A, Sinonasal fistula 2 years after orbital exenteration. B, Six weeks after repair of the fistula with a paramedian forehead flap and a cheek rotation flap.
A, Resection of recurrent chondrosarcoma involving the nasal dorsum and right medial canthus. B, Reconstruction of the intranasal lining with an epidermal turn-in flap. C, Calvarial bone reconstruction of the nasal sidewall. D, Paramedian forehead flap reconstruction of the medial canthus and nasal soft tissues. E, Ten months after resection and repair of a midfacial chondrosarcoma. F, Resection of recurrent chondrosarcoma with partial rhinectomy and bifrontal craniectomy. G, Calvarial bone reconstruction of the glabella and nasal dorsum. H, Twenty-two months after the third resection and reconstruction of midfacial chondrosarcoma.
A, Midfacial defect after resection of a basal cell carcinoma. B. Calvarial bone reconstruction of the floor of the orbit. C, Calvarial bone spanning the pyriform aperture and reconstruction of the wall of the maxillary sinus. D, A modified Hughes tarsoconjunctival flap. E, Soft tissue reconstruction with a paramedian forehead flap and a cervicofacial rotation flap. F, Sixteen months after periorbital reconstruction.
Price DL, Sherris DA, Bartley GB, Garrity JA. Forehead Flap Periorbital Reconstruction. Arch Facial Plast Surg. 2004;6(4):222-227. doi:10.1001/archfaci.6.4.222
From the Mayo Medical School (Dr Price) and the Division of Facial Plastic Surgery, Departments of Otorhinolaryngology (Drs Price and Sherris) and Ophthalmology (Drs Bartley and Garrity), Mayo Clinic, Rochester, Minn.
Copyright 2004 American Medical Association. All Rights Reserved.
Applicable FARS/DFARS Restrictions Apply to Government Use.2004
Objective To evaluate functional and aesthetic results of periorbital defect repair using forehead flaps.
Design Retrospective review of patients who received periorbital defect repair by 3 of us with a paramedian forehead flap alone or in conjunction with other local or regional flaps, bone grafts, or cartilage grafts. Flap survival, functional results, and postoperative complications were determined by physical examination at regular follow-up. Three experienced surgeons other than us quantified aesthetic outcomes using a 10-cm visual analog scale.
Results Eighteen patients underwent periorbital defect repair between August 1, 1989, and December 31, 2000. Defects ranged from 8 to 300 cm2 (mean, 46.8 cm2) in area. The most commonly involved primary structures were the medial canthus, lacrimal drainage system, and medial upper eyelid. The mean improvement on a 10-cm visual analog scale was 1.6 from before resection to after reconstruction and 3.8 from tumor resection to after reconstruction. In all relevant cases, globe coverage and lacrimal drainage system patency were excellent. No patients experienced fistula formation or eyelid retraction.
Conclusion The reliability, versatility, and relative technical simplicity of the forehead flap provide excellent cosmetic and functional results in reconstruction of intermediate-sized periorbital defects, especially those associated with nasal defects.
SKIN FLAPS were first described by the Indian physician Sushruta in the Samithá, written in approximately 500 BC, to replace noses amputated as punishment for theft and adultery.1-2 In the 19th century, local flaps were developed in the Western world by several surgeons, including Szymanowski, Burow, Esser, Lexer, Joseph, and Davis.3 Forehead flaps were first performed in America in the 1830s by Warren.4-5 The midline forehead flap was refined by Kazanjian,6 who described for the first time the primary blood supply, via the supratrochlear and supraorbital arteries, and advocated primary closure of the donor site. Forehead flaps are a reconstructive mainstay for nasal defects, which frequently occur in conjunction with periorbital defects.
Periorbital defects often present a surgical challenge because of the need to provide ocular protection, lacrimal drainage system patency, eyelid function, and aesthetics. When a defect is too small to require free flaps or too large to be repaired with an eyelid flap, a forehead flap may be a useful option.
This retrospective series reviews the experience of 3 of us (D.A.S., G.B.B., and J.A.G.) with paramedian forehead flap repair of periorbital defects. The assessment of the defects, flap design, and surgical techniques are discussed. In addition, functional and cosmetic results are analyzed, and selected cases are demonstrated.
Following institutional review board approval, all patients who had undergone reconstruction of periorbital defects with a paramedian forehead flap by 1 of 3 of us (D.A.S., G.B.B., and J.A.G.) were identified from a computerized database, and their medical records were reviewed. Periorbital involvement was determined by review of the surgical notes and preoperative and intraoperative photographs. Periorbital defects were classified as any defects involving the medial or lateral canthus, upper or lower eyelid, or brow. Medical records were reviewed for demographic data, defect classification, surgical procedures, and outcome. Flap survival, functional results (including globe coverage and lacrimal drainage system patency), and postoperative complications (such as epiphora, infection, or scarring) were determined by physical examination at regular follow-up.
A panel of 3 experienced surgeons, excluding us, was shown preoperative and postoperative photographs of the patients, along with photographs of the defect after the lesion had been removed. Using a 10-cm visual analog scale, the surgeons rated the aesthetic result, with 10 representing the best appearance and 0 representing the worst.
The paramedian forehead flap harvest is described in detail elsewhere.7-9 This flap has a rich vertical blood supply, primarily from the supratrochlear vessels. The supratrochlear artery, a terminal branch of the ophthalmic artery, exits the orbit superficial to the corrugator supercilii muscle and deep to the orbicularis oculi. It then courses superficially to the frontalis muscle, approximately 2 cm lateral to the midline. The dorsal nasal vessels and the supraorbital vessels, which pass 1 to 2 cm lateral to the supratrochlear vessels, provide secondary blood supply. Before flap planning, the supratrochlear vessels must be precisely located using palpation or Doppler ultrasound. This improves flap survival and allows for a narrower pedicle base, which will facilitate flap rotation and gain flap length.7
Flap planning begins by creating a template of the defect. A foil template can be created based on corresponding intact tissue opposite to the defect. The flap should then be planned so that the donor site can be closed near to the midline as possible. The length of the flap can be determined by stretching a suture from the distal-most aspect of the defect to the base of the flap. Flaps can be as wide as 6 cm and are limited in length by the hairline.7 Although tissue expansion is an option, it generally is not warranted, as flaps measuring 5 × 6 cm have been described without the use of tissue expansion.10 Blunt dissection, beginning 1 to 2 cm superior to the pedicle base, is used to elevate the pedicle in the subgaleal plane. When raising the flap, care must be taken to avoid damaging the blood supply.
Appropriate reconstructive steps must be completed before flap insertion. For nasal sidewall defects, required mucosal, bone, and cartilaginous reconstruction should be completed. If additional flaps are needed, such as cheek advancement flaps or tarsoconjunctival flaps, these too should be created and inset before forehead flap insertion. These reconstructive steps establish the attachment site and foundation for the forehead flap.
The flap should be thinned to match the thickness of the defect site tissue. Thinning to the subdermal layer is appropriate when repairing eyelid and nasal defects. Defects created by orbital exenteration or maxillectomy may require no thinning at all. The flap is inset to the recipient site using subcutaneous absorbable sutures and monofilament skin sutures.
In women and men with no hair-loss risk, the donor site can be closed with a running W-plasty along the hairline, combined with bilateral subgaleal advancement flaps. If alopecia is a concern, bilateral advancement flaps can be created without the use of the W-plasty, but it is preferred because it provides better aesthetic results.10 The W-plasty is designed with units approximately 1 cm in length and peaks greater than 90°. Three to four units are placed cephalad in the donor site, and the W-plasty is extended bilaterally along the hairline, with beveled incisions opposite to the direction of the hair growth to allow hair to grow through the scar. Subgaleal advancement flaps are elevated over both sides of the forehead and closed in the midline with 2-0 or 3-0 long-lasting absorbable sutures. Any dog-eared formation can be excised and closed. Gauze (Xeroform; Sherwood, St Louis, Mo) impregnated with petrolatum jelly is placed under the unattached pedicle, and the wound edges are covered with antibiotic ointment.
The patient is instructed to change the petrolatum-impregnated gauze daily, and the skin sutures are removed in 5 to 7 days. The flap's pedicle is divided and inset at 3 weeks, at which time care is taken to avoid disturbing the distal flap. The pedicle is sharply divided, any granulation tissue is debrided, and the pedicle base is thinned to match the area of closure. Placing tissue above the glabellar frown lines should be avoided to achieve the best cosmetic result. The flap is trimmed to slightly less than the size of the newly created defect. The subcutaneous tissue is closed with dissolvable buried sutures, and the skin is approximated with 5-0 and 6-0 monofilament sutures, which can be removed in 5 to 7 days.
Eighteen patients underwent the described procedure between August 1, 1989, and December 31, 2000. There were 9 male and 9 female patients, with ages ranging between 11 and 85 years (mean, 62.3 years). The most common underlying cause was basal cell carcinoma, which accounted for more than half of the lesions (Table 1). Defects ranged in size from 8 to 300 cm2 (mean, 46.8 cm2). The most commonly involved structures included the medial canthus, lacrimal drainage system, upper and lower eyelids, and nasal sidewall (Table 2). Five (28%) of the 18 patients required forehead flap reconstruction alone. Calvarial bone grafts, cheek advancement, and nasal turn-in flaps were the most common ancillary procedures (Table 3).
There were no operative or postoperative complications, except for 1 patient with liver failure who had prolonged bleeding from the operative site, which was corrected with local measures (ie, cauterization and wound care).
Follow-up ranged from 1 month to 7.8 years (mean, 1.5 years). No patients experienced flap failure. The most common sequelae related to the resection and reconstruction were epiphora, ectropion, and eyelid retraction (Table 4). Two patients required a conjunctivodacryocystorhinostomy with Jones tube, and 1 patient underwent a dacryocystorhinostomy to treat postoperative epiphora. Two patients underwent conjunctival Z-plasty for retraction secondary to scarring of tarsoconjunctival flaps. One patient developed ectropion during postoperative radiotherapy, which was repaired with a full-thickness skin graft.
The aesthetic outcomes were evaluated on a 10-cm visual analog scale in 14 patients for whom postoperative photographs were available (Table 5). Defects were subclassified as those involving soft tissues alone or in conjunction with bone or cartilage. Of these 14 patients, 10 had preoperative and 10 had intraoperative photographs. Six patients had photographs of all 3 stages, 4 patients had postoperative and intraoperative photographs, and 4 patients had postoperative and preoperative photographs.
An 80-year-old woman had recurrent sebaceous cell carcinoma of the right upper eyelid, which eventually required orbital exenteration. A sinonasal fistula (Figure 1A) developed 2 years later. A biopsy specimen was taken and found to be scar tissue. A cheek rotation flap was advanced into the floor of the orbit, and a forehead flap was used to repair the deep socket biopsy and fistula sites. Endoscopic ethmoidectomy was done on the fistula site to provide a route for sinus drainage into the nose. Figure 1B shows the patient immediately after division of the forehead flap pedicle.
A 23-year-old woman had recurrent nasal chondrosarcoma following 2 previous partial right rhinectomies. The tumor involved the nasal dorsum and right medial canthus (Figure 2A). An epidermal turn-in flap from the lateral nasal subunit was used to reconstruct the intranasal lining (Figure 2B). Calvarial bone recreated the lateral nasal sidewall and was fixed with 3 plates (Figure 2C). A paramedian forehead flap reconstituted the soft tissue defects (Figure 2D). Ten months after surgery, the patient had excellent globe protection and cosmetic outcome (Figure 2E). The tumor recurred 2 years later, involving the nasal bones, glabella, medial canthus bilaterally, and lacrimal sac on the left. Surgical resection required a partial rhinectomy and a bifrontal craniectomy (Figure 2F). Calvarial bone was fixed with 2 plates to reconstruct the glabellar defect, and 4-0 polypropylene was used to recreate the medial canthal tendon on the right. An epidermal turn-in flap from the dorsal nasal subunit recreated the intranasal lining. Calvarial bone was fixed with microplates to the glabellar graft for reconstruction of the nasal dorsum (Figure 2G). A paramedian forehead flap was used to reconstruct the nasal medial canthal soft tissue defects. Eyelid function and cosmesis were excellent 22 months after surgery (Figure 2H).
A 52-year-old man with basal cell carcinoma of his right maxilla underwent a partial maxillectomy and rhinectomy. Soft tissues from the cheek, lower eyelid, medial canthus, and lateral nose were excised to remove the tumor (Figure 3A).
A calvarial bone graft was fixed to the nasal bone and remaining maxilla to reconstruct the floor of the orbit (Figure 3B). Calvarial bone was also used to reconstruct the wall of the maxillary sinus and span the pyriform aperture (Figure 3C). A modified Hughes tarsoconjunctival flap was attached medially to the forehead flap (Figure 3D). Septoplasty was performed, and septal cartilage was used to reconstruct the lateral nasal sidewall. A cervicofacial rotation flap recreated the cheek soft tissues and was attached medially to a bone anchor at the pyriform aperture. The flap was thinned laterally, but subcutaneous fat was left medially to fill the maxillary defect. A paramedian forehead flap was used to reconstruct the nasal soft tissue and medial canthus (Figure 3E). Figure 3F shows the patient 16 months after surgery, with excellent globe protection and cosmesis.
Globe protection, lacrimal drainage system patency, eyelid function, and cosmesis are important considerations when reconstructing periorbital defects. Reconstruction is further complicated by the contours of the face in this area. Forehead flaps are an excellent choice for reconstruction of intermediate-sized periorbital defects, especially periorbital defects associated with nasal defects. They are useful in conjunction with other local and regional flaps in the reconstruction of larger periorbital defects.
Local flaps have traditionally been the first choice to repair small defects of the eyelids and periocular region. They provide superior cosmetic results through enhanced matching of skin color, texture, and structural characteristics; have a rich vascular supply and a low complication rate; and do not require any complex microvascular surgical techniques.11-13 Use of local flaps is limited by tissue availability. Large defects are best treated with regional, myocutaneous, or free flaps.14 From a functional and an aesthetic standpoint, the paramedian forehead flap is an excellent choice for small- or medium-sized defects. Because forehead flaps are designed with an intact major blood vessel, they provide an excellent vascular supply and do not require specialized microvascular surgical training. Forehead flaps provide ample tissue for the repair of nasal and maxillary defects that often accompany periorbital defects. The forehead skin more closely matches the pigmentation and structure of the periocular recipient site tissue.14-15 Forehead flaps can be used in conjunction with other local and regional flaps to repair large facial defects. Finally, forehead skin is pliable and can be trimmed to a desired thickness to conform to the complex landscape around the orbit.
Forehead flaps can be used safely and effectively to reconstruct periorbital defects. The relative ease of harvesting the flap minimizes operative time, and the robust blood supply decreases failure rates. The skin texture and color match those of the recipient bed better than skin harvested from more distal sites, which affords improved cosmesis. The versatility and ease of the forehead flap provide a reliable method for achieving an excellent cosmetic and functional result in the reconstruction of periorbital defects.
Correspondence: David A. Sherris, MD, Division of Facial Plastic Surgery, Department of Otorhinolaryngology, Mayo Clinic, 200 First St SW, Rochester, MN 55905.
Accepted for publication January 22, 2003.
This study was supported in part by a grant from Research to Prevent Blindness, Inc, New York, NY. Dr Price received a Resident Travel Award, Research Education Grant of Arbeitsgemeinschaft fur Osteosynthesefragen–Association for the Study of Internal Fixation, Devon, Pa.
This study was presented at the Arbeitsgemeinschaft fur Osteosynthesefragen–Association for the Study of Internal Fixation Craniomaxillofacial Advanced Symposium; February 4, 2002; Steamboat Springs, Colo.