AAPS, American Association of Plastic Surgeons
AAPS, American Association of Plastic Surgeons
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2008 Annual Meeting Abstracts

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The Marriage of Cover, Lining, and Support: The Three Stage Full Thickness Forehead Flap
Frederick J. Menick, MD.
St Joseph's Hospital, Tucson, AZ, USA.

PURPOSE: Illustrate the Workhorse of Nasal Repair
Traditionally, the forehead flap is thinned distally.
Cartilage grafts support and stiff, thick hingeover or intranasal flaps ( injuring the nose) add lining.
The distal nose is fixed. Its dimension, thickness, or outline cannot be changed.
Later, the pedicle is divided.
In the 3 Stage technique, a full-thickness forehead flap is transposed, without thinning, perfused by a random, myocutaneous, and axial blood supply. Primary cartilage grafts are sutured over flimsy lining. If lining is missing, a distal flap extension is folded or a skin graft applied to its deep surface without primary support or has been restored with a preliminary radial forearm free flap.
Weeks later, physiologically delayed forehead skin is elevated with two millimeters of fat over the entire inset. Its distal extension is cut free along the nostril margin or elevated from skin graft lining. Excess fat and frontalis are excised from the underlying healed rigid fabrication. Primary cartilage grafts are sculpted. Delayed primary cartilage grafts support reconstructed lining. Uniformly "thin" cover is reapplied to the recipient.
Later, the pedicle is divided.
RESULTS: In 200 patients, results improved;number-complexity of revision decreased. 75% of full thickness defects could be lined with the folded technique, including bilateral and adjacent nasal floor loss. All flaps survived in primary cases. The technique salvaged infectious complications ( flap reuse after infection) or unexpected lining shortage ( skin graft lining after free flap transfer).
Uniquely, the 3 stage full-thickness forehead flap integrates each anatomic layer in sequential, coordinated stages.
1. superb vascularity
2. Uniformly thin cover
3. New modified folded and skin graft lining options
4. Primary and delayed primary support grafts
5. Alteration of contour, dimension, and bulk , prior to pedicle division, with complete exposure
6. Salvage after fulminant infection or lining shortage
7. Better results- fewer revisions
8. No donor or recipient site injury

Implications for Nasal Reconstruction
1. A full-thickness forehead flap has maximum blood supply.
2. Forehead flap is physiologically delayed after transfer, permitting wide, uniform "thinning"
3. Fibrosis does not occur until subcutaneous fat or the frontalis muscle are excised.
4. Support can be placed primarily or in a delayed primary fashion because the tissues remain unscarred
5. The distal end of a folded flap or underlying graft integrate into residual lining and do not depend on cover for survival.

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