Introduction
The human forehead is the topmost part of the face, just above the eyebrows and below the hairline. Although it appears as a flat surface, it has various important functions. It supports the skull; the forehead muscles help in showing different emotions of the face. Apart from these basic functions, the tissues of the forehead are considered an excellent donor site for various reconstructive and plastic surgeries such as nasal reconstruction.
Based on the anatomical divisions of the forehead, the forehead flaps are of various types, such as median, paramedian, or transverse. Out of these, paramedian are the standard forehead flap procedure for reconstruction because of their excellent vascularity and skin color match.
What Is a Flap?
A flap consists of skin, tissue, or bone that is used for the reconstruction of any human body part, such as nose reconstruction, or ear reconstruction. It is a small piece of human tissue and is attached through an artery or vein (blood supply).
What Are the Types of Flaps?
There are different types of flaps:
1. Local Flap: It is also known as a pedicled flap. The flap or piece of tissue is taken from the site near or adjacent to the surgery site. The flap remains attached to its base and can rotate or freely move in any direction. There are four types of local flaps:
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Advancement Flap: It can move in the forward direction but not on lateral sides.
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Rotation Flap: It can rotate in different directions.
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Transposition Flap: It can move in lateral directions.
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Interpolation Flap: It can rotate in any direction and can be placed in the nearby site but not adjacent to it. It looks like a bridge.
2. Free Flap: The flap or piece of tissue is taken from a donor site located at a different body part, and the blood supply is reconnected adjacent to the surgery site.
What Are Forehead Flaps?
A flap taken from the forehead of the human body is called a forehead flap. It acts as a donor site for many reconstruction procedures and plastic surgeries. It is the most commonly used flap in nasal reconstruction. It is a two-stage tissue flap that is pedicled.
What Are the Types of Forehead Flaps?
Based on the anatomical location:
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Midline Forehead Flap: It is a mix of median and paramedian forehead flaps taken from the center of the forehead.
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Median Forehead Flap: It is taken from the middle of the forehead and is a pedicled type of flap whose base is attached to the center of the forehead.
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Paramedian Forehead Flap: It is an interpolated type of flap based on the supratrochlear artery (terminal branch of the ophthalmic artery that originates from the supratrochlear foramen).
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Oblique Forehead Flap: It is a long flap taken diagonally from the forehead at an angle of 45 degrees.
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Transverse Forehead Flap: It is a long flap taken from the anterior or front part of the ear containing the superficial temporal artery.
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Glabellar V-Y Advancement Forehead Flap: It is a V-Yshaped flap taken from the glabella region of the forehead - bony prominence on the forehead.
Based on forehead tissue area:
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Complete Flap: The entire forehead tissue is taken as a flap.
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Partial Flap: Only a small portion of forehead tissue is taken.
Based on the timing of flap division:
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Early: The pedicle division is done within 16 days.
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Conventional: The pedicle division is done between 16 to 28 days.
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Delayed: The pedicle division is done after 28 days.
What Are the Uses of Forehead Flaps?
The various uses of forehead flaps are:
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To treat or reconstruct nasal defects. For example, the use of midline forehead flaps in nasal reconstruction.
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Deep wounds of the distal nose.
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Exposed cartilage of the nose where skin grafts cannot be used.
What Is Forehead Flaps Procedure?
Forehead flap surgery is a simple technique. The paramedian forehead flap is the most commonly used flap for nasal reconstruction. In general, the surgical procedure includes:
Before Surgery:
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Patient education should be done by providing complete information about the procedure and flap.
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The patient should be prepared to manage the bleeding from the flap site, which is common for two days.
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The patient should avoid smoking one month before the surgery and avoid it after the surgery until complete healing.
During Surgery:
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A template or outline of the defect is made, and the pedicle length is measured to reach the defect from the pedicle base with a tube gauze.
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The tube gauze is rotated towards the forehead, and an inverted or reverse pattern is marked at the uppermost part of the pedicle.
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Then a pedicle flap of 1 to 1.5 cm in length is taken along with its base.
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The forehead or donor site is then closed with a skin graft.
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The flap is thinned according to the defect size and shape and is placed on the defect and closed with simple interrupted sutures.
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A nonadherent dressing is placed, and fluffed gauze is placed with gentle pressure and secured with tape.
After Surgery:
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The dressing is left for seven days.
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After two to three weeks, the pedicle of the flap is removed or excised.
What Are the Complications of the Forehead Flap Surgery?
The Complications of Forehead Flap Surgery include:
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Bleeding.
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Scar formation.
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Infection.
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Delayed or poor healing.
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When the flap does not receive adequate blood and oxygen supply, it may die, which is called necrosis of the flap. This leads to flap failure that may require re-surgery.
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The forehead flap is based on the supratrochlear artery, which supplies blood to the scalp and forehead. Injury to this artery further increases the risks of complications.
Which Forehead Flap Is Most Commonly Used in Nasal Reconstruction?
The paramedian forehead flap is most commonly used in nasal defects, especially distal nose reconstruction. It has many advantages over other forehead flaps:
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It has a good vascular supply which is the biggest advantage.
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It provides the best skin color match and skin texture match.
Who Is an Ideal Candidate for Forehead Flap Surgery?
To undergo forehead flap surgery, the patient must have these characteristics:
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Non-smoker or have quit smoking one month before surgery.
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Healthy.
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Young in age because elderly patients are not advised to undergo this surgery.
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Do not have comorbidities or chronic conditions such as diabetes.
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Do not take medications such as anticoagulants.
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Be ready to undergo surgery.
Conclusion
Forehead flaps are used to repair extensive defects, especially nasal defects. When skin grafts or other techniques do not provide adequate coverage, then forehead flaps are the choice of procedure. These can be used alone or in combination for effective results. Forehead flaps are the ideal choice for reconstruction in most patients as they are performed safely on an outpatient or inpatient basis.
