Paramedian Forehead Flap

This axial flap is commonly used for external coverage in nasal reconstruction. It is based on the supra-trochlear artery and vein, running on the undersur-face of the flap.19 The flap is designed using a precise template of the missing nasal subunits and is placed on the contralateral forehead. Usually the distal third of the flap is elevated subcutaneously; the middle third includes part of the frontalis muscle, and from 1 cm above the supraorbital rim, flap elevation is in the subperiosteal plane. The flap is rotated 180 degrees and remains attached to the

Figure 18-11. Reconstruction of scalp defect using the orticochea 4-flap technique.

Figure 18-11. Reconstruction of scalp defect using the orticochea 4-flap technique.

pedicle for 3 to 6 weeks, to allow development of collateral circulation, before division of the feeding vessels (Figure 18-13). The forehead donor defect is generally closed primarily. When the donor site cannot be completely closed, healing by secondary intention of the remaining defect produces good esthetic results (Figure 18-14).

Nasolabial Flaps

The skin parallel to the nasolabial fold can be raised as an axial cutaneous flap. Depending upon flap design (either superiorly- or inferiorly-based), the

Paramedian Forehead Flap Design
Figure 18-12. Nasal reconstruction with the Converse scalping flap.

blood supply is provided by branches of the facial, infraorbital and angular vessels. Superiorly-based nasolabial flaps are more useful for reconstruction of small-sized nasal defects, due to easier transposition. The inferiorly-based pedicle flap is often advanced in a V-Y fashion for cheek or upper lip defects (Figure 18-15).20 Nasolabial flaps are usually elevated in a superficial subcutaneous plane that excludes the main vascular pedicle. The donor site is usually closed primarily, with the scar concealed within the skin fold. Sometimes a secondary revision may be needed. Bilateral nasolabial flaps, based on the facial artery and vein, have been used to resurface floor of mouth and intraoral defects.21,22

Deltopectoral Flap

The deltopectoral flap was the workhorse for intraoral, cheek and neck reconstruction in the 1960s and 1970s.23-25 The flap is based on the first, second, and third perforators of the internal mammary artery and associated venae comitantes. The base of the flap is located at 2 cm from the sternal edge, where the perforators pierce. Cranial incision follows the infra-clavicular line and the caudal incision parallels the cranial incision. The flap extends to the shoulder or even the upper arm. However, depending upon the

Paramedian Forehead Flap
Figure 18-13. Design of the paramedian forehead flap.
Paramedian Forehead Flap

Figure 18-14. A, Intraoperative appearance of nasal reconstruction with paramedian forehead flap. B, Flap healed in place prior to thinning and inset. C, Late appearance after inset.

Figure 18-14. A, Intraoperative appearance of nasal reconstruction with paramedian forehead flap. B, Flap healed in place prior to thinning and inset. C, Late appearance after inset.

size of the flap needed, one or more delays may be required prior to transfer.24 The deltopectoral flap has been used to resurface defects of the neck, face, and oral cavity (Figure 18-16). The donor site must be skin grafted, resulting in a significant disfigurement.

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