forehead flap

1. FOREHEAD FLAP
DR DIPTI PATIL (1ST MDS)
DEPT OF ORAL MAXILLOFACIAL SURGERY
KCDS,BANGLORE.

2. CONTENT
 Introduction
 History
 Anatomy
 Indications
 Technique
 Complications
 Advantages
 Disadvantages

3. Introduction

4. Flap
 Defined as movement of adjacent skin &
subcutaneous tissue from one location to other with
direct vascular supply
 Local flaps
-random flap
-axial pattern
 Distant flaps
 Myocutaneous flap
 Osteomyocutaneous flap
 Free flap.

5. Axial pattern
 Based on the named arteriovenus pedicle that run
within the skin superficial to underlying muscle layer
parallel to overlying skin.
 Extremely good blood supply so can be raised greater
length than the random flaps.
 Eg forehead flap, deltopectorial flap

7. Random pattern
 Gets vascular supply from cutaneous artery which
runs deep to underlying muscle ie direct cutaneous
artery
 Height of random pattern flap should not extend 1.5
times length of the base.
 Blood supply of flap apex is inversely proportional to
its height
 Eg rhomboid flap, rotational flap, transpositional flap.

9. History

10. Forehead flap
 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…

11. Anatomy

12. SCALP
Extends from
 top of forehead in front
to the superior nuchal
line behind.
 Laterally it projects
down to the zygomatic
arch and external
acoustic meatus.

13. 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

14. Clinical note
 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.

15. 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 c.4 cm and
divides into frontal (anterior) and parietal
(posterior) branches.
 It is accompanied by corresponding
veins, & auriculotemporal nerve lies
posterior to it.

16.  The superficial temporal artery supplies –
-skin and muscles at the side of the face
-the scalp,
-parotid gland and
- the temporomandibular joint.
 Its branches are
 the transverse facial,
 auricular,
 zygomatico-orbital,
 middle temporal,
 frontal and parietal arteries.

17. POSTERIOR AURICULAR ARTERY
 The posterior auricular artery is small branch arises in
the neck from the external carotid artery posteriorly
just above digastric and stylohyoid muscle.
 ascends between the auricle and mastoid process and
gives off an auricular branch supplying the cranial
surface of the auricle and an occipital branch to supply
the occipital belly of occipitofrontalis and the scalp
behind and above the auricle

18.  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.

20.  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.

21. 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.

22. Indications

23. Indication
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.

24. Technique

25. Laterally 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.

26.  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.

27. 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.

28. 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.

29.  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.

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

32. Submandibular incision
 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

33. Secondary defect
 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.

34. Second surgery
 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.

35. Rotation
forehead
flap

36. Median
forehead
flap

37. Complication
 Infection
 Cosmetically detrimental
 Facial nerve injury
 Need donor area grafting (STG is placed at donor
area).
 Patient need to expose for second surgery.
 Flap necrosis (in rare conditions).

38. Advantage
 Rich in vascular supply , so rare chances of flap
necrosis.
 Long flaps are possible to raise ,can reach to most of
oromaxillary defect.
 No major vital structure approximating the flap.
 Lifeboat flap can be easily raised, not a technique
sensitive.

39. Disadvantage
 Donor site defects especially in the younger patient are
detrimental.
 Compromise of blood supply is possible via the superficial
temporal artery if a simultaneous radical neck dissection
has sacrificed the external carotid artery. Most important to
include the posterior auricular artery with a portion of the
scalp above and behind the ear. Delay is advised.

40.  There is danger of compromise of blood supply if the
flap is tunnelled deep to the zygomatic arch. If this is
the approach to reach the oral cavity, it is best to
fracture the arch outward with two osteotomies.
 Injury to the facial nerve may occur when performing
an access to the oral cavity.
 Second surgery is required.

41. References
 Grey’s anatomy
 Atlas of head & neck surgery- Lore & Madina.
 Cancer of face & mouth- Lan Mcgregor
 Heads & surgery – Stell & Maran
 Local flaps in facial reconstruction- Baker & Swanson

42. THANK YOU