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  • Title: Broadening applications and insights into the cross-paramedian forehead flap over a 19-year period.
    Author: Rudolph MA, Walker NJ, Rebowe RE, Marks MW.
    Journal: J Plast Reconstr Aesthet Surg; 2019 May; 72(5):763-770. PubMed ID: 30737127.
    Abstract:
    BACKGROUND: Forehead flap reconstruction of large nasal defects can be challenging. The senior author has used a paramedian forehead flap modification using the supratrochlear artery on the contralateral side of the defect. METHODS: A 9-year retrospective review (2008-2016) was performed for patients undergoing nasal reconstruction with the cross-paramedian forehead flap. Outcomes were analyzed by comparing our previous reviews, which allows us to analyze patient outcomes for over 19 years. RESULTS: Fifty-three patients were identified. The aasal defect was most frequently due to basal cell carcinoma (n = 37, 69.8%). Twenty-three (43%) patients were smokers, and nine (17%) had diabetes. The mean defect size was 12.9 cm2, involving an average of 2.6 nasal subunits. One-third of the patients had cartilage defects (n = 18) and mucosal lining defects (n = 19). Periorbital involvement was present in five patients. Complications included partial flap loss (n = 6), donor site dehiscence (n = 4), flap dehiscence (n = 2), and postoperative infection (n = 1). Only two of the partial flap losses were considered significant, as they required additional reconstructive procedures for soft tissue coverage. Complications were 12 times as likely as those in diabetes (OR = 11.97, p = 0.007, 95% CI 1.94-72.44), six times as likely as those in cartilage defects (OR = 6.4, p = 0.007, 95% CI 1.64-24.92), and nearly five times as likely as those in mucosal lining defects (OR = 4.8, p = 1.27-18.09, 95% CI 1.27-18.09). Thirty-one patients required revisions most commonly for flap debulking (n = 16). CONCLUSION: The cross-paramedian forehead flap is a reliable option in the armamentarium of the reconstructive surgeon for large and complex defects in addition to those with periorbital extension. SUMMARY: Coverage of distal nasal defects after tumor extirpation remains a challenge to the reconstructive surgeon. Our institution uses the cross-paramedian forehead flap for these defects. This flap is based on the supratrochlear artery on the contralateral side of the defect and is oriented obliquely across the forehead for additional length and an improved donor site scar at the level of the eyebrow. The technique and outcomes were published in 2009, and this manuscript serves as an update on outcomes and applications during the past 9 years. By including all our data, we can analyze outcomes for over 19 years. During the past 9 years, 53 patients underwent the cross-paramedian forehead flap technique between 2008 and 2016. These patients were found to have an average defect size of 12.9 cm2 and an average loss of 2.6 nasal subunits. Cartilage defects were present in 34.6% (n = 18) and mucosal defects were present in 36.5% (n = 19) of patients. Five patients had periorbital reconstruction with the forehead flap, of which three patients underwent a single-stage islandized forehead flap reconstruction. Given the large defect size, additional local flaps were frequently used, including nasolabial flaps (n = 16) and cheek rearrangement (n = 11). Complications included partial flap loss (n = 6), donor site dehiscence (n = 4), and postoperative infection (n = 1). Only two of these partial flap losses were considered significant, as they required additional reconstructive procedures to address areas of soft tissue loss. Increased rates of complications were associated with the presence of diabetes and defect characteristics, which reflects increased complexity including mucosal and cartilage loss. When comparing with our prior review of this technique, the more recent population have had increasing complexity of the nasal defects with a large surface area involvement. Overall, the cross-paramedian forehead flap is a reliable option in the armamentarium of the reconstructive surgeon for large and distal nasal defects.
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