Indication

The paramedian forehead flap (PFF) is a workhorse in facial reconstruction. Although it may close any wound on the central face, its best application is to the distal nose (tip, ala, and columella) where tissue thickness and sebaceousness are closely matched by forehead skin.² The PFF is ideal for recreating the convexity and projection of the nasal tip. Subtotal nasal tip and/or alar defects may be candidates for the PFF. Proximal wounds on the nasal dorsum, sidewall, nasal root, and medial canthus have inherently thinner skin and may be incongruous for the much thicker PFF unless a substantially deep defect is present.

Anatomy

The primary and secondary vascular supply to the PFF is the supratrochlear (internal carotid system) and dorsal nasal artery (external carotid system), respectively. The supratrochlear artery (SA) is reliably located at the medial border of the eyebrow, 1.5–2 cm from the facial midline. At the medial eyebrow, a glabellar crease (if present) delineates where the SA crosses the superior orbital rim to enter the forehead (Figure 8.1). Below the orbital rim, the SA lies deep to the periorbital muscles (orbicularis oculi and frontalis). Above the rim, however, the SA pierces the frontalis muscle and ascends superficially into the forehead, sandwiched between the frontalis muscle below and the subcutis above. Consequently, to preserve the SA near the orbital rim, dissection must be below the frontalis muscle and deep fascia.

Figure 8.1 Supratrochlear artery location 1.5 cm lateral from midline at the medial eyebrow, marked by a lateral glabellar crease.

Flap Design

The ideal PFF is an aesthetic covering that restores normal contour and symmetry without creating a shapeless blob. Table 8.1 discusses the critical design issues in a PFF. The covering provided by a PFF requires a stable nasal infrastructure (cartilage support and mucosal lining). Structural cartilage grafts (SCG) to prevent nasal valve collapse and alar rim contraction are usual considerations in PFF repairs. More neglected, however, are SCG that restore contour to the nasal supratip. Contour grafts should be considered in patients that have thick nasal tip skin and supratip defects (Figure 8.2). Without a contour graft in these patients, a PFF alone may be insufficient to restore normal tip projection.³

TABLE 8.1 ISSUES IN PFF DESIGN FOR DISTAL NOSE DEFECT (NASAL TIP AND/OR ALA)

Figure 8.2 Supratip defect in a woman with inherently thick nasal tip skin who would benefit from a contour cartilage graft.

Measurements of the defect must be accurate, neither over- nor undersized for the wound. The PFF template should be measured after the residual subunit has been outlined, but prior to the excision of any remaining skin (Figure 8.3). This avoids an artificially enlarged dimension from a retracted wound edge. A template should also reflect the 3-dimensional nature of the nose, especially if a defect extends to the infratip, columella, and ala (Figure 8.4a). If the vestibular mucosa is missing, the PFF may be extended and turned down to provide nasal lining. The soft nasal triangle, however, is best approached with second intention as the PFF, even when skeletonized, will never match the thin, soft concavity in this area (Figure 8.4b). Whenever possible, the unaffected contralateral side should be used as a template to restore symmetry. A right-sided nasal tip and ala wound, for example, should be repaired based on the normal left tip and ala.

Figure 8.3 PFF template designed to include the eventual removal of nasal tip subunit; pedicle base is 1 cm in width.

Figure 8.4 (a) Complex Mohs defect of the nasal tip, soft triangle, and medial ala, necessitating a 3-dimensional design. (b) Paramedian forehead flap designed to cover complex nasal tip and ala defect except for the nasal soft triangle, which is best recreated with second intention healing (see Figure 8.13b for long-term results).

The vertical height of the forehead (from orbital rim to anterior frontal hairline) will determine the potential reach of this flap, and may be estimated by using a suture. If the vertical length is inadequate (short forehead height relative to distal defect), then the modifications listed in Table 8.2 will significantly extend a flap’s distal reach.

TABLE 8.2 MODIFICATIONS TO THE PARAMEDIAN FOREHEAD FLAP FOR EXTENDED REACH

Design considerations for the pedicle include its position and width. Identifying the SA pedicle may be done clinically, by using the anatomic landmarks mentioned earlier, or definitively by confirming with a manual Doppler (8–10 MHz frequency). The pedicle width, therefore, rarely needs to be greater than 1.5 cm.⁴ Wider pedicles in fact are counterproductive and restrict flap mobility as well as vascular integrity (by increasing torque and compression on the artery during flap rotation). This author routinely develops a pedicle base of 1.0 cm (Figure 8.3). Pedicle positioning should be contralateral to the predominant side of the wound to minimize pedicle twisting during movement. The right SA, for example, should be the PFF pedicle for a predominantly left-sided nasal defect.

Anesthesia

The PFF may be safely performed as an outpatient procedure. Tumescent anesthesia is useful by rapidly anesthetizing large areas with minimal patient discomfort. Local anesthesia (local infiltration and nerve blocks) may be supplemented by oral benzodiazepines (lorazepam, midazolam) and oral analgesics. Rarely, conscious sedation may be needed and are safely performed by dermasurgeons.^5,6 Appropriate credentialing for advanced cardiac life support and sedation are essential for the latter modalities.

Execution

Prior to the first incision, all design elements should be measured and remeasured, and anesthesia must be complete. The execution sequence for this author is (1) cartilage support and nasal lining restoration (if needed), (2) flap harvesting and pedicle mobilization, (3) defect preparation, (4) flap preparation and inset, (5) donor site closure, and (6) postoperative care.

Cartilage and Lining Restoration

Cartilage grafts (CG) and nasal lining are essential ingredients for a stable nasal architecture. CG are either structural (native cartilage present but additional CG needed for support) (Figure 8.5) or restorative (replacing missing cartilage). Structural cartilage grafts serve to (1) support heavy flap tissue, (2) maintain airway patency of the internal nasal valve (priority in nasal reconstruction), (3) minimize scar contraction, and (4) restore contour projection (nasal tip). CG may be auricular (antihelix or concha; Figure 8.6), nasal (septum), or costal in nature. Auricular cartilage harvest is easiest and may be performed from an anterior or posterior approach. Anterior incisions are more accessible but scars are more visible than posterior incisions. Antihelical cartilage is excellent for long, straight segments whereas conchal cartilage is ideal for grafts that demand more curvature and substance.^7,8 The subject of nasal lining is beyond the scope of this chapter. General options, however, for smaller mucosal defects (< 1 cm) include (1) turnover hinge flap, (2) turndown of a forehead flap extension, (3) full-thickness skin graft (FTSG), and (4) bipedicle vestibular skin advancement flap. Larger lining restoration may require (1) turnover forehead flap, (2) septal mucoperichondrial hinge flap, (3) composite septal chondromucosal pivotal flap, or (4) larger FTSG vascularized by an overlying PFF.⁹

Figure 8.5 Cartilage graft placed close to the alar rim for structural stabilization and support of the overlying PFF.

Figure 8.6 Anterior approach to auricular cartilage harvesting. Conchal skin is elevated, and cartilage with perichondrium removed for grafting.

Flap Harvesting and Pedicle Mobilization

The PFF may be mobilized at its superior edge to include just the skin and subcutis or down to underlying galea. The former approach facilitates flap debulking during inset but results in greater bleeding. A subcutaneous level is preferred if the flap is in hair-bearing scalp to expose terminal hair bulbs for depilation. The level of undermining, however, delves deeper into the subgaleal plane as one approaches the eyebrow to preserve the SA. The transition from subcutis to subgalea should occur at least 3 cm above the orbital rim. Undermining past the orbital rim should be under direct visualization as the SA is at risk of transection. Occasionally, subperiosteal release of the arcus marginalis and brow complex is required to enhance flap extension (Table 8.2). The PFF should now overlie the defect without tension (Figure 8.7).

Figure 8.7 PFF lies without tension, draping to patient’s columella.

Flap Preparation and Inset

Prior to any suturing, the flap thickness must be revised to fit the defect. Aggressive debulking except for a thin subdermal layer is possible because of the excellent vascularity of the SA (Figure 8.8). Constant reference to the defect is mandatory to prevent excessive thinning. Flap inset begins with interrupted epidermal sutures to secure its leading edge with the defect. If dermal-buried sutures are placed, this author prefers Poliglecaprone 25 (Monocryl, Ethicon) because of its minimal tissue reaction, a desirable feature on the sebaceous nasal tip.¹⁰ Dermal sutures contribute to flap security and minimize incision line separation. The proximal flap as it abuts the nasal dorsum is not sutured until pedicle division.

Figure 8.8 The distal forehead flap may be substantially debulked except for a thin subdermal fat layer.

Donor Site Closure

Donor areas are approximated as much as possible and any remaining wound heals by second intention (Figure 8.9). Patients may be reassured that this open portion will be significantly smaller because of inevitable wound contraction (Figure 8.10). Tissue expansion and complex scalp flaps should be avoided as they often lead to excessive morbidity on both donor and recipient tissue without cosmetic benefits. At most, unilateral or bilateral W-plasties along the frontal hairline may be considered for complete closure of the forehead wound. These W-plasties act as bilateral advancement and rotation flaps, with the W design to camouflage incision scars and preserve hairline continuity.⁴ Broad scalp paresthesia may be a price of donor site closure.

Figure 8.9 Second intention wounds at the midline or paramedian forehead heal exceptionally well. More lateral forehead wounds, however, are less predictable and usually result in poor donor site cosmesis.

Figure 8.10 One-year postoperative scar from primary closure and second intention healing of PFF donor site.

Postoperative Care

Postoperative bleeding at the sides of the exposed pedicle is common and may be prevented with meticulous electrocoagulation and a Surgicel or Surgicel Nu-Knit wrap of the exposed pedicle. This oxidized cellulose gauze promotes hemostasis and its removal causes less discomfort than Vaseline gauze.¹¹ Visual fields are blocked with pressure dressings and the wearing of glasses is usually not possible without preoperatively customized devices.

Postoperative observation for several hours is advisable, especially for patients at risk of bleeding. Hospitalization is not necessary although patients must stay locally in the charge of a caretaker. Postoperative prescriptions include antibiotics (optional), analgesics, and antiemetics as needed. Wound care for the PFF may be intimidating and patients often express fear of detaching the pedicle. Detailed guidance with the first dressing change and the availability of a wound-dressing video will preempt much anxiety. Most reassuring is the surgeon’s telephone call in the immediate perioperative period.

Final

After pedicle division, additional revisions may be needed, such as dermabrasion (6–8 weeks from stage I), de-epilation, and contouring (Figure 8.12). After 8 weeks, however, further tuning should be deferred for several months to permit flap maturity and scar evolution. Early intervention for self-resolving issues only leads to unnecessary morbidity. A functional airway should always be evaluated prior to any intervention. The PFF is an extremely resilient and vascularized flap that has no equal in the aesthetic restoration of large complex nasal defects (Figures 8.13a,b and 8.14).

Figure 8.12 Flap contouring proceeds in incremental strips to prevent excessive thinning during revision procedure 5 months after stage I.

Figure 8.13 (a, b) Eighteen-month appearance of a PFF with cartilage grafting after 4 stages (including one dermabrasion session). Note soft triangle cosmesis from second intention healing.

Figure 8.14 Twelve-month result of a PFF without cartilage grafting.

Indications

The CNIF is best at repairing small to medium-sized defects of the ala, infratip, and columella. The medial cheek donor skin is especially similar to the sebaceous texture of the ala. The CNIF is ideal for a deep defect (up to mucosa) that is confined to the ala and consumes 50% or more of this subunit (Figure 8.15). Although other closures may be considered for such wounds (melolabial transposition flap), the CNIF is advantageous in preserving the alar groove and concealing donor scar within the melolabial fold.^13,14 Single-stage buried island pedicle flaps and subcutaneous hinge flaps are also viable alternatives for strictly alar defects.^15,16 Wounds of the ala and cheek are not optimal for the CNIF alone and should be repaired in combination with other options (ie, cheek advancement flap).

Figure 8.15 Deep Mohs defect consuming most of the ala but not beyond the alar groove, an ideal candidate for the cheek-to-nose interpolation flap.

Anatomy

The flap is harvested from the skin and subcutis of the lower medial cheek and melolabial fold. In bearded men, transfer of terminal hairs is a potential disadvantage. The pedicle is proximal near the lateral alar groove and is nourished by arterial muscular perforators from the angular artery.

Flap Design

Nasal infrastructure (cartilage and mucosal lining) requirements are stringent as with the PFF. A cartilage graft for the CNIF is structural and not restorative (as cartilage is absent from most of the fibrofatty ala). A CG braces the heavy CNIF and prevents alar retraction and adjacent nasal valve collapse (Figure 8.16). Further, it restricts the inevitable flap contraction to create a soft convex alar lobule rather than a bulbous prominence. In width, the CG should span up to the alar groove and in length, beyond the alar defect by 3–4 mm at each end. Its placement is close to the alar rim for support. CG attachment with nonabsorbable sutures is to the native cartilage medially and within an alar base pocket laterally. CG often requires thinning and sculpting to be 1 mm thin and rounded with beveled edges peripherally. Any CG must be secured prior to flap incision.

Figure 8.16 Structural cartilage graft in place. Note positioning of flap template slightly above oral commissure and narrow taper of upper flap triangle (arrow) below the alar–cheek sulcus.

The entire alar lobule should be resurfaced when possible. The remaining ala up to the alar groove, except for a 1-mm margin of alar base and rim, will eventually be excised in stage II for full subunit repair. Flap design should include this enlargement. Some even advocate a flap template that is 1 mm larger in all dimensions, partially to counteract wound contraction and partially to exploit the trapdoor effect and recreate a lobular convexity.¹⁷ This mild oversizing may be achieved by incising on the outside edge of flap markings. Similar to the PFF, the contralateral normal side may serve as a model for template creation.

The template is now transferred to the medial cheek and lower melolabial fold and outlined, with the widest part of the flap positioned across or slightly above the oral commissure. Triangles are now drawn above and below the flap outline to create a curvilinear ellipse. The lower triangle will be excised full thickness to close the donor site. Proximally, the upper triangle must taper at least 0.5 cm below the lateral alar groove to avoid effacement of this landmark (Figure 8.16). Although this proximal triangle is drawn narrowly, the underlying pedicle is more wide and deep to maximize vascular supply. Flap reach should be confirmed with a stretched gauze that simulates actual movement. From the donor site, the flap transposes and rotates counterclockwise for a right-sided alar wound and clockwise for the left side. Template orientation must account for these directional distinctions.

Execution

The CNIF pedicle may be developed to be either myocutaneous or myosubcutaneous. The myocutaneous design includes skin, subcutis, and muscle fibers of the levator labii superioris alequae nasi (LLSAN). The myosubcutaneous pedicle excludes the overlying dermis and epidermis, which is excised at the time of flap harvest. Features of both designs are discussed in Table 8.3.

TABLE 8.3 PEDICLE VARIATIONS FOR THE CHEEK-TO-NOSE INTERPOLATION FLAP

Superficial incisions indelibly score the flap outlines and prevent the inaccuracies of blurred pen markings. The lower triangle is then fully excised and the distal flap sharply elevated with a 3- to 4-mm subdermal fat layer. As one nears the proximal pedicle, dissection delves deeper to incorporate muscle fibers of the LLASN (Figure 8.17). Partial muscle inclusion is essential to preserving the arterial perforators for this flap. Hook retraction of the cheek laterally, the cutaneous lip medially, and the flap superiorly will expose these muscle fibers. Searching for the angular artery is contraindicated. Flap dissection is similar to that of an island pedicle flap in that excessive flap mobilization exacts the price of a smaller pedicle.

Figure 8.17 Proximal pedicle requires deep dissection to incorporate muscle fibers at base that contain arterial perforators. The angular artery itself, however, is not within the pedicle.

Resistance to flap movement may be alleviated by these maneuvers: (1) scoring incision (to dermis) at the proximal triangle (if a myocutaneous design was chosen), which frees proximal skin attachments tethering the flap, (2) closing the donor cheek in a superior oblique vector (northeast for the right cheek and northwest for the left), which progressively brings the flap medially and superiorly (Figure 8.18), and (3) temporary suspension suture lifting the flap to the upper cutaneous lip, which is removed in 1 week.

Figure 8.18 Donor site closure in a superiorly oblique vector (arrows) progressively elevates the flap toward the defect and facilitates final closure.

Once the flap reaches the defect with minimal tension, defect preparation begins with (1) peripheral undermining, (2) angulating rounded borders (theoretically reducing the trapdoor effect), and (3) debeveling all wound edges. The alar rim, however, should remain beveled and, likewise, the flap’s margin at the alar rim must be reverse-beveled to achieve a flush closure. The remaining alar subunit is not resected by this author until pedicle division.

The flap must then be debulked of fat (except for a thin subdermal fat layer to preserve the superficial vascular plexus) to fit the defect. The first key sutures close the donor site, which progressively lifts the flap toward the defect. Interrupted epidermal sutures then align and inset the flap. For this author, strategically placed buried monofilament sutures (Poliglecaprone) are essential for minimizing incision line separation. Throughout the execution phase, constant assessment of alar rim symmetry and airway patency must occur.

Postoperative Care

Wound care for the CNIF is less demanding than that for the PFF. Glasses may be worn and bandages are less cumbersome. A Xeroform gauze wraps around the exposed pedicle and another roll rests under it for support. Bleeding is uncommon at the pedicle edges as the arterial supply is less vigorous. Intranasal dressings may be needed for bilayer support, especially if mucosal lining was repaired. Postoperative nausea is rare and pain, if any, is most often felt at the cartilage donor site. Postoperatively, respiration may be impaired despite nasal valve support because of transient surgical edema, which may require several weeks to subside.

Final

Issues that may require revisions following stage II typically target the following: (1) flap trapdooring (intralesional steroids, surgical debulking), (2) alar groove definition (incising and debulking underlying scar at sulcus), (3) alar thickness (excising a wedge of fibrous scar via an intranasal approach), and (4) airway patency.

The CNIF’s value as a staged repair lies in its tissue match with the lateral ala and distal nose. Donor scar is minimal and well camouflaged. The flap preserves important landmarks (alar groove) and meets high aesthetic standards (Figure 8.22). It is flexible in its reach and may even extend to resurface the floor of the nasal vestibule. Compared to the PFF, the CNIF differs by (1) repairing smaller, less complex nasal defects, (2) being better suited for repair of the lateral ala, (3) being less reliable in its vascularity, and (4) requiring less postoperative wound care and lifestyle restrictions.

Figure 8.22 One-year result following CNIF, an excellent outcome with preservation of airway, alar groove, contour, and symmetry (Figure 8.15 shows original defect).

Indications

A number of flaps are applicable for medium to large full-thickness lip defects. These include the Abbé, Estlander, Karapandzic, Gilles fan flap, and McGregor repairs. Among these options, the Abbé is best at restoring neuromuscular function with the least disruption to the perioral anatomy.¹⁸ Lip defects amenable for the Abbé are those that (1) are lateral to midline but do not involve the oral commissure (although wounds isolated to the philtrum are candidates), (2) consume ⅓ to ½ of the lip, and (3) involve significant loss of the orbicularis oris muscle. It is this last factor that demands functional muscle replacement, which is best provided by the Abbé procedure.

Anatomy

Nourishing the Abbé is the inferior labial artery (ILA), which branches off the facial artery and has a variable course across the lower cutaneous and mucosal lip. At midline, the ILA is always posteriorly located within the mucosal lip (red lip) at the level of the vermilion border. Here, it lies between the orbicularis muscle anteriorly and the mucosa posteriorly. Lateral to midline, the ILA location is less predictable. Within the lip, the ILA may be found either within the orbicularis oris muscle (minority) or between the muscle and mucosa (majority).¹⁹ The ILA is never located between the muscle and subcutis, a reassuring fact during flap creation.

Flap Design

The Abbé template is best positioned at midline where arterial location is most predictable and donor site symmetry may be preserved. Paramedian locations may also be considered to match the vermilion border thickness between the donor and recipient lip. Extremely lateral flap designs, however, are contraindicated because of the potential distortion of the oral commissure. Donor site morbidity is low unless excessively resected, which may compromise stoma size.

Proper repair of the full-thickness defect in Figure 8.23 requires its enlargement to the upper cutaneous lip borders. The template fashioned may be less than the defect as the inherent stretch of lip tissue compensates for a smaller flap size. The nasal sill and alar crease must be preserved with any flap design and all landmarks (vermilion border, philtrum, etc) must be outlined prior to local anesthesia and incision (Figure 8.24).

Figure 8.23 Left upper cutaneous composite defect involving skin, muscle, and mucosa.

Figure 8.24 Natural landmarks and subunit enlargement of defect are outlined prior to local anesthesia infiltration. Template is positioned midline and marked in solid line while dashed extension addresses the standing cutaneous cone and permits donor site closure.

Execution

Table 8.4 details the execution sequence for the Abbé repair, which may be safely performed as an ambulatory procedure.

TABLE 8.4 ABBÉ FLAP SEQUENCE FOR CLASSIC LIP-SWITCH (LOWER LIP FLAP TO UPPER LIP DEFECT)

Final

For male patients, any transferred hairs from the lower cutaneous lip and chin will continue to grow within the flap. The hair growth direction, however, will be reversed. Following stage II, revision surgery is rarely needed unless the vermilion border requires re-positioning. Flap edema will resolve with time (Figure 8.29). The time for neuromuscular recovery varies and can be age-dependent. Younger patients have almost full recovery within 6 months whereas older patients may require one year or more (Figure 8.30). The Abbé repair is extremely flexible in its applications. Two or more Abbé flaps may be harvested from the same donor lip, provided that overall oral patency is not compromised. Abbé patterns extending into the submental region have been described with some designs tunneling under an intact upper vermilion border.^21,22 These modifications may resurface large and complex central-facial defects. The lip-switch flap may also be combined with other repairs for subtotal lip restoration.²³

Figure 8.29 Postoperative appearance at 4 months. Mucosal edema is almost resolved and there is excellent symmetry of upper and lower lips, with accurate vermilion approximation.

Figure 8.30 Recovery of muscle function is rapid even at 4 months.

Complications with surgery

Even with perfect planning and execution, surgical outcomes may still be suboptimal. The impact of failed (partial or total) staged repairs is devastating to both patient and surgeon. The author’s approach to these disappointments consists of four steps. Step one is an honest patient discussion, which begins with a sincere expression of regret. If identifiable factors for the complication are noted, then these may be avoided in subsequent surgeries. Patients, however, must never feel abandoned. Surgeons are human and imperfection is the plight of humanity. Step two assesses what revisions are needed. Fortunately, necrosis or dehiscence is often only partial with staged repairs and thus some salvage is possible although flexibility with subunit excission is key. The number of revisions needed and the timing of these surgeries are relevant issues. Patients must also be informed that revision plans may change, depending on the outcome of each intervention. Step three is a decision with the patient on who will be performing the revisions. Generally, the primary surgeon should also perform subsequent revisions, unless skill-sets are not present. A referral externally (to a trusted and nonjudgmental colleague) is not a source of shame and is part of sound surgical judgment. Finally, a realistic appraisal of the eventual outcome is important but is not always possible.

The cheek-to-nose interpolation flap in Figure 8.21a partially necrosed due to a shallow pedicle (minimal incorporation of muscle perforators at base). Fortunately, the necrotic area was small and superficial (gentle curettage of eschar). Pedicle division proceeded and the shallow wound healed secondarily. Dermabrasion followed (6 weeks from stage I) and final results are seen in Figure 8.21b. An alternative approach would have been to delay pedicle division for an additional 2 weeks to allow for a better assessment of second intention healing. This necrosis exemplifies the need to defer subunit enlargement until stage II and only if flap survival is assured. Had the subunit been excised at stage I and had flap necrosis been more extensive at stage II, then an unfortunate outcome would have turned disastrous.