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Objectives: To determine the safety of early pedicle division of two-stage nasolabial flaps.

Methods: A review was conducted of medical records of patients who had immediate reconstruction with two-stage nasolabial flaps following MOHS surgery between 1999 and 2007.

Results: Sixteen staged nasolabial flap nasal reconstructions were performed with an average patient age of 60 years old, ranging from 38 to 82 years old, with a 5:3 female to male ratio. The most common dermatologic pathology was basal cell carcinoma. The nasal ala was involved in 50% of cases, while the tip and dorsum were involved in 38% and 19% of surgical defects, respectively. Three patients were active smokers. The average defect area was 1.2 cm2, ranging from 0.12 to 4 cm2. Pedicle division occurred at any point between four and sixteen days, with a mean time to division of 7.3 days.

Conclusions: The presented experience indicates that it is safe and effective to divide a staged nasolabial flap pedicle well before three weeks after the initial surgery. In the case of patients who are active smokers or who have bleeding disorders, however, the surgeon must consider delaying pedicle division to at least one week to decrease the risk of complications. By shortening the time to the second stage, patients may be able to minimize many of the inconveniences and infectious complications of prolonged soft tissue exposure.

Two-Stage Nasolabial Flaps for Facial Reconstruction: Revisiting the Three Week Rule for Pedicle Division

Jeremy B White, MD1; Steven D Macht, MD, DDS2

The George Washington University 1Division of Otolaryngology and 2 Plastic Surgery

Sixteen two-stage nasolabial flap nasal reconstructions were performed in thirteen patients (Table 1). The average patient age was 62 years-old, ranging from 38 to 82 years-old, with an approximately equal male to female ratio. The most common dermatologic pathology was basal cell carcinoma, present in 75% of cases, but there was also one case of basosquamous cell carcinoma and three melanomas. The nasal ala was involved in 50% of cases, while the tip and dorsum were involved in 38% and 19% of surgical defects, respectively. Three patients (19%) were active smokers, one of which continued to smoke during the treatment period. The average defect area was approximately 1.2 cm2, ranging from 0.12 to 4 cm2. Pedicle division occurred at any point between four and sixteen days, with a mean time to division of 7.3 days.

Medical records of patients who had immediate reconstruction with two-stage flaps following MOHS micrographic surgery on the face were reviewed. All patients were referred by a single MOHS surgeon between 1999 and 2007. Data regarding patient age, pertinent medical history, pathologic diagnosis, surgical defect size, time of pedicle division, and postoperative complications were noted. The typical postoperative course for these patients included a dressing change on the first postoperative day followed by removal of half of the sutures on postoperative day four. The pedicle was clamped on postoperative day six and, if the distal edge of the flap did not blanch significantly, the pedicle was divided. The flap was immediately trimmed and the proximal edge was sutured in place, while the distal sutures were removed. Wound checks were subsequently conducted two days, one week, and 3 months after flap inset.

The presented experience indicates that it is safe and effective to divide nasolabial flap pedicles well before three weeks after the initial surgery. In the senior author’s experience (SM), the same concept can be applied successfully to other two-stage flaps, such as the paramedian forehead flap. In the case of patients who are active smokers or who have bleeding disorders, however, the surgeon must consider delaying pedicle division to at least one week to decrease the risk of complications. By shortening the time to the second stage, patients may be able to minimize many of the inconveniences and infectious complications of prolonged soft tissue exposure.

The nasolabial flap is one of the most versatile local skin flaps that is used in the reconstruction of surgical defects of the face. The ease of flap design is largely due to its random blood supply based on small subcutaneous and subdermal vessels, rather than the angular or facial arteries via muscle perforators.1 This vascular supply pattern allows for a large amount of defatting in non-smoking patients, or those who have stopped smoking for at least four weeks.2 In comparison with the lower parts of the body, skin of the head and neck has a superior capillary density in the papillary and reticular dermis that allows for the design of long flaps without vascular compromise.3 The nasolabial flap is particularly useful since it can be used in both one and two staged procedures while maintaining an opportunity to hide the incision in the natural nasolabial fold. An unfortunate disadvantage of a two-staged approach is that, due to dictum in training, many surgeons divide the pedicle at 18-21 days. This is often leaves the patient with the inconveniences of wound checks, a lingering period of tissue exposure with potential infection, and an embarrassing bandage for a prolonged period of time. The following is a review of twenty two-stage nasolabial flaps that had pedicle division significantly earlier than the traditional three week period.

INTRODUCTION

METHODS AND MATERIALS

[1] Hagerty RF, Smith W. The nasolabial cheek flap. Am. Surg. 24:50, 1958. Barron JN, Emmett AJJ. Subcutaneous pedicle flaps. Br J Plastic Surgery, 1965. 18:51

[2] Rohrich RJ, Conrad MH. The superiorly based nasolabial flap for simultaneous alar and cheek reconstruction. Plastic and Reconstructive Surgery, Nov 2001. 108(6):1727-30.

[3] Pasyk KA, et al. Regional differences in capillary density of the normal human dermis. Plast Reconstr Surg 1967; 39:125.[4] Seitchik MW, Kahn S. The effects of delay on thecirculatory efficiency ofpedicled tissue. Plast Reconstr Surg 1964; 33:16.[5] Pang CY, Forest CR, Neligan PG. Augmentation of blood flow in delayed random skin flaps in the pig: effect of length of delay period and

angiogenesis. Plast Reconstr Surg 1986; 78:68.[6] Lopez JLA, Nieto CS, Garcia PB, Ortega JMR. Evaluation of angiogenesis in delayed skin flaps using a monoclonal antibody for the

vascular endothelium. BR J Plast Surg 1995; 48:479.[7] Serafin D, Shearin JC, Georgiade NG. The vascularization of free flaps. Plast Reconstr Surg 1977; 60:233.[8] Garcia PB, Nieto CS, Ortega JMR. Morphological changes in the vascularisation of delayed flaps in rabbits. BR J Plast Surg 1991; 44:285.[9] German W, Finesilver EM, Davis S. Establishment of circulation in tubed skin flaps. Arch Surg 1933; 26:27.[10] Gatti J, La Rossa D, Brousseau DA, Silverman DG. Assessment of neovascularization and timing of flap division. Plast Reconstr Surg

1984; 73:396-402.[11] Park SS, White GJ, Cook TA, Wang TA, Kessler S, Cohen JI. Cartilage viability with interpolated skin flaps: an experimental study.

Otolaryngology Head and Neck Surgery 1997;116 (4): 483-488. [12] Klingenstrom P, Nylen B. Timing of transfer of tubed pedicles and cross-flaps. Plast Reconstr Surg 1966;37(1):1-12.[13] Hallock GG. Preliminary assessment of laser Doppler flowmetry for determining timing of division of the cross-finger flap. J Hand Surg

1990;15A:898-901.[14] Hauser WH, Tauxe WN, Owen CA, Lipscomb PR. Determination of the vascular status of pedicle skin grafts by radioactive tracer studies.

Surg Gynecol Obstet 1961;112:625-629.

CONCLUSIONS

DISCUSSION

RESULTS

REFERENCES

ABSTRACT

Jeremy White, MDChief ResidentDivision of OtolaryngologyThe George Washington University

E-mail: jwhite@gwu.edu

CONTACT

N16 0.12 cm2BCC nasal tipY (1.5pk/d)66

N128.75 cm2melanoma in situ, L nasal ala & dorsumN72

N4?BCC R ala N82N81x1cmBCC L alaN77N70.6x0.2cmBCC nasal tipN38N80.8x0.5cmBCC R nasal tipN62N61.2x1.2cmBCC nasal tipN66

Delayed bec bruising at distal tip (qualitative platelet defect)111.4 x 0.8cmfull thickness L nasal ala,

basosquamous cell CAY (1.5pk/d)72

N61.4cmnasal tip BCCN49N61.6x 0.8x 0.3cmmelanoma in situ R nasal alaN52N51cmBCC 1mm above R alar rimN59

N81.5cmBCC nasal tip, portion of alar cartilage exposedN74

N52x2cmnonulcerated melanoma R nasal dorsum/alaN47

N51x1 cmBCC R nasal dorsumN43~ 80% perfectly adherent40.5x0.4x0.1cmnodular BCC nasal tipY (20cig/day)53

N61x1.6cmmultinodular BCC nasal alaN78Complication?

POD pedicle divisionDefect sizeDiagnosisSmoking statusAge

TABLE 1

Numerous studies have been conducted to examine the possibility of earlier pedicle division. In the first week after the first stage of a delayed, tubed flap, the small feeding vessels increase in size, multiply in number, and reorient parallel to the long axis of the pedicle.4 Capillary blood flow has been shown to plateau as early as the fourth to the seventh postoperative day until two weeks after flap inset.5,6 Despite more than a quadrupling in blood flow of delayed flaps compared to acute flaps in this study by Pang, et al., there was no significant increase in capillary density in the delayed flap pig model. This study did not, however, evaluate the distal flap edges.

In addition to the previously mentioned flap studies, the timing of pedicle division has been challenged in animal models. Pedicled flaps in dogs have been divided as early as one week postoperatively with excellent flap viability as early as 1933.9 In an evaluation of cranially based, tubed- pedicle skin flaps on rats, there was 100% flap survival when flaps were divided on the fourth postoperative day.10 In a rabbit model of paramedian forehead flaps with composite grafts of cartilage for full thickness nasal defects, 60% of the flaps that were divided on the fourth postoperative day exhibited superficial skin sloughing after pedicle division with decreased hair growth by the end of the study.11 The remaining two cases had full hair growth after ten weeks. There was partial hair loss without necrosis in the two flaps that were divided in each of the seven and ten day groups. The pedicles that were divided at three weeks, however, had full hair growth in all five cases. While this might seem to indicate that flap viability is superior when divided at three weeks, the study is limited by a small sample size. Interestingly, there was no significant difference in cartilage viability, even in the group that did not undergo pedicle division. This finding highlights the difference in depending on nutrient diffusion in cartilage, as opposed to vascular in-growth in skin flaps. Cross leg gastrocnemius flaps have been divided as early as 11 days postoperatively

with complete flap survival in both patients.10 These flaps were assessed with fluorometry, which caused no complications and enabled the surgeons to be comfortable with early pedicle division. This technique is likely most clinically useful in assessing the optimal timing for division of large flaps, particularly in the case of smokers and patients with potential vascular compromise at the inset site. However, fluorometry is invasive, requiring and intravenous injection, and it sometimes produces equivocal results. Moreover, the precise percent fluorescence threshold to reach before successful pedicle division is not known and needs to be evaluated further in clinical trials. A laser Doppler blood perfusion monitor, a non-invasive method, has been used to divide cross-finger flaps as early as two weeks postoperatively once flap blood flow is indicated at 50% of baseline values.13 Other objective tests that have been used for a similar end are thermography, radioisotopes, transcutaneous oxygen, and photoplethysmography.10,14 Despite these methods, cross clamping the pedicle with subjective assessment of the distal flap blood flow by color was adequate in this case series of nasolabial flaps.

In this analysis of two-stage nasolabial flaps, most of the patients were generally healthy, although three cases had a medical history of coronary artery disease and three patients smoked routinely. As expected with a one-pack daily smoker, case 2 was at a higher risk of flap complications than a non-smoker would be and, after pedicle division on POD #4, 20% of his flap was not perfectly adherent two days later. Nonetheless, the final cosmetic result was excellent and no revision beyond the expected flap trimming was necessary.

The average time to pedicle division was 7.3 days after the initial reconstruction, ranging from 4 to 16 days. Case 9 had the longest delay before flap division because of concern regarding bruising at the distal tip of the flap in a patient with a qualitative platelet defect. Ultimately, this flap integrated well without any necrosis. The last case was delayed intentionally due to risk concerns regarding the patient’s continued smoking throughout the treatment period.

Left nasal tip skin defect s/p nasolabial flap before (A) and after (B) nasolabial flap division

FIGURE 1

A B