17 Attachment(s)
Dr. Lindsey Stage 1 of a 3 stage major flap failure repair case, McLean VA
This pleasant Aussie-UK fellow had an attempted temporal flap procedure done 25 years ago. Although he describes it getting infected, I’m pretty sure that the pedicle (blood vessel supplying the flap) got compressed or kinked, leading to rapid failure and necrosis (death) of the distal aspect of the flap. I say this for 3 reasons….1: If you look at what’s left, the portion that lived is essentially 3 times as long as it is wide—a standard ratio for random-non pedicled flaps used in facial reconstruction; 2: Its practically impossible to infect the forehead of a young healthy person after clean surgery; and 3: Having personally done about 80 vascularized pedicle nose reconstructions---this is the horror that we all worry about for the first few days—that the supplying blood vessel will get blocked and the flap will die.
Anyhow, he came over last week and our plan is 2 or 3 surgeries. First, we’ll do a strip hair transplant placed in a hairline that he finds acceptable, just a little above his flap. Second, after the hair has started to grow and is doing well, probably in 8-12 months, we’ll excise his flap, and advance his hairline down just a little, while at the same time taking advantage of his loose forehead skin to get a nice closure with hopefully an acceptable scar line…that looks better than the failed flap scar he currently has. We’ll take the hair out of the flap and place this behind his step 1 transplant, more on the right than left, as the blood supply to the right side of his head won’t be compromised by excision of the flap like the left side’s blood supply may be. And third, we’ll possibly do a 2nd strip case a year later to bolster the back.
All in all, quite an interesting case. As usual, he arrived the day before surgery so that we could make sure the plan was acceptable to both of us, then on Friday he arrived at 7:30 ready to go. The pictures show his donor area with some of his old flap scar visible on the left corner. He had an easy 3 layer closure and then received 2700 grafts. If you look at the distribution, you may wonder why there are more grafts placed on the left….and its due to our plan to put his failed flap hair in in part 2. The placers think we’ll get 700 out of the flap, I think it’s more likely to be 500, but I don’t want to put them on the left as the flap excision will cut through the supra-orbital and supra-trochlear vessels. While there is a lot of blood supply coming in from the sides and even the other side…I’m still cautious enough to want to place hair in the middle and right at step 2.
There weren’t any surprises in his case and he emailed me that he’s back in the UK and will get his sutures out on day 7 and then start scar care. I’m really excited about this case and I’m hopeful that his results are everything we both want.
Dr. Lindsey McLean VA
