Two-stage flap method boosts results

Denver - Two-stage flaps offer what can be a superior method for reconstructing complex defects, and more dermatologic surgeons are employing these techniques in their practices.

There are technical tips that can help to maximize the aesthetic reconstructive results of flap surgery, according to J. Ramsey Mellette Jr., M.D., a dermatologist and Mohs surgeon and professor of dermatology at the University of Colorado Health Sciences Center.

Interpolated flaps

The paramedian forehead flap is based on one of a pair of supratrochlear neurovascular bundles, which branches off the ophthalmic artery, comes out around the orbit and goes into the forehead. The vessel provides blood supply to the forehead flap.

The interpolated cutaneous pedicle cheek flap, developed in the melolabial fold and attached to the nose, is based on perforating vessels arising from the angular artery. The ear pedicle is a less-specific system; nevertheless it has a rich blood supply based on postauricular vessels, Dr. Mellette tells Dermatology Times.

"All of these flaps require at least two stages. The first stage is the attachment of the flap to the defect and the second stage is the division of the flap and insertion to complete the reconstruction - usually at two weeks," Dr. Mellette says.

Revisions

Dermatologic surgeons should keep in mind that these flaps can require additional revisions.

Forehead flaps and interpolated cheek flaps, for example, often repair defects of more than one reconstructive subunit. A defect might involve the nasal tip, alar, sidewall and dorsum.

"Let us say we have repaired the tip, alar and adjacent sidewall of the nose; then, in order to reestablish the lines and creases to make those flaps look normal and give an aesthetic appeal to the reconstruction, we have to come back and recreate the grooves," Dr. Mellette says.

Dr. Mellette usually accomplishes this by making a template or pattern of the uninvolved side of the nose - outlining it and creating a mirror image for the side he is treating.

"The same is done when we take the cheek flap and put it on the alar. Oftentimes, it is not just the alar, but also the sidewall, so we have to come back surgically and make an incision to re-establish the crease. We spread out the tissues above and below the flap and then flatten it down so that it recreates that groove and that normal nose appearance," he says.

Refinements

Other tips for aesthetically pleasing reconstructions:

Notches can result from one's repair of the tip and adjacent alar. The contracture often occurs in the small area between the tip of the nose and alar, called the soft triangle of the nose.

Dr. Mellette repairs the notch by using a hinged flap. He takes tissue from the nasal tip, turns it over on a hinge, attaches it to the alar and then covers the area with a graft.

"Sometimes, after surgery on the upper lip area - between the lip line and nose - you can get a pulling up of the lip, resulting in a snarl. We relieve in upward contracture with Z-plasty, where we go into the scar that caused the contracture and lengthen it, thereby releasing the contracture," Dr. Mellette says.