Second stage median forehead flap
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This is Richard Allen at the University of Iowa. This video demonstrates a second stage median forehead flap. The patient had a relatively deep right cheek/nasal wall defect which was repaired approximately 2 months previously. Note in particular that the head of the left brow is shifted medially as well as inferiorly. This will be addressed during the second stage procedure. Markings have been made at the areas of the proposed incision. The area is infiltrated with 1% lidocaine was 0.375% bupivacaine with epinephrine. As is demonstrated with the hemostat, this is a pedicle flap. The pedicle is transected with a 15 blade taking care not to injure the underlying skin. An incision is then made along the base of the pedicle superiorly and proceeds to the area of the original donor site. The scar of the donor site will be excised with the 15 blade. A needlepoint cautery is used to excise the scar and wide undermining is then performed on each side of the donor site. The flap is then thinned and trimmed appropriately to fill the gap. By performing this, the head of the left brow will be shifted laterally and superiorly into its original position. I believe this is very important to pay attention to in order to place the brow of the patient into appropriate position. The base of the flap is sutured into position with deep interrupted 4-0 or 5-0 Vicryl sutures followed by 5-0 Prolene sutures placed in a vertical mattress fashion.
Attention is then directed to the distal portion of the flap. An additional portion of the pedicle is removed. An incision is then made around the area of the flap. The flap is then raised from the bed of the original defect. The flap is thick and will be thinned with Westcott scissors. This is usually thinned down to the dermis along the flap. The bed of the defect is then excised in order to thin it appropriately. Unfortunately, a buttonhole was made in the flap during the procedure. Again the base of the flap is thinned so that the flap can be laid appropriately. This was a relatively deep defect at time of the initial surgery. The flap can be thinned down to the dermis with Westcott scissors. Portions of the flap are trimmed so that will lay into the defect appropriately. The flap will then be sutured into position with superficial 5-0 fast-absorbing sutures. At the conclusion of the case, the brow is in appropriate position. The flap is then thinned appropriately. The patient will use antibiotic ointment over the area and return in approximately one week for reevaluation.