A 10-year experience in nasal reconstruction with the three-stage forehead flap

Because of its ideal color and texture, forehead skin is acknowledged as the best donor site with which to resurface the nose. However, all forehead flaps, regardless of their vascular pedicles, are thicker than normal nasal skin. Stiff and flat, they do not easily mold from a two-dimensional to a three-dimensional shape. Traditionally, the forehead is transferred in two stages. At the first stage, frontalis muscle and subcutaneous tissue are excised distally and the partially thinned flap is inset into the recipient site. At a second stage, 3 weeks later, the pedicle is divided. However, such soft-tissue "thinning" is limited, incomplete, and piecemeal. Flap necrosis and contour irregularities are especially common in smokers and in major nasal reconstructions. To overcome these problems, the technique of forehead flap transfer was modified. An extra operation was added between transfer and division.At the first stage, a full-thickness forehead flap is elevated with all its layers and is transposed without thinning except for the columellar inset. Primary cartilage grafts are placed if vascularized intranasal lining is present or restored. Importantly, at the first stage, skin grafts or a folded forehead flap can be used effectively for lining. A full-thickness skin graft will reliably survive when placed on a highly vascular bed. A full-thickness forehead flap can be folded to replace missing cover skin, with a distal extension, in continuity, to supply lining. At the second stage, 3 weeks later during an intermediate operation, the full-thickness forehead flap, now healed to its recipient bed, is physiologically delayed. Forehead skin with 3 to 4 mm of subcutaneous fat (nasal skin thickness) is elevated in the unscarred subcutaneous plane over the entire nasal inset, except for the columella. Skin grafts or folded flaps integrate into adjacent normal lining and can be completely separated from the overlying cover from which they were initially vascularized. If used, a folded forehead flap is incised free along the rim, completely separating the proximal cover flap from the distal lining extension. The underlying subcutaneous tissue, frontalis muscle, and any previously positioned cartilage grafts are now widely exposed, and excess soft tissue can be excised to carve an ideal subunit, rigid subsurface architecture. Previous primary cartilage grafts can be repositioned, sculpted, or augmented, if required. Delayed primary cartilage grafts can be placed to support lining created from a skin graft or a folded flap. The forehead cover skin (thin, supple, and conforming) is then replaced on the underlying rigid, recontoured, three-dimensional recipient bed. The pedicle is not transected. At a third stage, 3 weeks later (6 weeks after the initial transfer), the pedicle is divided.Over 10 years in 90 nasal reconstructions for partial and full-thickness defects, the three-stage forehead flap technique with an intermediate operation was used with primary and delayed primary grafts, and with intranasal lining flaps (n = 15), skin grafts (n = 11), folded forehead flaps (n = 3), turnover flaps (n = 5), prefabricated flaps (n = 4), and free flaps for lining (n = 2). Necrosis of the forehead flap did not occur. Late revisions were not required or were minor in partial defects. In full-thickness defects, a major revision and more than two minor revisions were performed in less than 5 percent of patients. Overall, the aesthetic results approached normal.The planned three-stage forehead flap technique of nasal repair with an intermediate operation (1) transfers subtle, conforming forehead skin of ideal thinness for cover, with little risk of necrosis; (2) uses primary and delayed primary grafts and permits modification of initial cartilage grafts to correct failures of design, malposition, or scar contraction before flap division; (3) creates an ideal, rigid subsurface framework of hard and soft tissue that is reflected through overlying skin and blends well into adjacent recipient tissues; (4) expands the application of lining techniques to include the use of skin grafts for lining at the first stage, or as a "salvage procedure" during the second stage, and also permits the aesthetic use of folded forehead flaps for lining; (5) ensures maximal blood supply and vascular safety to all nasal layers; (6) provides the surgeon with options to salvage reconstructive catastrophes; (7) improves the aesthetic result while decreasing the number and difficulty of revision operations and overall time for repair; and (8) emphasizes the interdependence of anatomy (cover, lining, and support) and provides insight into the nature of wound injury and repair in nasal reconstruction.     

Geometric considerations in the design of rotation flaps in the scalp and forehead region

The classical transposition and rotation flaps are well known. Cosmetic considerations in the scalp and forehead region limit the use of a flap design that requires a skin graft for a donor defect. On sound geometric principles, the classical flap designs are suitably modified here to have a somewhat equal proportion of transposition and rotation. This "modified rotation flap" design works to a maximum advantage in the inextensible region of the scalp and forehead by providing single-stage primary closure of moderate to large defects. No backcuts are ever necessary with this flap design. Use of this principle to modify the rotation flap design for closure of an extended midline forehead defect following rhinoplasty allows a still wider (up to 6.5 cm) midline forehead flap to be available for rhinoplasty with primary closure of the donor defect.     

The role of tissue expansion in the management of large congenital pigmented nevi of the forehead in the pediatric patient

The authors present a cohort of 21 consecutive patients who had congenital pigmented nevi covering 15 to 65 percent of the forehead and adjacent scalp and who were treated at their institution within the last 12 years. All patients were treated with an expansion of the adjacent texture- and color-matched skin as the primary modality of treatment. The median age at presentation was approximately 1 year; mean postoperative follow-up was 4 years. Nevi were classified according to the predominant anatomic areas they occupied (temporal, hemiforehead, and midforehead/central); some of the lesions involved more than one aesthetic subunit.The authors propose the following guidelines: (1) Midforehead nevi are best treated using an expansion of bilateral normal forehead segments and advancement of the flaps medially, with scars placed along the brow and at or posterior to the hairline. (2) Hemiforehead nevi often require serial expansion of the uninvolved half of the forehead to minimize the need for a back-cut to release the advancing flap. (3) Nevi of the supraorbital and temporal forehead are preferentially treated with a transposition of a portion of the expanded normal skin medial to the nevus. (4) When the temporal scalp is minimally involved with nevus, the parietal scalp can be expanded and advanced to create the new hairline. When the temporoparietal scalp is also involved with nevus, a transposition flap (actually a combined advancement and transposition flap because the base of the pedicle moves forward as well) provides the optimal hair direction for the temporal hairline and allows significantly greater movement of the expanded flap, thereby minimizing the need for serial expansion. (5) Once the brow is significantly elevated on either the ipsilateral or contralateral side from the reconstruction, it can only be returned to the preoperative position with the interposition of additional, non-hair-bearing forehead skin. Expansion of the deficient area alone will not reliably lower the brow once a skin deficiency exists. (6) In general, one should always use the largest expander possible beneath the uninvolved forehead skin, occasionally even carrying the expander under the lesion. Expanders are often overexpanded.     

Free-flap reconstruction of large defects of the scalp and calvarium

Beyond a certain size, full-thickness defects of scalp are not amenable to local flap repair. Staged distant flaps have now been virtually eliminated by free-flap reconstruction. The authors present 12 patients in whom full-thickness scalp defects with an average area of 275 cm2 were reconstructed utilizing free flaps. Nine patients had corresponding large calvarial defects. Ten patients had reconstruction with free latissimus dorsi muscle flaps and overlying skin grafts, and one patient had reconstruction with a scapular free flap. Of the 12 patients, 8 had extirpative surgery for tumor with immediate reconstruction and the remaining 4 had reconstruction for chronic radionecrosis of the scalp, usually associated with infected osteoradionecrosis of the calvarium. Of this latter group, 2 patients underwent simultaneous acrylic cranioplasty. The technique and results are discussed.     

Refinements of the subcutaneous pedicle flap for closure of forehead and scalp defects

Two representative cases of repair of forehead defects using a modification of the subcutaneous pedicle flap are reported. Complications are minimal if proper technique is followed. Application of this flap to include difficult donor areas, such as the scalp and forehead, should be considered.     

Nasal reconstruction with a forehead flap in children younger than 10 years of age

Nasal reconstruction has been analyzed extensively in adults but not in children. The purpose of this article is to review the authors' experience with the forehead flap for nasal reconstruction in 10 children under the age of 10 during a 10-year period. Outcomes were assessed by an objective grading system for cosmetic surgical results. Subjective criteria were also applied by an assistant surgeon and by the patients' relatives. Appropriate results were obtained by the following principles: (1) A modified approach that considers three subunits consisting of the dorsum, tip, and ala was used; (2) a forehead flap is the best option for an entire subunit or a full-thickness defect repair; (3) the forehead flap design should be paramedian, oblique, and opposite to the major defect to avoid the hairline and allow better caudal advancement; (4) ear or costal cartilages are good options for structural support (the septum is a nasal growth center that should not be touched); (5) infundibular undermining of vestibular mucosa, turnover flaps, and skin grafts are good options for internal lining; (6) reconstruction is a three-stage procedure (an intermediate operation is added to thin the flap and perform secondary revisions for lining and support); (7) reconstruction should be completed before the child is school aged, to achieve good aesthetic results immediately and avoid psychosocial repercussions; and (8) the reconstructed nose, with skin, lining, and support, will grow with the child (no final surgery should be planned at the age of 18, other than revisions of late complications).     

Prevention and treatment of wide scar and alopecia in the scalp: wedge excision and double relaxation suture

The visible linear scar of the scalp is a cosmetically serious complication of a scalp incision in scalp surgery, forehead lift, and craniofacial surgery, especially on the temporal scalp. Its causes are cicatrical alopecia and scar widening. To solve this problem, we performed the wedge excision of the scalp and the double relaxation suture of the galea in 2 patients undergoing facial surgery through the coronal approach and in 15 patients with scalp alopecia ranging from 0.5 to 3.0 cm in width. The wedge excision using the beveling incision at an angle of 30 degrees to the hair follicles preserves the deep hair follicles of the flap margins and allows the hair to grow into the scar, eventually preventing cicatricial alopecia and camouflaging the linear scar. The double relaxation suture of the trimmed galea with nonabsorbable suture with or without the relaxation incision minimizes skin tension for a long time, eventually preventing scar widening. This procedure was followed by the superficial skin suture for maintaining the skin sutures for a long time and avoiding the injury of the superficial hair follicles. In all patients, we observed an excellent cosmetic result of unnoticed scar line without complications during the follow-up period of 10 weeks to 6 months.     

Circumauricular incision (water-drop shape) for mid- to lower face lift

The conventional method of mid- to lower face rhytidectomy that involves removing a strip of occipital scalp always creates a conspicuous transverse scar crossing the postauricular skin, which may leave a stair-step deformity at the occipital hairline. The author has designed a new face lift method using a circumauricular incision, shaped like a water droplet, that curves around the auricle. In this new method, the upper part of the "O" shape is modified to the tip of a water droplet. The dissection of the cheek and neck is performed as in the conventional method with light-retractor assistance. The temporal region above the deep temporal fascia is managed under endoscopic control. This dissection can extend to the forehead region lateral to the supraoptic nerve and around the lateral orbital rim to release the arcus marginalis. A mesentery of superficial temporal fascia is created cephalic to the zygomatic arch. The postauricular dissection is performed beneath the galea in the upper part and beneath the occipital scalp and neck skin in the lower area. The lifting vector is upward and backward for the anterior skin flap and upward for the posterior skin flap. The excess skin is trimmed around the ear. The wound at the upper pole of the incision is closed in a V-to-Y advancement fashion. The dog-ear is left above the normal hairline, and there is little or no hairy scalp to be removed. The skin pleating in the postauricular region will settle down spontaneously after several months. The dog-ear in the scalp will become smaller and flat as well. The scar around the ear is quite inconspicuous and well covered under the upper pole of the auricle. From the author's experience, the new "water drop" circumauricular incision is a good alternative for the mid- to lower face lift. It can also be used in conjunction with endoforehead lift for full-face rejuvenation.     

Composite reconstruction for chest wall and scalp using multiple ribs-latissimus dorsi osteomyocutaneous flaps as pedicled and free flaps

A composite flap is presented based on the latissimus dorsi myocutaneous unit together with the underlying ninth to eleventh ribs. Three patients are presented. In two, a full-thickness chest-wall defect was present. In one, a full-thickness scalp and cranial defect was present. Use of the composite osteomyocutaneous latissimus dorsi free flap as a pedicled flap in two patients and as a free flap in one patient resulted in successful definitive reconstruction in all with no complications. This procedure necessitates no transplantation of soft tissue prior to bone grafting to maintain local vascularity, so the simultaneous one-stage reconstruction of an osseous-soft-tissue defect becomes possible easily.     

Nasal reconstruction with the expanded forehead flap

This report details the experience with nine patients over a 3-year period who had partial or total nasal reconstruction using an expanded forehead flap. The history of nasal reconstruction is reviewed, emphasizing the evolution of the forehead flap as the ideal donor site. The author's experience with skin expansion of the forehead to produce a thin ideal flap is presented in detail. Complications of the procedure are reviewed. Technical considerations to achieve a good result are emphasized. The forehead donor site is minimal and well accepted. This procedure provides a solution to a major problem with partial and total nasal reconstruction.     

Repair of wide coup de sabre without cutaneous excision by means of pericranial-galeal padding flap

A case of double linear scleroderma of the forehead (coup de sabre) is described. The histopathology of this rare lesion is now well known with a normal epidermis and a sclerotic dermis. The correction was done with an original two-stage procedure: the lesion with alopecia was first treated by excision-suture and a transfer of the involved subcutaneous tissue along the right inner canthus; 1 year later, by a hemicoronal incision, we transferred a galeal-pericranial flap beneath the wider forehead lesion. We think that the use of a filling flap to correct wide coup de sabre lesions without cutaneous excision can be a simple alternative to the classic treatment by complete excision and flap reconstruction. The subcutaneous fascial system of the scalp can provide a good donor site with minimal morbidity.     

Skin graft from a scalp flap

We present a case of scalp avulsion treated with a transposition scalp flap utilizing a split-thickness skin graft from the flap. Using the flap as a donor site confined the operation to a single anatomic region and saved the patient an additional donor-site scar. The flap healed uneventfully with normal regrowth of hair, the donor site was well concealed, and there was complete take of the split-thickness skin graft.     

The skin of primates. 28. The stump-tail macaque (Macaca speciosa)

Though having some similarities to that of the rhesus monkey, the skin of the stump-tail macaque has several unique features. The epidermis has a sparse population of active melanocytes, and there is practically no pigmentation in the dermis. The dermis is rich in elastic fibers, the function of which seems to be to anchor the hair follicles and the arrectores pilorum muscles, and the superficial blood vessels. Large numbers of eccrine and apocrine sweat glands in the forehead and scalp are reminiscent of the axillary organ in the Hominioidea. The very large sebaceous glands on the face and bald forehead and scalp resemble those of man. The forehead and anterior portion of the scalp are bald in the adult but not in juvenile animals. In spite of an apparently rich pelage, these animals seem to show a trend toward nakedness.     

When does a random flap die?

A random flap can be constructed, its circulation determined, and the ischemic portion identified. Left untreated for a period, the critical ischemia time, the ischemic portion will die and is clinically recognized several days later. What is not known is when this tissue, destined to die, actually dies. To ascertain this time, we compared the percent necrosis of a distal 3 x 3 cm segment of a 10 x 3 cm reverse McFarlane random flap with a known distribution of necrosis to the percent necrosis of the distal 3 x 3 cm of full-thickness skin grafts taken from a similar reverse McFarlane flap at 0, 4, 8, 12, and 16 hours after pedicle construction. Implicit in this experiment is the assumption that necrosis of the full-thickness skin grafts in excess of that of control animals represented skin no longer viable. Sometime between 8 and 12 hours, the percent necrosis of the full-thickness skin grafts surpassed that of the control, and it was concluded that this graft was dead prior to grafting. Thus it is suggested that critical ischemia time and death of the flap tissue are nearly identical, and the latter occurs at between 8 and 12 hours.     

The extended V-Y flap.

The extended V-Y flap is a modification of the V-Y advancement flap, which is very useful in closing defects following excision of facial lesions. The modification involves the addition of an extension limb onto the advancing edge of the standard flap. This limb is located adjacent to the area requiring reconstruction and is hinged down as a transposition flap on the end of the V-Y advancement flap to close the most distal portion of the defect. The extended V-Y flap has been found to be very effective in closing large defects in areas that typically have inadequate subcutaneous tissue to allow extensive mobilization of the standard V-Y advancement flap. It has been used effectively with excellent cosmetic results in the temporal, scalp, forehead, and nasal areas, providing a well-contoured and aesthetically pleasing reconstruction.     

Conservative treatment of cutis aplasia

Three cases of cutis aplasia are presented. The defects involved include full-thickness defects of scalp and cranium as well as full-thickness skin defects of the abdomen and thigh. All patients were treated conservatively with the use of Silvadene cream dressings. Healing was obtained in all patients.     

Beards, baldness, and sweat secretion

The hypothesis according to which male common baldness has developed in the human species as a compensation for the growth of a beard in order to achieve heat loss has been tested. In 100 clean-shaven men direct measurement of the area of glabrous skin on the forehead and calvaria was found to be proportional to that of the hairy skin on the lips, cheeks, chin and neck. During light hyperthermia the evaporation rate on the bald scalp was 2 to 3 times higher than on the hairy scalp. Conversely the evaporation rate was practically equal on the foreheads and chins of women and unbearded young men, while in adult clean-shaven bearded men it was 40% less on the chin than the forehead. These results support the hypothesis that male baldness is a thermoregulatory compensation for the growth of a beard in adults.     

The skin of primates. 38. The skin of the red uacari (Cacajao rubicundus)

The skin of the red uacari (Cacajao rubicundus) is characterized by distinctive traits. Pigmentation of both the epidermis and dermis in juvenile animals resembles a similar condition recorded in adult Callithricidae. Extensive capillary sinuses pervade the upper dermis of the face, ears, forehead, and frontal scalp. Hederiform nerve endings are common in the face and scalp, as are papillary nerve endorgans in the volar friction surfaces; both are reactive for specific and pseudocholinesterase. A general diminution in size of hair follicles and a retarded generative cycle contribute to the phenomenon of “baldness” in the forehead and scalp of mature animals. Apocrine glands are quantitatively diminished over the dorsum. Eccrine sweat glands, confined to the palmar and plantar friction surfaces, are poorly differentiated; all secretory cells contain glycogen.