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An interpolated flap is a flap whose donor site is not directly adjacent to the recipient defect and whose pedicle, ie, a tissue bridge, traverses over an intervening segment of normal tissue. These flaps typically require a second-stage procedure to divide the pedicle. They are used when insufficient tissue or mobility in nearby skin prevents coverage of the tissue defect with primary closure or a local flap directly adjacent to the wound. They are like transposition flaps in that the flap is lifted over normal skin to reach the area to be repaired. The base of the interpolation flap is located away from the defect, whereas the base of a transposition flap is adjacent to the defect. This configuration creates a pedicle between the flap base and the surgical defect. The pedicle is usually removed during a second stage after vascularity is established between the flap and the wound. Learners can expect a comprehensive overview of the indications for using interpolated flaps, recognizing scenarios where the limitations of adjacent tissues necessitate this approach. The course explores contraindications, ensuring clinicians understand when alternative methods may be more appropriate. Participation in this course enhances competence through interprofessional collaboration. Surgical teams, including plastic surgeons, general surgeons, and nurses, develop a shared understanding of the nuances of interpolated flaps. Improved communication and collaboration among team members become instrumental in planning and executing successful procedures. Objectives: Identify suitable clinical scenarios warranting interpolated flap reconstruction based on complex tissue defects and limited adjacent tissue options. Differentiate between various types of local flaps (advancement, rotation, transposition) and interpolated flaps, elucidating their distinctive principles, benefits, and drawbacks. Select and prioritize interpolated flap techniques based on anatomical considerations, patient preferences, and surgeon expertise, aligning choices with expected functional and aesthetic outcomes. Collaborate with multidisciplinary teams involving radiologists, anesthetists, and wound care specialists, to ensure comprehensive patient care throughout the pre-operative, intra-operative, and post-operative phases. Access free multiple choice questions on this topic.

Local flaps for soft tissue reconstruction are commonly divided into 4 types depending on the type of movement required to transfer the flap into the defect: advancement, rotation, transposition, and interpolation.[1][2][3] Advancement, rotation, and transposition involve tissue transfer immediately adjacent to the defect, whereas interpolation transfers tissue over or under intervening normal tissue to reach the defect.[4] For this reason, interpolated flaps are often considered to be "regional" flaps rather than "local" flaps, and more often than not, require a second-stage procedure to divide the bridge of flap tissue, the pedicle, that traverses the normal tissue between the flap donor site and the defect to be reconstructed (see Image. Interpolated Flaps). While the need for a second procedure may be a drawback to many interpolated flap reconstruction techniques, the main advantages of interpolated flaps are their reliable blood supply and their ability to transfer larger amounts of tissue than many other local flap options provide. The "waltzing" or "walking" flaps were among the first interpolated flaps described. Early reconstructive surgeons, including Sir Harold Delf Gillies, Sir Archibald McIndoe, and Vladimir Filatov, popularized them during WWI and WWII. These flaps require multi-stage operations, as the flaps are initially transferred to an intermediate location before reaching the primary defect because the donor sites are too distant to permit defect coverage with the first stage. After 4 to 6 weeks, the pedicle is released from the donor site, and the intermediate inset site then acts as the base of the flap as the end of the flap that was initially connected to the donor site is then moved either into the defect or a new intermediate inset site closer to the defect.[5] Although the ability to employ a single type of flap in many different areas of the body is appealing, these flaps have fallen out of favor because of the prolonged waiting time between stages and the advent of numerous other techniques that have been developed for use in different anatomical regions and with varying types of tissue. Examples of currently used interpolated flaps include: Paramedian forehead flap Melolabial flap Postauricular flap Tarsoconjunctival flap Inferior turbinate flap Pericranial flap Facial artery musculomucosal flap Deltopectoral flap Supraclavicular artery island flap

The "waltzing" or "walking" flaps were among the first interpolated flaps described. Early reconstructive surgeons, including Sir Harold Delf Gillies, Sir Archibald McIndoe, and Vladimir Filatov, popularized them during WWI and WWII. These flaps require multi-stage operations, as the flaps are initially transferred to an intermediate location before reaching the primary defect because the donor sites are too distant to permit defect coverage with the first stage. After 4 to 6 weeks, the pedicle is released from the donor site, and the intermediate inset site then acts as the base of the flap as the end of the flap that was initially connected to the donor site is then moved either into the defect or a new intermediate inset site closer to the defect.[5] Although the ability to employ a single type of flap in many different areas of the body is appealing, these flaps have fallen out of favor because of the prolonged waiting time between stages and the advent of numerous other techniques that have been developed for use in different anatomical regions and with varying types of tissue. Examples of currently used interpolated flaps include: Paramedian forehead flap Melolabial flap Postauricular flap Tarsoconjunctival flap Inferior turbinate flap Pericranial flap Facial artery musculomucosal flap Deltopectoral flap Supraclavicular artery island flap Pectoralis major myocutaneous flap A selection of these is discussed in detail below.

Potential complications common to all skin surgery, including flaps, are infection, scarring, bleeding, damage to surrounding anatomy, need for additional procedures, and dissatisfaction with the cosmetic result. More specific to flap surgery is the potential for partial or total flap necrosis with subsequent need for additional reconstructive procedures. Each type of flap will also have potential donor site morbidity or other complications unique to it, such as nasal crusting from an inferior turbinate flap, shoulder scarring from a SCAIF, hairline shifting from a postauricular flap, or even transfer of hair to the tip of the nose with a paramedian forehead flap. Postoperative Bleeding Complications The surgical team should pay particular attention to the control of intraoperative and prevention of postoperative bleeding, most commonly experienced in the first 24 to 48 hours after surgery. Salient points are outlined below. The paramedian forehead flap is especially prone to postoperative bleeding, most commonly from the proximal flap pedicle in the glabella/brow area. This bleeding is best managed as follows: Careful and precise but conservative electrocoagulation must be performed at the end of the procedure. Hemostatic agents, such as cellulose mesh or Monsel ferric subsulfate solution, may be applied at the base of the flap. Alternatively, a split-thickness skin graft may be placed on the raw surface of the pedicle. When dressing the surgical site, extra gauze or other absorbent material should be applied near the flap base, being careful not to apply excessive pressure to avoid strangulation of the flap. The patient should return to the office for a dressing change in 1 to 2 days. If excessive drainage is absent, the new bandage may remain in place until the next visit in 5 to 7 days. Melolabial flaps are not as prone to heavy bleeding but tend to ooze in the early postoperative period. Thorugh, but precise, electrocoagulation should be administered before dressing the surgical site, similar to that performed for a paramedian forehead flap. A postoperative visit in 1 to 2 days should be scheduled, if possible. Any minor bleeding may be addressed during that visit. If no significant bleeding is noted, a less bulky dressing may be applied at that time.

Thorugh, but precise, electrocoagulation should be administered before dressing the surgical site, similar to that performed for a paramedian forehead flap. A postoperative visit in 1 to 2 days should be scheduled, if possible. Any minor bleeding may be addressed during that visit. If no significant bleeding is noted, a less bulky dressing may be applied at that time. When auricular transposition flaps bleed, they are particularly challenging due to being located in the tight confines behind the ear. Prevention is critical to success. Meticulous electrocoagulation must be applied at the end of surgery. Once hemostasis has been obtained, it is often a good idea to rub the wound vigorously with gauze to "battle test" one's work. Any additional bleeding can then be addressed before the inset of the flap. The unsutured portion of the pedicle is wrapped with a petrolatum-saturated gauze ribbon, followed by applying a non-adherent surgical dressing and fluffed gauze over the entire surgical site. An elastic adhesive bandage or an otologic dressing (eg, a Glasscock cup) is then applied to run in an anterior-to-posterior direction, thus pulling the ear toward the head. Doing so takes tension off the interpolated flap and helps apply pressure to minimize the risk of bleeding. Inferior Turbinate Flaps Inferior turbinate flaps are vulnerable to desiccation of their pedicles due to nasal airflow. Placement of a petrolatum-soaked cotton ball in the nostril on the same side as the turbinate flap to prevent airflow from drying out the flap's pedicle is standard practice. The cotton ball should be replaced daily. The patient should also be discouraged from nose blowing, which may result in more bleeding from the flap and pedicle. Deltopectoral and waltzing flaps can bleed from their large, wide, exposed pedicles. Tubing the pedicle minimizes exposure of raw surfaces prone to bleeding. Meticulous hemostasis with bipolar electrocautery at the time of elevation is critical.

Interpolated flaps necessitate a comprehensive approach from healthcare professionals, spanning skills in precise surgical techniques, strategic case selection, and ethical decision-making regarding patient autonomy and long-term outcomes. Physicians, nurses, pharmacists, and other health professionals must collaborate through effective interprofessional communication, exchanging expertise to ensure patient-centered care. They share responsibilities in vigilant postoperative monitoring, timely complication intervention, and judicious pain management to enhance patient safety. This coordinated effort leverages diverse perspectives to optimize team performance, improving outcomes and overall patient satisfaction.