Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 16  |  Issue : 1  |  Page : 9-17

The utility of the lateral forehead flap in demanding reconstructive situations: our experience in a tertiary care center


1 Department of Surgery, SN Medical College, Jodhpur, Rajasthan, India
2 Department of Plastic Surgery, SN Medical College, Jodhpur, Rajasthan, India
3 Department of Burns and Plastic Surgery, SMS Medical College, Jaipur, Rajasthan, India

Date of Submission03-Jun-2018
Date of Acceptance07-Jul-2020
Date of Web Publication17-Sep-2020

Correspondence Address:
Dr. Rajneesh Galwa
Department of Plastic Surgery, SN Medical College, Jodhpur, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njps.njps_10_18

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  Abstract 

The current century is an era of microsurgical reconstruction. However, there are situations when free tissue reconstruction is not possible due to extremes of age, their associated co morbidities and dearth of microsurgical expertise and equipment. The significance of local and regional flaps in such reconstructive scenario is paramount. These flaps are well vascularised, easy to master, quick to perform and can be used in both primary as well as salvage reconstruction. The Lateral forehead flap (LFF) is one such useful option. The LFF is an axial myocutaneous flap spanning the entire forehead aesthetic subunit. Herein we describe the operative technique of LFF elevation, advantages and disadvantages of the use of this flap in the reconstruction of facial and intra oral defects reconstruction, both in primary and salvage settings. We describe our experience in the use of this handy flap for various facial reconstructions in our institute. This versatile “forgotten” flap which is easy to master can be handy to all general plastic surgeons who indulge in such reconstructions.

Keywords: Facial reconstruction, lateral forehead flap, microsurgery, myocutaneous flap, salvage reconstruction


How to cite this article:
Midya M, Galwa R, Goil P. The utility of the lateral forehead flap in demanding reconstructive situations: our experience in a tertiary care center. Nigerian J Plast Surg 2020;16:9-17

How to cite this URL:
Midya M, Galwa R, Goil P. The utility of the lateral forehead flap in demanding reconstructive situations: our experience in a tertiary care center. Nigerian J Plast Surg [serial online] 2020 [cited 2020 Oct 29];16:9-17. Available from: https://www.njps.org/text.asp?2020/16/1/9/295252


  Introduction Top


The current century is an era of microsurgical reconstruction. Trainee plastic surgeons are brought up with the principles of microsurgical reconstruction right from the outset. Today post traumatic and post cancer ablation facial defects of any size and depths can be reconstructed using the principles of microsurgery.

However, there are situations when free tissue reconstruction is not possible due to extremes of age and their associated co-morbidities. There is dearth of microsurgical expertise and equipment which are usually the norm rather than exception in low resource set up like ours. This situation is compounded with ever increasing bane of high velocity trauma and intra oral cancers that is so rampant in our society. The reconstructive task is enormous and personnel are scarce.

The significance of local and regional flaps in such reconstructive scenario is paramount. These flaps are well vascularised, easy to master, quick to perform and can be used in both primary as well as salvage reconstruction. Pectoralis major myocutaneous flap,[5] Deltopectoral flap[6] and the lateral forehead flap (LFF) stand out among others.

The LFF is an axial myocutaneous flap spanning the entire forehead aesthetic subunit. It has been used previously to reconstruct various post cancer ablation soft tissue defects both intra orally and over the face.[7] We describe our experience of using LFF in reconstruction of soft tissue defects of the face due to various etiologies and circumstances.


  Materials and methods Top


Operative technique

The flap elevation is done under general endotracheal anaesthesia. The superior limit of flap elevation is at the hairline and the inferior limit is at the superior orbital ridge just above the eyebrow [Figure 1]. The flap elevation is done transversely across the forehead based on the right or the left superficial temporal artery depending on individual case requirements.
Figure 1 (a) Line diagram showing the superior, inferior and the lateral limits of LFF elevation. STA − Superficial temporal artery and (b) intra operative clinical photograph showing the subgaleal layer of flap elevation.

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The skin incision is made using a surgical knife starting at the distal end of the marked flap. Skin incision is deepened and dissection is carried out in the subgaleal layer of the scalp. The avascular layer of the loose areolar tissue between the galea aponeurotica and the pericranium is the proper plane of the flap elevation.

During flap elevation, the supraorbital and supratrochlear arteries need to be coagulated occasionally to avoid troublesome bleeding. The resultant defect on the forehead after flap elevation is the pericranium layer over the forehead which is covered with a split thickness skin graft (SSG) with minimal meshing to maximize aesthetics [Figure 2]. The grafted site is dressed with paraffin gauze with a tie over bolster applied over it to maintain pressure and provide stable engraftment. Donor site dressing is changed at day 5.
Figure 2 Intra operative clinical photograph showing the resultant defect on the forehead being resurfaced with a split thickness skin graft.

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The transfer of the LFF to the intraoral defects requires subcutaneous tunneling adjacent to the base of the flap. No additional incision is required for tunnel creation. The tunnel is created in the direction of the upper buccal sulcus in the loose areolar tissue plane. The part of the LFF which lies beneath the tunnel is then accurately marked and deepithelised to ensure proper inset. Finally the distal part of the LFF is then sutured in place to the intraoral defect using absorbable sutures.

The flap is detached after a period of 3 weeks. We do not routinely reposition the donor flap over the scalp to keep the forehead as one aesthetic subunit.

Patients and results

This is a retrospective case series undertaken in the department of Plastic Surgery of SMS Medical College, Jaipur which is a tertiary care center in the North West of India. The duration of the study was eighteen months from July 2016 to December 2017. We describe fourteen cases that had undergone soft tissue reconstruction with the LFF during this period, highlighting the utility of this now ‘forgotten’ flap in select clinical scenarios.

We summarize our cases in tabularized form with [Table 1] describing the demographic profile and clinical scenario of the patients included in the study. [Table 2] describes the reconstructive results and complications. The term primary flap is used where LFF was used as the first reconstructive option whereas Salvage flap is used where LFF was used as second option when primary reconstruction with a free flap or a local flap failed in first place [Figure 3] [Figure 4] [Figure 5] [Figure 6] [Figure 7] [Figure 8] [Figure 9] [Figure 10].
Table 1 The demographical profile and clinical scenario of the patients included in the study

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Table 2 The reconstructive results and flap complications of the patients under study

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Figure 3 Clinical photograph showing PRIMARY flap cover of the exposed root of nose and glabella with LFF.

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Figure 4 Clinical photograph showing SALVAGE flap cover of the post ablation defect of left hemi nose, orbital cavity and adjacent cheek with LFF.

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Figure 5 (a) Arrow shows the marginal mandibulectomy defect (b) Arrow shows the subcutaneous tunneling adjacent to the base of the flap (c) Long term follow up photograph of the same patient


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Figure 6 (a) Clinical photograph showing PRIMARY flap cover of the left hemi nasal skin, orbital cover and adjacent cheek with Left sided LFF and (b) arrow shows the remaining lower cheek soft tissue defect being reconstructed with local rotation skin flap from the ipsilateral neck.

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Figure 7 (a) Clinical photograph of the patient with arrow showing extensive BCC of the lower eyelid and involving the left eyeball and (b) clinical photograph showing PRIMARY flap cover of the orbital defect and adjacent cheek with right-sided LFF.

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Figure 8 (a) Carcinoma right buccal mucosa involving the commissure and extending to the skin and (b) PRIMARY flap cover of the soft tissue defect of the cheek, lips and commissure with right sided LFF.

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Figure 9 Clinical photograph showing SALVAGE flap reconstruction of the outer skin cover with left sided LFF. Arrow points to the previous reconstruction of the defect with PMMC flap.

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Figure 10 Clinical photograph showing SALVAGE flap cover of the post ablation defect of the cheek after previous failed reconstruction with local skin flap (arrow).

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  Discussion Top


LFF based on the superficial temporal arteries was first described by McGregor in 1962[2] and subsequently by Millard in 1963.[1]

The forehead region is one of the highly vascularised areas of the human body. [1] The forehead supplied by named axial vessels has been versatile in the reconstruction of soft tissue defects of the face due to diverse etiology.[2] The forehead has been divided into two angiosomes in each half [Figure 11].[3] The forehead flap based on supratrochlear and supra-orbital arteries has been used extensively for midface reconstruction.[4] The paramedian forehead flap is the gold standard for reconstruction of nasal defects.[4]
Figure 11 Line diagram of the forehead showing forehead angiosomes. 1. Based on ipsilateral Superficial Temporal artery. 2. Based on ipsilateral Supratrochlear and Supraorbital arteries. 3. Based on contralateral Supratrochlear and Supraorbital arteries. 4. Based on contralateral Superficial Temporal artery.

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The LFF is an axial myocutaneous flap based on the parietal branch of the superficial temporal vessels.[7] The overlying skin paddle is well vascularised from the musculocutaneous perforators of the underlying frontalis muscle.

In general, the forehead is widely known as the ideal donor for midface and nasal reconstruction due to its colour, texture match, robust vascularity and its aptness to resurface all or part of the reconstructed area.[8] The flap is generally designed to include the forehead skin of the entire forehead aesthetic unit.

The flap contains the forehead skin, subcutaneous connective tissue and the underlying frontalis muscle.[10] The motor supply of the LFF is the frontal branch of the facial nerve. The sensory nerves supplying the flap arise from the supratrochlear, supraorbital and auriculotemporal nerves.[8],[9]

It is a well-known fact that the frontal branch of the facial nerve innervates the frontalis muscle from below and becomes superficial progressively; one is fraught with the inability to elevate eyebrows after forehead flap elevation. Also the sensory nerves being sub-cutaneous all along their course, there is a liability of sensory loss over the entire forehead region after LFF elevation. These are probably the reason of LFF’s non popularity among the general plastic surgeons.

There are various clinical variants of this flap.[10] The standard forehead flap extends horizontally between the anterior hairline and the superior edge of the eyebrow. The modified forehead flap has its markings more posterior such that skin over the frontal skull can be used. A reverse flap can also be designed such that the skin island is placed in the preauricular area between the zygomatic arch and ear lobule.[9] Finally a bilobed LFF can also be planned based on both branches of the superficial temporal artery and is used to cover both the mucosal and outer lining of full thickness defects of the cheek.[10]

Based on the above mentioned clinical variants of the LFF, almost any area of the face can be covered by this flap.[9],[11] It was this versatility of the flap reach that it was used with success and confidence in the past.[9]

The particular advantages of LFF are:
  1. Flap transfer is easy to master.
  2. Similar in colour and texture to the face so follows the principle of replace ‘like with like’.
  3. Versatility of reach in the face in diverse reconstructive scenario like trauma, malignancy.
  4. Does not require any microsurgical expertise and equipment.
  5. Less in bulk than any free flap so has ideal contour characteristics for both intra oral and surface reconstructions.
  6. Quicker flap dissection and transfer so useful in high morbid cases like preexisting heart disease, hypertension and diabetes mellitus.
  7. Due to its versatile reach, easy flap transfer and its independence of microsurgical expertise, it is an excellent choice in high ‘case load’ conditions with limited microsurgical expertise.
  8. Due to excellent blood supply of the forehead skin from the musculocutaneous perforators of the underlying frontalis muscle, it is quite reliable in cases where radiotherapy is contemplated post operatively.
  9. Most importantly, due to its excellent vascularity, it can be used as a salvage flap in cases where primary reconstruction due to free flap or other local flaps has failed.
  10. The various clinical variants as described above give us multitude of options for large area reconstruction in almost any area of the face.


However there are certain inherent disadvantages which are associated with LFF.
  1. It requires a two stage operative procedure, the second one for flap detachment and insetting, adding length to the overall reconstruction time.
  2. There is loss of eyebrow elevation postoperatively.
  3. There is variable loss of forehead skin sensation.
  4. There can be problem of hairline distortion.
  5. Finally and most importantly, the donor site is re surfaced with SSG which can be aesthetically displeasing as forehead is the center figure of the face.


The cases that we have discussed above were due to trauma and post oncological resection defects. We live in a society which is fraught with road traffic accidents, oral cancers due to predilection of ‘gutkha’ (tobacco) chewing and skin cancers due to large hours of outdoor activity.

There is often ignorance of the disease process associated with the oral and skin cancers and the patients present late to the care givers. They require larger ablation of the disease and post-operative radiotherapy.

The reconstruction therefore has to be robust to endure the effects of radiotherapy and also for functional rehabilitation. In recent times, free tissue transfer is considered the gold standard for optimal reconstruction of such defects.[12]

This can be efficiently handled by a reconstructive option which can be mastered easily and effective in its task. LFF fits into these criteria easily.

However, we do agree with the donor site complications that are so inherent with LFF. We believe that LFF should be raised in its entirety rather than partially so that the entire aesthetic subunit of forehead donor site can be recreated by SSG.

The stigma of the scar following the SSG on the forehead remains. However, on long follow up, it is interesting to see that in many cases the healed graft tends to blend with the rather darker skin that is so typical of the Indian subcontinent. The forehead healed scar can be concealed in hair style or scarf. Alternatively, forehead skin can be expanded before flap transfer that will limit the scar on the forehead to a linear scar. [7]


  Conclusion Top


“Old is Gold”. This adage is quite appropriate for the LFF. This versatile flap is easy to master and can be handy to all general plastic surgeons. This flap should be considered in the reconstructive armamentarium for facial and intra oral defects both in primary and salvage settings.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Millard DR Jr. Forehead flap in immediate repair of head, face and jaw. Am J Surg 1964;108:508-13.  Back to cited text no. 1
    
2.
McGregor IA. The temporal flap in intra-oral cancer: its use in repairing the post-excisional defect. Br J Plast Surg 1963;16:318-35.  Back to cited text no. 2
    
3.
Houseman ND, Taylor GI, Pan WR. The angiosomes of the head and neck: anatomic study and clinical applications. Plast Reconstr Surg 2000;105:2287-313.  Back to cited text no. 3
    
4.
Correa BJ, Weathers WM, Wolfswinkel EM, Thornton JF. The forehead flap: the gold standard of nasal soft tissue reconstruction. Semin Plast Surg 2013;27:96-103.  Back to cited text no. 4
    
5.
Tripathi M, Parshad S, Karwasra RK, Singh V. Pectoralis major myocutaneous flap in head and neck reconstruction: an experience in 100 consecutive cases. Natl J Maxillofac Surg 2015;6:37-41.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Andrews BT, McCulloch TM, Funk GF, Graham SM, Hoffman HT. Deltopectoral flap revisited in the microvascular era: a single institution 10-year experience. Ann Otol Rhinol Laryngol 2006;115:35-40.  Back to cited text no. 6
    
7.
Supit L, Sudjatmiko G. The extended lateral forehead flap: today as was 50 years ago. J Plast Rekonstr 2012;1.  Back to cited text no. 7
    
8.
Menick FJ. Nasal reconstruction. In: Thorne CH, Beasley RW, Aston SJ, Bartlett SP, Gurtner GC, Spear SL, editors. Grabb & Smith’s Plastic Surgery. 6th ed. Philadelphia: Lippincott Williams & Wilkins 2007. p. 389-96.  Back to cited text no. 8
    
9.
Mathes SJ, Nahai F, Barrows ST. Reconstructive surgery: principles, anatomy & technique. New York:Churchill Livingston e;1997 271-88.  Back to cited text no. 9
    
10.
Frunza A, Beedasy A, Anghel A, Lascar I. The Forehead flap. Eplasty 2014;14:ic47.  Back to cited text no. 10
    
11.
Strauch B, Vasconez L, Hall-Findlay EJ. Grabb’s encyclopedia of flaps. Boston, Mass: Little & Co;1990 365-388.  Back to cited text no. 11
    
12.
Colletti G, Autelitano L, Tewfik K, Rabbiosi D, Biglioli F. Autonomized flaps in secondary head and neck reconstructions. Acta Otorhinolaryngol Ital 2012;32:329-35.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]
 
 
    Tables

  [Table 1], [Table 2]



 

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