Flap Delay or Not? A Technical Detail for Nasal Reconstruction with a Forehead Flap
28 July 2017 (online)
We work in a tertiary referral hospital and perform hundreds of nasal reconstructive surgeries every year. From recent nasal reconstruction–related articles, we find that clinical doctors generally do not pay close attention to flap delay, especially the physical method of flap delay. Sometimes, this step is even skipped, but it is essential to promote the neovascularization and ensure the survival of transferred flap.
In the three-stage forehead flap techniques, Menick uses an intermediate operation, including sculpturing subcutaneous fat and adding delayed primary cartilage grafts, to cause a physiological flap delay. Besides facilitating the placement of cartilage framework, this stage has positive influence on flap vascularization.
To achieve a similar purpose, we use another strategy, a physical method. Seven days after the forehead flap transplantation, flap exercises are performed to ensure blood supply ([Fig. 1]). Technically, long pliers with rubber hoses in the front are used to clip the root of the pedicle to limit the blood circulation. The distal flap should be kept warm and pink until 2 hours, two to three times a day, which is the standard protocol for pedicle division. The required time for this period varies from individual to individual, from 2 to 6 weeks.
In clinical practice, we find this kind of physical flap delay is indispensable. Patients who completed this procedure three times per day enjoyed more similar complexion between transferred flap and adjacent receiving areas after pedicle division. In comparison, the color of the transferred flap was relatively darker, if the patient performed this step only twice per day. But after 3 to 6 months, the difference gradually disappears. We believe this phenomenon is related to the degree of revascularization, especially the intravenous microcirculation which could impact hyperpigmentation. Additionally, for patients with smoking history, local radiation therapy, or a large amount of tissue defect, we tend to perform a stricter standard (thrice per day), because these patients are more likely to suffer from flap distal exfoliation or insufficient blood supply after pedicle division.
Meanwhile, there is another reason for our physical flap delay. Preexpanded forehead flap is our preference, considering the need for lining and Asians have lower hairline and are prone to scar hypertrophy compared with Caucasians. Although preexpansion itself is beneficial to neovascularization, the simultaneously placed cartilage framework with flap transfer is a potential factor responsible for adverse effect. In spite of this, as long as the physical flap delay is performed appropriately and meets the standard protocol for pedicle division, the flap could have a reliable blood supply. So, the flap can be properly refined in the meantime to build a relatively normal shape for reconstructive nose. And patients with financial difficulties can return to their normal work and social life earlier, although further revision is recommended.
In conclusion, physical flap delay facilitates neovascularization and a chance to avoid surgery. Therefore, besides focusing on flap and lining design, flap delay should not be neglected.
The authors have no financial disclosure. Written consents from patients were achieved before surgery.