Case 11 (2023): Paramedian forehead flap for nasal soft tissue reconstruction

After identifying the excision area, the tumor is removed with a 5 mm safety margin at an appropriate depth into the subcutaneous tissue, leaving a 30 x 30 mm nasal defect. Frozen sections are harvested from the defect borders at 12, 3, 6, 9 o’clock and the base and sent for rapid histological analysis.

• Frozen sections showed no malignancy at the margins at 3, 6, 9, 12 or the base. Therefore, the operation is continued by

The pedicle, defined by arterial inflow through the supratrochlear artery is located appr. 20 mm lateral to the midline. A reasonably narrow pedicle (ca. 15 mm) is drawn while blood supply to the flap is monitored by Doppler. A reverse Gilles test at the level of the eyebrow helps to ensure sufficient pedicle length.

Local anesthetics (Lidocaine + Adrenalin) are administered generously, which also helps to minimize bleeding. The flap is elevated from distal to proximal. Starting to dissect on the level of the galea, subperiosteal dissection begins from ca. 10 mm above the brow to safely capture subperiosteal perforators. The distal part of the flap (15-20 mm) is then thinned to the subcutaneous plane by removal of subcutaneous fat and frontalis muscle until the required thickness for defect reconstruction is achieved.

Medial rotation is used to bring the tip of the flap down to the defect. The distal one-eighth of the flap is now thinned to the level of the dermis as this part will not be elevated again. Subdermal inverted single sutures with 4-0 absorbable polyfilament followed by cutaneous single sutures with 5-0 non-absorbable monofilament are used to perform flap inset.

In this case, direct closure was possible by a few subdermal inverted sutures using 3-0 absorbable polyfilament to approximate the wound borders followed by a cutaneous layer of cutaneous single sutures using 3-0 non-absorbable monofilament.

Micropore was used on the sutured nasal tip and forehead. However, the posterior, raw side of the pedicle can be significantly inconvenient to the patient if not addressed properly. Therefore, extra care is taken to achieve the best possible hemostasis while not putting the flaps’ blood perfusion at risk. Small bleeding spots were coagulated with the bipolar tweezers and the pedicle was circumferentially dressed with Jelonet.

Final flap division and inset is performed 34 days after initial flap elevation. All suture sites are closed and show no sign of irritation or infection. The flap itself shows adequate perfusion.

For flap division and final flap inset, the pedicle is first separated at its origin medially to the eyebrow. To avoid eyebrow asymmetry by traction, a V-shaped skin flap is preserved from the pedicle and fitted to the remaining donor site defect. Next, the pedicle is separated from the flap at the tip of the nose, leaving enough tissue for final defect reconstruction. The flap is then re-elevated for about 50% (elevation is often possible up to 70-80%) [4], proximally thinned to the subcutaneous layer, and adjusted to the defect. Thorough hemostasis is performed. Both the remaining donor site defect as well as the final flap inset are sutured with subdermal inverted sutures using 5-0 absorbable polyfilament followed by cutaneous single sutures using 5-0 non-absorbable monofilament. Sutures are dressed with Micropore and dry gauze.