Flapbasicsiii: Interpolated Flaps

Flap Basics III
Interpolated Flaps
Lauren K. Reckley, MDa,*, Jessica J. Peck, MDb, Scottie B. Roofe, MDc,d
KEYWORDS
Interpolated flaps Paramedian forehead flap Melolabial flap Nasal ala Nasal dorsum
KEY POINTS
Interpolated flaps are designed from noncontiguous donor tissue, which is based on an axial or
random blood supply with the pedicle passing under or, typically, over normal tissue.
Interpolated flaps often require multistaged procedures with pedicle division typically performed at
3 weeks once neovascularization between the recipient and transposed tissue has occurred.
Longer intervals between procedures are advised for patients with comorbidities that delay wound
healing.
Paramedian forehead flaps are an excellent option for reconstruction of the nasal dorsum with an
axial blood supply based on the supratrochlear artery.
The melolabial flap provides an aesthetic advantage to the reconstruction of the lateral nasal side-
wall and ala due its preservation of the alar-facial sulcus and minimal distortion of the melolabial
crease.
INTRODUCTION: INTERPOLATED FLAPS disadvantage of these flaps. Despite this, how-

ever, flaps such as the paramedian forehead and
Due to excellent reliability, vascularity, and skin melolabial remain a popular technique when insuf-
color match, interpolated flaps are a valuable ficient tissue or mobility in nearby skin prevents
method for reconstruction of the midface following coverage of a surgical defect with primary closure
Mohs surgery. Interpolated flaps are designed or an adjacent flap.
from noncontiguous donor tissue, which is based
on an axial or random blood supply. Therefore,
Paramedian Forehead Flap
the pedicle must pass under or, more commonly,
over the intervening tissue. The overlying pedicle The paramedian forehead flap (PFF) serves as the
must typically be removed in a second stage after workhorse flap for modern reconstruction of large,
vascularity is established between the wound and complex defects. Providing a superior match for
the flap. Therefore, most interpolated flaps are nasal skin texture, color, and thickness, the ability
performed in 2 stages. The first stage leaves of the PFF to reconstruct defects involving more
a temporary bridge of vascularized tissue than one layer has made it a classic choice for
across normal adjacent skin and the second in- complex nasal reconstruction. However, the
volves detachment of the flap pedicle after neo- robust vascular supply, the ability to vary thick-
vascularization from the recipient bed. It is this ness of the design, and the ability to provide a
second stage requirement that is the greatest large amount of tissue allow for reconstruction of
facialplastic.theclinics.com
Disclosure: See last page of article.

a
Otolaryngology-Head and Neck Surgery, Tripler Army Medical Center, Honolulu, HI, USA; b Facial Plastic and
Microvascular Reconstructive Surgery, Otolaryngology-Head and Neck Surgery, Dwight Eisenhower Army Med-
ical Center, Fort Gordon, GA, USA; c Uniformed Services University of the Health Sciences, Bethesda, MD, USA;
d
Otolaryngology-Head and Neck Surgery, Department of Surgery, Womack Army Medical Center, Fort Bragg,
NC, USA
* Corresponding author.
E-mail address: lauren.k.reckley.mil@mail.mil
Facial Plast Surg Clin N Am 25 (2017) 337–346

http://dx.doi.org/10.1016/j.fsc.2017.03.006
1064-7406/17/Published by Elsevier Inc.
Downloaded for fk unpad 1 (fkunpadjurnal1@gmail.com) at Universitas Padjadjaran from ClinicalKey.com by Elsevier on July 10, 2018.
For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved.
338 Reckley et al
plane, passing deep to the orbicularis oculi muscle

and ascending superficial to the corrugator super-
cilii muscle approximately 1 cm above the brow.2
There are also important vascular anastomoses
from branches of the angular and supraorbital ar-
teries, as well as the medial forehead branch of
the dorsal nasal artery.2,3 The distal end of the
flap is considered a random blood supply that al-
lows for variation in design and preservation of
vascularity well beyond the distal end of the axial
vessel. It is this excellent vascularity that allows
incorporation of cartilage or tissue grafts into the
flap. These grafts can, in turn, serve as support
or lining tissue in nasal reconstruction. Fig. 1 is
an illustration of a PFF used to reconstruct the
nasal tip and Fig. 2 illustrates the vascular supply
of the flap. Figs. 3 and 4 demonstrate intraopera-
tive PFF reconstructive photos for nasal tip
defects.
Design and Technique

Fig. 1. Illustration of PFF for tip defect. The design of the PFF is based on the course of
the supratrochlear vascular pedicle. For lateral
multiple areas of the midface. Defects of the nasal defects, the flap is generally based on the
medial canthal region, upper and lower eyelids, contralateral pedicle to avoid kinking of the ves-
medial cheek, nasolabial region, and upper lip sels and for maximum rotation and length.4
may all be reconstructed with a properly designed Doppler may be used to confirm the location of
PFF. the vessel. However, cadaver studies show that
the supratrochlear artery reliably exits the orbit
History
The PFF has been used with a variety of modifica-
tions since at least 3000 BC. Initially, the primary
design was based on the midline forehead
involving the central forehead and glabellar skin,
resulting in significant donor site deformity. How-
ever, in the late nineteenth and early part of the
twentieth century, variations were introduced that
altered the flap to the median position. Labat
modified the median forehead flap to base it on a
unilateral supratrochlear artery. Millard is credited
with the shift to the paramedian design which
excluded the central glabellar skin, subsequently
eliminating a significant source of morbidity.1
Anatomy and Blood Supply

The PFF is clearly thicker than the original skin of
the nose due to the unique composition of skin,
subcutaneous tissue, frontalis muscle, and thin
areolar tissue. Knowledge of the donor area anat-
omy is, therefore, essential because it allows thin-
ning of the flap for better inset, as well as Fig. 2. Illustrated and labeled PFF anatomy. (a) Supra-
narrowing of the base of the flap for improved rota- trochlear artery. (b) Supraorbital artery. (c) Supraor-
tion without limiting the overall size of the flap. The bital plexus. (d) Backfill through subdermal plexus.
primary blood supply of the PFF is the supratro- (e) Periosteal elevation captures the periosteal branch
chlear artery. This vessel runs in the submuscular of supratrochlear artery.
Flap Basics III: Interpolated Flaps 339
1.7 to 2.2 cm from the midline.3 Taking this into ac-

count, the stalk of the flap may be designed to reli-
ably include the supratrochlear pedicle without the
use of Doppler, by making the vertical incisions at
1.5 and 2.5 cm from midline. The corrugator com-
plex and frontalis muscles may also be incorpo-
rated into the base of the stalk, a technique that
is advocated by some investigators to further
ensure flap viability.5
The use of a foil or paper template is useful to
match the defect to the proposed forehead flap.
While confirming adequate length required to
reach the defect in a tension-free manner, keep
in mind the need to include a small amount of extra
length to allow for flap thickness and swelling. The
random nature of the distal portion of the flap lends
itself to variety of designs without compromising
blood supply to that area.4 By extending the PFF
superiorly into the hairline or by creating a flap
that courses across the midline, the flap may be
extended to reconstruct the lower nose and colu-
mella. Similarly, for full-thickness defects that
involve the intranasal lining, the PFF can be folded
over to close the intranasal defect as an alternative
to full-thickness skin grafting or a mucosal flap.
Local anesthetic is injected along the periphery
Fig. 3. Marked left PFF for nasal tip defect. Notice
of the pedicle to aid in hemostasis while avoiding
that the entire nasal subunit has been removed.
the supratrochlear vessels. The distal flap is then
elevated in the subcutaneous plane from the un-
derlying frontalis musculature, leaving 1 to 3 mm
of subcutaneous fat on the underside of the flap.
Maintaining the thinness of the flap distally avoids
bulkiness and allows a more natural appearance of
the flap after inset. As dissection proceeds proxi-
mally, the flap is then harvested in progressively
deeper layers to preserve the supratrochlear ves-
sels and nerves. After raising the portion for inset,
dissection proceeds in the subgaleal plane to pre-
serve the underlying periosteum.4 Three centime-
ters above the supraorbital rim the periosteum is
incised, and elevation continues in the subperios-
teal layer to preserve the periosteal branch of the
supratrochlear artery, which supplies additional
perforators to the flap. This periosteal incorpora-
tion does not decrease the rotational freedom of
the flap when using the contralateral forehead,
nor does it deter flap length. It does, however,
aid in supporting the base of the flap and prevent-
ing excessive pedicle torque.
Extending 7 mm above the supraorbital rim, the
supraorbital plexus, composed of the supratro-
chlear, supraorbital, and dorsal nasal artery, pro-
vides additional perfusion to the PFF. In higher
risk patients, such as smokers or those with poorly
controlled diabetes, maintaining this plexus maxi-
mizes flap perfusion with a 3-vessel blood supply
Fig. 4. First stage of left PFF 1 week postoperatively. to the PFF. Conversely, extending the design
340 Reckley et al
below the orbital rim allows for maximal rotation.2 Inferiorly, the flap is amputated near the margin
The flap is then rotated and sutured into position. of the defect and inset. If additional sculpting is
To close the primary defect, wide undermining is required, further conservative thinning of the flap
performed. For wider defects, further laxity is may be performed before closure. Fig. 5 demon-
achieved by performing galeotomies incised paral- strates a female patient years after multistaged
lel to the skin margins. The wound is then closed in right PFF for a dorsum defect after Mohs surgery.
a layered fashion. Although most of the donor site
may be closed primarily, often the distal aspect is Variations
too wide and under too much tension to close pri-
marily. This portion of the donor site may be Single-stage
allowed to heal by secondary intention with excel- To avoid the second-stage procedure associated
lent results and minimal scarring. Alternatively, with the traditional technique of forehead flaps,
a full-thickness skin graft may be harvested single-stage techniques have been described.9,10
from the postauricular area, or the surgeon may These include tunneling de-epithelialized tissue
consider a W-plasty closure along the frontal for transposition under existing intact skin to
hairline with bilateral advancement flaps.4 reconstruct a variety of defects. Avoidance of a
If necessary, tissue expansion can be per- second stage can be particularly advantageous
formed secondarily after nasal reconstruction to in patients with significant comorbidities, or with
close the donor site or to allow for forehead scar those who are less likely to be compliant with
revision.1 Tissue expanders should be avoided follow-up. These flaps may be bulky and apparent
before PFF harvest, however, due to the potential under the bridging tissue between the donor site
for the reconstructed area to contract after and the defect. However, this often resolves within
completion of nasal reconstruction. a few months as the pedicle atrophies. Neurovas-
cular injury secondary to compression is possible
but unlikely with adequate undermining and avoid-
Detachment ance of a narrow tunnel.9
Once neovascularization between the recipient Three-stage
and the transposed tissue has occurred, the Millard first described the 3-stage technique in
pedicle may be safely divided and inset. This has 1974 using an intermediate procedure after flap
typically been performed at 3 weeks, with longer transfer and before division of the pedicle with
periods added for patients in whom impaired heal- the intent of minimizing flap necrosis. During the
ing is expected, such as those with poorly intermediate phase, the flap was thinned and had
controlled diabetes, vasculopathies, or a history the added benefit of some degree of aesthetic
of smoking. Klingenstrom and Nylen remarkably improvement over the traditional 2-stage tech-
performed flaps on themselves to determine the nique. Some surgeons advocate that the 3-stage
optimal time for flap takedown and published their approach allows the use of skin grafts at the first
findings.6 However, other studies have been per- stage for internal lining and placement of cartilage
formed to establish the appropriate time for take- grafts at the second stage without putting them at
down of forehead flaps using more objective risk because of tenuous vascularity. However, a
techniques.6,7 More than 3 decades ago, Gatti review of 100 3-stage flaps by Stahl and col-
and colleagues6 used fiberoptic perfusion fluorom- leagues11 found no evidence to support a lower
etry to measure tissue fluorescence, examining tis- rate of necrosis or an enhanced aesthetic result.
sue in an animal model at various times after flap
transposition and demonstrating that vascular Vascular delay
ingrowth begins in the first few days. More recently, Vascular delay has been used for a variety of flaps
Woodard and Most7 prospectively found evidence in surgical reconstruction to improve survival but
of vascular in-growth 1 week following transfer. In a less frequently with forehead flaps. Vertical limbs
later study, Surowitz and Most8 demonstrated of the flap are incised and elevated off of the loose
adequate vascular perfusion by 2 weeks in non- areolar tissue at the deep surface. The flap is then
nicotine users using the same technology. Addi- sutured back into position. After 14 days, the su-
tionally, these investigators suggest that real-time perior margin is incised, and the flap is rotated to
imaging with this system can also be used to iden- fill the distant defect. Four weeks later, the flap is
tify the origin and course of the supratrochlear inset and incised. Vascular delay improves flap
artery preoperatively, as well as provide guidance perfusion through several transient effects. Early
for timing of flap transfer in high-risk patients. changes include vascular dilation caused by
The flap pedicle is taken down by incising the division of sympathetic nerves, causing initial
superior portion of the flap, in an inverted V. release and then depletion of adrenergic factors
Fig. 5. (A–E) 2 years after multistaged right PFF.
from nerve endings.12 A relative ischemia of the their superior color match can also be contoured
tissue and subsequent metabolic changes that to match the variable skin thickness of the perior-
contribute to increased flap survival. Later, pro- bital complex. Excellent coverage of the medial
longed alterations in tissue metabolism and neo- canthus, lacrimal drainage system, and medial
vascularization occur via both angiogenesis and upper eyelid has been achieved, particularly in de-
vasculogenesis. This technique may be consid- fects that also involve the nose in that region.15
ered in smokers in whom vascular compromise
can be expected.13 However, most surgeons will MELOLABIAL FLAP
simply prolong the time until takedown to 4 weeks
or beyond in this subset of patients. The melolabial flap (also referred to as the nasola-
bial flap) is a versatile flap with multiple uses for
Other uses midface reconstruction. It may be designed as a
The use of forehead flaps to provide internal lining, skin and subcutaneous tissue flap that is useful
particularly in the case of large full-thickness nasal for partial-thickness nasal reconstruction or as a
defects has been well described.14 Paramedian full-thickness flap of skin, subcutaneous tissue,
flaps have also been described for use in recon- and mucosa that is useful for reconstructing full-
struction of periorbital defects. Similar to the thickness defects of the lip. This flexibility in
concept of nasal reconstruction, these flaps with design, combined with the excellent skin color
342 Reckley et al
and texture match, makes it particularly useful for to preserve the normal concavity.20 Superiorly,
nasal reconstruction of the lower nasal sidewall, the excised nasal sidewall skin should reach the
the ala, the columella, and the lateral internal lin- alar crease at an angle of less than 30 to prevent
ing.16 The excellent vascularity allows incorpora- a dog-ear deformity at the point of rotation and to
tion of cartilage grafts to recreate structural avoid torsion on the proximal melolabial blood
support of the nose. Aesthetically, the most impor- supply. Figs. 6–8 illustrate the typical superiorly
tant advantage of the melolabial flap is that it does based melolabial flap at different surgical stages.
not violate the alar-facial sulcus, thereby mini- The contralateral side conveniently serves as an
mizing distortion of the melolabial crease.17 Similar appropriate template, keeping in mind to under-
to the PFF, it may be designed as a multistaged size the flap by approximately 20% to account
procedure. It may also be designed as a single- for intrinsic elastic properties surrounding the
stage procedure for defects of the lower sidewall defect, which will cause the enlargement from
and ala. the initial excision.19 However, when the defect is
within 5 mm of the alar rim, it is advisable to design
History the flap to the exact size of the defect to prevent
The nasolabial flap was first described by Sushruta, alar retraction. Whenever possible, the primary
an Indian surgeon, shortly after 700 BC. More than defect should be deepened to establish uniformity
300 surgical procedures were described, the and symmetry with the contralateral side rather
most well-known of which covered reconstructive than overthinning the flap.16
techniques following nasal amputation, performed The preferred pedicle width is generally 1.5 to
at the time as a form of criminal punishment. During 2 cm, with the medial border of the flap aligned
the 1800s, multiple alterations of the flap were with the melolabial crease.16 Proximally, the
described to reconstruct a variety of defects, pedicle skin incisions should narrow to facilitate
including defects of the palate, tongue, and lips.18 closure of the donor site, whereas the subcutane-
ous portion is allowed to remain wide to maximize
Anatomy and Blood Supply arterial perforators. The flap is elevated, defatted,
and advanced medially, maintaining at least 3 mm
The ability to camouflage scarring in the nasolabial of fat on the underside of the flap to optimize blood
crease is an important advantage of using the supply.19 The flap is inset into the defect, proximally
melolabial flap for reconstruction. This crease be-
gins slightly superior to the alar crease and ex-
tends to approximately 1 cm lateral to the oral
commissure. The crease itself is created by a
dense concentration of fibrous muscular attach-
ments to the dermis. The blood supply is usually
considered to be random, dependent on the sub-
dermal plexus located between the reticular
dermis and the superficial musculoaponeurotic
system (SMAS) within the superficial adipose
layer.19 This plexus receives perfusion from
branches of the distal facial and labial arteries
perforating through the levator labii, as well as
lesser contributions from the infraorbital artery. It
is the rich anastomoses at the subdermal plexus
that allow the flap to be based superiorly or inferi-
orly as the reconstruction requires.
Design
When used to reconstruct the lower nasal sidewall
or ala, the melolabial flap is usually designed as a
single-stage, superiorly based, flap. If the defect is
greater than 50% of the aesthetic subunit, it is
most advantageous to remove the skin and recon-
struct the entire subunit with the melolabial flap.
When reconstructing the ala, however, the sur-
geon should attempt to leave 1 mm of alar skin Fig. 6. Superiorly based illustration of melolabial flap
just anterior to the alar-facial sulcus, if still intact, for alar defect.
to distally. When the alar crease is reached, a

buried permanent suture should be placed to an-
chor the flap, thus recreating the crease.
The donor site is closed primarily by undermin-
ing the cheek skin. The SMAS may also be pli-
cated to aid in closure of larger donor site
defects in a tension-free fashion.17 However, due
to tissue laxity lateral to the melolabial crease,
particularly in the older patient, the closure of the
donor site is usually uncomplicated.16 For the
best cosmetic result, the vectors for scar forma-
tion should be oriented within the melolabial
crease and prevent distortion of the lower eyelid,
upper lip, or oral commissure (Fig. 9). Fig. 10 dem-
onstrates a female patient after she has healed
from completion of a right melolabial flap for right
alar reconstruction.
Variations
The melolabial flap may be designed as an interpo-
lated flap or as an island advancement flap based
on a subcutaneous pedicle. The interpolated flap
is elevated in the subcutaneous plane while pre-
serving thickness of the pedicle base for flap
Fig. 7. Illustration of melolabial flap for alar defect
survival.16 The island pedicle is incised on the
after rotation and primary closure of donor site.
cutaneous borders while maintaining a vascular-
ized subcutaneous and muscular pedicle at the
central third of the flap.
Fig. 8. Illustration of melolabial flap for alar defect Fig. 9. Intraoperative depiction of left melolabial
after detachment. flap.
344 Reckley et al
Fig. 10. Female patient 4 months after right alar

reconstruction with melolabial flap.
Fig. 11. Illustration of single-stage melolabial flap.

As with the PFF, when the melolabial flap is
performed in 2 stages, detachment is typically
performed after 3 weeks or longer in patients
with comorbidities that impair healing or micro- it does occur, however, patients may be treated
vascularity. The distal aspect of the flap may be with corticosteroids with reasonable improvement.
thinned initially to fit within the defect, while Other common complications include nasal
saving thinning of the proximal aspect for the sec- obstruction, thick scars, bulky flaps, and alar notch-
ond stage. ing. It is also important to limit the incorporation of
The melolabial flap may also be used to recon- fibrofatty tissue into the defect and to not rely on
struct the intranasal lining. By designing the melo- fibrofatty tissue adding bulk to the ala. Preferably,
labial flap to fold on itself, full-thickness alar a larger free cartilage graft is used to recreate bulk
defects can be repaired while avoiding additional and provide structure to the nasal skeleton to pre-
difficult intranasal flaps.21 Unfortunately, such vent alar notching and collapse of the external nasal
reconstruction often results in excessive bulk, valve postoperatively.24
which can distort the alar-facial sulcus and crowd Overall, flap failure is uncommon, with com-
the airway.22 Fig. 11 is an illustration of a single- plete flap failure limited to approximately 2%.
stage melolabial flap reconstruction. Several risk factors have been evaluated for flap
failure, including defect thickness, use of a carti-
lage graft, and presence of comorbidities. How-
COMPLICATIONS ever, these factors did not affect outcome.24 Not
The most common complication following interpo- surprisingly, there is a greater risk of flap loss in
lated flaps is bleeding. Hematomas occur in 0.4%, active smokers.
whereas active bleeding requiring intervention oc-
curs in 8.4% of cases.23 Such bleeding may be SUMMARY
prevented with meticulous hemostasis while
raising the flap and, when it does occur, can be The reliability and ease of harvesting of interpo-
controlled without detrimental effects to the flap lated flaps provide excellent functional and
or patient. aesthetic results for reconstruction of large nasal
Pincushioning occurs in up to 6.5% of cases.24 defects. Their excellent skin color and texture
Slightly undersizing the flap and avoiding curvilinear match, along with the ability to contour to
incisions aids in minimizing this complication. When various thicknesses, allow superior long-term
results. The complication rates are very low and, 4. Quatela VC, Sherris DA, Rounds MF. Esthetic refine-
when they do occur, tend to be minimal. Patient ments in forehead flap nasal reconstruction. Arch
selection is essential, and it is important to Otolaryngol Head Neck Surg 1995;121(10):1106.
educate the patient about healing and the goals 5. Jellinek NJ, Nguyen TH, Albertini JG. Paramedian
of each stage of the procedure to obtain the forehead flap: advances, procedural nuances, and
best result. variations in technique. Dermatol Surg 2014;
40(Suppl 9):S30–42.
6. Gatti JE, LaRossa D, Brousseau DA, et al.
DISCLOSURE Assessment of neovascularization and timing of
flap division. Plast Reconstr Surg 1984;73(3):
Institution where the work was primarily per-
396–402.
formed: Tripler Army Medical Center, Hawaii, USA.
7. Woodard CR, Most SP. Intraoperative angiography
Source of Financial Support or Funding: None.
using laser-assisted indocyanine green imaging to
Financial Interests and Disclosures: None.
map perfusion of forehead flaps. Arch Facial Plast
Financial Disclosure: (1) No financial and no ma-
Surg 2012;14(4):263–9.
terial support for this research and work. (2)
8. Surowitz JB, Most SP. Use of laser-assisted indocya-
Authors have no financial interests in any com-
nine green angiography for early division of the fore-
panies or other entities that have an interest in
head flap pedicle. JAMA Facial Plast Surg 2015;
the information in the contribution (eg, grants,
17(3):209–14.
advisory boards, employment, consultancies,
9. Kishi K, Imanishi N, Shimizu Y, et al. Alternative
contracts, honoraria, royalties, expert testimony,
1-step nasal reconstruction technique. Arch Facial
partnerships, or stock ownership in medically-
Plast Surg 2012;14(2):116–21.
related fields).
10. Fudem GM, Montilla RD, Vaughn CJ. Single-stage
Conflict of Interest: None.
forehead flap in nasal reconstruction. Ann Plast
This article has not been presented at a
Surg 2010;64(5):645–8.
meeting. The views expressed in this article
11. Stahl AS, Gubisch W, Haack S, et al. A cohort study of
are those of the authors and do not reflect the
paramedian forehead flap in 2 stages (87 Flaps) and 3
official policy or position of the Department of
stages (100 Flaps). Ann Plast Surg 2015;75(6):615–9.
the Army, Department of Defense, or the US
12. Ghali S, Butler PE, Tepper OM, et al. Vascular
Government.
delay revisited. Plast Reconstr Surg 2007;119(6):
All authors met the criteria for authorship
1735–44.
established by the International Committee
13. Kent DE, Defazio JM. Improving survival of the para-
of Medical Journal Editors, specifically: L.K.
median forehead flap in patients with excessive to-
Reckley, J.J. Peck, and S.B. Roofe were respon-
bacco use: the vascular delay. Dermatol Surg
sible for substantial contributions to the concep-
2011;37(9):1362–4.
tion, design, analysis, and drafting the work,
14. Parikh S, Futran ND, Most SP. An alternative method
revising the work, and reviewing the article.
for reconstruction of large intranasallining defects:
Additionally, all authors provided final approval
the Farina method revisited. Arch Facial Plast Surg
of the version to be published and agreed to
2010;12(5):311–4.
be accountable for all aspects of the work,
15. Price DL, Sherris DA, Bartley GB, et al. Forehead
including ensuring the accuracy and/or integrity
flap periorbital reconstruction. Arch Facial Plast
of the work.
Surg 2004;6(4):222–7.
16. Jewett BS. Interpolated forehead and melolabial
flaps. Facial Plast Surg Clin North Am 2009;17:
REFERENCES
361–77.
1. Menick FJ. Aesthetic refinements in use of forehead 17. Baker SR, Johnson TM, Nelson BR. The importance
for nasal reconstruction: the paramedian forehead of maintaining the alar-facial sulcus in nasal recon-
flap. Clin Plast Surg 1990;17(4):607–22. struction. Arch Otolaryngol Head Neck Surg 1995;
2. Reece EM, Schaverien M, Rohrich RJ. The parame- 121:617–22.
dian forehead flap: a dynamic anatomical vascular 18. Schmidt BL, Dierks EJ. The nasolabial flap. Oral
study verifying safety and clinical implications. Plast Maxillofacial Surg Clin N Am 2003;15(4):487–95.
Reconstr Surg 2008;121(6):1956–63. 19. Yellin SA, Nugent A. Melolabial flaps for nasal recon-
3. Shumrick KA, Smith TL. The anatomic basis for the struction. Facial Plast Surg Clin North Am 2011;19:
design of forehead flaps in nasal reconstruction. 123–39.
Arch Otolaryngol Head Neck Surg 1992;118(4): 20. Drisco BP, Baker SR. Reconstruction of nasal alar
373–9. defects. Arch Facial Plast Surg 2001;3:91–9.
346 Reckley et al
21. Cook JJ. The reconstruction of the nasal ala with 23. Simmons A, Xu JC, Bordeaux JS. Improving the
interpolated flaps from the cheek and forehead; design and execution of interpolation flaps. Curr
design and execution modifications to improve sur- Dermatol Rep 2015;4:119–24.
gical outcomes. Br J Dermatol 2014;171(2):29–33. 24. Paddack AC, Frank RW, Spencer HJ, et al. Out-
22. Weber SM, Wang TD. Options for internal lining in comes of paramedian forehead and nasolabial
nasal reconstruction. Facial Plast Surg Clin North interpolation flaps in nasal reconstruction. Arch Oto-
Am 2011;19:163–73. laryngol Head Neck Surg 2012;138(4):367–71.

Flapbasicsiii: Interpolated Flaps

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Flapbasicsiii: Interpolated Flaps

Uploaded by

Copyright:

Available Formats

Flap Basics III

INTRODUCTION: INTERPOLATED FLAPS disadvantage of these flaps. Despite this, how-

Disclosure: See last page of article.

Facial Plast Surg Clin N Am 25 (2017) 337–346

plane, passing deep to the orbicularis oculi muscle

Design and Technique

Anatomy and Blood Supply

1.7 to 2.2 cm from the midline.3 Taking this into ac-

Fig. 5. (A–E) 2 years after multistaged right PFF.

to distally. When the alar crease is reached, a

Fig. 10. Female patient 4 months after right alar

Fig. 11. Illustration of single-stage melolabial flap.

You might also like