Clinical Otolaryngolo~qy1979,4, 303-305
SURGEON’S WORKSHOP The forehead flap: a modification in technique J. A. S . CARRUTH Department of Otolaryngology, Royal South Hants Hospital, Graham Road, Southampton SO9 4PE
Accepted j i r publicntioii 18 April I 978 CARRUTH J.A.S. (1979)Clinical Otolaryngology 4, 303-305 The forehead flap: a modification i n technique The use of the forehead flap for reconstruction within the oral cavity after tumour resection is discussed. A minor modification in technique is described. The sub-zygomatic route to the oral cavity is used and a piece of teflon or sialalastic sheet is sewn over the raw surfaces of the flap which lies within the tunnel in the cheek to facilitate retrieval of the pedicle.
Keywords forehead Jlnp cancer inoutli reconstruction
It is often possible to obtain primary closure of a defect in the oral cavity after resection of a tumour by bringing together the residual soft tissues. However, after extensive resections this may not be possible even by rotating local tissue flaps: or if possible may result in fixation of the tongue remnant with consequent problems in swallowing and speech-the crippled oral cavity well described by Conley. It is generally accepted that it is essential to bring soft tissue into the oral cavity to repair such defects and to obtain maximum function in the tongue remnant. Several techniques are available for achieving this. Possibly the most widely used distant flaps at the moment are the forehad flap and the medially based chest flap. On occasions both will be used to provide lining and cover after a major composite resection. T h e use of the forehead flap was first described by Blair, Moore, and Byars in 1 9 4 1 . ~ The flap is based in the superficial temporal artery and may be moved into the oral cavity undelayed. It provides excellent vascular unirradiated skin for reconstruction. There has been some difference of opinion as to the best route to use to take the flap into the oral cavity. First the flap may be folded laterally and brought into the oral cavity through a separate incision in the cheek.3 Retrieval of this flap is easy but there will be another scar on the face and it is possible to damage the facial nerve while constructing the tunnel in the cheek. Second the flap may be folded medially and brought down lateral to the zygomatic arch.4 Dissection lateral to the arch again puts the facial nerve at risk and damage is not uncommon. 0307-7772/79/0800-0303$02.00
0 1979Blackwell Scientific Publications
303
304
J . A . S. C A R R U T H
One of the most popular routes to the oral cavity is that described first by Davis & H ~ o p e s . ~ They describe the utilization of the space beneath the zygomatic arch and state that it is preferable to other routes for the following reasons: I Subcutaneous dissection is eliminated obviating the need for a separate incision and avoiding any danger to the facial nerve. 2 A lesser degree of folding of the flap on itself is required. 3 Additional flap length is gained by virtue of the more direct anatomical route into the oral cavity. 4 The zygomatic arch protects the flap from accidental external compression. In the cases which they describe the mandible was removed on each occasion and there was therefore no problem in passing the flap beneath the zygomatic arch. However, if it is not necessary to remove the mandible in the resection of the tumour then it is essential to remove the coronoid process of the mandible to permit the flap to lie in the subzygomatic tunnel without compression. They suggest that a part of the flap may be de-epithelialized as it lies within the tunnel in the cheek to render retrieval of the pedicle unnecessary. However, I believe that most people prefer to retrieve the pedicle to decrease to a minimum the cosmetic deformity on the forehead and in addition the presence of the flap within the cheek gives rise to some cosmetic deformity. I have used the forehead flap on many occasions and have used the subzygomatic route for the reasons mentioned above. I believe there is little risk of kinking the vessels within the pedicle as it is folded medially if the flap is folded over a substantial roll of vaseline gauze to reduce the angulation. However, I have always found it difficult to retrieve the pedicle as the raw surface of the flap becomes adherent to the wall of the sub-zygomatic tunnel and a lot of dissection is always needed. It is not possible to tube the pedicle as there is insufficient room beneath the zygomatic arch. I have adopted a minor modification of technique which others may find helpful in retrieving the pedicle. In order to prevent the flap sticking within the tunnel it is possible to attach over the raw surface that will lie within the tunnel a piece of sialastic or Teflon sheeting. This can in no way interfere with the blood supply of the flap or affect the healing within the oral cavity. After division of the flap within the mouth it is extremely easy to retrieve the pedicle and to return the majority of the flap to the forehead. After a major resection of a tumour of the oral cavity the aim will be to restore the oral physiology to as near normal as possible, and also to create the minimal cosmetic deformity. The use of the forehead flap is one way of preventing crippling of the oral cavity, and retrieval of the pedicle, to return the majority of the flap to the forehead, minimizes the cosmetic deformity. References I
CONLEY J.J. (1962)The crippled oral cwity. Plastic and Reconstructive Surgery 30, 469.
ForehenilJlap
305
2 BLAIR V.P., MOORES. & BYARS L.T. (1941) Cancer of the Face and Mouth. C.V. Mosby, St. Louis. 3 MCGREGOR I.A. (1963) The temporal flap in intra-oral cancer: its use in repairing the post-excisional defect. British Journal of Plastic Surgery 16,3 18. 4 Hoop= J.E. & EDGERTON M.T. (1966) Immediate forehead flap repair in resection for oropharyngeal cancer. American Journal of Surgery 112, 527. 5 DAVISG.N. & HOOPES J.E. (1971) New route for passage of forehead flap to inside of mouth. Journal of Plastic and Reconstructive Surgery 47, 393.
SURGEON’S WORKSHOP The forehead flap: a modification in technique J. A. S . CARRUTH Department of Otolaryngology, Royal South Hants Hospital, Graham Road, Southampton SO9 4PE
Accepted j i r publicntioii 18 April I 978 CARRUTH J.A.S. (1979)Clinical Otolaryngology 4, 303-305 The forehead flap: a modification i n technique The use of the forehead flap for reconstruction within the oral cavity after tumour resection is discussed. A minor modification in technique is described. The sub-zygomatic route to the oral cavity is used and a piece of teflon or sialalastic sheet is sewn over the raw surfaces of the flap which lies within the tunnel in the cheek to facilitate retrieval of the pedicle.
Keywords forehead Jlnp cancer inoutli reconstruction
It is often possible to obtain primary closure of a defect in the oral cavity after resection of a tumour by bringing together the residual soft tissues. However, after extensive resections this may not be possible even by rotating local tissue flaps: or if possible may result in fixation of the tongue remnant with consequent problems in swallowing and speech-the crippled oral cavity well described by Conley. It is generally accepted that it is essential to bring soft tissue into the oral cavity to repair such defects and to obtain maximum function in the tongue remnant. Several techniques are available for achieving this. Possibly the most widely used distant flaps at the moment are the forehad flap and the medially based chest flap. On occasions both will be used to provide lining and cover after a major composite resection. T h e use of the forehead flap was first described by Blair, Moore, and Byars in 1 9 4 1 . ~ The flap is based in the superficial temporal artery and may be moved into the oral cavity undelayed. It provides excellent vascular unirradiated skin for reconstruction. There has been some difference of opinion as to the best route to use to take the flap into the oral cavity. First the flap may be folded laterally and brought into the oral cavity through a separate incision in the cheek.3 Retrieval of this flap is easy but there will be another scar on the face and it is possible to damage the facial nerve while constructing the tunnel in the cheek. Second the flap may be folded medially and brought down lateral to the zygomatic arch.4 Dissection lateral to the arch again puts the facial nerve at risk and damage is not uncommon. 0307-7772/79/0800-0303$02.00
0 1979Blackwell Scientific Publications
303
304
J . A . S. C A R R U T H
One of the most popular routes to the oral cavity is that described first by Davis & H ~ o p e s . ~ They describe the utilization of the space beneath the zygomatic arch and state that it is preferable to other routes for the following reasons: I Subcutaneous dissection is eliminated obviating the need for a separate incision and avoiding any danger to the facial nerve. 2 A lesser degree of folding of the flap on itself is required. 3 Additional flap length is gained by virtue of the more direct anatomical route into the oral cavity. 4 The zygomatic arch protects the flap from accidental external compression. In the cases which they describe the mandible was removed on each occasion and there was therefore no problem in passing the flap beneath the zygomatic arch. However, if it is not necessary to remove the mandible in the resection of the tumour then it is essential to remove the coronoid process of the mandible to permit the flap to lie in the subzygomatic tunnel without compression. They suggest that a part of the flap may be de-epithelialized as it lies within the tunnel in the cheek to render retrieval of the pedicle unnecessary. However, I believe that most people prefer to retrieve the pedicle to decrease to a minimum the cosmetic deformity on the forehead and in addition the presence of the flap within the cheek gives rise to some cosmetic deformity. I have used the forehead flap on many occasions and have used the subzygomatic route for the reasons mentioned above. I believe there is little risk of kinking the vessels within the pedicle as it is folded medially if the flap is folded over a substantial roll of vaseline gauze to reduce the angulation. However, I have always found it difficult to retrieve the pedicle as the raw surface of the flap becomes adherent to the wall of the sub-zygomatic tunnel and a lot of dissection is always needed. It is not possible to tube the pedicle as there is insufficient room beneath the zygomatic arch. I have adopted a minor modification of technique which others may find helpful in retrieving the pedicle. In order to prevent the flap sticking within the tunnel it is possible to attach over the raw surface that will lie within the tunnel a piece of sialastic or Teflon sheeting. This can in no way interfere with the blood supply of the flap or affect the healing within the oral cavity. After division of the flap within the mouth it is extremely easy to retrieve the pedicle and to return the majority of the flap to the forehead. After a major resection of a tumour of the oral cavity the aim will be to restore the oral physiology to as near normal as possible, and also to create the minimal cosmetic deformity. The use of the forehead flap is one way of preventing crippling of the oral cavity, and retrieval of the pedicle, to return the majority of the flap to the forehead, minimizes the cosmetic deformity. References I
CONLEY J.J. (1962)The crippled oral cwity. Plastic and Reconstructive Surgery 30, 469.
ForehenilJlap
305
2 BLAIR V.P., MOORES. & BYARS L.T. (1941) Cancer of the Face and Mouth. C.V. Mosby, St. Louis. 3 MCGREGOR I.A. (1963) The temporal flap in intra-oral cancer: its use in repairing the post-excisional defect. British Journal of Plastic Surgery 16,3 18. 4 Hoop= J.E. & EDGERTON M.T. (1966) Immediate forehead flap repair in resection for oropharyngeal cancer. American Journal of Surgery 112, 527. 5 DAVISG.N. & HOOPES J.E. (1971) New route for passage of forehead flap to inside of mouth. Journal of Plastic and Reconstructive Surgery 47, 393.
