Expanded forehead flaps for reconstruction of different faciocervical units: selection of flap types based on 143 cases

Dynamic alterations in M2 macrophage subtypes enhance flap expansion efficiency and tissue regeneration

Dilatation of soft skin tissue is a common surgical procedure in plastic surgery. M2 macrophages play a critical role in reducing inflammation, promoting epithelial and vascular endothelial cell proliferation, enhancing collagen synthesis in fibroblasts, and orchestrating extracellular matrix remodelling by promoting angiogenesis, epithelialisation, and fibrosis. Macrophages improve flap survival by promoting microangiogenesis and collagen remodelling. However, the role of macrophages in flap expansion has not yet been investigated. Improving the expansion efficiency of dilatation flaps and promoting flap vascularisation are the pressing problems in the fields of plastic and reconstruction surgery. In the present study, we used a mouse model to assess the effects of macrophage activation on skin expansion, thickness, ultrastructure, intradermal angiogenesis, and collagen and cytokine levels. Our findings revealed dynamic changes in the macrophage content and subtypes within the expansion flaps. The enrichment of M2 macrophages significantly enhanced the efficiency of flap expansion, vascularisation, and collagen synthesis. Our findings underline the pivotal role of M2 macrophages in tissue regeneration at the molecular and biochemical levels. These findings provide a basis for improving flap expansion efficiency using M2 macrophages.

The Expanded Forehead Flap for Resurfacing of Multi-unit Congenital Nevi of the Face

The forehead flap is a timeless and robust reconstructive option for complex facial defects. In accordance with aesthetic subunit principles, it has traditionally been used to resurface defects affecting a single cervicofacial region, most commonly the nose or periorbital unit. In this article, we present three cases of congenital nevi treated with expanded forehead flap reconstruction of the nasal, periorbital, and cheek units in early childhood. This series demonstrates an approach that, while violating facial units, limits total scar burden and optimizes aesthetic and functional results. With precise staging and execution, this reconstructive technique allows for a single flap to resurface multi-unit defects in the pediatric population with excellent long-term results.

Crowdsourcing the Impact of Illustration in Cleft Surgery Education

OBJECTIVE

This study aimed to (1) assess layperson preferences for how surgical information is presented; (2) evaluate how the format of visual information relates to layperson comfort with undergoing surgery, perceptions of surgeon character traits, and beliefs about artistic skill impacting plastic surgery practice; and (3) identify sociodemographic characteristics associated with these outcomes.

DESIGN

A survey was developed in which one of five standardized sets of information depicting a unilateral cleft lip repair was presented as (1) text alone, (2) quick sketches, (3) simple drawings, (4) detailed illustrations, or (5) photographs.

SETTING

Online crowdsourcing platform.

PARTICIPANTS

Raters aged 18 years and older from the United States.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE(S)

After viewing the surgical information, participants answered three sets of Likert scale questions. Ratings were averaged to produce three composite scores assessing (1) comfort with undergoing surgery (2) perceptions of surgeon character traits, and (3) beliefs about plastic surgery and artistry.

RESULTS

Four hundred seventy-nine participants were included. Surgeon character traits score was highest among participants who viewed detailed illustrations at 4.46 ± 0.59, followed by photographs at 4.43 ± 0.54, text alone at 4.28 ± 0.59, simple drawings at 4.17 ± 0.67, and quick sketches at 4.17 ± 0.71 (p = 0.0014). Participants who viewed detailed illustrations rated surgical comfort score and plastic surgery and artistry score highest, although differences did not achieve statistical significance.

CONCLUSIONS

Viewing detailed cleft lip repair illustrations was significantly associated with positive perceptions of surgeon character traits. Our data help to contextualize methods of communication and education valued by the public when seeking cleft care.

A New Option to Preserve Esthetics in Perioral Defect Reconstruction With Normal Anatomical Structures: Bipedicled Preexpanded Forehead Flap With Random Skin Flap Extension

Plastic surgeons charged with reconstructing extensive perioral defects face dual challenges of functional restoration and esthetic considerations. While forehead flaps are commonly used to reconstruct perioral defects, in cases involving partial upper lip defects where normal anatomical structures are preserved, traditional forehead flaps may compromise esthetics. This study aimed to address this issue by employing bipedicled preexpanded forehead flaps based on the frontal branches of the superficial temporal artery (hereafter, "STA-bfb-based preexpanded forehead flap") with random flap extensions to repair perioral defects. Between April 2004 and July 2020, 7 patients (5 males and 2 females; 6 had post-burn facial scars involving the entire lower lip and part of the upper lip, and 1 presented with noma sequelae) underwent perioral defect reconstruction using this approach. Tissue expanders were placed in the forehead donor area, and an STA-bfb-based preexpanded forehead flap with random flap extensions was used to repair the perioral defect. The flap pedicle was divided into 3 weeks. All flaps remained viable with no perfusion-related complications. At follow-up 12 to 96 months later, the color and texture of the flaps demonstrated excellent compatibility with the surrounding skin, suggesting that the use of an STA-bfb-based preexpanded forehead flap with random skin flap extensions is a reliable method for repairing perioral defects. The authors' results have implications for plastic surgeons seeking a solution for challenging perioral defect reconstructions, balancing the need for esthetic outcomes with functional restoration.

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 .

The Dynamic Changes in Hemodynamics of the Forehead Flap During Tissue Expansion

Background: The tissue expansion process brings changes in hemodynamics. Objective: To measure the change in vessel diameter, blood flow, and resistance in the blood vessels using ultrasound before, during, and after tissue expansion. Methods: Patients undergoing the embedment of a forehead expander from September 2021 to October 2022 were included. Hemodynamics parameters, including vessel diameter, blood flow velocity, and resistance index (RI) of the supraorbital artery (SOA), supratrochlear artery (STrA), and frontal branch of the superficial temporal artery (FBSTA), were measured with ultrasound before and 1, 2, 3, and 4 months after expansion. Results: Nine males and six females with ages ranging from 15 to 26 years (mean, 20 years) were included. After 4 months of expansion, the diameter of the STrA, SOA, and FBSTA increased significantly, the RI decreased significantly, and except the right SOA, peak systolic flow velocity increased significantly. Conclusion: The parameters of flap perfusion were significantly improved in the first 2 months of expansion and tended to stable values.

The Dynamic Changes in Skin Thickness of Forehead during Tissue Expansion

In addition to providing extra flap size, the tissue expansion process also brings changes in flap thickness. This study aims to identify the changes in the forehead flap thickness during the tissue expansion period. Patients undergoing forehead expander embedment from September 2021 to September 2022 were included. The thickness of the forehead skin and subcutaneous tissue were measured with ultrasound before and 1, 2, 3, and 4 months after expansion. Twelve patients were included. The average expansion period was 4.6 months, and the mean expansion volume was 657.1 mL. The thickness of skin and subcutaneous tissue in the central forehead changed from 1.09 ± 0.06 to 0.63 ± 0.05 mm and from 2.53 ± 0.25 to 0.71 ± 0.09 mm, respectively. In the left frontotemporal region, skin and subcutaneous tissue thickness changed from 1.03 ± 0.05 to 0.52 ± 0.05 mm and 2.02 ± 0.21 to 0.62 ± 0.08 mm. On the right side, skin and subcutaneous tissue thickness changed from 1.01 ± 0.05 to 0.50 ± 0.04 mm and 2.06 ± 0.21 to 0.50 ± 0.05 mm. This study measured the dynamic changes in the thickness of the forehead flap during expansion. The thickness of the forehead flap decreased the fastest in the first 2 months of expansion, and the changes in skin and subcutaneous thickness slowed down in the third and fourth months and tended to a minimum value. Additionally, the thickness of subcutaneous tissue decreased greater in magnitude than the dermal tissue.

Handheld Doppler Detection and Light Illumination for Vascular Mapping in Nasal Reconstruction

BACKGROUND

The application of the expanded forehead flap in nasal reconstruction has the advantage of being able to provide a sufficient amount of flap and can provide good aesthetic results. For an expanded forehead flap to survive, there must be adequate arterial supply and venous return. Despite this, limited studies have been conducted on preoperative vascular mapping and the design of the expanded forehead flap for nasal reconstruction. In this article, the authors present a technique of hand-held Doppler detection with light illumination for vascular mapping.

PATIENTS AND METHODS

The study included patients who underwent total nasal reconstruction with expanded forehead flaps between May 2016 and April 2021. The design of the flap was based on the result of preoperative vascular detection by hand-held Doppler detection assisted by light illumination.

RESULTS

A total of 32 patients underwent total nasal reconstruction with an expanded forehead flap. The distal part of the flap became necrotic 1 week after the surgery in 2 patients. Following dressing changes and the administration of antibiotics, the distal flap in these patients survived well. No complications were reported in the long term.

CONCLUSIONS

Hand-held Doppler detection combined with light illumination is a convenient and effective preoperative design method for nasal reconstruction with an expanded forehead flap. All flaps survived well in the long term.

LEVEL OF EVIDENCE

Level IV.

Optimal Timing of Laser Hair Removal in Expanded Forehead Flap in the Reconstruction of Facial Defects: During or After Tissue Expansion?

Background: The optimal timing of laser epilation with expanded forehead flaps in facial defect reconstruction remains undetermined. Objective: To compare the efficacy and safety of hair removal during or after flap expansion. Methods: This prospective exploratory study included 15 (11 women and 4 men, 16.47 ± 16.331 years of age) and 26 (19 women and 7 men, 10.69 ± 10.899 years of age) patients who underwent 755 nm long-pulsed alexandrite laser epilation during flap expansion and after surgery, respectively. Facial reconstruction was performed in these patients because of congenital melanin nevus, scar or port-wine stains. Evaluation included hair reduction rate, patient satisfaction, and adverse events. Results: The median number of laser sessions for hair removal during flap expansion was significantly lower than that after surgery (2.00 vs. 3.00, p < 0.01), and the hair reduction rate was also significantly higher during flap expansion (79.5% ± 21.93% vs. 68.3% ± 17.44%, p < 0.05). No severe adverse events were reported. Conclusion: Laser hair removal is safe and efficient when performed both during flap expansion period and after surgery, but its efficacy was significantly higher, and fewer sessions were required when performed during tissue expansion. Clinical trial registration information: ChiCTR1900026090.

The Immediate Contraction of the Expanded Forehead Flap

INTRODUCTION

Flaps contract immediately after harvest, which added difficulty to flap design. This study aims to investigate the immediate contraction rate of the expanded forehead flap used in nasal reconstruction.

METHODS

Patients undergoing nasal reconstruction with expanded forehead flaps from September 2021 to January 2023 were included. Objective measurements of the pedicle width, maximum width, maximum length, and flap size of the expanded forehead flap before and after harvest were conducted.

RESULTS

Fourteen patients, including 9 males and 5 females, were included. The average expansion period was 4.6 months, and the mean injection volume was 658.6 ml. The average retraction rate of pedicle width, maximum width, maximum length, and size of the flap after harvest were 16.15%, 30.26%, 26.86%, and 50.89%, respectively.

CONCLUSION

This study presents the contraction rate of the expanded forehead flap used for nasal reconstruction. The data from the measurement will help surgeons to design the expanded forehead flap.

LEVEL OF EVIDENCE

Level-Level IV.

Reconstruction of Hemifacial Congenital Giant Nevus with Pre-expanded Scalp Flaps and Deltopectoral Skin Flaps

BACKGROUND

The hemifacial congenital giant nevus impacts both physical and mental health of the patients. Excision is typically the most suitable option in these situations, but reconstructing the subsequent surgical defects is always a serious challenge.

METHODS

Between February 2012 and January 2021, a retrospective review of 4 patients who suffered from hemifacial congenital giant nevus was conducted, and they were treated by pre-expanded scalp flap and deltopectoral flap simultaneously. All patients receive tissue expansion, nevus resection, expanded skin flap transfer, and pedicle division.

RESULTS

Four patients with hemifacial congenital giant nevi were successfully treated with no major complications. One patient with a transferred deltopectoral flap experienced distal necrosis of the flap, and healed after dressing changes. No recurrence of the nevus was found during the follow-up period, and the transferred skin flaps match well with facial skin in contour and color.

CONCLUSION

This modified pre-expanded scalp flap combined with a deltopectoral flap provides an easy and reliable way for hemifacial reconstruction in patients with a congenital giant nevus.

Expanded forehead flap in Asian nasal reconstruction

This article reviewed our experience of Chinese nasal reconstruction over 12 years and evaluated the effect of expanded forehead flap both aesthetically and functionally. The special skin type and other anatomic features of Chinese patients was understood thoroughly during the treatment. This article thus catered for the need of multiracial nasal reconstruction. We analyzed existing clinical data and demonstrated a typical case in detail. The postoperative result supported our strategy which advocated the extensive application of expanded forehead flap, together with flip scar flap as the internal lining. The features of Chinese patients also prompted the use of costal and auricular cartilage. Emerging technology like 3D-printing would benefit nasal reconstruction from more aspects.

Comparison of Hand-Held Doppler and Indocyanine Green Angiography in Preoperative Design of Expanded Forehead Flaps for Nasal Reconstruction

BACKGROUND

Despite the different approaches for detection of perforators, methods of vascular mapping of the expanded forehead flap for nasal reconstruction are rarely described. This article aimed to present our experience in the preoperative design of the expanded forehead flap for nasal reconstruction and to compare the clinical practice of hand-held Doppler and indocyanine green angiography (ICGA) in vascular mapping for nasal reconstruction with the expanded forehead flap.

METHODS

From October 2019 to April 2022, 26 patients underwent nasal reconstruction using expanded forehead flap. The authors performed preoperative vascular mapping on 16 patients by hand-held Doppler alone, and on 10 patients by hand-held Doppler and ICGA primary outcomes considered were the visualization of the main vascular course of the flap obtained by hand-held Doppler or ICGA, intraoperative observation of the flap, and its postoperative complications.

RESULTS

Indocyanine green angiography provides a better detection in distal flap and the branches of the supratrochlear artery. Vein detection by ICGA generally corresponds to the results obtained by the combination of hand-held Doppler and transillumination test. In the group that only used hand-held Doppler, 2 patients presented hemodynamic complications in the margin of the flap and 1 patient presented partial necrosis postoperatively. No complication was found in the group that used ICGA.

CONCLUSIONS

It is recommended to use the ICGA for preoperative planning, as it yields highly accurate vascular courses. As an alternative to other methods, hand-held Doppler is also an effective tool.

LEVEL OF EVIDENCE

IV.

Ultrathin Supratrochlear Artery Cutaneous Branch Flaps for Large Defects Around Eyebrows

BACKGROUND

The key point of repairing large defects around eyebrows is to keep the eyebrow undistorted. The limited skin elevates the application difficulty of conventional methods such as direct suture or local flap. Forehead pedicle flaps do well in tension control. However, most of them are too thick for defects because the frontalis muscle must be included. Recently, 1 stable supratrochlear artery cutaneous branch was found, which provides an opportunity to make an ultrathin forehead flap with a good blood supply. This study aims to investigate whether the supratrochlear artery cutaneous branch flap could perform good esthetic reconstruction for defects around the eyebrow.

METHODS

The authors retrospectively included 15 patients whose defect around the eyebrows was repaired by the supratrochlear artery cutaneous branch flap from June 2017 to June 2020. The authors followed up about their flap color and texture, scar, abnormal sensation, any complication, recurrence, and patient satisfaction for at least 6 months online or face-to-face.

RESULTS

All of the flaps survived, without distortion of the eyebrows or inner canthi. Similar flap color, texture, and thickness with the nearby skin were obtained, except 2 patients reported pigmentation. Donor and receptor scars were acceptable. There was no recurrence or other complications. All of the patients were satisfied with the surgery effect.

CONCLUSIONS

The supratrochlear artery cutaneous branch flap is a valuable alternative method to repair large defects around the eyebrows. It can avoid facial distortion and achieve good esthetic outcomes in single-stage surgery.

A Reversal Forehead Free Flap Transplantation Without Interrupted Perfusion for Esthetic Repairing the Mentocervical Scar Deformity

The forehead flap is widely used to repair facial defects. The traditional method would transfer some hair to the recipient area, where the reconstructed beard lies in a misplaced position. The authors designed a reversal forehead free flap method that transposed the flap to 180 degrees, rebuilding the reconstructed beard in the normal position. In addition, the authors used the frontal branches of the superficial temporal vessels on both sides to anastomose with the contralateral parietal branches to lengthen the pedicle and avoid ischemia-reperfusion injury. Level of Evidence : 4.

The Transfer of Expanded Forehead Superthin Flap Without Frontalis and Less Hair Follicles Pedicled by Superficial Temporal Vessels

BACKGROUND

The expanded forehead flap pedicled with superficial temporal vessel(s) is a common method to treat facial scar deformity. However, local bulkiness and hair retention have limited the use of this flap.

METHODS

Five cadavers were used for anatomy to confirm the forehead "safety zone." A retrospective study was performed on 15 patients with facial scar deformity who were undergoing the expanded forehead superthin flap (without the expanded capsule, frontalis muscle, and with less hair follicles) pedicled with superficial temporal vessel(s) to transfer and repair the deformity.

RESULTS

Through cadaver anatomy, the range where the subdermal vascular network laid superficial to the hair follicle level was named the "safety zone," whose average distance between the bilateral penetrating points was 10.2 cm (8.7-11.6 cm). Fifteen patients with facial scar deformity were treated with the superthin flap technique. The trimming size of the safety zone flap was (6-10) × (12-20) cm. The median time of thinning the safety zone was 35 minutes (range, 25-40 minutes). All flaps healed well. The median residual ratio of the hair follicle was 39.8% (29.9%-50.5%). All patients were satisfied with the contour of the flap.

CONCLUSION

We firstly proposed a concept of forehead safety zone and used the superthin flap without the frontalis muscle and less hair follicles to treat facial scar deformity, and obtained an improved therapeutic effect. We think this is an appealing technique that can manifest facial concave and convex in the fine part, improve compliance of the flap, and reduce the times of laser hair removal.

Transfer Patterns and Clinical Applications of the Forehead Flaps Based on the Supratrochlear Artery and Supraorbital Artery

This study aimed to describe the application of transferring preexpanded forehead flaps based on the supratrochlear and supraorbital arteries in 3 patterns for facial reconstruction: Pattern I, interpolated flap; Pattern II, island flap; and Pattern III, propeller flap, which was subdivided into direct propeller flap (Pattern IIIa) and indirect propeller flap (Pattern IIIb). During the first stage, a tissue expander was inserted underneath the forehead. After sufficient inflation of the expander, a forehead flap based on the supratrochlear or supraorbital artery was elevated and transferred to reconstruct the facial defects. Three weeks after the surgery, pedicle division was performed, in which Pattern I and Pattern IIIb flaps were used. Twenty-four patients underwent facial reconstruction. Twenty-three flaps survived without any perfusion-related complications. Venous congestion developed in an island flap. All patients were followed up after surgery, ranging from 2 to 156 (mean, 19) months. The color and texture of the flap matched those of the adjacent skin. The patients and their families were satisfied with the final functional and esthetic outcomes. The forehead flap based on the supratrochlear and supraorbital arteries provides reliable coverage of facial defects. The conventional interpolated flap continues to be the most dependable. Single-stage reconstruction using the island flap and direct propeller flap is applicable to patients who decline the pedicle division procedure. The novel technique of using the indirect propeller flap is safe for cheek reconstruction with minimal donor-site morbidity and esthetically pleasing results.

Reconstruction of facial defects using a pre-expanded scalp flap: A description of the method used and outcomes of 43 patients

Background

A technique for reconstructing facial units with matching colour, similar texture and sufficient contour is ideal for patients with various facial defects. The current report aimed to present the experience of the authors in facial reconstruction using pre-expanded scalp flaps combined with laser hair removal.

Methods

From January 2014 to August 2021, 43 patients with different facial defects, such as post-burn scar and congenital nevus, were treated using this surgical technique that involved tissue expansion, scalp flap transfer and laser hair removal. Facial defects were artificially classified into three regions (forehead, n = 19; cheek, n = 15; and lips and chin, n = 9). Pedicle delaying and division were performed in patients who underwent reconstruction with pedicled flaps.

Results

Of the included patients, one presented with haematoma, one with infection and three had distal necrosis after expanded scalp flap transfer. The donor site was primarily closed in all patients. Further, all patients were successfully treated without major complications. The texture, colour and contour of the scalp flap after laser hair removal matched well with the surrounding skin tissues at 2–30-month follow-up.

Conclusion

Reconstruction using pre-expanded scalp flaps combined with laser hair removal is an effective and reliable option for facial reconstruction with excellent colour and texture match.

Expanded Paramedian Forehead Flap for Nasal Reconstruction Following Congenital Nevus Excision

In this report, we discuss the excision of a large congenital nevus covering the nose and face and the reconstruction of the defect using an expanded forehead flap, in a 24-year-old man. We observed that after incorporating specific modifications including tissue expansion, thinning of the distal part of the flap, and placing the pedicle over the cutaneous branch of the supratrochlear artery, we were able to provide excellent aesthetic results using this time-tested paramedian forehead flap for nasal reconstruction. After we inset the flap, there was negligible donor site morbidity during a 33-month follow-up period.

Expanded scalp flap combined with laser hair removal to reconstruct facial defects around the hairline

BACKGROUND

Congenital and acquired facial lesions around the hairline can bring huge physical and psychological trauma to patients. At present, reconstruction of this area remains a challenge. In this study, we present an alternative technique to reconstruct the aesthetic units using an expanded scalp flap combined with laser hair removal.

METHODS

We retrospectively reviewed 25 cases of facial lesions around the hairline reconstructed with this surgical technique between May 2014 and May 2020. Expander was implanted under the scalp as designed before the operation. After the expander was fully expanded, the lesion was removed and the scalp flap was transferred. Laser hair removal was performed on the transplanted skin flap 2 weeks after flap transfer.

RESULTS

There were ten cases of postburn scar, nine cases of congenital nevus, four cases of traumatic scar, one case of haemangioma, and one case of nevus sebaceous. The median times of laser treatment was 3 (range, 1-8). The median follow-up time was 11 months, ranging from 1 to 27 months. The colour and texture of expanded flaps were similar to adjacent tissue in all cases. The direction of reserved hair in transferred flaps was consistent with the direction of hair in the recipient area or contralateral hair. There were no complications, such as infection, blistering, discolouration, and ulceration. All patients were satisfied with the appearance of the reconstructed hairline and the surgical outcomes.

CONCLUSIONS

The expanded scalp flap combined with laser hair removal is a feasible and effective technique to reconstruct both sides of the hairline simultaneously from a single donor site with a good colour match and a similar texture and thickness.

Different Transfer Forms of the Expanded Forehead Flap Pedicled with Superficial Temporal Vessels to Treat Chin and Submental Scar Deformities

BACKGROUND

The chin and submental regions are located at the junction of the face and neck. Its function and aesthetic appearance can be seriously affected when scar deformities cause the cervicomental angle to disappear. The expanded forehead flap pedicled with superficial temporal vessel(s) is a surgical treatment for chin and submental scar deformities. Different transfer types have developed for this flap based on individual situations. At present, there is no unified treatment strategy for applying this forehead flap to treat different regions and ranges of chin and submental scar deformities.

METHODS

Ninety one cases were collected from patients with chin and submental scar deformities that were treated using the expanded forehead flap pedicled with superficial temporal vessels from January 2008 to December 2018. The authors divided the chin and submental scar deformities into 4 types according to different regions and ranges, and summarized flap survival and complications of 5 different transfer forms used to treat scars for creating feasible treatment strategies. We followed up 76 cases, investigating the satisfaction of appearance and texture of the flaps, improvement of neck movement, and scar recurrence.

RESULTS

Expanded forehead flaps were used to repair 91 cases of chin and submental scar deformities. According to the postoperative flap survival and complications of flap blood supply, the treatment strategies are as follows: Bilateral cutaneous and subcutaneous pedicled forehead flaps are applied to treat scars in bilaterally symmetrical large-scale scars in Zone LCL. Unilateral pedicled forehead flaps are applied to treat small-scale scars in Zone C and Zone L. Unilateral pedicled plus contralateral vascular anastomosis and unilateral pedicled plus contralateral super thin forehead flaps are applied to treat the moderate-scale scars of Zone LC. Mean follow-up period was 81 months (range 28-131), 93.4% (71/76) was satisfied with appearance and texture of the flaps, 97.4% (74/76) was satisfied with the improvement of neck movement, and 2.6% (2/76) occurred scar recurrence.

CONCLUSIONS

Five different types of expanded forehead flaps pedicled with superficial temporal vessels can be used to repair differential scar deformities of the chin and submental regions and achieve good therapeutic effects.

Use of Indocyanine Green Angiography to Identify the Superficial Temporal Artery and Vein in Forehead Flaps for Facial Reconstruction

ABSTRACT

The superficial temporal artery (STA) frontal branch flap is susceptible to venous congestion because of its unpredictable and variable outflow. The authors applied indocyanine green angiography in identifying the superficial temporal vessels to help surgeons with proper flap designs to avoid severe complications. A retrospective review from 2015 to 2020 was conducted. All the patients who underwent indocyanine green angiography before forehead flap transfer for facial defect reconstruction were reviewed. The STA and vein were observed using indocyanine green angiography preoperatively. The relationship between the artery and vein was investigated. The venous anatomy was analyzed to guide the pedicle design. The survival of the flap and complications were assessed. A total of 12 patients were identified and included in this study. Indocyanine green angiography allows clear visualization of the detailed anatomy of the STA and vein. The frontal branch of the vein had great variations and generally diverged from the arterial branch. The tiny venae comitantes provided sufficient drainage for 2 small forehead flaps. The frontal branch of the vein entered the forehead and was used as the outflow channel in 4 patients. The parietal branch of the vein, which consistently gave off secondary tributaries to the superior forehead, was included in the pedicle in 6 patients. All flaps survived without complications. Indocyanine green angiography provided accurate localization of the superficial temporal vessels. This technique may be helpful in the precise planning forehead flap surgeries and in avoiding the risk of venous congestion.

Aesthetic Design of Expanded Bilateral Superficial Temporal Vascular Fascial Pedicled Flap for Repairing Maxillocervical Scars

BACKGROUND

Large-scale maxillocervical scars impair face and neck function and damage appearance. The forehead expanded bilateral superficial temporal pedicled flap is a good treatment strategy for this area; however, the traditional cutaneous pedicled flap damages the temporal hair area. This impairs aesthetics and causes alopecia; furthermore, requires an additional pedicle-cut operation.

METHODS

A retrospective study was performed on 7 patients with large-scale maxillocervical scars from January 2014 to August 2018. Forehead expanders were implanted in the first-stage operation for all patients. After the injection and rest period, patients were treated using the forehead expanded bilateral superficial temporal vascular fascial pedicled flap. Superficial temporal vascular fascia pedicles were carefully harvested. The use of an intralesional or hidden retrotragus incision was determined by the presence of a preauricular scar. Patient satisfaction with postoperative neck activity and the incision scar was evaluated.

RESULTS

Intralesional and retrovagus incisions were used in 4 and 3 cases, respectively. One flap developed hematoma, which recovered completely after conservative treatment; all other cases had no complications. All flaps healed well. The neck mobility of the patients was significantly improved with no visible scar in the temporal region. Six cases reported being "very satisfied" and one was "relatively satisfied" with their improvement in neck mobility. All cases reported being "very satisfied" with frontotemporal morphology.

CONCLUSIONS

The forehead expanded bilateral superficial temporal vascular fascial pedicled flap is a good choice for patients with large-scale maxillocervical scars. This technique can maintain the aesthetics of temporal hair and reduce patients extra surgical injury.

A Strategy for Integrative Reconstruction of Midface Defects Using an Extended Forehead Flap

Background: Midface reconstruction is challenging because the structures and deformities involved are complicated. In this study, we present a strategy for integrally reconstructing nasal and midface defects, including hair-bearing defects, using extended forehead-expanded flaps. Methods: From 2015 to 2018, a total of 22 patients with midface defects underwent reconstruction with extended forehead-expanded flaps. The far end of the expanded flap, which included scalp hair, was used to cover the upper lip defect (Type 1). In cases with large perioral defects (Type 2), we designed two separate supratrochlear artery flaps, one with a shorter pedicle for nasal reconstruction and the other with a longer pedicle for partial reconstruction. The pedicle of the longer flap was saved for upper lip recovery after pedicle interruption. Results: Among the 22 patients (13 male and 9 female), 17 were caused by burns and 5 by trauma. Nineteen patients had Type 1 defects, and three had Type 2 defects. The average postoperative follow-up was 17.6 ± 4.3 months. Patient satisfaction was excellent in most patients. Conclusions: Our extended forehead flap strategy can achieve aesthetic recovery of nasal and perioral defects with a single expansion treatment. The expanded flap can be flexibly designed to fit diverse midface defects.

Office-Based Forehead Flaps: A Safe and Reliable Reconstructive Option

BACKGROUND

Forehead flaps are one of the workhorse flaps for nasal reconstruction, especially for large defects involving the nasal tip, ala, or multiple nasal subunits. Forehead flaps are often performed on older patients who have accompanying comorbidities and who may be at higher risk for anesthetic complications. The aim of this retrospective study was to compare the safety and success of forehead flap nasal reconstruction in 2 different clinical settings: those performed under local anesthesia in an office-based procedure room, compared with those performed in the operating room under either general anesthesia or intravenous sedation.

METHODS

A retrospective chart review was performed on all patients who underwent forehead flap reconstruction between the years of 2011 and 2018 by the senior author. Patient demographics, operative details, and postoperative complications were recorded and analyzed. Patients were followed for 1 year postoperatively or until the end of the study period. Patients were excluded if they had an accompanying unrelated cosmetic procedures performed during first-stage forehead flap reconstruction.

RESULTS

A total of 96 forehead flaps were performed, 35 of which (36.5%) were done in an office-based procedure room using local anesthesia only. Patient ages ranged from 45 to 92 years, with an average age of 71.9 years. The majority of flaps (n = 81, 85.3%) were divided at the second-stage procedure. There was no statistically significant difference in time elapsed between first- and second-stage procedures between groups (procedure room: 22.6 days; operating room: 23.8 days). There were 13 total postoperative complications (13.5%), but there was no statistically significant difference in complication rate between groups (office-based: 3 complications, 8.6%; operating room: 10 complications, 16.4%).

CONCLUSIONS

Our data suggest that forehead flap reconstruction can be done safely with acceptable postoperative results when performed under local anesthesia in an office-based outpatient setting.

Infrared thermography-guided designing and harvesting of pre-expanded pedicled flap for head and neck reconstruction

BACKGROUND

Pre-expanded pedicled flaps possess a more flexible transfer pattern and higher tissue utilization than random flaps, but the perfusion is fully dependent on the chosen axial vessels. A precise mapping of the vessels would assist the surgical design and increase the likelihood of success. The application of Infrared thermography (IRT) has been previously reported for perforator location. The aim of this study is to report the use of IRT in mapping the course and distribution of axial vessels in the pre-expanded flap to guide the designing and harvesting.

METHODS

Patients who underwent head and neck reconstruction using pre-expanded flaps were included. After tissue expansion, IRT was used to mark the vessel distribution along the expanded flap. The results were compared with color Doppler ultrasound (CDU) and/or computed tomographic angiography (CTA). The flap was designed and raised based on the pre-operative marking by IRT. The mark was verified intraoperatively.

RESULTS

A total of 26 expanded flaps were performed, including 20 pedicled flaps and 6 free flaps. IRT succeeded to map the vessel distribution in all cases. All marked results were verified by CDU, CTA, and intraoperative dissection (26/26, 100%). IRT showed more comprehensive distribution of vascular branches than CDU or CTA, and could be utilized intraoperatively to identify the arteries.

CONCLUSION

IRT provides accurate and comprehensive mapping of the axial vessel distribution in the pre-expanded flaps, assisting with flap design and harvest. It is easy to use and non-invasive as an important tool pre- or intraoperatively to ensure the safe elevation.

Efficacy of pre-expanded forehead flap based on the superficial temporal artery in correction of cicatricial ectropion of the lower eyelid

Lower eyelid retraction or ectropion bring suffering to the patients both physically and mentally. Efforts to explore pertinent surgical treatments are still needed. Here we have described our preferred surgical technique for lower eyelid ectropion repair with pre-expanded island forehead flaps or pedicled forehead flaps. Between July 2007 and March 2017, a retrospective review of 12 patients who suffered from cicatricial lower eyelid ectropion as a result of trauma, surgery, or infection was conducted. Forehead skin flap based on the superficial temporal artery was expanded depending on the area of defect of the lower eyelid. Tissue expansion, flap transfer, pedicle delaying and division were involved in this process. There were no major complications, such as expander exposure, infection, haematoma or large skin flap necrosis in all the 12 patients. Venous congestion was reported in two patients. No recurrent ectropion was noted in any patient. During the three-month to two-year follow-up all patients were satisfied with the results in terms of the skin texture, colour, and flexibility after the treatment with an expanded forehead skin flap. This study suggests that expanded forehead skin flaps are effective for correction of cicatricial lower eyelid ectropion.

Reconstruction of Hair-Bearing Areas

Hair-bearing areas reconstruction is a difficult field because of limited donor area. Various techniques have been described for hair-bearing areas reconstruction, but the choice of the flap is variable depending on surgeons and patients. In this study, the authors present 7 patients who underwent soft tissue reconstruction with the pedicled superficial temporal artery-based flaps in the hair-bearing areas. No postoperative complications like bleeding, flap congestion, wound dehiscence, and flap necrosis were observed. This flap can be an alternative to the other methods because it is compatible with the face by the flap color and thickness, it can be easily harvested, it has a reliable circulation and minimum donor site scar.

Complications of tissue expansion in the head and neck

BACKGROUND

The authors aim to present a comprehensive review detailing the present state of evidence with regard to complications following tissue expansion in the head and neck.

METHODS

A systematic literature search was conducted to identify all studies reporting complications of tissue expansion in the head and neck between 2000 and 2019. Subgroup comparisons based on expander locations and planes were conducted.

RESULTS

A total of 7058 patients were included. Tissue expansion was associated with an overall complication rate of 8.73% (616/7058). The most common complications were extrusion (207/7009; 3.0%) and hematoma (200/7009; 2.9%). Overall complications were highest in the scalp (65/238; 27.3%) and lowest in the mastoid (347/5688; 6.1%). Complications were more common with expansion in the non-subcutaneous plane (63/590; 10.7%).

CONCLUSION

In the absence of large clinical trials, systematic reviews such as these can help inform clinical guidelines and provide practitioners with an evidence-based reference to improve informed consent.

Forehead deformities after tissue expansion: Retrospective analysis and recommendations

BACKGROUND

Tissue expanders can lead to bone deformity as well as bone resorption. Not all changes in the cranial bone can be completely normalised after tissue expander extraction. This study aimed to investigate the potential factors for persistent forehead deformities after tissue expansion.

PATIENTS AND METHODS

Cases of forehead tissue expansion performed from 2011 to 2015 were retrospectively reviewed. Demographic and clinical data were collected. Two plastic surgeons (Y.Q. and C.Q.) evaluated changes in the forehead by comparing preoperative and most recent postoperative photographs. The Fisher exact, chi-square and Student t tests, and univariate and multivariate logistic regression analyses were performed in this study.

RESULTS

Sixty-seven patients underwent forehead expanded flap reconstructions and continuous follow-ups were done in the outpatient service. The mean duration of the follow-ups after expander removal was 33.86 months. Overall, 28 (41.8%) patients had forehead changes. Age, sex, indications for tissue expansion and follow-up time were not associated with forehead changes. There were significant differences in the total injection volume and expansion period between patients with forehead changes (41.8%) and those without (58.2%). No significant negative correlation was found between the duration of pressure bandage usage post-operatively and the occurrence of forehead changes.

CONCLUSIONS

Our recommendations for performing tissue expansion in the skull area are as follows: (1) always choose expanders with the largest base dimension; (2) perform tissue expansion as quickly as possible and (3) do not cause overexpansion. In addition, there was no proven benefit of using pressure bandages when skeletal changes occurred.

The Application of a Jigsaw Puzzle Flap Based on a Freestyle Perforator and an Aesthetic Unit for Large Facial Defects

BACKGROUND

The single-stage reconstruction of large facial defects remains a conundrum due to the balance between function and aesthetics after skin cancer radical resection.

OBJECTIVE

The goal of this study was to explore a novel surgical procedure for large facial defects that not only resurfaces the large defect in single stage but also improves aesthetic outcomes for both defects and donor sites.

METHODS

The reconstructions were performed using local flaps in the form of a "jigsaw puzzle" flap based on a freestyle perforator and facial aesthetic unit. This procedure starts with a Doppler signal of the perforator and proceeds sequentially in conjunction with adjacent flaps, similar to fitting puzzle pieces, to create a new, large, jigsaw puzzle-like flap that complies with the concept of a facial aesthetic unit. All defects achieved tensionless primary closure with suturing in a concealed area.

RESULTS

Procedures were performed for 40 patients; the average size of the defects was 37 cm (range, 6-51 cm). The patients were followed up for a range of 6 months to 2 years, and reconstruction without flap loss was 100% successful.

CONCLUSION

Via a jigsaw puzzle flap based on a freestyle perforator and an aesthetic unit, we can take advantage of a greater freedom of flap selection and have a more versatile aesthetic design. The jigsaw puzzle flap concept represents a safe and favorable approach to the reconstruction of large facial defects.

Broadening applications and insights into the cross-paramedian forehead flap over a 19-year period

BACKGROUND

Forehead flap reconstruction of large nasal defects can be challenging. The senior author has used a paramedian forehead flap modification using the supratrochlear artery on the contralateral side of the defect.

METHODS

A 9-year retrospective review (2008-2016) was performed for patients undergoing nasal reconstruction with the cross-paramedian forehead flap. Outcomes were analyzed by comparing our previous reviews, which allows us to analyze patient outcomes for over 19 years.

RESULTS

Fifty-three patients were identified. The aasal defect was most frequently due to basal cell carcinoma (n = 37, 69.8%). Twenty-three (43%) patients were smokers, and nine (17%) had diabetes. The mean defect size was 12.9 cm², involving an average of 2.6 nasal subunits. One-third of the patients had cartilage defects (n = 18) and mucosal lining defects (n = 19). Periorbital involvement was present in five patients. Complications included partial flap loss (n = 6), donor site dehiscence (n = 4), flap dehiscence (n = 2), and postoperative infection (n = 1). Only two of the partial flap losses were considered significant, as they required additional reconstructive procedures for soft tissue coverage. Complications were 12 times as likely as those in diabetes (OR = 11.97, p = 0.007, 95% CI 1.94-72.44), six times as likely as those in cartilage defects (OR = 6.4, p = 0.007, 95% CI 1.64-24.92), and nearly five times as likely as those in mucosal lining defects (OR = 4.8, p = 1.27-18.09, 95% CI 1.27-18.09). Thirty-one patients required revisions most commonly for flap debulking (n = 16).

CONCLUSION

The cross-paramedian forehead flap is a reliable option in the armamentarium of the reconstructive surgeon for large and complex defects in addition to those with periorbital extension.

SUMMARY

Coverage of distal nasal defects after tumor extirpation remains a challenge to the reconstructive surgeon. Our institution uses the cross-paramedian forehead flap for these defects. This flap is based on the supratrochlear artery on the contralateral side of the defect and is oriented obliquely across the forehead for additional length and an improved donor site scar at the level of the eyebrow. The technique and outcomes were published in 2009, and this manuscript serves as an update on outcomes and applications during the past 9 years. By including all our data, we can analyze outcomes for over 19 years. During the past 9 years, 53 patients underwent the cross-paramedian forehead flap technique between 2008 and 2016. These patients were found to have an average defect size of 12.9 cm² and an average loss of 2.6 nasal subunits. Cartilage defects were present in 34.6% (n = 18) and mucosal defects were present in 36.5% (n = 19) of patients. Five patients had periorbital reconstruction with the forehead flap, of which three patients underwent a single-stage islandized forehead flap reconstruction. Given the large defect size, additional local flaps were frequently used, including nasolabial flaps (n = 16) and cheek rearrangement (n = 11). Complications included partial flap loss (n = 6), donor site dehiscence (n = 4), and postoperative infection (n = 1). Only two of these partial flap losses were considered significant, as they required additional reconstructive procedures to address areas of soft tissue loss. Increased rates of complications were associated with the presence of diabetes and defect characteristics, which reflects increased complexity including mucosal and cartilage loss. When comparing with our prior review of this technique, the more recent population have had increasing complexity of the nasal defects with a large surface area involvement. Overall, the cross-paramedian forehead flap is a reliable option in the armamentarium of the reconstructive surgeon for large and distal nasal defects.

Approach to Reconstruction of Nasal Defects

The nose is the most central and anterior projecting facial feature. Therefore, the presence of a defect is easily noticeable to the untrained eye. Return of the defect to the original form is an achievable end goal of reconstruction, necessitating appropriate reformation of three-dimensional geometry, proper establishment of symmetry, and excellent color and texture match to the adjacent structures. Regarding its physiological importance, disruption of the normal function may cause respiratory obstruction and contribute to patient distress. To achieve successful repair, preoperative preparation must consider the location, the layers involved, and the size of the defect. Prompt and well-organized repair minimizes the occurrence of progressive necrosis and severe late-stage deformity. Here the authors provide a framework to approach various nasal defects and provide a review of the novel ideologies and techniques. The workhorse of nasal repair, the forehead flap, is discussed independently due to the breadth of innovation.

Anatomical Study of Perfusion of a Periosteal Flap with a Lateral Pedicle

Background:

Pedicled periosteal flaps are commonly used for tissue defects between the base of the skull and the midfacial area. This study aimed to clarify the 3-dimensional vascular distribution of temporal region flaps.

Methods:

Ten fresh cadavers were used. Full-thickness cranial flaps were elevated from the cranial bone and each layer was detached separately. Contrast enhancement of the full thickness of the scalp, macroscopic evaluation, and histologic analyses were performed. Radiographs were obtained and image analysis was performed using a 3-dimensional monitor.

Results:

The mean number of deep vessels extending from the parietal branch of the superficial temporal artery was 68.7, including 14.2 and 54.5 vessels on the proximal and distal sides, respectively. The mean number of deep vessels extending from the frontal branch of the superficial temporal artery was 71.6, including 17.6 and 54.0 vessels on the proximal and distal sides, respectively. There were significantly more perforating branches in the distal area than in the proximal area of both the frontal and parietal branches (P = 0.005). There was no significant difference in the number of perforating branches between the frontal and parietal branches.

Conclusions:

Contrast-enhanced images of the loose areolar tissue and periosteal layers revealed vessels that extended radially. We successfully identified the 3-dimensional structure of the perforating vessels peripheral to the temporal fossa. Our findings provide a theoretical foundation for the feasibility of elevating a periosteal/loose areolar tissue flap with a reliable blood supply without sacrificing the temporal muscle.

Pre-expanded Bipedicled Supratrochlear Perforator Flap for Simultaneous Reconstruction of the Nasal and Upper Lip Defects

The double "S" principle should be followed for facial reconstruction: the "similarity" of the donor site to the defect area and the reconstruction should be based on the different "subunits" of the face. In this article the pre-expanded, bipedicled supratrochlear perforator flap method is described, which is used for the resurfacing of both nasal and upper lip defects. This method can provide 2 independent flaps with sufficient tissue from 1 single donor site, resurfacing the nasal and upper lip units separately and providing an unparalleled color and texture match and ideal reconstructive result.