ARTÍCULO CLÍNICO

Forehead flap. A simple method for the reconstruction of extensive nasal skin defects

Colgajo frontal. Método sencillo en la reconstrucción de defectos cutáneos nasales extensos

R. González-García, L. Navas-Gías, F.J. Rodríguez-Campo, J. Sastre-Pérez

Correspondence

ABSTRACT

The use of the forehead flap in the surgery of nasal defects is noteworthy because almost all of the nasal subunits, including the nasal vestibule, alar margin, and columella nasi can be reconstructed satisfactorily. The cutting technique is simple and there are few donor zone complications. The color of the skin, its texture, and the feasibility of obtaining a large amount of tissue, with or without previous tissue expansion, make forehead flaps the technique of choice in the reconstruction of extensive nasal skin defects. We report our recent experience with this flap and we review the current state-of-the-art in the use of this flap.

Key words: Forehead flap, nasal defect.

RESUMEN

Las aplicaciones del colgajo frontal en la cirugía de los defectos nasales son destacables, pues la práctica totalidad de las sub-unidades nasales, incluidos el vestíbulo nasal, el reborde alar y la columela pueden ser reconstruidos satisfactoriamente. Su técnica de tallado es sencilla y las complicaciones de la zona donante escasas. El color de la piel, su textura y la posibilidad de obtener una amplia cantidad de tejido, con o sin expansión tisular previa, lo hacen de primera elección en la reconstrucción de defectos cutáneos nasales extensos. Referimos muestra experiencia reciente en el uso de este colgajo y revisamos el estado del arte actual en el empleo del mismo.

Palabras clave: Colgajo frontal, defecto nasal.

Introduction

Reconstruction of the skin of the nose after oncologic resection with major soft tissue involvement is an important challenge for the maxillofacial surgeon, otorhinolaryngologist, and plastic surgeon. The nose, with its combination of convex and concave subunits separated by crests and valleys in symmetrical balance is an extremely problematic area.¹

Historically, the forehead flap was used by Susruta Samhita in 700 b.c. For that reason, it is now known as the Indian flap. Kazanjian² and Converse³ popularized this widebased flap. Successive improvements have been made in the forehead flap, such as the addition of lateral extensions,⁴ primary closure of the donor zone,² or in the design of the incisions under the orbital rim.⁵

It is fundamental to begin by assessing the size of the defect and its exact location. Ideally, proper function and aesthetics should be sought. In extensive nasal skin defects of more than 50%, the use of the flap described here is recommended, due to its similar texture and color and the large skin surface available. We report a sample of patients with extensive nasal skin defects secondary to oncologic resection who underwent reconstructive surgery using a forehead flap.

Material and methods

A sample of 6 patients (Figs. 1 to 4) diagnosed of neoplasm in the nasal region was collected in which tumor resection and reconstruction were made by means of a forehead flap The 6 patients, 5 men and 1 woman, had ages ranging from 71 to 87 years, mean 77.16 years. The diagnoses were squamous-cell carcinoma of the nasal skin in 2 cases, basal cell carcinoma in 3 cases, and melanoma of the nasal mucosa with skin infiltration in the last case. The follow-up period of the series ranges from 6 months to 8 years, with a mean of 4.91 years. All the patients are alive without signs of local or regional recurrence at time of writing. Two of the patients underwent cutaneous expansion of the forehead region prior to harvesting the flap In addition to expansion, a modification of the classic wide-based medial forehead flap design was used, taking advantage of the large skin surface of the forehead.

The forehead flap, as described originally, is based on both supratrochlear arteries and a collateral of the facial artery. Sometimes the supraorbital artery is included to enhance flap viability. The pedicle can be narrowed and extended below the orbital rim to facilitate flap transfer to the nasal tip. Doppler ultrasonography can be used to locate the supratrochlear artery accurately, generally at the point of exit at the level of the upper inner orbital rim. The forehead skin flap is lifted with the frontal muscle in a plane superficial to the periosteum. Once flap lifting comes to within 1 or 2 cm of the orbital rim, blunt dissection proceeds carefully until the supratrochlear artery is identified. When the flap has been completely lifted, it is rotated 180º on its base and the nasal defect is covered with the distal part of the flap. The distal three-fourths of the flap can be thinned by resecting the frontal muscle and subcutaneous adipose tissue.

Discussion

The subunits of the nose are defined by direct observation of the nasal contour, texture, and color. This concept was proposed originally by Burget and Menick in 1985 6 and results in 9 divisions: 5 convex (tip, dorsum, columella nasi, and two alar cartilages) and 4 concave (2 triangles of soft tissue and 2 nasal lateral walls). Positioning the incisions at the limits of these sub-units helps to camouflage the scars and scar contraction increases the projection of the reconstructed subunit. Adherence to this principle has gained acceptance, but it can be avoided in patients with Fitzpatrick phototypes I and II, sebaceous skin, very smooth-textured skin, and in patients with intense actinic damage. In these cases, the incisions can be positioned inside the nasal subunits because the scars will be well camouflaged.

As in other types of pediculated flaps, one of the disadvantages of the forehead flap is the need for a second surgical intervention. In our experience, it usually suffices separate the pedicle at 3 weeks, although we have observed a case of partial defect in the revascularization from the receptor zones. In such situations it is preferable to wait another three weeks before definitively sectioning the pedicle. This opinion coincides with the excellent results found in a patient of the Yoon group,¹ in which the pedicle was resected 8 months after reconstructive surgery, due to the concurrence of other medical factors. Naturally, for aesthetic and social reasons, the delay is usually not as long.

In relation to flap width, we achieved direct primary closure without tension using widths of up to 4 cm. However, we must remember that part of the pedicle will be replaced in the glabellar and forehead region to establish a normal distance between eyelids and to better close the donor zone. Direct primary closure of the entire length of the donor zone is not necessary. In this sense, to enable better approximation of the skin edges in the donor zone and to make primary closure possible, we suggest that vertical incisions be made at the level of the aponeurotic galea. Sometimes it is necessary to lift the tissue extensively toward the two temporal regions. The use of previous skin expansion will avoid the need for creating extensive defects in the donor zone. However, given the impossibility of primary closure, closure of part of the donor zone in a second intervention usually does not produce aberrant scars. In any case, one of the main disadvantages of the paramedial forehead flap is the vertical scar. The surgeon must make a concerted effort to close the wound without tension. The medial forehead flap, however, leaves a vertical scar in the center and produces a better aesthetic result, according to the postulates of cosmetic surgery. Patients with a low hairline may benefit from some modifications, such as an oblique forehead flap design, tissue expansion, or extension of the flap into the scalp followed by thinning and elimination of the hair follicles or laser depilation.⁷ Furuta et al.⁸ have reported the alternative of complete nasal reconstruction with previously expanded dual forehead flaps.

The greater thickness of the forehead skin has been cited as a disadvantage for properly reproducing the contours of the nasal cartilaginous skeleton. Supramuscular flap elevation has been proposed as a way of palliating this situation prior to intermediate-term transposition and thinning in situ before definitively sectioning the pedicle.⁸ All of these options are equally valid. However, in our opinion it seems reasonable to postpone sectioning the pedicle for a third surgical intervention 3 months after surgery. In any case, the processes of thinning in situ or in the intermediate term should be done with extreme care due to the possibility of associated vascular damage. Traditionally, a pediculated forehead flap of the supratrochlear artery on the opposite side of the nasal defect to be reconstructed has been used. By more exactly locating the artery by Doppler ultrasonography, the pedicle can be narrowed, thus diminishing the risks of arterial injury. This facilitates the rotation of the pedicle without increasing the risk of torsion and, consequently, same side nasal defects can be repaired with relative ease. In cases in which large defects exist, much of the skin surface of the forehead can be used. With this design, the width of the flap can be more than the 4 cm indicated above. In these cases, the rotation can be more difficult and, on occasions, a small section has to be made at level of the medial pedicle. This maneuver allows enough rotation to bring the flap to the tip of the nose, while vascularization is ensured by the supraorbital artery. We did not observe problems of vascularization in the two patients in which this modification was used.

The reconstructive possibilities of this flap are important because practically all the nasal subunits can be reconstructed, including the nasal vestibule, the alar edge, and the columella nasi. It has been recommended for alar defects of more than 1.5 cm, for defects of more than 2.5 cm that affect any nasal subunit, or for defects that involve several nasal sub-units.¹ Converse and Word-Smith⁹ reported an island forehead flap by means of which they performed nasal reconstruction in a single surgical time. The technique consists of skeletonization of the supratrochlear artery on the side opposite the nasal defect and tunneling the base of the flap below the nasal skin. It was used for defects of the lateral wall and dorsal nose, but not for defects of the alae or nasal tip. The main drawback to this variant is a greater probability of venous congestion due to pedicle compression in the glabellar region. Other authors, however, have not observed these problems.¹⁰

We consider reconstruction ad integrum of the nasal defects produced by oncologic resection to be mandatory. With regard to this point, we find cases in which the skin covering is sufficient for a satisfactory nasal reconstruction because the underlying nasal bone and cartilage structure can be conserved. Other cases, however, will require the use of bone grafts, cartilage, and restoration of the mucosal layer, in addition to the skin covering. We propose the use of a bone graft of the external table of the skull attached by means of miniplates to the glabellar region of the frontal bone, covered over by means of a segment of galea flap with the lower pedicle folded over the bone segment at the level of the new dorsal nose. Two of the cases presented here were reconstructed in this way.

The region of the nostrils is always complex in structure and difficult to imitate in the absence of alar cartilages. Although the aesthetic result was merely discrete, folding the skin flap over itself at the distal end allows an acceptable solution to be reached. Despite the possibility of conserving part of the patient’s nasal structure intact, sometimes complete resection is a better option, particularly when an important abnormality of the nasal subunits is generated with the first option. We can expect to achieve more symmetrical reconstructions when the nasal defect is total because the preservation of the contralateral nasal alar cartilage on the side opposite to the defect can be difficult to remedy with the skin flap.

On the other hand, we can place tissue expanders in the subcutaneous tissue of the forehead region in large defects or in patients who have been intervened more than once, in whom another type of reconstruction may not be possible due to excessive tension on the tissues. In a second surgical intervention, the expander is removed and the forehead flap is cut out of the expanded tissue. The use of skin expanders as a surgical option in the reconstruction of craniofacial defects has been evaluated by our group previously. ¹¹ The morbidity of the donor zone is minimal, and linear, tension-free scars with no tendency to dehiscence are created. We did not observe exposure of the expansion device, necrosis of the expanded skin, or suture dehiscence in either of the two cases in which we performed tissue expansion before harvesting the forehead flap.

Conclusions

In summary, we consider that the forehead flap with its diverse variants (medial, paramedial, lateral extensions, and tissue expansion) is a first-line reconstruction option in the treatment of extensive nasal skin defects. The use of bone graft techniques, cartilage, and an internal lining in the form of a nasal neo-mucosa is always desirable in total nasal defects with involvement of the underlying nasal skeleton. Respect for the nasal sub-units is the key to achieving a suitable aesthetic reconstruction. When the resection involves more than half of a nasal subunit, it may be advisable to restore the entire subunit with tissue of texture and color characteristics similar to the forehead flap. These properties and the possibility of obtaining ample skin coverage make the forehead flap especially useful when restoring the nasal tip and the skin region of both nasal alar cartilages and vestibules.

Correspondence:
Raúl González García
C/ Los Yébenes, 35 8ºC
28047 Madrid, España
e-mail: gonzalez-garcia@hotmail.com

Received: 15.11.06
Accepted: 28.01.09

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