Paramedian Forehead Flaps

Excerpt

Interpolated flaps, rotation, and transposition flaps comprise the pivotal flap category of facial reconstruction techniques. Interpolated flaps differ from other pivotal flaps in that the flap's base (or pedicle) is not contiguous with the defect and necessarily passes across intervening tissue between the defect and the flap harvest site. Many surgeons would classify interpolated flaps as regional flaps rather than local flaps, given that the tissue used to reconstruct the defect when an interpolated flap is transferred is not originally adjacent to the defect.

While numerous interpolated flap options may be employed in facial reconstruction (nasolabial flaps, temporoparietal fascia flaps, pericranial flaps, inferior turbinate flaps, facial artery musculomucosal flaps, and temporalis muscle flaps, among others), the forehead flap has remained a workhorse technique since Gillies popularized it during World War I. Gillies' protégé, Millard, was the first to describe basing the flap in a paramedian position to include a single set of supratrochlear vessels as an axial blood supply. Nevertheless, the flap's origins stretch back to at least 600 BC, when it was described in the Indian medical text Sushruta Samhita as a midline forehead flap for repair of nasal defects arising from punitive mutilation. The sebaceous gland quality and thickness of central forehead skin closely resemble those of the nose, and the flap's vascularity is highly reliable, which is why this technique has been selected for nasal reconstruction so consistently throughout history.

Using the paramedian forehead flap in nasal reconstruction typically requires at least a 2-stage procedure, with operations usually separated by 3 weeks. Some surgeons prefer to utilize a third stage to permit further refinement of the flap's contour. Even though flap harvest necessarily leaves a vertical scar on the forehead, it is not always particularly conspicuous—and the ultimate cosmetic and functional outcomes tend to be very acceptable to patients and surgeons alike.