Forehead Flaps

Anatomy and Physiology

The paramedian forehead flap is traditionally considered an axial flap based on the supratrochlear artery. However, results from recent studies have suggested that it can survive as a random flap due to the vast network of vascular anastomoses in the mid-forehead area. Results from cadaver studies have shown that the supratrochlear artery exits the orbit approximately 1.7 to 2.2 cm from the midline, passing deep to the orbicularis oculi muscle and ascending superficial to the corrugator supercilii muscle. This artery then passes medial to the eyebrow and through the frontalis muscle, ascending superiorly in the subcutaneous tissue, 1.5 to 2 cm from the midline.

The supratrochlear artery runs toward the scalp within 3 mm of a line drawn from the medial canthus. Contemporary research, including Doppler studies, further emphasizes the predictability of the supratrochlear artery's course and the robust contributions from the supraorbital, dorsal nasal, and angular arteries, which form a rich collateral network that enhances flap viability even with narrower pedicles. Other authors have demonstrated the safety of simply taking a pedicle from the glabellar midline to 1.2 cm lateral to the midline. Adequate pedicle width must be maintained to decrease the risk of inadvertent arterial injury and to maintain adequate venous drainage.[6] Understanding these intricate vascular networks allows for greater flexibility in flap design, including narrower pedicles when indicated, provided careful attention is paid to maintaining perfusion.

Indications

When simpler techniques cannot provide adequate coverage, the forehead flap repairs extensive defects on the nasal tip and ala (and occasionally the nasal lining). Deep wounds of the distal nose often consist of exposed cartilage that cannot sufficiently support the vascular requirements of a skin graft; even with a vascular base, a sustainable graft may not be sufficient to provide proper contour. Adjacent flaps can provide their vascular supply and thickness, but extensive wounds can exceed the limits of mobility and size, especially on the nose. Combining a cartilage graft with a forehead flap is possible if structural stability is compromised in a wound. 

Variations of the paramedian forehead flap have also been used to reconstruct the medial canthus and eyelid defects in appropriately selected patients.[7] Beyond the nose, the versatility of the paramedian forehead flap has expanded its indications to include complex defects of the medial canthus, lower eyelid, and even select cases of lip and cheek reconstruction, particularly where robust, well-vascularized tissue with an excellent color and texture match is required. The reliability of this procedure makes it a cornerstone in challenging facial reconstructive scenarios.[5][8][9]

Contraindications

The use of the paramedian forehead flap is contraindicated in patients unwilling or unable to tolerate multiple-staged surgical procedures or in patients who cannot leave their surgical sites undisturbed. Actively infected skin should not be covered with a flap or used to form a flap. The presence of dirty or infected wounds was associated with the highest likelihood of postoperative complications.[10] With a forehead of low vertical height, a variation of the forehead flap or another repair method may be required to minimize the transfer of hair-bearing scalp.

Smoking is a relative contraindication for the paramedian forehead flap because it increases the risk of flap necrosis. Still, these flaps can be performed safely if thinning is not too aggressive. However, patients who smoke should be rigorously counseled on the significantly increased risks of complications, including flap necrosis, infection, and delayed wound healing. Strict smoking cessation for at least 2 to 4 weeks preoperatively and throughout the healing period is strongly recommended. The use of previously irradiated skin or scar tissue should be avoided. Significant scarring or prior radiation therapy to the forehead can severely compromise the vascularity of the donor site and thus flap viability, necessitating thorough preoperative assessment and potentially ruling out the paramedian forehead flap in favor of alternative reconstructive options.

Interpolation flaps should be performed carefully in patients receiving anticoagulant therapy or with bleeding disorders. Before discontinuing any anticoagulant treatment, consult with the clinician who prescribed it; however, the authors rarely discontinue warfarin, clopidogrel, or aspirin before skin surgery. Contacting consulting clinicians is appropriate before operating on individuals with bleeding dyscrasias.

Equipment

Items required preoperatively include:

• Surgical marker
• Many surgeons employ a Doppler ultrasound probe to precisely mark the course of the supratrochlear artery and its perforators.
• Local anesthetic
• Foil or other material for use as a flap template
• Tubed gauze or other material to ensure the proper length of the planned flap
• Surgical antiseptic scrub

Intraoperatively, the following sterile items are required:

• Sterile drape
• Gauze
• Scalpel with a No. 15 blade
• Electrocoagulation device
• Tissue scissors
• Forceps
• Needle holder
• Absorbable subcutaneous sutures
• Absorbable or nonabsorbable superficial sutures
• Suture scissors
• Undermining scissors
• Normal saline

After completion of the flap, dressing materials and wound care may include:

• Monsel solution and/or cellulose mesh to aid in hemostasis
• Petrolatum-embedded mesh or gauze ribbon to wrap the flap pedicle
• Fluffed gauze
• Flexible surgical tape
• Additional surgical adhesive may also be utilized to stabilize the dressing.

Personnel

A clinician can perform the surgery with 1 surgical assistant, typically outpatient.

Preparation

Preoperatively, patients should be thoroughly evaluated and counseled to maximize positive outcomes of the procedure. The procedure must be explained to the patient, preferably with illustrations or with actual patient photos. They must understand that the flap will appear as a trunk connecting the medial brow to the nose/face, for 3 weeks or more, and a second surgical stage is required to separate the flap. Also, 1 or more additional stages may be necessary to revise the flap. The patient must be able and willing to leave the flap undisturbed until it is time for division and inset.

Bleeding is common in the first 24 to 48 hours, especially at the base of the flap pedicle, and the patient should be prepared for this occurrence with gauze to reinforce the dressing. Phone numbers should be given for contact if the bleeding is heavy or cannot be stopped. Smoking should be stopped as long before surgery as possible and for the duration of healing. Patients should also be asked about upcoming events or trips, as it is common to forget to divulge this information until after surgery. They should also be prepared to avoid strenuous or other activities that increase the bleeding risk. The authors do not routinely discontinue anticoagulants that have been prescribed, but this is at the discretion of the operating surgeon and the prescribing clinician. The potential risk of adverse events from stopping anticoagulants often outweighs the surgical bleeding risk; therefore, discontinuation should be considered only after careful interdisciplinary discussion with the prescribing physician and a thorough risk-benefit analysis tailored to the patient's medical history.

Technique or Treatment

The paramedian forehead flap is an axial flap based on the supratrochlear artery. However, results from recent studies have suggested that it can survive as a random flap due to the vast network of vascular anastomoses in the midforehead area. While Doppler ultrasound can identify the supratrochlear artery, surgeons may choose not to use an ultrasound and instead locate the artery based on anatomic landmarks. Results from cadaver studies have shown that the supratrochlear artery exits the orbit 1.7 to 2.2 cm from the midline, passing deep to the orbicularis oculi muscle and ascending superficial to the corrugator supercilii muscle. This artery then passes medial to the eyebrow and through the frontalis muscle, ascending superiorly in the subcutaneous tissue, 1.5 to 2 cm from the midline. The supratrochlear artery runs toward the scalp within 3 mm of a line drawn from the medial canthus. Other authors have demonstrated the safety of simply taking a pedicle from the glabellar midline to 1.2 cm lateral to the midline.

If more than 50% of an anatomic subunit is involved in the surgical defect, removing the remainder of the subunit is often preferable. A defect template is made, and then tubed gauze or similar material is used to measure the pedicle length needed to reach the defect from the pedicle base. The tube gauze is rotated to the forehead, and the inverted template pattern is marked at the uppermost aspect of the pedicle. From that area, a 1 to 1.5 cm wide pedicle is drawn down to the planned pedicle base. The pedicle can be from the defect's ipsilateral or contralateral side. Using the contralateral side results in a longer distance from the defect. 

The flap is then mobilized with its base at the inferior aspect of the forehead and often around the orbital rim. The forehead donor site is closed primarily, and the broader portion of that defect on the upper forehead may be allowed to heal secondarily. Alternatively, that portion of the donor site may be repaired with a full-thickness skin graft, but final cosmetic results are less optimal. The flap is then thinned distally and secured in the nasal defect with simple interrupted sutures. Hemostasis in the exposed pedicle stalk is controlled with precise electrocoagulation, hemostatic gauze, and aluminum chloride, or Monsel ferric subsulfate may be applied. The pedicle is then loosely wrapped in a nonadherent dressing such as petrolatum-impregnated gauze. Fluffed gauze is then used for absorption and gentle pressure and secured with hypoallergenic tape. Extra gauze may be applied at the base of the pedicle, as bloody oozing is a regular occurrence, especially in the first 24 to 48 hours. Patients should be apprised of this expectation and given extra gauze to apply pressure. Patients are instructed to call the physician if bleeding is heavy or uncontrollable.

The initial dressing can safely be left in place for 1 week, although some surgeons prefer to see the patient back in 1 to 2 days to examine the site and provide a new dressing. In 2 to 3 weeks, the pedicle trunk can safely be excised. Notably, 1 group reported good results when the pedicle was divided at only 1 week.[11] Early flap division is commonly performed in dermatologic surgery, depending on individual patient factors. Early flap pedicle division of 16 days or earlier can be safely considered in select patient populations, particularly in less complex procedures or limited use of cartilage grafts.[12] 

Results from recent studies continue to explore the optimal timing for pedicle division, with some advocating for division as early as 10 to 14 days in well-vascularized flaps, especially when meticulous flap thinning has been performed at the initial stage. This approach aims to reduce the time the patient carries the pedicle, improving social acceptance and potentially speeding up the reconstructive process.[5][13] The base of the pedicle stalk is excised in a fusiform manner to allow primary closure. Another option is to leave a portion of the stalk and then close the defect as an inverted "V," but this method is more prone to thickening, or "pincushioning." The incised portion of the nasal flap is then thinned, excess granulation tissue is resected, and skin edges are "freshened" before the inset of the proximal flap into the defect.

Minor revision procedures may be desired in the coming weeks, and it is best to discuss these revisions as expected parts of the procedure before the initial surgery. Photos from 1 or more prior patients, showing all stages of the procedure, revisions, and postoperative progression, should be available. Examples can also be found in textbooks and online. Rarely, a major revision may be required for concerns regarding structural support and function that cannot be repaired with a minor revision.[14] Extensive patient counseling will be needed to set patient expectations, discuss an additional procedure's emotional and physical recovery time, and review alternative procedural options to determine the best treatment course.

Complications

Bleeding, scar, and infection represent the most common potential complications with paramedian forehead flaps. Careful hemostasis and proper surgical dressings can decrease the risk of significant postoperative bleeding, as can patient avoidance of strenuous activities. Moderate oozing is common from the base of the flap in the first 48 hours, but can usually be controlled with pressure. Scar formation is unavoidable, but it can be minimized with the appropriate surgical techniques. The skin should be precisely approximated, and the flap should be sized and thinned appropriately. The use of the anatomic subunit principle can improve the aesthetic appearance as well. One or more revisions may be required, and the patient should be told this before the surgery. "Pincushioning," wherein the flap contracts at the wound base and results in a firm, round, raised appearance, is more common if the reconstructed defect is round. This is best prevented by adhering to subunit principles and avoiding rounded defects. Should it occur, it is treated with corticosteroid injection, which may require repeated treatment. Should this fail, revision surgery is needed. Sterile technique and preoperative antibiotic administration can minimize the risk of infection.

Necrosis of the flap may rarely occur and is usually due to smoking, overaggressive thinning of the flap, too narrow pedicle, or patient manipulation of the flap. This can often be managed expectantly with minimal debridement. Venous insufficiency presents as a profound purpleish discoloration of the skin and must be rapidly recognized and treated with leeches or serial pinpricks to relieve the venous congestion, or the flap will fail. True arterial insufficiency will present as a doughy-pale flap without capillary refill. This is usually a result of inadvertent arterial injury and often requires revision flap surgery. If this presents early in the postoperative period (postoperative day 0 or 1), it may be due to vasospasm, which can potentially be reversed with the application of nitroglycerin paste; this must be used with great caution in any patient with underlying heart disease. Timely recognition and management of vascular compromise are critical for flap salvage; while systemic anticoagulation and vasodilators may be considered in severe cases, their utility must be weighed against bleeding risks.

Clinical Significance

The paramedian forehead flap provides a well-vascularized option for covering distal nasal and intranasal surgical defects that are too extensive or deep to be repaired with local flaps or skin grafts. This flap is highly useful alone or in combination with other techniques to repair select defects, offering superior aesthetic and functional outcomes for complex nasal reconstruction.

Enhancing Healthcare Team Outcomes

A common potential problem with the paramedian forehead flap is postoperative bleeding, particularly in the first 48 hours. This most often arises from the proximal aspect of the flap pedicle and glabella, areas rich in vascularity. Expertise in hemostasis and bandaging is required to minimize the risk of this occurrence. Careful, precise electrocoagulation must be performed at the end of the procedure.

Then, hemostatic agents such as cellulose gel mesh and/or Monsel ferric subsulfate solution can be applied to the flap's proximal pedicle. An absorbent dressing under moderate—not excessive—pressure is then applied over the flap, particularly over the proximal aspect. While this dressing may remain in place for one week, it is often prudent to have the patient return within 48 hours for a dressing change and evaluation of the surgical site. After this period, there is much less chance of postoperative bleeding or complications.

Nursing, Allied Health, and Interprofessional Team Interventions

Optimal patient-centered care for forehead flaps—often used in nasal and facial reconstruction—requires a coordinated, multidisciplinary approach. Surgeons must demonstrate advanced technical skill in flap design, elevation, inset, and an understanding of vascular anatomy to preserve flap viability. Advanced clinicians and nurses are critical in perioperative planning, wound care, and early detection of complications such as flap congestion or necrosis. Pharmacists contribute by ensuring appropriate perioperative antibiotic prophylaxis, pain control regimens, and anticoagulation management when indicated. An effective strategy includes preoperative counseling to set realistic expectations, meticulous intraoperative execution, and structured postoperative monitoring protocols to optimize healing and aesthetic outcomes while minimizing risks.

Interprofessional communication is essential throughout the care continuum. Surgeons should provide clear operative plans and anticipated postoperative needs to the entire team, while nurses and advanced clinicians relay bedside observations promptly to facilitate timely interventions. Pharmacists should collaborate with prescribers to adjust medications based on comorbidities, potential drug interactions, and wound-healing considerations. Coordinated follow-up schedules, shared documentation, and multidisciplinary case reviews ensure continuity of care. This integrated approach improves patient safety and surgical success, strengthens team performance, and reinforces trust between the healthcare team and the patient.

Nursing, Allied Health, and Interprofessional Team Monitoring

Postoperative monitoring is critical, and nursing staff should assess the flap for color, temperature, capillary refill, and turgor, as these are key indicators of vascularity. Any dusky, pale, or excessively edematous appearance warrants surgical consultation. Close attention should also be paid to the donor site for signs of hematoma or infection. Patients should be educated on self-monitoring for excessive bleeding, pain, or foul odor from the surgical site. Regular photographic documentation can aid in tracking flap viability and healing progression. Long-term follow-up by nursing and allied health professionals can address cosmetic concerns, manage potential complications like pincushioning or scarring, and provide psychological support throughout the reconstructive journey.