A simple method for forehead unit reconstruction

A novel advancement flap for reconstruction of massive forehead and temple soft-tissue defects

OBJECTIVES/HYPOTHESIS

To describe the authors' experience with an extended deep-plane cervicofacial (EDPCF) advancement flap, a modification of the deep-plane cervicofacial flap, for reconstruction of large forehead and temple soft-tissue defects.

STUDY DESIGN

Case series at a tertiary referral medical center.

METHODS

The charts of 11 consecutive patients who underwent EDPCF flap surgery for reconstruction of forehead and temple skin cancer defects were reviewed for demographics, smoking status, defect size, length of surgery and hospitalization, American Society of Anesthesiologists Physical Status Classification (ASA) grade, and postoperative complications.

RESULTS

All patients had reconstruction of large forehead and temple defects following either primary resection or Mohs micrographic surgery for skin cancer. No skin grafting was required for secondary defects. The average defect size was 52.2 cm(2) . Patient ages averaged 74 years with a median ASA grade of 3. Thirty-six percent of patients admitted to smoking. Average operative time was 100 minutes, with 82% of patients treated on an outpatient basis. There were no complications of ectropion or facial nerve injury encountered. Partial distal flap necrosis occurred in one patient who admitted to smoking and resolved with conservative management.

CONCLUSIONS

The EDCPF flap is a robust flap with a dual arterial supply and both rotation and advancement components. It is ideal in frail patients with good soft-tissue laxity and provides an immediate one-stage reconstruction with ideal skin color, texture, and thickness matches for large forehead and temple defects.

Subcutaneous forehead island flap for nasal reconstruction

BACKGROUND

Reconstruction of nasal skin after tumor resection is imperative for full patient rehabilitation; and use of similar skin is necessary to achieve best esthetic and functional results.

METHODS

This clinical series study represent management of patients with large nasal defects (up to 4x7 cm) using subcutaneous pedicle island paramedian forehead flap, during a period of 2007-2009, 8 patients with large nasal defects were repaired with this flap, among them 5 patients were male and 3 patients were female with mean age of 53 years, all cases were reconstructed with island pedicle flap in a single stage.

RESULTS

Good and satisfying results were achieved in all cases except for one case that was operated again for debulking of flap.

CONCLUSION

Island paramedian forehead flap provides esthetic and functional results in a single stage reconstruction of defects with various sizes and locations. This variation of forehead flap is a good choice especially for those patients that have problems with cost or problem with multistage reconstruction of nasal defects.

Reconstruction of a large posterior scalp defect using occipital artery based pedicled island v-y advancement flap: a case report

Repair of scalp defects using local hair bearing scalp is technically challenging. Transposition or rotation of local flaps to close the defect has its own disadvantages. Reconstruction of a large posterior scalp defect using occipital artery based pedicled V-Y advancement flap following the excision of a recurrent fibrolipoma of epicranial aponeurosis is reported here. It is possible to reconstruct the defect with hair bearing scalp in a single stage along with primary closure of the donor site using this technique.

Superficial temporal fascia pedicled v-y advancement flap for scalp reconstruction

Repair of scalp defects using local hair bearing scalp is technically challenging. Transposition or rotation of local flaps to close the defect has its own disadvantages. Reconstruction of scalp defect using superficial temporal fascia pedicled V-Y advancement flap using both frontal and parietal branches of superficial temporal artery following the excision of a benign and a malignant pathology is reported here. It is possible to reconstruct the defect with hair bearing scalp in a single stage along with primary closure of the donor site using this technique.

Expanded narrow subcutaneous-pedicled island forehead flap for reconstruction of the forehead

To reconstruct the subsequent defects after resection of a unilateral large forehead lesion, we devised a revised method, "expanded narrow subcutaneous-pedicled island forehead flap." After unilateral forehead skin was expanded by a tissue expander, the flap was designed on the upper half of the expanded forehead skin nourished by the subcutaneous adipomuscular pedicle, including the supratrochlear or supraorbital artery. The elevated flap was then transposed or rotated 180 degrees toward the defect. The donor site was closed with upward advancement of the lower half of the expanded skin. Four patients were treated with this method. The flaps survived completely without serious complications, and acceptable results were obtained in all patients. This method has the advantage of increased freedom of flap design and transfer, providing an effective use of unaffected skin, less scars left on the forehead, and less formation of the dog-ear compared with the conventional procedure.

Reconstruction of Major Forehead Soft Tissue Defects with Adjacent Tissue and Minimal Scar Formation

Repair and reconstruction of soft tissue defects involving over 50% of the forehead using remaining forehead tissue has not been reported in the literature. The few existing reports mainly concern cases in which less than half of the forehead was involved. The forehead comprises one third of the face and with regard to its prominent position, it is one of the major contributing components to facial beauty. Considering the excellent color, thickness, and quality matching of the adjacent forehead skin, it is considered the ideal substitute for repair of forehead defects. Use of skin graft or free flaps for reconstruction of defects involving 50% or more of the forehead have not reported acceptable results because of the lack of similarity of the donor tissue with the remaining forehead tissue. In this study, we describe successful reconstruction of major forehead soft tissue defects of two thirds to three fourths of the forehead with use of a tissue expander and transverse supratrochlear pedicle flap in four patients who were diagnosed with giant hairy nevus. There were no serious complications such as hematoma, bleeding, infection, or flap necrosis. We recommend this technique for reconstruction of extensive forehead soft tissue defects.

Soft Tissue Reconstruction of the Forehead and Temple

Soft tissue reconstruction of the forehead and temple challenges facial plastic surgeons to balance esthetic goals with functional concerns. Understanding the muscular and neurovascular anatomy is essential to achieve these ends. Reconstructive considerations include maintaining hairlines and eyebrows, minimizing scarring, using relaxed skin tension lines, and preserving motor and sensory function. Reconstructive options range from healing by secondary intention to primary closure, skin grafts, local flaps, island flaps, or any combination of these techniques.

Forehead flag flap

We present a modification of the Okada and Maruyama's flap for forehead reconstruction, based solely on the supratrochlear vessels. The flap is raised extra-periosteally but in the area of the pedicle the periosteum is included in the flap to protect the vessels. The flap is advanced and rotated to cover full thickness defects on the contralateral hemi-forehead, like a flag on its flagpole. We have treated six patients with large malignant tumours of the forehead which required excision including the periosteum. The flap survived in all cases and no necrosis was observed in any. The main advantage of this flap is that it is relatively straightforward to raise, being a good solution in selected cases (elderly patients). The main disadvantages of this flap are that the supraorbital nerve is sacrificed and some distortion of the eyebrows occurs.