It is unnecessary to incise all the way to the periosteum. As one extends the pedicle incision inferiorly to just above the eyebrow area, the incision is carried superficially just beneath the dermis at first. Then, using tenotomy scissors, the subcutaneous tissue underneath the superficial incision is carefully separated so as not to transect the supratrochlear arteries. The flap and the donor site wound edges are then undermined, bleeding is stopped using biterminal electrocoagulation, and the flap is rotated ?.
The donor portion of the flap end is thinned, if necessary, to conform to the depth of the recipient wound. If underlying aponeurosis from the superior forehead is present, it is best to trim it off; if left, the aponeurosis will prevent vascularization of the flap from the wound below.
This vascularization might be critical for flap survival. The recipient nasal wound edges are undermined and verticalized by trimming excess subcutaneous tissue.
This suture anchors the flap in its proper position. A few more buried anchoring sutures may be necessary to further anchor the flap to different nasal contours. The donor site wound edges are also sutured closed in a vertical direction down the center of the forehead Figure 5. Care must be taken at this point to ensure that all bleeding vessels are electrocoagulated in the exposed flap pedicle. Three additional special aspects of forehead flap dressing include:.
The fluffed gauze is used to catch any bleeding that may occur during the first 24 hours after the procedure. The cut glove finger is stuffed with fluffed gauze, greased on the outside with ointment and inserted into the nasal vestibule. Nasal packing is generally used if the forehead flap abuts onto a significant portion of the nasal ala.
The nasal packing stays in place for 1 week. After the flap procedure, suture removal usually occurs after 1 week on the nose and 2 weeks on the forehead. The open wound at the pedicle base is kept moist with antibiotic ointment until it heals by second intention. When healed, the pedicle edges curl together. The open flap pedicle stays in place for weeks after the initial forehead flap Figure 6. Although some surgeons advocate insetting the pedicle as early as 14 days after the initial procedure, a longer time gives the distal flap end adequate time for full vascularization and allows for aggressive flap shaping should this procedure be necessary at the time of insetting.
The flap pedicle is transected horizontally at its midpoint. The lower end of healed donor site scar between the eyebrows is incised vertically.
The incision is carried further inferiorly and vertically along the healed scar in the proximal pedicle. The scar is a result of the pedicle healing by second intention. This whole incision creates a triangular wound at the base of the proximal pedicle and allows the distance between the eyebrows to return to normal.
The proximal portion of the pedicle is rotated superiorly and trimmed to fit the newly created triangular recipient area. Figure 8: Healed forehead flap 7 years after surgery. Telangiectasia can be removed by laser and small nasal bump by excision.
A Frontal view B Side view. After the proximal pedicle has been inset into the glabella, the distal part of the pedicle is then inset into the nose. The distal pedicle flap is lifted up and a rectangular recipient wound is created in the underlying nose.
Part of the newly created recipient wound connects underneath the superior portion of the distal pedicle to the original wound into which the pedicle was originally placed. The pedicle is then trimmed and thinned to fit the newly created recipient wound.
Additional thinning of the distal part of the pedicle flap overlying the original recipient wound may be necessary and can be done at this stage assuming an adequate blood supply.
Once the insetting site is healed, most forehead flaps can be improved by minor procedures. The most common touch-up procedures we do include flap thinning, and scar line excision with resuturing.
For removal of telangiectasias, the vascular laser e. Although the paramedian forehead flap is currently in vogue,3 we prefer the median forehead flap, which is described in this article. In the paramedian forehead flap, the pedicle is cut vertically and superiorly just above the medial side of one eyebrow.
In our opinion, the median forehead flap results in a much less noticeable donor site scar on the forehead than that resulting from the paramedian forehead flap. In addition, increased vascular supply is created by the broader median forehead flap base, although the central forehead has a rich blood supply. If the recipient wound only involves a portion of a whole aesthetic unit, should the recipient wound be enlarged to include the whole aesthetic unit?
In this case, a retroauricular graft will be taken. There is a separate video demonstrating this type of harvest. The graft is then thinned of all subcutaneous tissue so that only dermis and epidermis remain.
The graft is then placed into position over the defect and sutured into position with interrupted and running fast absorbing suture. I prefer this suture as it degrades relatively quickly and does not need to be removed. The sutures are cut long. Antibiotic ointment is then placed over the graft followed by the Telfa template followed by the bolster. Therefore with this 25th issue of our De la relation….
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