Overview of Forehead Flaps
Forehead flaps are a type of surgery where a piece of skin from the forehead is moved to repair damage to the nose. This process is broken down into two stages. The first record of such a surgery dates back to around 600 BC in India. Nowadays, surgeons use a narrower flap from around the forehead instead of the wide one from the middle of the forehead that was used in the past.
This surgery is a common type of what is called an interpolation flap. This is where a flap of skin, still attached to its blood supply, is placed over normal skin to reach the damaged area. The flap of skin is not fully detached from the forehead until it has formed its own new blood supply at the wound site. This is done in a follow-up surgical procedure.
Sometimes, a more complex version of this surgery is performed. This involves three stages and allows for the transfer of cartilage and/or skin into the nose before the skin flap is moved from the forehead. However, this three-stage process is used less frequently.
Anatomy and Physiology of Forehead Flaps
The paramedian forehead flap (PFF), also known as a forehead skin graft, is a type of medical procedure that uses a portion of the forehead skin and underlying blood vessels for reconstruction purposes, typically done for nose surgeries. The PFF requires a special blood vessel called the supratrochlear artery, for its survival. However, recent studies have shown that it can also survive just by the rich network of the smaller connecting blood vessels present in the mid-forehead area.
Research done on cadavers has provided an insight into the course of this blood vessel. The supratrochlear artery, comes out of the eye socket, approximately 1.7 to 2.2 cm from the middle of the forehead. From there, it goes underneath a muscle around the eye and comes up over the eyebrow muscle. After that, it goes along the eyebrow and penetrates the muscle of the forehead to ascend up in the layer of skin about 1.5 to 2 cm from the middle. Studies have also shown that this artery generally is within a 3 mm line from the inner corner of the eye, upwards towards the scalp.
Some experts also suggest a safer method is to take the blood vessel from the middle of the area between the eyebrows to about 1.2 cm to the side of this central line. It’s important that this vessel, taken from the middle forehead area, is wide enough to avoid any accidental injury to the artery, and also to make sure the blood circulation is maintained well.
Why do People Need Forehead Flaps
If someone has a major wound on the tip of the nose or the ala (the curved part on each side), doctors might use a method called a “forehead flap” to help it heal. This technique is often used when the injury is too severe for simpler healing techniques. The wound might go so deep that it exposes the cartilage, the firm tissue found in the nose. Such wounds need proper blood supply to recover, which they might not get from a skin graft (where skin is taken from another part of the body to cover the wound).
Although skin grafts could give the correct shape to the repaired area, they may fail to provide adequate blood supply, especially for larger wounds on the nose. Related techniques, using skin from areas nearby the wound, can offer both thickness and a blood supply. However, very big injuries could be beyond the capacity of this method.
Moreover, if the damage has affected the nose’s structural stability, another procedure might be conflated with the forehead flap technique. In such a case, a cartilage graft (where cartilage is taken from one part of the body and implanted to the nose) combined with the forehead flap would give better results.
When a Person Should Avoid Forehead Flaps
The PFF, a type of surgical procedure, may not be suitable for some patients. For instance, patients who don’t want to undergo several surgeries in stages or who can’t avoid interfering with their surgery sites may not be a good fit for PFF. Similarly, an active skin infection can be problematic for these types of procedures, as the infected skin should not be used to create a skin flap.
People with a low forehead might need a different version of the forehead flap or a different repair procedure altogether. This is to avoid transferring hair from the scalp to the forehead. Also, if you’re a smoker, there might be some risk involved, because smoking can increase the chance of tissue death in the flap. However, the procedure can typically still be done safely with careful treatment.
It’s generally a good idea to avoid using skin that has previously received radiation treatment or has scar tissue. Furthermore, if the patient is on blood thinning medication or has a bleeding disorder, the procedure needs to be done with caution. It’s a good idea to speak with the doctor who prescribed the blood thinners before stopping the medication. However, it’s usually not necessary to stop taking medication like warfarin, clopidogrel, or aspirin before the surgery.
If a patient has any disorder that causes abnormal bleeding, it’s a good idea to contact a specialist before the surgery begins.
Equipment used for Forehead Flaps
Before your surgery, your surgeon will need several items. These include a surgical marker, a special ultrasound tool called a Doppler ultrasound probe to accurately mark a particular artery, a local anesthetic to numb the area, and materials like foil for creating a flap template, which will serve as a guide during the surgery. In addition, they might need a tubed gauze or similar material to make sure the flap they’re planning to create is the right length, and a surgical antiseptic scrub to clean your skin.
During the surgery, your surgeon will use sterile (completely clean) materials called intraoperative items. These include a sterile drape to keep the area clean, gauze for absorbing blood and other fluids, a scalpel or No. 15 blade for making incisions, an electrocoagulation device to stop bleeding by heating the tissue, tissue scissors for cutting tissue, forceps for holding and manipulating tissues, and a needle holder to hold the sutures. They’ll also use different types of sutures, which are used to close the skin after surgery. Absorbable sutures disappear on their own over time, but non-absorbable sutures will need to be removed by your doctor later. They’ll also have suture scissors for cutting sutures, undermining scissors for separating tissue layers, and normal saline, a salt solution used to clean wounds.
After your flap surgery, your doctor will use several items to dress the wound (cover it up and protect it). They may use Monsel’s solution or cellulose mesh to aid in hemostasis, which is a way to stop the bleeding. They may also use petrolatum-embedded mesh or a gauze ribbon to wrap the flap pedicle, which is like the stem of the flap. They’ll cover the wound area with fluffed gauze, keep it in place with flexible surgical tape, and might even use additional surgical adhesive to stabilize the dressing and keep it in place.
Who is needed to perform Forehead Flaps?
The surgery is usually carried out by a doctor and a surgical assistant, meaning there are two medical professionals working together. This is typically done on a “outpatient” basis, which means you don’t have to stay in the hospital overnight, you can go home the same day.
Preparing for Forehead Flaps
The doctor needs to ensure that the patient understands the full procedure, including how they will look afterwards. This can be done with pictures or photos of other patients who have had the surgery. The surgical area will look like a trunk connecting the eyebrow to the nose or face, for at least three weeks. A second surgery will be needed to separate the flap and potentially more to adjust it. The patient must be prepared not to touch or disturb the flap until it is time for further surgery.
It’s normal for there to be some bleeding in the first one to two days after surgery, especially at the base of the flap, and the patient needs to be ready for this. The doctor should provide the patient with extra bandages to replace their dressings at home, and give them a phone number to call in case the bleeding becomes too heavy or doesn’t stop. Patients should also stop smoking as long as possible, both before and after the surgery, to aid in recovery.
Patients should let their doctor know if they have any big upcoming events or travel plans, as it’s easy to forget to share this information until after the operation. They’ll need to avoid any activities that could increase the risk of bleeding. While doctors usually don’t require patients to stop taking any blood thinning medications they’ve been prescribed, this can vary depending on the surgeon and the doctor who prescribed the medication. It’s important to discuss this with both doctors, as stopping these medications can potentially lead to more serious problems than continuing to take them during the surgery.
How is Forehead Flaps performed
A paramedian forehead flap is a kind of surgery involving a piece of skin from the forehead, which is moved to cover a defect, often on the face. The flap gets its blood supply from an artery known as the supratrochlear artery. However, recent studies suggest that this flap can survive even without this specific artery due to the rich network of blood vessels in that area. This artery usually exits near the eye socket and travels up through the muscles and skin of the forehead.
Furthermore, if more than 50% of a particular area or ‘anatomic subunit’ is involved in the surgical procedure, it might be better to remove the rest of it. The surgeon creates a template of the defect and measures the length of skin needed to cover it. This skin, known as the ‘pedicle’, is then marked out on the forehead.
The surgeon then lifts the flap with its base at the lower portion of the forehead, often close to the eye socket. The area on the forehead where the skin was taken from can be closed up directly or covered by a full-thickness skin graft, though this option may lead to less optimal cosmetic results. The flap is then thinned and sewn into the defect area.
Once the flap is in place, any bleeding is controlled by precise electrocoagulation (a way to use heat to stop bleeding), hemostatic gauze (a gauze that promotes blood clotting), and aluminum chloride or Monsel’s ferric subsulfate. The flaps are then wrapped in a special type of gauze that doesn’t stick to the wound.
Healing usually takes a few weeks. The patient can expect some blood seepage, especially in the first 24 to 48 hours. If the bleeding is heavy or uncontrolled, the patient should contact the doctor.
The dressing can be safely left in place for a week, though some doctors prefer to check it in 1 to 2 days. After 2 to 3 weeks, the remaining part of the flap (pedicle trunk) that connects the newly healed area to the forehead can be safely removed. Afterwards, minor adjustments may be necessary, and these are generally part of the overall healing process.
Showing the patient photographs of the healing process, from the initial procedure to the revisions and healing progression, can also be beneficial to manage expectations.
Possible Complications of Forehead Flaps
When undergoing a surgery that involves the use of a forehead flap, there are a few expected complications that might occur. These include bleeding, scarring, and infection. However, don’t worry, there are preventive measures to lessen these risks.
For instance, careful control of bleeding during the operation and the correct use of surgical dressings afterward can lessen the chances of significant bleeding after the surgery. It also helps if patients avoid physically strenuous activities. Some mild leakage from the base of the flap is common in the first two days but can usually be handled with pressure.
Scar formation is inevitable in any surgery, but with skillful surgical techniques, its appearance can be minimized. The skin should be stitched together accurately, and the size and thickness of the flap should be appropriate. Following anatomical principles can also enhance the look of the surgery site. Sometimes more than one procedure may be needed, and the patient should be prepared for this possibility before undergoing surgery.
In some cases, the flap may end up having a firm, round, raised appearance, a condition called “pincushioning.” This is more common if the area being repaired is round. The best way to avoid this is to follow anatomical principles and refrain from creating round defects. If pincushioning happens, it can be treated with a corticosteroid injection, and if that’s not successful, another surgery may be needed.
Practicing a sterile technique and giving antibiotics before the surgery can decrease the risk of infection. Rarely, the flap may start to die, usually due to smoking, over-thinning of the flap, a very narrow flap, or patient mishandling of the flap. This can often be treated with minimal surgical cleaning. If the skin turns a deep purple, it might be due to insufficient venous blood flow and must be treated quickly with medicinal leeches or by poking the skin with tiny pricks to ease the congestion, otherwise, the flap might fail.
If there is a problem with arterial blood flow to the flap, the flap might appear pale and doughy without normal blood return. This is generally due to accidental injury to artery and often needs another flap surgery. If this happens right after the surgery (day zero or one), it could be due to sudden narrowing of the artery which can possibly be reversed by the cautious application of a medication called nitroglycerin; however, it’s important to note that this medication should be used very carefully in people with underlying heart disease.
What Else Should I Know About Forehead Flaps?
The paramedian forehead flap is a method used by doctors to fix large or deep issues with the nose that cannot be fixed with simpler procedures like skin grafts or local flaps. This involves using well-supplied tissues from the forehead. It can be used on its own or with other methods depending on the size and complexity of the nasal issue.
