A, Marking of natural forehead rhytids, pedicle position, and 5-mm horizontal lines. B, W-plasty design of cutaneous forehead flap pedicle. C, Closure of W-plasty design with interdigitation of the limbs. D, Nasal defect closed with forehead flap with W-plasty pedicle design.
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Jáuregui EJ, Tummala N, Seth R, et al. Comparison of W-Plasty vs Traditional Straight-Line Techniques for Primary Paramedian Forehead Flap Donor Site Closure. JAMA Facial Plast Surg. 2016;18(4):258–262. doi:10.1001/jamafacial.2016.0099
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The paramedian forehead flap (PMFF) donor site scar is hard to disguise and may be a source of patient dissatisfaction.
To evaluate the aesthetic outcome of W-plasty vs traditional straight-line (SL) closure techniques of the PMFF donor site.
Design, Setting, and Participants
A retrospective cohort study was conducted at the University of California, San Francisco Medical Center. Clinical history and operative reports were reviewed for 31 patients who underwent a PMFF procedure performed between November 1, 2011, and May 29, 2014. Blinded photographic analysis of postoperative photographs was performed.
The pedicled component of the PMFF was raised primarily with either a W-plasty or traditional SL design.
Main Outcomes and Measures
Standard photographs of the donor site, obtained at least 90 days after surgery, were reviewed and scored in a blinded fashion by 4 dermatologic surgeons using a 100-point visual analog scale (from 0 [worst possible outcome] to 100 [best possible outcome]) and a 5-point Likert scale (from very poor to excellent). Interrater reliability was assessed via Cronbach α testing.
All 31 forehead flaps survived during this study period; 16 PMFFs were raised with the W-plasty technique and 15 were raised with the SL technique. The W-plasty and SL groups were similar in terms of age, sex, and race/ethnicity (mean [SD] age, 68.4 [12.4] vs 61.8 [11.6] years; 13 [84%] vs 9 [60%] men; and 15 [94%] vs 13 [87%] white). Patients undergoing W-plasty closure had significantly higher mean visual analog scale scores compared with those undergoing SL closure (72.8 [18.3] vs 65.6 [18.1]; P = .03). Mean Likert scale scores for W-plasty were higher than those for SL closure, but the difference was not significant (3.77 [1.02] vs 3.43 [0.98]; P = .08). Overall interrater reliability for the visual analog scale and Likert scale scores were 0.67 and 0.58, respectively.
Conclusions and Relevance
Patients undergoing PMFF donor site closure using a primary W-plasty technique demonstrated better mean scar appearance of the forehead donor site compared with SL closure. The primary W-plasty technique did not result in any PMFF losses and should be considered for appropriate patients.
Level of Evidence
The paramedian forehead flap (PMFF) is a robust, well-established technique for reconstruction of large nasal defects.1 The flap takes advantage of the blood supply provided by the supratrochlear and angular arterial arcades. The vascular pedicle supports a cutaneous paddle, which is often optimal in terms of skin color matching, texture, and thickness for the reconstruction of large cutaneous and composite nasal defects. Classically, the PMFF is raised with a straight-line (SL) incision from the medial eyebrow vertically within the forehead toward the hairline until the desired length is achieved.2
With the advent of the nasal subunit concept as advanced in the pioneering work of Burget and Menick,3 nasal defects reconstructed with the PMFF may be attractive and near normal in appearance. We have noted that patients more commonly are dissatisfied with the appearance of the vertical forehead scar resulting from the PMFF repair than they are with the reconstructed nose. Widespread recognition of this issue has led to the development of multiple postoperative donor site PMFF scar camouflage techniques, including self-adhesive silicone sheeting, corticosteroid and onabotulinumtoxinA injections, dermabrasion, and scar revision. Variations in donor site scar placement have also been advocated,4 such as camouflage of the scar in the exact anatomic midline of the forehead.
Ideally, scars are narrow, have no color mismatch with the surrounding skin, and are well hidden within anatomic subunit boundaries or relaxed skin tension lines. Without these characteristics, a scar can cause undue anxiety and depression and can disrupt patients’ daily activities.5 Scars oriented perpendicular to relaxed skin tension lines that do not fall along anatomic subunit borders (eg, the classic PMFF scar) may be reoriented using a W-plasty technique. This technique, like others,6 relies on breaking a long linear scar into smaller, triangular segments, which are typically less than 6 mm long and are oriented along relaxed skin tension lines.7 For scar revision, the existing scar is excised and the surrounding triangular segments of the W-plasty are interdigitated and closed, thus concealing a greater amount of the resulting scar in relaxed skin tension lines.
Although both the PMFF and W-plasty techniques have been used by surgeons for many years, the 2 are rarely applied in conjunction.8,9 Therefore, we sought to perform a comprehensive comparison to examine whether raising the pedicle component of the PMFF in a primary W-plasty technique would yield a better aesthetic outcome compared with the classic SL incision.
The University of California at San Francisco institutional review board approved a retrospective review of the medical records of 34 patients who underwent a PMFF procedure by either of 2 of us (R.S. and P.D.K.) at the University of California, San Francisco Medical Center between November 1, 2011, and May 29, 2014. Of these 34 patients, 31 individuals (91%) had postoperative photographs taken at least 90 days after the pedicle division was performed and were included in the analysis. Surgeon preference changed from SL closure to running W-plasty during the study period, leading to the 2 disparate groups. Rates of current use of tobacco, diagnosis of diabetes mellitus, and laterality of the flaps were recorded.
Sixteen PMFFs were raised primarily with a W-plasty design (Figure) in which the 1.2- to 1.5-cm-wide pedicle component was created with a series of 60° angled limbs measuring approximately 5 mm long with their peaks or troughs resting in the natural forehead rhytids. Alternatively, 15 PMFFs were raised with a traditional vertical SL design.2
The flaps were raised sharply and with sterile technique. Wound closure for both groups was performed with interrupted 3-0 polyglactin 910 (Vicryl; Ethicon Inc) deep dermal sutures and 5-0 nonabsorbable nylon (Ethilon; Ethicon Inc) sutures for superficial skin closure. Skin sutures were removed 7 to 10 days postoperatively, and standardized wound care instructions were provided to all patients.
Standard photographs (Canon EOS 60D SLR, 60-mm Canon EFS Ultrasonic Macro lens with dual box flashes; Canon USA Inc) of both groups of patients were taken during follow-up office visits at least 90 days postoperatively by either of the facial plastic surgeons. The photographs were deidentified and cropped to show only the glabella and forehead; no additional editing of the photographs was performed. Edited photographs from all 31 patients were compiled and distributed in the form of an electronic survey (Qualtrics) to 4 attending dermatologic surgeons (S.A., I.N., S.Y., and R.G.) who were blinded to the type of treatment received (W-plasty vs SL closure) for assessment of wound cosmesis.
The aesthetic outcome of each procedure was rated via a visual analog scale (VAS) and a Likert scale. The VAS is a continuous, 100-point scale (0, worst possible aesthetic outcome; 100, best possible aesthetic outcome) that has been used10-12 to measure similar subjective outcomes. The Likert scale consisted of 5 scoring options (1 [very poor], 2 [poor], 3 [average], 4 [above average], and 5 [excellent]) to describe the aesthetic wound outcome. Evaluators marked their score selection electronically, and scores were subsequently compiled and analyzed.
Statistical analysis to determine the significance of the findings was done for both groups. Cronbach α testing was used to determine interrater score reliability, with a score greater than 0.4 considered to be good. A 2-tailed, unpaired t test was used to analyze the VAS scores, and Wilcoxon rank sum tests were performed to analyze the Likert scale scores. Differences at P < .05 were considered to be statistically significant.
There were no associated procedural complications. Demographic comparisons between the W-plasty and SL groups in age, sex, smoking, diabetes mellitus, and side of PMFF are presented in Table 1. Overall, no significant differences were apparent between the closure technique groups.
Aggregate mean (SD) scores from all evaluators demonstrated a significantly higher VAS score with the postoperative W-plasty wound closure compared with the SL closure (72.8 [18.3] vs 65.6 [18.1]; P = .03) (Table 2). The difference in the mean Likert scale score for patients who had undergone a W-plasty compared with SL procedure was not significant (3.77 [1.02] vs 3.43 [0.98]; P = .08 with Wilcoxon sum rank test).
Biostatistical interrater reliability analysis of the VAS data revealed an overall Cronbach α value of 0.67, with 0.62 for the SL group and 0.68 for the W-plasty group (Table 2). The overall Likert scale Cronbach α value was 0.58, with 0.71 for the W-plasty group and 0.30 for the SL group (Table 3).
Patients undergoing PMFF nasal reconstruction prefer a result as near as possible to their expectation. Toward this end, most of the aesthetic attention and refinements associated with PMFF are focused on the reconstruction of the nasal defect. Many difficulties and challenges are associated with PMFF, including the arc of the rotation of the pedicle, limited length owing to the hairline, distortion of the eyebrow and glabellar region, and flap thickness.13 Nevertheless, attention should also be directed to the forehead donor site scar to optimize the overall aesthetic outcome of the entire reconstructive paradigm.
Multiple recent studies have focused on eye-tracking patterns and the degree of deformity required to be “noticeable”14 as well as the psychological effects of disfiguration. Although the morbidity of the forehead scar is minimal, it is not negligible, particularly among individuals with short hair that cannot easily cover the forehead scar.
Several previous studies10,11,15-17 have sought to achieve the ideal scar. Scar formation is a result of reparative rather than regenerative healing, starting with inflammation of the wound to secure against infection, followed by granulation tissue formation and proliferation of the extracellular matrix to support reepithelialization, and finally remodeling during the next several months to years.15 In addition, patient comorbidities, such as diabetes mellitus and tobacco smoking, can significantly affect wound healing. Smoking tobacco has been shown18 to decrease tissue oxygenation and attenuate the body’s ability to heal by prolonging the inflammatory phase and slowing proliferation. Diabetes mellitus damages the microcirculation of the skin, impeding tissue nutrition, waste removal, and the inflammatory response; combined, these factors impede the healing of skin wounds.19 Other measures of nutrition were not recorded in our population since they were not appropriate for our study. Skin pigmentation is also known16,20 to affect the appearance and severity of scar formation, with darker skin tones being more prone to severe scarring than lighter skin tones. Most of our patients (90%) self-identified as white, therefore minimizing variations in the scar aesthetics associated with different ethnicities.
The use of W-plasty, Z-plasty, and geometric broken-line closure techniques have been used successfully for revising scars that are oriented perpendicularly to relaxed skin tension lines, have poor skin length matching, or are shortened and contracted. A running W-plasty may extend directly above the lateral glabellar crease, or it may be curved to run in the anatomic midline. Rather than a running Z-plasty, W-plasty is not used to lengthen the scar. In our experience, a 1.2- to 1.5-cm pedicle width may easily be closed primarily. Moreover, once the peaks and troughs of the running W-plasty are incised through the dermis, a pedicle width of 1.5 cm can easily be maintained through the subcutaneous fat and frontalis muscle to ensure flap viability. We recommend that the peaks and troughs fall as much as possible within the natural rhytids and, if possible, that the individual limbs approximate 5 mm.
Our study shows that PMFFs raised primarily with a W-plasty technique have a significantly better aesthetic outcome based on a 100-point VAS score as well as a trend toward better postoperative aesthetic outcomes based on a 5-point Likert scale score. Among the 4 dermatologic surgeon reviewers, each scored the W-plasty higher than the SL technique on both the VAS and Likert scale.
Limiting factors in this study are present. Patients were photographed at least 90 days postoperatively; however, the SL-incision group had longer mean and median times between the date of surgery and the photograph. With these differences, it is possible that the results of the W-plasty group could have been better had there been a longer interval between the operation and the photograph. In addition, a larger patient population may have permitted significance to be realized with the Likert scale evaluation. A further limitation is that aesthetic outcomes are subjective. We attempted to address this issue by using 2 different scales and 4 blinded evaluators, none of whom had performed any of the surgical procedures.
Aesthetic outcomes of PMFF nasal reconstruction should also focus on the forehead donor site. Patients undergoing PMFF donor site closure using a W-plasty technique demonstrated significantly better mean scar appearance following surgery compared with patients whose donor sites were closed using an SL technique evaluated with a VAS. The primary W-plasty technique did not result in any PMFF losses and should be considered for appropriate patients.
Corresponding Author: P. Daniel Knott, MD, Section of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery, University of California, San Francisco Medical Center, 2233 Post St, Third Floor, San Francisco, CA 94115 (firstname.lastname@example.org).
Accepted for Publication: February 1, 2016.
Published Online: March 31, 2016. doi:10.1001/jamafacial.2016.0099.
Author Contributions: Drs Seth and Knott had full access to all of 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: Jáuregui, Tummala, Seth, Arron, Knott.
Acquisition, analysis, or interpretation of data: Jáuregui, Seth, Neuhaus, Yu, Grekin, Knott.
Drafting of the manuscript: Jáuregui, Tummala, Seth, Yu, Knott.
Critical revision of the manuscript for important intellectual content: Jáuregui, Seth, Arron, Neuhaus, Grekin, Knott.
Statistical analysis: Jáuregui.
Administrative, technical, or material support: Tummala, Seth.
Study supervision: Neuhaus, Knott.
Conflict of Interest Disclosures: None reported.
Additional Contributions: We thank the Clinical and Translation Science Institute at the University of California, San Francisco for their statistical assistance.