A New Technique of Scarless Expanded Forehead Flap.4

A New Technique of Scarless ExpandedForehead Flap for Reconstructive SurgeryJincai Fan, M.D., Ph.D.Beijing, China

The forehead flap is an ideal flap for reconstructivesurgery, especially for that involving reconstruction of theface and neck. However, it is usually limited to use in nasalreconstruction, even when performed in conjunction withtissue expansion, because of the severe visible morbidityof the donor site. In this article, the author discusses hisdevelopment of a new technique of forehead flap, per-formed in conjunction with tissue expansion, for recon-structive surgery without visible scarring at the donor site.The technique involved positioning a tissue expander inthe forehead pocket under the occipitofrontal muscle andserially inflating the expander over a period of approxi-mately 4 to 6 weeks. Thereafter, an expanded foreheadflap was created from the frontal hairline area on the basisof the location of the superficial temporal vessels andtransferred into 16 recipient sites in 13 patients as anisland flap (n 5 8), a free flap (n 5 1), or a local randomflap (n 5 7). The donor site was closed directly into thefrontal hairline, without any visible scar. With the author’sexperience in the use of the island flap for nasal, facial,and neck reconstruction and of the free flap for recon-struction in the extremities, the flap could be as large as8 3 18 cm without inducing flap necrosis or problems withdonor-site closure. All patients (n 5 13) had acceptabledonor-site aesthetic results, without visible scarring. Theresults indicate that the flap could be a safe, ample, andcolor-matched flap for reconstruction of the face and neckand could also diminish donor-site morbidity to a mini-mum, without an unsightly visible scar. Furthermore, theflap could be formed into a customized free flap, with theabove-mentioned advantages, to be transferred to any partof the body. (Plast. Reconstr. Surg. 106: 777, 2000.)

Soft-tissue reconstruction of the face andneck is usually one of the most challengingprocedures for plastic surgeons. This is truenot only because such reconstruction usuallyrequires a large amount of soft tissue for thefunctional restoration of a defect but also be-cause of the need for high-quality tissue forappearance purposes. Although full-thicknessskin grafting and numerous flaps can routinely

be used, it is usually difficult to match thehighly demanding aesthetics of appearance.1The forehead flap is an ideal flap for facialreconstruction but usually results in a greatdeal of aesthetic morbidity at the donor site, aprimary complaint of patients who undergosuch procedures. The forehead flap is there-fore usually limited to use in nasal reconstruc-tion,1,2 even when performed in conjunctionwith tissue expansion.3–7 In this article, I reportthe development a new technique of foreheadflap, performed in conjunction with tissue ex-pansion, that is not only able to restore a largedefect, e.g., resulting from nasal, facial,8 orneck reconstruction, but that could also dimin-ish donor-site morbidity to a minimum, with-out an unsightly visible scar. Furthermore, thisnew flap can be formed into a customized freeflap, with the above-mentioned advantages, fortransfer to any part of the body.

ANATOMIC CONSIDERATIONS

When designing a forehead flap, it is impor-tant to be familiar with the anatomy in theregion. The blood supply to the forehead isexcellent and allows development of a varietyof axial-pattern flaps. There are three pairs ofarteries for the main blood supply to the fore-head: the superficial temporal arteries andtheir frontal branches, which are the most im-portant structures in forehead surgery; the su-pratrochlear arteries; and the supraorbital ar-teries. Blood to the medial forehead area isprimarily supplied by the supratrochlear andsupraorbital branches from the internal ca-rotid artery, whereas the lateral frontal area isprimarily nourished by the superficial tempo-

From the Plastic Surgery Hospital of the Chinese Academy of Medical Sciences, Beijing, People’s Republic of China. Received for publicationAugust 27, 1999; revised December 1, 1999.

777

ral branch of the external carotid artery. Thefrontal branch of the superficial temporal ar-tery usually divides from the main arterial stemat a point between 2 and 4 cm above the zygo-matic arch. It runs upward and forward tortu-ously, supplying all layers of the forehead re-gion. Among these three pairs of arteries is anextensive network of vascular anastomoses.

This is an important reason why the foreheadflaps survive so well and can be designed asaxial-pattern flaps without delayed procedures.The veins of the forehead usually follow thepattern of the arteries.

Sensory innervation in the forehead is pro-vided by the paired supraorbital nerves andsupratrochlear nerves, which run from thepaired superior branches of the trigeminalnerves, whereas the occipitofrontal muscle isinnervated by the paired temporal branches ofthe facial nerves, which are usually situatedmore than 1 cm lower frontally than the ac-companying vessels. Knowledge of these struc-ture is particularly important when a proce-dure involving transference of an axial flapfrom the forehead is carried out.

MATERIALS AND METHODS

From April of 1990 to December of 1998, 13patients with 16 lesions underwent treatmentinvolving use of an expanded forehead flap forreconstruction of the face, neck, or extremity,including treatments for burn scars (n 5 10), acar injury (n 5 1), Ota’s nevus (n 5 1), and acongenital capillary hemangioma (n 5 1).Four lesions were located in the forehead, twoin the temporal facial region, five in the mid-facial region, two in the lower facial region, twoin the neck, and one in an extremity. Patients’ages ranged from 8 to 42 years.

While a patient was either locally or gener-ally anesthetized, a selected tissue expandershaped and sized to match the particular pa-tient’s forehead was first inserted in a submus-cular pocket of the forehead through a

FIG. 1. Preoperative view of the area of the neck to bereconstructed by use of an island flap created from an ex-panded forehead flap. The flap was designed on the basis ofthe location of the frontal branch of superficial temporalvessels.

TABLE IPatient Data

Case No. SexAge

(years)Expander Size

(ml)Inflated Period

(days)Inflated Volume

(ml) Flap PatternFlap Size

(cm)Survival Rate

(%)

1 M 8 300 35 350 Island flap 8 3 18 1002 M 28 400 30 420 Island flap 7 3 16 1003 M 24 300 33 360 Island flap 5.5 3 7.5 1004 M 26 250 30 300 Island flap 2.5 3 6 100

Local flap 4 3 7 1005 M 12 200 35 240 Local flap 4 3 10 1006 M 42 400 40 450 Free flap 8 3 16 1007 F 24 400 28 400 Island flap 6 3 18 1008 M 25 400 28 420 Axial flap 6 3 25 1009 F 20 140 23 180 Island flap 2 3 6 100

Local flap 5 3 10 10010 M 13 200 21 240 Local flap 4.5 3 8 100

Local flap 2 3 4 10011 M 16 50 11 70 Island flap 2 3 6 10012 M 22 130 25 160 Local flap 4 3 8 10013 M 18 150 30 150 Local flap 3 3 7 100

778 PLASTIC AND RECONSTRUCTIVE SURGERY, September 2000

frontal hairline incision or an incision close tothe hairline in the scalp. Beginning 10 to 14days after the operation, the expander was se-rially inflated by a repeated overfilling tech-

nique with a normal saline solution in 3-day to5-day intervals over a 4-week period until theexpander reached a previously determined vol-ume.9–12

FIG. 2. (Above, left) Preoperative view of the area of the neck to be reconstructed. (Above, right) View showing the fully inflatedforehead tissue expander. (Center) Intraoperative views. (Below) Views 2 weeks after the operation.

Vol. 106, No. 4 / SCARLESS EXPANDED FOREHEAD FLAP 779

When the final filling of the expander wascomplete, the second operation, the transfer-ence of the expanded forehead flap, could beundertaken. A Doppler flowmeter (ModelBFSA; Meda Sonics, Mountain View, Calif.) wasused to determine the course of the superficialtemporal artery, which was then marked on thesurface of the skin. An axial expanded fore-head flap could then be formed in the frontalhairline region on the basis of the location ofthe frontal branch of the superficial artery.The full expanded forehead area was dividedinto the lower region (donor part) and theupper region (flap part). The donor part wasused for the direct donor-site closure, whichwas designed to extend from eyebrow level tothe supra-line along the width of the originalforehead. The first flap was formed as an axialflap with an upper margin at the original fron-tal hairline. The axial flap could therefore beformed transversely, only if possible accordingto the location of the superficial temporal vas-cular pedicle. After the flap was elevated, itcould be transferred to a lesion of the face orneck as an island flap by being passed througha subcutaneous tunnel between the base of theflap and the lesion. Furthermore, an expandedfree flap could also be formed and transferredto any location on the body by anastomosis ofthe stumps of the superficial temporal vessels

to the stumps of the recipient vessels by a mi-crosurgical technique. The other part of theflap was used for direct closure of the donorsite into the hairline. Caution should be ob-served so that the lower margin of the islandpedicle does not extend more than 1 cm be-yond the superficial temporal vascular bundlebecause the frontal branch of the facial nerve isat high risk of being injured. Even when fol-lowing this policy, a random flap can easily beformed from the hairline region, with the do-nor site directly closed into the hairline. Adrain is usually needed under the flap for 24hours.

RESULTS

Between April of 1990 and December of1998, 13 patients with 16 lesions of the face,neck, or ankle were treated by use of the ex-panded forehead flap without major complica-tions. Flaps used in these patients includedeight island flaps, one free flap,10 and sevenlocal random flaps. No necrosis of the flapsoccurred. All donor sites were closed directlyinto the patients’ frontal hairlines without vis-ible scarring. There was only temporary weak-ness in occipitofrontal function, and full func-tion was usually recovered within 1 to 3 monthsafter the operation. Correspondence with the13 patients has demonstrated achievement of

FIG. 3. An island flap created from an expanded forehead flap, designed on the basis of thelocation of the ipsilateral superficial temporal vessels, was created for reconstruction of theright-side lower third of the face. The views show a lesion in the lower third of the face and neckand the fully inflated tissue expander in the forehead.


FIG. 4. Postoperative views after 8 months, showing the transplanted flap and the donor siteclosed directly into the hairline.

FIG. 5. Preoperative views of an island flap created from an expanded forehead flap and usedfor nasal reconstruction.


aesthetic acceptability in both the donor andthe recipient, with up to 18 months’ follow-up.The patients’ data are listed in Table I. Samplecases are reported in detail below.

Case 1

An 8-year-old boy burned approximately 80 percent of hisbody while playing with a fire, resulting in severe mental-sternal adhesion in his neck. The back-extension function of

his neck was totally lost as a result of contraction of the neckscarring (Figs. 1 and 2, above, left). Fortunately, the boy’s facewas not injured. A 300-ml rental tissue expander was insertedinto a submuscular pocket of his forehead through an inci-sion close to the frontal hairline in his scalp. The expanderwas serially inflated with normal saline to a volume of 350 mlover 5 weeks (Fig. 2, above, right). One week after the mostrecent saline filling was performed, an 8 3 20 cm expandedisland flap of the forehead, measured along the frontalbranch of the superficial temporal vessels, was raised in partof the expanded forehead region along the hairline andtransferred into the patient’s neck after the neck scar was

FIG. 6. (Above, left) The fully inflated tissue expander. (Above, right; center) Intraoperative views. (Below) One-month postop-erative views.


released (Fig. 2, center). The frontal donor site was closeddirectly into the frontal hairline, using the other part of theexpanded forehead tissue. The results were excellent (Fig. 2,below).

Case 2A 28-year-old man burned his lower face and neck during

a work accident in an oil field, resulting in perioral scarringcontraction and mental-sternal contraction. His mouth couldbe opened only wide enough for one finger to be inserted.A 400-ml rectangular tissue expander was inserted into asubmuscular pocket of his forehead through an incision inthe scalp and inflated with normal saline to a volume of 420ml over 4 weeks (Fig. 3). One week after the most recent salinefilling was performed, a 7 3 16 cm island expanded flap wasraised and transferred into the ipsilateral mandible region,using the technique mentioned above, for correction of thelower-lip ectropion and the mental-sternal contraction afterthe scar was released and partly excised. The frontal donorsite was closed directly into the frontal hairline, using the

other part of the expanded forehead tissue. A left-mandiblescar was repaired by use of the tissue-expansion technique onthe left cheek during the same operations. The results werevery satisfactory (Fig. 4).

Case 3A 26-year-old man lost dorsal soft tissue of his nose and had

a palm-contracting scar after he burned his face and handduring an accident at work (Fig. 5). While he was under localanesthesia, a 400-ml rectangular tissue expander was placedinto a submuscular pocket of his forehead and serially in-flated over 5 weeks to a volume of 450 ml. Once the tissueexpander was fully inflated, a 5.5 3 7.5 cm island flap with a“leaf” shape was designed transversely along the hairline (Fig.

FIG. 7. Preoperative view of a lesion on the lower third ofthe left leg, to be covered by an expanded free flap of theforehead.

FIG. 8. The fully expanded tissue expander.

FIG. 9. (Above and center) Intraoperative views. (Below)View of the recipient area 2 weeks after the operation.


6, above, left). After the dorsal scar of the patient’s nose wasremoved and the lining repaired with a “turndown” scar flappedicle from the lower margin of the nose, the island flapwas elevated and transferred to the dorsal area of the noseby being passed through a subcutaneous tunnel betweenthe base of the flap and the lesion (Fig. 6, above, right; center;and below). A full-thickness skin flap was also obtained fromthe other part of the expanded forehead skin area andgrafted onto the palm after the contracted palm scar wasreleased and partly excised. The forehead donor site wasclosed directly into the frontal hairline, using the remain-ing forehead tissue.

Case 4A 42-year-old man was burned on more than 90 percent of

his body during an accident in a steel factory, resulting in asoft-tissue defect of the lower third of his left leg (Fig. 7).Fortunately, his forehead was not injured. A 400-ml rectan-gular tissue expander was inserted into a submuscular pocketof his forehead and inflated to a volume of 450 ml overapproximately 6 weeks (Fig. 8). One week after the mostrecent saline filling was performed, an 8 3 16 cm free flap wasformed from the patient’s hairline region and then trans-ferred onto the leg lesion, using a microsurgical technique(Fig. 9, above and center). The frontal donor site was closeddirectly into the frontal hairline. A satisfactory result wasobtained (Fig. 9, below).

DISCUSSION

Reconstruction of the face and neck is usu-ally one of the most important and challengingoperations in plastic surgery. It requires notonly a large amount of soft tissue for functionalrestoration but also high-quality tissue for cos-metic appearance. Because of the limited avail-ability of adjacent donor tissue, full-thicknessskin grafts and distant flaps are commonly usedto repair a large defect in the face or neck.1,2

However, the desired results are usually notachieved because of the dramatic differencesbetween the transplanted tissue and recipient-site demand. The forehead flap is an ideal flapfor the reconstruction of the face and neck,but it is usually limited to use in nasal recon-struction because of the large donor-site mor-bidity, a common primary complaint of pa-tients who undergo such reconstruction.1,2,13

Tissue expansion provides a greater oppor-tunity for the repair of larger defects of theface and neck by supplying ideal tissue withreduced donor-site morbidity.4,5,8–12,14,15 How-ever, if it is not possible to create a soft-tissueenvelope in the face or neck that is largeenough to receive a tissue expander, a distantflap should be considered. The forehead is anideal region for tissue expansion: (1) it is easyto create a pocket in the forehead to receive atissue expander; (2) the forehead has a sup-

portive base to allow more effective tissue ex-pansion; (3) tissue expansion in the foreheaddoes not greatly influence underlying struc-tures; and (4) the circulation in the forehead isrich enough that complications can usually beavoided. However, the traditional design of theexpanded forehead flap usually results in aresidual unsightly scar in the donor ar-ea.3,6,13,16–18 The expanded forehead flap differsfrom the traditional technique for forming aforehead flap. It is basically an axial flap de-signed on the basis of the superficial temporalvessels and is created along the frontal hairline.For reconstruction of face and neck, the flapcould be formed as an island flap, to be used ina one-step transference procedure. It couldalso serve as a customized free flap for trans-ference to any part of the body. The otherimportant advantage of the flap is the reduc-tion of donor-site morbidity to a minimum,without visible scarring. The appropriate thick-ness of the flap and the color-matched tissuemeet the objectives of functional and aestheticreconstruction of the face and neck. Further-more, the technique could be developed into anew method for scarless nasal reconstruction,requiring only a one-step transference proce-dure with minimal donor-site morbidity and novisible scarring.

In conclusion, the technique for creation ofan expanded forehead flap could be used tocreate a safe, ample, and color-matched islandflap to be used in a one-step transference pro-cedure for routine face and neck reconstruc-tion. Donor-site morbidity could be reduced toa minimum, without an unsightly visible scar.The flap could also potentially serve as a cus-tomized free flap for reconstruction of any partof the body, with similar advantages.

Jincai Fan, M.D., Ph.D.Mid-2 Division of Plastic SurgeryPlastic Surgery HospitalChinese Academy of Medical SciencesBa-Da-Chu RoadBeijing 100041, People’s Republic of China

REFERENCES

1. Feldman, J. J. Facial Burns. In J. G. McCarthy (Ed.),Plastic Surgery, Vol. 3. Philadelphia: Saunders, 1990.Pp. 2153–2236.

2. Barton, F. E., and Byrd, H. S. Acquired Deformities ofthe Nose. In J. G. McCarthy (Ed.), Plastic Surgery, Vol.3. Philadelphia: Saunders, 1990. Pp. 1924–2008.

3. Adamson, J. E. Nasal reconstruction with the expandedforehead flap. Plast. Reconstr. Surg. 81: 12, 1988.


4. Argenta, L. C., Watanabe, J. J., and Grabb, W. C. Theuse of tissue expansion in head and neck reconstruc-tion. Ann. Plast. Surg. 11: 31, 1983.

5. Manders, E. K., Schenden, M. J., Furrey, J. A., et al.Soft-tissue expansion: Concept and complications.Plast. Reconstr. Surg. 74: 493, 1984.

6. Zuker, R. M., Capek, L., and de Haas, W. The expandedforehead scalping flap: A new method of total nasalreconstruction. Plast. Reconstr. Surg. 98: 155, 1996.

7. Munker, R. Nasal reconstruction with tissue expansion.Facial Plast. Surg. 5: 328, 1988.

8. Fan, J., and Yang, P. Versatility of expanded foreheadflaps for facial reconstruction. Scand. J. Plast. Reconstr.Surg. Hand Surg. 31: 357, 1997.

9. Fan, J. Tissue Expansion. Ph.D. thesis. Beijing: BeijingUnion Medical University, 1991.

10. Fan, J., Raposio, E., and Nordstrom, R. E. A. FillingPolicy. In R. E. A. Nordstrom (Ed.), Tissue Expansion.Boston: Butterworth Heinemann, 1996. Pp. 43–47.

11. Fan, J. Tissue expansion of tube flap during the last trans-ferring stage in reconstruction of the face and neck.Scand. J. Plast. Reconstr. Surg. Hand Surg. 32: 229, 1998.

12. Fan, J. Post-transferred tissue expansion of a musculo-cutaneous free flap for debulking and further recon-struction. Ann. Plast. Surg. 38: 523, 1997.

13. Galli, A., Berrino, P., and Santi, P. A systematic aestheticapproach to primary closure of the donor site follow-ing transposition of vertical forehead flaps. AestheticPlast. Surg. 15: 245, 1991.

14. Fan, J., and Yang, P. Aesthetic reconstruction of burnalopecia by using expanded hair-bearing scalp flaps.Aesthetic Plast. Surg. 21: 440, 1997.

15. Radovan, C. Tissue expansion in soft-tissue reconstruc-tion. Plast. Reconstr. Surg. 74: 482, 1984.

16. Denny, A. D. Expanded midline forehead flap for cov-erage of nonnasal facial defects. Ann. Plast. Surg. 29:576, 1992.

17. Iwahira, Y., and Maruyama, Y. Expanded unilateralforehead flap (sail) for coverage of opposite foreheaddefect. Plast. Reconstr. Surg. 92: 1052, 1993.

18. Toth, B. A., Glafkides, M. C., and Wandel, A. The roleof tissue expansion in the treatment of atypical facialclefting. Plast. Reconstr. Surg. 86: 119, 1990.


Documents

A New Technique of Scarless Expanded Forehead Flap.4