Forehead Flap Practices: A Cross-Sectional Survey of Facial Plastic and Reconstructive Surgeons

Background: The paramedian forehead flap (PMFF) is a well-established technique utilized for reconstruction of complex nasal defects. Objective: To identify the different techniques and management of patients undergoing PMFF reconstruction and compare these with current literature. Methods: Members of the American Academy of Facial Plastic and Reconstructive Surgery were sent a practice survey highlighting various nuances in PMFF reconstruction. The survey included questions about flap design, operative techniques, and perioperative care. Results: In total, 172 responses were received (14% response rate). Mean years of practice after fellowship was 15.8 years with most respondents performing either 1-5 (33.1%) or 6-10 (27.3%) PMFFs per year. Common practices included the use of general anesthesia, elevation of PMFF in the subgaleal plane (59.6%), and pedicle division at 3 weeks (80%) (p < 0.001). Complication rates ranged between 1% and 5%. The nose was the most common site for revision (p < 0.001) and the average number of secondary procedures after forehead flap division was 1.1 (standard deviation 0.81). The most variability in responses was seen for methods of internal lining reconstruction. Conclusion: Reconstructive surgeons frequently divide the PMFF pedicle at 3 weeks or later and have variable approaches to reconstruction of the internal lining with low complication rates overall.

Tranexamic Acid Prevention of Hemorrhagic Complications Following Interpolated Flap Repair: A Single-Center, Retrospective, Cohort Study

BACKGROUND

Tranexamic acid (TXA) is increasingly being used to prevent hemorrhagic complications after dermatologic surgery. Interpolated flap repairs following Mohs micrographic surgery are at risk for increased bleeding events and unplanned health care utilization, particularly among patients on antithrombotic medication.

OBJECTIVE

To assess bleeding events after interpolated flap repair in patients receiving TXA compared with those who did not.

MATERIALS AND METHODS

A retrospective review identified interpolated flap repairs in a 5-year period. Hemorrhagic complications were analyzed, defined as major bleeding events, which included all unplanned medical visits, and minor bleeding events, which included any unplanned patient phone calls or messages through electronic medical record.

RESULTS

One hundred fifteen patients had interpolated flap repair during the 5-year period, of which 21 (18.3%) received TXA postprocedure. Twenty-seven bleeding events were identified in the non-TXA group compared with 1 event in the TXA-treated group. Patients who received TXA were less likely to have had a bleeding event (28.7% vs 4.8%, p < .01).

CONCLUSION

Patients undergoing interpolation flap repair were less likely to experience a bleeding event after subcutaneous injection of TXA.

State of the Evidence for Facial Skin Cancer Reconstruction

This review provides a comprehensive presentation of the evidence available in facial reconstruction post-Mohs micrographic surgery. Given the large diversity in post-Mohs reconstruction, there are limited guidelines in the management of defects. The aim of the present work is to provide a review of the best evidence as it pertains to several considerations in facial reconstruction. Data suggests that Mohs micrographic surgery and many reconstructive procedures can be performed as outpatient procedures under local anesthesia, with narcotic pain medication only given in certain patient populations following a minority of reconstructive procedures. Perioperative and topical antibiotics are generally not indicated. Aspirin and warfarin can generally be continued for most reconstructive procedures, but clopidogrel and novel anticoagulants may predispose to increased bleeding complications. Delayed reconstruction appears to be safe, although data are discordant on this topic. No specific wound closure technique or suture choice appears to be consistently superior. Given the lack of robust comparative studies, consistent methodology, and variable defect sizes/locations, no robust evidence-based guidelines can be generated for reconstruction techniques of facial subsites.

Postoperative Complications After Interpolated Flap Repair for Mohs Defects of the Nose: A Multicenter Prospective Cohort Study

BACKGROUND

Dermatologists perform most interpolated flaps after skin cancer resection. Prospective, multicenter data on complications after interpolated flap repair in this setting are limited.

OBJECTIVE

To determine the rate of physician-reported complications after interpolated flap repair of the nose.

METHODS

Multicenter, prospective cohort study of 169 patients undergoing 2-stage interpolated flap repair of post-Mohs nasal defects. Frequency of bleeding, infection, dehiscence, necrosis, hospitalization, and death in the 30 days after flap placement and flap takedown are reported.

RESULTS

Patients experienced 23 complications after flap placement (13.61%) and 6 complications after flap takedown (3.55%) that were related to the surgical procedure. The most frequent complication after flap placement was bleeding (9, 5.33%, 95% confidence interval [CI]: 2.83%-9.82%). The most frequent complication after flap takedown was infection (5, 2.96%, 95% CI: 1.27%-6.74%). There was one hospitalization related to an adverse reaction to antibiotics. There were no deaths.

CONCLUSION

Most complications after interpolated flap repair for post-Mohs defects of the nose are minor and are associated with flap placement. Interpolated flap repair for post-Mohs defects can be performed safely in the outpatient setting under local anesthesia.

Viability and Cosmesis of Right Angle and Vertical Paramedian Forehead Flaps Are Equivalent: A Retrospective Quantitative Study

BACKGROUND

Paramedian forehead flaps (PMFFs) are commonly used for reconstruction of nasal defects. The classic PMFF is vertically oriented while the modified PMFF is designed with a 90-degree angle. No study has compared outcomes between these PMFF designs.

OBJECTIVE

To compare and quantify viability and cosmesis of 90-degree and vertical PMFF.

METHODS

Retrospective chart review of 70 consecutive patients with a vertical or 90-degree PMFF design for nasal repairs after Mohs micrographic surgery (MMS). Cosmetic outcome was assessed on a 10-cm, 100-point, visual analog scale (VAS) by an independent observer using standardized 3-month postoperative photographs. Flap viability was assessed using standardized 3-week postoperative photographs. Descriptive statistics, t -test, and Mann-Whitney test were used for statistical analysis.

RESULTS

Forty-eight patients were repaired with a vertical PMFF and 22 using the 90-degree PMFF. The mean defect area of vertical and 90-degree designs was equivalent (7.7 ± 4.0 cm 2 vs 8.1 ± 4.0 cm 2 , p = .70). There was no significant difference in cosmetic outcome (75.9 ± 9.4 vs 72.9 ± 6.8, p = .19) or flap viability (3.8% ± 11.6 vs 2.6% ± 7.9, p = .67) between vertical and 90-degree designs.

CONCLUSION

Vertical and 90-degree PMFF designs for nasal repairs after MMS are equivalent in cosmetic outcome and viability.

Postoperative Outcomes of Local Skin Flaps Used in Oncologic Reconstructive Surgery of the Nasal Ala: A Systematic Review

BACKGROUND

Despite numerous options for nasal ala reconstruction, advantages and disadvantages of each method are unclear.

OBJECTIVE

To summarize reported outcomes of local flaps without the use of grafts for nasal ala oncologic reconstructive surgery.

METHODS

A nasal ala-specific protocol was adapted from a previous head- and neck-specific PROSPERO submission (CRD42017071596). The search was conducted in MEDLINE, EMBASE, and CENTRAL on December 23, 2017 and updated on May 10, 2019. Two reviewers screened 9,313 results from head and neck literature. Study bias was evaluated with the ROBINS-I tool.

RESULTS

Subunit-based categorization of included studies identified 12 nasal ala-specific publications. Complications (flap necrosis, hematoma, wound infections, trapdoor deformities, and dehiscence), functional (nasal valve or respiratory dysfunction), and cosmetic (alar rim distortion/asymmetry/notching, secondary/revisionary procedures, and patient satisfaction) outcomes were extracted.

CONCLUSION

Generally favorable outcomes are seen in all flaps. Careful consideration of donor sites for interpolation flaps is needed for optimal cosmetic outcomes. Transposition flaps, including laterally based bilobed and trilobed flaps, created good outcomes, although melolabial transposition flaps may produce poorer outcomes compared with melolabial island pedicle advancement flaps. Caution is needed for rotation flaps to prevent nasal valve/respiratory dysfunction due to alar crease contracture or ridge elevation. Further research is needed.

Predictive indicators for revisional surgery in nasal reconstruction after Mohs surgery

Background

Reconstruction of nasal lesions is complex due to the topography, mobile free margins and borders of anatomical subunits. Reconstructive challenges can lead to multiple revisional surgeries to achieve the final aesthetic result. This study aimed to evaluate risk factors and predictors of revisional surgery in patients undergoing reconstruction after Mohs micrographic surgery for nasal tumours.

Methods

This was a prospective cohort study from April 2, 2008 to February 26, 2019. The study population included all consecutive patients who underwent Mohs micrographic surgery for nasal skin cancer. Resection and reconstruction of nasal skin cancer was performed by the Mohs team.

Results

A total of 988 cases met our study inclusion criteria with 64 (6.5%) cases requiring unplanned surgical revision. Revision rates were highest in the ala (9.0%, p < 0.05) and complex anatomical subunits (16.7%, p < 0.0001). In contrast, revision rates for dorsum lesions were lowest (1.8%, p < 0.001). In terms of reconstructive modalities, local flaps resulted in significantly higher rates of revision when compared to grafts (relative risk, 2.37; 95% CI, 1.15–5.0; p < 0.01). In terms of histological diagnosis, squamous cell carcinoma had significantly higher revision rates when compared to basal cell carcinoma (p < 0.05).

Conclusions

To our knowledge, this is the first study to report the risk factors and predictors of revision surgery in patients undergoing MMS for nasal tumours. This study highlights that the reconstructive modality utilised affects the functional and cosmetic outcome of MMS. We note that ala complex subunit lesions, squamous cell carcinoma and flap reconstruction were associated with an increased risk of revision after Mohs reconstruction of nasal lesions.

Level of evidence: Level III, risk/prognostic; therapeutic study.

Trial registration number

(Ref: PLA-19-20_A03) 04/02/2020.

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.

Interpolation Flaps in the Outpatient Mohs Surgery Setting: A Prospective Cohort Study of Patient Pain, Anxiety, and Satisfaction

BACKGROUND

Staged interpolation flaps (SIFs) have historically been performed under general anesthesia by specialties outside of dermatologic surgery. However, SIFs performed under local anesthesia by dermatologic surgeons have shown lower or equal complication rates.

OBJECTIVE

To date, no studies have evaluated pain, anxiety, satisfaction, and use of perioperative analgesics in patients undergoing SIFs in an outpatient setting under local anesthesia.

METHODS/MATERIALS

This is a prospective cohort study of 39 patients who received Mohs micrographic surgery and subsequent SIF repair in an outpatient setting under local anesthesia. Pain, anxiety, and satisfaction scores were recorded using 100-point validated visual analog scales. Perioperative analgesic use was quantified.

RESULTS

The defect size was ≥4 cm2 in 72% of patients; 41% had full-thickness (skin/cartilage/mucosa) defects. All pain and anxiety measures were minimal to mild. Pain scores ranged from highest (mean = 39 ± 4.1) on postoperative Day (POD) 1 to lowest (mean = 12.3 ± 2.0) on POD 7. Anxiety scores ranged from highest (mean = 42 ± 4.5) on POD 1 to lowest (mean = 18.5 ± 3.7) on POD 7. Perioperative patient satisfaction was high (mean = 95 ± 1.7). Postoperative narcotic analgesics were prescribed in 15% of patients.

CONCLUSION

Staged interpolation flaps performed under local anesthesia in the outpatient setting are well tolerated with low pain and anxiety, high patient satisfaction, and minimal analgesic use.

Neovascularization Perfusion of Melolabial Flaps Using Intraoperative Indocyanine Green Angiography

Importance

Assessment of melolabial flap perfusion using indocyanine green (ICG) angiography for nasal reconstruction has not been previously described.

Objective

To assess melolabial flap relative perfusion using ICG angiography in nasal reconstruction and highlight its clinical relevance.

Design, Setting, and Participants

In this retrospective case series at a tertiary referral center, 10 patients undergoing melolabial flap reconstruction of nasal defects between January 2015 to April 2018 with flap perfusion were assessed by ICG angiography.

Exposures

Indocyanine green angiography was performed to assess melolabial flap perfusion at second stage surgery after temporary clamping of the pedicle and after pedicle division and flap inset.

Main Outcomes and Measures

Flap perfusion in relation to a reference point on the cheek was calculated after both pedicle clamping and division by 2 methods: (1) ingress (arterial inflow) and egress (venous outflow) flap-to-cheek ratio; (2) flap-to-cheek perfusion (fluorescence) ratio at 3 time points (midpoint of ICG flap inflow, maximum [peak] fluorescence, and midpoint of ICG outflow), and their calculated mean. Correlations of perfusion with time between stages, and patient factors were performed; perfusion parameters after temporary pedicle clamping and after division and flap inset were compared.

Results

Ten patients (mean [SD] age, 66 [7.5] years) were enrolled with a mean (SD) interval of 23 (4) days between first and second surgery. No correlation existed between perfusion parameters and time interval between first and second stage, or any other patient factors. Of the different perfusion parameters, a statistically significant difference was observed when comparing temporary clamping and postdivision mean (SD) flap-to-cheek perfusion ratio (0.89 [0.22] and 0.80 [0.19]; 95% CI, 4.1-12.6; P = .001), as well as mean (SD) peak perfusion ratio (0.81 [0.2] and 0.77 [0.2]; 95% CI, 0.005-0.080; P = .02) only. No partial or complete flap necrosis was reported after pedicle division.

Conclusions and Relevance

Indocyanine green angiography is an effective method to determine neovascularization perfusion of melolabial flaps, with a mean perfusion of 89% after pedicle clamping. Future applications of this technology include use in patients at high risk for flap necrosis, or those who may benefit from early flap division to ensure adequate perfusion and minimize the time interval between staged procedures.

Level of Evidence

NA.

Retrospective Evaluation of the Safety of Large Skin Flap, Large Skin Graft, and Interpolation Flap Surgery in the Outpatient Setting

BACKGROUND

As the number of cutaneous surgeries continues to increase, it is important to evaluate the safety of dermatologic surgery in the outpatient setting.

OBJECTIVE

The authors sought to determine postoperative bleeding, infection, dehiscence, and necrosis rates in office-based dermatologic surgery using large flap, large graft, and interpolation flap repairs. The authors evaluated the relationship between these complications and surgical site, closure type, repair size, antibiotic use, and antithrombotic use.

METHODS

Eligible patients were identified through searching the electronic medical records from one Mohs micrographic surgeon at University Hospitals Medical Center. Patient information, surgery characteristics, and complication information were collected. Univariate and multivariate analyses were conducted to reveal associations between each complication and closure type, repair size, repair site, antithrombotic use, and antibiotic use.

RESULTS

Three hundred and thirty-one reconstruction procedures after Mohs micrographic surgery and excision qualified for the study. The rates of postoperative infection, hemorrhage, hematoma, necrosis, and dehiscence were 5%, 0.3%, 2.4%, 3%, and 0.9%, respectively.

CONCLUSION

Complications were infrequent and non-life-threatening. The authors' results indicate that dermatologic surgery using large flaps, interpolation flaps, and large grafts is safe in the office setting.

Staged retroauricular flap for helical reconstruction after Mohs micrographic surgery

Staged retroauricular flap is a great option for full-thickness defects along the helical rim and antihelix. Donor site consists of the posterior ear, postauricular sulcus and mastoid area. The advantages of this flap include hidden donor scar, donor tissue similarity and rich vascularity. We present a case of collision tumor on the left helix treated with Mohs micrographic surgery and the resulting full-thickness defect repaired with a staged retroauricular flap. This flap is an effective technique for full-thickness helical defect repair with relatively little operative morbidity. High esthetic and functional results may be obtained restoring the ear size and shape.

Paramedian forehead flap combined with hinge flap for nasal tip reconstruction

The paramedian forehead flap is a great option for restoration of complex nasal defects. For full-thickness defects, it may be used alone or in combination with other methods. We present a patient with a basal cell carcinoma on the distal nose treated by Mohs micrographic surgery, and a resulting full-thickness defect repaired with paramedian forehead flap combined with a hinge flap. For optimal results with the paramedian forehead flap, adequate surgical planning, patient orientation and meticulous surgical technique are imperative.

Ibuprofen May Not Increase Bleeding Risk in Plastic Surgery: A Systematic Review and Meta-Analysis

BACKGROUND

Nonsteroidal antiinflammatory drugs such as ibuprofen are common medications with multiple useful effects, including pain relief and reduction of inflammation. However, surgeons commonly withhold all nonsteroidal antiinflammatory drugs perioperatively because of bleeding concerns. However, not all nonsteroidal antiinflammatory drugs irreversibly block platelet function. The authors hypothesized that the use of ibuprofen would have no effect on postoperative bleeding in plastic surgery patients.

METHODS

A literature review was performed using MEDLINE (PubMed), EMBASE, and the Cochrane Collaboration Library for primary research articles on ibuprofen and bleeding. Inclusion criteria were primary journal articles examining treatment of acute postoperative pain based on any modality. Data related to pain assessment, postoperative recovery, and complications were extracted. Bias assessment and meta-analysis were performed.

RESULTS

A total of 881 publications were reviewed. Four primary randomized controlled trials were selected for full analysis. Articles were of high quality by bias assessment. No significant difference was noted regarding bleeding events (p = 0.32), and pain control was noted to be equivalent.

CONCLUSIONS

Ibuprofen is a useful medication in the setting of surgery, with multiple beneficial effects. This meta-analysis represents a small set of high-quality studies suggesting that ibuprofen provides pain control equivalent to narcotics. Importantly, ibuprofen was not associated with an increased risk of bleeding. Further large studies will be necessary to elucidate this issue further, but ibuprofen is a safe postoperative analgesic in patients undergoing common plastic surgery soft-tissue procedures.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.