Plastic surgery; its principles and practice . flap are made, thus cutting off thelateral circulation. The pedicle is dissected up so that the circula-tion of the flap enters through the upper and lower attachments. Thenthe lower attachment is gradually severed, and the circulation entersentirely through the upper attachment. It takes a considerable time(39 days in Lauensteins case) before the flap is shifted to the cheekdefect. Two weeks later the pedicle is cut and sutured (Fig. 687). This type of operation is a very valuable one. The gradual separa-tion of the flap from its attachments assu
Plastic surgery; its principles and practice . flap are made, thus cutting off thelateral circulation. The pedicle is dissected up so that the circula-tion of the flap enters through the upper and lower attachments. Thenthe lower attachment is gradually severed, and the circulation entersentirely through the upper attachment. It takes a considerable time(39 days in Lauensteins case) before the flap is shifted to the cheekdefect. Two weeks later the pedicle is cut and sutured (Fig. 687). This type of operation is a very valuable one. The gradual separa-tion of the flap from its attachments assures the adjustment of circu-lation, so that by this seemingly slow process much time can be saved,and there will be no sloughing after the flap has been shifted. Lerda has used a rather heroic method of closing a large check SURGERY OF THE CHEEK 585 defect. He shifts the entire mouth toward the gap by means ofhorizontal incisions continuous with the upper and lower borders ofthe defect. These incisions extend through the full thickness of the. Fig. 687.—Operation for closing a cheek defect (Lauenslein, Annals of Surgery, 1893,57).— I. A indicates the bridge flap which is undermined; B, the hinged flap which is tobe drawn under A. 2. The flap B drawn under A and sutured; D. the raw area, whichshould be grafted. 3. Outline of pedicle C. The lower pedicle of flap A is graduallysevered. The pedicle of flap B is cut, and the double-faced flap A is then shifted to thecheek. lips and are carried across on the opposite cheek a sufficient distanceto loosen the flap freely. Then the flap is shifted over and sutured tothe margins of the defect in layers. The mouth is now much dis-placed, but after healing is complete it is returned to its central posi-
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