Abstract
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.
Keywords: Paramedian forehead flap, Aesthetic outcomes
Introduction
The nose is located in the center of the face and is a key aesthetic element of face. A deformed nose quickly gets attention and is disabling psychologically and functionally for the patient.
Reconstruction of nasal defects is a challenging procedure for an aesthetic surgeon as it is associated with the patient’s self esteem issues. Of all the known techniques for nasal reconstruction, the forehead flap technique is the most commonly used for nasal reconstruction. The forehead flap provides a robust source of tissue that closely matches the color, texture, and thickness of the nasal skin, making it an ideal option for nasal reconstruction. This technique allows for the reconstruction of complex nasal defects, including those involving the lining, cartilage, and outer skin. Paramedian forehead flap is commonly done as it has got axial blood supply. It can be done in two or three stages. The two- stage forehead flap is well tolerated among local population.Indian population is blessed with comparatively thick forehead skin which is approximately 3 mm at the forehead and 4.5 mm at the supraorbital area [1]. This leads to a stable nasal framework without the need of cartilage in most cases.
The nose is a complex structure that can be divided into nine subunits. The upper two thirds contain the dorsum and nasal sidewalls, whereas the lower third is composed of the columella, nasal tip, paired alae and soft triangles (Fig. 1).
Fig. 1.
Nasal subunits
Subunit principle was described by Burget and Menick in 1985. In patients with more than 50% of subunit loss, Burget and Menick proposed removing the remaining portion of the subunit and reconstructing the entire subunit. This allowed placement of incisions along the borders of aesthetic subunits, minimizing scar lines [2]. The subunit principle in nasal reconstruction has been incorporated as an essential step in preoperative planning. Even though it is the best tool for reconstructing nasal defects, complications are not completely absent. Complications of the paramedian forehead flap can be flap related, donor site related and related to cosmetic dissatisfaction of the patients.
Objective
This study analyses the early flap and donor site healing related complications and delayed aesthetic and functional complications of 2 staged paramedian forehead flap.
Material and Methods
This prospective study was done in Department of Burn and Plastic Surgery, SMS Medical college and Hospital from January 2020 to December 2022. Total of 29 patients of nasal defects due to different causes were included in the study. All underwent two stage paramedian forehead flap cover. The following variables were considered: age, gender, mechanism of injury, involved subunits, flap and donor site complications and cosmetic issues of the patients. Aesthetic satisfaction evaluation was done of the patients who were not satisfied with the results 3 month after completion of both the stages. Secondary procedures were carried out according to the complaints of the patients and at the end of 6 months aesthetic satisfaction evaluation was done again in these patients as per VAS. Patients were asked to complete questionnaire to assess aesthetic satisfaction (Visual Analogical Scale, VAS = 1–10, VAS: 1 no satisfaction, 10: total satisfaction).
Technique of 2 stage paramedian forehead flap has been illustrated in Fig. 2. The collected data were subjected to statistical analysis. Data collection was conducted within the study period and analysed by SPSS software (Version 20, Chicago, IL, USA). Descriptive data is presented as mean ± SD. Numerical data were presented using mean ± SD or medians and ranges if not normally distributed, whereas percentages were used for categorical data.
Fig. 2.
Planning and execution of paramedian forehead flap
Surgical Technique (Fig. 2)
After appropriate preoperative evaluation and anaesthetic work up, under general anaesthesia, Supratrochlear artery was marked by Doppler. A template was made and planning in reverse was done. The flap was marked on the forehead and incision line was locally infiltrated. Incision was given at distal margin of the planned flap. Flap harvested by conventional method including subcutaneous tissue distally and then including frontalis muscle.
Distal most part was folded to form lining of the nose in 18 patients having tip and ala defects. Turn over flaps were also used to make the lining in 9 cases having dorsum and sidewall defects. Flap insetting was done in single layer with nylon 5–0.
Donor site was closed primarily in 19 cases, secondary healing was allowed in 5 and grafting was done in rest 5 cases. Post operative assessment of the flap was done in the form of colour of the flap. On post op day 3 donor site dressing was checked and patient was discharged. Flap detachment and insetting was done after 3 weeks. Suture removal done on post op day 7.
Results
The total of 29 patients were studied who came to us with nasal defects due to various ethologies like malignancy, trauma, burn and bites due to human or animal origin. 21 (72.4%) of them were male and 8 (27.6%) female. Mean age was 38.5 ± 16.78 years ranging from 18 to 72 years. 21 (72.4%) patients had multiple subunits involved, 6 (20.7%) had involvement of single subunit and 2 (6.9%) patients had total nasal defect (Table 1).
Table 1.
Location of the nasal defect
| Defect | Sum | Subunit involved | Number |
|---|---|---|---|
| Multiple subunits | 21 | Ala (unilateral/bilateral) and tip | 5 |
| Ala and sidewall (unilateral) | 3 | ||
| Dorsum and sidewall (tip spared) | 6 | ||
| Ala, tip and dorsum (central defect) | 7 | ||
| Single subunit | 6 | Tip | 2 |
| Ala | 4 | ||
| Total nose including columella | 2 | 2 |
Most common aetiology leading to nasal defect was trauma present in 17 (58.7%) patients followed by Oncological resection in 10 (34.4%) patients and post burn scar nose in 2 (6.9%) patient. Trauma also included the cases of dog bite or animal bite (Fig. 3).
Fig. 3.
Etiology of nasal defects
Complications were classified as early and delayed complications. The early complications were flap and donor site healing related complications which were seen in 8 (27.5%) cases. 21 (72.5%) flaps healed uneventfully. Early Complications seen were nasal distal flap necrosis, suture dehiscence at flap insetting site and donor site delayed healing. Complete loss of flap was seen in none (Table 2).
Table 2.
Flap and donor site related complications (early complications)
| S. no | Complications | Secondary procedure | Number (%) |
|---|---|---|---|
| 1 | Distal necrosis of flap | Flap advancement and reinsetting | 2 (6.9%) |
| 2 | Suture dehiscence | Resuturing | 2 (6.9%) |
| 3 | Donor site partial graft loss | Regular dressing and SECONDARY healing | 1 (3.4%) |
| 4 | Donor site suture dehiscence | Regular dressing and secondary healing | 3 (10.3%) |
After completion of two stages, patient were assessed for aesthetic and functional concerns 22 (75.8%) patients had aesthetic issues. More than one cosmetic concerns were present in few patients. Most common cosmetic issues was bulky flap seen in 18 (62%) patients. 10 (34.4%) patients had complaint of hair growth on the tip mostly male patients. Obscure nasal definition, nose scarring and donor site scarring were some of the other problems reported. Table 3 summarise aesthetic problems of the patients and the management done. 4 patients had complain of nasal obstruction. On assessment of these patients, it was found that nasal obstruction was either as the result of nostril stenosis due to web formation at internal valve level or nostril collapse due to absent cartilage support (Table 4).
Table 3.
Cosmetic issues and their management
| S. no | Cosmetic issue | Management | Number (%) of patients |
|---|---|---|---|
| 1 | Bulky flap | Thinning of the flap and redundant skin excision | 18 (62%) |
| 2 | Hair growth on distal flap | Laser hair removal | 6 (20.6%) |
| 3 | Obscure nasal subunits | Alar groove recreation | 4 (13.8%) |
| Dorsal onlay cartilage graft | 1 (3.4%) | ||
| Alar batten graft support | 1 (3.4%) | ||
| 4 | Asymmetry from the opposite nasal subunit | Readjustment and resuturing | 3 (10.3%) |
| 5 | Inset scar on dorsum of nose | Z plasty | 3 (10.3%) |
| CO2 laser | 1 (3.4%) | ||
| 6 | Donor site scarring | Scar revision | 1 (3.4%) |
| Fat grafting | 1 (3.4%) | ||
| Conservative approach like silicon sheets and gel | 5 (17.2%) |
Table 4.
Delayed functional complications
| S. no | Function issue | Management | Number (%) of patients |
|---|---|---|---|
| 1 | Nostril stenosis | Web excision and packing | 1 (3.4%) |
| 2 | Nostril collapse | Cartilage support placement | 3 (10.4%) |
The average values of aesthetic satisfaction in these patients (VAS) was 4.7 ± 1.609 at initial assessment after completion of 2 stages and 7 ± 1.281 at 6 months post operatively after completion of all secondary procedures (Table 5). Mean stages of surgery were 2.6 per patient.
Table 5.
Aesthetic satisfaction evaluation (n = 20) (VAS: 1 no satisfaction, 10: total satisfaction)
| S. no | VAS at 3 month | VAS at 6 months |
|---|---|---|
| 1 | 4.7 ± 1.609 | 7 ± 1.281 |
Discussion
Many studies have been published over principles and techniques of forehead flap. A few studies have elaborated flap and donor site related complications but literature is deprived of data emphasising aesthetic outcomes following forehead flap.
In our study, all the patients were managed for nasal defects by standard two stage paramedian forehead flap cover. No expansion was done preoperatively, however the donor site healed satisfactorily. Cartilage was not used for support in first 2 stages but was used in secondary stages as and when required.
Mean age was 38.5 ± 16.78 years which coincides with the mean age of study done by Dr. Dinesh Kumar [3]. The mean age was higher where study of paramedian forehead flaps were done for nasal defects due to malignancy [4, 5]. It is the most common cause of nasal defects in developed countries while in the developing country like India, nasal trauma due to road traffic accidents and assaults is common. It is worth noting that the proportion of population living in rural areas is 64% which is close to wild lands and therefore have a greater risk of being exposed to wild animals and thus animal bites.
Reconstructing a nose involves more than just masking the defect. The patient's satisfaction with both their appearance and their functionality is crucial. Proper knowledge of subunits of nose is essential for achieving best outcome of a forehead flap. According to the principles of nasal subunits described by Burget and Menick, if the nasal defect is more than 50% of a nasal subunit, then the defect should be enlarged to encompass the entire subunit and then the entire subunits replaced. Placement of incisions along the borders of subunits minimises the scars. Also the tissue contracts in trapdoor manner, making subunit to bulge that mimics normal contour of nose [2]. Although we tried to adhere to the subunit principle of nasal reconstruction in our cases but the surgeon’s preference dictated the defect creation and maximal conservation of native tissue was attempted.
Rohrich et al. in his report also supported the reconstruction of the defect, not the subunit [6].We studied the distribution of nasal subunits in different etiologies and figured out that most commonly involved subunits were ala and tip in trauma cases in our series where in Oncological resections, dorsum and sidewalls were the most commonly affected subunits. There is no consensus in literature on nasal subunits involved in trauma but many studies reported dorsum and sidewalls as most common subunits affected by malignancy [7].
Early Complications related to forehead flap and donor site healing have been described by many authors. Distal margin flap necrosis has been commonly described in smoker patients in various studies for which smoking cessation is advised before the surgery. If flap necrosis still occurs, it is managed in the form of revision by FTSG or flap advancement [8]. Studies have also shown healing of distal marginal necrosis by secondary healing. In our study smoking history was negative for both the patients who had distal flap necrosis. Distal flap necrosis was managed by flap advancement. Resuturing was done in case of suture dehiscence. Donor site delayed healing issues were managed by dressings and healing by secondary intention.
Delayed complications were enumerated in the form of aesthetic and functional outcomes. We assessed our patients for their aesthetic satisfaction for approximately 8–12 weeks after the flap insetting and found that few patients had more than one cosmetic concerns. For instance, patient with bulky flap also complained of hair growth on the tip and donor site scarring whereas the couple of others experienced nostril blockade due to flabby thick flap. All the aesthetic concerns were not exclusive of each other and patients reported more than one issues in some cases. In such patients single stage surgical resolution of complaints was attempted so that final result doesn’t delay.
Revision surgeries after two staged paramedian forehead flap is something inevitable unless the patient is not willing. Either by the surgeon’s choice or patient’s demand, some secondary procedures have to be done. As stated by Ibrahim et al. the desire to achieve the best aesthetic and functional result through continual revisions and touchups until the goal is reached, is the principle of revision surgery [9]. Thornton said about forehead flaps that they result in the highest revision rates, as flap contour frequently needs improvement. Improving alar definition and revisions to the forehead donor site are also frequently needed with forehead flaps [10].
Cosmetic outcomes of 2 staged forehead flap is a less discussed topic and needs further discussion. Few of the authors have attracted attention on cosmetic issues like hair growth on distal forehead flap. In our study 10 patients had this complaint out of which 4 patients were determined to go for conventional methods of hair removal like hair removal creams or razors. 6 patients opted for laser hair removal. According to Correa et al. Intraoperative depilation from underside of the flap can be considered at initial flap elevation and inset, still patients might need chemical and laser depilation later [11].
In our surgical technique, we thinned the flap distally at the time of harvest and inset which served two purposes—refinement of tip and alar contour and also hair depilation. However, most common aesthetic complaint was bulky flap. All those patients with bulky flaps underwent flap thinning. Thinning of the flap was something that gave patients immediate satisfaction and also helped to define the nasal subunits. Boyd et al. commented on thinning of the flap that thinning should be done in initial stage to decrease the need of revision surgeries. Even if further thinning is required, it should be delayed 3–6 months to allow complete wound healing, contracture and beginning of scar maturity before undertaking thinning second time [12]. Thornton suggested to evaluate every patient individually. He advised not to make patient wait unnecessarily and go for thinning if deformity is significant [10]. Corticosteroid infiltration in the thickened area can also accelerate the thinning process [13].
In second part of our delayed outcome assessment, the functional complications of the patients were analysed. Four patients reported issues like nostril stenosis and nostril collapse for with conventional procedures were undertaken. Thinning of flap combined with conchal cartilage support was done for cases of nostril collapse in our study as also done by Schmidt et al. in 2021 in his study [8]. To resolve nasal obstruction, stents were given temporarily. Web excision and nasal packing was done in the cases of nasal stenosis. Quatela et al. correlated the functional outcome to the method of inner lining reconstruction and stated that the functional results obtained with epidermal turn-in flaps for inner lining reconstruction have been excellent [14]. However in our study, no such observations were made.
Though we didn’t use cartilage grafts in initial stages but in 5 patients who had significant collapsed nostrils and depressed dorsum, secondary procedures were done to introduce alar batten and dorsal onlay graft. Alar batten graft resolved both cosmetic and functional complaints simultaneously to quite an extent. Donor site and nose scarring was also a bothersome complaint by the patients. For this both conventional and surgical methods of scar management were tried. Conventional methods like silicon sheet and silicon ointments were prescribed to patients while fat grafting, scar revisions and CO2 laser scar resurfacing were done in the rest. Z Plasty technique for scar revision have been practised for over a century. It irregularises a linear scar, making it less noticeable; changes the direction of the scars and aligns them to the RSTLs; helps in lengthening of the webbed or contracted scar; and it helps changing the position of a displaced anatomical point by elevating or depressing it [15]. On the other hand fat grafting is a viable alternative to surgical excision for unsightly forehead donor site scar. The volume filling capabilities allow the natural contours of skin to be regained while counteracting the depressive and retracted nature of scar tissue [16]. Laser scar therapy, particularly fractional ablative laser resurfacing, represents a promising and vastly underused tool in the multidisciplinary treatment of traumatic scars.
Surgical scar revision ~ 3 months after surgery may be considered, but laser therapy can be considered as early as a few weeks after surgery [17]. When two staged paramedian flap cover was compared against three staged paramedian forehead flap in terms of flap necrosis, it was found that three stage forehead flap is advantageous in complex nasal defects when patient is at high vascular compromise risk but outcomes regarding cosmesis is equivocal in both. That’s why Oleck et al. suggested that flap selection should be according to surgeon’s preference and comfort [18]. Satisfaction results of the patients in our study after aesthetic refinement is comparable to study done by Hsiao et al. They traversed subunit boundaries keeping contracture of flap in mind, structural and contouring cartilages were rebuilt stronger than pre-existing tissue, thinning was conservative to minimise devascularization, tissue trauma, and contracture [19].
Case 1:
Forehead flap done in 73 year old female for basal cell carcinoma of nose
( this patient had donor site suture line dehiscence, healed by secondary intention)
Case 2: Forehead flap done in 35 year male for traumatic amputation of nose
(This patient was dissatisfied with bulk of the flap and hair growth at the distal part)
Case 3: Forehead flap done in 40 year male for traumatic amputation of nose
Case 4: Forehead flap done in 26 year female for traumatic amputation of tip of nose
(This patient had cosmetic concern about bulbous nasal tip)
Conclusion
Paramedian forehead flap is a rescue technique when it comes to nasal reconstruction. Due to it’s technical ease and reliable blood supply, paramedian forehead flap is exclusive option for coverage of nasal defects. Complications are lesser and patient satisfaction is high. The key for successful paramedian forehead flap is to maintain axial pattern. Take ipsilateral flap to defect whenever possible. With the help of preoperative doppler, narrow pedicle can be ensured to improve aesthetics of donor side. Following all this principles can aid to successful outcome. Revisions for further aesthetics refinement following forehead flap is inevitable and should be accepted. Two staged paramedian forehead flap in Indian population is easily accepted mode of nasal reconstruction and with minor secondary procedures it can aid to the satisfaction of the patient.
Funding
None.
Declarations
Conflict of interest
None to disclose.
Ethical Approval
Ethical approval was provided by institutional ethical committee.
Informed Consent
Written and informed consent taken from the patients in the study.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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