Pedicle/Interpolation Flaps

Pedicle/Interpolation Flaps

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An interpolation flap is a 2-stage tissue flap in which the base of the flap is not immediately adjacent to the recipient site. These flaps are used when insufficient tissue or mobility in nearby skin prevents coverage of a surgical defect with primary closure or an adjacent flap. Interpolation flaps are similar to transposition flaps in that the flap is lifted over an area of normal skin to reach the defect. While the base of a transposition flap is adjacent to the defect, the base of the interpolation flap is located a distance away from the area to be repaired. This arrangement results in a bridge of tissue, or pedicle, between the flap base and the surgical defect that typically must be removed in a second stage after vascularity is established between the wound and the flap. [1]

The following 3 interpolation flaps are used most commonly in dermatologic surgery:

Forehead flap

Cheek interpolation flap

Postauricular flap

The forehead flap uses tissue from the forehead to repair the nose. The cheek interpolation flap takes advantage of the loose skin of the cheek to repair small but somewhat deep defects in the nose, and the postauricular flap uses skin from the posterior part of the ear and the retroauricular aspect of the scalp to repair defects in the helix and anterior surface of the ear.

Also see Forehead Anatomy, Forehead and Temple Reconstruction, and Cheek Reconstruction.

The forehead flap is believed to have been used in India as early as 700 BCE. Antonio Bronca of Italy performed the procedure in the 15th century. The first reports of the midline forehead flap in the English-language literature appeared in 1793. Since the 1960s, many advances have been made, including Menick’s use of the paramedian forehead flap, which is based on a narrow vascular pedicle supplied by the supratrochlear artery. [2] This modification allows easier closure of the forehead defect, as well as greater flap mobility, and it is currently the most commonly used forehead interpolation flap.

The cheek interpolation flap is believed to have been used since 600 BC, when it was first used in India. In contrast, the 2-stage postauricular helical flap is a relatively recent technique, which Lewin described in 1950. [3]

The forehead flap is used to repair more extensive defects on the nasal tip and ala for which simpler techniques cannot provide adequate coverage. It is sometimes used to provide nasal lining as well. In very extensive defects, the forehead can be used in combination with other techniques such as microvascular free flaps, cartilage or bone grafts, and mucosal flaps to achieve satisfactory function and appearance. [4, 5]

Select small-to-medium, deeper defects on the nasal ala and nasal tip can be repaired by using the cheek interpolation flap.

The postauricular helical flap provides good coverage and cosmesis in medium-to-large defects on the helix and adjacent antihelix, with or without the loss of small amounts of cartilage. [6]

The described interpolation flaps are most commonly used to repair surgical defects resulting from tumor excision, but they can also be used to repair traumatic wounds.

The paramedian forehead flap is an axial flap based on the supratrochlear artery. Cadaver studies show that the supratrochlear artery exits the orbit 1.7-2.2 cm from the midline, passing deep to the orbicularis oculi muscle and ascending superficial to the corrugator supercilii muscle. It then passes medial to the eyebrow and through the frontalis muscle ascending superiorly in the subcutaneous tissue, 1.5-2 cm from the midline. The angular and supraorbital arteries also contribute to the vascularity of this flap through a rich periorbital plexus of anastomoses. [7]

The cheek interpolation flap is a random flap, but it receives an ample blood supply from the perforating branches of the angular, nasal, and superior labial arteries.

The postauricular scalp has a rich vascular supply from branches of the posterior auricular, superficial temporal, and occipital arteries. Therefore, the postauricular helical flap, which is a random flap, is rarely affected by vascular necrosis.

Also see Anatomy in Cutaneous Surgery.

The use of pedicle flaps is contraindicated in patients who are unwilling or unable to tolerate multiple-staged surgical procedures. Likewise, these procedures should be avoided in patients who cannot leave their surgical sites undisturbed, or special measures must be taken to protect the sites in these patients.

Actively infected skin should never be covered with a flap or used to form a flap. With a forehead with a low vertical height, a variation of the forehead flap or another repair method may be required.

Smoking is a relative contraindication to the use of staged island pedicle flaps because it increases the risk of flap necrosis. However, procedures with these flaps can usually be performed safely if fat is not thinned from the undersurface of the flap. In addition, avoiding the use of previously radiated skin or a previous surgical site is generally best, unless no better repair options are available.

Interpolation flaps should be performed with great care in patients who are receiving anticoagulant therapy or in patients with bleeding disorders. Consultation with the physician who prescribed the medication is prudent before discontinuing any anticoagulant therapy. The author rarely discontinues warfarin prior skin surgery. Similarly, the author only stops aspirin usage initiated by the patient and not when prescribed by a physician. Contacting consulting physicians is appropriate before operating on individuals with bleeding dyscrasias.

Ramsey ML, Al Aboud AM. Flaps, Interpolated. 2018 Jan. [Medline]. [Full Text].

Menick FJ. Aesthetic refinements in use of forehead for nasal reconstruction: the paramedian forehead flap. Clin Plast Surg. 1990 Oct. 17(4):607-22. [Medline].

Lewin ML. Formation of the helix with a postauricular flap. Plast Reconstr Surg (1946). 1950 May. 5(5):432-40. [Medline].

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. 2007 Oct. 120(5):1171-207; discussion 1208-16. [Medline].

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

Cochran JH Jr, Shinn JB. The postauricular flap in helical injuries. Laryngoscope. 1979 Aug. 89(8):1347-50. [Medline].

Reece EM, Schaverien M, Rohrich RJ. The paramedian forehead flap: a dynamic anatomical vascular study verifying safety and clinical implications. Plast Reconstr Surg. 2008 Jun. 121(6):1956-63. [Medline].

Angobaldo J, Marks M. Refinements in nasal reconstruction: the cross-paramedian forehead flap. Plast Reconstr Surg. 2009 Jan. 123(1):87-93; discussion 94-7. [Medline].

Christenson LJ, Otley CC, Roenigk RK. Oxidized regenerated cellulose gauze for hemostasis of a two-stage interpolation flap pedicle. Dermatol Surg. 2004 Dec. 30(12 Pt 2):1593-4. [Medline].

Blazquez-Sanchez N, Fernandez-Canedo I, Repiso-Jimenez JB, Rivas-Ruiz F, Martin MT. Usefulness of the Paramedian Forehead Flap in Nasal Reconstructive Surgery: A Retrospective Series of 41 Patients. Actas Dermosifiliogr. 2015 Nov 10. [Medline].

Sanniec K, Malafa M, Thornton JF. Simplifying the Forehead Flap for Nasal Reconstruction: A Review of 420 Consecutive Cases. Plast Reconstr Surg. 2017 Aug. 140 (2):371-80. [Medline].

Fisher GH, Cook JW. The interpolated paranasal flap: a novel and advantageous option for nasal-alar reconstruction. Dermatol Surg. 2009 Apr. 35(4):656-61. [Medline].

Selcuk CT, Durgun M, Bozkurt M, Kinis V, Ozbay M, Bakir S. The reconstruction of full-thickness ear defects including the helix using the superior pedicle postauricular chondrocutaneous flap. Ann Plast Surg. 2014 Feb. 72 (2):159-63. [Medline].

Wright TI, Baddour LM, Berbari EF, et al. Antibiotic prophylaxis in dermatologic surgery: advisory statement 2008. J Am Acad Dermatol. 2008 Sep. 59(3):464-73. [Medline].

[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. 2007 Oct 9. 116(15):1736-54. [Medline].

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

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

Farber N, Haik J, Weissman O, Israeli H, Winkler E, Zilinsky I. Delay techniques for local flaps in dermatologic surgery. J Drugs Dermatol. 2012 Sep. 11(9):1108-10. [Medline].

Newlove T, Cook J. Safety of Staged Interpolation Flaps After Mohs Micrographic Surgery in an Outpatient Setting: A Single-Center Experience. Dermatol Surg. 2013 Oct 17. [Medline].

Michael L Ramsey, MD 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 Surgery

Disclosure: Nothing to disclose.

Faith Miller Whalen, MD Procedural Dermatology Fellow, Department of Dermatology, Geisinger Medical Center

Faith Miller Whalen, MD is a member of the following medical societies: American Academy of Dermatology, American Society for Dermatologic Surgery

Disclosure: Nothing to disclose.

David F Butler, MD Former Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Society for MOHS Surgery, Association of Military Dermatologists, Phi Beta Kappa

Disclosure: Nothing to disclose.

John G Albertini, MD Private Practice, The Skin Surgery Center; Clinical Associate Professor (Volunteer), Department of Plastic and Reconstructive Surgery, Wake Forest University School of Medicine; President-Elect, American College of Mohs Surgery

John G Albertini, MD is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Surgery

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: QualDerm Partners; Novascan<br/>Have a 5% or greater equity interest in: QualDerm Partners – North Carolina.

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

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

Disclosure: Nothing to disclose.

Desiree Ratner, MD Director, Comprehensive Skin Cancer Center, Continuum Cancer Centers of New York; Director of Dermatologic Surgery, Beth Israel Medical Center and St Luke’s and Roosevelt Hospitals; Professor of Clinical Dermatology, Columbia University College of Physicians and Surgeons

Desiree Ratner, MD is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Surgery, American Medical Association, American Society for Dermatologic Surgery, Phi Beta Kappa

Disclosure: Nothing to disclose.

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.

Pedicle/Interpolation Flaps

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