INTRODUCTION:
Forehead Flaps have been in use since ancient times as has been depicted in the
classical paintings of the great Susrutha at work repairing the nose of those
unfortunate to have their noses cut off as a punishment. The forehead flaps hold a
closer relation to us Indians as we seem not only to be pioneers in utilizing this area
for reconstruction but also contribute to the further development of their uses. The
bipolar Narayanan flap is a point in case.
The forehead flaps have waxed and waned in their popularity at various periods
in the long history of plastic surgery. Although it has proved its reliability time and
again there seems to be a continued reluctance among the younger generations of
plastic surgeons in using this virtual treasure trove of tissue for reconstructive options
in the head and neck region due to concerns about the donor area scarring.
Probably the easy accessibility to technology and the ever increasing popularity
of free flaps with their promise of a single-stage procedure – where the tissue can be
sculpted to exactly fit the defect and thereby allowing the patient to return to nearnormal
life as early as possible – as compared to the multiple stages generally
required when the forehead flap is used, distracts surgeons from these age-old and
time-tested options.
It is also widely accepted that local tissues give the best colour and texture
match to any reconstructed area. This is especially applicable to the face. Thus,
currently the central forehead flaps are favoured in the nasal reconstruction.
The forehead flaps have lent themselves to such a wide variety of uses that a
revisit to their different clinical applications is well justified, if only to serve to bring
the spotlight back to the most versatile donor area in the face.
AIM OF THE STUDY:
This study on the versatility of the forehead flaps as a reconstructive tool was
done with following aims.
1) To review the various flaps used from the forehead region in Department of
Plastic and Reconstructive Surgery, Government Medical College, Chennai.
2) To study the effectiveness of these flaps in various clinical situations.
3) To report our experiences along with the other uses of forehead flaps reported
in the literature.
MATERIALS AND METHODS:
This study was conducted in the Department of Plastic Surgery, Government
General Hospital and Madras Medical College over a period of 32 months September
2005 to April 2008.
All cases where a forehead flap was used in the reconstruction of a soft tissue
defect in the face – either primarily or secondarily – were included in the study. The
flaps were loosely classified as central forehead flaps (paramedian, median, oblique
forehead flaps and the glabellar V-Y advancement flap) and laterally based forehead
flaps (transverse forehead flap, bilobar Narayanan flap, scalping flap, forehead
rotation flap, Fricke flap, etc., ).
Forehead flaps were done for a total of 29 patients for various indications. One
patient died during post-operative period due to anesthetic complications and was not
included in the study. So a total of 28 patients accounting for 28 flaps were enrolled
for the study after getting their informed written consent.
The proforma for the collection of data was made. All the relevant details of the
patient during preoperative, surgical, postoperative and follow up periods were
collected and analysed.
Indications for forehead flap cover in our study included :
1) Post-excision defects in patients with malignancies.
2) Soft tissue defects in patients acute trauma.
3) Patients presenting with post traumatic soft tissue defects at a later date.
4) Patient presenting with a post-surgical defect.
The regions where defects were covered with forehead flaps included :
1) Nose,
2) Cheek,
3) Forehead,
4) Eyelid/Periorbita.
The age range of the patients was from 3 - 80 yr (average age – 45.21 yr). The
study included 2 children (ages 3 and 4 yr) and 2 senior citizens (ages 73 and 80 yr).
The study included 18 male patients and 10 female patients.
The defects around the medial canthus, eyelids and nose were favoured with
one of the central forehead flaps whereas cheek, lateral canthus and lower face and
neck defects were favoured with the transverse forehead flaps.
RESULT:
A total number of 28 patients were included in the study over a period of 32
months between September 2005 to April 2008. Among the 28 patients who underwent various forehead flaps, 15 patients had primary or delayed primary cover for post-excisional defects. The majority of these were transverse forehead flaps with or without modifications. The majority of the flaps healed well although they invariably were staged procedures. Transverse forehead flaps seem to require a minimum of 3 stages – flap elevation and inset, flap division and flap thinning/commissuroplasty with or without reanimation of the oral
sphincter. This is also the group that had maximum post-operative complications
(partial/complete flap necrosis).
Although an objective assessment was not made regarding the patient
satisfaction with the esthetic outcome, most of the patients were not happy with the
end result in terms of appearance in the immediate post-op period. On further followup,
however, most of the patients seem to be satisfied with the end result.
CONCLUSION:
The following conclusions can be made from this study:
1. The forehead is a versatile donor area for head and neck reconstruction.
2. The forehead flaps have a robust vascularity and are reliable.
3. Properly planned forehead flaps are adequate and effective for most of the
nasal defects and many of the post-excision defects in the face and neck.
4. The uses of the forehead flaps are only limited by the imagination and skill
of the surgeon
