Forehead Flap with Dr. Jeffrey Marcus

Flap Cast

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Anatomy Overview: 

  • One of the oldest described surgical procedures in plastic surgery – its earliest description was in an ancient Indian text in 600BC. It gained popularity again in the early 1800s and was further refined by Dr. Gilles during WWI. 
  • Stood the test of time as a mainstay of reconstruction of large, multi-layer defects of the distal third of the nose. 
  • Robust flap with reliable vascular pedicle. It is easily harvested and acceptable donor site and finally is a near perfect skin match for the nose 
  • Blood supply to forehead:
    • Supraorbital, supratrochlear, superficial temporal, dorsal nasal, and facial/angular vessels
    • Run in subcutaneous plane in the forehead/scalp 
    • When we talk about the paramedian forehead flap, the blood supply to our flap is the supratrochlear artery and vein 
  • Supratrochlear artery is a terminal branch of ophthalmic artery
    • Emerges at the superonasal aspect of the orbit, medial to the supraorbital artery
    • Divides in to a superficial and deep branch
    • About 2cm above the superior orbital rim the superficial branch pierces the underside of the frontalis to run in a subcutaneous plane, eventually terminating in to multiple small branches near the hairline
    • You can typically identify the artery 1.5-2cm lateral to midline and 1cm superior to the brow with a doppler

Topics Covered:

  • General thoughts on the forehead flap, it’s history, and its utility in your practice?
  • Indications and contraindications?
    • Smokers/diabetes/peripheral vascular disease?
    • Children?
  • Preoperative planning
  • Can you take us through your markings?
    • Doppler?
    • Base width of the pedicle?
    • Pivot point?
    • What if you need more length, into the hairline or horizontal component?
  • Dissection:
    • Initial incisions and elevation
    • When do you transition to the subperiosteal plane?
  • Thinning:
    • How aggressive are you with flap thinning during the index operation?
    • Do you thin during this index operation do you have an intermediate procedure?
    • Vary with patient comorbidities?
  • Donor site closure? 
    • Any tips to obtain primary closure?
    • Secondary intention if too wide?
  • Do you routinely use SPY during this index operation? Prior to pedicle division?
  • Second Stage:
    • First, how long do you wait before pedicle division?
    • Any preoperative testing to determine if flap ready for division?
    • SPY routinely?
    • Technical steps of procedure?
  • What are your thoughts on the three stage forehead flap?
    • Specific indications? 
    • Aesthetics?
    • Comorbidities?
    • Folded forehead flap for lining?

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