eMedicine Specialties > Dermatology > Surgical

Pedicle/Interpolation Flaps

Author: Michael L Ramsey, MD, Director, Mohs Surgery Fellowship, Co-Director, Procedural Dermatology Fellowship, Department of Dermatology, Geisinger Medical Center
Coauthor(s): Heidi Kozic, MD, Mohs Fellow, Department of Dermatology, Geisinger Medical Center
Contributor Information and Disclosures

Updated: Oct 1, 2009

Introduction

An interpolation flap is a 2-stage tissue flap in which the base of the flap is not immediately adjacent to the recipient site. These flaps are used when insufficient tissue or mobility in nearby skin prevents coverage of a surgical defect with primary closure or an adjacent flap. Interpolation flaps are similar to transposition flaps in that the flap is lifted over an area of normal skin to reach the defect. While the base of a transposition flap is adjacent to the defect, the base of the interpolation flap is located a distance away from the area to be repaired. This arrangement results in a bridge of tissue, or pedicle, between the flap base and the surgical defect that typically must be removed in a second stage after vascularity is established between the wound and the flap.

The following 3 interpolation flaps are used most commonly in dermatologic surgery:

  • Forehead flap
  • Cheek interpolation flap
  • Postauricular flap

The forehead flap uses tissue from the forehead to repair the nose. The cheek interpolation flap takes advantage of the loose skin of the cheek to repair small but somewhat deep defects in the nose, and the postauricular flap uses skin from the posterior part of the ear and the retroauricular aspect of the scalp to repair defects in the helix and anterior surface of the ear.

Also see Forehead Anatomy, Forehead and Temple Reconstruction, and Cheek Reconstruction.

History of the Procedure

The forehead flap is believed to have been used in India as early as 700 BCE. Antonio Bronca of Italy performed the procedure in the 15th century. The first reports of the midline forehead flap in the English-language literature appeared in 1793. Since the 1960s, many advances have been made, including Menick's use of the paramedian forehead flap, which is based on a narrow vascular pedicle supplied by the supratrochlear artery.1 This modification allows easier closure of the forehead defect, as well as greater flap mobility, and it is currently the most commonly used forehead interpolation flap.

The cheek interpolation flap is believed to have been used since 600 BC, when it was first used in India. In contrast, the 2-stage postauricular helical flap is a relatively recent technique, which Lewin described in 1950.2

Indications

The forehead flap is used to repair more extensive defects on the nasal tip and ala for which simpler techniques cannot provide adequate coverage. It is sometimes used to provide nasal lining as well. In very extensive defects, the forehead can be used in combination with other techniques such as microvascular free flaps, cartilage or bone grafts, and mucosal flaps to achieve satisfactory function and appearance.3

Select small-to-medium, deeper defects on the nasal ala and nasal tip can be repaired by using the cheek interpolation flap.

The postauricular helical flap provides good coverage and cosmesis in medium-to-large defects on the helix and adjacent antihelix, with or without the loss of small amounts of cartilage.4

The described interpolation flaps are most commonly used to repair surgical defects resulting from tumor excision, but they can also be used to repair traumatic wounds.

Relevant Anatomy

The paramedian forehead flap is an axial flap based on the supratrochlear artery. Cadaver studies show that the supratrochlear artery exits the orbit 1.7-2.2 cm from the midline, passing deep to the orbicularis oculi muscle and ascending superficial to the corrugator supercilii muscle. It then passes medial to the eyebrow and through the frontalis muscle ascending superiorly in the subcutaneous tissue, 1.5-2 cm from the midline. The angular and supraorbital arteries also contribute to the vascularity of this flap through a rich periorbital plexus of anastomoses.5

The cheek interpolation flap is a random flap, but it receives an ample blood supply from the perforating branches of the angular, nasal, and superior labial arteries.

The postauricular scalp has a rich vascular supply from branches of the posterior auricular, superficial temporal, and occipital arteries. Therefore, the postauricular helical flap, which is a random flap, is rarely affected by vascular necrosis.

Also see Anatomy in Cutaneous Surgery.

Contraindications

The use of pedicle flaps is contraindicated in patients who are unwilling or unable to tolerate multiple-staged surgical procedures. Likewise, these procedures should be avoided in patients who cannot leave their surgical sites undisturbed, or special measures must be taken to protect the sites in these patients.

Actively infected skin should never be covered with a flap or used to form a flap. With a forehead with a low vertical height, a variation of the forehead flap or another repair method may be required.

Smoking is a relative contraindication to the use of staged island pedicle flaps because it increases the risk of flap necrosis. However, procedures with these flaps can usually be performed safely if fat is not thinned from the undersurface of the flap. In addition, avoiding the use of previously radiated skin or a previous surgical site is generally best, unless no better repair options are available.

Interpolation flaps should be performed with great care in patients who are receiving anticoagulant therapy or in patients with bleeding disorders. Consultation with the physician who prescribed the medication is prudent before discontinuing any anticoagulant therapy. The author rarely discontinues warfarin prior skin surgery. Similarly, the author only stops aspirin usage initiated by the patient and not when prescribed by a physician. Contacting consulting physicians is appropriate before operating on individuals with bleeding dyscrasias.

More on Pedicle/Interpolation Flaps

Overview: Pedicle/Interpolation Flaps
Workup: Pedicle/Interpolation Flaps
Treatment: Pedicle/Interpolation Flaps
Follow-up: Pedicle/Interpolation Flaps
Multimedia: Pedicle/Interpolation Flaps
References
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References

  1. Menick FJ. Aesthetic refinements in use of forehead for nasal reconstruction: the paramedian forehead flap. Clin Plast Surg. Oct 1990;17(4):607-22. [Medline].

  2. Lewin ML. Formation of the helix with a postauricular flap. Plast Reconstr Surg (1946). May 1950;5(5):432-40. [Medline].

  3. Burget GC, Walton RL. Optimal use of microvascular free flaps, cartilage grafts, and a paramedian forehead flap for aesthetic reconstruction of the nose and adjacent facial units. Plast Reconstr Surg. Oct 2007;120(5):1171-207; discussion 1208-16. [Medline].

  4. Cochran JH Jr, Shinn JB. The postauricular flap in helical injuries. Laryngoscope. Aug 1979;89(8):1347-50. [Medline].

  5. Reece EM, Schaverien M, Rohrich RJ. The paramedian forehead flap: a dynamic anatomical vascular study verifying safety and clinical implications. Plast Reconstr Surg. Jun 2008;121(6):1956-63. [Medline].

  6. Angobaldo J, Marks M. Refinements in nasal reconstruction: the cross-paramedian forehead flap. Plast Reconstr Surg. Jan 2009;123(1):87-93; discussion 94-7. [Medline].

  7. Christenson LJ, Otley CC, Roenigk RK. Oxidized regenerated cellulose gauze for hemostasis of a two-stage interpolation flap pedicle. Dermatol Surg. Dec 2004;30(12 Pt 2):1593-4. [Medline].

  8. [Guideline] Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. Oct 9 2007;116(15):1736-54. [Medline].

  9. Robinson JK. Laser and Light Treatment of Acquired and Congenital Vascular Lesions. In: Surgery of the Skin. Philadelphia, Pa: Mosby; 2005:625-44.

  10. Baker SR. Interpolated paramedian forehead flaps. In: Local Flaps in Facial Reconstruction. Philadelphia, Pa: Mosby; 2007:265-312.

  11. Burget GC, Menick FJ, eds. Aesthetic Reconstruction of the Nose. St. Louis, Mo: Mosby-Year Book; 1994.

  12. Antia NH, Daver BM. Reconstructive surgery for nasal defects. Clin Plast Surg. Jul 1981;8(3):535-63. [Medline].

  13. Baker SR. Melolabial flaps. In: Local Flaps in Facial Reconstruction. Philadelphia, Pa: Mosby; 2007:231-64.

  14. Boyd CM, Baker SR, Fader DJ, Wang TS, Johnson TM. The forehead flap for nasal reconstruction. Arch Dermatol. Nov 2000;136(11):1365-70. [Medline].

  15. Brodland DG. Paramedian forehead flap reconstruction for nasal defects. Dermatol Surg. Aug 2005;31(8 Pt 2):1046-52. [Medline].

  16. Burget GC. Aesthetic restoration of the nose. Clin Plast Surg. Jul 1985;12(3):463-80. [Medline].

  17. Burget GC, Menick FJ. Nasal reconstruction: seeking a fourth dimension. Plast Reconstr Surg. Aug 1986;78(2):145-57. [Medline].

  18. Burget GC, Menick FJ. Nasal support and lining: the marriage of beauty and blood supply. Plast Reconstr Surg. Aug 1989;84(2):189-202. [Medline].

  19. Climo MS. Nasolabial flap for alar defect. Case report. Plast Reconstr Surg. Sep 1969;44(3):303-4. [Medline].

  20. Fader DJ, Baker SR, Johnson TM. The staged cheek-to-nose interpolation flap for reconstruction of the nasal alar rim/lobule. J Am Acad Dermatol. Oct 1997;37(4):614-9. [Medline].

  21. Fosko SW, Dzubow LM. Nasal reconstruction with the cheek island pedicle flap. J Am Acad Dermatol. Oct 1996;35(4):580-7. [Medline].

  22. Fryer MP. Subtotal nose reconstruction with a cheek flap. Plast Reconstr Surg. Apr 1974;53(4):436-9. [Medline].

  23. Furnas DW. Complications of surgery of the external ear. Clin Plast Surg. Apr 1990;17(2):305-18. [Medline].

  24. Johnson TM, Fader DJ. The staged retroauricular to auricular direct pedicle (interpolation) flap for helical ear reconstruction. J Am Acad Dermatol. Dec 1997;37(6):975-8. [Medline].

  25. Levasseur JG, Mellette JR Jr. Techniques for reconstruction of perialar and perialar-nasal ala combined defects. Dermatol Surg. Nov 2000;26(11):1019-23. [Medline].

  26. Nguyen TH. Staged cheek-to-nose and auricular interpolation flaps. Dermatol Surg. Aug 2005;31(8 Pt 2):1034-45. [Medline].

  27. Pharis DB, Papadopoulos DJ. Superiorly based nasolabial interpolation flap for repair of complex nasal tip defects. Dermatol Surg. Jan 2000;26(1):19-24. [Medline].

  28. Quatela VC, Sherris DA, Rounds MF. Esthetic refinements in forehead flap nasal reconstruction. Arch Otolaryngol Head Neck Surg. Oct 1995;121(10):1106-13. [Medline].

  29. Shumrick KA, Smith TL. The anatomic basis for the design of forehead flaps in nasal reconstruction. Arch Otolaryngol Head Neck Surg. Apr 1992;118(4):373-9. [Medline].

  30. Swanson NA. Classifications, definitions and concepts in flap surgery. In: Baker SR, Swanson NA, eds. Local Flaps in Facial Reconstruction. St. Louis, Mo: Mosby-Year Book; 1995:63-74.

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Further Reading

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Keywords

pedicle/interpolation flaps, pedicle flap, interpolation flap, paramedian forehead flap, forehead flap, cheek interpolation flap, staged cheek-to-nose interpolation flap, cheek island pedicle flap, staged nasolabial flap, superiorly based nasolabial interpolation flap, melolabial interpolation flap, interpolated cheek flap, postauricular helical flap, staged retroauricular-to-auricular direct pedicle (interpolation) flap, retroauricular interpolation flap, direct mastoid flap

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Contributor Information and Disclosures

Author

Michael L Ramsey, MD, Director, Mohs Surgery Fellowship, Co-Director, Procedural Dermatology Fellowship, Department of Dermatology, Geisinger Medical Center
Michael L Ramsey, MD is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Micrographic Surgery and Cutaneous Oncology, and American Society for Dermatologic Surgery
Disclosure: Nothing to disclose.

Coauthor(s)

Heidi Kozic, MD, Mohs Fellow, Department of Dermatology, Geisinger Medical Center
Heidi Kozic, MD is a member of the following medical societies: American Academy of Dermatology, American Society for Dermatologic Surgery, and Women's Dermatologic Society
Disclosure: Nothing to disclose.

Medical Editor

Désirée Ratner, MD, Director of Dermatologic Surgery, Professor of Clinical Dermatology, Department of Dermatology, Columbia University Medical Center, New York Presbyterian Hospital
Désirée Ratner, MD is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Micrographic Surgery and Cutaneous Oncology, American Medical Association, American Society for Dermatologic Surgery, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Pharmacy Editor

David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic
David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Managing Editor

John G Albertini, MD, Consulting Staff, Dermatologic Surgery, The Skin Surgery Center; Program Director, ACGME accredited Fellowship in Procedural Dermatology
John G Albertini, MD is a member of the following medical societies: American Academy of Dermatology and American College of Mohs Micrographic Surgery and Cutaneous Oncology
Disclosure: Nothing to disclose.

CME Editor

Glen H Crawford, MD, Assistant Clinical Professor, Department of Dermatology, University of Pennsylvania School of Medicine; Chief, Division of Dermatology, The Pennsylvania Hospital
Glen H Crawford, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Phi Beta Kappa, and Society of USAF Flight Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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