Forehead Flaps 

Updated: Apr 10, 2019
Author: Stephen S Park, MD; Chief Editor: Arlen D Meyers, MD, MBA 

Overview

Background

The modern era of nasal reconstruction has brought significant advancements and offers unparalleled opportunities for reconstructive surgeons to maximize functional and aesthetic outcomes. The forehead flap has been used for many centuries and remains a workhorse flap for major nasal resurfacing. This article explores the history of forehead flap surgery, contemporary concepts in flap design, surgical steps, and potential complications.

History of the Procedure

Nasal reconstruction originated almost 3000 years ago in India, where large cheek flaps were developed to reconstruct noses. Nasal amputation was a common form of social punishment for various crimes, from theft to adultery, thus giving rise to a large group of individuals in need of total or subtotal nasal reconstruction. A seventh century Indian medical document, the Sushruta Samita, describes a technique using a flap from the forehead for nasal restoration. In the 15th century, Antonio Branca of Italy discovered an Arabic translation of the Sushruta Samita and is believed to be the first to perform a similar procedure outside of India. In Europe, Italian surgeons used a pedicled flap from the medial surface of the upper arm for nasal reconstruction.

In the late 18th century, JC Carpue found a description of this Indian technique, giving rise to the modern era of nasal resurfacing with the use of a pedicled forehead flap. Carpue first practiced these techniques on cadavers and later applied them to live patients, eventually publishing his results. His writings soon spread across Europe and to America, revolutionizing nasal reconstruction. Carpue's basic techniques laid the foundation for modern nasal reconstruction for the next century.

These techniques were modified further and popularized by other surgical giants. Kazanjian advanced the development of the forehead flap by advocating primary closure of the forehead donor site.[1] Millard, in the 1960s and 1970s, used a characteristic gull-wing design with lateral extensions for alar reconstruction and extended the pedicle incisions below the brow to provide greater flap length.[2, 3] Burget and Menick made further contributions to the design by emphasizing aggressive thinning of the skin paddle, narrowing the pedicle base for easier rotation and length, and modifying defects to follow aesthetic subunits of the nose.[4] The midline forehead flap is based on a narrow pedicle centered on the medial brow area, often capturing the proximal supratrochlear artery. The base of the pedicle is no more than 1.5 cm and often close to 1.2 cm.

The skin paddle can be positioned in the precise center of the forehead. An advantage of placing the skin paddle in the midline rather than paramedian is that the pedicle is slightly longer and the donor site scar is in a more aesthetic midline position. The vertical donor site scar can be more inconspicuous when centered in the midforehead area.

Problem

Nasal reconstruction poses the challenges of restoring aesthetics in a prominent area on the face while preserving function. A full-thickness defect requires a multilayered reconstruction that addresses each of the 3 separate layers of the nose (ie, cutaneous surface, internal lining, structural support). Once structural grafting is placed, its covering must be durable and of similar thickness and texture to native nasal skin and it must have its own blood supply. Ideally, this is accomplished with minimal donor site morbidity and with reproducible dependability.

Epidemiology

Frequency

Nasal defects may occur from a variety of etiologies, the most common being related to cutaneous malignancies and their excision. The incidence of nonmelanotic skin cancers is rising, with the estimation being that more than 3 million Americans per year are affected by these disorders.[5] Mohs surgical excision remains the procedure of choice for management of infiltrating or complex skin cancers, and it creates nasal defects of different sizes. Traumatic causes of nasal defects also occur and may require major repair with a forehead flap.

Indications

Numerous techniques are available for nasal reconstruction but the forehead flap remains the criterion standard technique for large cutaneous defects. Not only does it provide the optimal color and texture match to the native nasal skin, but it carries its own vascular supply and can nourish underlying grafts and tenuous flaps. A single forehead flap can be used for resurfacing the entire nose, from ala to ala. Its dependability and consistent anatomy make the forehead flap a workhorse for major nasal restoration, setting the bar for an aesthetically inconspicuous reconstruction and restoration of function. The donor site on the forehead is similarly acceptable.

No absolute indications for a forehead flap exist because patient considerations may override the selection of this flap. The forehead flap is more complex and more involved than smaller local flaps, requiring a second stage at roughly 3 weeks after the original flap transfer. The overall health of the patient, including his/her surgical candidacy, must be reviewed.

Other considerations include patients' aesthetic expectations (recognizing that simpler methods may leave contour problems), poor color match, or some degree of alar base distortion and contraction. These outcomes can be anticipated when using a skin graft for a deeper defect or when pushing the limits of a local nasal flap (creating excessive tension). When these aesthetic results from these simpler flaps are unacceptable, the forehead flap is indicated. For most large or complex nasal defects, the forehead flap provides the most dependable and aesthetically acceptable reconstruction.

Generally, cutaneous defects involving the nasal tip fare poorly with skin grafts, even thicker ones, and either a local flap or a forehead flap is indicated. Conversely, native nasal skin of the upper third is much thinner and amenable to grafts. Defects larger than 1.5 cm may exceed the limits of a local flap and often do better with the interpolated forehead flap. Defect size is influenced by the consideration of the aesthetic nasal subunits that are often excised when involved with the primary defect. Finally, any reconstruction that requires structural grafting necessitates a resurfacing flap that has its own blood supply; this represents a common indication for the forehead flap.

Relevant Anatomy

Forehead flaps are based on the robust vasculature to the forehead via the supraorbital, supratrochlear, and terminal branches of the angular and dorsal nasal vessels. The first anatomic point involves forehead flap terminology. The median forehead flap is harvested from the mid forehead and has a wide pedicle based in the center of the forehead, which originally captured both supratrochlear vessels as seen in the image below.

A is a median forehead flap over the forehead vasc A is a median forehead flap over the forehead vasculature. B is the paramedian forehead flap over the forehead vasculature. C is the midline forehead flap over the forehead vasculature.

The paramedian forehead flap is designed around a narrower pedicle based on the medial brow area over the superior/medial orbital rim. The skin paddle and pedicle are aligned vertically, with the supratrochlear notch in the paramedian position of the forehead as seen in the image above. The resultant donor scar is oriented vertically and aligns with the medial brow.

The midline forehead flap is a hybrid of median and paramedian flaps, with the skin paddle harvested from the precise center of the forehead. The associated pedicle runs obliquely and is based on a unilateral supratrochlear vessel and collaterals from the medial brow area as seen in the image above. Collateral flow from the angular artery can contribute to significant perfusion pressure at the pedicle base. The body of the midline flap is harvested from the precise center of the forehead, allowing a less conspicuous donor scar that is more consistent with facial aesthetic units. The pedicle may be based on either side, allowing choices between flap length and the arc of pedicle rotation.

The primary blood supply to the forehead flap comes from both the supratrochlear artery and the collateral flow at the medial brow region (terminal branch of the angular artery). This is a rich anastomoses among the supratrochlear, dorsal nasal, and angular arteries, providing a robust perfusion pressure; thus, it drives the vascular design of the forehead flap. The pedicle base is usually narrow but captures this complex anastomosis at the superior/medial orbital rim. A prominent central vein should be incorporated into the pedicle design. The precise anatomic anastomosis between the named major vessels in the medial brow region varies.

The supratrochlear artery exits at the superior and medial corner of the bony orbit, approximately at the medial point of the eyebrow. It passes superficial to the corrugator muscle and deep to the orbicularis, ascending in a paramedian position for approximately 2 cm before piercing the frontalis muscle as seen in the image below.

The anatomic relationship of the supratrochlear ve The anatomic relationship of the supratrochlear vessels and the periorbital and forehead musculature.

The supratrochlear artery then travels superiorly in the subcutaneous plane, above the galea/frontalis muscle, maintaining numerous anastomoses with the contralateral vessels. The terminal angular artery may ascend the forehead as a distinct vessel or communicate with the ipsilateral supratrochlear artery. The paired dorsal nasal arteries usually merge to form a single central artery of the forehead.

Forehead flap design is influenced by nasal anatomy. The thickness and mobility of the nasal skin varies across different anatomic sites. The skin overlying the dorsum and sidewalls is thin and mobile, whereas the skin of the nasal tip and nasal alae is thicker and less mobile. Nasal topography is a combination of convex and concave surfaces that provide the foundation of nasal aesthetic subunits as seen in the image below. These subunits are the block images the casual eye detects upon viewing a nose. These images are then synthesized into the expected and familiar nose shape. Borders between these subunits tend to be inconspicuous, and they provide optimal scar-concealment areas.

Aesthetic subunits of the nose. Aesthetic subunits of the nose.

When planning a nasal defect reconstruction, one often replaces the entire involved aesthetic subunit rather than just filling in the original hole. Strategically controlling the shape of the defect, flap shape, and, ultimately, the resultant scars, leaves the optimal reconstruction that is as inconspicuous as possible.

Contraindications

A contraindication to the forehead flap may be anatomic issues relating to the axial blood supply to the skin paddle. Deep, horizontal scars across the base of the forehead may preclude the successful mobilization of this flap. One must inspect the mid-forehead area closely, especially because most patients have a history of prior cutaneous malignancies (and are at risk for future recurrences). Small superficial scars may be acceptable, but scars that extend to the galea create a significant barrier to the blood supply through the pedicle.

A history of previous forehead flaps is not necessarily a contraindication. Certainly, one would base the flap on contralateral side if one previous flap has been elevated. Even if both sides have been used, one may mobilize a third flap due to the robust collateral blood supply at the medial brow area and the angular artery.

Additional contraindications are based on the patient's comorbidities and his or her ability to tolerate surgery. Potential clotting problems or easy bruising indicates a potential surgical risk. Additionally, the patient's general health status may indicate an anesthetic risk and should be fully considered.

Patient expectations are a significant consideration. Some patients may not be particularly concerned with their appearance and want little or no intervention. They may prefer to keep the reconstruction as simple as possible at the expense of the aesthetic appearance or even function.

Emphasize the significant postoperative care needed for the pedicle. A strong possibility of poor patient compliance may contraindicate surgery.

 

Workup

Laboratory Studies

See the list below:

  • Laboratory testing follows standard preoperative evaluation and screening.

  • A history of clotting problems or easy bruising indicates that hematological studies or bleeding times may help identify potential surgical risks.

  • If general anesthesia is used, other testing, such as ECG, chest radiographs, and chemistry panels, may be indicated depending on a patient's particular health status and anesthetic risk.

  • Other preoperative preparations include various methods of optimizing surgical outcome depending on specific medical history.

    • Maximize the nutritional status of malnourished patients.

    • Serum albumin levels less than 3 g/dL impair healing.

    • If a patient's skin has excessive comedones, a brief presurgical course with tretinoin may reduce severity.

    • Dermabrasion may be used to minimize the degree of rhinophyma and improve recipient site contour.

    • Patients with diabetes should have tight glucose control to improve healing.

    • Patients who use tobacco products may be counseled at this time about the significant deleterious effects of nicotine, including compromised flap viability.

Imaging Studies

See the list below:

  • No specific radiographic imaging studies are required.

  • Preoperative photography is essential to document the defect, allow outcome review and comparison, and educate the patient regarding the condition prior to surgery.

  • Confirmation of the supratrochlear artery location and its path up the forehead can be achieved using Doppler studies, angiography, or palpation. These are not typically necessary because the anatomy in this region is consistent.

 

Treatment

Surgical Therapy

Forehead flaps are the mainstay for reconstruction of large cutaneous nose defects. The median forehead flap is mentioned mainly for historical interest, having been replaced by paramedian and midline forehead flaps. These 2 flaps have been refined and modified and provide dependable coverage with good cosmetic results.

The forehead flap uses a vascular pedicle based on the medial brow area, often centered on a unilateral supratrochlear artery. This pedicle provides nutrient supply to the skin paddle of the flap after elevation and during the neovascularization process from the nose into the skin paddle.[6]

Traditionally, the pedicle is divided and inset into the donor site after a 3-week interval, although sufficient vascular ingrowth probably occurs by the end of 2 weeks. In high-risk individuals (eg, persons who smoke, patients with diabetes), the flap may be elevated in a manner that creates a thicker flap, with the frontalis muscle intact, and debulked at an intermediate stage after 3 weeks. Final pedicle division occurs as a third stage 3 weeks later. On these rare occasions, the forehead flap is a three-stage procedure rather than a two-stage procedure.

Conversely, the forehead flap can be transferred as a single-stage procedure on select individuals (eg, young persons, patients who do not smoke). Excise the skin of the pedicle, and tunnel the deepithelialized pedicle under intact glabellar skin to fill the nasal defect. This converts the forehead flap into an island flap and allows the reconstruction to be performed in a single stage. The vascular pedicle may be compromised somewhat with this technique; therefore, restrict its use to special circumstances and ideal patients.

A retrospective study by Faris et al indicated that a midline central artery forehead flap can be successfully used in nasal reconstruction, possibly with less transposition of frontal hair to the nose than in supratrochlear-based flaps because of the more inferior pedicle base. The investigators reported that the rate of vascular compromise did not differ statistically between central artery forehead flaps and either glabellar paramedian or classic paramedian flaps.[7]

A study by Stigall et al indicated that the use of a paramidline forehead flap employing no Doppler examination to ensure inclusion of the supratrochlear artery can lead to nasal reconstruction outcomes similar to those of a traditional paramedian forehead flap using Doppler identification of the artery. Among the 50 nasal defects repaired in the study, flap survival and complication rates for the paramidline flaps, which extended from the glabellar midline to 1.2 cm lateral to the midline, did not significantly differ from those of the paramedian flaps.[8]

Preoperative Details

Preoperative assessment for nasal reconstruction begins with a determination of patient goals and desires for repair. Some patients may not be particularly concerned with their appearance and want little or no intervention. Others may accept a compromise in aesthetic outcome in return for a less-complicated or single-stage repair. If a patient desires optimal aesthetic appearance with the best chance for function preservation, a staged forehead flap is the best option.

An important part of preoperative counseling includes a review of the prospective resultant scars. This is especially important because a long scar is created on the forehead, where there previously was none. Moreover, in order to accommodate the aesthetic subunits, the nasal scars do not correspond to the existing nasal defect after modification. Although this technique is performed to improve final aesthetics, patients and family are occasionally upset by the increased size of the defect.

Other special considerations include forehead numbness, medialization of the eyebrows, and transposition of potentially hair-bearing skin from the distal aspect of the forehead flap to the nose. Emphasize the significant postoperative care needed for the pedicle and appearance. Analysis of the defect starts with a description of missing tissue and structures. Evaluate missing cartilage or structural support disruptions to determine the need for cartilaginous grafting and function restoration.

Intraoperative Details

Infiltrate local anesthetic with epinephrine throughout the nose and forehead, even with patients under general anesthesia. Carefully outline aesthetic subunits of the nose at the outset of the procedure to help define the defect in terms of aesthetic units.

Excise these units accordingly to place strategically the flap borders (and consequently the final scars) along the borders of these units, thus rendering them less conspicuous. Although the aesthetic units are drawn independent of the existing nasal defect, they are not always completely excised. Some modifications can be used to minimize the amount of skin excised while still preserving the camouflage of scars. The key concept is modifying the defect in terms of shape and borders such that the resultant scars consist of straight lines and sharp corners. They are most inconspicuous when placed along the borders of subunits.

Although strict adherence to a numerical value is unnecessary, some feel that 50% involvement mandates a complete excision of the subunit. This varies, especially when it extends caudally and requires a longer flap. The authors tend to be more aggressive when the additional excision does not mandate a longer forehead flap (ie, when the aesthetic unit of concern is cephalad to the original defect). On the other hand, when a defect only marginally involves the superior border of a nasal tip unit, one is less likely to complete the tip excision because doing so requires extending the forehead flap superiorly and, possibly, into the hairline.

The defect depth is taken down to the perichondrium of the existing nasal skeleton, even if the original defect is more superficial. This allows for less bunching up of the skin paddle, more even scar distribution beneath the flap, and improved topography of the nasal surface.

After involved subunits are excised and the defect shape is modified, cut and mold a malleable foil template (eg, a suture package) to match the new defect as seen in the image below.

A is a nasal defect template (from suture package) A is a nasal defect template (from suture package). B is the template transferred to the precise midline of the forehead.

This template serves 2 purposes: (1) precisely describing the shape of the defect (especially any irregular and sharp edges) and (2) demonstrating 3-dimensional contours often lost by simple ruler measurements. Account for alar lobule convexity during the initial measurements. Unrecognized convexity results in a flap that is too narrow and a lobule that is flat, without the normal acute alar-facial angle.

The foil template is then transferred to the exact midline of the forehead for markings as seen in the image above. By placing the template (and so the skin paddle of the flap) in the precise midline, the resultant scar is positioned strategically in the center of the forehead and tends to be less conspicuous than paramedian scars.

Plan the vertical position of the template by rotating gauze from the pedicle base, near the medial brow, from the defect site to the upper forehead. This technique assures that the planned flap reaches all defect borders. An ipsilateral flap refers to a pedicle base on the same side as the nasal defect and has the advantage of an effective greater flap length to reach the distal border of the defect. This comes at the expense of a greater arc of rotation, which may comprise the pedicle base.

Alternatively, a contralateral flap has less rotation at the pedicle base but may not reach as far caudally as the ipsilateral flap. Additionally, the contralateral flap tends to cause less visual interference than the ipsilateral flap. Midline defects have no advantage, and the decision is arbitrary.

Elevate the skin paddle of the flap in the subcutaneous plane, superficial to the frontal muscle as seen in the image below. Additional selective thinning is then performed to better match the variable skin thicknesses of different regions of the nose as seen in the image below. If the patient has small vessel disease, such as a smoker, then an intermediate stage is anticipated. In this case, the skin paddle is lifted in the subgaleal plane, with planned thinning as an intermediate stage after 3 weeks. Final pedicle division then occurs at the third stage, another 3 weeks later.

A is a flap elevation in the subcutaneous plan, su A is a flap elevation in the subcutaneous plan, superficial to the frontalis muscle. B is a selective thinning to best match normal nasal skin thickness.

The pedicle portion of the flap is always elevated in a subgaleal plane to the level of the orbital rim. At the inferior border of the pedicle, the dissection continues under the corrugator muscle, allowing the supratrochlear artery to be kept between the orbicularis oculi muscle and corrugator. The periosteum in this region can be incised and incorporated into the pedicle base (as seen in the image below), allowing greater caudal reach and some rigidity to the base for vascular protection.

Periosteum incorporated into the pedicle base. Periosteum incorporated into the pedicle base.

With the ipsilateral or contralateral flap or the midline versus paramedian flap, center the pedicle base on the medial brow, capturing the supratrochlear artery. The blood flow is not only through the supratrochlear vessel but is also driven by the rich collateral vasculature of that region. The pedicle base must be narrow, no wider than 1.5 cm and usually closer to 1.2 cm. Excessive width in this area compromises the blood flow during the twisting of the pedicle. A narrow pedicle base allows for easier rotation with less kinking and greater reach.

The pedicle base can be extended beyond the supraorbital rim and into the brow as needed for additional flap length without a compromise of flap perfusion. The supratrochlear foramen or notch may be palpated in some individuals and can serve as a reference point. Some authors advocate using a Doppler probe to locate and follow the course of the supratrochlear artery. This practice is used only very rarely because of the dependable anatomy and robust vascular perfusion in this area. After flap elevation, it is rotated to fill the nasal defect and closed in layers with attention to eversion of the skin edges as seen in the image below.

Midline forehead flap transferred to the nose. Midline forehead flap transferred to the nose.

The cephalic border of the nasal defect is under the flap pedicle and is not closed. The forehead donor site is usually closed primarily in a layered fashion, with attention to reapproximating the strong galeal layer. Donor site defects larger than 3.5 cm often cannot be closed primarily and are best allowed to heal by secondary intention rather than with ancillary flaps or skin grafts. The forehead wound undergoes progressive contracture, and the center of the wound fills with granulation tissue, resulting in a final scar that exceeds other techniques. The pedicle is loosely wrapped with antibiotic-impregnated gauze and is changed regularly.

Some surgeons apply a skin graft to the pedicle undersurface to reduce wound weeping.

Pedicle division is performed safely after 3 weeks as seen in the image below. One must aggressively thin the cephalic border of the flap from above to best match surrounding skin thickness; however, exercise caution to avoid extending the level of undermining beyond 50% of the original skin paddle. The vascular supply to the flap is retrograde from the recipient bed, and excessive undermining can jeopardize viability. The original nasal defect wound is freshened, and the superior portion of the skin paddle trimmed to fit the remaining defect. The pedicle base is amputated, thinned, and then inset back into the medial brow region.

The left photograph is the planned pedicle divisio The left photograph is the planned pedicle division. The right photograph is the pedicle stump partially inset into the glabella.

On occasion, the base of the pedicle can be entirely excised and the resultant donor site closed primarily. Meticulous attention must be paid to restoring brow symmetry during the pedicle inset because the involved side is usually displaced inferiorly and medially. When unrecognized, the asymmetry (in the future) may be the most distracting feature.

Vigorously debulk the pedicle stump to avoid the common "pincushioning" from a trap-door effect.

Postoperative Details

Avoid excessive pressure dressings on the nose despite the risk of a small hematoma forming under the skin paddle. (Venous congestion is a greater concern than arterial ischemia, and any extrinsic pressure exacerbates that risk.) A pressure dressing is usually applied to the forehead, although this region is typically quite taut and a hematoma is unlikely.

Observe traditional wound care, including cleaning with dilute hydrogen peroxide and a liberal application of moisturizing ointment. Avoid peroxide on any open wound or skin graft because of the potential for delayed epithelialization and cellular toxicity.

Sun protection is of paramount importance for at least 6 months. Facial scars and flaps are particularly sensitive to pigmentation effects of ultraviolet rays, which can result in permanent discoloration with respect to surrounding skin.

Follow-up

Patients are usually seen the first or second day postoperatively so their dressings can be changed, their wounds can be cleaned (especially intranasally if involved in the repair), and they can be emotionally supported. Once pedicle division is accomplished successfully, long-term follow-up concentrates on tumor surveillance, because these patients are at significant risk for future cutaneous malignancies, which makes early diagnosis essential. Additional ancillary procedures are often performed at follow-up visits (eg, steroid injections to expedite contour improvement or flatten scars, segmental dermabrasion).

Complications

Postoperative complications may be classified as either early or late. Vascular compromise is a significant early complication, and the physician must distinguish between arterial or venous events. Arterial ischemia typically manifests as a cool, pale flap that fails to blanch with gentle pressure. On the other hand, venous congestion may be warm to touch and have a darker (even purple) color. The congested flap demonstrates prompt capillary refill and brisk venous bleeding following a pinprick. The distinction is important because respective interventions may be unique.

Venous congestion is more common and may respond to simple measures, such as release of suture lines, medicinal leech therapy, or serial pin pricks. Arterial insufficiency is more problematic, and patient observation may be the only alternative. Conservative debridement and aggressive wound care is the initial measure. Once a clear line of demarcation is identified, elevating and sliding the flap more caudally may be necessary to repair the necrotic segment, especially before wound contracture and alar notching ensue.

Hyperbaric oxygen is a proven modality to enhance marginal tissue viability and is beneficial to congested and ischemic tissues. Achieving a positive outcome mandates prompt recognition and early intervention, (ie, within the first 24 h postoperatively). The extremely high partial pressures generated allow greater oxygen diffusion and penetration of marginal tissues while reducing arterial inflow through vasoconstriction. Hyperbaric oxygen is used preoperatively for patients with known small vessel disease who are in need of complex, total nasal reconstruction. It involves 20 dives preoperatively and 10 more postoperatively.

A hematoma can develop underneath the flap bed and can jeopardize the outcome through compromised viability, delayed vascular ingrowth into the flap, or predisposition to infection. Prompt aspiration of the hematoma and appropriate-spectrum antibiotic therapy are indicated in this situation.

If an area of superficial necrosis or epidermolysis occurs, conservative treatment with observation and gentle debridement is usually prudent. Complete flap loss and death has not been observed and represents an exceedingly rare complication.

A retrospective study by Santos Stahl et al indicated that incidence of partial flap necrosis may be similar for the two- and three-stage techniques for paramedian forehead flap nasal reconstruction. The study involved 87 patients who underwent the two-stage procedure and 100 patients who underwent the three-stage operation, with a follow-up period of at least 6 months. Partial necrosis rates for the procedures were 3.4% (two-stage flap) and 5% (three-stage flap). However, although the relative risk of partial flap necrosis rate did not differ significantly between the two groups, the three-stage flap was used for more complex nasal reconstructions, creating a natural selection bias characteristic of a retrospective review.[9]

Some patients may present with epistaxis early after surgery. This is more common following intranasal mucosal flaps used for full-thickness defects. The exposed surface of the pedicle is subject to bleeding, but gentle pressure or focal application of silver nitrate usually resolves the problem.

Late complications are also encountered. Contracture may cause distortion or notching of the nasal ala. This can be a difficult problem to correct secondarily and often requires a 3-layered approach. Pincushioning or excessive thickness of the flap is not uncommon and can be treated with additional thinning or steroid injections. These complications may warrant flap revision or selective thinning. Unfavorable and hypertrophic scars may be minimized with dermabrasion, generally after at least 8 weeks postsurgically. Often, the entire aesthetic subunit also may be dermabraded to assist in blending the flap into surrounding nasal tissue.

Nasal obstruction can occur as an early or late problem and is usually due to a collapse of the sidewall and ala of the nose. Cutaneous defects in this region of the nose are especially susceptible to collapse and functional problems. It is best addressed at the primary stage with aggressive cartilage grafting to serve as a batten of support to this region. The grafting is placed in a nonanatomic area of the nose but is critical to ensure functional results. Secondary grafting for nasal obstruction can be successful.

A retrospective study by Chen et al of 2175 patients who underwent skin cancer–related facial reconstruction with paramedian forehead flaps found infection to be the most common complication (63 patients; 2.9%), while postoperative bleeding occurred in 30 patients (1.4%), and postsurgical deep venous thrombosis was noted in 10 or fewer individuals (0.5% or below). Patients who had postoperative bleeding, used alcohol, or had a neurologic disorder were at greater risk for immediately returning to the emergency department or for readmission within 48 hours postsurgery, with odds ratios of 13.05, 7.70, and 4.11, respectively.[10]

A retrospective study by Choi et al of patients who underwent facial reconstruction with median forehead flaps reported acceptable forehead scarring and no donor-site complications. Although postoperative brow height was slightly elevated and interbrow distance was narrowed, possibly as a result of wound healing–related contracture, brow symmetry did not change.[11]

Outcome and Prognosis

Surgical results with the forehead flap for nasal reconstruction remain very encouraging. Even large and complex defects of the nose are often repaired to a standard of excellent nasal function (nasal airway), acceptable donor site (forehead scar), and an inconspicuous nasal reconstruction. Optimal outcomes depend on a meticulous approach to surgical preparation and technique and to postoperative management. After the decision is made to use a forehead flap, thorough patient education and preparation is critical, especially in regard to the intermediate period in which the pedicle remains intact. Long-term effects should provide good color match, inconspicuous scars, normal nasal contours without excessive bulk, and an acceptable donor scar as seen in the image below.

The left photograph shows a 2-year postoperative f The left photograph shows a 2-year postoperative frontal view. The right photograph is an oblique view of the same patient.

Future and Controversies

Future studies in the development of forehead flaps will attempt to further describe the physiologic features of these flaps, especially in terms of neovascularization and healing. Better understanding of these 2 processes may maximize outcomes for many patients.

Patients with small vessel disease, such as those who smoke and those with diabetes, will benefit from improved techniques that preserve pedicle vascular supply or advance neovascularization into the donor flap. Hyperbaric oxygen therapy has proven promising in this area.

The healing process itself can cause complications. Future studies may describe treatments that limit contracture or scarring, improving outcomes and further advancing the art of nasal reconstruction.