Case 10 Island Pedicle Flap

Island pedicle flaps with their vascular pedicles can be isolated in various locations in the head and neck area. One of the most versatile and easily available island pedicle flaps is based on the anterior branch of the superficial temporal artery and vein which provides blood supply to the forehead. This flap is elevated from the lateral aspect of the forehead.

Its advantages include fairly regular and identifiable artery and vein, a long vascular pedicle, and thick forehead skin to provide for replacement of excised skin and soft tissues. The color match is also excellent for coverage of facial surgical defects. The disadvantages are that the size of the flap is limited and occasionally it may be hair-bearing. It is important to ensure smooth rotation of the pedicle since a kink in the vascular pedicle of the flap can result in a disaster with complete loss of flap.

A patient with a recurrent basal cell carcinoma who had previous curettage and desiccation as well as surgical excision of this lesion performed elsewhere is shown in Figure 4-14A. The lesion is indurated and adherent to the underlying zygoma.

The plan of surgical excision and repair showing the incision at the site of the primary tumor is shown in Figure 4-14A. The surgical defect shows a through-and-through three-dimensional excision of

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Figure 4-13. A, The patient has a basal cell carcinoma on the left chin. B, An area of excision has been outlined around the tumor along with the proposed cervical flap for reconstruction of the defect.

Figure 4-13. A, The patient has a basal cell carcinoma on the left chin. B, An area of excision has been outlined around the tumor along with the proposed cervical flap for reconstruction of the defect.

the recurrent basal cell carcinoma (Figure 4—14B). All margins of resection are checked at this point to ensure adequacy of excision.

The island pedicle flap is now isolated with a circular disk of skin from the forehead on the vascular pedicle from the anterior branch of the superficial

temporal artery and vein (see Figure 4-14Band C). The flap is elevated, rotated and sutured into place and the donor defect is covered with a split-thickness skin graft.

The postoperative appearance of the patient approximately 2 months after surgery is shown in

Figure 4-14. A The surgical excision is outlined around the scar of previous surgery and a corresponding island of skin is marked on the lateral forehead based on the anterior branch of the superficial temporal artery. B and C, After excision of the primary lesion, the flap is elevated on its vascular pedicle, rotated cauded to fill the surgical defect, and the donor site is skin grafted. D, The postoperative appearance of the patient 2 months after surgery.

Figure 4-14D. Although excellent coverage of the surgical defect is obtained, the esthetic result is not as pleasing as one would like to see, due largely to loss of underlying zygoma and masseter muscle, causing lack of soft-tissue support. This in turn causes lack of fullness and a sunken appearance of the cheek.

Island pedicle flaps are excellent for coverage of certain surgical defects resulting from loss of skin and soft tissues in the region of the nose or the side of the cheek. However, extreme caution and skill must be exercised in anticipation of the size of both the surgical defect and the elevated skin flap. Meticulous attention should be paid to extremely careful and skillful dissection and gentle handling of the vascular pedicle, as injury to the vascular pedicle would mean loss of the flap. Those branches of the vessels that are not necessary for the vascularity of the flap are sacrificed, but short stumps of these vessels must be left attached to the main vascular pedicle so that the lumen of the feeding artery and draining vein is not compromised. Similarly, extreme care must be exercised during transport of the flap and its rotation to avoid any kinking or torsion. The island flap generally manifests venous congestion in the first 48 hours, but as long as capillary filling is present the flap will survive.

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