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Khushalani A, Thakurani S, Garg P. Outcome Analysis of Two-Stage Paramedian Forehead Flap for Nasal Defects Reconstruction in Local Population: Experience of 3 Years at Our Center. Indian J Otolaryngol Head Neck Surg 2024; 76:559-566. [PMID: 38440631 PMCID: PMC10908939 DOI: 10.1007/s12070-023-04212-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 08/30/2023] [Indexed: 03/06/2024] Open
Abstract
The nose is a key aesthetic element of face. Nasal defect reconstruction by forehead flap has been done since ancient times. The aim of this study is to review our experience of the outcomes of two- stage paramedian forehead flap in nasal defects of various aetiologies in the local population. This prospective study was done from January 2020 to December 2022 in the Department of Plastic and Reconstructive Surgery at SMS Medical College and Hospital. A total of 29 patients were included in this study who were candidates for a forehead flap for nose reconstruction due to any aetiology. After informed and written consent, two- stage paramedian forehead flap was done and patients were followed up to 6 months for analysis of outcomes. 29 participants were included in the study. Age range was 18-72 years (mean age 38.5 ± 16.78). 21 (72.4%) were male and 8 (27.6%) were female.23 (79.3%) patients had multiple subunit involvement, 4 (13.8%) patients had single subunit defect and 2 (6.9%) had total nasal defect. Most common aetiology was trauma (58.7%). Early complications including flap and donor site healing related complications were present in 8 (27.5%) patients. Delayed complications were grouped into cosmetic and functional complications and were seen in 22 (75.8%) patients. Cosmetic dissatisfaction was high with the two- stage paramedian forehead flap. Forehead flap is an established gold standard reconstructive option for nasal defects. In a two stage paramedian forehead flap, flap and donor site related issues are minor but cosmetic dissatisfaction is high. With some additional stages, satisfaction among patients increases significantly.
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Affiliation(s)
- Asha Khushalani
- Department of Plastic, Reconstructive and Burns Surgery, SMS Hospital, Jaipur, Rajasthan India
| | - Sangeeta Thakurani
- Department of Plastic, Reconstructive and Burns Surgery, SMS Hospital, Jaipur, Rajasthan India
| | - Paheli Garg
- Department of Plastic, Reconstructive and Burns Surgery, SMS Hospital, Jaipur, Rajasthan India
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Chouhan M, Dhakar P, Solanki B, Kumari R, Gupta R. Eccrine Porocarcinoma of Dorsum of Nose: A Rare Case Report. Indian J Otolaryngol Head Neck Surg 2023; 75:1093-1095. [PMID: 37206727 PMCID: PMC10188804 DOI: 10.1007/s12070-023-03632-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 02/23/2023] [Indexed: 03/08/2023] Open
Abstract
Eccrine porocarcinoma (EPC) is an uncommon malignant tumor derived from the eccrine sweat glands. Because of its various pathological features, it is often confused with other malignant cutaneous tumors. We present a case of 78-year- old female having ulcerative lesion over external nasal pyramid. Biopsy suggested of squamous cell carcinoma. Tumor was excised and reconstruction was done using paramedian forehead flap. Post operative Histopathological Examination (HPE) suggested of eccrine porocarcinoma.
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Affiliation(s)
- Mahendra Chouhan
- Department of Otorhinolaryngology and Head and Neck Surgery, Dr. Sampurnanad Medical College, Jodhpur, Rajasthan 342001 India
| | - Preeti Dhakar
- Department of Otorhinolaryngology and Head and Neck Surgery, Dr. Sampurnanad Medical College, Jodhpur, Rajasthan 342001 India
| | - Bharti Solanki
- Department of Otorhinolaryngology and Head and Neck Surgery, Dr. Sampurnanad Medical College, Jodhpur, Rajasthan 342001 India
| | - Rama Kumari
- Department of Pathology, Dr. Sampurnanad Medical College, Jodhpur, Rajasthan India
| | - Ruchika Gupta
- Department of Otorhinolaryngology and Head and Neck Surgery, Dr. Sampurnanad Medical College, Jodhpur, Rajasthan 342001 India
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Angermayer ME, Rangwani SM, Anderson SR, Johnson RM, Kadakia SP. Forked Paramedian forehead flap combined with nasolabial flap for pre-radiation coverage of exposed maxilla in the Total Rhinectomy patient. Am J Otolaryngol 2023; 44:103825. [PMID: 36898217 DOI: 10.1016/j.amjoto.2023.103825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 02/24/2023] [Indexed: 03/06/2023]
Abstract
Total rhinectomy is ontologically necessary for large and locally invasive carcinomas of the nasal cavity owing to the complex three-dimensional structure of the nose. Reconstruction options include singular or combined options of local tissue rearrangement, free flap reconstruction, and prosthetic reconstruction which may be delayed in the setting of post-ablative radiation therapy. If significant bony exposure is present prior to radiation, there is a substantial risk of osteoradionecrosis and the ensuing sequalae. In these cases, coverage of the bony defect may be advantageous prior to radiation and final reconstructive treatment. We present a case of a total rhinectomy defect for squamous cell carcinoma in a patient who had significant bony exposure prior to radiation which was resurfaced with a combined forked paramedian flap and nasolabial flap. The patient went on to be treated with a full course of radiation and had planned for a post-treatment nasal prosthesis.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Achena A, Placentino A, Mevio N, Pilolli F, Roncoroni L, Borin M, Mantini G, Ormellese GL, Dragonetti AG. VITOM-3D assisted paramedian forehead flap for nasal reconstruction. Am J Otolaryngol 2022;:103493. [PMID: 35715292 DOI: 10.1016/j.amjoto.2022.103493] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 05/01/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND The study was designed with the purpose of showing the potential advantages of the VITOM-3D assisted paramedian forehead flap for nasal reconstruction. METHODS A 72 years-old female patient presented to our department with a wide left nasal defect. On her clinical history she referred a basal cell carcinoma of the left nasal skin treated with multiple excision in another center without reconstruction. On clinical examination, we observed the absence of the left nasal tip, columella, upper lateral and lower lateral cartilage. In our experience the paramedian forehead flap based on supratrochlear artery is a feasible reconstruction (Shokri, T., et al). The first surgeon (Dr. Placentino) along with the head and neck team decided to reconstruct the nasal defect assisted by the 3D 4 K exoscope (VITOM®; Karl Storz, Tuttlingen, Germany). RESULTS The goal of reconstruction is to carefully evaluate the nasal defects and rebuild the nose as close as possible to its original shape with the multilayer technique, creating the internal lining, the intermediate bony-cartilage structure and external skin. (Kim, I.A., et al). The exoscope allowed us to reconstruct the inner layer with the mucoperiostal septal flap, middle layer with auricular cartilage and the external skin through the elevation of the paramedian forehead flap. The flap is elevated from cranio-caudal direction including skin, subcutaneous tissue, frontalis muscle and associated fascia or periosteum. Donor site was primarily closed with the exception of a small defect. Post-operative period was uneventful, and after a period of 4 weeks when vascularization was complete, the patient underwent pedicle excision. At the recent 6 months follow-up, the flap had healed completely with the shape of nose restored with good symmetry. CONCLUSION High-definition (4 K), three-dimensional (3D) exoscope are being used to perform a growing number of head and neck surgeries (Bartkowiak, E., et al). However, the use of the 3D exoscope in the nasal reconstruction has not been previously described. In our opinion the potential advantages of this technique are, firstly, to achieve a better magnification and to improve the vision of anatomical structure that leads to a better functional and aesthetic result, secondly, to reduce surgical times. High-definition allowed us to highlight the scar tissue and preserve as much healthy tissue as possible. In addition, we underline the use of the exoscope for a better remodeling of cartilage.
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Weerdt GD, Luyten P, Dubrulle F, Loonen M. Reconstruction of an Extensive Periocular and Bilamellar Defect of the Lower and Upper Eyelid Using Local, Regional and Free Chondral Graft Techniques: A Case Report. World J Plast Surg 2021; 10:125-131. [PMID: 33833965 PMCID: PMC8016385 DOI: 10.29252/wjps.10.1.125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
A 65-year-old female patient with a histologically confirmed basal cell carcinoma located at the right lateral lower eyelid was referred for surgical tumour excision and reconstruction of the periorbital area. The periocular zone was reconstructed in a two-staged procedure with bilamellar repair of both eyelids. An autologous chondral graft, mucosal advancement techniques and a periosteum-temporalis fascia hinged turnover flap were used for reconstruction of the posterior lamellae. A modified Tenzel flap and a paramedian forehead flap were used for reconstruction of the anterior lamellae. An acceptable functional and aesthetic outcome of the reconstruction was achieved.
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Affiliation(s)
- Glenn De Weerdt
- Department of Plastic, Reconstructive and Aesthetic surgery at AZ Groeninge Hospital Kortrijk, Belgium
| | - Pieter Luyten
- Department of Plastic, Reconstructive and Aesthetic surgery at AZ Groeninge Hospital Kortrijk, Belgium
| | - Fabrice Dubrulle
- Department of Plastic, Reconstructive and Aesthetic surgery at AZ Groeninge Hospital Kortrijk, Belgium
| | - Martain Loonen
- Beverly Hills Sunset Surgery Center at Valiant Clinic Dubai, United Arab Emirates
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Kim MJ, Choi JW. Total nasal reconstruction with a forehead flap: Focusing on the facial aesthetic subunit principle. J Plast Reconstr Aesthet Surg 2020; 74:1824-1831. [PMID: 33386264 DOI: 10.1016/j.bjps.2020.12.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 11/04/2020] [Accepted: 12/02/2020] [Indexed: 11/26/2022]
Abstract
The nasal aesthetic subunit principle has been widely accepted as the standard for nasal reconstruction with forehead flaps. However, in our experience, one's impression of a reconstructed face can easily be represented by the nose's entire appearance rather than a single nasal component. Accordingly, we hypothesized that total nasal reconstruction focusing more on the facial aesthetic subunit principle would be superior to focal nasal subunit partial reconstruction. Here, we investigated the indication range of total nasal reconstruction and analyzed its effectiveness. Between July 2006 and December 2017, 32 patients who underwent total or subtotal nasal reconstruction were recruited. The total nasal reconstruction group (n = 20) was treated according to our modified facial aesthetic unit concept, while the subtotal reconstruction group (n = 16) was treated according to the nasal aesthetic subunit principle. Using retrospective reviews, we compared surgical details and aesthetic, and functional outcomes with visual analog scale scores. In aesthetic evaluation, nose contour (p = 0.009), nasal symmetry (p = 0.001), and nostril shape (p = 0.041) were superior in the total nasal reconstruction group. Satisfaction regarding the nose (p = 0.036) was significantly higher than that regarding the forehead and labial folds in the total group. Regarding function, there were no significant intergroup differences in nasal airflow, snoring, or olfaction. We suggest that total nasal reconstruction is not a strategy to avoid because of its aggressive nature. For selected suitable patients, the use of the total nose reconstruction focusing on our one nose concept can be a successful surgical option, and the reconstructed nose can be visualized as a real part of the face.
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Affiliation(s)
- Min Ji Kim
- Department of Plastic and Reconstructive Surgery, Ajou University, School of Medicine, Suwon, Korea
| | - Jong Woo Choi
- Department of Plastic and Reconstructive Surgery, Ulsan university, College of medicine, Asan medical center, Seoul, Korea.
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Peters F, Mücke M, Möhlhenrich SC, Bock A, Stromps JP, Kniha K, Hölzle F, Modabber A. Esthetic outcome after nasal reconstruction with paramedian forehead flap and bilobed flap. J Plast Reconstr Aesthet Surg 2020; 74:740-746. [PMID: 33189616 DOI: 10.1016/j.bjps.2020.10.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 01/08/2020] [Accepted: 10/08/2020] [Indexed: 10/23/2022]
Abstract
The incidence of skin cancer, which often affects the facial skin, has risen worldwide. After resecting such facial lesions, plastic reconstruction is necessary in most cases. The paramedian forehead flap (PFF) and the bilobed flap (BF) are commonly used for nasal reconstruction, but whether patients and physicians are satisfied with the esthetics is undetermined? In this study, scar questionnaires (Manchester Scar Scale, Vancouver Scar Scale, and Patient and Observer Scar Assessment Scale) and optical three-dimensional (3D) imaging were used for subjective and objective evaluation of esthetical outcomes after plastic reconstruction of the nose in 30 patients. The distances between landmarks and changes in volume between the treated and both the mirrored, healthy side of the face as well as an untreated, matched control group were measured using the optical (3D) scans. The questionnaires ascertained whether the patient was content with the esthetical outcome of both flaps. In the opinion of the observer, the esthetical outcome of both flaps was sufficient; only a few of the measured distances differed significantly between the patients and the control group. However, the measured volume differences of the donor site of the flap differed significantly between the PFF group and the control group (p = 0.0078). The BF was used for smaller defects, while the PFF was used for major defects. Besides a greater donor-side morbidity for the PFF, both flaps led to esthetically sufficient results and could be used for the reconstruction of the nose depending on the defect size and localization.
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Affiliation(s)
- Florian Peters
- Department of Oral, Maxillofacial and Facial Plastic Surgery, School of Medicine, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany.
| | - Matthias Mücke
- Department of Oral, Maxillofacial and Facial Plastic Surgery, School of Medicine, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Stephan Christian Möhlhenrich
- Department of Orthodontics, University Witten/Herdecke, Private Universität Witten/Herdecke GmbH, Alfred-Herrhausen-Straße 45, 58448 Witten, Germany
| | - Anna Bock
- Department of Oral, Maxillofacial and Facial Plastic Surgery, School of Medicine, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Jan-Philipp Stromps
- Department of Plastic and Reconstructive Surgery, Hospital Cologne-Merheim, Ostmerheimer Str. 200, 51109 Cologne, Germany
| | - Kristian Kniha
- Department of Oral, Maxillofacial and Facial Plastic Surgery, School of Medicine, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Frank Hölzle
- Department of Oral, Maxillofacial and Facial Plastic Surgery, School of Medicine, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Ali Modabber
- Department of Oral, Maxillofacial and Facial Plastic Surgery, School of Medicine, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
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Rudy SF, Abdelwahab M, Kandathil CK, Most SP. Paramedian forehead flap pedicle division after 7 days using laser-assisted indocyanine green angiography. J Plast Reconstr Aesthet Surg 2020; 74:116-122. [PMID: 32565139 DOI: 10.1016/j.bjps.2020.05.079] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Revised: 04/13/2020] [Accepted: 05/15/2020] [Indexed: 11/29/2022]
Abstract
The paramedian forehead flap is a major workhorse for reconstruction of medium- to large-sized nasal defects. The tissue bridge that results from the vascular pedicle results in significant cosmetic deformity, with associated social and occupational costs to the patient. This prospective cross-sectional study sought to assess efficacy and safety of takedown of the flap pedicle at 1 week using indocyanine green (ICG) angiography to assist in determining neovascularization of the flap. This study was performed at a tertiary care center from April 13, 2018 to March 22, 2019. Patients eligible for enrollment included those with defects appropriate for reconstruction with a paramedian forehead flap, partial-thickness defect, vascularized tissue in more than 50% of the recipient bed, and lack of nicotine use. Ten patients were included, and all underwent reconstructive surgery by a single surgeon. Laser-assisted ICG angiography was used during the first stage as well as at the second stage both immediately before and after flap division. Perfusion was in both time-independent and time-dependent analyses relative to a cheek reference point. Herein, we found successful 7-day flap takedown with no flap-related complications in all patients. There was an average of approximately 44% flap-to-cheek vascularity across all patients, and pre-division flap perfusion correlated well with post-division perfusion. In conclusion, in carefully selected patients with amenable defects, division of the pedicle at 1 week after initial flap transfer is safe and has the potential to limit the morbidity associated with the procedure.
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Affiliation(s)
- Shannon F Rudy
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head & Neck Surgery, Stanford University, School of Medicine, Stanford, CA, United States.
| | - Mohamed Abdelwahab
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head & Neck Surgery, Stanford University, School of Medicine, Stanford, CA, United States; Department of Otolaryngology-Head & Neck Surgery, Mansoura University Faculty of Medicine, Mansoura, Egypt
| | - Cherian K Kandathil
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head & Neck Surgery, Stanford University, School of Medicine, Stanford, CA, United States
| | - Sam P Most
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head & Neck Surgery, Stanford University, School of Medicine, Stanford, CA, United States
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Bresler AY, Mir G, Grube J, Hegazin M, Liu JK, Eloy JA, Paskhover B. Endoscopic Paramedian Forehead Flap Reconstruction of the Anterior Skull Base for Recalcitrant Cerebrospinal Fluid Leaks: Minimally Invasive Adaptation of Ancient Flap. World Neurosurg 2019; 130:37-41. [PMID: 31260852 DOI: 10.1016/j.wneu.2019.06.162] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 06/19/2019] [Accepted: 06/20/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND The anterior skull base (ASB) remains one of the greatest challenges for reconstructive surgeons. The current armamentarium includes endoscopic placement of free grafts, endonasal vascularized pedicled flaps, regional flaps, and microvascular free flaps. As the defect size increases, reconstruction complexity increases along with potential complications. Here, we report an endoscopic-assisted paramedian forehead flap, a novel adaptation of an age-old technique, for ASB reconstruction. CASE DESCRIPTION A 66-year-old male underwent a dual bifrontal and transnasal endoscopic approach for the resection of a T4N0M0 sinonasal squamous cell carcinoma. The resulting ASB defect was repaired using simultaneous pericranial and nasoseptal flaps. Adjuvant radiation therapy resulted in delayed radiation necrosis in the right frontal lobe 3 years later requiring debridement via a supraorbital approach. Recovery from this operation was complicated by an ASB defect and cerebrospinal fluid (CSF) leak. The defect remained despite multiple attempts at endoscopic repairs. Due to multiple medical comorbidities, the patient was not a candidate for microvascular reconstruction. Prior surgeries had disrupted the traditional regional flaps (i.e., pericranial, nasoseptal, and temporoparietal fascia flaps) bilaterally. Therefore the novel endoscopic-assisted paramedian forehead flap was used to successfully repair the ASB defect. Postoperatively, the patient has done well with no recurrences in the CSF leak. CONCLUSIONS The endoscopic-assisted paramedian forehead flap is a robust regional flap whose advantages include the utilization of muscle, low donor morbidity, and endoscopic placement with avoidance of craniotomies. Therefore it should be considered an important option for ASB reconstruction of recalcitrant CSF leaks when all other options are unavailable.
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Rudolph MA, Walker NJ, Rebowe RE, Marks MW. Broadening applications and insights into the cross- paramedian forehead flap over a 19-year period. J Plast Reconstr Aesthet Surg 2018; 72:763-770. [PMID: 30737127 DOI: 10.1016/j.bjps.2018.12.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Revised: 11/28/2018] [Accepted: 12/02/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Forehead flap reconstruction of large nasal defects can be challenging. The senior author has used a paramedian forehead flap modification using the supratrochlear artery on the contralateral side of the defect. METHODS A 9-year retrospective review (2008-2016) was performed for patients undergoing nasal reconstruction with the cross-paramedian forehead flap. Outcomes were analyzed by comparing our previous reviews, which allows us to analyze patient outcomes for over 19 years. RESULTS Fifty-three patients were identified. The aasal defect was most frequently due to basal cell carcinoma (n = 37, 69.8%). Twenty-three (43%) patients were smokers, and nine (17%) had diabetes. The mean defect size was 12.9 cm2, involving an average of 2.6 nasal subunits. One-third of the patients had cartilage defects (n = 18) and mucosal lining defects (n = 19). Periorbital involvement was present in five patients. Complications included partial flap loss (n = 6), donor site dehiscence (n = 4), flap dehiscence (n = 2), and postoperative infection (n = 1). Only two of the partial flap losses were considered significant, as they required additional reconstructive procedures for soft tissue coverage. Complications were 12 times as likely as those in diabetes (OR = 11.97, p = 0.007, 95% CI 1.94-72.44), six times as likely as those in cartilage defects (OR = 6.4, p = 0.007, 95% CI 1.64-24.92), and nearly five times as likely as those in mucosal lining defects (OR = 4.8, p = 1.27-18.09, 95% CI 1.27-18.09). Thirty-one patients required revisions most commonly for flap debulking (n = 16). CONCLUSION The cross-paramedian forehead flap is a reliable option in the armamentarium of the reconstructive surgeon for large and complex defects in addition to those with periorbital extension. SUMMARY Coverage of distal nasal defects after tumor extirpation remains a challenge to the reconstructive surgeon. Our institution uses the cross-paramedian forehead flap for these defects. This flap is based on the supratrochlear artery on the contralateral side of the defect and is oriented obliquely across the forehead for additional length and an improved donor site scar at the level of the eyebrow. The technique and outcomes were published in 2009, and this manuscript serves as an update on outcomes and applications during the past 9 years. By including all our data, we can analyze outcomes for over 19 years. During the past 9 years, 53 patients underwent the cross-paramedian forehead flap technique between 2008 and 2016. These patients were found to have an average defect size of 12.9 cm2 and an average loss of 2.6 nasal subunits. Cartilage defects were present in 34.6% (n = 18) and mucosal defects were present in 36.5% (n = 19) of patients. Five patients had periorbital reconstruction with the forehead flap, of which three patients underwent a single-stage islandized forehead flap reconstruction. Given the large defect size, additional local flaps were frequently used, including nasolabial flaps (n = 16) and cheek rearrangement (n = 11). Complications included partial flap loss (n = 6), donor site dehiscence (n = 4), and postoperative infection (n = 1). Only two of these partial flap losses were considered significant, as they required additional reconstructive procedures to address areas of soft tissue loss. Increased rates of complications were associated with the presence of diabetes and defect characteristics, which reflects increased complexity including mucosal and cartilage loss. When comparing with our prior review of this technique, the more recent population have had increasing complexity of the nasal defects with a large surface area involvement. Overall, the cross-paramedian forehead flap is a reliable option in the armamentarium of the reconstructive surgeon for large and distal nasal defects.
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Affiliation(s)
- Megan A Rudolph
- Department of Plastic Surgery, Wake Forest Baptist Medical Center, 1 Medical Center Boulevard, Winston-Salem, NC 27157, United States.
| | - Nicholas J Walker
- Department of Plastic Surgery, Wake Forest Baptist Medical Center, 1 Medical Center Boulevard, Winston-Salem, NC 27157, United States
| | - Ryan E Rebowe
- Department of Plastic Surgery, Wake Forest Baptist Medical Center, 1 Medical Center Boulevard, Winston-Salem, NC 27157, United States
| | - Malcom W Marks
- Department of Plastic Surgery, Wake Forest Baptist Medical Center, 1 Medical Center Boulevard, Winston-Salem, NC 27157, United States
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Vandersteen C, Culié D, Dassonville O, Bozec A, Guevara N, Savoldelli C, Poissonnet G. An original procedure for orbitonasal cutaneous infiltrative tumor repair, using combined forehead and melolabial propeller flaps. Eur Arch Otorhinolaryngol 2018; 276:535-540. [PMID: 30519922 DOI: 10.1007/s00405-018-5237-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 12/02/2018] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Resections of cutaneous tumors in the medial orbitonasal region can be transfixing. Repairs using a single local flap run the risk of failure and that of secondary sinonasal fistula, especially in cases of surgery on a radiated field. We propose an original and reliable repair procedure using two pedicled regional flaps vascularized by two distinct arterial systems clinched together to reconstruct the mucosal and cutaneous planes. MATERIALS AND METHODS A first melolabial propeller flap (MPF) with a superior perforating pedicle was elevated and the cutaneous side was sutured to the deep plane of the loss of substance (mucosal lining). A second homolateral or contralateral paramedian forehead flap (PFF) was then lifted and sutured over the first flap (superficial plane). The forehead pedicle flap was divided at 1 month. RESULTS No trophic complication or failure was recorded on two patients. The 7-year carcinologic, aesthetic, and functional results were satisfying. CONCLUSION This technique involving the superimposition of two local flaps, vascularized by two different arterial systems, appears to offer a simple and reliable repair technique for transfixing cutaneous losses of substance in the medial orbitonasal region. It could be used in the first-line treatment, particularly if an additional radiotherapy is to be performed.
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Affiliation(s)
- Clair Vandersteen
- Institut Universitaire de la Face et du Cou, Centre Hospitalier Universitaire de NICE, 31 Avenue de Valombrose, 06100, Nice, Alpes-Maritimes, France.
- Institut Universitaire de la Face et du Cou, Centre Antoine Lacassagne, Nice, Alpes-Maritimes, France.
| | - Dorian Culié
- Institut Universitaire de la Face et du Cou, Centre Hospitalier Universitaire de NICE, 31 Avenue de Valombrose, 06100, Nice, Alpes-Maritimes, France
- Institut Universitaire de la Face et du Cou, Centre Antoine Lacassagne, Nice, Alpes-Maritimes, France
| | - Olivier Dassonville
- Institut Universitaire de la Face et du Cou, Centre Hospitalier Universitaire de NICE, 31 Avenue de Valombrose, 06100, Nice, Alpes-Maritimes, France
- Institut Universitaire de la Face et du Cou, Centre Antoine Lacassagne, Nice, Alpes-Maritimes, France
| | - Alexandre Bozec
- Institut Universitaire de la Face et du Cou, Centre Hospitalier Universitaire de NICE, 31 Avenue de Valombrose, 06100, Nice, Alpes-Maritimes, France
- Institut Universitaire de la Face et du Cou, Centre Antoine Lacassagne, Nice, Alpes-Maritimes, France
| | - Nicolas Guevara
- Institut Universitaire de la Face et du Cou, Centre Hospitalier Universitaire de NICE, 31 Avenue de Valombrose, 06100, Nice, Alpes-Maritimes, France
- Institut Universitaire de la Face et du Cou, Centre Antoine Lacassagne, Nice, Alpes-Maritimes, France
| | - Charles Savoldelli
- Institut Universitaire de la Face et du Cou, Centre Hospitalier Universitaire de NICE, 31 Avenue de Valombrose, 06100, Nice, Alpes-Maritimes, France
- Institut Universitaire de la Face et du Cou, Centre Antoine Lacassagne, Nice, Alpes-Maritimes, France
| | - Gilles Poissonnet
- Institut Universitaire de la Face et du Cou, Centre Hospitalier Universitaire de NICE, 31 Avenue de Valombrose, 06100, Nice, Alpes-Maritimes, France
- Institut Universitaire de la Face et du Cou, Centre Antoine Lacassagne, Nice, Alpes-Maritimes, France
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Abstract
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.
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Affiliation(s)
- Lauren K Reckley
- Otolaryngology-Head and Neck Surgery, Tripler Army Medical Center, Honolulu, HI, USA.
| | - Jessica J Peck
- Facial Plastic and Microvascular Reconstructive Surgery, Otolaryngology-Head and Neck Surgery, Dwight Eisenhower Army Medical Center, Fort Gordon, GA, USA
| | - Scottie B Roofe
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA; Otolaryngology-Head and Neck Surgery, Department of Surgery, Womack Army Medical Center, Fort Bragg, NC, USA
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Krishnamurthy A. The Use of a Combined Local Flap for Reconstructing a Complex Nasal Defect. Indian J Surg 2018; 80:194-196. [PMID: 29915489 DOI: 10.1007/s12262-018-1733-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 01/22/2018] [Indexed: 11/29/2022] Open
Abstract
The main goals of reconstruction of nasal defects are to restore the topographic subunit outline, thereby maintaining the aesthetic three-dimensional facial contours and more importantly ensuring a patent airway. Wide excision of tumours of the external nose can at times result in complex defects causing significant facial disfigurement and this poses a significant reconstructive challenge. Nasal reconstruction with only micro-vascular free flaps can at times produce poor aesthetic outcomes as distant skin often appears as a mismatched patch within the surrounding normal facial skin. We describe a novel technique for external nose reconstruction using a combination two well described local flaps, superiorly based nasolabial flap alongside a paramedian forehead flap.
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Affiliation(s)
- Arvind Krishnamurthy
- Surgical Oncology, Cancer Institute (WIA), 38, Sardar Patel Rd, Adyar, Chennai, 600036 India
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Akhoondinasab M, Sobhani R. Paramedian Forehead Flap Raised in the Base of Previously Used Median Forehead Flap Pedicle. World J Plast Surg 2016; 5:323-324. [PMID: 27853700 PMCID: PMC5109398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
| | - Roohollah Sobhani
- Corresponding Author: Roohollah Sobhani, MD; Department of Plastic Surgery, Hazrat Fatemeh Hospital, Iran University of Medical Sciences, Tehran, Iran, Tel: +98-912-8343264, E-mail:
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Innocenti A, Innocenti M. An alternative single-stage application of the paramedian forehead flap in reconstruction of the face. J Craniomaxillofac Surg 2016; 44:1678-1681. [PMID: 27569383 DOI: 10.1016/j.jcms.2016.07.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 06/13/2016] [Accepted: 07/18/2016] [Indexed: 10/21/2022] Open
Abstract
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.
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Affiliation(s)
- Alessandro Innocenti
- Department of Plastic and Reconstructive Surgery, CTO Azienda Ospedaliero Universitaria Careggi, Florence, Italy.
| | - Marco Innocenti
- Department of Plastic and Reconstructive Surgery, CTO Azienda Ospedaliero Universitaria Careggi, Florence, Italy
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Morrison JL, Mahmood S, Scott JS. Modification to facilitate the wearing of spectacles by patient after reconstruction with a paramedian forehead pedicled flap. Br J Oral Maxillofac Surg 2016; 54:1036-1037. [PMID: 26830067 DOI: 10.1016/j.bjoms.2015.12.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 12/14/2015] [Indexed: 11/16/2022]
Affiliation(s)
- Jennifer L Morrison
- Oral and Maxillofacial CT2, OMFS Department, Dumfries and Galloway Royal Infirmary, Bankend Road, DG1 4AP, Scotland.
| | - Shaukat Mahmood
- OMFS Department, Dumfries and Galloway Royal Infirmary, Bankend Road, DG1 4AP, Scotland.
| | - John S Scott
- 3 Forest Cottages, Boreland, Lockerbie, DG11 2LJ, Scotland
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Blázquez-Sánchez N, Fernández-Canedo I, Repiso-Jiménez JB, Rivas-Ruiz F, De Troya Martín M. Usefulness of the Paramedian Forehead Flap in Nasal Reconstructive Surgery: A Retrospective Series of 41 Patients. Actas Dermosifiliogr 2016; 107:133-41. [PMID: 26574122 DOI: 10.1016/j.ad.2015.09.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Revised: 09/03/2015] [Accepted: 09/05/2015] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Surgical reconstruction of the external nose, a common site for nonmelanoma skin cancer, is difficult. Oncologic surgery often leaves large skin defects, occasionally involving the underlying cartilage and nasal mucosa. We describe our experience with the paramedian forehead flap for reconstruction of nasal defects. METHODOLOGY We performed a retrospective study of consecutive patients in whom a paramedian forehead flap was used to repair surgical defects of the nose between July 2004 and March 2011. We describe the clinical and epidemiologic characteristics, the surgical technique, complications, secondary procedures, and cosmetic results. RESULTS The series comprised 41 patients with a mean (SD) age of 67 (10.36) years. The majority were men (male to female ratio, 2.4:1). Associated risk factors included diabetes in 27% of patients, cardiovascular risk factors in 49%, and smoking or drinking in 19.5%. The tissue defects were distal in 80% of cases and nonpenetrating in 78%. The mean (SD) diameter was 21.6 (6.78) mm. Early postoperative complications occurred in 14.6% of patients and late complications in 31.7% (trap door effect in 22% and hair transposition in 19%), with a need for Readjustment in a second operation was needed in 19.5% of patients. The cosmetic results were considered acceptable or excellent in 90.2% of cases. DISCUSSION The paramedian forehead flap is versatile and provides skin of a similar color and texture to that of the external nose. It has a reliable vascular pedicle that guarantees the viability not only of the flap but also of other tissues that may be used in combination, such as chondromucosal or chondrocutaneous grafts. Revision of the technique in a second operation may sometimes be required to achieve an optimal result.
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Affiliation(s)
- O Cogrel
- Service de dermatologie, hôpital du Haut-Levêque, CHU de Bordeaux, avenue de Magellan, 33604 Pessac cedex, France.
| | - J Ofaiche
- Service de dermatologie, hôpital du Haut-Levêque, CHU de Bordeaux, avenue de Magellan, 33604 Pessac cedex, France
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Abstract
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.
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Affiliation(s)
- Ryan J Smart
- Department of Oral and Maxillofacial Surgery/Head and Neck Surgery, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Melvyn S Yeoh
- Department of Oral and Maxillofacial Surgery/Head and Neck Surgery, Louisiana State University Health Sciences Center, Shreveport, LA, USA.
| | - D David Kim
- Department of Oral and Maxillofacial Surgery/Head and Neck Surgery, Louisiana State University Health Sciences Center, Shreveport, LA, USA
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