This document discusses the paramedian forehead flap technique for reconstructing facial defects. It was first used in 1500 BC for nasal reconstruction. The flap gets its blood supply from the supratrochlear artery and vein. The surgical technique involves marking the flap based on the defect size and pivot point, elevating the flap above the frontalis muscle while protecting the vascular pedicle, and insetting the flap into the defect. After 3 weeks, the flap is divided and donor site closed in a second stage. Examples provided show reconstruction of nasal and infraorbital defects using this versatile flap.

1. PRESENTER
DR. A.F.M. SHAKILUR RAHMAN
BDS, BCS(HEALTH),FCPS(OMS)
DEPT. OF ORAL & MAXILLOFACIAL SURGERY.
DHAKA DENTAL COLLEGE & HOSPITAL.
BANGLADESH

2. INTRODUCTION
 The paramedian forehead flap is 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.
 The forehead flap became popular in the United
States when Blair in 1925 and Kazanjian in 1946
described the median forehead flap for nasal repair.

3. CONTINUED-
 Millard revised the flap by narrowing the base and
rendering the perfusion based solely on the
supratrochlear vessels, several years later.
 The modification allowed for an increase in the
length of the flap to be harvested and ease of
rotation of the flap due to the narrower pedicle width.

4. INDICATION
Reconstruction
of partial to
total nasal
defects.

5. INDICATION
Reconstructing
defects in the
forehead, and
the periorbital
region.

6. ADVANTAGE
 The main advantages of this flap rest on its texture,
thickness, and color match to the surrounding skin,
making it an indispensable option in reconstructing a
vast range of nasal defects.

7. SURGICAL ANATOMY
 The layers of the forehead consist of the skin, the
subcutaneous skin, the frontalis muscle, areolar
tissue, and the pericranium.
 The vascular supply to the forehead comes from the
paired supraorbital arteries, which divide into a
superficial and a deep branch, and the paired
supratrochlear arteries.
 The glabellar region of the forehead also receives
terminal branches from the angular artery, branch of
facial artery.

8. SURGICAL ANATOMY
 The sensory innervation of the forehead is
supraorbital and supratrochlear nerve, while the
motor innervation to the frontalis muscle is frontal
branch of the facial nerve.
 The blood supply of the paramedian forehead flap is
based on the supratrochlear artery and vein. It’s
axial and random blood supply from the
anastomosing vessels from the terminal branches of
the angular artery .

9. FLAP HARVEST TECHNIQUE
FIRST STAGE
 The path of the
supratrochlear artery is
marked.
 The size of the defect
is measured and the
location of the defect is
noted.

10. CONTINUED
 The outline of the defect
can be retraced with a
marking pen. Using a
small piece of paper
from the surgical glove
packing, the imprint of
the defect is picked up
onto the paper by
pressing down over the
marking

11. CONTINUED
 With a suture string, a
pivot point along the
brow is marked and the
string is then rotated to
the most inferior point of
the defect.

12. CONTINUED
 Tansfer of template into
defect.
 The elevation of the flap
is begun on the most
superior portion of the
flap and is extended to
a depth superior to the
frontalis muscle.

13. CONTINUED
 The incision is made
along the marked flap
and dissection is carried
out in a caudal direction
towards the nasal
bridge and medial
canthus along the main
axial direction of the
artery.

14. CONTINUED
 The depth of the
dissection is extended
to the subperiosteal
layer about 3 cm
superior to the brow
region. This depth offers
a layer of protection to
the vascular pedicle.

15. CONTINUED
 The medial portion of the pedicle should be
extended in a curvilinear fashion towards the medial
canthus, leaving at least a 1 cm bridge of skin
overlying the vascular pedicle.
 The dissection in the brow region should be made
with care not only to maintain the integrity of the
vascular pedicle but also to release the periostium in
this area, therefore aiding rotation of the flap to
reach the defect site passively.

16. CONTINUED
 The flap is inset in the
recipient site from the
most caudal area to the
most cephalad region.
 The forehead defect is
undermined widely and
advanced towards the
midline.

17. CONTINUED
 The closure of the
defect is begun from the
inferior aspect and
extended in a superior
direction. In cases
where primary closure is
not possible, the area is
then left to heal in a
secondary intention.

18. CONTINUED
 View of lateral nasal
reconstruction.

19. CONTINUED
SECOND STAGE
 The flap is allowed to heal and develop collateral
circulation for a period of no less than 3 weeks.
 The flap can then be sectioned and the superior
aspect of the defect closed along with insetting of the
donor site in the brow region.

20. CONTINUED
 View after takedown of
paramedian flap.

21. Infraorbital region reconstruction
with paramedian flap
This is a 48-year-old
male with longstanding
basal cell carcinoma of
the left infraorbital
region. The resection
and reconstruction was
done with contralateral
paramedian forehead
flap.

22.  Defect size after
resection.

23.  Elevation of the
paramedian forehead
flap prior to transfer.

24.  Elevated flap prior to
transfer to the defect
site.

25.  Inset of the flap into the
left infraorbital defect.

26. Early post operative healing
prior to takedown of the flap
Appearance after the takedown
of the flap

27. Late view after reconstruction
Lateral view of the reconstructed
infraorbital defect.

28. Reconstruction of nasal tip &
dorsum in SCC patient.
Nasal defect
Transfer of the defect template
to the forehead donor site.

29. Appearance of the markings for
the flap.
Elevated forehead flap prior to
transfer.

30. Assessment of the arc of
rotation of the flap into the
defect.
Inset of the flap into the defect.

31. Appearance of the flap
immediately prior to the second
stage
Early appearance of the
reconstruction prior to
debulking.