Skin Cancer Reconstruction (skin grafts and local flaps)

As with any surgery, there are both potential benefits and risks. The following information will help you understand the risks of surgery. As with any operation, there may be some unanticipated complications in addition to those listed here.

The risks of skin grafts and local flaps include, but are not limited to:

Bleeding, including hematoma: If there is severe bleeding after the procedure, your surgeon might need to quickly take you back to the operating room to stop the bleeding.

Infection: Parotidectomies are done under completely sterile conditions. Still, as with any surgical procedure, there is always risk of an infection after the surgery. This might require antibiotics and/or drainage of the infection.

Anesthesia: There are risks associated with any type of anesthesia including but not limited to respiratory problems, drug reaction, heart attack, stroke, brain damage, or even death. Other risks and hazards that may result from the use of general anesthetics include but are not limited to minor discomfort due to injury to the vocal cords, teeth, or eyes. You can discuss these risks with your anesthesiologist prior to surgery.

Scar: Scar location and extent will vary depending on the procedure you are having. Initially, this will be swollen and red. As it heals, the swelling and redness will lessen. It is a good idea not to expose the scar to direct sunlight for the first 6 months after surgery to prevent the scar from hyperpigmenting (getting dark).

Numbness: A lack of sensation around the area of your incision is very common and last for several months. In rare instances, the numbness can be permanent.

Revision Procedure: Although every attempt is made to promote survival of the donor tissue, there is a possibility of tissue death. This may require additional surgery. Additional revision procedures may be necessary for cosmetic reasons.

Cervicofacial rotation flap
A cervicofacial rotation flap is used to transfer skin and soft tissue from the lower face and neck to defects of the face and cheek closer to the center. The primary goals of cheek reconstruction include the restoration of native function, maximization of aesthetic outcome, and limitation of repair-related morbidity. The skin is incised along the natural definition lines of the face and ear, and the incision is carried down into the neck. The tissue is then elevated off the underlying soft tissues and rotated into the defect. Typically this requires another small incision or two at the base of the rotation in order to get the entire site to close without tension. The sutures are left in place for 7-10 days and removed at follow up. A drain may also be placed depending on the extent of the procedure.

Paramedian forehead flap
Traditionally, the forehead flap is transferred in three stages:

First stage
This part of the procedure is usually performed under a general anaesthetic, which means you will be asleep.
A template is made using a piece of paper and is designed from the intact side of the nose to make a precise symmetric reconstruction of the nose. The template resembling the defect is placed just under the hairline and the bridge of skin is drawn downwards to the inner eyebrow. The skin is incised according to the template and the flap is turned upside-down and inset into the area of the defect on the nose. This is done using fine sutures. Extra pieces of cartilage grafts are often needed for creating support and a good shape to the nose. These are obtained from the ear be creating a small cut at the back that is usually invisible once it has healed. There is “donor” defect which is limited to small part of the forehead. Most of the defect can usually be closed using a T-shaped scar. The adjoining tissues are stitched together vertically and horizontally. Often there is a small persisting defect on the upper part of the forehead near the hairline depending on the size of the flap. Often this is simply left to heal without stitching and the scar is usually remarkably good and easily disguised. This process takes 4-6 weeks.

Second stage
The second stage is performed three to four weeks later, when the flap is well healed at the recipient site. It is usually done under a general anaesthetic (asleep) but can be performed under a local anaesthetic (awake) with a few injections to make the area go numb if you prefer. At this stage the pedicle is divided, a small part of the lower forehead is reopened and the inner eyebrow is recreated. If needed the recipient site can be altered to reach a better aesthetic result. Most patients are discharged home on the same day as their procedure and the sutures are removed a week later.

Third stage
The third stage is performed approximately four months later, when the flap has settled in well at the recipient site. Often the flap still appears to bulky or “blobby” at this stage. The aim of this stage is to remodel the flap to improve the appearance of the flap to make it look more like a nose. It is usually done under a general anaesthetic (asleep) but can be performed under a local anaesthetic (awake) with a few injections to make the area go numb if you prefer.
At this stage small incisions are made by the flap to allow the remodelling process to take place. In the unlikely event that there have been problems with the scars by the eyebrow, these can be adjusted at the same time
Most patients are discharged home on the same day as their procedure and the sutures are removed a week later.

Nasolabial flap
Traditionally, the nasolabial flap is transferred in three stages:

First stage
This part of the procedure is usually performed under a general anaesthetic, which means you will be asleep.
A template is made using a piece of paper and is designed from the intact side of the nose to make a precise symmetric reconstruction of the nose. The template resembling the defect is placed along the natural crease between the base of the nose and the corner of the mouth. The skin is incised according to the template and the flap is turned 180 degrees and inset into the area of the defect on the nose. This is done using fine sutures. Extra pieces of cartilage grafts are often needed for creating support and a good shape to the nose. These are obtained from the ear be creating a small cut at the back that is usually invisible once it has healed. There is “donor” defect which is limited to the line between the nose and mouth.. Most of the defect can usually be closed using a straight line.
Second stage
The second stage is performed three to four weeks later, when the flap is well healed at the recipient site. It is usually done under a general anaesthetic (asleep) but can be performed under a local anaesthetic (awake) with a few injections to make the area go numb if you prefer. At this stage the connection from the nose to the donor site is divided. If needed the recipient site can be altered to reach a better aesthetic result. Most patients are discharged home on the same day as their procedure and the sutures are removed a week later.
Third stage (possible)
The potential third stage is performed approximately four months later, when the flap has settled in well at the recipient site. Often the flap still appears to bulky or “blobby” at this stage. The aim of this stage is to remodel the flap to improve the appearance of the flap to make it look more like a nose. It is usually done under a general anaesthetic (asleep) but can be performed under a local anaesthetic (awake) with a few injections to make the area go numb if you prefer.
At this stage small incisions are made by the flap to allow the remodelling process to take place. In the unlikely event that there have been problems with the scars,, these can be adjusted at the same time . Most patients are discharged home on the same day as their procedure and the sutures are removed a week later.

Abbe (cross-lip) flap
Traditionally, the cross-lip flap is transferred in three stages:

First stage
This part of the procedure is usually performed under a general anaesthetic, which means you will be asleep.
A template is made using a piece of paper and is designed from the intact side of the nose to make a precise symmetric reconstruction of the lip. The template resembling the defect is placed on the opposite lip, slightly offset from the defect. The skin is incised according to the template and the flap is turned upside-down and inset into the area of the defect on the deficient lip. This is done using fine sutures. There is “donor” defect which is limited to a vertical line in the donor lip. The scar is usually remarkably good and easily disguised. This process takes 4-6 weeks.
Second stage
The second stage is performed three to four weeks later, when the flap is well healed at the recipient site. It is usually done under a general anaesthetic (asleep) but can be performed under a local anaesthetic (awake) with a few injections to make the area go numb if you prefer. At this stage the connection between the two lips is divided, a small part of the donor lip is re-opened and the natural contours are re-established if needed. If needed the recipient site can be altered to reach a better aesthetic result as well. Most patients are discharged home on the same day as their procedure and the sutures are removed a week later.

Third stage
The third stage is performed approximately four months later, when the flap has settled in well at the recipient site. The flap may still appears to bulky or “blobby” at this stage. The aim of this stage is to remodel the flap to improve the appearance of the flap to make it look more like a natural lip.. It is usually done under a general anaesthetic (asleep) but can be performed under a local anaesthetic (awake) with a few injections to make the area go numb if you prefer. At this stage small incisions are made by the flap to allow the remodelling process to take place. In the unlikely event that there have been problems with the scars of the donor or recipient lips, these can be adjusted at the same time. Most patients are discharged home on the same day as their procedure and the sutures are removed a week later.

Scalp flap
The scalp skin is some of the least elastic skin on the body. For this reason, it is often necessary to perform multiple opposing rotation flaps (called a camera-shutter or stellate closure). Often, even after these rotational flaps, there is the need for a small skin graft to cover the central-most area of the defect that is unable to be closed by the advanced tissues. If this is necessary, an antibiotic-soaked gauze dressing will be sutured in place for a week after surgery. The remaining staples/sutures may be left in place for up to 2 weeks depending on the tension of the closure.

Skin graft
A skin graft is taken from a donor site area with good color and thickness match to the area that needs reconstruction. Some potential skin graft donor sites include: behind the ear, in front of the ear, on the neck overlying the clavicle, and in the natural groin crease. After the skin is excised from one of these areas, the surgical site is able to be closed with layered sutures in a linear fashion. The sutures are removed one week after surgery.

On the evening after your procedure, you will feel rather tired and sleepy and should warn your visitors that you may not be very good company. There may be dressings on your face/scalp that will need to be regularly changed. The wounds may drip blood for two or more days after the operation. You may look very bizarre to other people at this stage of the treatment if you have undergone a staged procedure (paramedian forehead flap, nasolabial flap) and you will want to avoid most social engagements. Remember that this is only temporary phase in your treatment and will be back to normal soon. At first you will feel rather tired and you should spend the first week or so taking it easy. After that you will be able to slowly build up to doing your usual activities.