Extended Paramedian Forehead Flap for Total Upper Lip: A Case Report

Case Report

A 64-year-old man was diagnosed with squamous cell carcinoma of the palate. His original resection of the palate, maxilla, and total lip was reconstructed with a temporal parietal fascial rotation flap followed by a maxillary reconstruction utilizing a fibula-free bone transfer. He underwent a right neck dissection as well as postoperative radiation.

One year later on follow-up, he was found to have upper lip retraction and collapse of the maxilla and underwent bone graft as well as a split thickness skin graft to the upper lip. On further follow-up, his lip continued to retract and he had breakdown at the leftmost aspect of the former flap and part of his plate was exposed (Figure 1). Further reconstruction was then planned with an extended paramedian forehead flap (PMFF; Figures 2 –4). He had close follow-up over the years showing success of this flap. Although recommendations for further reconstruction to continue to improve the cosmesis of the flap were suggested, the patient was satisfied with his appearance. His most recent follow-up was 4 years after surgery (Figure 5). He has had dental implants into his neomaxilla (fibula-free flap). He remains cancer free.

Figure 1.

Prior to paramedian forehead flap reconstruction. Exposed plate can be seen on the leftmost aspect of the previous flap reconstruction. The lip is also retracted upward.

Figure 2.

Surgical plan for extended paramedian forehead flap reconstruction.

Figure 3.

Rotation of extended paramedian forehead flap reconstruction.

Figure 4.

Completed extended paramedian forehead flap reconstruction.

Figure 5.

Follow-up 4 years out from extended paramedian forehead flap reconstruction.

Discussion

The PMFF is a well-established, robust flap used primarily for complex reconstruction of the nose and nasal tip. ¹ Forehead flap nasal rhinoplasty can be traced back to as early as 1400 AD by the Khangiara family of India, although regional flap reconstruction of the nose had been used prior, as early as 600 BC. ¹ It was brought to Western Europe in the 1800s by Carpue. ² Since its early use, modifications to the forehead flap have led to its use in a wider variety of midface reconstruction, including the orbit, ^3,4 periorbit, ⁵ and rarely the upper lip, but it is still primarily used for nasal reconstructions.

The PMFF is primarily vascularized by the supratrochlear artery ^6,7 and receives additional arterial supply from the supraorbital plexus as it anastomoses with the supraorbital artery and nasal branch of the angular artery. ⁸ The flap generally starts at medial canthus and extends vertically as a narrow (1-1.5 cm) vertical strip following the paramedian line of the supratrochlear artery until it reaches the forehead where it extends into a superior paddle that can be widened depending on the defect to be repaired. ⁹ Preoperative tissue expansion can be used where necessary ^10,11 but is not required ¹² and prone to contraction.

The PMFF is known as the workhorse of nasal reconstruction because of the similarities in texture, color, and thickness. ¹³ It is favored due to its surgical ease compared to more complicated approaches. Additionally, flap success is high. ¹⁴ Disadvantages include the conspicuous donor site ¹ ; however, the scar has been historically well accepted by patients.

Previous literature reporting the use of the PMFF for upper lip reconstruction usually involves tissue expansion ^15,16 or other significant variations. ^17,18 Tissue expansion takes time, and postoperative contraction can complicate postoperative outcomes. In our experience, one solution to postoperative flap contraction is expanding the tissue on either side of the flap donor site, which allows for improved primary closure without the risk of reconstruction contraction when a large amount of tissue is needed.

Prior to this patient’s operation, other options of reconstruction included a submental pedicled flap from the left as the right had had a previous neck dissection, another pedicled flap from the neck, or another free flap reconstruction were considered. Due to the patient’s previous surgery and radiation, obtaining tissue from nearby was contraindicated secondary to scar from surgery and fibrosis from radiation. A free flap, although always an option, was not ideal considering the patient’s comorbidities because of the significant time it would require under anesthesia. The patient’s male pattern baldness type VI also made a PMFF, a quick and simple method for reconstruction. If hairs were present, the hair follicles would be in an unnatural orientation.

Reconstruction of the upper lip can be complicated, and there are many different approaches depending on the type and extent of the lesion. The “reconstruction ladder” described by Lubek and Ord suggests starting by considering the simplest procedure (primary closure) and then moving to more complex solutions: local flaps, pedicled flaps, and microvascular-free flaps. ¹⁹ Although more complicated approaches may involve much better cosmetic outcomes, ²⁰ patients with significant comorbidities may not be able to undergo such long, complicated surgeries. Therefore, in select patients, the use of an extended PMFF is a good option for providing functional coverage of defects.