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How to Kill a Forehead Flap and Other Design Errors
How to Kill a Forehead Flap and Other Design Errors
9
C H A P T E R
Forehead skin is ideal for nasal resurfacing. Although the vertical paramedian forehead flap is the first choice, forehead tissue can be transferred on numerous vascular pedicles. At least two to three flaps can be harvested from the forehead depending on the size, height, laxity, history of prior injury and the size of the nasal defect. The forehead donor site almost never limits nasal repair. Do not minimize the aesthetic and functional importance of restoring a normal nose. Do not exaggerate your concerns regarding forehead donor deformity. The forehead is a forgiving donor site. However, it must be used correctly. Technique does matter.
Errors 1. Flap too short or pivot point too high Position the template at the hairline. Check the arc of rotation and ensure that the flap will comfortably reach the defect — measure to the columella and to each alar base, as required for the specific defect. Use a tape to verify the distance from the planned pivot point to the distal inset. Double check prior to incising the flap. If the flap will not comfortably reach the defect, its design can be extended into the hairline or the base of the flap can be lowered, moving the pivot point inferiorly. If, after elevation, the flap seems short, further extend the skin incisions of the pedicle, inferiorly. It crosses through the medial brow towards the medial canthus. Then release restricting fibrous or muscle fibers within the soft tissue at the flap’s base. Preserve visible vessels. Do not elevate periosteum under the pedicle base. The supratrochlear vessels pass over the supraorbital periosteum within the corrugator soft tissue. A subperiosteal dissection is not helpful and restricts the flap’s movement. Cut and release, as you go, until the flap can be positioned to the defect without tension. Vascular compromise is very unlikely to occur. Although rarely performed, one can carefully incise the frontalis muscle transversely, at the base of the flap, to expose the subcutaneous fat. This permits the overlying soft tissue to stretch, gaining a few extra millimeters of length. The vessels pass under the frontalis, at the orbital rim, and travel through the muscle into the subcutaneous layer, within 2 cm of the brow. Muscle transection is positioned to protect the distal axial vessels, superficial to the frontalis.
Chapter • 9 • How to Kill a Forehead Flap and Other Design Errors
2. Flap too wide or too narrow A forehead flap should be designed as a tailored garment which covers the nose without excess or deficiency. If the flap is too small, it will crush the underlying support and distort the tip and alar base positions. Tension will also impair its blood supply. If the flap is too large, it will not conform to the underlying framework. The nose will look like a baggy shapeless suit of clothes. Intraoperatively, a three-dimensional template, based on the contralateral normal or ideal, is designed. After replacing missing lining and cartilage grafts, its dimension is reconfirmed. The 3-D template is then flattened to two dimensions, and positioned on the forehead. The template determines the dimension and outline of the flap. Rely on your pattern. The dimension and outline of tissue needed to repair the face cannot be ‘eyeballed’.
3. Pedicle too narrow or too wide A paramedian forehead flap should be designed with a pedicle 1.2 to 1.5 cm in width. Even though a narrower flap will survive, it has no advantage. Conversely, a wider flap twists less easily and kinks. This limits its reach. A wider flap does not increase flap vascularity. Closure of the inferior forehead will also be more difficult after flap elevation. Base the flap over the supratrochlear vessels with a 1.2 to 1.5 cm pedicle width. Cut across the brow towards the medial canthus. At the time of flap division, return the proximal aspect of the flap’s base to the brow. Discard the excess. Inset it as a small inverted ‘V.’ The scar simulates the normal frown line. Because the flap’s base is narrow, the eyebrow is not medialized.
4. Incorrect rotation on transfer At the time of elevation, the flap is incised along the two parallel incisions at its base. The medial incision is carried more inferiorly than the lateral incision. The flap is rotated medially towards the nose. Its narrow pedicle easily transposes 180 degrees. If the flap is rotated laterally towards the eye, the base kinks, jeopardizing blood supply and shortening flap reach. It also obstructs vision more significantly.
5. An incorrectly oriented pattern Templates are employed to determine the correct dimension and outline of cover, lining flaps and the support grafts. They are designed from the contralateral normal or ideal. But once prepared, they must be properly oriented. A pattern, based on the contralateral normal, must be flipped so that it correctly defines the tissue requirements of the opposite ‘mirror’ recipient defect. A template designed to resurface a central defect must also maintain proper orientation. The lateral borders of a midline defect often vary in outline, from one side to the other. The pattern is designed from the contralateral normal. It is then flipped and positioned over the recipient site. The template is then rotated medially, swung to the forehead donor site, and flattened on the forehead. The flap’s outline is marked with ink, cen272
Errors
tered over the supratrochlear vessels. Then the outline of the proximal pedicle is drawn as a gentle taper that extends inferiorly to the pedicle base. Employ the foil of a suture pack which is colored on one side. It is helpful to routinely create a template so that the silver or colored side of the surgical foil faces outward when it is placed over the normal side. When it is correctly positioned over the recipient site, the opposite side should be visible. If the ‘wrong’ side is up, recheck the orientation. This habit diminishes the risk that the surgeon will fail to flip the pattern correctly, after its design on the contralateral normal. Do not use an incorrectly oriented pattern to design your flap.
6. Incorrect paramedian pedicle choice Midline defects can be repaired with a paramedian flap based on either the right or left supratrochlear vessels. However, unilateral defects are best repaired with a flap based on the ipsilateral pedicle. The distance from the pivot point to the recipient site is the shortest — the flap is effectively lengthened. Of course, if the ipsilateral pedicle or its forehead skin territory is unavailable, the contralateral flap will survive. However, the flap must be longer to ensure adequate length and reach without tension. Routine use of the contralateral pedicle does not ease its transposition or protect its vascularity. It makes the repair more difficult and should be avoided, unless necessary. Although recommended by some, designing a flap to cross the forehead obliquely does not facilitate its rotation or significantly increase the forehead’s available length. It does create a donor defect that is more difficult to close without distortion of the eyebrows. It also transects many of the vertically oriented vessels, decreasing vascularity. If the flap seems short, most often the surgeon has simply based the vertical paramedian flap too high over the brow. Lengthen the flap by accepting hair on its distal aspect or, more often, lower the pedicle base across the eyebrow to drop the pivot point and bring the base closer to the defect.
7. Inset under tension Forehead flaps are highly vascular. But they do not tolerate tension. The flap must not be too small or short. It must comfortably drape over the defect. If the flap seems short, redissect the pedicle base and lower the pivot point, if necessary. Approximate the flap to the recipient site with interrupted sutures. If a suture is tight, remove it. Sometimes a simple suture readjustment and flap redraping will solve the problem. If blanching occurs on closure and the flap seems small, flap dimension or outline cannot be altered after elevation. However, the surgeon may be able to save the day by cautiously excising frontalis muscle along the borders of a full-thickness forehead flap. Or remove a projecting tip graft to modestly reduce the overall size of the cartilage construction. The excess cartilage is banked and replaced during the intermediate operation. 273
Chapter • 9 • How to Kill a Forehead Flap and Other Design Errors
If the flap is designed with a proximal taper, it may be possible to pull the flap inferiorly and redrape the tissue more effectively.
8. Inset too tight or complete At inset, the flap is first sutured to the columella and nostril margins in one layer, one suture at a time. Then individual sutures are placed laterally, progressing superiorly on either side. If the closure appears tight and blanching occurs, stop. The flap is allowed to dangle from the brow to the inset without further suture approximation. It is not necessary to fix the flap to the recipient side along its entire periphery. Loosely applied, the flap will heal spontaneously to the defect over the next 10 days. Its final appearance will be indistinguishable from another flap that was sutured more completely to the recipient defect. Insisting on complete wound closure, at the time of inset, can kill the flap.
9. Excessive thinning on transfer A forehead flap is thicker than nasal skin. Excess frontalis muscle and subcutaneous fat must be trimmed before the completion of the repair. It is safe, in nonsmokers, to thin the distal 1.5 cm during the first stage of a two-stage transfer. But as soft tissue is excised, the flap’s blood supply is diminished and the flap is more susceptible to tension. The two-stage flap is best used to repair small defects that did not require wide excision of excess fat and frontalis muscle. Because the flap must be thinned over only a small area of its surface, the risk is modest. A three-stage flap is employed for large defects which require large flaps or in those with a questionable blood supply — the smoker, a scar in the territory of the flap, or a flap with complex extensions.
10. Inadequate or overly extensive re-elevation of the flap at the pedicle division Once healed to the recipient bed, the distal flap receives an ample blood supply from the inset. No longer dependent on the flap pedicle, it can be divided. Distally, the flap is re-elevated, inferiorly, towards the tip and nostril rims. This permits further sculpting of the dorsum, sidewalls, and alar creases, prior to completing the inset. It is routine to elevate the distal flap to within 1 to 1.5 cm of the tip and nostril margins. This provides adequate exposure to shape the desired three-dimensional contour. However, the surgeon must balance the risk versus the gain. If the re-elevation is too timid, a revisional operation will be required to sculpt the correct contour, secondarily. If too aggressive, the flap may be put in vascular jeopardy. It is difficult to kill facial flaps, but judgment and experience are important. Ask yourself — is it safe? Will the size of the remaining inset support the elevated skin? How much soft tissue excision is required? Will the exposure be sufficient to sculpt the recipient bed adequately? Is a late revision required for other purposes? If so, would it be safer to do additional debulking, during a later stage? 274
Errors
If in doubt, be safe and improve the contour later. The final appearance of the nose is important but tissue must survive. Limit the flap’s re-elevation, if needed. Plan a late revision to improve the result after the pedicle is divided. It may be helpful to put off pedicle division until a later date. Perform additional sculpting during an intermediate operation, leaving the pedicle intact for an additional few weeks. Even if a two-stage flap was planned and the distal aspect of the flap has been thinned initially, you can postpone its division. Re-elevate the entire inset, thin the forehead flap and sculpt the entire recipient bed. Then reinset the flap and wait several more weeks before dividing the blood supply.
11. Failure to identify a scar within the flap’s territory Consider the site, length, direction, depth and etiology of a scar. A vertical scar is less worrisome — a deep transverse scar more troubling. If the flap seems at risk, outline your options. Consider a preliminary surgical delay, move the flap in three stages as a full-thickness forehead flap, transfer a skin paddle from the opposite side of the forehead on a contralateral pedicle, expand residual normal forehead skin to avoid the injured area, or employ a non-paramedian forehead flap based on other named vessels.
12. Poor vascular design The vertical paramedian forehead flap is the first choice for nasal reconstruction. An Oblique, Scalping, Up and Down, Horizontal or Washio flap are poor second choices. Their blood supply is less reliable, their transfer more morbid and their donor sites more problematic. Carefully note the advantages and disadvantages of each method. Choose carefully.
13. Fear of hair Transfer of hair to the nose is to be avoided. But it is of secondary importance. The patient can shave, pluck, depilate, laser or ablate hair bulbs secondarily. The nose is the thing! Misdirected by hair, surgeons often choose the wrong flap design, the wrong pedicle, a flap too small or too short, or use expansion unnecessarily. They ‘give up’ and accept a poor result. They use a skin graft or local flap to repair the nose when only a forehead flap will restore the ‘normal’ and ‘heal’ the patient.
14. Morbid insistence on primary closure of the forehead donor site The narrow base of the paramedian forehead flap ensures primary closure of the inferior forehead. Depending on the size of the flap and the amount of forehead excess, a gap may remain superiorly, which cannot be reapproximated. Lying under the hairline, this should be allowed to heal secondarily. It will granulate, contract and reepithelialize. It can be revised at a later date, once healing is completed. This is often not necessary. 275
Chapter • 9 • How to Kill a Forehead Flap and Other Design Errors
If closed with a skin graft, the area will be visible as an atrophic discolored patch. If closed with a local scalp flap or horizontal advancement, scarring is increased and skin denervation greater. Tissue expansion, when applied just to ease closure, delays the nasal repair, subjects the patient to unnecessary pain and morbidity, and adds its own unique complications and limitations to the reconstruction. Such techniques are unnecessary, prolong the operation, and do not improve the final result.
15. Smoking and prior radiation A history of radiation for acne does not demonstrably diminish vascularity or wound healing. Of course, severe atrophy, induration or ulceration, subsequent to other types of radiation therapy, would be cause for concern. Because of the risk of a future cancer developing within transferred irradiated skin, it may be appropriate to avoid hingeover lining flaps developed from such tissue. A new cancer would be difficult to see intranasally. Diagnosis and treatment would likely be delayed. Smokers should stop smoking. Smoking increases the risk of flap necrosis. Because of its greater vascularity, a three-stage full-thickness forehead flap is useful in smokers, especially if the defect is large or requires complex extensions. Of course, all flaps are inset without tension. During the intermediate operation, the flap is normally completely re-elevated from the recipient inset. In high risk patients, leave the distal flap attached to the columella or nostril rim to maintain a bipedicle blood supply during the second stage. Later, when the flap is divided, re-elevate the proximal flap conservatively. Accept the need for a secondary revision to further refine soft tissue contour later. If these guidelines are followed, smokers do well.
16. Giving up and fear Almost any problem can be solved, if the time is taken and thought is given to the problem. Think. Consult. Review the literature. Develop a preoperative vision and plan. Perform the repair mentally and try to foresee the limitations, possible problems and likely solutions. Operate when ready. If you do not know what to do, refer.
276
9
C H A P T E R
Forehead skin is ideal for nasal resurfacing. Although the vertical paramedian forehead flap is the first choice, forehead tissue can be transferred on numerous vascular pedicles. At least two to three flaps can be harvested from the forehead depending on the size, height, laxity, history of prior injury and the size of the nasal defect. The forehead donor site almost never limits nasal repair. Do not minimize the aesthetic and functional importance of restoring a normal nose. Do not exaggerate your concerns regarding forehead donor deformity. The forehead is a forgiving donor site. However, it must be used correctly. Technique does matter.
Errors 1. Flap too short or pivot point too high Position the template at the hairline. Check the arc of rotation and ensure that the flap will comfortably reach the defect — measure to the columella and to each alar base, as required for the specific defect. Use a tape to verify the distance from the planned pivot point to the distal inset. Double check prior to incising the flap. If the flap will not comfortably reach the defect, its design can be extended into the hairline or the base of the flap can be lowered, moving the pivot point inferiorly. If, after elevation, the flap seems short, further extend the skin incisions of the pedicle, inferiorly. It crosses through the medial brow towards the medial canthus. Then release restricting fibrous or muscle fibers within the soft tissue at the flap’s base. Preserve visible vessels. Do not elevate periosteum under the pedicle base. The supratrochlear vessels pass over the supraorbital periosteum within the corrugator soft tissue. A subperiosteal dissection is not helpful and restricts the flap’s movement. Cut and release, as you go, until the flap can be positioned to the defect without tension. Vascular compromise is very unlikely to occur. Although rarely performed, one can carefully incise the frontalis muscle transversely, at the base of the flap, to expose the subcutaneous fat. This permits the overlying soft tissue to stretch, gaining a few extra millimeters of length. The vessels pass under the frontalis, at the orbital rim, and travel through the muscle into the subcutaneous layer, within 2 cm of the brow. Muscle transection is positioned to protect the distal axial vessels, superficial to the frontalis.
Chapter • 9 • How to Kill a Forehead Flap and Other Design Errors
2. Flap too wide or too narrow A forehead flap should be designed as a tailored garment which covers the nose without excess or deficiency. If the flap is too small, it will crush the underlying support and distort the tip and alar base positions. Tension will also impair its blood supply. If the flap is too large, it will not conform to the underlying framework. The nose will look like a baggy shapeless suit of clothes. Intraoperatively, a three-dimensional template, based on the contralateral normal or ideal, is designed. After replacing missing lining and cartilage grafts, its dimension is reconfirmed. The 3-D template is then flattened to two dimensions, and positioned on the forehead. The template determines the dimension and outline of the flap. Rely on your pattern. The dimension and outline of tissue needed to repair the face cannot be ‘eyeballed’.
3. Pedicle too narrow or too wide A paramedian forehead flap should be designed with a pedicle 1.2 to 1.5 cm in width. Even though a narrower flap will survive, it has no advantage. Conversely, a wider flap twists less easily and kinks. This limits its reach. A wider flap does not increase flap vascularity. Closure of the inferior forehead will also be more difficult after flap elevation. Base the flap over the supratrochlear vessels with a 1.2 to 1.5 cm pedicle width. Cut across the brow towards the medial canthus. At the time of flap division, return the proximal aspect of the flap’s base to the brow. Discard the excess. Inset it as a small inverted ‘V.’ The scar simulates the normal frown line. Because the flap’s base is narrow, the eyebrow is not medialized.
4. Incorrect rotation on transfer At the time of elevation, the flap is incised along the two parallel incisions at its base. The medial incision is carried more inferiorly than the lateral incision. The flap is rotated medially towards the nose. Its narrow pedicle easily transposes 180 degrees. If the flap is rotated laterally towards the eye, the base kinks, jeopardizing blood supply and shortening flap reach. It also obstructs vision more significantly.
5. An incorrectly oriented pattern Templates are employed to determine the correct dimension and outline of cover, lining flaps and the support grafts. They are designed from the contralateral normal or ideal. But once prepared, they must be properly oriented. A pattern, based on the contralateral normal, must be flipped so that it correctly defines the tissue requirements of the opposite ‘mirror’ recipient defect. A template designed to resurface a central defect must also maintain proper orientation. The lateral borders of a midline defect often vary in outline, from one side to the other. The pattern is designed from the contralateral normal. It is then flipped and positioned over the recipient site. The template is then rotated medially, swung to the forehead donor site, and flattened on the forehead. The flap’s outline is marked with ink, cen272
Errors
tered over the supratrochlear vessels. Then the outline of the proximal pedicle is drawn as a gentle taper that extends inferiorly to the pedicle base. Employ the foil of a suture pack which is colored on one side. It is helpful to routinely create a template so that the silver or colored side of the surgical foil faces outward when it is placed over the normal side. When it is correctly positioned over the recipient site, the opposite side should be visible. If the ‘wrong’ side is up, recheck the orientation. This habit diminishes the risk that the surgeon will fail to flip the pattern correctly, after its design on the contralateral normal. Do not use an incorrectly oriented pattern to design your flap.
6. Incorrect paramedian pedicle choice Midline defects can be repaired with a paramedian flap based on either the right or left supratrochlear vessels. However, unilateral defects are best repaired with a flap based on the ipsilateral pedicle. The distance from the pivot point to the recipient site is the shortest — the flap is effectively lengthened. Of course, if the ipsilateral pedicle or its forehead skin territory is unavailable, the contralateral flap will survive. However, the flap must be longer to ensure adequate length and reach without tension. Routine use of the contralateral pedicle does not ease its transposition or protect its vascularity. It makes the repair more difficult and should be avoided, unless necessary. Although recommended by some, designing a flap to cross the forehead obliquely does not facilitate its rotation or significantly increase the forehead’s available length. It does create a donor defect that is more difficult to close without distortion of the eyebrows. It also transects many of the vertically oriented vessels, decreasing vascularity. If the flap seems short, most often the surgeon has simply based the vertical paramedian flap too high over the brow. Lengthen the flap by accepting hair on its distal aspect or, more often, lower the pedicle base across the eyebrow to drop the pivot point and bring the base closer to the defect.
7. Inset under tension Forehead flaps are highly vascular. But they do not tolerate tension. The flap must not be too small or short. It must comfortably drape over the defect. If the flap seems short, redissect the pedicle base and lower the pivot point, if necessary. Approximate the flap to the recipient site with interrupted sutures. If a suture is tight, remove it. Sometimes a simple suture readjustment and flap redraping will solve the problem. If blanching occurs on closure and the flap seems small, flap dimension or outline cannot be altered after elevation. However, the surgeon may be able to save the day by cautiously excising frontalis muscle along the borders of a full-thickness forehead flap. Or remove a projecting tip graft to modestly reduce the overall size of the cartilage construction. The excess cartilage is banked and replaced during the intermediate operation. 273
Chapter • 9 • How to Kill a Forehead Flap and Other Design Errors
If the flap is designed with a proximal taper, it may be possible to pull the flap inferiorly and redrape the tissue more effectively.
8. Inset too tight or complete At inset, the flap is first sutured to the columella and nostril margins in one layer, one suture at a time. Then individual sutures are placed laterally, progressing superiorly on either side. If the closure appears tight and blanching occurs, stop. The flap is allowed to dangle from the brow to the inset without further suture approximation. It is not necessary to fix the flap to the recipient side along its entire periphery. Loosely applied, the flap will heal spontaneously to the defect over the next 10 days. Its final appearance will be indistinguishable from another flap that was sutured more completely to the recipient defect. Insisting on complete wound closure, at the time of inset, can kill the flap.
9. Excessive thinning on transfer A forehead flap is thicker than nasal skin. Excess frontalis muscle and subcutaneous fat must be trimmed before the completion of the repair. It is safe, in nonsmokers, to thin the distal 1.5 cm during the first stage of a two-stage transfer. But as soft tissue is excised, the flap’s blood supply is diminished and the flap is more susceptible to tension. The two-stage flap is best used to repair small defects that did not require wide excision of excess fat and frontalis muscle. Because the flap must be thinned over only a small area of its surface, the risk is modest. A three-stage flap is employed for large defects which require large flaps or in those with a questionable blood supply — the smoker, a scar in the territory of the flap, or a flap with complex extensions.
10. Inadequate or overly extensive re-elevation of the flap at the pedicle division Once healed to the recipient bed, the distal flap receives an ample blood supply from the inset. No longer dependent on the flap pedicle, it can be divided. Distally, the flap is re-elevated, inferiorly, towards the tip and nostril rims. This permits further sculpting of the dorsum, sidewalls, and alar creases, prior to completing the inset. It is routine to elevate the distal flap to within 1 to 1.5 cm of the tip and nostril margins. This provides adequate exposure to shape the desired three-dimensional contour. However, the surgeon must balance the risk versus the gain. If the re-elevation is too timid, a revisional operation will be required to sculpt the correct contour, secondarily. If too aggressive, the flap may be put in vascular jeopardy. It is difficult to kill facial flaps, but judgment and experience are important. Ask yourself — is it safe? Will the size of the remaining inset support the elevated skin? How much soft tissue excision is required? Will the exposure be sufficient to sculpt the recipient bed adequately? Is a late revision required for other purposes? If so, would it be safer to do additional debulking, during a later stage? 274
Errors
If in doubt, be safe and improve the contour later. The final appearance of the nose is important but tissue must survive. Limit the flap’s re-elevation, if needed. Plan a late revision to improve the result after the pedicle is divided. It may be helpful to put off pedicle division until a later date. Perform additional sculpting during an intermediate operation, leaving the pedicle intact for an additional few weeks. Even if a two-stage flap was planned and the distal aspect of the flap has been thinned initially, you can postpone its division. Re-elevate the entire inset, thin the forehead flap and sculpt the entire recipient bed. Then reinset the flap and wait several more weeks before dividing the blood supply.
11. Failure to identify a scar within the flap’s territory Consider the site, length, direction, depth and etiology of a scar. A vertical scar is less worrisome — a deep transverse scar more troubling. If the flap seems at risk, outline your options. Consider a preliminary surgical delay, move the flap in three stages as a full-thickness forehead flap, transfer a skin paddle from the opposite side of the forehead on a contralateral pedicle, expand residual normal forehead skin to avoid the injured area, or employ a non-paramedian forehead flap based on other named vessels.
12. Poor vascular design The vertical paramedian forehead flap is the first choice for nasal reconstruction. An Oblique, Scalping, Up and Down, Horizontal or Washio flap are poor second choices. Their blood supply is less reliable, their transfer more morbid and their donor sites more problematic. Carefully note the advantages and disadvantages of each method. Choose carefully.
13. Fear of hair Transfer of hair to the nose is to be avoided. But it is of secondary importance. The patient can shave, pluck, depilate, laser or ablate hair bulbs secondarily. The nose is the thing! Misdirected by hair, surgeons often choose the wrong flap design, the wrong pedicle, a flap too small or too short, or use expansion unnecessarily. They ‘give up’ and accept a poor result. They use a skin graft or local flap to repair the nose when only a forehead flap will restore the ‘normal’ and ‘heal’ the patient.
14. Morbid insistence on primary closure of the forehead donor site The narrow base of the paramedian forehead flap ensures primary closure of the inferior forehead. Depending on the size of the flap and the amount of forehead excess, a gap may remain superiorly, which cannot be reapproximated. Lying under the hairline, this should be allowed to heal secondarily. It will granulate, contract and reepithelialize. It can be revised at a later date, once healing is completed. This is often not necessary. 275
Chapter • 9 • How to Kill a Forehead Flap and Other Design Errors
If closed with a skin graft, the area will be visible as an atrophic discolored patch. If closed with a local scalp flap or horizontal advancement, scarring is increased and skin denervation greater. Tissue expansion, when applied just to ease closure, delays the nasal repair, subjects the patient to unnecessary pain and morbidity, and adds its own unique complications and limitations to the reconstruction. Such techniques are unnecessary, prolong the operation, and do not improve the final result.
15. Smoking and prior radiation A history of radiation for acne does not demonstrably diminish vascularity or wound healing. Of course, severe atrophy, induration or ulceration, subsequent to other types of radiation therapy, would be cause for concern. Because of the risk of a future cancer developing within transferred irradiated skin, it may be appropriate to avoid hingeover lining flaps developed from such tissue. A new cancer would be difficult to see intranasally. Diagnosis and treatment would likely be delayed. Smokers should stop smoking. Smoking increases the risk of flap necrosis. Because of its greater vascularity, a three-stage full-thickness forehead flap is useful in smokers, especially if the defect is large or requires complex extensions. Of course, all flaps are inset without tension. During the intermediate operation, the flap is normally completely re-elevated from the recipient inset. In high risk patients, leave the distal flap attached to the columella or nostril rim to maintain a bipedicle blood supply during the second stage. Later, when the flap is divided, re-elevate the proximal flap conservatively. Accept the need for a secondary revision to further refine soft tissue contour later. If these guidelines are followed, smokers do well.
16. Giving up and fear Almost any problem can be solved, if the time is taken and thought is given to the problem. Think. Consult. Review the literature. Develop a preoperative vision and plan. Perform the repair mentally and try to foresee the limitations, possible problems and likely solutions. Operate when ready. If you do not know what to do, refer.
276