(79) Case Series on Lessons Learned in Forehead Flaps for Nasal Reconstruction in Complex Donor or Recipient Sites Scenarios

Abstract:

Introduction: This case series describes the lessons learned and surgical technique refinements necessary to overcome challenges using different types of forehead flaps for nasal reconstruction in complex donor and/or recipient sites. We are presenting 10 patients with thick and short foreheads, unusual anatomical variations, or previous post-traumatic forehead scars leading to the deviation of standard approaches in 2 to 3 steps for nasal reconstruction with forehead flaps. ParaMedian Forehead Flaps (PMFF) are primarily used in extensive nasal defects (>1.5-2 cm diameter) spanning multiple nasal subunits and can reconstruct transfixing defects of the nose. Unique aspects of the selected cases include using Virtual Surgical Planning, designing a unique supra-orbital forehead flap by autonomization (first description in literature), venous selection, and exceptional flap thickness management.
Material and

Methods: This is a prospective non-comparative case series investigating the clinical outcomes of the Forehead Flaps for reconstructing nasal defects in our Institution, New York State, USA. Demographics and complications were reviewed as patient satisfaction using a FACE-Q questionnaire titled “Satisfaction with Outcome.” We highlighted our different indications for nasal reconstruction and unique variations, providing a recording of the procedures’ key steps and versatility.
Outcomes Data: FACE-Q mean score = 9/10
Mean procedure number = 4

Results: This case series includes 10 patients (Female = 4; Male = 6), operated between November 2023 and February 2025, with a median age of 46 (range 27-68). The primary indications were acute trauma and post-traumatic sequels. Defect locations involved the dorsum [6/10], nasal tip [9/10], columella [5/10], right lateral wall [3/10], left lateral wall [5/10], right alar [5/10], left alar [7/10], and bilateral soft triangles [4/10]. Extreme flap thickness was 4 mm to 11 mm. The mean procedure number was 4.
The main complication was tissue bulk initially due to local lymphedema. Patient satisfaction was high (FACE-Q Mean Sum score = 9/10).

Conclusion: Nasal reconstructions are related to postoperative social and appearance satisfaction and nasal functions. Our study found no significant complications despite challenging scenarios such as extreme flap thickness, short forehead, previous large forehead scars, vascular anatomy variations, or recipient site sequels. Donor site morbidity, medical contraindications, and psychological well-being should always be balanced, especially when choosing a multiple-stage flap procedure for nasal reconstruction, with or without preoperative virtual surgical planification.

References:
1. Zito, Patrick M. “Paramedian Forehead Flaps.” StatPearls [Internet]., U.S. National Library of Medicine, 19 Apr. 2024, www.ncbi.nlm.nih.gov/books/NBK499932/.
2.Tiwana, Paul S., and Deepak Kademani. Atlas of Oral and Maxillofacial Surgery. Saunders, 2024.