BACKGROUND:
The median and paramedian forehead flaps are considered as the procedure of choice for extensive nasal defects caused by trauma or cancer resection. The classic description involves a second stage operation to divide the pedicle, and more recently, Menick used a third intermediate stage for acute thinning. We present here a series of 10 patients who underwent a single-stage forehead flap. Our indications included children, very old people and patients who are not ideal candidates for a staged procedure with an external, exposed pedicle. The majority were adults with partial and full-thickness defects after cancer excision. One patient was reconstructed after radical excision of a severe, recurrent rhinophyma, and three patients were children reconstructed for extensive skin malignancy due to xeroderma pigmentosa. The design of the musculocutaneous flap is not different in concept from the Indian forehead flap described centuries ago. We have however modified it to allow immediate inset and thus avoid the temporary “elephant trunk” and all of the other sequelae of an external pedicle like bleeding, dressings and inablility to wear eyeglasses. The technique is also different from the “island midline forehead flap” described by Converse and Wood-Smith which was tunneled under intact glabellar skin and led to significant venous congestion.
METHODS:
Our modification involves removal of radix and proximal nasal skin and fat and deepithelialization of the proximal pedicle to allow inset without excess compression or kinking. For full thickness defects, the proximal nasal skin and fat can be used as a hinge flap for nasal lining or alternatively, a split-thickness skin graft is quilted to the underside of the forehead flap. If a skin graft is used, a secondary cartilage grafting procedure may be necessary for skeletal support.
RESULTS:
CONCLUSIONS:
The single-stage forehead flap has provided acceptable results and avoids the need for a mandatory secondary procedure. Additional contouring and/or cartilage grafting procedures are usually recommended for optimal aesthetic results, but not absolutely required. A single-stage forehead flap can be used for nasal reconstruction when multiple stages are contraindicated or inconvenient.