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Objectives1.Present a case of difficult nasal dorsal reconstruction due to loss of supratrochlear and supraorbital vascular pedicles.2.Review the Converse flap and detail current indications for its use.

MethodsCase report

ResultsOne patient identified in the authors' institution presenting with a large soft tissue defect of the nasal dorsum and sidewalls secondary to Mohs micrographic surgery. A modified Converse flap was used to reconstruct the wound due to absence of supratrochlear and supraorbital vessels.

ConclusionThe Converse forehead scalping flap is still a useful tool in the armamentarium of the reconstructive surgeon. Its use is well-established in large nasal defects, but should be especially considered in the reconstruction of nasal defects in the vessel-depleted forehead.

A Dilemma in Nasal Soft-Tissue Reconstruction: The Converse Flap Revisited

Laura M. Dominguez MD, Andrew T. Huang MD, Alan Burke MDDepartment of Otolaryngology – Head and Neck Surgery

Virginia Commonwealth University

One patient required a modification of the Converse scalping flap for dorsal nasal soft-tissue reconstruction secondary to prior sacrifice of the supratrochlear vessels and absent supraorbital vasculature. The procedure was tolerated well with adequate aesthetic result and without incurring undue delay in necessary adjuvant therapy. No operative complications were encountered, and the use of skin grafting was avoided.

The Converse scalping flap was first described in 1942 in an effort to provide an option in subtotal and total nasal reconstruction3. Unfortunately, due to its need for a greater extent of dissection, and its more complicated secondary defects, it has found less clinical use in the modern era of nasal reconstruction and has been reported seldomly in the current literature4,5. Classically, the scalping forehead flap included elevation of distal lateral forehead skin in a subcutaneous plane with contiguous elevation of the majority of the remaining forehead and anterior scalp deep to the frontalis and galea3,6,7,8. This allowed a large degree of rotation and extended the length of soft tissue for coverage of large lower nasal defects. Similarly, the forehead flap described by McGregor in 1963, also based off of the superficial temporal vessels, involved dissection deep to the frontalis, but was mainly utilized in the reconstruction of cheek and intraoral defects9,10. The flap described here has several modifications from the classic Converse flap, borrowing from principles of McGregor’s transverse forehead flap. First, an inferolateral subcutaneous dissection to harvest the donor skin was not done due to the fact that additional length in flapwas not required. In addition, the flap described here utilizedan inferior limb of dissection staying superior to the frontalismuscle in order to prevent dissection of the muscle and avoid possible consequences to the mobile forehead and brow. Unlike McGregor’s transverse forehead flap, our modification of the Converse flap still retains the original premise of dissection onto the scalp in order to capture the axial blood supply of the superficial temporal artery and the direct communicating branches with the contralateral artery, while avoiding areas vascularized by the distal branches of the ophthalmic arteries in the paramedian forehead. As evidenced in the patient described here, the ability to maintainan axial flap with only 1 angiosome removed portends a higher likelihood of complete flap success compared to a flap traversing multiple areas of choke vessels.

Report of one case in the authors’ institution requiring a modified Converse scalping forehead flap reconstruction of a large dorsal nasal defect.

The Converse scalping forehead flap is a flap of historical significance in the reconstruction of nasal soft tissue defects.In addition to its known indications in the repair of subtotal and total nasal defects, the case represented here demonstrates another notable use: the reconstruction of nasal defects in the vessel-depleted forehead.

Non-melanoma skin cancer is the most common malignancy in Caucasians1. Timely reconstruction of skin cancer defects is important, especially in lesions with concerning histopathologic features necessitating adjunctive therapy. Closure of nasal soft-tissue defects following excision of cutaneous malignancies is a difficult endeavor due to the lack of tissue laxity compared to other areas of the face, its convex nature, and its intimate relationship with the brow and eyelid as well as aesthetic considerations due to its prominence in the central face. The paramedian forehead flap, based off of the supratrochlear vascular bundle, is recognized as the ideal form of reconstruction of large nasal cutaneous defects due to its limited morbidity and close skin color, thickness, and texture matches2. Reconstruction of large nasal soft-tissue defects in the absence of the supratrochlear and supraorbital vessels, however, is a more complicated endeavor, and one infrequently addressed in the literature. The purpose of this report is to revisit the Converse scalping forehead flap technique in nasal reconstruction , and demonstrate its usefulness and indication in the vessel-depleted forehead.

INTRODUCTION

METHODS AND MATERIALS

1. Diepgen TL, Mahler V. The epidemiology of skin cancer. British Journal of Dermatology. 2002;146(suppl. 61):1-6.

2. Thorne CH. Grabb & Smith’s Plastic Surgery: 6th Edition. Lippincott Williams & Wilkins. 2007, pp 389-396.

3. Converse JM. New forehead flap for nasal reconstruction. Proc R Soc Med. 1942;35:811.

4. Ramsey KWD, Georgeu GA, Pereira JA, El-Muttardi N. Nasal reconstruction in the Yemen with the Converse scalping flap. J R Soc Med. 2003;96:230-232.

5. Thomaidis V, Seretis K, Fiska A, Tamioloakis D, Karpouzis A, Tsamis I. The scalping forehead flap in nasal reconstruction: report of 2 cases. J Oral Maxillofac Surg. 2007;65:532-540.

6. Converse JM. Reconstruction of the nose by the scalping flap technique. Surg Clin North Am. 1959;39:335-365.

7. Converse JM. Clinical applications of the scalping flap in reconstruction of the nose. Plast Reconstr Surg. 1969;43:247-259.

8. Converse JM, McCarthy JG. The scalping forehead flap revisited. Clinics in Plastic Surgery. 1981;8:413-434.

9. McGregor IA. The temporal flap in intraoral cancer: its use in repairing the postexcisional defect. Br J Plast Surg. 1963:16:4.

10. McGregor IA, Reid WH. The use of the temporal flap in the primary repair of full-thickness defects of the cheek. Plast Reconstr Surg. 1966;38:1.

CONCLUSIONS

DISCUSSION

RESULTS

REFERENCES

ABSTRACT

Laura M. Dominguez M.D.Department of Otolaryngology – Head and Neck Surgery, Virginia Commonwealth Universityent@vcu.edu804-828-3965

CONTACT

A 70 year-old male presented to the Facial Plastic Surgery Division of the Department of Otolaryngology –Head and Neck Surgery following Mohs micrographic surgery for resection of a squamous cell carcinoma of the nasal dorsum. Due to extensive perineural and vascular invasion, a large soft-tissue defect was created with sacrifice of the supratrochlear vascular bundles bilaterally. As adjuvant radiotherapy was planned due to the concerning histopathologic features, a forehead flap based off of the supraorbital vessels was scheduled urgently. Intraoperatively, the supraorbital vessels were not able to be identified by doppler. The decision was made to pursue scalping flap reconstruction based on the right superficial temporal vessels (Figure 1). The flap was modified from Converse’s original description3 by limiting distal inferior skin elevation as no nasal tip soft-tissue reconstruction was necessary and an elongated scalping flap not required. Retention sutures were placed to minimize retraction of the skin flaps of the secondary scalp defect. No skin grafting was required for secondary defects. Three weeks post-operatively, the patient underwent second-stage inset of the flap and closure of the scalp wound. No distal flap necrosis was encountered. The patient received adjuvant radiotherapy without delay or complications (Figure 2).

CASE REPORT

Operative Details1. The scalping flap is planned based off of the anterior and zygomatic branches of the superficial temporal vessels.2. The upper limb of the flap is drawn curvilinearly into the hair-bearing scalp. As the nasal soft-tissue defect in this case

was high on the nasal dorsum, the flap was modified to include an inferior limb, parallel to the superior dissection thus eliminating the need for lower forehead dissection and disruption. Due to the patient’s alopecia, the flap was drawn to include only the soft tissues superior to the upper margin of the frontalis so as to avoid dissection and distortion of the muscle during flap elevation.

3. Sharp dissection is carried out through the galea, and the scalp flap tissue is then elevated in the loose areolar plane toward the vascular pedicle. The elevation continues past the temporal line in order to maximize flap rotation without kinking the pedicle.

4. The distal aspect of the flap is inset into the wound and the secondary forehead defect is approximated with retention sutures to prevent wound retraction and forego the need for temporary split-thickness skin grafting. Transverse galeotomies can also be made to relieve tension further. Non-adherent dressings are placed over the secondary defect to prevent wound desiccation.

5. Delayed inset is planned 3 weeks post-operatively. The flap is sectioned and inset into the superior aspect of the original nasal dorsal wound. The remainder of the scalp flap is then replaced into the secondary defect and primarily closed.

Figure 1: Intraoperative photographs of case presentation. A. Frontal view of nasal and glabellar soft tissue defect. B. Lateral view of nasal and glabellar soft tissue defect. C. Flap planning. Dotted line indicates temporal line. D. Flap inset completed with resultant forehead defect.

A B

C D

Figure 2: 6 weeks post-radiotherapy. A. Lateral view. B. Frontal view. C. Donor site scar

A B

C