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Pedicle/Interpolation Flaps Workup

  • Author: Michael L Ramsey, MD; Chief Editor: Dirk M Elston, MD  more...
 
Updated: Jan 04, 2016
 

Laboratory Studies

Laboratory studies are usually not necessary before the use of interpolation flaps. Preoperative consultations with physicians about treatment and testing in patients with known bleeding disorders or in those receiving anticoagulant agents are prudent.

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Imaging Studies

Using a Doppler probe may be helpful to accurately identify the location of the supratrochlear artery for a paramedian forehead flap.

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Contributor Information and Disclosures
Author

Michael L Ramsey, MD 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 Surgery

Disclosure: Nothing to disclose.

Coauthor(s)

Faith Miller Whalen, MD Procedural Dermatology Fellow, Department of Dermatology, Geisinger Medical Center

Faith Miller Whalen, MD is a member of the following medical societies: American Academy of Dermatology, American Society for Dermatologic Surgery

Disclosure: Nothing to disclose.

Specialty Editor Board

David F Butler, MD Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic

David F Butler, MD is a member of the following medical societies: American Medical Association, Alpha Omega Alpha, Association of Military Dermatologists, American Academy of Dermatology, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Phi Beta Kappa

Disclosure: Nothing to disclose.

John G Albertini, MD Private Practice, The Skin Surgery Center; Clinical Associate Professor (Volunteer), Department of Plastic and Reconstructive Surgery, Wake Forest University School of Medicine; President-Elect, American College of Mohs Surgery

John G Albertini, MD is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Surgery

Disclosure: Received grant/research funds from Genentech for investigator.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Desiree Ratner, MD Director, Comprehensive Skin Cancer Center, Continuum Cancer Centers of New York; Director of Dermatologic Surgery, Beth Israel Medical Center and St Luke's and Roosevelt Hospitals; Professor of Clinical Dermatology, Columbia University College of Physicians and Surgeons

Desiree Ratner, MD is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Surgery, American Medical Association, American Society for Dermatologic Surgery, Phi Beta Kappa

Disclosure: Nothing to disclose.

Acknowledgements

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.

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

  2. Lewin ML. Formation of the helix with a postauricular flap. Plast Reconstr Surg (1946). 1950 May. 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. 2007 Oct. 120(5):1171-207; discussion 1208-16. [Medline].

  4. Monarca C, Rizzo MI, Palmieri A, Chiummariello S, Fino P, Scuderi N. Comparative Analysis between Nasolabial and Island Pedicle Flaps in the Ala Nose Reconstruction. Prospective Study. In Vivo. 2012 Jan. 26(1):93-8. [Medline].

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

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

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

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

  9. Blazquez-Sanchez N, Fernandez-Canedo I, Repiso-Jimenez JB, Rivas-Ruiz F, Martin MT. Usefulness of the Paramedian Forehead Flap in Nasal Reconstructive Surgery: A Retrospective Series of 41 Patients. Actas Dermosifiliogr. 2015 Nov 10. [Medline].

  10. Fisher GH, Cook JW. The interpolated paranasal flap: a novel and advantageous option for nasal-alar reconstruction. Dermatol Surg. 2009 Apr. 35(4):656-61. [Medline].

  11. Selcuk CT, Durgun M, Bozkurt M, Kinis V, Ozbay M, Bakir S. The reconstruction of full-thickness ear defects including the helix using the superior pedicle postauricular chondrocutaneous flap. Ann Plast Surg. 2014 Feb. 72 (2):159-63. [Medline].

  12. Wright TI, Baddour LM, Berbari EF, et al. Antibiotic prophylaxis in dermatologic surgery: advisory statement 2008. J Am Acad Dermatol. 2008 Sep. 59(3):464-73. [Medline].

  13. [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. 2007 Oct 9. 116(15):1736-54. [Medline].

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

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

  16. Farber N, Haik J, Weissman O, Israeli H, Winkler E, Zilinsky I. Delay techniques for local flaps in dermatologic surgery. J Drugs Dermatol. 2012 Sep. 11(9):1108-10. [Medline].

  17. Newlove T, Cook J. Safety of Staged Interpolation Flaps After Mohs Micrographic Surgery in an Outpatient Setting: A Single-Center Experience. Dermatol Surg. 2013 Oct 17. [Medline].

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

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

  20. Glass GE, Nanchahal J. Why haematomas cause flap failure: An evidence-based paradigm. J Plast Reconstr Aesthet Surg. 2012 Jan 5. [Medline].

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

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

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Nasal defect after Mohs surgery. The boundaries of the nasal tip are outlined for excision to allow replacement of the entire anatomic subunit.
Surgical defect.
Diagram shows a nasal defect due to tumor removal and the remnants of significantly involved anatomic subunits.
Doppler ultrasonography is used to identify the course of the supratrochlear artery prior to flap surgery.
The course of the supratrochlear artery is identified by using Doppler ultrasonography and marked on the skin.
Gauze or other flexible material is used to measure the necessary length of the flap, and a mark is made at the most distal portion.
The gauze is rotated and placed over the course of the supratrochlear artery, and the distal end of the planned flap is marked on the forehead skin.
A foil template of the surgical defect is placed with its most distal aspect touching the mark representing the distal end of the flap. The template is outlined with a surgical marker.
Template of nasal tip subunit is drawn on the forehead after the length of tissue flap needed to reach the defect is carefully measured.
A 1- to 1.5-cm-wide pedicle is drawn over the course of the supratrochlear artery from its origin to the outline of the template.
Planned nasal subunit excision and flap incisions are drawn with a surgical marker.
Forehead flap is elevated and ready for placement.
Flap affixed to nasal wound with planned closure of forehead donor defect.
Paramedian forehead flap in place. Although a full-thickness skin graft was later placed in this patient, the widest portion of the forehead donor site is usually allowed to granulate.
The forehead flap is incised, elevated, and sutured into the nasal defect. The forehead defect is repaired as completely as possible, and any remaining defect on the forehead is allowed to heal secondarily.
Appearance 2 weeks after flap surgery, immediately after division and inset of the pedicle flap. A delayed full-thickness skin graft has been placed in the donor defect on the forehead.
The pedicle is severed in 2-3 weeks, and the flap is inset in the proximal portion of the wound. The proximal stalk can be excised and inset in an inverted V shape, as shown in the diagram.
The proximal pedicle can be excised in a fusiform fashion, and the defect can be closed primarily. This is the preferred method in the author's experience.
Forehead flap at 3 weeks, at the time of suture removal.
Nasal defect prior to cheek interpolation flap repair.
Nasal defect.
Template of nasal defect. This may be expanded to include entire anatomic subunit.
Template is rotated and placed on medial cheek.
Nasal defect with planned cheek interpolation flap. The needed flap length was previously measured with a rolled gauze, and a template of the defect is used to mark the necessary width of the flap.
Cheek flap sutured in place.
Cheek interpolation flap is elevated and trimmed to fit into the nasal defect after the cheek donor defect is closed.
Appearance after division and inset of cheek interpolation flap. The proximal pedicle will be excised and the resulting defect will be closed primarily.
Appearance of the cheek interpolation flap after division and inset. The proximal stump of the pedicle has been excised as an ellipse, and the cheek defect has been closed primarily.
Cheek interpolation flap after division and inset.
Postoperative result of cheek interpolation flap before dermabrasion.
Alternately, skin can be incised and a subcutaneous pedicle may be used.
Subcutaneous pedicle flap in place.
Finished repair.
Helical rim defect after Mohs surgery.
Surgical defect on the helix of the ear.
Planned incision for a postauricular flap.
Planned postauricular flap is marked on the skin. The flap should be of sufficient size to cover the defect without significant tension in any direction. Burow triangles are planned to allow advancement of the skin.
Postauricular flap sutured in place.
A postauricular flap is sutured in place. One or 2 temporary retention sutures can be placed between the ear and the postauricular skin to decrease tension, if necessary.
Mohs surgery defect anterior to the helix.
Postauricular flap in place.
Postauricular flap after division and inset.
 
 
 
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