Standard Forehead Flap Applications Coverage Middle and Inferior Thirds of Face Lateral Face Oral Cavity Frontal and Maxillary Sinus Reconstruction Eyelids Nose ‘Tongue272 Regional Flaps: Anatomy and Basic Techniques / Headand Neck Standard flap Extended flap Dominant pesice: Froniatoranch of superficial emporal artery (0) Minor pedicles: Supratrochlear ater (m:supraorbtalantery (m;)Standard Forehead Flap 273 FEATURES LOCATION: This flap comprises the hairless skin of the forehead between the scalp and the eyebrows and extends laterally to the preauricular and temporal hair-bearing skin, The flap is based laterally on one side of the forehead and extends across the forehead to the edge of the hair-bearing temporal sealp on the contralateral side. In the patient with alopecia of the frontal scalp the flap may be shifted superiorly tothe cexisting hairline. SIZE:22 X Tem Muscle: Occipitofrontalis ORIGIN: Procerus, corrugator supercilii, orbicularis oculi, and zygomatie process of the frontal bone INSERTION: Galea aponeurotica Flap Type: Fasciocutaneous Pattern of Circulation: Type \ VASCULAR ANATOMY Dominant Pedicle: Superficial temporal artery and vein REGIONAL SOURCE: External carotid artery and vein “TH:4em DIAMETER:2m LOCATION: Originates posterior to the vertical ramusof the mandible within ordeep to the parotid gland and extends over the zygomatic process of the temporal bong ‘The superficial temporal artery is located anterior to the superficial temporal vei and both course in a superior direction deep to the superficial temporal fascia. Ap- proximately 4 em superior to the zygomatic arch the artery divides into its terminal branches, including the frontal and parietal branches. The frontal branch courses anteriorly and supplies the frontalis muscle and overlying forchead and frontal scalp skin, Minor Pedicle: Supratrochlear artery and venae comitantes REGIONAL SOURCE: Terminal branch of ophthalmic artery LENGTH 3m DIAMETER: I mum LOCATION: Exits the orbit at the medial edge and courses through the frontal muscle and cephalad over the anterior epicranium. Minor Pedicle: Supraorbital artery and venae comitantes REGIONAL SOURCE: Ophthalmic artery LENGTH: 4m DIAME LOCATION: Exits the supraorbital foramen or notch beneath the frontalis muscle and courses cephalad over the anterior epieranium. ER Imm274 Regional Flaps: Anatomy and Basie"Techniques / Head and Neck NERVE SUPPLY MOTOR: Temporal branch of facial nerve NSORY: Supratrochlear, supraorbital, Ia nerves al, temporomalar, and auriculotemporal FUNCTION: Facial animation and elevation of brow. Brow function is completely lose with use of the standard forchead flap. As a result, there is no animation of the upper third of the face, requiring skin graft coverage after flap transposition. VASCULAR ANATOMY OF STANDARD FLAP i} Deep surface of flap Radiographic view Dominant pedicle: Superficial temporal artery (O) Minor pecicles: Supratrochlaar artery (m,)-supraorbital artery (m.)Standard Forehead Flap 275 ARC OF ROTATION Standard Flap: Extends to the middle and lower third of the face and to the oral cavity. The arc to the mouth requires entry into the oral cavity through the cheek skin, passing either superficial or deep to the zygomatic arch. Elevation of fap ‘Ate to mid-and lower third of face Coverage of lower third of face276 Regional Flaps: Anatomy and Basic'Techniques / Head and Neck ARC OF ROTATION—cont’d Standard Flap—cont’d Arctooral cavity Intraoral reconstruction (lap turned 180, degrees over zygomatis arch) Intraoral reconstruction with Combined coverage of intraoral eavity and flap passed over zygomatic arch and through lower third of face (distal lap folded to position cheek tunnel into oral cavity ‘skin for external face coverage)Stundard Forehead Flap 277 ‘Standard lap elevation Coverage of nose Extended Scalp Flap: ‘his flap is designed to reach the middle third of the face and nose. Are to middle third of face and nose278 Regional F and Basic Techniques / Head and Neck ARC OF ROTATION—cont'd Island Flap: When the skin island is designed on the ipsilateral forehead, the flap will reach middle third face defects. Roth the standard and extended scalp flaps may be designed as an island flap either by deepithelialization of the cutaneous portion of the flap base or by isolation of the flap on the superficial temporal artery and vein. Elevation of the flap as an island will increase the arc of rotation, particularly when the flap is passed through a cheek:tunnel into the oral eavity. Flap design Arctelateral aceReverse Flow Island Flay head and superior orbit. ‘Standard Forehead Flap his flap design will reach defects on the ipsilateral fore- ‘Arctolateral aspect of middle and upper thirds of face 279280 Regional Flas: Anatomy and Basie Techniques / Head and Neck SKIN TERRITORY DESIGN: The entire forchead skin is included in the territory of this flap. DIMENSIONS: Standard flap size is 22 X 7 em but varies depending on forehead height and the position of the hairline, both anteriorly and laterally. BLOODSUFPLY: Direct fasciocutaneous and musculocutaneous vessels <& Standard tlap design Extended scalp tlap desionReverse skin island design Standard Forehead Flap 281282 Regional Flaps: Anatomy and Basie Techniques / Head and Neck FLAP MODIFICATIONS ‘Tissue Expansion: The standard forehead flap generally has adequate dimensions forcoverage of intraoral defects and defects of the midface and the lower third of the face. Direct donor site closure is not possible, and preoperative tissue expansion has limited advantages. Sensory Flap: The supraorbital nerve opposite the base ofthe flap may be included in the flap. Coaptation of thisnerve to asuitable sensory nerve at the lower third of the face and oral cavity will provide protective sensation within the flap territory. APPLICATIONS Coverage: Middle and inferior thirds of face, lateral face, oral cavity, and frontal and maxillary sinus Reconstruction: Fyelids, nose, and tongue GUIDELINES FOR FLAP ELEVATION Markings TANDMARKS: The standard forehead flap (temporal-based flap) includes all or part of the forehead skin, Pertinent landmarksare the anterior hairlineand superior edge of, the eyebrow. The modified forehead flap places the markings more posteriorly in the bald patientso that the skin over the frontal skull can be used. Asmall island flap may also be designed with a skin island located over the ipsilateral eyebrow at the level of the anterior hairline or at the junction of the forehead and scalp. In this instance an oblique incision extends from the skin island to the preauricular region. “The coronal suture line generally determines the posterior incision for the extended scalp flap. Dominant pedicle: Supertcial temporal artery (0) ‘Minor pecicles: Supratiochlear artery (m,);supreorbita artery (m.)Sundard Forehead Flap 283 FLAP DIMENSIONS: The standard flap is 5 X 10 cm, If the flap extends to the opposite hairline, the flap is 5 15 em. The extended scalp flap is often required ifthe flap is to fold on itself to provide oral lining and simultaneous cheek skin coverage. The base of the flap may only include the vascular pedicle or a small bridge of skin overlying the vascular pedicle. ‘The flap is usually designed as an aesthetic unit and includes the skin between the anterior hairline and the superior eyebrows. SKINISLANDS: The fiap generally extends across the midline to the level of the eontra- lateral eyebrow. However, it may only extend to the midline or to the level of the contralateral temporal hairline. In patients with frontal alopecia the flap may be designed over the frontal skull or may include hair-bearing scalp if required for lower face reconstruction. A separate skin island may be designed based on the parietal or retroauricular branches of the superticial temporal artery and vein. PEDICLE LOCATION: The pedicle, the superficial temporal artery and vein, is palpable anterior to the tragus of the ear beneath the preauricular skin, A Doppler probe is used to trace the pedicle along the zygomatic arch to the level ofits bifurcation into the frontal and parietal branches, This bifurcation occurs 2 to 4 cm superior to the zygomatic arch. At this level the frontal branch is traced until the territory of the supraorbital and supratrochlear vessels reached in the midline of the forehead. Patient Positioning: ‘The patient is kept in the supine position during flap elevation and inset. Incisions: Outlines of the flap are incised with the skin beveled toward the flap to minimize the contour deformity of the flap donor site after subsequent skin graft closure. The incision is then carried through the frontalis muscle on the contra- lateral forehead Identification of Anatomic Landmarks MUSCLE/FASCIA: The flap is generally elevated at the level of the periosteum. Itis also possible to elevate the flap superficial to the frontalis and corrugator muscles to pre- serve facial expression. At the lateral one third of the forehead dissection is deep to the temporoparietal fascia. The superficial temporal artery and vein are visualized or palpated through the thin fascia and carefully preserved at the level of the zygo- maticarch. ‘The frontal branch of the facial nerve crosses the medial zygomatic arch and passes in close proximity to the lateral eyebrow into the frontal musculature. IF a dissection is performed superficial to che frontal muscles, loupe magnification is required to avoid injury to the frontal branch of the facial nervein the plane beneath the superficial fascia. The medial sensory nerves (supraorbital) are divided during flap elevation, PEDICLE: The superficial temporal artery and vein are traced inferior to the zygomatic arch where the vessels pass beneath the parotid gland. Ifa skin island is formed by dividing the skin superficial to this pedicle, the arc of rotation is extended.284 Regional Flaps Anatomy and Basic’Techniques / Head and Neck FLAP ELEVATION TECHNIQUES Standard Flap: The perimeter of the forehead flap is incised either to the surface of the frontalis muscle or to the periosteum of the frontal bone. Flap elevation begins at the distal fap margin located on the forehead contralateral to the base of the flap. As flap elevation proceeds across the orbital rim the supraorbital and supratrochlear vessels are divided. The dissection reaches the ipsilateral orbit. At this point dissec- tion proceeds from the superior aspect of the flap edge at the hairline toward the ipsilateral zygomatic arch. ‘The parietal branch of the superficial temporal artery and associated vein are divided and dissection proceeds deep to the temporoparietal fascia inferiorly. At the level of the zygomatic arch the dissection proceeds toward the tragus of the ear only as required to increase the flap are of rotation. In the standard forehead flap design, particularly for intraoral defect coverage, the flap elevation is completed 1.5 em inferior to the zygomaticarch. At this level a tunnel is formed to transpose the flap into the oral cavity Extended Scalp Flap: The posterior bicoronal incision represents the posterior as- pect ofthe extended scalp flap. This incision is made through the galea to the peri- ‘osteum. The contralateral forehead skin opposite the flap base has been designed to provide extemal skin coverage for nasal reconstruction. his skin is elevated seart- ing at the orbital rim and proceeding superiorly to the hairline, The plane of eleva- tion hereis superficial to the frontalis muscle. Atthe level of the hairline the dissec- tion enters the deeper plane between the galea and the frontal bone periosteum, ‘The anterior scalp in continuity with the contralateral forehead flap skin is elevated asasingle unit to the flap base superior 1 the zygomatic arch. The ipsilateral orbital vascular connections to the forehead skin (supraorbital and supratrochlear vessels on the side of the flap base) are preserved. The contralateral nonhair-bearing fore- head skin portion of the flap is now ready for transposition to the nasal defect. Island Flap: The skin island is designed either over the eyebrow orat the hairline. An incision is then made between the proximal edge of the skin island to the zygomatic arch over the course of the frontal branch of the superficial temporal artery and associated vein, The forehead skin is elevated both superior and inferior to this incision superficial to the temporoparietal fascia to isolate the frontal branch of the temporal artery and vein at its junction with the temporal artery and vein in the preauricular region. After the temporal artery and vein branches to the skin island are isolated, the skin island borders are incised to the level of the frontalis muscle or to the periosteum of the frontal bone. Care is necessary to avoid lar pedicle as it enters the base of the skin island flap. The flap is now elevated in continuity with the vascular pedicle. The plane of dissection is located deep to the temporoparictal fascia and the superficial musculoaponeurotic system atthe level of the zygomatic arch. The superficial temporal artery and vein to the level of the ear tragus can be dissected to achieve an adequate arc of rotation for the flap. Reverse Flap: The skin island is designed in the preauricular skin between the zygo- maticarch and ear lobule. The lateral preauricular incision is made to the superficial musculoaponeurotic layer. Immediately superior to the tragus the superficial tem- poral artery and vein are isolated and the dissection proceeds deep to the temporal vessels to complete elevation of the skin island. A 3 to4 cm incision is now made superior to the skin island either at the junction of forehead skin with the hairline or ry tothe vaseu-Standard Forchead Flap 285 slightly medial on the lateral forehead directly over the course of the superficial temporal artery and associated vein. The superficial temporal artery and vein are divided at the midpoint of the deep surface of the skin island where the vessels pass into the parotid gland. The skin island with the superior continuation of the superfi- ial temporal artery and vein is dissected to inchude a strip of superficial temporo- parietal fascia. The reverse pedicle with the skin island is elevated 3 to 4 cm to the level of the zygomatic arch until the are of rotation is adequate for defect coverage. EXTENSION OF PEDICLE LENGTH: When the standard, island, or ex- tended scalp flap requires a greater arc of rotation, it is possible to elevate the vascu- lar pedicle to the flap, the superficial temporal artery and vein, to the level of the external meatus of the ear atthe midcragal region. At this level the vessel progresses deep in the parotid gland and further dissection may result in vascular injury. This extension of the vascular pedicle length below the zygomatic arch generally pro- vides an arc of rotation to cover middle and inferior defects of the face and defects, within the oral cavity and lateral pharyngeal wall ‘TRANSPOSITION: Ii the flap is to be used for external face coverage or combined face skin and oral lining, the flap is rotated over the lateral zygomatic arch onto the face. However, if the flap is primarily designed for intraoral coverage, a tunnel be- tween the donor site and the oral cavity is required. Four methods are currently described for tunneling the flap to reach the intraoral defect. 1, Fold the flap laterally, pass the flap over the zygomatic arch, and enter through a separate transverse cheek incision via a tunnel made into the oral c: 2. Fold the flap medially over the zygomaticarch through the flap incision. 3. Fold the flap medially and pass deep to the zygomatic arch. 4. Pass the extended flap under the upper edge of the neck dissection into the mouth, ‘The tunnel is located anterior, directly through, or posterior to the masseter muscle ifthe vertical ramus of the mandible is present. Access to the oral cavity is less complicated in the absence of the vertical ramus of the mandible, In each instance the most direct route is preferred to permit maximal usc of the skin surface of the flap for intraoral reconstruction. viaa tunnel FLAP INSET: After standard, island, or reverse island flap elevation for face cover- age, the flap is tailored to fit the defect and sutured to the defect skin edges. ‘The standard flap may be converted into an island flap at the flap base to eliminate the necessity for flap base revision of redundant skin ina second procedure. In the initial description for use of the standard forehead flap for intraoral cov- ‘erage, the continuity of the skin base of the flap was maintained and the raw surface ofthe flap skin grafted as the flap entered the tunnel into the oral cavity. Deepithe- lialization or excision of skin overlying the vascular pedicle allows permanent flap inset. This minimizes the donor site deformity, permits a controlled fistula, and climinates the need for secondary inset of the base of the flap. If the cutaneous portion of the flap base is left intact (no subcutaneous pedicle), the flap is generally inset at3 weeks. The distal flaps either sutured directly into the mucosal defect or folded on itselfin a double layer if used for palate or mandibular graft coverage.286 Regional Flaps: Anatomy and Basie Techniques / Head and Neck DONOR SITE CLOSURE: The donor site is usually skin grafted as an aesthetic unit. If the flap is tubed or folded laterally, the skin is divided within the eunnel and rotated back to the lateral forehead and inset to avoid donor site deformity. The distal flap is inset via the intraoral approach to complete closure of the controlled fistula, PRECAUTIONS + Confirm the patency of the superficial temporal artery and vein by physical and Doppler examination. If questionable, an arteriogram is indicated. + Ifradical neck dissection is performed, preserve the patency of the external carotid artery and its terminal branch, the superficial temporal artery. Ifthe external carotid artery is divided, considera contralateral forehead flap or an alternate procedure. + Ifthe forehead flap is elevated superficial to the frontalis muscles, the dissection of lateral muscle must remain deep to the temporoparietal fascia. Be careful not to divide the frontal branch of the facial nerve adjacent to the lateral eyebrow and avoid injury to the superficial temporal artery and its frontal branch into the flap. + Avoid a tight tunnel and use blunt dissection behind, through, or anterior to the masseter muscle to avoid injury to the zygomatic and buccal branches of the facial nerve, + Avoid injury to the parotid gland while making the tunnel. If a parotid fistula de- velops, closure is generally spontancous. + For the reverse temporal artery island flap, superior dissection of the temporal ves- sels to the level of the zygomatic arch is required to achieve an adequate flap arc of rotation. Dissection of the pedicle superior to this level may jeopardize retrograde flow and should not proceed beyond the bifurcation of the superficial temporal ar- tery into its anterior and parietal branches. Annotated Bibliography Anatomic Studies (Conway HRB, Stark RB, Kavanaugh JD. Variations of the temporal flap. Plast Reconstr Surg 9410, 1952. “This review article presents an excellent historical analysis ofthe development of the temporal flap. The anatomy of the superficial temporal artery is demonstrated in cadaver dissections. ‘This report includes a careful review of 18 patients in whom this lap (16 based on the frontal branch of superficial temporal artery and two based! on the parietal branch) was suecessfully used for reconstruction of a variety of facial defects. The authors advise locating the inferior border of the flap immediately above the eyebrow, primarily to include the inferior branch of the superficial eemporal but also to improve the donor site deformity by the use of askin graf asa forehead aesthetic unit Mazzola RF, Marcus S. History of total nasal reconstruction with particular emphasis on the folded forehead flap technique. Plast Reconstr Surg 72:408, 1983. The history of total rhinoplasty is reviewed. Three surgeons, Natale Petrali (1842) from Italy ‘and Johann Friedrich Dieffenbach (1845) and Ernst Blesins (1848) from Germany, are eredived with the introduction of a single forchead flap to rebuild the tip, columella, and lining of the nose. Original photographs and drawings are included n thisinceresting article.Standard Forehead Flap 287 Clinical Series Champion R, Closure of full-thickness cheek loss by a forehead flap. Br] Plast Surg 13:76, 1960. Full-thickness cheek defects are reconstructed in asingle stage using a laterally based forchead flap. The flap is designed 5 em beyond the midline on the contralateral forehead and has a narrow baseat the zygomatic arch, which includes its vascular pedicle containing the temporal vessels. The distal flap is folded on itself for simultaneous restoration of mucosal lining, The width of the flap pedicle is reduced to 2 cm. The author reports successful use ofthis tecinigue in 12 patients, Hessler F. Commentari et annotationesin Susrutae Ayurvedam. Fasciculus secun FEnke, 1855, p12. ‘Anaccount of the Indian method for forehead reconstruction. Horsley JS, Transplantation of the anterior temporal artery. Clin J 45:193, 1916. ‘This is one ofthe initial descriptions ofthe temporal artery island flap using forchead skin for cheek reconstruction, The author acknowledges articles by George H. Monks of Boston in 1898 who used similar flap design and an earlier description ofthe forchead flap by ‘Theodore Dunham of New York who performed this procedure on August 24, 1892, Unlike Horsley, who clevated the flap as an island, the forehead flap initially raised by Dunham was described as follows:"This flap was so cutas to contain, traversingits pedicle and ramifyinginitthe anterior temporal artery.” McGregor IA. The temporal flap in intra-oral cancer: [ts use in repairing the post-excisional defect. Br J Plast Surg 16:318, 1963, ‘This is a classic article that introduces the temporal flap for immediate reconstruction after ‘extirpation of intraoral cancer. This flap is wed in 16 patients with malignant intraoral tumors in whom the defect precluded closure with local tissues. ‘The flap is designed to the midline of the forehead and passed through a tunnel viaa separate incision below the zygomatic arch. The flap isinset for3 weoks with return ofthe fap base to the forehead donorsite. No flap loss or fis tulss were noted, This procedure was used in 12 patients after radical neck dissection without flap problems developing. The author notes, “Repair by the temporal fap is immediate, does not require immobilization, etc, of the patient and is complete in four weeks.” He also states, “In cancer of head and neck, a balance is constantly being struck between surgery and radio therapy and equilibrium isuneasy and unstable.” With this fap, immediate reconstruction with reliable technique allowed the cancer surgeon to remove intrioral cancer with adequate mar- gins andstll obtain an acceptable functional result. Thesuccess ofthis flapin head and neck re~ constructive surgery firmly establishes the concept of immediate reconstruction after removal of head and neckcancer, Millard DR Jr. A.new approach to immediate mandibular repair. Ann Surg 160:306, 1964. A forchead flap is used for immediate coverage of an iliac bone graft for simultaneous recon- struction of the mucosa and mandible following radical excision for jaw malignancy: ‘The value of immediate as opposed to delayed mandible reconstruction is demonstrated by comparison ‘ofa patient undergoing immediate reconstruction with a forchead fap and bone grafts with a second patient undergoing delayed reconstruction with more conventional flap techniques. ‘Tongue movement was not restricted and facial mandibular contour was maintained in the pa- tient who had the immediate forehead flap procedure. This patient successfully wears a fanc~ tioning denture. Wilson JSP. The application of the two-centimetre pedicle flap in plasticsurgery. Br J Plast Surg 20278, 1967. A forchead flap with a narrow 2 cm deepithelialized pedicle is used for immediate reconstruc~ tion ofa varity of head and neck tumor estrpative defects. The flap frequently extends across ‘he midline. When the ipsilateral temporal vessels are unavailable, the contralateral based ten poral flap is successfully used. is. Brlangen:288 Regional Flaps: Anatomy and Basie Techniques / Head and Neck Flap Modifications Bostwick J LIL, Briedis J, Jurkiewicz MJ. The reverse flow temporal artery island flap. C_ Surg 3:41, 1976. An island preauricular skin flap is elevated tothe level ofthe zygomatic arch where i is trans posed for coverage of defects ofthe lateral forehead. This lap includes the superficial temporal artery and vein, which are ligated at the inferior distal edge, and is based on retrograde flow through this vascular pedicle. The authors cecommend use of this flap as a source of nonhair- bearing tissue for forehead defect coverage. Davis GN, Hoopes JE. New route for passage of forehead flap to inside of mouth. Plast Reconstr Surg 4:396, 1971 ‘The forehead flap is passed medial to the zygomatic arch to reach the oral cavity. This new technique provides a direct route for the flap that results in less distal facial nerve injury and fewer salivary fistulas, Juri C, Cerisola J. Contribution to Converse’s flap for nasal reconstruction, Plast Reconstr Surg 69:697, 1982. ‘The limitation of the forehead flap in nasal reconstruction is the donor deformity in the lateral forcheal supraorbital region. A temporofasciocervical flap is deseribed for reconstruction of the donor defectafter removal of the skin graft. ‘The authors also emphasize methods to reduce the donorsite atthe second stage when the scalp apis replaced inits original site, Leonard AG. The forchead flap: Minimising the secondary defect by preservation of the fron- talismuscle. BrJ Plast Surg 36:322, 1983. ‘The authors demonstrate an excellent technique to elevate the forchead flap superficial to the frontalis muscle. An anatomic specimen confirms the location of the superficial temporal artery superficial to the frontalis muscle and the frontal branch of the facial nerve deep to the muscle. Skin grafts placed on the functional frontalismuscle preserve expressive movementofthe upper face, This flap innovation markedly improves the secondary donor defect after use ofthe fore= head flap. Plast Jones RE, Engrav LH. Sepsis of the cheek over a subcutaneous forehead flap. Plast Surg 65:347, 1980. “Two infections with abscess formation occurred within the tunnel used to transfer the forehead flap to the oral cavity for closure of oral defects. Fach flap was folded medially and passed superficial to the zygomatic arch and parotid gland. The flaps enter the oral cavity anterior to the parotid gland. The authors recommend a more direct route with a lessdependent tunnel. A shorter route is possible by folding the flap medially and passing it superficial to the zygomatic arch and then through the mesenteric fascia. The flap is then located deep to the masseter muscle and enters the mouth anterior t the vertieal ramus of the mandible. The authors pre- dicta lower incidence of wound complications with thisshorter tunnel.