April 2020 HSC Section 4 - Plastic and Reconstructive Problems

Plastic and Reconstructive Surgery • July 2019

Fig. 4. Intraoperative photographs of patient 2 (see also Fig. 8). ( Above , right ) Forearm flap design. ( Above , left ) The flap is anastomosed to the to the same-side neck vessels. The upper radial portion of the flap will be placed beneath the dorsal graft for vault lining. ( Center , right ) The folded flap encases the dorsal graft. The lower ulnar segment of the flap is turned over and folded in one plane to cover the graft. The thick forearm flap and absence of contralateral recipient vessels preclude two-plane folding for columellar lining. ( Below , left ) Healed forearm flap in the second stage. Arrows show the course of the vascular pedicle. Inflated forehead expander in place is shown. ( Below , right ) Two months later, external skin is hinged over inferiorly to adjust bilateral alar base inset position and folded centrally to line the columella for a columellar strut. Additional delayed primary grafts are placed to support the columella, tip, and ala.

RESULTS Reconstruction was completed in 46 patients. One patient died as a result of unrelated causes. The patients were followed up for an average of 6 years (range, 1 to 17 years). Flap design, inset variations, and complications are summarized in

The pedicle is routed into the neck through the lateral aspect of the lining defect. An addi- tional buccal sulcus incision is recommended to increase surgical exposure (Fig. 5, below , right ), minimize the risk of injury to the flap perforators, and permit use of a sentinel flap.

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