The forehead consists of skin, subcutaneous fat, and frontalis muscle. It is perfused by an arcade of anastomotic vessels from the supratrochlear, supraorbital, infratrochlear, angular, dorsal nasal, zygomatic orbital, and infraorbital vessels. For nasal repair, the vertical paramedian forehead flap, based unilaterally on the supratrochlear vessels, has become the design of choice because of its availability, efficiency, and reliability.
A midline nasal defect can be closed with either a right or left paramedian forehead flap. Unilateral defects are more easily resurfaced with an ipsilateral flap because an ipsilateral pedicle base is closer to the defect, permitting a shorter flap and decreasing the risk of tension—a primary cause of necrosis. If old scars, prior forehead harvest, or direct injury to the unilateral supratrochlear vessels is present, a contralateral flap is considered. However, the pedicle base of the contralateral flap is farther away from the defect. A contralateral-based flap must be longer, risking the transfer of distal hair-bearing scalp to the nose. A vertical forehead flap can be “lengthened” by orienting it obliquely. Oblique flaps also transect the vertically oriented axial supratrochlear vessels, creating a less vascular random extension. Oblique flaps increase eyebrow distortion on forehead closure and, importantly, “scar” both sides of the forehead, making the harvest of a second flap more difficult in the future.
The vertical paramedian forehead flap is perfused by a random dermal plexus and by subcutaneous, myocutaneous, and deep axial vessels.1 Because of its rich vascularity, a paramedian flap does not need the supratrochlear or supraorbital vessels to survive.2
In the clinical case presented in my CME article published in April of 2013, no vessels were audible by Doppler across the entire brow, presumably because of bilateral microembolization of the supratrochlear and supraorbital vessels by filler injection of the facial artery. However, the patient’s forehead skin was not clinically injured by history or examination and was expected to survive without a named vessel assessable with Doppler imaging. A preoperative angiogram was not obtained.
In my opinion, modern plastic surgery has become fixated on “named” vessels and algorithms. Forehead flaps die because of poor design—too small or too large, too short or too long, too narrow or too wide pedicle, tension, or a scar within its skin territory. A right unilateral flap remained the first choice. A contralateral flap held no advantage.
A reconstructed nose appears normal when an aesthetically contoured bone and cartilage framework is enveloped by supple, conforming, thin cover and lining that are designed with the correct dimension and border outline. Cover and lining flaps should be as exact as possible to avoid distorting adjacent landmarks or obscuring or collapsing underlying cartilage grafts. Intraoperative templates, based on the contralateral normal or the ideal, are used as a guide but, practically speaking, minor imperfections in the template are inevitable. Flat foil is crimped and folded into three-dimensional shape to fit the defect, positioned on the flat donor forehead, and then the flat flap is draped over the three-dimensional contours of the nose.
The forehead is thicker than nasal skin, and excess subcutaneous fat and frontalis muscle must be removed to thin the flap to nasal skin “ thinness.” During the intermediate stage of a three-stage full-thickness forehead flap, a thin skin flap is elevated with a few millimeters of subcutaneous fat. The underlying bulky subcutaneous fat and frontalis is then excised, sculpting the excess soft-tissue bulk and adding further cartilage grafts, if needed. If a few millimeters of excess skin is noted along the flap’s lateral borders when it is reinset, it is trimmed to fit the defect as precisely as possible. Nonexpanded (and expanded flaps) forehead flaps do not shrink,3–53–53–5 especially when supported and braced by an adequate cartilage framework. It is unnecessary and impractical to wait up to 2 years to trim this minimal excess.
The author has no financial interest to declare in relation to the content of this communication.
Frederick J. Menick, M.D.
Private practice, and
St. Joseph’s Hospital
1. Reece EM, Schaverien M, Rohrich RJ. The paramedian forehead flap: A dynamic anatomic vascular study verifying safety and clinical applications. Plast Reconstr Surg. 2008;121:1956–1963
2. McCarthy JG, Lorenc ZP, Cutting C, Rachesky M. Median forehead flap revisited: The blood supply. Plast Reconstr Surg. 1985;76:866–869
3. Lu KH. Expanded forehead flap for reconstruction of the nose (in Chinese). Zhonghua Zheng Xing Shao Shang Wai Ke Za Zhi. 1989;5:182–183
4. Weng R, Li Q, Gu B, Liu K, Shen G, Xie F. Extensive forehead skin expansion and single stage nasal subunit plasty for nasal reconstruction. Plast Reconstr Surg. 2010;125:1119–1128
5. Menick F Nasal Reconstruction: Art and Practice. 2009 Edinburgh Saunders
Letters to the Editor, discussing material recently published in the Journal, are welcome. They will have the best chance of acceptance if they are received within 8 weeks of an article’s publication. Letters to the Editor may be published with a response from the authors of the article being discussed. Discussions beyond the initial letter and response will not be published. Letters submitted pertaining to published Discussions of articles will not be printed. Letters to the Editor are not usually peer reviewed, but the Journal may invite replies from the authors of the original publication. All Letters are published at the discretion of the Editor.
Letters submitted should pose a specific question that clarifies a point that either was not made in the article or was unclear, and therefore a response from the corresponding author of the article is requested.
Authors will be listed in the order in which they appear in the submission. Letters should be submitted electronically via PRS’ enkwell, at www.editorialmanager.com/prs/.
We reserve the right to edit Letters to meet requirements of space and format. Any financial interests relevant to the content of the correspondence must be disclosed. Submission of a Letter constitutes permission for the American Society of Plastic Surgeons and its licensees and asignees to publish it in the Journal and in any other form or medium.
The views, opinions, and conclusions expressed in the Letters to the Editor represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.
The Journal requests that individuals submit no more than five (5) letters to Plastic and Reconstructive Surgery in a calendar year.