Paramedian Forehead Flap: Indications, Techniques, and Care

The paramedian forehead flap is a widely used technique for reconstructing nasal and facial defects, offering reliable vascularity and an excellent tissue match. It is particularly valuable for restoring significant soft tissue loss after tumor excision or trauma. Success depends on careful planning, precise execution, and proper postoperative management to achieve optimal aesthetic and functional outcomes.

Basic Anatomy Of The Forehead Region

The forehead is a critical donor site for reconstruction due to its rich vascular supply, pliable soft tissue, and color match with adjacent facial structures. Its anatomy consists of multiple layers, each essential to the success of a paramedian forehead flap. The skin, subcutaneous tissue, frontalis muscle, and vascular network all contribute to tissue viability.

The skin is relatively thick, especially in the glabellar and superior areas, and contains a dense network of sebaceous glands that influence texture and healing. Beneath it, the subcutaneous tissue varies in thickness depending on age, sex, and individual anatomy. This layer houses small vascular branches that support perfusion while allowing some skin mobility.

The frontalis muscle elevates the eyebrows and creates horizontal forehead wrinkles. Unlike other facial muscles, it lacks a bony attachment and instead connects to the galea aponeurotica superiorly while blending with periorbital muscles inferiorly. Preserving or partially incorporating this muscle in the flap maintains vascular integrity. Beneath it, loose areolar tissue allows movement between the muscle and the periosteum of the frontal bone.

The vascular supply is dominated by the supratrochlear and supraorbital arteries, both branches of the ophthalmic artery. The supratrochlear artery, the primary pedicle for the paramedian forehead flap, emerges from the superomedial orbit and ascends along the medial forehead, providing robust axial blood flow. The supraorbital artery, running more laterally, contributes to collateral circulation and can support larger reconstructions.

Criteria For Flap Design

Successful forehead flap reconstruction requires meticulous design to ensure functional restoration and aesthetic harmony. The supratrochlear artery serves as the axial pedicle, making precise identification of its course—typically 1.7 to 2.2 cm lateral to the midline—crucial. Doppler ultrasound can enhance accuracy, reducing the risk of perfusion issues. Maintaining a pedicle width of 1.0 to 1.5 cm preserves blood flow while allowing sufficient mobility for inset.

Flap dimensions and orientation must match the recipient site’s defect, considering tissue volume, contour, and skin texture. Aesthetic subunits are particularly important in nasal reconstruction, where aligning the flap with natural shadowing and contour transitions improves the final appearance. The donor site should provide enough tissue without excessive redundancy, which could cause contour irregularities or require secondary revisions. Designing the flap along relaxed skin tension lines minimizes donor site morbidity and improves scar concealment.

Tissue thickness is another key factor. For thin-skinned areas like the nasal tip, careful defatting may be necessary to prevent excessive bulk. Deeper defects may require a thicker flap incorporating subcutaneous layers or portions of the frontalis muscle for structural support. Layered closure techniques at both donor and recipient sites help prevent unnatural transitions.

Outline Of Tissue Transfer Steps

A structured approach ensures vascular integrity and optimal contouring during flap transfer. Preoperative planning dictates the flap’s shape and orientation, often using a template to match the defect’s size and curvature. Once marked, the incision follows the predetermined design while preserving the pedicle’s vascular integrity. The supratrochlear artery is carefully identified and protected throughout elevation.

During flap elevation, balancing tissue mobility with subcutaneous and muscular preservation maintains perfusion. Dissection occurs just above the periosteum to ensure vascularization while avoiding unnecessary bulk. A two-stage technique is commonly used, keeping the pedicle attached initially to establish a robust blood supply before division. This approach reduces ischemic risks and improves long-term viability.

Once mobilized, careful rotation and positioning ensure proper alignment with the defect. Tension-free inset prevents distortion, especially in areas requiring fine contouring, such as the nasal tip or alar region. Layered closure techniques enhance stability and minimize step-offs. In some cases, additional cartilage grafting or structural support may be incorporated before final fixation.

Flap Inset Techniques

Achieving a natural and functional reconstruction depends on precise inset techniques that preserve vascular integrity and aesthetic contouring. The flap must align with the recipient site’s topography to ensure smooth transitions. A multi-layered suturing approach secures the dermis and subcutaneous layers separately, distributing tension evenly to minimize distortion and prevent complications like trapdoor deformity.

Thinning the flap is often necessary for areas requiring fine contouring, such as the nasal tip or alar subunits. Initial elevation preserves a robust subcutaneous layer for perfusion, but staged defatting—either at inset or during a revision—helps achieve a more natural profile. Gradual tissue adaptation improves aesthetic outcomes while reducing vascular compromise risks.

Typical Postoperative Care

Postoperative management focuses on maintaining flap vascularity, minimizing complications, and optimizing healing. The flap’s survival depends on adequate perfusion through the supratrochlear artery, so surgeons monitor for signs of compromised blood flow, such as pallor, cyanosis, or venous congestion. Patients should avoid excessive head movement or pressure on the flap. Mild edema and bruising are expected, but prolonged swelling or discoloration requires immediate evaluation.

Wound care involves keeping surgical sites clean and moist to promote healing and reduce infection risk. Non-adherent dressings with antibiotic ointments are commonly used, and sutures are typically removed within seven to ten days. Pain management is tailored to individual tolerance, with most patients needing only mild analgesics after the first few days.

For staged procedures, pedicle division usually occurs three to four weeks postoperatively, allowing time for the flap to establish an independent blood supply. Once divided, additional refinements such as contour adjustments or secondary defatting may enhance the final outcome.

Use In Reconstructive Procedures

The paramedian forehead flap is a versatile option for facial reconstruction, particularly in nasal reconstruction after oncologic resection, trauma, or congenital deformities. Its robust vascularity and pliability make it ideal for replicating the nasal tip, dorsum, and alae. In extensive defects, it can be combined with structural grafts, such as autologous cartilage from the ear or rib, for additional support. The staged approach allows for precise contouring and refinement, yielding superior results compared to skin grafts or local flaps.

Beyond nasal reconstruction, the forehead flap is used for defects in the orbit, cheek, and perioral region when local tissue is insufficient. It is effective in Mohs surgery defects requiring wide excision and in complex trauma cases where primary closure is not feasible. Studies show high success rates with forehead flaps, with low complication rates when planning and postoperative care are meticulous. As surgical techniques evolve, refinements in flap design and inset strategies will further improve outcomes, offering enhanced form and function in facial reconstruction.