Converse Scalping Flap Forehead Scalp Flap

Use of the converse scalping flap is illustrated for subtotal or total nasal reconstruction with partial reconstruction of the upper lip and cheek (Fig. 5.50). The neighboring esthetic units should be reconstructed prior to the nasal reconstruction (Fig. 5.50a, b). Soft-tissue expansion in the forehead (see Figs. 4.5 and 5.16) may precede the reconstruction.

Fig. 5.51 Reconstruction of the external nose with a Converse scalping flap (see Fig. 5.50). The outline of the laterally based forehead flap is shown (minimum width 8 cm, spans full height of forehead).

a The scalp flap is incised to the galea, and meticulous he-mostasis is obtained.

Stage I: If necessary, a median forehead flap is used for nasal lining (Fig. 5.50a, b; see also Fig. 5.15). This flap is turned inferiorly (Fig. 5.50c) and sutured to the residual nasal mucosa. Silicone stents or acrylate struts are inserted at this stage for structural support. The incision for the forehead-scalp flap starts above the eyebrow to the right or left of the median forehead flap and is continued upward. For a total nasal reconstruction, this flap should be at least 8 cm wide and should span the full height of the forehead. Care is taken to preserve the frontial muscle as the flap is dissected upward. The scalping portion of the incision curves behind the hairline and ends behind the auricle on the opposite side. This large flap is supplied by numerous branches of the superficial temporal artery along with the contralateral supraorbital vessels (Fig. 5.51a, b; see also Fig. 2.8c).

b Elevation of the forehead and scalp flap (see Fig. 5.50a). c The distal portion of the forehead flap is folded and sutured to create a new nose.

Total Forehead Flap

Fig. 5.51 Reconstruction of the external nose with a Converse scalping flap (see Fig. 5.50). The outline of the laterally based forehead flap is shown (minimum width 8 cm, spans full height of forehead).

a The scalp flap is incised to the galea, and meticulous he-mostasis is obtained.

b Elevation of the forehead and scalp flap (see Fig. 5.50a). c The distal portion of the forehead flap is folded and sutured to create a new nose.

Sickle Forehead Flap Converse

d The new nose is inset over silicone stents with an outer diameter of approximately 8 mm. e, f After the granulation tissue in the residual defect has been conditioned (see text), the defect is grafted with retro-

auricular and postauricular full-thickness skin (good color and texture match). The auricular defect is grafted with split-thickness skin from the buttock or groin.

d The new nose is inset over silicone stents with an outer diameter of approximately 8 mm. e, f After the granulation tissue in the residual defect has been conditioned (see text), the defect is grafted with retro-

auricular and postauricular full-thickness skin (good color and texture match). The auricular defect is grafted with split-thickness skin from the buttock or groin.

Following careful hemostasis, the entire scalp flap is brought downward with the well-perfused, relatively thin forehead flap. The forehead flap is folded to the desired shape (Figs. 5.50d and 5.51c) and inset into the nasal defect (Figs. 5.50e and 5.51d, e). The galea and pericranium are preserved and are covered with impregnated gauze or film (Fig. 5.51d). We allow the forehead defect to fill with granulation tissue. The soft granulations are repeatedly removed until a firm, stable granulating bed has reached the level of the surrounding forehead skin. Then the defect is grafted with full-thickness skin from the retro-auricular and postauricular region on one or both sides or with skin from the supraclavicular region (Figs. 5.50e and 5.51e, f). As a guide, we use a paper or foil pattern tailored to the size of the defect.

A full-thickness skin graft from the supraclavicular region can be used for nasal lining as an alternative to the median forehead flap. However, the somewhat thicker midline forehead flap provides a better framework for the cartilage strut that will be inserted later for structural support. We prefer to add supporting materials at a later time rather than insert cartilage grafts during the first operation. If the forehead region has been expanded, large portions of the forehead defect can be closed in the initial sitting. Stage II: About 3 weeks later the scalp flap can be incised and eventually detached from the reconstructed nose. The granulations on the scalp are removed, the edges of the flap freshened, and the unused portion of the flap is returned. At this time (no later!) the forehead defect is again freed of soft granulations and grafted with full-thickness skin (see Figs. 5.50e and 5.51e). Any necessary corrections such as defatting, scar revisions, etc. are performed about 6 months later. Further minor corrections can be added in later touch-up operations.

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