British Journal of Plastic St4rgery (2001), 54, 705-707 �9 2001 The British Association of Plastic Surgeons doi: 10.1054/bjps.2001.3689

B R I T I S H J O U R N A L OF P L A S T I C S U R G E R Y

POINT OF TECHNIQUE

The H-flap: a useful flap for forehead reconstruction

V. Rose, S. Overstall, D. M. Moloney and B. W. E. M. Powell

Department of Plastic and Reconstructive Surgery, St George's Hospital, London, UK

SUMMARY. We have found that double opposing rectangular advancement flaps in the forehead may be easily performed under either local or general anaesthesia, and are associated with high patient satisfaction and low morbidity. We claim no originality for the mode of reconstruction, but highlight its broad spectrum of application and its popular- ity with junior plastic surgeons passing through our unit. We have found that the term 'H-flap' provides a readily communicated alternative to 'double opposing rectangular advancement flaps'. �9 2001 The British Association of Plastic Surgeons

Keywords: H-flap, double opposing rectangular advancement flaps, forehead reconstruction.

Malignant and non-malignant skin lesions of the fore- head are regularly seen in the minor operations unit. Our usual mode of reconstruction for small and intermediate defects in the central forehead area is the 'H-flap'. The concept is not novel, based as it is on double opposing rectangular advancement flaps, but we emphasise the utility of the technique and highlight some points of practice.

As illustrated (Fig. 1), the lesion is outlined, together with a suitable margin (Fig. 1A,B), It is then converted to a square and excised. Bilateral advancement flaps are designed, with the long axes oriented along the trans- verse skin creases (Fig. 1C). Although usually elevated in the subcutaneous plane, the flaps can be more easily raised in the subgaleal-subfrontalis plane in elderly patients with thinner skin. Closure proceeds from lateral to medial, feeding the flaps centrally and thus, unlike

other methods, 1 avoiding the need to excise Burrow's tri- angles, which would result in unnecessary vertical scar- ring. The two flaps meet centrally to form a sideways 'H ' (Fig. 1D); we have not found it necessary to leave a residual central defect to heal by secondary intention. ] We commonly use the technique for defects up to 30 mm in diameter, raising flaps with a length-breadth ratio of up to 2 : 1 without loss of the distal portions (Fig. 2).

Several local flaps have been described for the recon- struction of central forehead defects, including subcuta- neous V-Y pedicled flaps, 2'3 'A to T' rotation-advancement flaps for defects close to the hairline j and multiple hatchet flaps. 4 Double opposing rectangular advancement flaps are an old tool in the plastic surgeon's armamentarium, but one not frequently discussed in the context of forehead reconstruction.1 In our unit, the technique was introduced by the senior author (BWEMP) several years ago, and it

Figure 1--Design and execution of the H-flap. (A,B) The lesion is outlined with a suitable margin.

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Figure l~ontinued. (C) Bilateral rectangular advancement flaps are elevated in the subgaleal-subfrontalis plane with the long axes oriented in the direction of the transverse skin creases. (D) Closure does not require excision of Burrow's triangles nor does it leave a residual central defect.

Figure 2~The use of the H-flap. (A) A basal cell carcinoma with a diameter of 15 mm, and (B) the postoperative result 6 months after reconstruction with a subcutaneous H-flap. (C) A basal cell carcinoma with a diameter of 12mm, and (D) the postoperative result 6 weeks after reconstruction with a subcutaneous H-flap.

has become a favoured mode of reconstruction for such defects. Our reasons are primarily ones of cosmesis: the transverse scars tend to be camouflaged in the forehead skin creases, and the length of the more obvious vertical scar is minimised by equalling the vertical dimension of the defect. The altemative local flaps mentioned above result in a more significant vertical scar, or in oblique scars less well camouflaged in the skin creases, or in dis-

ruption of the hairline. Although the transverse incisions do jeopardise the supratrochlear and supraorbital nerves, especially if the flaps are raised in the subgaleal plane, careful dissection should considerably reduce the risk of such damage. 4 It should also be pointed out that altered sensation is commonly associated with local cutaneous flaps, but our experience suggests that the symptoms are minimally troublesome to the patients.

The H-flap: a useful flap for forehead reconst ruc t ion 707

Figure 2--Continued. (E) A squamous cell carcinoma with a diameter of 30 ram, and (F) the postoperative result 6 months after reconstruction with a subcutaneous H-flap. Note that in all three cases primary closure was achieved and no Burrow's triangles were excised.

References

1. TerKonda RP, Sykes JM. Concepts in scalp and forehead reconstruc- tion. Otolaryngol Clin North Am 1997; 30: 519-39.

2. Barton JN, Emmett AJJ. Subcutaneous pedicle flaps. Br J Plast Surg 1965; 18: 51-78.

3. Hallock GG, Trevaskis AE. Refinements of the subcutaneous pedicle flap for closure-of forehead and scalp defects. Plast Reconstr Surg 1985; 75: 903-5.

4. Fatah ME Innervation and functional reconstruction of the forehead. Br J Plast Surg 1991; 44: 351-8.

Dominique Moloney FRCS, DPhil, Specialist Registrar Barry Powell MB BCh, FRCSEd, MCh, Consultant

Department of Plastic and Reconstructive Surgery, St George's Hospital, Blackshaw Road, Tooting, London SWt7 0QT, UK.

Correspondence to Miss V. Rose, The Gatehouse, Jameson Close, Acton Lane, London W3 8NR, UK.

Paper received 3 April 2001. Accepted 23 July 2001, after revision.

The Authors

Victoria Rose MBBS, MRCS, Registrar Simon Overstall BSc, MBBS, House Officer