Paramedian Forehead Flap (PMFF)

Considerations

• • Anatomy (eMedicine: Forehead Anatomy)

    • Forehead layers 

      • Skin, subcutaneous tissue, frontalis muscle, areolar tissue, pericranium

    • Forehead blood supply 

      • Pedicle: Suptrochlear a. <-- ophthalmic a. <-- ICA

        • Surface landmark = vertical alignment with the medical canthus

          • 2008: A reliable surface landmark for localizing supratrochlear artery: medial canthus 

      • Supraorbital a. <-- ophthalmic a. <-- ICA

      • Angular a. <-- facial a. <-- ECA

    • Corrugator muscle 

  • Indications 

    • Nasal defects involving one or more subunits 

• 1998: Improvements in forehead flap design for nasal reconstruction

• 2006: The forehead flap for nasal reconstruction: how we do it

• 2010: Reconstruction of extensive nasal defects with staged bilateral paramedian forehead flaps

• 2011: Elegant solutions for complex paramedian forehead flap reconstruction

• 2012: Outcomes of paramedian forehead and nasolabial interpolation flaps in nasal reconstruction

• 2014: Paramedian forehead flap

• 2016: Comparison of W-Plasty vs Traditional Straight-Line Techniques for Primary Paramedian Forehead Flap Donor Site Closure

Preparation

Procedure

Stage 1 

• • Doppler and mark the supratrochlear artery 

  • Make a template of the nasal defect and transpose to the forehead using a string and pivot point on the brow along the path of the pedicle 

    • Center the flap on the axis of the pedicle 

    • Narrow the base of the flap to ~15 mm, again centered on the pedicle 

  • Elevate the flap

    • Incise the skin

    • Starting the at most superior aspect, raise the flap in the subcutaneous plane for 1-2 cm

    • Raise the flap in the areolar plane (sub-frontalis m) until 2-3 cm from the orbital rim

    • Complete the elevation in sub-periosteal plane

  • Rotate and lay the flap over the primary defect, avoid tension

  • Optional: Thin the flap; May remove fascia and muscle from the inset tissue but must keep subdermal plexus 

  • Inset the flap starting caudally

  • Close the secondary defect starting caudally, leaving what cannot close with undermining open to heal by secondary intention

  • Wait 3 weeks  

Stage 2 

• • Optional: Assess flap collateral perfusion by placing a soft tie (like a rubber band) around the pedicle minutes prior to stage 2 

  • Divide the pedicle 

  • Thin and narrow the cephalad aspect of the flap 

  • Inset the cephalad aspect of the flap

  • Close the residual brow defect 

    • Return the base of the pedicle to its natural (cephalad) orientation and lay into the forehead incision established in stage 1 

    • Incise the pedicle so that it forms a triangle and fits into the medial brow defect 

    • Inset the pedicle base 

Touch-up work 

• • The flap may be further contoured via a combination of thinning and quilting sutures 

Sample operative report

Post-op

Pearls & Pitfalls

High-Yield

• • Name the key anatomical factor that contributes to the high reliability of the PMFF

    • The axial blood supply; namely, the supratrochlear artery 

Links

• eMedicine - Forehead Flaps

• eMedicine - Nasal Reconstruction Treatment & Management

• eMedicine - Paramedian Forehead Flap Nasal Reconstruction

• eMedicine - Principles and Techniques of Nasal Reconstruction

• eMedicine - Pedicle/Interpolation Flaps Treatment & Management

  • Iowa protocols - Paramedian Forehead Flap 

• YouTube (5:41) - PARAMEDIAN FLAP by MICROSURGERY MADE EASY !!

• YouTube (6:50) - Paramedian Forehead Flap by HD plastic and maxillofacial surgery