sharp entry into the deep plane, blunt dissection can be used to elevate the subsuperficial musculoaponeurotic system and skin as a composite flap.

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Figure 4.
Immediate Postoperative Deep-Plane Cervicofacial Flap

The highlighted area marks the deep-plane portion of the flap. This patient required a full-thickness skin graft to cover the most medial portion of the defect.

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Figure 5.
Depiction of Patient With Subcutaneous Flap

A, Preoperative infraorbital and cheek defect on a 68-year-old man. B, Intraoperative elevation of a subcutaneous cervicofacial flap. C, One-month postoperative image showing secondary wound healing due to distal edge necrosis. This patient subsequently required a full-thickness skin graft for ectropion repair.

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Figure 6.
Distal Edge Necrosis

A, Preoperative infraorbital, temporal, and lateral cheek defect in a 79-year-old woman. B, One-month postoperative image showing secondary wound healing 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.

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

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 postoperative image; this patient had no distal edge necrosis.

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Figure 8.
Complex Defect Treated With Deep Plane Flap

A, Large, complicated defect in a 73-year-old man involving the nose, cheek, and perioral region. B, Postoperative results at 6 months after a deep-plane cervicofacial flap combined with a paramedian forehead flap; this patient had no distal edge necrosis.

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