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The Single-Stage Forehead Flap in Nasal Reconstruction
An Alternative With Advantages
Stephen S. Park, MD
Arch Facial Plast Surg. 2002;4:32-36.
ABSTRACT
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Objective To review the single-stage forehead flap for patient selection, technique,
and main outcome measures.
Methods Patients undergoing nasal reconstruction between January 1, 1995, and
June 30, 2000, were reviewed from medical records, photographs, and personal
communication. All work was performed in an academic medical center.
Results Fifty-one patients had a forehead flap for nasal reconstruction, of
which 10 (20%) were repaired in a single stage. All patients had no evidence
of small vessel disease, eg, hypertension, diabetes mellitus, or tobacco use.
Nasal defects were limited to the upper two thirds of the nose. The technique
is modified from the original description by creating a unilateral, subcutaneous
pedicle, wide undermining, and partial resection of the procerus muscle. One
patient had superficial epidermolysis at the distal tip of the flap. The remaining
9 patients maintained complete viability with satisfactory outcomes. One debulking
procedure was performed to the glabellar area for aesthetic reasons. The average
interval for returning to work was 6.6 days compared with the minimal 3 weeks
for conventional interpolated flaps.
Conclusion In select cases, a single-stage, island midline forehead flap can be
used safely as an advantageous alternative to the conventional interpolated
forehead flap.
INTRODUCTION
THE FOREHEAD has served as a source of tissue for nasal reconstruction
for centuries and many different flaps have been designed with distinct advantages
and disadvantages.1-5
The classic Indian forehead flap became popular in the United States when
Blair6 in 1925 and Kazanjian7
in 1946 described the median forehead flap for nasal repair. This flap was
based on a wide pedicle, capturing both supratrochlear vessels and, occasionally,
the supraorbital artery. Unfortunately, this pedicle design could not extend
below the eyebrows, thus limiting the arc of rotation and flap reach. Furthermore,
the wide pedicle created greater torsion on vessels, thus jeopardizing flap
viability with venous congestion. It was later shown that the forehead flap
could be based on a solitary supratrochlear vessel and that this paramedian
design afforded greater flap length and significantly enhanced the versatility
of the forehead flap.5, 8 The midline
forehead flap combined features of both flaps with a narrow, unilateral pedicle
but with the skin paddle centered in the forehead.9
The midline forehead flap can leave a less conspicuous donor site scar running
obliquely within the glabellar furrows and vertically in the precise center
of the forehead. All 3 forehead flap designs are of interpolated flaps, necessitating
an interval with an external pedicle and a second-stage procedure for pedicle
division.
A single-stage, island flap from the forehead was first described by
Converse and Wood-Smith10 in 1963, during an
era when the traditional, interpolated forehead flap was of a median design.
His hope was that this modification would enhance the inferior reach for distal
nasal defects. This island flap also used a wide pedicle that could not extend
below the brows, creating similar problems with flap congestion, inadequate
reach, and marked fullness along the glabella and nasion, all of which led
him later to abandon this design.
Based on our current understanding of the robust nature of the midline
forehead flap and the perfusion pressure of the medial brow area, a single-stage,
island, midline forehead flap has been designed.
MATERIALS AND METHODS
DESIGN
A retrospective review was performed from January 1, 1995, to June 30,
2000, of all patients with nasal defects repaired with a forehead flap. Data
were collected from medical records as well as preoperative, intraoperative,
and postoperative photographs. For those patients who were repaired with a
single-stage forehead flap, the following data were collected: age, sex, subunits
involved, defect dimension, defect depth, risk factors (ie, tobacco use, diabetes
mellitus, hypertension, or a history of radiotherapy), follow up, interval
for returning to work, and surgical outcome. The surgical outcome was described
in terms of percent of viability, percent of flap congestion, areas of epidermolysis,
and need for revision or debulking.
SURGICAL TECHNIQUE
All internal lining deficits as well as the need for structural grafting
are addressed prior to the resurfacing portion of the procedure. In every
case, the internal lining is repaired as needed and liberal cartilaginous
grafting is used for framework support. Patient selection for the single-stage
flap includes only those without risk of small vessel disease. Specifically,
those persons with a history of tobacco use, diabetes mellitus, hypertension,
previous radiotherapy to the face, peripheral vascular disease, and collagen
vascular disease, are excluded for consideration of this single-stage repair.
The primary cutaneous defect is modified in each case to conform to the principle
of aesthetic subunits (Figure 1).
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Figure 1. Dorsal nasal defect with planned
modification of defect shape.
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When a suspicious cutaneous lesion or scar exists in the midline forehead
area, template position can be adjusted laterally to avoid this. In each case
a template is made of the cutaneous defect and transferred to the midline
of the forehead (Figure 2). The
vertical position of the template is determined by careful measurement from
the medial brow area. This vertical position can also be adjusted based on
the hairline; a low hairline may require a lower pedicle with clear extension
below the level of the eyebrows to maintain adequate reach. The subcutaneous
pedicle is carefully outlined although a Doppler ultrasound is not typically
used for identification of the supratrochlear artery. The skin paddle is elevated
in the subdermal plane rather than the subgaleal layer. This dissection must
be done meticulously to avoid inadvertent devascularization of the skin paddle.
Following this elevation, however, we frequently perform additional selective
flap thinning to match the native skin of the nose. As the dissection reaches
the pedicle, the plane drops to the subgaleal layer and continues toward the
medial brow region. A W-plasty is often incorporated along the inferior border
of the cutaneous closure to avoid the standing cutaneous deformities. This
resultant scar often lies along preexisting glabellar furrows. The skin is
then carefully excised and dissected off the pedicle. Once the superficial
and deep layers of the subcutaneous pedicle have been defined, the vertical
incisions are made through the subcutaneous tissue ensuring a 1- to 1.3-mm
pedicle centered on the medial brow region (Figure 3).
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Figure 2. Template placed in the precise
midline of the forehead with the contralateral, subcutaneous pedicle outlined.
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Figure 3. Island forehead flap elevated,
based on subcutaneous pedicle from the medial brow region. The glabellar skin
has been elevated and tunnel created with the nasal defect.
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If the skin paddle does not appear as robust as anticipated, one can
avoid the deepithelializing portion of the pedicle dissection and convert
this to a conventional interpolated flap. Once the island forehead flap is
created, the glabellar skin is elevated to create the tunnel with the nasal
defect. The procerus muscle is partially resected to create adequate space
for the subcutaneous pedicle. This muscle can also be mobilized as a flap
and transposed into the donor site of the forehead flap pedicle, thus improving
forehead contour. Without this, one often finds a subtle depression in the
glabellar region. The skin paddle is sewn to the nasal skin in the usual fashion
with particularly superficial bites along the superior border of the skin
paddle as this area also represents the flap pedicle (Figure 4A-B). While a head wrap is applied to the forehead, great
care is observed to minimize pressure on the subcutaneous pedicle as flap
congestion is probably the greatest risk of this procedure. Most donor sites
can be closed primarily with wide undermining.
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Figure 4. A, Island flap is transposed under
intact glabellar skin. B, Nine-month postoperative view of the same island
flap.
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RESULTS
From January 1, 1995, through June 30, 2000, there were 51 patients
with nasal defects repaired with a forehead flap. Of these, 10 patients (20%)
underwent the single-stage modification. Patient demographics are outlined
in Table 1. Mohs micrographic
surgery for either a basal cell carcinoma or squamous cell carcinoma was the
cause of all nasal defects. No patients had a history of small vessel disease
in the form of peripheral vascular disease, coronary disease, hypertension,
diabetes mellitus, or a history of facial radiotherapy. The patients' mean
age was 57 years (age range, 46-65 years) and sex distribution was equal.
The mean dimension of the defect was 18 mm (range, 12-22 mm). Two patients
had cartilaginous deficits although the intranasal lining was preserved. Defects
were limited to the upper two thirds of the nose in most patients. One patient
had 20% involvement of the cephalic border of the nasal tip subunit and this
area was modified without completing the excision. Mean follow-up was 28 months
(range, 6 months to 5 years).
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Characteristics of 10 Patients Who Underwent Single-Stage Forehead
Flap
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All patients accomplished successful nasal resurfacing although 1 patient
suffered epidermolysis along the distal 2-mm border of the skin paddle. This
area was treated conservatively and reepithelialized uneventfully. No flaps
suffered full-thickness necrosis or congestion that required intervention.
One patient requested a revision to the nasal root region due to persistent
fullness that was bothersome to this patient. The average number of days taken
off work postoperatively was 6.6 (range, 3-14 days). Two patients were unemployed
and they were excluded from this statistic.
COMMENT
The interpolated forehead flap remains the standard method for resurfacing
larger nasal defects and was used with most patients in this series. Recent
modifications of this flap have contributed to a more versatile and aesthetic
method of repair, yet each continues to push the envelope for viability. One
recurring feature is the robust nature of this flap, eg, unilateral supratrochlear
artery, narrow pedicle, aggressive thinning, and now, conversion to an island
flap. One reason for the dependable nature of the forehead flap, one that
may have been less appreciated years ago, is the significance of perfusion
pressure at its pedicle base, ie, along the medial brow region. The understanding
of flap physiology has evolved and the length-width ratio, once thought to
be dictum for ensuring viability, has been shown to be fallacy.11
Perfusion pressure is the dominant variable when designing cutaneous flaps
and this may explain the unusual versatility of the contemporary forehead
flap. By capturing the supratrochlear artery along with the rich collaterals
from the terminal angular artery, the forehead flap is uniquely designed to
withstand a lengthy and narrow pedicle. This occurs despite the fact that
the supratrochlear vascular trunk is rarely incorporated for more than a few
centimeters within the flap. Inflow from the facial artery, via the angular
vessel, is a significant contributor to the perfusion pressure and allows
the pedicle to extend well below the brow. This has been demonstrated by selective
perfusion of the facial artery with a silicone rubber case (Microphil; Flow
Tech, Carver, Mass) following elevation of a midline forehead flap.9 Dissection of the vascular arcade along the pedicle
base demonstrates an extensive collateral network from the angular artery,
this occurring without the supratrochlear artery being cannulated. Some surgeons
have reported harvesting 3 separate flaps from a given patient, the third
presumably based on collateral flow from the angular artery alone (Ted A.
Cook, MD, oral communication, September 23, 2000). The axial orientation of
small subdermal vessels also contributes toward the robust nature of this
flap, occurring in both the conventional interpolated and single-stage designs.
Deepithelializing the pedicle and transferring it as a single-stage,
island forehead flap has been described by others,12
including the repair of full-thickness nasal defects. This modification is
the extreme toward pushing the limits of flap viability and has been performed
in low-risk patients only. Those with small vessel disease or with inferior
subunit involvement, eg, columella or distal nasal tip, have been avoided.
Earlier problems with the island flap related to the width of the subcutaneous
pedicle and the necessary arc of rotation with subsequent venous congestion
of the skin paddle. By creating a unilateral, narrow pedicle less than 1.5
cm wide, and basing it off the medial brow region, one can transfer the flap
with less rotation at the pedicle base. This seems to minimize the venous
congestion seen with earlier attempts. Using the patient selection criteria
described, it appears that the single-stage forehead flap designed similar
to the current interpolated flap can be performed successfully and dependably.
The other criticism of the original single-stage flap related to the
disfiguring bulk at the nasal root. A narrow pedicle, wide undermining, and
resection of the procerus muscle, all help to minimize this contour problem.
Furthermore, natural regression occurs over several months and can be accelerated
with incremental injections of triamcinolone acetonide. Surgical debulking
is easily accomplished when necessary, although only 1 patient (10%) requested
it.
The most significant advantage of this flap is the ability to bury the
pedicle and obviate the second stage. While it is not a major procedure, some
persons suffer significantly during the interim period with the interpolated
pedicle and the obligatory second procedure. The necessity of transportation,
time off work, and wound care, all play into their anxiety and inconveniences.
On occasion, it has been this consideration alone that has persuaded some
to select a local transposition flap or skin graft for a large nasal defect
and accept the compromised aesthetic and functional outcomes. A buried subcutaneous
pedicle has several advantages over the conventional interpolated flap: (1)
The pedicle undersurface is often a source of bleeding and drainage that continues
for a couple days postoperatively. Those who are in a public workplace or
dusty environment are obligated to stay off work until pedicle division has
been completed. Placing a small skin graft to the pedicle undersurface can
reduce this problem, and may be worthwhile when the source of skin is normally
discarded, eg, standing cutaneous deformities from donor site closure. (2)
Those who are dependent on eyeglasses for daily activities are significantly
impaired by the pedicle; the inability to use eyeglasses can been the sole
reason for employment disability. A single-stage flap allows the use of eyeglasses
but pressure on the skin paddle must still be avoided by taping the bridge
of the eyeglasses to the forehead. (3) Finally, the pedicle creates sufficient
aesthetic peculiarity that most people remain out of the public eye for the
interval 3-week period. The buried pedicle allows the patient to return sooner
to the public eye although periorbital ecchymosis often remains.
The average duration of time off work for this group was 6.6 days, excluding
the 2 patients who were unemployed. Although those patients repaired with
an interpolated forehead flap were not formally reviewed, it is exceedingly
unusual for a patient to work in the public eye with such an external deformity.
Moreover, the disability of not using eyeglasses can be underappreciated in
the elderly population, especially when many do not use contact lenses. Finally,
it is recognized that those patients repaired with a single-stage flap and
in dire need of uninterrupted work may have continued to do so even with an
interpolated forehead flap.
There are disadvantages of the single-stage forehead flap. First, the
procedure is technically more challenging and adds surgical time to an already
lengthy procedure. Elevating skin off the pedicle and creating the subcutaneous
tunnel under intact glabellar skin is tedious; inadvertently dissecting in
the wrong plane runs the risk of amputating the flap. Transposing the procerus
muscle as a small muscular flap to fill the donor site defect is also an additional
step not needed with the conventional, interpolated method.
Second, the island design is logically more tenuous than traditional
methods; pedicle rotation and compression from overlying skin can compromise
viability. One patient suffered a superficial epidermolysis along the distal
border of the skin paddle, which resulted in a slightly wider scar than expected.
No further intervention or revision was selected. In general, arterial inflow
is probably adequate from the strong perfusion pressure. Venous congestion,
however, is more ominous and every effort is observed to monitor for this.
Although we have not seen significant congestion in this patient group, it
has occurred with interpolated flaps and prompt intervention is prudent. Multiple
options exist including release of suture lines, serial pin pricks, medicinal
leeches, or hyperbaric oxygen. In addition, the skin paddle of the flap is
elevated in a similar manner for both the single-stage and interpolated flaps,
preserving the option of converting to an interpolated design intraoperatively.
If the flap margins do not bleed briskly or unexpected scar is encountered,
the pedicle can be elevated in a standard fashion with preservation of overlying
skin. This did not occur in this series but all patients provided informed
consent for both methods of repair.
Finally, even a narrow subcutaneous pedicle can leave an unnatural fullness
to the glabellar region, which may be distracting as a blunted nasofrontal
angle. As previously discussed, the tissue tends to regress and gradual improvement
in profile contour can be expected. The pedicle occasionally carries intact
neural sensation where light touch to the nose is interpreted as from the
forehead. This is resolved with the surgical debulking.
The retrospective design and subjective evaluations are intrinsic limitations
that are recognized. An objective study of such a technique would require
a blinded, randomized, and prospective analysis comparing results with a control
group, ie, two staged interpolated flap. There are practical difficulties
with such a design. This series does demonstrate, however, that with the patient
criteria used, the single-stage flap is an alternative to the conventional
interpolated flap. It is our practice to limit this method of repair only
for those candidates without evidence of small vessel disease and in whom
an interval with an external pedicle poses significant hardship that cannot
be easily overcome.
CONCLUSIONS
The single-stage midline forehead flap is an addition to the multiple
refinements of the forehead flap that have occurred over the last several
decades. The contemporary flap can be aggressively thinned, harvested from
the midline of the forehead, and based on a narrow pedicle that extends well
below the level of the brow. Deepithelializing the pedicle with conversion
to an island flap further pushes the envelope of a robust and versatile flap.
This single-stage flap is an alternative method of nasal reconstruction with
some advantages. The review suggests that, with careful patient selection,
the forehead flap pedicle can be deepithelialized and tunneled under glabellar
skin, preserving a viable flap and completing the nasal resurfacing in a single-stage
procedure.
AUTHOR INFORMATION
Accepted for publication August 22, 2000.
This study was presented in part at the fall meeting of the American
Academy of Facial Plastic and Reconstructive Surgery, Washington, DC, September
22, 2000.
Corresponding author: Stephen S. Park, MD, Department of Otolaryngology–Head
and Neck Surgery, University of Virginia Medical Center, PO Box 800713, Charlottesville,
VA 22908-0713 (e-mail: ssp8a{at}virginia.edu).
From the Department of Otolaryngology–Head and Neck Surgery,
University of Virginia Medical Center, Charlottesville.
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12. Steenfos H, Fogdestam I. Prepared neurovascular forehead island flap for reconstruction of minor
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THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
Update on Major Reconstruction of the Head and Neck
Wax et al.
Arch Facial Plast Surg 2007;9:392-399.
ABSTRACT
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