Alternative 1-step nasal reconstruction technique

Tunneled island flaps in facial defects reconstruction

The reconstruction of facial surgical defects is usually challenging for the dermatologic surgeon. Three different cases of facial defects in which tunneled island flaps were used are reported. In 2 cases, wide defects involving the nasal dorsum and ala were repaired using a nasolabial island flap tunneled through the lateral side of the nose. A tunneled island glabellar flap was used for medial canthus reconstruction in the third case. Despite complex pedicle dissection and frequent trapdoor deformation, tunneled island flaps allow reconstruction of wide defects in a single-staged procedure, camouflaging the scar of the donor area in boundaries of cosmetic units and preserving the facial central symmetry.

Flap Basics III: Interpolated Flaps

Paramedian forehead and melolabial flaps are the most common examples of interpolated flaps used by facial plastic surgeons and are excellent options for reconstruction of the midface after Mohs surgery. They provide superior tissue match in terms of thickness, texture, and color, while leaving minimal defects at the tissue donor sites. The main advantage of interpolated flaps is the robust blood supply, which can be either axial of randomly based, and the maintenance of the integrity of facial landmarks. The main disadvantage is the frequent need for a multistage procedure, which eliminates some patients from consideration.

A Cohort Study of Paramedian Forehead Flap in 2 Stages (87 Flaps) and 3 Stages (100 Flaps)

BACKGROUND

In nasal reconstruction, the paramedian forehead flap is traditionally performed in 2 stages. To minimize the risk of flap necrosis, Millard described a 3-stage technique in a series of 5 cases in 1974. In this technique, an intermediate step of flap thinning is performed after flap transfer and before pedicle division. In this article, we compare the 2- and 3-stage techniques of paramedian forehead flaps for nasal reconstruction to determine the type and prevalence of complications related to each procedure.

METHODS

Here, we present a retrospective review of a prospectively maintained database of paramedian forehead flaps for nasal reconstruction performed during a period of 6 years. We included all patients with 2- (n=87) and 3-stage (n=100) paramedian forehead flaps who had consistent and complete electronic patient records and followed them up for at least 6 months after pedicle division. We performed a regression analysis to adjust for the unequal distribution of complex cases.

RESULTS

Demographic factors and the causes for the nasal defects were similar in both groups. Although the nasal reconstructions were significantly more complex in the 3-stage group, the rate of partial forehead flap necrosis was similar in both groups (2-stage, 3.4%; 3-stage, 5%; P=0.601). A regression analysis showed that the relative risk of partial flap necrosis in complex cases did not differ significantly between groups (relative risk, 0.80; P=0.705).

CONCLUSIONS

To our knowledge, our study is the largest series published to date and the first one to compare the prevalence of forehead flap necrosis in the 2- versus the 3-stage technique for paramedian forehead flaps. We found no evidence that the use of a 3-stage forehead flap lowers the prevalence of necrosis. Until larger multicenter studies or meta-analyses can be conducted, smaller yet well-conducted studies such as the present one provide critical data and represent an important contribution to the field. Future research should investigate whether the 3-stage technique produces better aesthetic results than the 2-stage technique.

An alternative single-stage application of the paramedian forehead flap in reconstruction of the face

BACKGROUND

Paramedian forehead flap represents a workhorse in facial soft tissue reconstruction but always requires a second step in order to interrupt the skin bridge. Direct visualization and dissection of vascular pedicle may avoid this drawback.

METHODS

Twenty one patients were treated between January 2012 and January 2014: 6 underwent nasal reconstruction and 15 full thickness defect of medial canthus of an orbital region. The follow-up ranges between 6 months and 2 years. All procedures were carried out in a single stage.

RESULT

All flaps were performed in a single-stage procedure, survived and healed uneventfully.

CONCLUSION

The authors describe a refinement of the original technique to be reserved for cases where vessels could be identified by Doppler, consisting in the direct visualization and dissection of the initial tract of the vascular pedicle, thus providing an extremely mobile pedicle whose size allows to locate the first part of the pedicle in the nasion, tunneling under a skin bridge between the emergence of the vessels and the defect.

Tunneled and transposed island flaps in facial reconstructive surgery

BACKGROUND

Surgical wounds on the central face present reconstructive challenges given the aesthetic prominence of these visually important areas and a general lack of local tissue availability.

MATERIALS AND METHODS

Illustrative case examples demonstrate the potential clinical utility of nontraditional island flaps that are tunneled or transposed into operative defects.

RESULTS

Aesthetically successful reconstruction of difficult facial wounds was accomplished with island flaps that used less traditional operative designs.

CONCLUSION

When designed and executed properly, island flaps offer unrivaled opportunities to reconstruct the face with maximal preservation of central facial symmetry.

Paramedian forehead flap

The paramedian forehead flap (PMFF) is a versatile flap with a robust vascular supply that is well suited for reconstruction of complex or large nasal defects. Although a 2-stage technique is most common, a single-stage procedure involving tunneling the proximal pedicle and 3-stage procedures involving tissue expansion, vascular delay, and flap tailoring after inset before pedicle division have also been described. This article describes a traditional 2-stage technique and presents the case of a patient with a posttraumatic nasal deformity reconstructed with a PMFF.

Updates in forehead flap reconstruction of facial defects

PURPOSE OF REVIEW

The versatile and reliable paramedian forehead flap is the workhorse interpolated flap for nasal reconstruction and its use has been expanded to reconstruct other areas of the face. The goal of this article is to review the recent research describing the modern concepts and techniques in forehead flap reconstruction of facial defects.

RECENT FINDINGS

A variety of forehead flap concepts, techniques, and applications have been described in the recent literature in both nasal and facial reconstruction. Recent concepts include the phenomenon of vascular delay as well as more detailed study of the perfusion of the forehead flap at its various stages. Novel techniques include various approaches in staged reconstruction, adoption of the forehead flap for reconstruction of internal lining defects, and flap thinning.

SUMMARY

Although basic principles of the forehead flap have remained unchanged over the years, specific techniques and applications continue to be refined. The forehead flap continues to be a mainstay in the armamentarium of facial plastic and reconstructive surgeons.

Acquired defects of the nose and naso-orbitoethmoid (NOE) region

Nasal injuries coupled with midface fractures of the orbit and ethmoids constitute a nasoorbitoethmoid (NOE) fracture pattern, which is typically the most challenging facial fracture to repair. Hard and soft tissue defects of this region may require advanced reconstruction techniques, including local rotational flaps, free tissue transfer, and even prosthetics. The restoration of form and function dictates treatment, and the success of primary repair is paramount, because secondary correction is challenging in this area of the midface. Because of the complex nature of this region, this discussion is divided into hard tissue defects, with a focus on trauma, and soft tissue defects, with a focus on oncology.