[Folded paramedian forehead flap - Surgical technique: About 17 patients]. / Lambeau frontal paramédian plicaturé ­ technique chirurgicale : à propos de 17 patients.

OBJECTIVE: In this article, we present our academic experience with the reconstruction of the dorsum and nasal tip by folded paramedian forehead flap described by F.J. Ménick (LFPP). We take a closer look at the technical aspects of this surgical technique and the aesthetic results at the donor sites. We compare our surgical technique with those reported in the literature. MATERIAL AND METHOD: A monocentric retrospective study was carried out on patients operated on by LFPP for surgical reconstructions of the nasal dorsum and nasal tip between January 2017 and December 2022. In each case, we analysed the typology of the type of substance loss for reconstruction, the type of reconstruction and the aesthetic result of reconstruction. A satisfaction survey on the aesthetic and functional results was sent to patients who had undergone LFPP reconstruction at 6 months post-op. RESULTS: There was no necrosis, even partial in any of the 17 cases of LFPP reconstruction. The average size of the substance loss was 3.5±0.6cm [2.5-5]. The number of aesthetic subunit (SUE) to be reconstructed was 2.6±0.9 [1-4]. The etiologies of substance loss were mainly related to skin tumors, including 58% basal cell carcinoma basal cell carcinoma (n=10), 24% squamous cell carcinoma (n=4), 6% adenoid cystic carcinoma adenoid cystic carcinoma (n=1) and 12% melanoma (n=2). The patients were very satisfied overall, both from a functional point of view with a questionnaire result of 89% (8.94±1.98 [2-10]), aesthetic, with a result of 87% (8.76±1.75 [3-10]). CONCLUSION: Among the various techniques for reconstructing the nasal pyramid, including paramedian 2-stage paramedian forehead flaps combined with a local flap of the internal lining, the technique of reconstruction described by J.F. Menick using a 3-stage paramedian folded flap is the most reliable option for complex nasal reconstructions with low donor-site morbidity.

A Single Staged Reconstruction of Upper Eyelid and Eyelashes.

The upper eyelid is a complex structural part of the face that plays an important role in protecting the cornea from drying and damage to preserve vision. The eyelashes are an essential part of the upper eyelid and help in protecting the eyes from dust, foreign bodies, and sweat. Being a part of the face, which is the most noticeable part of the body, both structures hold an important role in reconstructive procedures. Reconstruction of both structures simultaneously is tricky but helps reduce the number of procedures required in achieving an aesthetically acceptable eye. Our techniques describe the use of the paramedian forehead flap with an anterior hairline to reconstruct the upper eyelid and eyelashes in a single stage in a posttraumatic near-total upper eyelid defect with a favorable outcome. Depending on the parting of the patient's hair, the anterior hairline of one side can be included in the distal edge of the flap while raising, which can be inset so that the direction and orientation of the eyelashes perfectly match. Our technique refurbishes an established technique for eyelid reconstruction to include eyelash reconstruction at the same time, thus saving time and resources without any inconvenience to the patient.

A prospective study of psychological adjustment during and after forehead flap nasal reconstruction.

The psychological effects of staged nasal reconstruction with a forehead flap were prospectively investigated. Thirty-three patients underwent nasal reconstruction with forehead flaps between March 2017 and July 2020. Three questionnaires were used to assess psychosocial functioning before surgery (time 1), 1 week after forehead flap transfer (time 2), 1 week after forehead flap division (time 3), and after refinement procedures (time 4). The patients were categorized into three groups according to the severity of nasal defects. Between- and within-group comparisons were conducted. All patients reported increased satisfaction with their appearance during nasal reconstruction. For most patients, levels of distress and social avoidance were highest before reconstruction (time 1). Both levels decreased as reconstruction advanced, and were significantly improved by times 3 and 4. The stage of reconstruction had a greater effect on these levels than did severity of nasal defect. Nasal reconstruction with forehead flap is beneficial physically and psychologically. Psychological evaluation before and after surgery facilitates patient-surgeon interactions and further enhances outcomes.

Decision Making in Nasal Reconstruction: When to Use the Forehead Flap?

In this review, the paramedian forehead flap indications and uses are reviewed, specifically examining clinical situations where patient selection is important. In these settings, a preoperative discussion with a patient regarding surgical expectations and goals in the setting of their defect is paramount. The authors review the literature regarding the psychosocial aspects of major nasal reconstruction and review preoperative discussion points that are key to a well-informed patient and improved patient satisfaction through the nasal reconstructive process.

Nasal Lining Reconstruction with Prelaminated Forehead Flap.

A successful nasal reconstruction relies heavily on a stable internal lining. Larger defects pose unique challenges for internal lining reconstruction as obtaining tissue of adequate size while maintaining airway patency is difficult. The prelamination technique uses a staged skin graft to the paramedian forehead flap prior to transfer. As such, a composite flap can be later transferred to reconstruct internal and external nasal defects concomitantly. This article reviews the current background, techniques, and clinical considerations in the use of the prelaminated forehead flap for nasal lining reconstruction in partial to total nasal defects.

Nuances in Forehead Flap Reconstruction for Large Nasal Defects.

The forehead flap is a time-tested and robust resurfacing flap used for nasal reconstruction. Owing to its excellent color and texture match, acceptable donor site morbidity, and robust and independent blood supply that can support both structural and internal lining grafts, this flap remains the workhorse flap for resurfacing large nasal defects. Various nuances of this technique relating to defect and template preparation, flap design, flap elevation, flap inset, donor site closure, and pedicle division are discussed in this article. These nuances are the guiding principles for improved outcomes using a forehead flap for the reconstruction of large nasal defects.

Reconstruction of Large Composite Defects Extending Beyond the Nose.

Nasal reconstruction remains one of the most challenging surgeries for facial plastic and reconstructive surgeons. The addition of defects extending beyond the nose adds a layer of complexity to an already technically demanding surgery. This article will focus on the management of composite defects extending beyond the boundaries of the nose. Surgeons need to have a variety of techniques at their disposal. These complex defects often require multiple local flaps, multiple stages, and, in select cases, free tissue transfer.

Revision Nasal Reconstruction After Previous Forehead Flap.

Reconstructing the nose poses considerable challenges, even for the most skilled surgeons. Significant nasal reconstructions often require later revisions to address persistent issues in both form and function, and it is crucial to discuss this possibility with the patient before embarking on the reconstructive process. Minor revisions can often be managed by making direct incisions between nasal subunits, coupled with soft tissue sculpting or the use of structural grafts for augmentation. When minor adjustments prove insufficient, the initial reconstruction may need to be entirely revised with a second forehead flap.

Clinical Application of Botulinum Toxin A on Nasal Reconstruction with Expanded Forehead Flap for Asian Patients.

BACKGROUND: Because of its unique advantages, frontal expansion has become a common tool for Asian nasal reconstruction, but it has the limitations of prolonging the duration and pain in the expansion area. Based on the fact that the denervation effect of botulinum toxin type A (BTX-A) has been widely used in the reconstruction of superficial organs, we hypothesized that BTX-A would shorten the length of nasal reconstruction sequence and alleviate the discomfort of patients. METHODS: A comparative retrospective study was conducted of consecutive patients underwent sequential treatment of nasal reconstruction between June 2010 and July 2012. Data on demographics, BTX-A injection plan and expansion duration were collected and analyzed. Phased pain intensity outcomes were evaluated by visual analogue scale (VAS). Photographs were collected during the follow-up period. RESULTS: Thirty patients were enrolled in the study; 15 (50%) with and 15 (50%) without BTX-A pre-injection. Demographic data were homogeneous. The duration of the observation group (BTX-A pretreated) (133.87 ± 13.64 days) was significantly shortened versus the control group (164.27 ± 14.08 days, P<0.001). At the initial stage, no significant difference was found in the VAS scores (P=0.64). At the medium stage, the VAS score of the observation group (2.07 ± 0.80) was significantly lower than the control group (3.00 ± 0.53, P<0.01). At the terminal stage, the VAS score of the observation group (1.93 ± 0.59) was significantly lower than the control group (2.73 ± 0.70) but with a narrower disparity. CONCLUSION: Pre-injection of BTX-A is effective in shortening the duration of the expansion phase, as well as relieving the pain associated with expansion. LEVEL OF EVIDENCE IV: The journal asks authors to assign a level of evidence to each article. For a complete description of Evidence-Based Medicine ratings, see the Table of Contents or the online Instructions for Authors at www.springer.com/00266 .

Reconstructive Options for Basal Cell Carcinoma Defects in the Head and Neck Region: An Institutional Experience.

Basal cell carcinoma (BCC) is the most common skin cancer with more than 80% occurring on the face occurring mainly due to exposure to ultraviolet rays in the elderly due to cumulative exposure of the UV rays during their lifetime. Though various treatment modalities are available for the treatment of basal cell carcinomas, wide local excision is the standard line of management. However, reconstruction of facial BCC poses a challenge to the reconstructive surgeon. Over a 4-year-old period from 2017 to 2021, a total of 30 patients of head and neck basal cell carcinoma were surgically excised in our institution. We have explored all modes of reconstruction from small to large BCC defects in terms of cosmesis, form and function. Four patients underwent primary closure, 8 patients underwent skin grafting, 13 patients underwent closure by local and advancement flaps and 5 patients with large defects underwent free flap reconstruction. No flap loss was reported. None reported any functional deficit. To achieve adequate aesthetic surgical outcomes after reconstruction, knowledge of facial aesthetic regions is of utmost importance. The size and location of the defect and the presence of vital structures adjacent to the defect should be assessed to determine the kind of reconstruction that should be carried out without adversely affecting adjacent structures. For greater patient satisfaction, the method of reconstruction should be tailor made, where donor tissue resembles native tissue with good contour and texture match, suture line scars are camouflaged, and complications are nil.

Outcome Analysis of Two-Stage Paramedian Forehead Flap for Nasal Defects Reconstruction in Local Population: Experience of 3 Years at Our Center.

The nose is a key aesthetic element of face. Nasal defect reconstruction by forehead flap has been done since ancient times. The aim of this study is to review our experience of the outcomes of two- stage paramedian forehead flap in nasal defects of various aetiologies in the local population. This prospective study was done from January 2020 to December 2022 in the Department of Plastic and Reconstructive Surgery at SMS Medical College and Hospital. A total of 29 patients were included in this study who were candidates for a forehead flap for nose reconstruction due to any aetiology. After informed and written consent, two- stage paramedian forehead flap was done and patients were followed up to 6 months for analysis of outcomes. 29 participants were included in the study. Age range was 18-72 years (mean age 38.5 ± 16.78). 21 (72.4%) were male and 8 (27.6%) were female.23 (79.3%) patients had multiple subunit involvement, 4 (13.8%) patients had single subunit defect and 2 (6.9%) had total nasal defect. Most common aetiology was trauma (58.7%). Early complications including flap and donor site healing related complications were present in 8 (27.5%) patients. Delayed complications were grouped into cosmetic and functional complications and were seen in 22 (75.8%) patients. Cosmetic dissatisfaction was high with the two- stage paramedian forehead flap. Forehead flap is an established gold standard reconstructive option for nasal defects. In a two stage paramedian forehead flap, flap and donor site related issues are minor but cosmetic dissatisfaction is high. With some additional stages, satisfaction among patients increases significantly.

Efficacy and feasibility of a forehead flap surgical guide for nasal reconstruction.

For successful nasal reconstruction using a forehead flap, three-dimensional (3D) nasal defects need to be translated into a two-dimensional (2D) forehead surface. For this study, a patient-specific 3D-printed forehead flap guide that could precisely translate a virtually simulated nasal shape into a 2D flap template was developed. The study aimed to evaluate the feasibility and efficacy of a 3D-printed forehead flap guide for nasal reconstructions. The 3D nasal surface was scanned using a 3D camera, and a 'digital clay' process was performed to correct the nasal deformity. The 3D morphology was flattened into a 2D forehead flap guide. The guide was 3D-printed and used for the forehead flap design. Photographic records were used to conduct anthropometric and aesthetic evaluations. Between October 2016 and August 2020, forehead flaps were performed using the forehead flap guide (guide group) and traditional templating method (control group) in 16 and 15 patients, respectively. The alar shape was more symmetric in the guide group than in the control group, with smaller right-to-left differences in alar width (p = 0.01) and height (p = 0.05). Regarding aesthetic evaluations, nose contour (p = 0.02) and nasal symmetry (p = 0.033) were better in the guide group than in the control group. The mean operative time was significantly shorter (91.9 ± 10.7 min) in the guide group than in the control group (116.4 ± 13.6 min) (p = 0.001). Our findings suggest that a 3D-printed forehead flap surgical guide can be effectively used in nasal reconstruction to reduce operative time and improve aesthetic outcomes.

Resolving trapdoor phenomenon without secondary procedure after forehead flap on medial canthal region.

Herein, we present a case of basal cell carcinoma in a 59-yearold woman. It presented with painless itchy, black, gradually enlarged patches which were easily bled under her left eye since three years ago. A dermatological examination of the left medial canthus region obtained hyperpigmented plaques (2x0.8x0.1 cm) with uneven skin texture, irregular borders, and erosion on the center of the lesion. We performed forehead flap technique surgery followed by eight-month monitoring, resulting in a satisfying outcome in both function and appearance. The thinning technique and adjusting the flap size from the forehead area to the medial canthus should be as thin as possible to avoid differences in skin thickness and post-reconstruction hypertrophic scars. A bulging appears on the surgical site a month after the procedure, known as the trapdoor phenomenon, on the 8th month of followup, the trapdoor phenomenon disappeared.

[Application of indocyanine green angiography in repair of facial soft tissue defect using superficial temporal artery based forehead flap].

Objective: To explore the feasibility of using indocyanine green angiography in mapping the superficial temporal vessels and assisting design and harvesting of the superficial temporal artery based forehead flap. Methods: A clinical data of 14 patients with facial soft tissue defects repaired with superficial temporal artery based forehead flaps between October 2015 and November 2022 was retrospectively analyzed. There were 9 males and 5 females with a median age of 9.5 years (range, 3-38 years). The forehead flaps were used to reconstruct facial soft tissue defects following excision of facial scar (8 cases) or congenital melanocyte nevus (6 cases). The size of defects ranged from 3 cm×2 cm to 24 cm×9 cm. Before operation, the indocyanine green angiography was used to map the superficial temporal artery and vein, and to analyze the relationship of the arteries and veins. The forehead flaps with unilateral superficial temporal fascia as the pedicle was transferred to repair the small facial defect in 2 cases. The facial pedicle contained the frontal branch of the superficial temporal artery and 2 cm of the superficial temporal fascia around the vessel, and the tiny accompanying vein of the frontal branch of the superficial temporal artery was used as the outflow of the flap. The forehead flaps with the skin pedicle including bilateral or unilateral superficial temporal fascia and the overlying skin was pre-expanded and transferred to repair the large facial defect in 12 cases. The skin pedicle contained the frontal branch of superficial temporal artery and one of main branches of superficial temporal vein. Among the 12 cases, the frontal branch of superficial temporal vein was used as the outflow in 4 cases, and the parietal branch was used as the outflow in 8 cases. The size of the flaps ranged from 3 cm×2 cm to 30 cm×13 cm. The skin pedicles were divided at 3 weeks after the flap transfer. Results: Indocyanine green angiography could clearly showed the course and branching of the superficial temporal artery and vein. Individual differences existed in the location where the frontal branch of the superficial temporal artery entered the forehead. The superficial temporal vein had great variability and did not follow the artery. One patient had expander-related complication, which resulted in 3-cm flap necrosis. The necrotic tissue was debrided and repaired with skin grafting. The other flaps totally survived and the incisions healed by first intention. All patients were followed up 2-24 months, with a median of 11.5 months. The color, texture, and thickness of the flaps matched well with those of recipient sites. Hypertrophic scar was not observed in recipient or donor site. All patients were satisfied with the reconstructive outcomes. Conclusion: Indocyanine green angiography can clearly visualize the course and the branches of the superficial temporal arteries and veins, which can help surgeons understand the position, distribution, and concomitant relationship of the superficial temporal vessels, and make a rational surgical plan of the forehead flap.

Use of Paramedian Forehead Flap in an Octogenarian:A Case Report.

Increase in life expectancy has led to increased number of octogenarian and nonagenarians population. These old people have increased chances of developing skin tumours like slow growing basal cell carcinoma on the sun exposed parts of body. Many a times surgeons all over the world are bit conservative in managing these elderly patients and compromise on cosmetic aspects due to very advanced age of these patients. This report is about an 87-year-old female with BCC of nasal dorsum who underwent a major surgical procedure to maintain facial aesthetics.

Nasal Reconstruction in 4-years-old Child Affected by Nasal wing Cleft.

Congenital and pediatric nasal lesion resection and their reconstructive outcomes are not well studied. A surgeon must consider the site, depth, size, age, etiology and effect on future function (including growth). The path of total reconstruction or of portions of the cartilaginous / cutaneous nasal structure in the pediatric patient must undergo a series of totally different needs with respect to the management of the adult. First of all, it is essential to understand at what age to intervene, given that the child in the growth phase up to adolescence sees the nasal skeleton change significantly and in relation to the possible psychological repercussions that the tissue deficit can cause. This path will often require serious interventions in order to recreate a structure that is aesthetically ideal, functionally effective and finally suitable for the growth phase of the rest of the body and facial structures. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-022-03364-y.

Eccrine Porocarcinoma of Dorsum of Nose: A Rare Case Report.

Eccrine porocarcinoma (EPC) is an uncommon malignant tumor derived from the eccrine sweat glands. Because of its various pathological features, it is often confused with other malignant cutaneous tumors. We present a case of 78-year- old female having ulcerative lesion over external nasal pyramid. Biopsy suggested of squamous cell carcinoma. Tumor was excised and reconstruction was done using paramedian forehead flap. Post operative Histopathological Examination (HPE) suggested of eccrine porocarcinoma.

Local Random Pattern and Axial Flaps for Reconstruction of Nasal Surgical Defects: Retrospective Analysis with an Attempt to Inspire ENT Surgeons.

Aim: Reconstruction of the surgical defects of the external nose has been challenging and largely considered to be the domain of plastic reconstructive surgeons. The present study aims to share our experience in reconstructing such defects. Materials and methods: A retrospective analysis of 11 patients who underwent external nasal reconstruction secondary to surgical defect at our otolaryngology department in a tertiary care hospital from 2017 to 2019 was done. All the patients underwent surgical excision of a part of the external nasal dorsum followed by reconstruction by our team of otolaryngology surgeons using local random pattern/ axial flaps. The patients were followed up postoperatively for a period ranging from 3 months (for benign pathologies) to 2 years (malignant pathologies). Results: The flaps were taken up in all the patients. Minor complications like postoperative infection were seen in 2 cases, resulting in wound dehiscence in one that required resuturing that was uneventful. The appearance was bulky in all the patients, although the patients were satisfied with the overall cosmetic appearance. The average hospital stay was 2 to 4 days. Conclusion: Reconstruction of external nasal surgical defects is a challenging task. Thorough knowledge of relevant anatomy, proper planning, and availability of abundant vascularized donor tissue in the near vicinity of the defect makes this challenge acceptable with good outcomes even in the hands of otolaryngologists.

Human Bites Over Nose: Management and Reconstruction.

Background Human bite wounds in emergency department need evaluation in regard of reconstruction. These are due to occlusive bite injuries over face. Most commonly, human bites over face involve ear and nose, and may lead to avulsion injury. Defects over nose can be reconstructed immediately after debridement or delayed till the wound heals and scar becomes supple. Thorough wash and lavage with broad- spectrum antibiotic cover has utmost importance in preventing cartilage infection. Methods We report 20 cases of human bite injuries over nose who presented to us in emergency department between 2018 and 2020. At the time of presentation the wound was assessed for closure. If not possible, patient was planned for delayed reconstruction after 3 months. In case delayed reconstruction was planned, the skin and nasal mucosa were approximated at first presentation. The patients underwent paramedian forehead flap after recreation of defect with conchal cartilage graft. Second stage of flap detachment and insetting was done after 3 weeks. After three weeks of second stage, third stage of flap thinning was done. Patients were followed for 3-6 months and subjective satisfaction was noted. Results Nineteen patients underwent delayed staged reconstruction with paramedian forehead flap and one underwent primary wound closure. The flap survival was 100%. The patient satisfaction was excellent in most cases. Conclusion We recommend delayed reconstruction for human bite nasal injuries. For reconstruction, paramedian forehead flap with conchal cartilage graft, if required, provides excellent reconstructive option with good contour and color match and minimal donor site scar.