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Lin HY, Bu X, Yang X, Zhen YH, Li D, Zhao ZM, An Y. Repair of Asian nasal subunit defects using nasolabial perforator flaps: A retrospective study. J Cosmet Dermatol 2024; 23:630-638. [PMID: 37846506 DOI: 10.1111/jocd.16032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 09/11/2023] [Accepted: 10/03/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND The application of nasolabial perforator flap for nasal reconstruction has been reported previously with satisfactory outcomes, but the outcomes and risk factors of postoperative adverse events have been unclear to plastic surgeons. AIMS To statistically analyze the effectiveness of the nasolabial perforator flap in nasal reconstruction and the risk factor of postoperative complications and re-operation. PATIENTS/METHODS This retrospective study evaluated 58 Chinese patients who underwent nasal reconstruction with the nasolabial perforator flap from 2009 to 2021. The esthetic and blood supply outcomes were measured by plastic surgeons on a 5-point Likert scale. Binary logistic regression was used to determine the risk factors associated with postoperative complications and re-operation. RESULTS The mean age of the cohort was 66.4 ± 2.0 years. The defect size ranged from 6.5 × 5.5 mm2 to 40 × 70 mm2 , and 48.3% of defects covered more than one nasal subunit. Venous congestion occurred in 4.9% of flaps, and the immediate overall postoperative score was 7.72/10. More than one nasal subunit of involvement was the risk factor associated with re-operation (p = 0.004), but no risk factor was associated with complications. CONCLUSIONS The nasolabial perforator flap is reliable for nasal reconstruction with good esthetic outcomes and fewer complications. However, a large number of involved subunits may lead to multiple surgeries for flap trimming in easterners.
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Affiliation(s)
- Hong-Ying Lin
- Department of Plastic Surgery, Peking University Third Hospital, Beijing, China
| | - Xi Bu
- Department of Plastic Surgery, Peking University Third Hospital, Beijing, China
| | - Xin Yang
- Department of Plastic Surgery, Peking University Third Hospital, Beijing, China
| | - Yong-Huan Zhen
- Department of Plastic Surgery, Peking University Third Hospital, Beijing, China
| | - Dong Li
- Department of Plastic Surgery, Peking University Third Hospital, Beijing, China
| | - Zhen-Min Zhao
- Department of Plastic Surgery, Peking University Third Hospital, Beijing, China
| | - Yang An
- Department of Plastic Surgery, Peking University Third Hospital, Beijing, China
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DeSisto NG, Arnaud EH, Chowdhury N, Davis SJ, Kimura KS, Stephan SJ, Patel PN, Yang SF. Forehead Flap Practices: A Cross-Sectional Survey of Facial Plastic and Reconstructive Surgeons. Facial Plast Surg Aesthet Med 2023. [PMID: 38150510 DOI: 10.1089/fpsam.2023.0115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023] Open
Abstract
Background: The paramedian forehead flap (PMFF) is a well-established technique utilized for reconstruction of complex nasal defects. Objective: To identify the different techniques and management of patients undergoing PMFF reconstruction and compare these with current literature. Methods: Members of the American Academy of Facial Plastic and Reconstructive Surgery were sent a practice survey highlighting various nuances in PMFF reconstruction. The survey included questions about flap design, operative techniques, and perioperative care. Results: In total, 172 responses were received (14% response rate). Mean years of practice after fellowship was 15.8 years with most respondents performing either 1-5 (33.1%) or 6-10 (27.3%) PMFFs per year. Common practices included the use of general anesthesia, elevation of PMFF in the subgaleal plane (59.6%), and pedicle division at 3 weeks (80%) (p < 0.001). Complication rates ranged between 1% and 5%. The nose was the most common site for revision (p < 0.001) and the average number of secondary procedures after forehead flap division was 1.1 (standard deviation 0.81). The most variability in responses was seen for methods of internal lining reconstruction. Conclusion: Reconstructive surgeons frequently divide the PMFF pedicle at 3 weeks or later and have variable approaches to reconstruction of the internal lining with low complication rates overall.
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Affiliation(s)
- Nicole G DeSisto
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ethan H Arnaud
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Naweed Chowdhury
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Seth J Davis
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kyle S Kimura
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Scott J Stephan
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Priyesh N Patel
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Shiayin F Yang
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Chakraborty SS, Goel AD, Sahu RK, Midya M, Acharya S, Shakrawal N. Effectiveness of Nasolabial Flap Versus Paramedian Forehead Flap for Nasal Reconstruction: A Systematic Review and Meta-analysis. Aesthetic Plast Surg 2023; 47:313-329. [PMID: 36102958 DOI: 10.1007/s00266-022-03060-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 08/04/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Different studies performed on nasal subunit reconstruction by either the nasolabial flap or the paramedian forehead flap have reported contradictory outcomes and complications, claiming one flap or the other as superior. This inconsistency has led to a gap in existing literature regarding the preferable flap for nasal reconstruction. Our aim was to statistically evaluate and compare these two flaps for nasal reconstruction, in terms of subunit preference, complications, and outcomes, using data from previous studies. METHODS This systematic review is reported using PRISMA protocol and was registered with the International prospective register of systematic reviews. The literature search was done using "paramedian forehead flap", "nasolabial flap", "melolabial flap", "nasal reconstruction". Data regarding demography of study and population, subunit reconstructed, complications, and aesthetic outcomes were extracted. Meta-analysis was performed using MetaXL and summary of findings using GRADEpro GDT. RESULTS Thirty-eight studies were included, and data from 2036 followed-up patients were extracted for the review. Meta-analysis was done on data from nine studies. Difference in alar reconstruction by forehead versus nasolabial flap is statistically significant [pooled odds ratio (OR) 0.3; 95% CI 0.01, 0.92; p = 0.72; I2 = 0%, n = 6 studies], while for dorsum and columella reconstruction the difference is not statistically significant. Risk of alar notching is marginally more in forehead flap, however difference in incidence of partial/complete flap necrosis, alar notching and hematoma/bleeding among the flaps is not statistically significant. CONCLUSION Alar reconstruction is preferred by nasolabial flap. Complications are similar in both groups. Comparison of aesthetic outcome needs further exploration. LEVEL OF EVIDENCE III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- Sourabh Shankar Chakraborty
- Department of Burns and Plastic Surgery, South Eastern Railway Central Hospital, Kolkata, West Bengal, 700043, India
| | - Akhil Dhanesh Goel
- Community Medicine and Family Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, 342005, India
| | - Ranjit Kumar Sahu
- Department of Burns and Plastic Surgery, All India Institute of Medical Sciences, Bhubaneswar, Odisha, 751019, India
| | - Manojit Midya
- Department of Burns and Plastic Surgery, Government Medical College, Kota, Rajasthan, 324005, India
| | - Sudeshna Acharya
- Trauma and Emergency, Goodwill Nursing Home, Kolkata, West Bengal, 700018, India.
| | - Neha Shakrawal
- Department of Otorhinolaryngology Head and Neck Surgery, All India Institute of Medical Sciences, New Delhi, 110029, India
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Development of a Risk Prediction Model for Complications Following Forehead Flaps for Nasal and Periorbital Reconstruction. J Craniofac Surg 2023; 34:362-367. [PMID: 36184771 DOI: 10.1097/scs.0000000000009030] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Accepted: 08/20/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Forehead flaps are a workhorse for nasal reconstruction, but complications occur in up to 30% of patients and risk factors are not well characterized. This study aimed to identify risk factors for complications, and provide clinicians a method to stratify patient risk to facilitate shared decision-making. MATERIALS AND METHODS This retrospective study included patients who underwent forehead flaps between 2007 and 2020. Demographic and treatment characteristics were abstracted, in addition to clinical outcomes data. Multivariable regression was conducted, with step-wise variable elimination to determine inclusion in the final model. From the final regression, a risk-stratification scheme was developed. RESULTS One hundred ninety-seven patients underwent forehead flap reconstruction, with a mean age of 68.5 years. Mean follow-up time was 42 months. There were 50 (25.4%) patients who developed a complication, including impaired nasal function (18.8%), flap congestion (5.1%), infection (2.5%), poor donor site healing (2.5%) wound dehiscence (2.0%), and flap congestion (1.5%). On univariate analysis, female sex, immunosuppression, prior radiotherapy, and larger resection area were associated with complications ( P <0.05). On multivariable analysis, female sex [odds ratio (OR): 3.89, P <0.001], hypoalbuminemia (OR: 3.70, P =0.01), and prior wide local excision (OR: 3.62, P =0.04) were predictors of complications. A clinical calculator was developed incorporating these risk factors, with a C-statistic of 0.85, indicating strong predictive value. CONCLUSIONS We conducted the most comprehensive review of risk factors for the development of complications after forehead flap reconstruction. From this analysis, a novel, implementable, risk-stratification scheme was developed to equip surgeons with the ability to provide individualized risk assessment to patients and address preoperative comorbidities to optimize outcomes.
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Single-staged Tunneled Forehead Flap for Medial Canthal and Eyelid Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2022; 10:e4223. [PMID: 35475283 PMCID: PMC9029905 DOI: 10.1097/gox.0000000000004223] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 01/20/2022] [Indexed: 11/29/2022]
Abstract
Purpose: The paramedian forehead flap, while initially used for reconstruction of nasal defects, has been adapted for repair of anatomical subunits in the medial canthal and eyelid area. A significant obstacle for utilizing the flap has been the bulky, unsightly vascular pedicle that is maintained between surgical stages. We describe our surgical experience using the tunneled variation in a single stage procedure. Methods: A retrospective chart review was performed of three surgeons’ charts over a 5-year period. All patients who underwent the tunneled paramedian forehead flap variation were selected. Outcomes measured included underlying pathology, Mohs defect area and depth, and canalicular involvement. Results: A total of 20 tunneled flaps were performed after successful Mohs excision of cutaneous malignancies. The average Mohs defect surface area was 13.57 cm2 with depth down to periosteum (n = 13), bone (n = 5), or orbital fat (n = 2). Five patients had full-thickness eyelid defects (25%), and nine (45%) had canalicular defects. The overall complication rate for this study was low with no flap failure. Two patients (10%) desired thinning of the subcutaneous flap for improved cosmesis, and one patient (5%) required further eyelid revision due to the complexity of the initial Mohs defect. The remaining 17 patients required no further surgical procedures. Conclusion: The tunneled paramedian forehead flap is a useful technique for medial canthal and eyelid reconstruction. This technique allows reconstruction of a challenging area. Complication rates are low, and this tunneled variation provides a single stage variation to the traditional multistage forehead pedicle flap.
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Jeong M, Jun D, Kim J, Choi H, Shin D, Cho J, Lim Y, Lee M. Reconstruction of a large nasal defect using a folded forehead flap: a case report. ARCHIVES OF AESTHETIC PLASTIC SURGERY 2022. [DOI: 10.14730/aaps.2021.00311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Forehead flaps are widely used to reconstruct nasal defects. The authors report a case wherein a folded forehead flap was used to reconstruct a large nasal defect after wide excision of squamous cell carcinoma. A 65-year-old man was diagnosed with squamous cell carcinoma by a punch biopsy conducted at the dermatology department, and the mass was located in the left nasal vestibule. A forehead flap was planned to cover the full-thickness defect that occurred after wide excision. A flap with an extended transverse skin paddle was designed; thereafter, the distant part of the flap was folded up to the nasal lining inside the nose. The interpolation flap was properly maintained for 3 weeks, and flap division was performed. The reconstructed nose exhibited symmetry during a 5-month observation period. A folded forehead flap is a surgical option when considerable nasal restoration, including soft tissue and the internal lining, is necessary.
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Clinical consequences of head and neck free-flap reconstructions in the DM population. Sci Rep 2021; 11:6034. [PMID: 33727645 PMCID: PMC7966812 DOI: 10.1038/s41598-021-85410-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 03/01/2021] [Indexed: 01/13/2023] Open
Abstract
Diabetes mellitus (DM) is a common comorbidity and risk factor for postoperative complications in head and neck (H&N) microsurgical reconstructions. Our study focused on the association between DM and individual complications regarding both surgical and medical aspects. A meta-analysis of English-language articles comparing a series of complications between DM and non-DM H&N free-flap recipients was performed by comprehensive meta-analysis (CMA). Twenty-seven articles presented 14,233 H&N free-flap reconstructions, and a subset of 2329 analyses including diabetic cases was included for final analysis. Total postoperative (RR = 1.194, p < 0.001; OR = 1.506, p = 0.030) and surgical (RR = 1.550, p = 0.001; OR = 3.362, p < 0.001) complications were increased in DM subjects. Free-flap failure/necrosis (RR = 1.577, p = 0.001; OR = 1.999, p = 0.001) and surgical site infections (OR = 2.414, p < 0.001) were also increased in diabetic recipients. However, return to the operating room, dehiscence, fistulas, plate exposures, readmissions, and mortalities were not increased in DM patients. DM increased various complications in H&N free-flap reconstructions. Surgical indications should be cautiously evaluated, and aggressive treatments should be implemented for high-risk recipients.
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Felcht M, Wetzig T. Complete division of the pedicle of the forehead flap is possible after 1Â week of engraftment in selected patients. JAAD Int 2020; 2:5-11. [PMID: 34409346 PMCID: PMC8361906 DOI: 10.1016/j.jdin.2020.10.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2020] [Indexed: 12/29/2022] Open
Abstract
Background Recent studies have demonstrated that early division of the forehead flap (FHF) is possible if angiography is performed or a remnant of the pedicle is left behind. Whether or not careful selection of patients allows for complete division of the pedicle has not been studied. Objective To assess if careful selection of patients allows for early complete division of the FHF. Methods The exclusion criteria were trauma in the donor region, full-thickness defects, or a larger cartilage grafting. In the selected patients, complete division of the FHF pedicle was performed at early time points, when the pedicle was clinically engrafted (n = 12). Results The median age of the patients was 80 years ± 8. The average size of the wounds was 6.6 cm2 ± 4.0. The complete division of the pedicle was performed in 10 patients after 7 days, 1 patient after 8 days, and 1 patient after 11 days (median 7.4 days ± 1.1). One patient developed a wound infection, and 1 suffered from postoperative bleeding. The latter patient was the only 1 who required debulking in a third surgical procedure. No necrosis or flap failures were observed. Limitations Retrospective, single-center study. Conclusion Careful selection allows for complete early division of the pedicle of FHF.
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Affiliation(s)
- Moritz Felcht
- Department of Dermatology, Venereology and Allergy, Mannheim University Medical Center, Medical Faculty Mannheim, University of Heidelberg, Center of Excellence in Dermatology in Baden-Württemberg, European Center for Angioscience (ECAS), Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Tino Wetzig
- Department of Dermatology, Dermatosurgery and Allergy, Asklepios Medical Center, Weissenfels, Germany
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Rajan S, Akhtar N, Kumar V, Gupta S, Misra S, Chaturvedi A, Chaudhary S, Suryavanshi P. Paramedian forehead flap reconstruction for skin tumors involving central subunit of face: An analysis of 37 cases. J Oral Biol Craniofac Res 2020; 10:764-767. [PMID: 33134043 DOI: 10.1016/j.jobcr.2020.10.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 10/13/2020] [Accepted: 10/19/2020] [Indexed: 11/30/2022] Open
Abstract
Introduction Tumors of facial skin are common in upper part of central subunit of face. Defects after resection require a flap, which is pliable, thin, and has a good colour match. Among the various local flaps available paramedian forehead flap is a good option. Patients and methods Patients reconstructed with paramedian forehead flap during the period from January 2015 to March 2020 were included in the study. Data regarding the demographic, clinical characteristics, and treatment details was recorded, and analyzed for postoperative complications and cosmetic outcomes. Results Paramedian forehead flap reconstruction was performed in 37 patients who were resected for tumor involving upper central subunit of face. Median age of patients was 57 years. Male to female ratio was 1.4:1. All tumors were resected with a negative margin. Nodal disease was managed by superficial parotidectomy only (4/37), superficial parotidectomy along with supra-omohyoid neck dissection (6/37) and modified neck dissection (1/37). In five patients additional buccal mucosa graft was used to reconstruct conjunctiva. Additional flaps were required in two patients in whom nasolabial and mustarde flaps were used. Partial flap loss occurred in one patient. There was no major flap loss. Surgical site infection developed in only one patient, who had partial flap loss. On subjective assessment, nearly 60% patients described their appearance as good. Conclusion Facial reconstruction in area of dorsum of nose and medial aspect of both eyelids using paramedian forehead flaps is a simple and quick procedure.
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Affiliation(s)
- Shiv Rajan
- Department of Surgical Oncology, King George's Medical University, Lucknow, UP, India
| | - Naseem Akhtar
- Department of Surgical Oncology, King George's Medical University, Lucknow, UP, India
| | - Vijay Kumar
- Department of Surgical Oncology, King George's Medical University, Lucknow, UP, India
| | - Sameer Gupta
- Department of Surgical Oncology, King George's Medical University, Lucknow, UP, India
| | - Sanjeev Misra
- All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Arun Chaturvedi
- Department of Surgical Oncology, King George's Medical University, Lucknow, UP, India
| | - Shashank Chaudhary
- Department of Surgical Oncology, King George's Medical University, Lucknow, UP, India
| | - Parijat Suryavanshi
- Department of Surgical Oncology, King George's Medical University, Lucknow, UP, India
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