Reuse of the paramedian forehead flap pedicle: A case report

Abstract

The paramedian forehead flap is an axial flap which utilizes vascular support from the supratrochlear artery to repair extensive nasal defects. Adverse outcomes including flap necrosis, infection, alar rim pull, and poor cosmesis can be seen with this flap. We report an 85-year-old woman with chronic obstructive pulmonary disease who underwent a staged paramedian forehead flap repair with a cartilage inlay complicated by moderate left alar rim necrosis and pedicle notching. In this patient, we were able to salvage the original pedicle and reposition it to achieve a satisfactory functional and cosmetic outcome.

Introduction

The paramedian forehead flap (PFF) is an axial flap that can repair extensive nasal defects. The tissue harvested from the forehead is an excellent match for the color, texture, and thickness of the distal nose, and the donor site repair usually heals well with acceptable scarring. ¹ The procedure is typically performed in one, two, or three stages depending on the size and severity of the defect and patient considerations. ² For example, a three-stage PFF procedure could be considered for patients with an extensive smoking history or for patients with donor and/or recipient site scarring. ² Although rare, the most common complications of the PFF procedure include flap necrosis, infection, alar rim pull, and poor cosmesis. ² Caution should be used in those patients with risk factors such as smoking, chronic obstructive pulmonary disease (COPD), diabetes, recipient bed scarring, or who have poor donor site skin. These patients typically have higher rates of flap necrosis and failure. ¹ When this occurs, instead of being discarded the pedicle can be reused as a graft or flap to repair the remnant nasal defect. In clinical scenarios where alar notching or necrosis is apparent, the existing axial pedicle can be salvaged and strategically repositioned to achieve an acceptable cosmetic outcome. Overall patient satisfaction with the PFF is high, with some patients requiring multiple touch up procedures for aesthetic refinement. ²

Case report

An 85-year-old woman with COPD was noted to have a recurrent micronodular basal cell carcinoma of the supranasal tip. Tumor clearance was achieved after four stages of Mohs micrographic surgery (Figure 1). The surgical repair was delayed for one week to help facilitate granulation tissue formation and to allow for wound contraction. ³ Based on this patient’s age, multiple comorbidities, and her inability to tolerate longer surgery times, it was determined that three short-staged PFF procedures, including a cartilage inlay, would be necessary for an optimal repair. A telfa template of the defect was made and utilized to design the forehead pedicle. Once harvested, the PFF was rotated, folded, and sutured into place to restore both the nasal lining and skin defect. After confirming adequate blood flow to the Mohs defect, the pedicle was gently wrapped with surgical and xeroform gauze. At her four-week follow-up, the patient was found to have moderate left alar rim necrosis and notching (Figure 2). To correct this complication, we decided to perform a partial takedown and reuse the pedicle a second time. The salvaged flap was contoured to match the shape of the remnant nasal defect. It was secured with deep buried sutures and the wound edges were reapproximated. Figure 3 depicts the two-week post-op photo from this procedure. Four weeks later, a full-thickness cartilage inlay was harvested from the left antihelix and inset into the left ala for structural reinforcement. The delay between procedures was necessary because the patient could not tolerate longer surgical times. Figure 4 shows an acceptable functional and cosmetic result at her four-month post-op visit.

Figure 1.

Initial defect and initial repair.

Figure 2.

Left alar rim necrosis and notching.

Figure 3.

Two weeks after reuse of pedicle.

Figure 4.

Final outcome.

Discussion

Surgical staging is often utilized to stabilize blood flow for flap and graft procedures. ³ PFF pedicles can be fragile and have compromised blood flow in patients who have multiple comorbidities such as ours. Factors such as vascular congestion at the recipient site can lead to alar rim notching and flap necrosis. Smoking is another significant risk factor in which a surgical staging could be considered. ² Our patient suffered from end-stage COPD and had extensive recipient bed scarring. These factors likely contributed to the alar notching and necrosis seen at her four-week post-op visit.

When alar notching is minor, the axial pedicle can be salvaged and repositioned if there is minimal tension on it. If more pedicle laxity is needed, the surgeon can incise more inferiorly to create greater flap reach as long as the dissection does not compromise the supratrochlear artery. In our case, we found that the temporary upward pull after the pedicle’s reuse did not negatively impact her final cosmetic outcome. With this in mind, we recognize that the concept of PFF reuse would not be as effective for more distal necrosis in locations such as the infratip or columella. This is due to both the inherent difficulty of designing the salvage repair to reach these distal locations and the greater amount of tension restricting flap movement.

To summarize, we believe that this is the first case report which illustrates the salvaging of a PFF pedicle to address significant nasal defect after Mohs micrographic surgery. Reconstructive surgeons should no longer think of axial pedicles as something to discard during takedown procedures as they can have an inherent reuse value. This idea is similar to the concept described by Gondolfi et al. ⁴ and Feng et al. ⁵ in which a previously harvested flap can become its own donor site by recycling its blood supply. In our case, we were pleased to note that PFF pedicle reuse led to an acceptable final functional and cosmetic result.