A, Intraoperative photograph before reconstruction. B, Intraoperative photograph after bilateral cheek advancement flaps, paramedian forehead flap, and lateral forehead rotation flap for donor site closure. C, Frontal view of the patient 13 months after the reconstruction. D, Profile view of the patient 13 months after the reconstruction.
Butz DR, Warner J. Use of Lateral Forehead Rotational Flaps to Close Paramedian Forehead Flap Donor Sites. JAMA Facial Plast Surg. 2016;18(2):146-148. doi:10.1001/jamafacial.2015.2002
The paramedian forehead flap is commonly used for nasal reconstruction.1- 4 The donor site can typically be closed primarily with acceptable scarring. However, for larger nasal defects, the donor site at the cephalic portion of the forehead is frequently too large to be closed primarily.5 Historically, these donor sites have been left to heal secondarily. However, this process can take months and comes at significant morbidity to the patient. This study reviews our experiences using lateral forehead rotational flaps to help close primarily large forehead flap donor sites.
A retrospective medical record review was performed on 5 patients who underwent paramedian forehead flaps and lateral forehead rotation flaps for nasal defect reconstruction after Mohs surgical excision from January 1, 2012, through December 31, 2014. Patient age and sex, defect size and location, operative reports, follow-up, and complications were evaluated.
All patients were treated by the same surgeon, and defects were managed under the subunit principle, excising remaining subunits to provide for whole subunit reconstruction.6 The forehead flap is raised and inset as traditionally described.2 The donor site is closed primarily caudally up to the cephalic portion using wide subgaleal undermining and a 2-layered closure. If the cephalic portion cannot be closed primarily, a lateral forehead flap is designed as a rotational flap along the hairline. The incision is placed pretrichially and extended to the temporal region. This is rotated to close the donor site defect. If this is not adequate, the incision can be extended or a contralateral flap can be created. If possible, the contralateral side should be spared in the event that a contralateral paramedian forehead flap becomes necessary. The final incisions are closed with running 6-0 nylon.
The mean age of the patients was 76 years (age range, 56-84 years). Patient demographics and defect size are in listed in the Table. Nasal defect size ranged from 2 × 2 cm to 7 × 3 cm before subunit excision. One patient had a trichial incision and required scar revision for alopecia. Four patients required unilateral forehead rotational flaps for closure, and one required bilateral flaps.
No major complications occurred. One patient had a nasal recurrence and required an additional Mohs excision. Because of the patient’s age, comorbidities, and patient preference, this secondary defect was closed with a skin graft.
A 76-year-old man with basal cell carcinoma presented to the operating room after Mohs resection of the lesion. He had an 8 × 7-cm defect, including the dorsum, nasal sidewalls, and medial cheek junction and tip (Figure, A). The defect was reconstructed with a paramedian forehead flap and bilateral cheek advancement flaps. The forehead donor site could not be closed primarily, so a lateral forehead rotational flap was used to provide primary closure (Figure, B). Postoperative photographs at 13 months are shown in Figure, C and D.
The forehead flap is an essential tool in the nasal reconstructive surgeon’s armamentarium but can leave a donor site that is too large to close primarily. There is a paucity of literature regarding the forehead flap donor site. Numerous articles1,2,5 on forehead flap techniques have barely one sentence dedicated to the donor site. The technique described is a simple way to close these wounds with minimal morbidity.
Jewett3 discusses donor site management and closure and advocates for placement of an acellular dermal matrix over the periosteum and then a staged full-thickness skin graft once the area has fully granulated. If the subsequent scar is unacceptable, Jewett recommends waiting at least 3 months before revising the scar. This procedure requires an additional donor site for the skin graft and subsequent surgery. One benefit of letting the donor site heal secondarily is that it permits wound contraction. Skin grafting would limit contraction and leave a skin-grafted patch. It is unlikely that this would be aesthetically pleasing.
The lateral forehead rotational flap is easy to perform, has a low risk of complications, and provides patients with a primarily closed wound. This is superior to an open forehead wound that may take several weeks to heal. Pretrichial incisions decrease the risk of alopecia and prominent scarring.
Corresponding Author: Jeremy Warner, MD, Division of Plastic Surgery, NorthShore University HealthSystem, 501 Skokie Blvd, Northbrook, IL 60062 (firstname.lastname@example.org).
Published Online: January 21, 2016. doi:10.1001/jamafacial.2015.2002.
Author Contributions: Drs Butz and Warner had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Both authors.
Acquisition, analysis, or interpretation of data: Both authors.
Drafting of the manuscript: Both authors.
Critical revision of the manuscript for important intellectual content: Warner.
Statistical analysis: Butz.
Study supervision: Warner.
Conflict of Interest Disclosures: None reported.
Previous Presentation: This study was presented as a poster at the Combined Otolaryngology Spring Meeting; April 23, 2015; Boston, Massachusetts.
Additional Contributions: We thank the patient for granting permission to publish this information.