Pedicle/Interpolation Flaps Workup

  • Author: Michael L Ramsey, MD; Chief Editor: Dirk M Elston, MD   more...
 
Updated: Jan 26, 2012
 

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, 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 Pennsylvania Academy of Dermatology

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.

Specialty Editor Board

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.

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.

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.

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, Ackerman Academy of Dermatopathology, New York

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

Disclosure: Nothing to disclose.

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. 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. Jan 2012;26(1):93-8. [Medline].

  5. Cochran JH Jr, Shinn JB. The postauricular flap in helical injuries. Laryngoscope. Aug 1979;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. Jun 2008;121(6):1956-63. [Medline].

  7. 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].

  8. 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].

  9. [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].

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

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

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

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

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

  15. 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].

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

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

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

  19. 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].

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

  21. 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].

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

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

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

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

  26. 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].

  27. 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].

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

  29. 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].

  30. 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].

  31. 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].

  32. 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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Nasal defect after Mohs surgery. The boundaries of the nasal tip are outlined for excision to allow replacement of the entire anatomic subunit.
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.
Template of nasal tip subunit is drawn on the forehead after the length of tissue flap needed to reach the defect is carefully measured.
Planned nasal subunit excision and flap incisions are drawn with a surgical marker.
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.
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.
A forehead flap is elevated and ready for placement.
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 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 remainder of the nasal flap is trimmed and sutured into the defect. In this illustration, the proximal pedicle has been incised and inset in a V pattern at its base.
Appearance of the cheek interpolation flap after division and inset. In this illustration, 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.
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 two 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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