Forehead Flap

CME Nasal Reconstruction: Forehead Flap Frederick J. Menick, M.D. Tucson, Ariz. Learning Objectives: After studying this article, the participant should be able to: 1. Understand the history of nasal reconstruction and its implications to modern nasal repair. 2. Understand current developments in the use of intranasal lining flaps and primary cartilage grafts. 3. Understand the use of the two-stage and, specifically, the three-stage paramedian forehead flap with an intermediate operation. 4. Understand methods that allow the use of skin grafts and a modified folded forehead flap for lining. 5. Understand the use of regional unit reconstruction as it applies to repair of nasal defects. Nasal reconstruction remains the historic centerpiece forehead deformity and scarring, or believe of plastic surgery, and the forehead flap, the workhorse of that they cannot use the forehead because it is repair. All anatomic layers—cover, lining, and support— must be replaced to reestablish the aesthetic quality of the of inadequate size. 2 nose and a patent airway. This article addresses the ob- The origins of forehead rhinoplasty (the jectives and principles of aesthetic nasal reconstruction, Indian method) are obscure, but it has been emphasizing the use of the two- and three-stage forehead performed in India since 1440 A.D. and proba- flap, intranasal flaps, skin grafts and the folded flap for bly long before the birth of Christ.3 Sicily was lining, and primary and delayed primary cartilage grafts for support. (Plast. Reconstr. Surg. 113: 100e, 2004.) the center of Arabian, Greek, and Occidental learning at the time, which probably made “The tint of forehead skin so exactly matches knowledge of Arabic translations of the Indian that of the face and nose that it must be first operations accessible to the Branca family in choice. Is not the forehead the crowning Italy during the fifteenth century. The first feature of the face and important in expres- written account in English of the Indian mid- sion? Why then should we jeopardize its line forehead rhinoplasty appeared in the Ma- beauty to make a nose? First, because in dras Gazette in 1793. One year later, it was pub- many instances, the forehead makes far and lished in the Gentleman’s Magazine of London. away the best nose. Second, with some plastic Carpue, an English surgeon, published his ac- juggling, the forehead defect can be camou- count of two successful operations in 1816.4 flaged effectively.” The classic median forehead flap, which took a —Sir Harold Gillies and D. Ralph Millard1 vertical flap from the midline of the forehead, was popularized in the United States by Ka- AHISTORY OF NASAL RECONSTRUCTION zanjian5 in 1946. It received its blood supply The origins of plastic surgery are rooted in from paired supratrochlear vessels. The base of the relief of facial deformity. Even though car- the flap twisted 180 degrees, with an arc of tilage, bone, and mucous membrane are often rotation at or above the eyebrows. The fore- missing in larger defects, when the nose has head donor sites in the early operations were been injured the most obvious deficiency is allowed to heal by secondary intention. skin. The forehead has been acknowledged as Between 1940 and World War I, it became the best match for nasal skin because of its apparent that the results of repair using un- superb color and texture. Well vascularized lined flaps were poor.6 The external shape of and lying adjacent to the nose, it is the ideal the nose and its airways became distorted by donor material. However, many surgeons will contracting scar on the underlying raw surface not use a forehead flap because of a fear of of the covering flap. Residual intranasal mu- Received for publication December 10, 2002. DOI: 10.1097/01.PRS.0000117382.57120.23 100e Vol. 113, No. 6 / NASAL RECONSTRUCTION: FOREHEAD FLAP 101e cous membranes seemed inadequate. Around ways.5 In 1873, Volkmann turned down por- 1842, Petralli folded the distal end of the flap tions of residual nasal skin adjacent to the de- onto itself, so that it created its own inside and fect, hinged down on scar to provide lining. outside and, in a manner of speaking, formed Thiersch transferred flaps from other facial the tip, ala, and columella while eliminating areas in 1879. More recently, Millard8,9 advo- raw surfaces in the lower part of the recon- cated rolling over bilateral nasolabial flaps to structed nose.2 However, normal hairline posi- line both the ala and the columella. tion limited the length of a vertical median In 1898, Lossen first described skin grafts for forehead flap, unless hair was transferred. Mid- lining. Most often, grafts of split- or full- line forehead tissues seemed unable to provide thickness skin were placed under the covering enough tissue to create a long columella that flap during a preliminary operation. Weeks could, at the same time, maintain projection, later, once the viability of the grafts was as- allow infolding of the covering flap for lining, sured, these prelaminated flaps were trans- and avoid unnecessary tension that might di- ferred to the nose. Although described much minish flap vascularity. To obtain a longer flap, earlier by Konig, in 1943 Gillies10 popularized Auvert, in 1850, slanted it across the forehead the placement of composite chondrocutane- 5,6 at an oblique angle of 45 degrees. German ous grafts to supply both lining and support. In surgeons of the same period positioned fore- 1956, Converse11 suggested a septomucoperi- head flaps horizontally; the flaps were supplied chondrial graft as an alternative. by the supraorbital vessels on one side. In 1935, 7 During the same period, it became obvious Gillies described an up-and-down flap that was that without a skeletal framework, the soft centered over one supraorbital pedicle, passed tissue of cover and lining would collapse in into the hear-bearing scalp, and then de- major reconstructions, impairing the airway scended into the forehead. In 1942, Converse and limiting projection. A rigid skeleton was modified the up-and-down flap by creating a needed to provide support, projection, and long pedicle that was camouflaged within the contour. However, folded flaps were thick hear-bearing skin and that included the major and often ischemic, and precluded the accu- vascular supply of the scalp.2,5 All these flaps rate placement of primary columellar, alar, were designed solely to provide additional and tip support. When residual nasal skin or length, and each created a forehead defect that was harder to close. Surgeons were caught adjacent cheek skin was turned over to line in a difficult predicament. On the one hand, the nose, the tissues were thicker than nor- they worried about forehead scarring. On the mal intranasal lining and distorted the exter- other hand, they bemoaned insufficient tissue nal nasal shape and clogged the airway. Only to make a nose. To add insult to injury, they after the soft tissue had healed could large often used forehead tissue not only for nasal bone and cartilage pieces be placed as canti- reconstruction but also for adjacent defects. lever grafts to lift the dorsum and tip. Be- Neighboring cheeks, lips, and nose losses in cause of their bulk and risk of extrusion, they the midface were filled with one even larger were not used primarily but were added flap, creating a single plump lump that re- much later in final touch-up operations. Un- placed the subtle three-dimensional contours fortunately, once gravity and the contractual of these multiple contiguous facial units. The effects of the healing process had distorted forehead was scarred beyond repair. Despite its nasal contour, it could rarely be regained. limitations, the folding of covering skin for Covering skin became contracted and stiff. lining, and specifically the Converse scalping Multiple revisions were required to sculpt flap, came to be the most commonly used subcutaneous tissue into the semblance of a method of nasal reconstruction during most of nasal shape. When lining and cartilage sup- the twentieth century. The median forehead port were supplied as a composite graft un- flap was recommended only to replace small der a prelaminated forehead flap, one or nasal losses, unless the patient was bald or had more preliminary stages were required be- an unusually high hairline that might allow a fore the nose could be put together. Their longer vertical flap. shape was fixed both by their natural config- Rather than folding the forehead flap, oth- uration and by the scar that surrounded ers sought to eliminate the raw area on the them as they sat in the forehead awaiting deep surface of the covering flap in other transfer to the nose. 102e PLASTIC AND RECONSTRUCTIVE SURGERY, May 2004 MORE RECENT ADVANCES wings extend horizontally and lie in the natural The classic Indian forehead flap carried mid- transverse wrinkle lines of the forehead. The line tissue on paired supraorbital and su- vertical component resurfaces the dorsum, tip, pratrochlear vessels. Its base lay at or above the and columella, and the lateral extensions are eyebrows. When so designed, its length was wrapped around the ala and carried into the quickly limited by the hairline; it is reached by nostril flare as alar bases. The flap takes excess the pedicle’s high arc of rotation. A 180-degree forehead tissue in both horizontal and vertical twist could lead to kinking at the nasal root and dimensions. This facilitates primary closure of could impair blood supply. Early on, changes the forehead wound as an inconspicuous mid- in flap design were made to overcome these line T-shaped scar. It became apparent that limitations.5 If the height of the forehead could simple undermining of adjacent wound mar- gins was satisfactory for near-complete primary not be changed, the flap could be effectively closure.

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