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?