Paramedian Forehead Flap
The nose occupies a central location in the face, thus maintaining a principal factor in facial aesthetics. Any distortion would have major adverse repercussions on facial beauty. This has led to a near obsession in nasal reconstructive surgery preoccupyi
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Husain T. AlQattan and Seth R. Thaller
Indications 1 . Nasal defects greater than 2 cm in length 2. Excellent for tip, dorsum, subtotal or total nasal reconstruction
Essential Steps tage One of a Paramedian Forehead S Flap for Nasal Reconstruction Preoperative Markings 1. Midline of the scalp is marked from the hairline down to the nasal bridge. 2. Supratrochlear artery’s course from the medial brow going superiorly is marked with the aid of a Doppler ultrasound or by anatomical landmarks (1.7–2.2 cm from the midline on either side).
H.T. AlQattan, M.D. (*) General Surgery, University of Miami/Jackson Memorial Hospital, Miami, FL, USA e-mail: [email protected] S.R. Thaller, M.D., D.M.D., F.A.C.S Division of Plastic Surgery, Department of General Surgery, University of Miami/Jackson Memorial Hospital, Miami, FL, USA e-mail: [email protected]
3. Nasal subunits are marked to help guide need for defect modification to enhance donor fit and optimize final aesthetic result. If more than 50 % of a nasal subunit had been removed then excising the remaining portion may give a better final aesthetic result. 4. An exact template of the defect is made using a suitable material (e.g., foil from a suture pack). This permits a 3-dimensional representation of flap design to ensure adequate dimensions. Distal end of the template lies over the defect whilst the proximal part is centered on the axis of the supratrochlear artery. Template is placed over the ipsilateral supratrochlear artery if the defect is unilateral. However, if the defect is in the midline or covers most of the nose, then either vessel is suitable. Template is rotated 180° superiorly to lie directly vertical and above the pedicle, at the hairline. Then using this template the flap is now outlined on the skin.
Intraoperative Details 1. Patient is in the supine position. 2. General anesthesia with endotracheal tube. 3. Scalp, face, and neck are prepped and draped to permit access to the nose and ears in case conchal cartilage grafts are needed. 4. Skin incision over the template is made on the inside of the ink mark to avoid including excess skin in the flap. Pedicle width is 1–1.5 cm to ease arc of rotation.
© Springer International Publishing Switzerland 2017 T.A. Tran et al. (eds.), Operative Dictations in Plastic and Reconstructive Surgery, DOI 10.1007/978-3-319-40631-2_75
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5. Distal third of flap dissection is carried into the subcutaneous plane using electrocautery and/or sharp dissection. 6. Once the area where the template will cover the nasal defect is elevated, the dissection progresses through the muscle and into a subgaleal plane. Dissection in this plane is continued until corrugator supercilii muscle is identified. 7. At this point the dissection goes deeper into a subperiosteal plane to protect the vascular pedicle. 8. Dissection is performed inferiorly up to 1.5 cm into the root of the nose to enable a tension free arc of rotation. 9. Donor site is closed by wide undermining in a subgaleal plane followed by primar
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