British _%urnal of Plastic Surgery (19771, 30, 4~43
BIPEDICLED
(VASCULAR) By S. S.
RAWAT,
FOREHEAD
FLAP
M.S.
Professor of Surgery and Plastic Surgeon, Department of Surgery, Mow1 University College of Medicine, Mosul, Iraq ESSER (1918)used a forehead flap with a vascular pedicle passed through a subcutaneous
tunnel for a one-stage repair of nasal defects. Lexer (1931) also used the forehead skin based on the temporal vessels of one side. This flap, however, cannot be taken to the lower third of the face. The visor flap is designed to transfer large areas of forehead to the middle and lower thirds of the face but is sometimes not long enough for the lower third. It is considered necessary to delay such flaps before transfer (Schroder, 1972) and a further stage is required to return the skin pedicles. I have been transferring large forehead flaps based on bilateral pedicles of the superficial temporal arteries and veins for one-stage reconstructions of the lips and chin. TECHNIQUE
The forehead skin flap is raised along with the musculature on the superficial temporal arteries and veins of both sides. The vascular pedicle is dissected from the lateral margins of the flap to the pre-auricular area along with the soft tissues, the width of the pedicle being the same as the width of the skin flap so that small arterial branches
FIG. I.
Squamous cell carcinoma of the lower lip. The lip had been oedematous for the last IO years due to a deep bum just under the lip 13 years ago.
FIG. 2. The forehead skin and muscle flap raised on the vascular pedicles, and transferred to the defect after lip excision. The upper margin of the flap is folded on itself. The forehead defect has been covered by a split skin graft. FIG. 3. The flap after 4 weeks. Superficial skin necrosis (I x I cm) near the right edge, healed in IO days. 42
BrrEnrcL~~
(VASCULAR) FOREHEAD FLAP
43
The skin incisions are then extended on both and venous tributaries are not injured. sides from the pre-auricular area obliquely down to the edges of the defect and the vascular pedicles are buried under the cheek skin while the edges of the flap are sutured to the edges of the defect. The forehead defect is covered by a thick split skin graft and the skin incision sutured (Figs. 1-3). DISCUSSION It appears that division of the supra-orbital and supra-trochlear vessels without previous delay does not influence the viability of the flap. If the trunks of the superficial temporal arteries and veins are raised along with the branches and tributaries to the flap, by including the surrounding soft tissues in the pedicles, sufficient arterial nourishSince it is possible to dissect the ment and adequate venous drainage are ensured. pedicle as low as the pre-auricular area, it is possible to transfer the forehead flap without tension to the lower third of the face. In the postoperative period it is important that the suture lines are left exposed or merely covered with Vaseline gauze without applying The flap appears rather blue for about 4 days but gradually any pressure whatsoever. recovers in colour thereafter. REFERENCES &RR, J. S. (1918). Biological flaps. Berliner Klinische Wochenschri’t, 55,122. LEXER, E. (1931). “Die gesamte Wiederherstelhmgschirurgie.” Leipzig: Barth. SCHRODER, F. (1972). “Plastic and Reconstructive Surgery of the Face and Neck”, Conley, J. and Dickinson, J. T., p. 181. Stuttgart: Georg Thieme Verlag.
edited by
BIPEDICLED
(VASCULAR) By S. S.
RAWAT,
FOREHEAD
FLAP
M.S.
Professor of Surgery and Plastic Surgeon, Department of Surgery, Mow1 University College of Medicine, Mosul, Iraq ESSER (1918)used a forehead flap with a vascular pedicle passed through a subcutaneous
tunnel for a one-stage repair of nasal defects. Lexer (1931) also used the forehead skin based on the temporal vessels of one side. This flap, however, cannot be taken to the lower third of the face. The visor flap is designed to transfer large areas of forehead to the middle and lower thirds of the face but is sometimes not long enough for the lower third. It is considered necessary to delay such flaps before transfer (Schroder, 1972) and a further stage is required to return the skin pedicles. I have been transferring large forehead flaps based on bilateral pedicles of the superficial temporal arteries and veins for one-stage reconstructions of the lips and chin. TECHNIQUE
The forehead skin flap is raised along with the musculature on the superficial temporal arteries and veins of both sides. The vascular pedicle is dissected from the lateral margins of the flap to the pre-auricular area along with the soft tissues, the width of the pedicle being the same as the width of the skin flap so that small arterial branches
FIG. I.
Squamous cell carcinoma of the lower lip. The lip had been oedematous for the last IO years due to a deep bum just under the lip 13 years ago.
FIG. 2. The forehead skin and muscle flap raised on the vascular pedicles, and transferred to the defect after lip excision. The upper margin of the flap is folded on itself. The forehead defect has been covered by a split skin graft. FIG. 3. The flap after 4 weeks. Superficial skin necrosis (I x I cm) near the right edge, healed in IO days. 42
BrrEnrcL~~
(VASCULAR) FOREHEAD FLAP
43
The skin incisions are then extended on both and venous tributaries are not injured. sides from the pre-auricular area obliquely down to the edges of the defect and the vascular pedicles are buried under the cheek skin while the edges of the flap are sutured to the edges of the defect. The forehead defect is covered by a thick split skin graft and the skin incision sutured (Figs. 1-3). DISCUSSION It appears that division of the supra-orbital and supra-trochlear vessels without previous delay does not influence the viability of the flap. If the trunks of the superficial temporal arteries and veins are raised along with the branches and tributaries to the flap, by including the surrounding soft tissues in the pedicles, sufficient arterial nourishSince it is possible to dissect the ment and adequate venous drainage are ensured. pedicle as low as the pre-auricular area, it is possible to transfer the forehead flap without tension to the lower third of the face. In the postoperative period it is important that the suture lines are left exposed or merely covered with Vaseline gauze without applying The flap appears rather blue for about 4 days but gradually any pressure whatsoever. recovers in colour thereafter. REFERENCES &RR, J. S. (1918). Biological flaps. Berliner Klinische Wochenschri’t, 55,122. LEXER, E. (1931). “Die gesamte Wiederherstelhmgschirurgie.” Leipzig: Barth. SCHRODER, F. (1972). “Plastic and Reconstructive Surgery of the Face and Neck”, Conley, J. and Dickinson, J. T., p. 181. Stuttgart: Georg Thieme Verlag.
edited by
