Para-median forehead flap
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This is Richard Allen at the University of Iowa. This video demonstrates a para-median forehead flap for repair of a relatively deep lateral nasal wall/medial mid-face defect. The flap is been planned. I personally do not map the supraorbital artery as I believe that the vascular supply is adequate without marking. A 15 blade is then used to make an incision along the markings. The needlepoint cautery is then used to dissect in the subgaleal plane. Hemostasis is obtained with the needlepoint cautery as well as bipolar cautery. This dissection is taken down to approximately 2 centimeters above the superior orbital rim. The flap is transposed. An incision is then made through the periosteum approximate 2 centimeters superior to the superior orbital rim. Dissection is then carried out in a subperiosteal plane in order to spare the supratrochlear and supraorbital vascular structures. The flap is then transposed and appears to adequately cover the defect. Wide undermining is then performed with the needlepoint cautery around the donor site. The donor site will then be closed with deep interrupted 4–0 Vicryl sutures. These are placed in order to take tension off of the skin. A dogear is taken out superiorly. This is performed with a Burow's triangle technique. The skin can then be closed with interrupted 5–0 Prolene sutures which are placed in a vertical mattress fashion.
Attention is then directed to transposition of the flap. The flap can be placed into position without significant tension. Due to disjunction of the thick flap and the skin in eyelid skin, the flap will be thinned superiorly. The flap is then sutured into position at cardinal positions with deep interrupted 5–0 Vicryl sutures. These are placed in order to take tension off of the skin. The skin can then be closed with a combination of interrupted 5–0 Prolene sutures placed in a vertical mattress fashion as well as simple interrupted fashion. Attention is then directed to the posterior surface of the flap which is engaged with a 5-0 Vicryl suture followed by the periosteum of the bed of the defect. Tying the suture allows the flap to be seated appropriately into position. The remainder of the skin closure is then performed with a combination of 5-0 and 6-0 Prolene sutures. Antibiotic ointment is placed over the repair and the patient will return in approximately 1 week for suture removal and reevaluation.