The forehead flap is a versatile flap used for reconstructing various facial defects. It has reliable blood supply from branches of the superficial temporal artery. The flap can be raised in different planes and tunneled to reach intraoral defects. It is commonly used in a two-stage procedure for nasal reconstruction, where the flap is first transferred to the defect and then the pedicle is divided later. Pre-expansion of the donor site can increase the available skin but comes with disadvantages like delaying the repair.

1. FOREHEAD FLAP
DR SAMIK SHARMA

2. HISTORY
 Also called as temporal flap.
 800 BC - Sushruta, described a nasal reconstruction approach based
on pedicled forehead skin flap.
 Later describe by McGregor, in 1963.
 Its axial pattern myocutaneous flap provide large area of skin &
subcutaneous tissue.
 Called as lifeboat may be raised quickly to get surgeon out of trouble…

3. ANATOMY

4. It consists of five layers:
 (S) skin,
 (C) subcutaneous tissue (superficial fascia),
 (A) occipitofrontalis (epicranius) and its aponeurosis,
 (L) subaponeurotic areolar tissue and
 (P) pericranium

6.  Aponeurotic layer is movable along the upper three
layers of the scalp,& can easily slide on deepest layer
is the periosteum of the skull.
 It is very easy to raise a scalp flap within the plane
between the galea and the pericranium without
compromising the blood or nerve supply of the scalp,
because all of these structures lie in the superficial
fascia.

7. SUPERFICIAL
TEMPORAL
ARTERY
 its smaller terminal branch of the
external carotid artery.
 It arises in the parotid gland behind the neck
of the mandible, where it is crossed by
temporal and zygomatic branches of the facial
nerve.
 Initially deep, it becomes superficial as it
passes over the posterior root of the zygomatic
process of the temporal bone, where its pulse
can be felt.
 It then runs up the scalp for 4 cm and divides
into frontal (anterior) and parietal (posterior)
branches.
 It is accompanied by corresponding veins,
& auriculotemporal nerve lies posterior to
it.

9.  Supratrochlear artery
 emerges from the orbit onto the face at the frontal notch. It
supplies the medial parts of the upper eyelid, forehead and
scalp.
 The supratrochlear artery anastomoses with the supraorbital
artery and with its contralateral fellow.
 Supraorbital artery
 leaves the orbit through the supraorbital notch (or foramen).
 divides into superficial and deep branches, supplying skin
and muscle of the upper eyelid, forehead and scalp.
 It anastomoses with the supratrochlear artery, frontal branch
of the superficial temporal and its contralateral fellow.

12.  The forehead is perfused from
 supraorbital,
 supratrochlear, the
 superficial temporal and posterior auricular arteries.
 Flaps can be based on each of these pedicles
 the median forehead flap,
 the horizontal forehead flap,
 the up-and-down flap, or the scalping flap.

13.  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.

14. Based on the site–
 Median forehead flap based on primarily on
Supratrochlear artery, supplemented by dorsal nasal
artery.
 Paramedian forehead flap based on primarily on
Supratrochlear artery, supplemented by supraorbital
artery.
 Laterally based forehead flap based on primarily on
Superficial temporal artery , supplemented by
posterior auricular artery.

16. INDICATIONS
 Used for a large number of reconstruction procedures:
 nose,
 upper eyelid,
 cheek (inside and outside),
 floor of the mouth,
 chin covering for reconstructed mandible,
 portion of tongue, and
 alveolar region.

17. TECHNIQUE

18. LATERALY BASED
FOREHEAD FLAP
 The forehead flap is
outlined.
 contour follows the eyebrows (must
not extend beyond the level of the
lateral canthus to avoid injury to the
facial nerve) to anterior border of
pinna at level of zygomatic arch and
along forehead hairline more pleasing
cosmetically.

19.  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.

20. 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.

21. Through the
cheek
 Tunnel is made outside the cheek
avoiding facial nerve damage.
 Skin incised horizontally in front of ear
appro 1.5 below zygomatic arch(length
of incision 2/3 of the flap.
 Incision deepened to the parotid
level using scalpel then tissue
scissor thrust through the substance
of cheek in the defect.

22.  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 .
 Difficult if defect is
extended both forward &
backward.
 Needs to raise longer flaps
 Drawback- salivary fistula.

23.  By Davis & Hoopes, 1971
 Flap is passed downward deep to the arch in to mouth
following the pathway of the temporalis muscle.

25.  By Millard ,1964.
 While his study on primary
bone grafting after mandibular
resection, he used forehead
flap to provide a lining to
cover the bone graft through
the submandibular incision of
neck dissection.
 Flap enter the mouth medial
to the mandible extending far
back till tongue.
 Drawback – inferior fistula

26.  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.

27.  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.

28. NASAL RECONSTRUCTION
 The forehead with its superior color, texture, size,
reach, vascularity, lining applications, and forgiving
donor site is the first choice for most nasal repairs.
 Paramedian forehead flap is most often used .
 Its pedicle is based on either the right or left
supratrochlear vessels. A central nasal defect can be
resurfaced on either pedicle, but a unilateral nasal
defect is resurfaced with the ipsilateral pedicle to
decrease the distance between its pivot point and the
defect,

29.  Traditionally, a forehead flap is transferred in two
stages.
 The flap can be transferred as an island flap, in one
stage, but excessive bulk of the pedicle, passing under
tight glabellar skin, may jeopardize its blood supply or
distort the nasal root. Most importantly, an aesthetic
reconstruction can rarely be obtained in a single stage.

30. Technique of the two-stage
forehead flap
 Stage 1: flap transfer
 An exact pattern of the defect, based on the contralateral normal or
the ideal, is outlined, under the hairline, directly over the
supratrochlear artery, which lies just lateral to the frown crease. It can
be identified by Doppler.
 Pedicle width at the brow is about 1.2–1.5 cm.
 The reach of the flap is verified using a simple gauze measure,
checking the distance from the pivot point below the eyebrow to the
distal end of the flap on the forehead and most inferior aspect of the
defect.
 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.

32.  Frontalis muscle and excess
subcutaneous fat are excised
within its distal 1.5–2 cm,
producing a skin flap with 2–3
mm of fat distally which will be
applied to the inferior aspect of
the nasal defect.
 The dissection then passes
under the frontalis and over
the periosteum, through the
medial brow until the flap
reaches the defect without
tension.

33.  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.

34.  Stage 2
 The pedicle is divided 3–4 weeks later, the proximal
aspect of the flap is re-elevated with 2–3 mm of fat,
and the underlying excess soft tissue (fat, frontalis, and
scar), which is adherent to recipient site, is excised,
contouring the superior aspect of the defect.
 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

36. The three stage full-
thickness forehead flap
 Millard, in the 1970s, and Burget, in the 1990s, added
an intermediate operation between transfer and
division of the traditional two-stage forehead flap to
improve vascular safety and permit more aggressive
soft-tissue contouring.
 They thinned the flap distally at transfer but, 3 weeks
later, elevated it from its bed over the mid-nose.
 The proximal pedicle remained intact while the distal
inset was left attached over the tip, alar margins, and
columella. Underlying fat and muscle over the
dorsum and mid-vault were excised to improve mid-
vault contour.

37.  Menick, in the late 1990s, modified the approach by
transferring a full-thickness flap in three stages with an
intermediate operation which permitted complete flap
re-elevation and three-dimensional hard- and soft-
tissue contouring over the entire nasal surface.

40. Expansion of the forehead
 Pre-expansion, although not routinely helpful, can
enlarge the available surface of the forehead for
transfer to the nose.
 Forehead expansion should be considered:
 1. In an especially tight forehead with limited available
skin due to scarring or prior forehead flap harvest.
Expansion can increase the length and width of
available skin within the proposed flap.

41.  2. In the occasional, especially short forehead (less
than 3–4 cm in height) to increase flap length and
minimize hair transfer to the nose.
 3. To expand the donor forehead adjacent to the
proposed flap to facilitate closure of the forehead
defect

42.  However, there are many disadvantages to expansion –
delay in repair, increased number of operative stages,
added expense, more office visits, risk of infection and
extrusion, and recoil.
 Expanded skin, if not rigidly braced with a hard-tissue
support framework, contracts, leading to retraction
and nasal shortening. Expansion does not clinically
improve flap blood supply.

44. ROTATION ON FOREHEAD
FLAP

45. THANK YOU