Head and Neck Surface Defect Reconstruction

The skin covering the head and neck region is unique and its characteristic varies greatly depending on its anatomical location.  The skin of the scalp is the thickest skin in the body and has a high density of hair follicles; this skin is not found anywhere else in the human being.  It serves a protective function by enveloping the skull and its hair has an aesthetic purpose.  Conversely, the upper eyelid skin is the thinnest skin in the human.  It is thin and light and is easily closed and opened by the eyelid muscles to protect the underlying eye through rapid, dynamic movements.  The pigmentation of the skin also differs from region to region and is affected by one’s ethnicity and degree of sun exposure.

 

How do surface defects arise?

Surface defects of the head and neck region may arise from a multitude of possible causes.  Causes include injury (accidents, burn etc), infection and most commonly, defects resulting from tumor resection surgery.

How do surface defects manifest?

Surface defects of the head and neck may manifest in all different shapes, sizes and depths.  Acute injuries often result in visible wounds whereas defects that have healed may manifest as a tight scar contracture that when released, unveils the extent of the tissue deficiency.  Surface defects of the head and neck may expose critical underlying structures such as vital nerves, blood vessels and bone.  Soft tissue coverage of these defects is important to maintain vitality of these structures, prevent bacterial infection from the external environment and to restore the facial form to facilitate social reintegration.

treatment

The important factors when contemplating reconstruction of surface defects include the size and location of the defect, the skin thickness and pigmentation.   A variety of skin grafts and flaps may be used to resurface these defects optimally.  Attaining attractive and functional results requires accurate assessment, precise technical execution and an experienced practitioner.  Successful reconstruction may be attained in most cases; this restores form and function, improves self-confidence and social functioning.

Skin grafts possibly originated in India 3,000 years ago.  It was a common practice then to punish thieves by amputating the tips of their noses.  Medical practitioners would resurface these defects with skin grafts taken from the buttock region.  The art and science of skin grafting has significantly improved since and skin grafts are simple and reliable procedures performed for resurfacing of defects in many cases.

Skin grafts are often used in the setting of burn injury, trauma (e.g. accidents or interpersonal violence) and tumor resection defects.  Skin grafts may be harvested as split-thickness or full-thickness skin grafts.  In the head and neck region, it is common to perform full thickness skin grafts as this minimizes graft contracture and produces better long-term results.  Grafts are often harvested from the back of the ear, neck, upper chest or forearm to provide the best color and thickness match.

Skin grafts “heal” to the underlying wound bed within 1 to 2 weeks.  During this interval, the blood vessels from the wound bed grow into the skin grafts and provide them with their permanent blood supply.  Because of the necessity for ingrowth of blood vessels to sustain the tissue, skin grafts are always thin and are suitable for covering shallow defects.

Flaps are tissues that are harvested from a donor site and moved to a recipient site with its intact blood supply.  This permits the harvest of thicker pieces of tissue, as well as tissue composites to resurface complex and deep defects.  The principles of local flap reconstruction are:

  • Use tissue adjacent to or nearby the defect that has similar properties (thickness, contour, pigmentation)
  • Use of tissue in areas with sufficient laxity that permits donor defect closure
  • Careful donor site harvest and reconstruction to minimize morbidity arising from flap harvesting
  • Selection of tissue with a good and reliable intrinsic blood supply

Local and regional flaps are usually performed for small-to-medium sized defects in the head and neck.  They may be harvested together with skin, fat, muscle, bone and/or cartilage to reconstruct a wide range of defects.  These flaps may be moved into the defect by direct advancement, rotation or transposition.  Regional flaps may be harvested from the scalp, neck or chest to reconstruct large composite defects of the facial skin and skeleton including the jaws.  Flaps heal to the adjacent wound bed within 1 to 2 weeks.

Distant flaps are flaps that are harvested from a donor site that is anatomically remote from the recipient site with its intact blood vessels.  Similar to local and regional flaps, distant flaps harvest thicker pieces of tissue, and may also include skin, fat, muscle, bone and/or cartilage to perform a like-for-like reconstruction in the head and neck.

Distant flaps are normally used where no local or regional tissue is available, or where the wound defects are large and complex.  This may include harvesting flaps from the back and the upper and lower extremities.  Following flap harvest, the blood vessels that supply the flap will need to be connected to blood vessels in the vicinity of the defect using microsurgical techniques, where ultra-fine sutures that are thinner than a strand of hair are used.  Microsurgery is a niche surgical technique that is technically demanding technique that requires intensive training over many years.  Successful outcomes are possible in the vast majority of cases and require careful preoperative planning, precise technical execution and an experienced practitioner.

The Picasso Advantage

The head and neck region is a complex and intricate one that serves critical physical, emotional, social and psychological functions.  Reconstruction of this region requires restoration of both function and aesthetic and necessitates experienced and skilled practitioners.  Dr Yeo has a keen clinical interest in this area and has been at the forefront of delivery of this care.  He completed a fellowship in Advanced Reconstructive Microsurgery as an international fellow under the illustrious Professor Hung-Chi Chen, one of the global leaders for such surgeries.  Dr Chen is also one of the leading international authorities in intestinal flap reconstruction of the head and neck region and Dr Yeo is pleased to have performed the first successful case of colon flap reconstruction of the pharynx in Singapore.

Botulinum toxin injection

Forehead wrinkles are reliably treated with botulinum toxin injection and attains a high degree of satisfaction in most cases. The popularity of botulinum toxin injection has grown rapidly since the 1990s, and it is now one of the most commonly administered procedures in the world. A detailed explanation of botulinum toxin treatments may be found here.

Brow Lift

Brow lifts are the most comprehensive method of addressing the components of forehead aging and produces exquisite, bespoke and sustained forehead rejuvenation. Brow lifts are ambulatory procedures performed under intravenous sedation or a short general anesthesia.

Individuals with forehead skin laxity, elongation of the forehead height and deep horizontal forehead skin creases are good candidates for brow lifts. Individuals who have had suboptimal result with botulinum toxin injection may consider brow lift surgery. Botulinum toxin injection does not reduce forehead skin laxity.

Brow lift surgery delivers sustained reduction of horizontal forehead wrinkles, elevation of eyebrows to their natural position (at or above the bony eye socket) and restoration of an aesthetic brow shape. Men generally have eyebrows that are horizontal, whereas women tend to have eyebrows that are gently upward sloping or arched. Brow lift surgery also reduces excess forehead height if present. The scars are well-concealed within the hairline.

Individuals are advised to stop herbal supplements and traditional medicine and start special medications 7 days prior to surgery to minimize bruising and swelling.

An incision is usually made behind the hairline, and the forehead skin and muscle is elevated from the underlying forehead bone. The eyebrows are fixed in the correct position, and the excess skin and muscle removed. Skin closure is also performed in a meticulous manner to optimize wound healing and camouflage its final appearance.

Dr Yeo is experienced with surgical brow lifts and incorporates proprietary techniques to deliver exquisite and sustained results while minimizing the postoperative recovery time. The initial skin incision is performed using a special angled technique for preservation of the hair follicles, so that hair will eventually grow through and camouflage the scar. A special wound closure technique is used to optimize the final postoperative scar appearance. Our clinic has an en suite operating facility, which assures your maximal privacy and convenience, and keeps facility and equipment costs contained. Our operating room carries a full range of equipment tailored for brow lifts.

Mild bruising and swelling is expected, which will mostly resolve by the 10th postoperative day. The swelling is often more visible in the upper eyelid region than in the forehead because the eyelid skin is thinner. Stitches are removed on the 10th postoperative day and most individuals are able to return to work by then.

Postoperative swelling is reduced by remaining upright during the daytime and by elevating the head of the bed with extra pillows when asleep at night. Gentle hair washing is possible from the second postoperative day onwards. Strenuous activity should be avoided for the first two weeks to minimize bruising.