Doppler-guided Supratrochlear artery-based forehead paramedian flap for nasal
defect reconstruction in patients with basal cell carcinoma
Gamal Saleh & Mostafa Elsayed
Department of General Surgery, Faculty of Medicine, Benha University
ABSTRACT
Objectives: Evaluation of the outcome of Doppler-guided supratrochlear arterybased paramedian forehead flap for nasal reconstruction after basal cell carcinoma
(BCC) surgical treatment.
Patients & Methods: The study included 17 patients; 13 males and 4 females with
mean age of 53.2±6.3 years with biopsy confirmed BCC. Patients were assigned for
lesion excision and defect closure by supratrochlear artery-based paramedian
forehead flap. Aesthetic outcome was judged and scored as excellent (score=4),
good (score=3), fair (score=2) and poor (score=1). The functional result was judged
regarding evaluation of their breathing through the reconstructed side compared with
preoperative function and expressed as better, the same, slightly worse, or much
worse than preoperatively.
Results: The mean aesthetic outcome of forehead flap was 3.2±0.9; 9 patients
(52.9%) found the aesthetic appearance of the recipient area excellent, another 5
patients (29.5%) found it good, 2 patients (11.8%) found the outcome fair and only
one patient (5.8%) reported poor outcome. As regards the donor area; 2 patients
(11.8%) found the donor area aesthetically poor, another patient (5.8%) found it fair,
2 patients (11.8%) found it good while the remaining 12 patients (70.6%) found it
excellent. Functional outcome expressed as breathing self-assessment in comparison
to preoperative assessment was better in 13(76.5%) patients; no changes in 3(17.6%)
patients and one patient (5.8%) reported worsening of breathing.
Conclusion: This technique is simple, reliable, and could be considered an
appropriate procedure for nasal construction after excision of BCC as it offers
similar color, texture, with high satisfaction rate of aesthetic and functional
outcome.
INTRODUCTION
Basal cell carcinoma (BCC) occurs most frequently on sun-exposed areas of
the body, with approximately 4 of 5 BCCs occurring on the face(1).
Moreover, the nose is particularly vulnerable to cutaneous malignancies(2).
The aim of nasal reconstruction is to achieve a nose which appears normal
and
functionally,
allow
for
unobstructed
breathing.
Anatomically
(3)
reconstruction focuses on cover, support & lining . Aesthetically, the nose is
divided into 9 subunits: dorsum, 2 nasal side walls, tip, 2 ala, 2 soft tissue
triangles, and the columella. Of these, 5 of them are convex (dorsum,
columella, tip, and 2 nasal ala) and 4 are concave (2 sidewalls and 2 soft
tissue triangles). In order to maintain these concavities and convexities, it is
usually best to repair the nasal defect with a different flap or graft technique
for each subunit. Often, reconstruction of entire subunit rather than the defect
itself yields superior results(4).
If the defect is small and superficial it can be resurfaced with a skin graft or it
can heal by secondary intention(5). Limited alar defects can be resurfaced
using a nasolabial flap, however, the amount of tissue available from the
nasolabial area is limited and the flap is thicker, less vascular, and hair
bearing in males(5). Zitelli modification of the bilobed flap is a useful tool for
the reconstruction of nasal defects, particularly if the defect is between 0.51.5 cm in diameter in the thick-skinned part of the nose. Glabellar/Finger
flap, a rotational flap utilizing the lax skin of the glabella can be used to fill
in small defects of the upper 1/3 of the nose(6-10). A forehead flap is usually
required if the nasal defect is larger than 1.5 cm, requires replacement of
support or lining, or if it is located within the infra-tip or columella(5).
This study was designed to evaluate the outcome of Doppler-guided
supratrochlear artery-based paramedian forehead flap for nasal reconstruction
after BCC surgical treatment.
PATIENTS & METHODS
This prospective nonrandomized study was conducted at General Surgery
department, Benha University Hospital over a period of 30 months, started
October 2008 and comprised 17 patients with biopsy confirmed BCC.
Patients underwent full history taking and clinical examination as regards
age, sex, medical history, the site and size of the lesions and the defect size.
Patients with significant loss of cartilage or had nasal mucosa defect were
excluded off the study. Written consent was obtained before surgery from all
patients after explanation & discussion of the procedure and possible
complications of various surgical modalities for nasal reconstruction. All
operations were performed under general anesthesia.
Surgical procedure & Case presentation:
Supratrochlear artery-based flap was designed using a Doppler probe to
precisely locate the supratrochlear artery as it exits the superior medial orbit.
The pedicle was designed on the ipsilateral, (Case-1) or contralateral side
(Case 2) of the primary nasal defect with its length usually determined by
measuring with gauze or a suture from the base of the pedicle to the tip of the
flap template at the hairline, while the suture was held at the base of the
pedicle, the remaining position was rotated 180° in the coronal plane to the
distal recipient site on the nose. If the suture cannot reach this site, the
template was repositioned higher on the forehead or the pedicle base was
lowered below the level of the eyebrow.
Then, the flap was precisely outlined on the forehead with a marker as close
to midline as the pedicle will allow and with the right edge of the template
corresponded to the left edge of the primary defect and a flap width of 1-1.5
cm. The defect was debrided of nonviable tissue and the margins were refined
with a scalpel. Then, the flap was elevated together with the frontalis muscle
along a cleavage plane superficial to the periosteum of the frontal bone from
superior to inferior with careful dissection down to 1-2 cm above the
eyebrow. Blunt dissection was then performed to avoid cutting the
supratrochlear artery as it exits over the corrugator supercilii muscle. Once
the artery has been identified and preserved, the dissection was continued
down to the root of the nose to achieve adequate flap length.
Once the flap was elevated, it was pivoted 180° on its base. The distal three
fourths of flap were thinned by removing the distal frontalis muscle and
subcutaneous fat to match the precise depth and breadth of the defect but the
proximal one fourth was left thick until the pedicle is detached. The edge of
the reconstructed flap was sutured to the edges of the defect using 5-0
polypropylene suture material in interrupted fashion. The skin of the donor
area was closed with a 5-0 polypropylene suture.
On the seventh postoperative day, the sutures were removed and flap
detachment was scheduled at 3 weeks postoperative. The pedicle was
separated sharply, and enough of the base of the pedicle was returned to the
glabellar region to achieve a normal inter-eyebrow distance without allowing
excess pedicle to be returned to the forehead above the level of the eyebrows
to enhance the cosmetic outcome.
The follow up was performed as outpatient clinic visits 2 & 4 weeks & 3 months after
surgery and 6-monthly thereafter. Aesthetic outcome was judged as excellent
(score=4); when review showed no asymmetry and no evidence of reconstruction,
good result (score=3) showed minimal asymmetry or minimal visibility of scar, but
was not distracting to the patients' appearance. A fair result (score=2) showed
moderate asymmetry or scar that was somewhat distracting to the patients'
appearance. A poor result (score=1) showed obvious asymmetry or scar that
dominated the patients' appearance. The same criteria were also applied to the donor
site scar. The functional result was judged by the patient interview regarding
evaluation of their breathing through the reconstructed side compared with
preoperative function. The choices were better, the same, slightly worse, or much
worse than preoperatively.
Statistical analysis: Data were analyzed using t-test and Chi-square test. Statistical
analysis was conducted using the SPSS (Version 10, 2002) for Windows statistical
package.
Case (1): Ipsilateral forehead flap
a)-Nasal defect after excision of the lesion and edge
debridement; alar cartilage (C) was intact and not
involved
b)- The assigned forehead flap was marked on
ipsilateral side of the lesion with grafting (G) area
properly assigned to the size and shape of the
defect (the upper forehead circle), the location of
supratroclear artery (S) as defined by Doppler
was marked, the assigned wound edges were
marked about 2.5 cm away from midline and the
pivot of rotation (P) was about 1-cm below the
glabella.
c)-The forehead flap (F) was rotated 180o around its
base and the assigned graft (G) was sutured to the
defect edge and donor area (D) closed by interrupted
sutures.
d)-Appearance at the end of the procedure.
Case (2): Contralateral forehead flap
a)-Nasal defect after excision of the lesion and edge
debridement; nasal cartilage (C) was intact and not
involved.
b)-The forehead flap (F) was rotated 180o around
its base.
c)-Adjustment of the flap to the tip of the nose (T).
RESULTS
The study comprised 17 patients; 13 males and 4 females with mean age of
53.2±6.3; range: 43-63 years. The mean size of the defect after lesion
excision and tissue debridement was 4.5±1.8; range: 1.89-7.13 cm2. For all
patients supratrochlear artery was identified by Doppler at a site appropriate
for flap designing.
complications.
All
surgeries
were
conducted
without
intraoperative
The mean aesthetic outcome of forehead flap was 3.2±0.9; range: 1-4. Nine
patients (52.9%) found the aesthetic appearance of the recipient area
excellent, another 5 patients (29.5%) found it good, 2 patients (11.8%) found
the outcome fair and only one patient (5.8%) reported poor outcome, (Fig. 1).
As regards the donor area; 2 patients (11.8%) found the donor area
aesthetically poor, another patient (5.8%) found it fair, 2 patients (11.8%)
found it good while the remaining 12 patients (70.6%) found it excellent,
(Table 1, Fig. 2).
Functional outcome expressed as breathing self-assessment in comparison to
preoperative assessment was better in 13 patients; no changes in 3 patients
and one patient reported worsening of breathing, (Fig. 3)
No postoperative morbidity was reported apart from occurrence of mild
infection of the exposed part of forehead flap that was mildly edematous
immediately postoperative but infection and edema subsided on conservative
treatment.
Table (1): Patients' distribution according to the aesthetic outcome
Outcome
Excellent
Good
Fair
Poor
Total
Recipient area
Number
9
5
2
1
17
Donor area
%
52.9
29.5
11.8
5.8
100
10
Number
12
2
1
2
17
%
70.6
11.8
5.8
11.8
100
13
Excellent
Good
Fair
Poor
Excellent
Good
Fair
12
9
11
8
10
7
9
8
Patients
Patients
6
5
4
7
6
5
4
3
3
2
2
1
1
0
0
Fig. (1): Patients' distribution according to aesthetic outcome
of recipient area at 3-months after surgery
Fig. (2): Patients' distribution according to aesthetic outcome of
donor area at 3-months after surgery
Poor
14
Better
Same
Worse
13
12
11
10
9
Patients
8
7
6
5
4
3
2
1
0
Fig. (3): Patie nts' distribution according to bre athing se lf asse ssme nt
DISCUSSION
The repair of nasal defects is a frequent challenge to surgeons, mainly due to
the high frequency of basal cell carcinomas. In general, small defects of up to
1 cm in diameter may be closed directly, whereas larger defects of up to 2.5
cm require the use of local flaps. For more extended defects, regional flaps
such as the paramedian forehead flap are the method of choice. These rules
have to be modified for the nasal tip, the alar region and the columella where
free skin grafts and auricular composite grafts have to be considered. In order
to achieve pleasing aesthetic results, the aesthetic subunits of the nose have to
be respected in each situation(11).
The decision making regarding the use of forehead vasculrized flap depended
on the previous work of Burget & Menick(12) who recommended resurfacing
of entire nasal subunit if the defect includes more than half of the surface area
of the subunit. The subunit principle is based on the observation that the
ridges and valleys of nasal contour create visual patterns of topographical
regional units and subunits that reflect the contour of the underlying hard and
soft tissues. The outline and definition of each subunit are determined by
observing the light and shadow reflected from each individual nose. The
subunits are defined by direct visual observation of surface contour, texture,
color, and adnexal content and quality.
The paramedian forehead flap is an axial flap designed on the medial side of
the eyebrow centered on a single supratrochlear artery(13,14). A flap width of
1-1.5 cm was used; this narrow pedicle reduces donor site morbidity and
preserved the contralateral artery for harvesting a second forehead flap at the
same time or secondarily if needed. Another advantage for the use of
supratrochlear artery-based flap is the fact that the end arterioles of the
supratrochlear vessels travel superficial to the frontalis muscle in the upper
third of the flap(15), this allowed considerable flap thinning so as to achieve
the precise contour of the various nasal subunits that it is used to cover and
greatly decreased the need for revision surgery to debulk the flap.
Throughout the present study no wound dehiscence, flap untaken, skin
discoloration were reported, this could be attributed to the excellent vascular
supply of the flap dependent on the supratrochlear artery. Similarly, Lee &
Baskin,(16) reported that nasal reconstructive problems previously thought to
be optimally managed by microvascular tissue transfer could be successfully
reconstructed using full-thickness forehead flap due to rich regional vascular
anatomy. Such ambient blood supply was anatomically evaluated by Kelly et
al.,(17), who studied, experimentally in cadaver, the anatomical vascular
relationships allowing supratrochlear artery-based flap to be successful and
detected an anastomotic relationship between the supratrochlear and facial
arteries and a consistent relationship between the infraorbital and facial
arteries and such anastomosis was confirmed by radiographic assessment
where the vascular network of the flap was filled through the facial artery by
means of the dorsal nasal and supratrochlear arteries.
The mean aesthetic outcome of forehead flap was 3.2±0.9; 9 patients (52.9%)
found the aesthetic appearance of the recipient area excellent, another 5
patients (29.5%) found it good, 2 patients (11.8%) found the outcome fair
and only one patient (5.8%) reported poor outcome. These figures go in hand
with that previously reported in literature; Price et al.,(18) evaluated functional
and aesthetic results of periorbital defect repair using forehead flaps and
reported that the reliability, versatility, and relative technical simplicity of the
forehead flap provide excellent cosmetic and functional results in
reconstruction of intermediate-sized periorbital defects, especially those
associated with nasal defects.
Lee & Zimber(19) and Sedwick et al.,(20) evaluated the outcome of fullthickness paramedian forehead flap for nasal reconstruction and reported that
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. Also,
Rotunda & Bennett,(21) reported that the forehead flap is a useful technique to
reconstruct deep and large nasal defects that can safely be performed and it
provides an excellent color and texture match to the missing nasal skin.
Xing et al.,(22, 23) reported good match of the repaired tissue with surrounding
tissue, with nice nasal contour, and cosmetic results were satisfactory and
concluded that based on the nasal aesthetic subunit principle, forehead flap
could be used to reconstruct nasal tip defects, and obtain good color, contour
and texture in match with the surrounding skin with satisfactory cosmetic
results. Also Kadlub et al.,(24) applied the forehead flap for nasal
reconstructions in a 15-month-old boy presented after traumatic subtotal
nasal amputation and provided excellent functional and esthetic outcome.
Menick(4) considered paramedian flap as the workhorse in nasal
reconstruction of the modern surgeon.
In conclusion; paramedian forehead flap could be considered an appropriate
procedure for nasal construction after excision of BCC as it offers similar
colour, texture, with high satisfaction rate of aesthetic and functional
outcome.
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