The post- and retro-auricular scalping flap (the PARAS flap)
Prakash Chhajlani1987, British Journal of Plastic Surgery
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Abstract
The possibility of an axial pattern scalp flap with a random extension is presented on the basis of cadaveric dissection and clinical studies. The study shows promise of an aesthetic flap for covering facial defects. The vascular anatomy is discussed and the surgical technique described, and its clinical application in five patients illustrated. More clinical work and long term follow-up are in progress. Surgery, 43,247. CM&ir, G. F. (1956). A method of partial ear reconstruction for avuision of upper portion of the ear. Pia& and ~~~~t~~ Surgery> 17,438. Gatvao, M. S. L. (1981). A post-auricuiar flap based on the contralateral superficial temporal vesseis. Pfitsric and &con-s@fict&e Sm;aer_v, 68,891. N&t& P., Hurteau, J. ml Ymmz, L. 0. (I 978). Rep~an~t~on of an entire scalp and ear by microvascular anastomosis of only one artery and one vein. British Journa~ofHastic Surgery, 31,339. Onticochea, M. (1971). A new method for total ~onstmction of the nose: the ears as donor areas. British Journal of Plastic Surgery, 24,225. SmM, P. J. and McGregor, I. A, (1973). The vascular basis of axial vat&m flaw. British Joumi of Plastic Suraerv. 26. 150. Washlo; H. (lBS$. Retroa~riGular i!emporal flap. %a& and Re~t~t~~ Surgery, 43% 162, The Aatiiors
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South African Journal of Plastic & Reconstructive Aesthetic Surgery & Burns
Forehead flaps are well known for their reliable blood supply, hence the successful use of this flap over thousands of years. [1,2] A detailed study of the blood supply of the forehead has led to the identification of precise landmarks for midline forehead flap planning, similar to the old Indian rhinoplasty landmarks described by Daver and Antia. [3] Further investigation into pedicle rotations has shown that the best technique for one-stage pedicle inset was to use an inverted-kite pedicle base modification of the midline forehead flap. [4] Other authors have described their positive experiences with the one-stage forehead flap, but despite this, the paramedian forehead flap became the gold standard flap in the West. [5-10] The correct application of the landmarks and pedicle base modification allows for one-stage pedicle inset of a reliable robust flap, and almost no need for pedicle separation at a second stage. [4] This depends on the reconstructive demands of the defect. In some cases, only pedicle base refinements or minor debulking may be necessary. Some cases may require complete flap elevation, in which case the blood supply and sensation can be safely maintained, which is not practical with a paramedian forehead flap once the pedicle has been separated. The one-stage forehead flap may be highly advantageous for surgeons doing missionary surgery where surgeon follow-up is suboptimal, and onestage primary surgery with minimal secondary operations is ideal. It is also a useful procedure in elderly patients, for whom ultimate aesthetic outcomes may be less important. Using fewer stages means that there is less cosmetic refinement, but using the one-stage inset technique does not mean that further stages for refinement cannot be done. In the author's experience, the paramedian forehead flap has become as obsolete as a cross-leg flap. Methods A retrospective review was carried out of all the cases operated on from January 2006 until September 2018 by the author. The technique used for midline forehead flap planning is as follows: any scars or injuries to the arterial pedicles must be excluded by clinical examination of the facial skin overlying the source arteries, from the facial artery to the angular artery, the dorsal nasal artery, the central artery, the paramedian and the supratrochlear artery communicating branch area in the medial canthal region. [2] Next, a central vein of the forehead should be found. This vein is more prominent when patients frown, become emotional, or valsalva, or when they are in a prone position. The vein is a cutaneous landmark of the subcutaneous arterial patterns. [3] When present, the central vein is then used as the central axis for the flap. Since the central arteries are tightly woven around the central vein and have interarterial communications, it is possible to design a narrow pedicle of about 5-10 mm in width. [4] As the central vein drains into either left or right orbits in the supramedial canthal region (the frontonasal angle), the pedicle base will turn in that direction. A rare central arterial and venous variation is that the vein may be exactly in the midline, and fork at the glabella to drain into the medial canthal areas. [4] This vein has been named a median vein, and has a corresponding
Nose defects reconstruction with forehead flap - case report
Mædica, 2014
Nasal reconstruction has be one of the most challenging procedures in reconstructive plastic surgery. Small nasal defects may be closed by primary suture or covered by small local flaps or skin graft. But in large nasal defects, we need to find a bigger source of color and texture matching tissue that will ensure functional and aesthetical outcomes. We chose a case report of one patient admitted in our clinic in 2012, who represented a daring task for us. Best suited for paramedian forehead flap reconstruction, the patient underwent a procedure in 2 steps, which led to a very satisfying nose both for the patient and for the surgeon. In order to achieve a good coverage with the smallest donor site defect, we used a flap based only on the left supratrocheal artery, which gave us the possibility to rotate the flap without distorting the vessels. In such cases, the best option, aesthetically and functionally, for the patient still remains the paramedian flap, modified from the original ...
The transverse parietooccipital transposition flap for the closure of extensive frontoparietal scalp defects
Journal der Deutschen Dermatologischen Gesellschaft = Journal of the German Society of Dermatology : JDDG, 2015
Staged Cheek-to-Nose and Auricular Interpolation Flaps
Dermatologic Surgery, 2006
BACKGROUND. Staged interpolation flaps are priceless options in skin cancer reconstruction. Their value lies in their flexibility, reach, reliability, and ability to repair distant, complex facial defects. Familiar interpolation flaps to dermatologic surgeons include the paramedian forehead flap, cheek-to-nose interpolation flaps, and auricular staged flaps. OBJECTIVE. In this special reconstructive issue, the paramedian forehead flap is discussed separately. This article highlights the cheek-to-nose and auricular interpolation flaps as applied to skin cancer defects. Design considerations, anatomic basis, execution, and the distinctions of each repair are presented. MATERIALS AND METHODS. Patients with facial defects from Mohs micrographic surgery serve to illustrate the surgical techniques of each repair. RESULTS. With meticulous planning and thoughtful execution, cheek-to-nose and auricular staged flaps are capable of restoring both function and cosmesis. Several surgical stages are necessary, and an adequate supporting infrastructure is essential for an optimal outcome. CONCLUSION. Skin cancer patients with complex facial wounds from Mohs micrographic surgery may be assured of the highest possible cure rate. Further, their esthetic and functional reconstructive goals may be achieved with staged flaps for the nose and ear.
The Prefabricated Temporalis Fascio-Cutaneous Free Flap
Journal of Oral and Maxillofacial Surgery, 2009
Coverage of moderately sized oral and facial defects has always been a difficult problem because of the limited availability of local tissue and excessive bulk of common free flaps.
Novel flaps for head and neck reconstruction
Indian Journal of Surgical Oncology, 2010
The head and neck region is important both functionally and aesthetically and its reconstruction poses a formidable challenge for plastic surgeons. A perforator flap is a flap of skin or subcutaneous tissue supplied by a vessel that perforates the deep fascia to gain access to flap. With improvement in our knowledge of the anatomy of blood supply to the skin, the perforator flaps have opened a whole new horizon for the plastic surgeon to choose flaps with better function and cosmesis. The locally available perforators enable flaps to be designed with excellent match in tissue characteristics. Perforator flaps limit donor site morbidity and as they are islanded complete insetting is possible in a single stage. The principal perforator flaps such as facial artery perforator flap, platysma flap and its variant the submental flap and supraclavicular artery flap used in the head and neck reconstruction are discussed. The more commonly used flaps are the free radial artery forearm flap and the anterolateral thigh flap while the novel ones are the thoracodorsal artery perforator flap, medial sural artery perforator flap and the toe-web flap for commissure reconstruction. The indications, reach and drawbacks of these flaps have been discussed in this review.
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Head and Neck-journal for The Sciences and Specialties of The Head and Neck, 2002
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Microvascular Free Flaps: a Major Advance in Head and Neck Reconstruction
Acta Oto-Laryngologica, 2002
The full-thickness forehead flap for complex nasal defects: A preliminary study
Otolaryngology - Head and Neck Surgery, 2005
To report a new technique using a bivalved, full-thickness paramedian forehead flap. The unique vascular anatomy of the supratrochlear artery allows the skin and subcutaneous tissue to be separated from the frontalis muscle and pericranium. The deep layers serve as a pliable, vascularized intranasal lining. Bone and cartilage grafts can be placed as "sandwich" grafts between the deep and superficial layers of the flap. A retrospective review of 5 cases. All flaps survived. Four minor complications occurred in 3 patients. These resolved with minimal treatment. The full-thickness forehead flap is a viable option for large defects or for the difficult situation in which intranasal local flaps are not an option. The gold standard for replacement of the intranasal lining is a septal mucosal or vestibular local flap. The full-thickness forehead flap is an option in patients for whom other lining flaps are not available. C-3.
Forehead flap in nasal reconstruction
Otolaryngology - Head and Neck Surgery, 1995
We establish criteria for aesthetic forehead flap reconstructions and evaluate the effect of mathematical models and computer simulation of the operation in preoperative and perioperative planning. We study a case series of 13 patients in an academic tertiary referral medical center. Most patients had nasal defects after Mohs' surgery for tumor ablation. Patients were followed up for 2 years after reconstructive surgery. Three patients underwent midline forehead flap nasal reconstructions, and t0 patients underwent paramedian forehead flap nasal reconstructions. We used patient satisfaction and physician evaluation of aesthetic form and function restoration as the main outcome measures. There were no major complications. Minor complications included short-term pincushioning in all patients, scar contrac-Lure that resolved after 8 months in one patient, and forehead necrosis after primary closure of the upper forehead in one patient. Computer simulation correlated two-dimension flap design to the transposition process. We conclude that the forehead flap is the optimal reconstructive modality for resurfacing large nasal defects. The paramedian forehead flap is superior to the midline forehead flap for nasal reconstruction, especially for distal tip reconstructions. Mathematical models and computer simulation of the reconstructive procedure that relate the two-dimensional flap design to the transposition process reveal subtle geometric relationships of the flap transposition that facilitate the design of the optimal flap for reconstruction. (OTOLARYNGOL HEAD NECK SURG 1995; 113: 740-7.) rain I¥1any surgeons consider forehead skin the best match of color and texture in reconstructing nasal defects. Unfortunately, because of the thickness of forehead skin, composite grafts cannot survive reliably solely on imbibition. Thus surgeons traditionally transpose the tissue from the forehead onto the nose by a two-stage procedure: the first stage transfers the tissue on a vascular pedicle, and the second stage divides the pedicle after inosculation and
The H-flap: a useful flap for forehead reconstruction
British Journal of Plastic Surgery, 2001
We have found that double opposing rectangular advancement flaps in the forehead may be easily performed under either local or general anaesthesia, and are associated with high patient satisfaction and low morbidity. We claim no originality for the mode of reconstruction, but highlight its broad spectrum of application and its popularity with junior plastic surgeons passing through our unit. We have found that the term 'H-flap' provides a readily communicated alternative to 'double opposing rectangular advancement flaps'.
Modifications of Paramedian Forehead Flap
2021
Introduction Paramedian forehead flap an interpolated flap based on supratrochlear vessels is considered as a workhorse for nasal and periorbital reconstruction however it re-quires modification’s to meet reconstruction requirement. Modifications includes islanded single stage forehead flap, expanded forehead flap, pre-fabricated with rib cartilage, folded forehead flap, split forehead flap and delayed flap, are associated with complications which can be minimized using different techniques. This article’s objective is to re-view indications for modification of Paramedian forehead flap, its complications and techniques of minimizing them. Methods: Twenty-three patients with facial defects reconstructed with modified Paramedian forehead flap were analysed by non-probability purposive sampling from September 2010 to August 2014, while traditional forehead flap reconstructions were excluded. Results: Nasal and periorbital region defects were present in twenty-one and two patients respe...
The Submental Flap in Facial Reconstruction: Advantages and Limitations
Journal of Oral and Maxillofacial Surgery, 2007
Purpose: Complex defects resulting from surgical excision of facial cancer sometimes require reconstruction using microvascular free tissue transfer. Tissue transfer from areas distant from the face can resolve many problems, but often provides a poor cosmetic match with facial skin. The submental flap helps surmount this problem. Cervical skin has similarities with face skin, and because this is a regional flap, it helps eliminate microsurgical risks. In this article we present a series of 9 cases, review the anatomy and the surgical technique, and explain the advantages and limitations of the submental flap. Patients and Methods: A successive series of 9 patients in which this reconstruction was performed was reviewed retrospectively, and the results were analyzed. Results: Submental flap facial reconstruction was performed on 9 patients (8 men and 1 woman) between 1993 and 2004. Mean patient age was 53.6 years (range, 43 to 81 years). Eight of the 9 external skin coverage cases were associated with excision of cutaneous malignancies; 1 case involved treatment of burn sequelae. There were no cases of marginal mandibular nerve palsy. In 6 cases, venous drainage was disrupted after raising the flap, but without causing flap loss. This disruption was overcome in 4 to 5 days without the need for flap revision or any other interventions. Partial loss of the distal extent of the flap occurred in 2 cases. In all cases, moderately good skin color and texture match was achieved. Debulking of the flap was needed in 6 cases. The donor site recovered well with no hypertrophic scarring and no restriction to neck movement. Conclusions: The submental artery island flap is a useful reconstructive procedure that offers options to the reconstructive surgeon and has definite advantages over distant flaps in terms of ease of dissection and donor site appearance.
Reverse-Flow Retroauricular Island Flap in Facial Reconstruction
Dermatologic Surgery, 2007
BACKGROUND Reconstruction of facial skin defects requires good-quality skin cover to satisfy aesthetic expectations of patient, especially when the skin defect is on the uncovered area of the face. Limitations in the available local tissue and donor-site morbidity restrict the options. OBJECTIVE In an effort to solve these problems, we have begun to use a subcutaneous pedicled retroauricular reverse-flow flap. METHODS Between January 1997 and December 2005, reverse-flow subcutaneous pedicled retroauricular island flap was used to cover facial defects in 12 patients who underwent surgical excision of skin tumor. The patients ranged in age from 44 to 81 years with a mean age of 58 years. RESULTS Only one case experienced a superficial necrosis in the distal one-quarter part of the flap. The functional and aesthetic results were satisfactory for both patients and surgeons, and no tumor recurrence was observed during the 12 to 28 months (mean, 18.8 months) follow-up period. CONCLUSIONS This flap can be used reliably for the reconstruction of facial skin defects of small and medium size. The preference of frontal branch pedicled flap enables more distal facial area defects to be covered, such as dorsal nasal, nasolabial, and upper lip, than flaps based on parietal branch.
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