April 2020 HSC Section 4 - Plastic and Reconstructive Problems

Plastic and Reconstructive Surgery • July 2019

Fig. 2. Two-fold technique of radial forearm flap for total/subtotal nasal reconstruction. A single-paddle distal forearm flap with a long vascular pedicle and floor extension is used to provide temporary exter- nal coverage, permanent lining, and floor repair. The ulnar midpoint of the flap is folded side-to-side to create a “columella” and the ulnar corners ( lower asterisk ) of the flap are infolded and sutured to the midline of the defect ( upper asterisk ) to line both nasal vaults. The floor extension is rotated medially to resurface a nasal floor defect. Dotted lines indicate the folds along the nostril rims. (Previously published in Menick F, Salibian A. Microvascular repair of hemi-nasal, subtotal, and total nasal defects with a folded radial forearm flap and a full-thickness skin graft. Plast Reconstr Surg . 2011;127:637–651.)

If the skin closure at the pedicle entry site appears tight, a skin graft is applied over the ped- icle to avoid pressure on the vessels. The donor site is covered with a full-thickness skin graft from the suprapubic or groin areas, and the residual cartilage grafts are banked in the chest wound for later use. The neck is drained with a small vacuum drain. If the flap (Fig. 4, above , right ) is to be folded in a single plane for an ipsilateral anastomosis, the radial surface of the flap is placed under the dorsal graft to line the vault (Fig. 4, above , left ). The ulnar end of the flap is folded back over the dorsal graft for external nasal cover (Fig. 4, center ,

right ) for use in the second stage (Fig. 4, below , left ) to shape the nostrils and columella (Fig. 4, below , right ). During the second-stage forehead flap (single- or double-fold), the vascular pedicle is preserved and the external skin is hinged over inferiorly to provide additional nostril lining, adjust bilateral alar base inset position, and line the columella, if needed. Delayed primary grafts are added to support and shape the columella, tip, and ala. To improve the airway, the radial forearm flap is thinned during the forehead flap transfer, the third intermediate stage, and subsequent one or two late revisions.

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