FOREHEAD

FLAP
Dr Gautam Kalra
Senior Resident
AFMC, Pune
 CONTENT

 History
 Anatomy
 Indications
 Technique
 Complications
 Advantages
 Disadvantages
 HISTORY
 Also called as temporal flap.

 800 BC – Sushruta (nasal reconstruction) based on

pedicled forehead flap (Indian Flap).

 Later describe by McGregor, in 1963.

 Its axial pattern flap

 terminal branch of the
external carotid artery.

 It arises in the parotid gland behind the

neck of the mandible

 Initially deep, it becomes superficial as

it passes over the posterior root of the
zygomatic process.

 It then runs up the scalp for 4 cm and

divides into frontal (anterior) and parietal
(posterior) branches.
 Supratrochlear artery

The supratrochlear artery (ophthalmic artery-ICA)

Runs in the supero-medial orbit to the orbital rim.

It exits the orbit approximately 2 cm from the

midline through the supratrochlear notch
 Supra Orbital Artery

• From the ophthalmic artery, runs anteriorly, between the orbital roof
and levator palpebrae superioris
• It exits the orbit through the supraorbital notch or foramen.
 Based on the mangold
et al (1980) study on
vascular anatomy of the
forehead . He divided
forehead in vascular
territories-

 Dorsal nasal artery

 Supratrochlear artery
 Supraorbital artery
Superficial temporal
artery.
 Indications

Used for a large number of reconstruction procedures:

 nose
 Middle and lower third of face
 cheek
 Oral cavity
 chin covering for reconstructed mandible
Technique
Laterally based forehead flap

 The forehead flap is

outlined.
 contour follows the eyebrows
to anterior border of pinna at
level of zygomatic arch and
along forehead hairline
 The incisions are beveled
to minimize the cosmetic
deformity along the
remaining edges of the
forehead and scalp
 for longer flap most often
extends to hair-line of
opposite temple.
As it is used for intraoral reconstruction a tunnel is
constructed through which flap is passed so that distal end
reaches the intra-oral defect.

Based on the route in the mouth-

 Directly through the cheek(cheek portal)
 Deep to the zygomatic arch
 Posterior part of submandibular incision of neck
dissection.
 Through the cheek
 Tunnel is made outside the
cheek

 Skin incision - horizontally

in front of ear approx.

 Incision deepened to the

parotid level using scalpel
then tissue scissor thrust
through the substance of
cheek in the defect.
 When Ramus is dissected
tunnel is made directly
through the mouth with min
resistance of parotid.

 When ramus is intact tunnel

has to bring round in front of
bone .
 Deep zygomatic arch
 Davis & Hoopes
 Flap is passed downward deep to the arch into mouth
following the pathway of the temporalis muscle.
 Submandibular incision

 By Millard ,1964.

 Flap enter the mouth medial to

the mandible
 Secondary defect
 Secondary defect is covered by split skin graft.
 Second surgery is done 3 week later & bridge
segment of the flap is returned to the temple or
forehead.
 Second surgery

 Done after 3 weeks, flap is tunneled & divided it from

outside as far down the tunnel.

 Skin closure is done from outside n tunnel is kept

patent inside to drain freely.
 Advantage

 Rich in vascular supply , so rare chances of flap

necrosis.
 Long flaps are possible to raise ,can reach to most of
oromaxillary defect.
 No major vital structure approximating the flap.
 Lifeboat flap can be easily raised, not a technique
sensitive.
Disadvantage
 Donor site defects especially in the younger patient are
detrimental.

 Compromise of blood supply is possible via the superficial temporal

artery if a simultaneous radical neck dissection has sacrificed the
external carotid artery.
 Complication

 Infection
 Cosmetically detrimental
 Facial nerve injury
 Need donor area grafting (STG is placed at donor
area).
 Patient need to expose for second surgery.
 There is danger of compromise of blood supply if the
flap is tunnelled deep to the zygomatic arch. If this is the
approach to reach the oral cavity, it is best to fracture the
arch outward with two osteotomies.

 Injury to the facial nerve may occur when performing

an access to the oral cavity.
 PARA MEDIAN FOREHEAD
FLAP
⚫ one of the oldest flaps in use for the reconstruction of facial defects.

⚫ It was first used to reconstruct nasal amputation defects in 1500 BC.

INDICATIONS

Reconstruction of nasal defects

periorbital defects
Vascular Anatomy

The vascular supply to the forehead comes from the

supraorbital arteries
supratrochlear arteries.
angular artery (Glabellar region)
PLANE OF DISSECTION
 TECHNIQUE OF THE TWO-STAGE
FOREHEAD FLAP
•▶ Stage 1: flap transfer
▶ An exact pattern of
the defect, is outlined,
directly over the
supratrochlear artery
▶ Pedicle width at the
brow is about 1.2–1.5
cm.
▶The reach of the flap is verified
▶ The flap can be lengthened by extending the
design into the hairline or, more often, the
pedicle is extended inferiorly across the eyebrow
towards the medial canthus.
▶ It is sutured to the
recipient site, from
distal to proximal, with
a single layer of fine
suture. If the flap
blanches, stop suturing
and let the unsutured
lateral flap edges heal
secondarily to the
recipient site.
▶ Stage 2
▶ The pedicle is divided 3–4
weeks later
▶ The flap remains well
vascularized through its
distal inset. The superior
inset is completed. The
proximal pedicle is untubed
and returned to the medial
brow as a small inverted
“V,” discarding any excess
Infraorbital region reconstruction with
paramedian flap
Advantages

Matches the texture, thickness and color

Reliable anatomy and rich vascularity
Forgiving donor site
THANKYOU