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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 32  |  Issue : 4  |  Page : 1282-1288

Outcomes of paramedian forehead flap for reconstruction of large nasal defects: Menoufia experience


1 Department of Plastic and Reconstructive Surgery, Menoufia University Hospital, Menoufia, Egypt
2 Department of General Surgery, Menoufia University Hospital, Menoufia, Egypt

Date of Submission26-Jan-2016
Date of Decision06-Apr-2016
Date of Acceptance13-Apr-2016
Date of Web Publication31-Dec-2019

Correspondence Address:
Hanan Ali Ali Dawoud
El Maryotia, Giza
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_18_16

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  Abstract 


Objective
The aim of this case series study was to evaluate outcomes of paramedian forehead flap in reconstruction of large nasal defects.
Background
Nasal reconstruction is a challenging pursuit owing to its complex three-dimensional structure; the different components of skin, bone, cartilage, and mucosal lining; and the variations in skin thickness and color of the nose. This study describes forehead flap technique for reconstruction of large nasal defects more than 2 cm after excision of a neoplasm.
Patients and methods
From January 2012 to December 2015, 14 patients who had large nasal defects received surgical treatment in the form of either expanded paramedian forehead flap (group A, n = 5 patients) or nonexpanded paramedian forehead flap (group B, n = 9 patients). Demographic data, nasal defect characteristics, postoperative complications (infection, wound dehiscence, and flap necrosis), comparison between two groups of patients, and doctor and patient satisfaction were recorded.
Results
The overall results were satisfactory regarding function and appearance without major complications according to patient and doctor satisfaction. Wound dehiscence occurred in one (7.14%) case and healed with conservative treatment. Another patient (7.14%) was complicated with infection at the site of expander port and was treated with antibiotics.
Conclusion
The forehead flap continues to be one of the best options for closure of surgical defects of the nose larger than 3 cm. Adequate knowledge and careful application of the technique and its modifications allows excellent results to be obtained with few complications.

Keywords: forehead flap, large defect, nasal defects, nasal reconstruction


How to cite this article:
Keshk T, El-kased AF, El-Sakka DM, El-kashty SM, Dawoud HA. Outcomes of paramedian forehead flap for reconstruction of large nasal defects: Menoufia experience. Menoufia Med J 2019;32:1282-8

How to cite this URL:
Keshk T, El-kased AF, El-Sakka DM, El-kashty SM, Dawoud HA. Outcomes of paramedian forehead flap for reconstruction of large nasal defects: Menoufia experience. Menoufia Med J [serial online] 2019 [cited 2020 Jan 20];32:1282-8. Available from: http://www.mmj.eg.net/text.asp?2019/32/4/1282/274223




  Introduction Top


Nasal reconstruction is a challenging pursuit owing to its complex three-dimensional structure; the different components of skin, bone, cartilage, and mucosal lining; and the variations in skin thickness and color of the nose. It is critical to consider aesthetic subunits of the nose when planning the reconstruction, as the optimal technique will allow for scar placement at the borders of subunits and will have one type of skin in a subunit [1].

The forehead is acknowledged to be one of the best, if not the best, donor sites for reconstruction of postoperative nasal defects after ablation in patients with cancer. The versatility, color match, and texture are among the benefits of this flap [2].

The forehead flap is a myocutaneous flap with an axial blood supply derived from the supratrochlear artery. The classic median forehead flap was based on both supratrochlear vessels. Recently, the paramedian variant was described based on a single supratrochlear artery; this flap has a narrower pedicle, which allows for greater rotation and length, facilitating the closure of extensive or distal nasal defects [3].

Soft tissue repair of skin defects in the middle of the face is very important, and attention should be paid to its functional and aesthetic outcome toward successful rehabilitation of the patient. In the majority of these cases, soft tissue reconstruction using local and regional flaps is indicated after choosing an appropriate treatment plan based on location, size of the defect, the patient's age, and his or her wishes. Flaps from the nasal skin, glabella, forehead, as well as nasolabial fold provide good possibilities to cover the defect and ensure the existence of equivalent color and texture [4].

Tissue expansion is helpful in three ways. First, it can provide extra flap length, which allows better tip coverage or lining reconstruction. Second, it serves as a form of flap delay, which contributes to better flap survival. Finally, tissue expansion allows for better donor site closure with less tension, resulting in less objectionable donor site scars [5].

So the aim of the study was to evaluate outcomes of paramedian forehead flap in reconstruction of large nasal defects.


  Patients and Methods Top


This is a prospective study done on 14 patients with large nasal defects after tumor excision, presented to Menoufia University Hospitals during the period from January 2012 to December 2015. There were eight males and six females, who were classified into two groups: group A included five patients whose age ranged from 5 to 7 years and underwent nasal reconstruction with expanded paramedian forehead flap, and group B included nine patients whose age ranged from 50 to 65 years and underwent nasal reconstruction with nonexpanded paramedian forehead flap. Informed consent (for the operation and photo publication) was obtained from all patients included in the study, which was approved by the Local Ethics Committee. All patients were evaluated by full history taking, and general and local examination regarding site and size of the defect. The following preoperative investigations were done: complete blood picture, coagulation profile, and liver and kidney function tests.

Operative details

The surgical procedures were done under general anesthesia. The patient was placed supine with head up.

The paramedian forehead flap was performed in two stages. The first stage is usually performed under general anesthesia. The outline of the defect is drawn preferably on the healthy side to avoid distortion owing to scarring of the operated area. The pedicle of the flap is then outlined on the superomedial aspect of the orbit, between 1.5 and 2.5 cm from the midline.

In unilateral defects, we prefer to use a contralateral flap to avoid excessive rotation of the flap and obstruction of the patient's visual field. The length of the flap is then determined by measuring the distance between the defect and the pedicle; the arc of rotation is simulated with a suture, and the outline is then copied onto the forehead.

The initial incision of the flap was made at its uppermost point, to reach a superficial plane in the subcutaneous areolar tissue. Flap elevation from superior to inferior was done at three levels. In the upper third of the forehead, the flap was elevated in subcutaneous level, then in submuscular level, in the middle third, and in the lower third, sharp dissection was done in subperiosteal level. After dissection of the flap, it was sutured to the recipient site by direct suture [Figure 1].
Figure 1: Nonexpanded paramedian forehead flap. (a) Preoperative frontal view, showing rodent ulcer in the left ala and nasal sidewall and marking of right paramedian forehead flap; (b) postoperative frontal view after 1 year; (c) intraoperative view showing incisions of the flap and nasal defect of the left ala and sidewall and reconstruction of the lining with ispsilateral muchoperichondrial hinge flap; (d) intraoperative view showing elevation of the flap in three levels (subcutaneous in the upper third, submuscular in the middle third and subperiosteal level in the lower third); (e) intraoperative view showing direct closure of the donor site after bilateral forehead undermining and reflected forehead flap to cover the defect after cartilage and lining reconstruction.

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Closure of the donor area was achieved by direct suture in 10 cases. It was necessary to create bilateral advancement flap after excessive submuscular undermining. Split-thickness skin graft was used in two patients. Finally, at 3–4 weeks, the base of the flap is sectioned in a second operation, usually under local anesthesia.

In cases of expanded forehead flap (three cases), expander application in the forehead was done in a separate stage. The incision was oriented 3 cm behind the hairline. A recipient pocket was created by a blunt dissection between the periostem and the deep fascia of frontalis muscle. Hemostasis was achieved with an electrocautery judiciously. The pocket was irrigated with saline garamicine solution.

Tissue expander was folded on itself and inserted into the pocket through the incision. The expander was unfolded within the pocket and manipulated until the base lied flat against the frontal bone without kinking. The injection port was tunneled posteriorly beneath the scalp. The expander was partially expanded with saline. The wound was closed in layers, and dressing was done. Inflation started 2 weeks postoperatively [Figure 2].
Figure 2: Expanded paramedian forehead flap. (a) Preoperative frontal view showing expanded forehead and hemangioma of the nose; (b) postoperative frontal view after pedicle separation showing skin resurfacing with expanded forehead skin and vertical forehead scar at the donor site; (c) preoperative lateral view; (d) postoperative lateral view.

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Postoperative care and follow-up

For all operated patients, the following was done: patients were advised to avoid trauma and potential shearing forces to the flaps. The wound was carefully checked for flap viability and signs of infection. Flap monitoring was closely done in the early postoperative period through color and temperature of the flap. Antibiotic therapy was prescribed for 1 week after the operation as well as anti-inflammatory and analgesic drugs. Postoperative wound care was consisted of cleaning the suture lines with saline and povidone iodine with application of antibiotic ointment twice daily for a week. Sutures were removed after 7 days. The first visit was scheduled after 1 week to remove stitches, then at 3 weeks after suture removal to ensure no immediate postoperative complication, followed by routine 3-month interval visits to detect late complication and to evaluate the results.


  Results Top


The study was conducted on 14 patients, divided into two groups. Group A (expanded forehead flap) included five patients, comprising two males and three females, and their age ranged from 5 to 7 years, with a mean age of 5.8 years. Group B (nonexpanded forehead flap) included nine patients, with a mean age of 56.7 years [Table 1]. Two patients were diabetic and two were hypertensive in group B [Table 2].
Table 1: Clinical characteristics of the studied patients (n=14)

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Table 2: Comorbidities among the studied patients (n=14)

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According to the type of nasal skin tumor, seven patients had basal cell carcinoma, representing most cases (58.3%) in group B. Five patients had hemangioma in group A [Table 3].
Table 3: Type of tumor among the studied patients (n=14)

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Nasal ala was involved in all defects. Isolated lower third defects represented 60% in group A and 44.4% in group B [Table 4]. Size of the defect was more than 3 cm in group A patients [Table 5]. Five patients had full-thickness nasal defect in group B [Table 6].
Table 4: Site of defect among the studied patients (n=14)

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Table 5: Size of defect among the studied patients (n=14)

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Table 6: Depth of defect among the studied patients (n=14)

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In full-thickness nasal defects, ipsilateral mucoperichondrial hinge flap was used in three patients, and folded paramedian forehead flap was used in two patients [Table 7]. Cartilage reconstruction was done in cases of cartilage defect with conchal and costal graft in two patients [Table 8].
Table 7: Lining reconstruction among the studied patients (n=5)

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Table 8: Cartilage reconstruction among the studied patients (n=5)

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Forehead donor site was closed directly in group A patients whereas graft was used in two patients in group B [Table 9].
Table 9: Forehead donor site closure among the studied patients (n=14)

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Postoperative complications occurred in two patients. One (7.14%) patient in group B was complicated by forehead donor site wound dehiscence and was treated conservatively by dressing and local antibiotic ointment without surgical interference. Another patient (7.14%) in group A was complicated by infection at the site of expander port and was treated with antibiotics [Table 10].
Table 10: Complications among the studied patients (n=14)

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Patient satisfaction (parents satisfaction in group A) was evaluated on a scale from 1 to 4 (1 = poor results, 2 = fair, 3 = good, and 4 = excellent). Excellent results represented 60% in group A and 22.2% in group B [Table 11].
Table 11: Patient satisfaction among the studied sample (n=14)

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Doctor satisfaction was evaluated on a scale from 1 to 4 (1 = poor results, 2 = fair, 3 = good, and 4 = excellent). Excellent results represented 60% in group A and 28.6% in group B [Table 12].
Table 12: Doctor satisfaction among the studied patients (n=14)

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The limited number of patients, especially in group A, made statistics not highly significant.


  Discussion Top


The median forehead flap was used for decades as the technique of choice for reconstruction of large defects of the nose. However, this flap, taken from a midline position as it was first described, has certain limitations. It has a broad base, producing a significant defect in the donor area, difficult flap rotation, and insufficient length, particularly for reconstruction of the distal areas of the nose [6].

Okada and Maruyama [7] reported a forehead flap based on the wide subcutaneous pedicle, including bilateral supraorbital and supratrochlear vessels. In our experience, the pedicle of the paramedian forehead flap was much longer and narrower, including only unilateral supratrochlear vessels. Kelly et al. [8] demonstrated the existence of a rich anastomotic arcade formed by the supratrochlear artery, infraorbital artery, and branches of the facial artery; this ensures the blood supply to the flap.

Reece et al. [9] proposed including the periosteum for the 3 cm above the supraorbital ridge with the aim of including the deep branch of the supratrochlear artery in the flap. He considered that this modification would be particularly useful in patients who were smokers or diabetic, as it would increase and optimize the vascular supply to the flap. In our study, we dissected the forehead flap at three levels (subcutaneous in the upper third, submuscular in the middle third, and subperiosteal in the lower third), and we record no incidence of flap necrosis.

In our experience and that of Belmar et al. [6], the paramedian forehead flap is an excellent alternative for the reconstruction of nasal defects with diameter greater than 2 cm and situated on the lateral wall, tip, columella, or ala nasi, and achieved good cosmetic and functional results.

In our study, we performed other procedures in the same operation of skin coverage with forehead flap, such as reconstruction of the lining and osseocartilaginous support in full-thickness defects with good cosmetic and functional outcome. A hypothesis that was supported by studies performed by Belmar et al. [6].

Mehmet Altýparmak [10] reported the usage of expanded forehead flap in a child after a horse bite, and the flap provided a well-vascularized, color-matched skin with appropriate thickness and covered the tip, columella, and one-third of the alae. In our study, we used expanded forehead flap in children after hemangioma excision and provided an excellent coverage for nasal tip and alae or ala and side wall.

Kelly and colleagues demonstrated the existence of a rich anastomotic arcade formed by the supratrochlear artery, infraorbital artery, and branches of the facial artery; this ensures the blood supply to the flap. Modifications to the classic technique have been proposed on the basis of these findings, using a narrower pedicle with its base at the level of or below the medial canthus. In this way, the pedicle of the flap can be extended to enable reconstruction of more distal or larger areas without affecting viability of the flap, as in our experience, we used this technique in folded paramedian forehead flaps for columella and lining reconstruction [9].

Ebrahimi et al. [11] managed to reconstruct the nose in a single stage using forehead flap by islanding it and passing it under a skin tunnel at the medial side of the eyebrow. In this way, they avoided division of the flap in a second stage, but using this technique, the flap could only reach till above the tip of the nose. This was not suitable for our cases, which required also columella reconstruction.

Belmar et al. [6] experienced significant forehead flap necrosis in 10% of patients, partial necrosis in 10%, and postoperative bleeding in 60%. In our study, we did not record flap necrosis or bleeding. Our results showed forehead donor site wound dehiscence in one (8.3%) patient. This patient was old, diabetic, and hepatic. Another patient was complicated with infection at the expander port (8.3%).

In our study and that of Giugliano et al. [12], results showed no donor-site morbidity and no flap necrosis in pediatric nasal reconstruction with forehead flap after hemangioma excision.


  Conclusion Top


Paramedian forehead flap is a cornerstone in nasal reconstruction. Especially when reconstructing large nasal defects. It provides good matching in color and texture. Tissue expansion does add additional surgical procedure, and it causes temporary deformity of the forehead. Nevertheless, the added safety from the delay of the flap, the additional achievable flap length, and the reduced tension in the closure of the donor site more than compensate for these minor and temporary disadvantages.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Arora A, Attwood J. Common skin cancers and their precursors. Surg Clin North Am 2009; 89:703–712.  Back to cited text no. 1
    
2.
Firat Y, Kizilay A, Akarcay M, Miman MC. Second primary cancer occurrence on forehead flap after reconstruction of nasal carcinoma. J Craniofac Surg 2008; 19:1549–1551.  Back to cited text no. 2
    
3.
Brodland D. Paramedian forehead flap reconstruction for nasal defects. Dermatol Surg 2005; 31 (Pt 2):1046–1052.  Back to cited text no. 3
    
4.
Lunatschek C, Schwipper V, Scheithauer M. Soft tissue reconstruction of the nose. Facial Plast Surg 2011; 27:249–257.  Back to cited text no. 4
    
5.
Kheradmand AA, Garajei A, Motamedi MH. Nasal reconstruction: experience using tissue expansion and forehead flap. J Oral Maxillofac Surg 69:1478–1484, 2011.  Back to cited text no. 5
    
6.
Belmar P, de Eusebio E, Sánchez C, Vergara A, Martín A, Juanes A, et al. Paramedian Forehead flap for the reconstruction of extensive nasal defects. Actas Dermosifiliogr 2011; 102:187–192.  Back to cited text no. 6
    
7.
Okada E, Maruyama Y. A simple method for forehead unit reconstruction. Plast Reconstr Surg 2000; 106:111–114.  Back to cited text no. 7
    
8.
Kelly C, Yavuzer R, Keskin M, Bradford M, Govila L, Jackson I. Functional anastomotic relationship between the supratrochlear and facial arteries: an anatomical study. 2008; Plast Reconstr Surg 121:458–465.  Back to cited text no. 8
    
9.
Reece EM, Schaverien M, Rohrich RJ. The paramedian forehead flap: a dynamic anatomical vascular study verifying safety and clinical implications. Plast Reconstr Surg 2008; 121:1956–1963.  Back to cited text no. 9
    
10.
Altýparmak M. Reconstruction of a nasal injury caused by a horse bite: case report. Erciyes Med J 2011; 33:335–340.  Back to cited text no. 10
    
11.
Ebrahimi M, Kalantar Motamedi MH, Nejadsarvari N, Shams Koushki E. Subcutaneous Forehead Island flap for nasal reconstruction. Iran Red Crescent Med J 2012; 14:271–275.  Back to cited text no. 11
    
12.
Giugliano C, Andrades PR. Benitez Nasal reconstruction with a forehead flap in children younger than 10 years of age. Plast Reconstr Surg 2004;114:316-25; discussion 326-8.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12]



 

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