Case 11 (2023): Paramedian forehead flap for nasal soft tissue reconstruction

Linn Anna Fiehn; Anna Louise Norling; Magnus Balslev Avnstorp

Journal of Plastic, Breast & Reconstructive Surgery·Rapports de cas chirurgicaux en libre accès, évalués par les pairsÉvalué par les pairs · Libre accès

Case 11 (2023): Paramedian forehead flap for nasal soft tissue reconstruction · JPBRS

Rapport de cas

Case 11 (2023): Paramedian forehead flap for nasal soft tissue reconstruction

Linn Anna Fiehn, Anna Louise Norling, Magnus Balslev Avnstorp

Publié 29 avril 2023127 vues7 min de lecture

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Résumé

67-year-old male was referred to the dept. of Plastic Surgery by his local dermatologist with basal cell carcinoma (BCC) of the infiltrating type localized on the apex nasi, measuring 25 x 25 mm. The diagnosis was previously confirmed by histological analysis of a punch biopsy. Pre-existing conditions: bronchial asthma, adipositas, COPD and AFib. Currently medicated with edoxaban, digoxin and vera

Points clés à retenir

Conseils pratiques

The paramedian forehead flap should be considered the gold standard for reconstruction of larger nasal tip defects, providing patients predominantly with excellent functional and cosmetic outcomes [4, 5].
The procedure can be safely performed in an outpatient setting on patients of all ages, with multiple comorbidities and even active smokers [4].
Multiple adjustments/ extensions can be made to the procedure to best address the individual defect regarding lining, support, and coverage [4].

Écueils

Carefully assess for preinstalled Clopidogrel treatment as it puts patients at risk of excessive bleeding [4].
The degree of thinning is case- and patient-dependent and should therefore undergo constant intraoperative evaluation. Flap thinning in smokers is not recommended and should be done, if necessary, only with great caution in risk of necrosis [4].
Whenever possible, hair transferal with the flap should be avoided as it can cause hair growth or ingrown hair, which are highly inconvenient to the patient and can be challenging to manage [4].
If direct donor site closure is not possible, it has to either heal in secondary intention or receive an allograft, xenograft, equine products, or skin graft [4], which can compromise the aesthetic outcome.
Avoid closing the donor site at the flap rotation point to prevent pinching and venous congestion [4].

Patient history

Examination

The patient appears alert, oriented, and in good general condition. The tumor sits medially on the apex nasi, measures 25 x 25 mm and fills out the entire nasal tip subunit [1]. It presents itself as a pale color with irregular borders, and a non-ulcerous central dent. Overall, the clinical examination agrees with the finding of a BCC. No palpable lymphadenopathy at the head, neck, supra-, or infraclavicular.

Pre-operative considerations

Although generally considered to be at very low risk of distant metastasis, the BCCs have a potential of local invasive growth. Tumors’ excision with a 5 mm safety margin is indicated [2]. Taking the psychosociological effect and functional risk of the tumors’ location into account, the best possible reconstruction should follow the necessary excision [3]. The paramedian forehead flap poses an excellent option for the repair of > 20 mm nasal defects and should be considered the gold standard for the reconstruction of this type of defect [4]. The procedure can be safely performed in patients of all ages, with multiple comorbidities, in active smokers, and with no need to adapt the patient’s anticoagulation status [4]. Only treatment with Clopidogrel was described to increase the risk of strong bleeding and should therefore be carefully assessed preoperatively [4].

Plan: For a paramedian forehead flap, guiding principles suggest the use of a reasonably narrow pedicle (13 – 15 mm), leading to an axial flap pattern defined by blood supply through the supratrochlear artery [4, 5]. Early subperiosteal dissection will ensure adequate blood supply to the flap [4]. Adequate distal thinning and medial rotation of the pedicle will help with correct flap insertion and is followed by donor site closure [4]. After 3-4 weeks, the flap is divided, and the final flap inset is performed.
Patient information: The procedure can be performed under local anesthesia in the outpatient clinic. As it is a two-step procedure, it includes a 3- to 4-week period between flap elevation + primary inset and flap division + final inset. Depending on tissue quality and availability on the forehead, direct suture is not always possible and the donor site has to potentially heal in secondary intention or receive an allograft, xenograft, equine products, or skin graft [4]. Complications include bleeding, infection, and distal flap necrosis [6, 7]. In line with the experience in our clinic and findings from literature [4-6, 8], we conclude a low perioperative risk and expect an excellent functional and aesthetic outcome.

Références

Burget, G.C., Aesthetic restoration of the nose. Clinics in plastic surgery, 1985. 12(3): p. 463-480.
Krammer, C.W., et al., Treatment algorithm for non-melanoma skin cancer. Ugeskr Læger, 2018. 180:V01180044.
John, J., et al., Outcomes Associated with Nasal Reconstruction Post-Rhinectomy: A Narrative Review. Arch Plast Surg, 2022. 49(2): p. 184-194.
Correa, B.J., et al., The forehead flap: the gold standard of nasal soft tissue reconstruction. Semin Plast Surg, 2013. 27(2): p. 96-103.
Menick, F.J., Aesthetic refinements in use of forehead for nasal reconstruction: the paramedian forehead flap. Clin Plast Surg, 1990. 17(4): p. 607-22.
Chen, C.L., et al., Postoperative Complications of Paramedian Forehead Flap Reconstruction. JAMA Facial Plast Surg, 2019. 21(4): p. 298-304.
Hammer, D., F. Williams, and R. Kim, Paramedian forehead flap. Atlas of the Oral and Maxillofacial Surgery Clinics of North America, 2020. 28(1): p. 23-28.
Cerci, F.B., Usefulness of the subunit principle in nasal reconstruction. An Bras Dermatol, 2017. 92(5 Suppl 1): p. 159-162.

Post-operative plan

If the procedures were performed at the outpatient clinic and according to general guiding principles, the postoperative care for both operations is usually minimal. Dicillin 1000 mg x 4 is administered in a prophylactic dosage. The patient is advised to keep the head elevated and avoid hot food and drinks during the next 24-48 h. Fresh bandages (Micropore for the sutures, Jelonet for the pedicle) are provided for self-conducted dressing changes every other day. Analgesia can be steered by the patient with up to 4 x 1g paracetamol per day. 10 days after initial flap inset, the sutures can be removed at the outpatient clinic together with flap evaluation and division planning. Until then, the patient should avoid exhausting physical activities such as exercise or home chores.

Pearls

The paramedian forehead flap should be considered the gold standard for reconstruction of larger nasal tip defects, providing patients predominantly with excellent functional and cosmetic outcomes [4, 5].
The procedure can be safely performed in an outpatient setting on patients of all ages, with multiple comorbidities and even active smokers [4].
Multiple adjustments/ extensions can be made to the procedure to best address the individual defect regarding lining, support, and coverage [4].

Pitfalls

Carefully assess for preinstalled Clopidogrel treatment as it puts patients at risk of excessive bleeding [4].
The degree of thinning is case- and patient-dependent and should therefore undergo constant intraoperative evaluation. Flap thinning in smokers is not recommended and should be done, if necessary, only with great caution in risk of necrosis [4].
Whenever possible, hair transferal with the flap should be avoided as it can cause hair growth or ingrown hair, which are highly inconvenient to the patient and can be challenging to manage [4].
If direct donor site closure is not possible, it has to either heal in secondary intention or receive an allograft, xenograft, equine products, or skin graft [4], which can compromise the aesthetic outcome.
Avoid closing the donor site at the flap rotation point to prevent pinching and venous congestion [4].

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Case 11 (2023): Paramedian forehead flap for nasal soft tissue reconstruction

Résumé

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Patient history

Examination

Pre-operative considerations

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Étape 1 — BCC excision

Étape 2 — Flap definition

Étape 3 — Flap elevation and thinning

Étape 4 — Initial flap inset

Étape 5 — Donor site closure

Étape 6 — Wound dressing

Étape 7 — Pre-flap division 34 days postoperative

Étape 8 — Flap division and final inset

Étape 9 — Follow-up

Post-operative plan

Pearls

Pitfalls