If the median or oblique forehead flap cannot adequately cover a defect or if larger, full-thickness defects are present, excellent results can be achieved with the somewhat difficult frontotemporal flap of Schmid (1952) as modified by Meyer (1964, 1988) (Fig. 5.17). Because of its technical complexities, however, this flap is no longer widely used. The flap is mobilized in stages approximately 16-20 days apart. In about 8 weeks the surgeon can swing the flap downward, freshen the wound edges, and inset the flap into the defect.
Fig. 5.17 Frontotemporal flap of Schmid and Meyer (1964).
a A narrow bipedicled flap is raised above the eyebrow to function as a "transport flap." The cut is widened slightly toward the bone. The defect is closed primarily, tacking the upper wound edge to the frontal periosteum to avoid drawing the eyebrow upward. The bipedicled flap is sheathed with split-thickness skin. The reconstructive flap is outlined in the temporal area using a pattern.
b A small bridge of skin (arrows) is left between the temporal flap and the bipedicle flap.
c About 6-7 weeks after creating the bipedicle flap and 3 weeks after dividing the small bridge between the two flaps, the temporal flap is transferred and inset into the nasal defect. About 3--4 weeks later the nutrient pedicle is detached at the nasal tip. If the tubed flap will be used to reconstruct the columella, the pedicle is divided at the eyebrow.
Stage I: First a narrow, superciliary bipedicle flap is created. The flap incisions above the eyebrow should be spaced at a width of no more than 8 mm, but the lateral ends can be angled superiorly and inferiorly in a trapezoidal design. The superciliary defect below the bipedicle flap is closed by mobilizing the fore head skin (Fig. 5.17a). The upper edge of the wound is tacked subcutaneously to the periosteum of the frontal bone to prevent eyebrow distortion. The superciliary segment of the flap is then sheathed with a split-thickness skin graft. The bipedicle flap serves merely as a transport flap; the reconstructive flap is outlined in the temporal area to conform to the nasal defect (Fig. 5.17b). Split-thickness skin, cartilage, or composite grafts can be added to the temporal flap during the initial sitting (Fig. 5.18). Stage II: About 15-20 days later, the bridge between the prelined temporal flap and the transport flap is incised (Fig. 5.17b).
Stage III: After a total of 3-4 weeks the entire flap can be raised on its median pedicle, and the temporal flap is inset into the nasal defect (Fig. 5.17c). Stage IV: About 3-4 weeks later the pedicle can be divided or opened up, inset to reconstruct the columella (Meyer 1988), or discarded. Additional stages: Further steps may be needed to complete the insetting of the temporal flap in the nose, or scar revisions may be necessary to improve the outcome. This technique can also be used for alar reconstruction using a composite graft from the auricular concha (Fig. 5.18). Other flap options for partial nasal reconstruction are described on pages 47-51
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