Two flag flaps based on the supratrochlear vessels for nasal reconstruction

A short forehead or a low hairline sometimes precludes the use of a median forehead flap for reconstruction of defects of the lower nose when both lining and cover are needed. Two flag flaps based on the supratrochlear vessels were used in a patient with a full-thickness alar defect and a narrow, short forehead.     

The pedicled lateral forehead flap in reconstructing oral floor defect - The last resort; case report

Introduction and importanceLocoregional flaps, particularly the pedicled lateral forehead flap, are not usually used in reconstructing oral floor defects following oncologic resection. Rather, microscopic free flaps have evolved to be the standard of care in head and neck reconstruction. However, the pedicled lateral forehead flap could be valuable in floor of the mouth reconstruction in the absence of resources or other options.Case presentationA-56 years old lady with multiple comorbidities who underwent near total glossectomy, bilateral supraomohyoid neck dissection, and right lateral mandibulotomy due to a locally advanced lingual squamous carcinoma. The last resort was the pedicled lateral forehead flap after many unsuccessful reconstructive attempts utilizing the free anterolateral flap, free radial forearm flap, and pedicled pectoralis major flap.Clinical discussionDecreased donor site morbidity and reliable anatomy are among many of the advantages that made free flaps favorable over locoregional pedicled flaps, especially in oral cavity defects coverage. Of the latter, the pedicled forehead flap, rich in vascularity and neighboring the oropharyngeal defects, could be used with different techniques and modifications. Close monitoring and patient condition optimization is required.ConclusionChoosing a particular reconstructive option should be done considering the available resources and expertise and the patient's condition. The pedicled forehead flap remains valuable when other options are inappropriate or have failed.     

A pedicled split extended vertical deep inferior epigastric (s-vDIEP) flap and an adipo-dermal thigh local flap for the reconstruction of the medial thigh compartment after sarcoma resection: A case report

Large upper medial thigh defects in prior irradiated tissue require challenging reconstructions. Several techniques have been reported to reconstruct this region and according to the literature, pedicled perforator flaps are the first reconstructive option. The anterolateral thigh flap is considered the gold standard, while surprisingly the pedicle deep inferior epigastric (DIEP) flap in vertical fashion has not been frequently employed, if compared with its muscular counterpart, the pedicle vertical rectus abdomins flap (vRAM). We report a case of a multilayered flaps reconstruction of the left medial thigh after an excision of a sarcoma involving the whole adductors compartment. A 75-year-old male patient underwent a free margins resection of the sarcoma. After the resection, a soft tissue defect of 24 cm × 14 cm × 14 cm spreading from the groin to the medial tuberosity of the tibia, was left. We performed a reconstructive technique based on a pedicled split extended vertical deep inferior epigastric (s-vDIEP) flap and an adipo-dermal thigh local flap in order to fill and cover the thigh defect. The s-vDIEP had 2 islands: a cranial de-epithelialized island to fill the dead space and a caudal for the skin closure. The postoperative follow-up was complicated by seroma formation and it was managed by sclerotherapy and at the 6 months follow-up the patient showed good cosmetic and functional outcomes with no sign of tumor relapse. Our result suggests that the proposed multilayered reconstruction may be employed for the restoration of large and deep upper medial thigh defects.     

Aesthetic pubic reconstruction after electrical burn using a portion of hair-bearing expanded free-forehead flap

Background  Electrical burn in the pubic region usually results in a severe and contractive scar with pubic hair loss. The aesthetic restoration of this area often has become very difficult. Methods  A 22-year-old male electrical engineer experienced severe pubic scarring with hair loss after electrical burn. He was treated successfully with an expanded free-forehead flap including a portion of hair-bearing scalp after microsurgical vascular anastomoses between the bilateral superficial temporal vessels and the bilateral deep inferior epigastric vessels. The donor forehead site was closed directly in the frontal hairline without visible scarring. Results  The pubic area was repaired functionally and cosmetically with the flap, and the pubic hair was growing well after a 1-year following-up period. Conclusions  This successful case strongly indicates that a microsurgical tissue transfer can be a good option for reconstruction of a pubic defect and that the expanded forehead flap could fulfill the high cosmetic demands of pubic reconstruction with minimal donor morbidity.     

The extended brow lift: the toucan technique

Brow ptosis is the main consequence of aging in the upper third of the face. Many methods have been described to correct it: skin excisions of the brow hairline, skin excisions of the forehead natural creases, skin trimmings of the temporal, coronal, or forehead hairline flaps, and endoscopic methods [1,15,17,18,24,26,27]. The authors created a procedure which is based on a forehead-temporal subcutaneous flap and a muscular relocation. It treats the brow ptosis and its surrounding area—temporal ptosis, upper and lower lateral eyelid ptosis, crow's feet—and at the same time improves the sclera show or ectropion. The method preserves the sideburn and the temporal hairline and can reduce the width between the temporal hairline and the lateral end of the eyebrow. The method produces maximum improvement, with high-quality scars and minimal evidence of surgery. The procedure is called "The Toucan Technique," due to the shape of the skin resection which looks like a toucan bird [11,13,14].     

Utility of the omentum in sacral reconstruction following total sacrectomy due to recurrent and irradiated giant cell tumour of the spine

Reconstruction of the lumbosacral region after surgical excision of irradiated and recurrent spinal giant cell tumours remains a challenging problem. In this case report, we describe the use of the pedicled omentum flap in reconstruction of an irradiated and infected wide sacral defect of a 19-year-old male patient. The patient had radiotherapy and subsequent wide surgical resection after recurrence of the tumour. A myocutaneous flap from the gluteal area had failed previously. Local flap options could not be used because of the recent radiotherapy to the gluteal area. Since the patient had a laparotomy for tumour resection and a colostomy, abdominal muscles were not considered reliable for reconstructive procedures. A pedicled omentum flap was chosen as a reconstructive option because of its rich blood supply, large surface area, and angiogenic capacity. This report aims to describe the use of the pedicled omentum flap for reconstruction of the lumbosacral area following surgical resection of a spinal tumour, when gluteal and abdominal flap options for reconstruction are jeopardised.KEY WORDS: Omentum flap, radiotherapy, reconstruction, sacral tumour     

Reconstruction of a large pelvic defect by transfer of a quadruplet combination of pedicled flaps from the medial thigh using bilateral muscular gracilis flaps and bilateral vertical posteromedial thigh (vPMT) propeller flaps—A case report

The reconstruction of defects of the perianal area and vagina places a high demand on a reconstructive surgeon. Different reconstructive methods include a skin graft, a local skin flap, a musculocutaneous flap, and a pedicled perforator flap. Here, we report the case of a 59-year-old female patient with a pelvic defect, who underwent reconstruction with a quadruplet combination of pedicled flaps from the medial thigh, due to an extensive resection of a recurrence of a squamous cell carcinoma of the anus, vulva, and partially the colon. The surgical oncologist performed a rectum amputation, a partial colectomy, a complete hysterectomy, and a resection of the dorso-lateral vaginal vault in order to achieve tumor-free margins. The resulting defect measured 14 × 11 cm² with 8 cm of deep space. The defect was covered and reconstructed by employing a bilateral pedicled gracilis muscle flap rotated about 120° and advanced to fill up the residual spare space in the deep and a bilateral vertical posteromedial thigh (vPMT) using a propeller flap measuring 27 × 10 cm² rotated 180° in order to reconstruct the vagina and the perianal area. All flaps survived without major post-operative complications. The donor site morbidity was minimal. The range of motion was not limited over both hip and knee joints. Patient had no problem with urination. Sexual intercourse was not highly considered due to patient's old age. The follow-up at 6 months showed acceptable cosmetic results with a satisfying contour of the coverage and reconstructed area. The combination of pedicled gracilis muscle flap and vPMT propeller flap may represent a valuable option in such a defect where deep space obliteration and reconstruction of the vagina with perianal contouring are needed.     

Butterfly reconstruction of the anterior scalp hairline using bilaterally apposing STA island flaps

Traditional methods of reconstruction of the hair-bearing scalp can provide incorrect directional hair growth and may require secondary procedures to complete. We present a case of reconstruction of the anterior hairline after tumour resection in an infant. Lessons learned from the case have led to a novel method for a single stage reconstruction of the anterior hairline using pedicled superficial artery flaps.     

Four parallel flaps for correction of a wide forehead defect

A simple method for closure of a defect in the forehead area by four parallel flaps along the forehead wrinkle lines is illustrated. The main advantage of this method lies in its simple design, which enables the surgeon to close large defects with no elevation of the eyebrow, while preserving the hairline, and most of the suture lines are parallel to the forehead wrinkle lines.     

Eyebrow island flap for reconstruction of a partial eyebrow defect

A diverse variety of methods for reconstructing eyebrow defects has been described previously, and each procedure has inherent advantages and disadvantages. The authors present a case of reconstruction of a partial eyebrow defect using two eyebrow island flaps, which are modifications of the subcutaneous pedicle flap.     

A case report of chest wall reconstruction utilizing microvascular surgery

A 62-year-old man underwent left chest wall reconstruction after resection of the chest wall including 4-6th ribs for the metastatic tumor of squamous cell carcinoma of the left lung. The chest wall defect measuring 15 x 10 cm was reconstructed with double Marlex mesh in skeletal chest and covered with pedicled free mucocutaneous flap of tensor fasciae latae which was implanted by the vascular anastomoses to the thoracodorsal artery and vein using microvascular surgical technique. The flap was attached well and its blood supply was excellent on postoperative angiography.     

Repair of Full Thickness Defect of the Nose Using an Expanded Forehead Flap and a Glabellar Flap

We describe a method to repair full thickness defects of the nose using a glabellar flap as the lining of the nasal cavity and an expanded forehead flap for external closure. We consider our method useful in the reconstruction of a nose with a full thickness defect for which the flap donor site is limited. The patient was a 45-year-old man who underwent resection of a basal cell carcinoma located over the dorsum of the nose which was associated with a hemangioma simplex on the face. As a result, about two-thirds of the nose, from the dorsum to the tip, as well as a part of the right cheek became deficient and the right nasal cavity became exposed. The nose was reconstructed using the above-mentioned method. The result was satisfactory both cosmetically and functionally.     

Prefabricated hair-bearing temporal flap for two different facial aesthetic subunits reconstruction: case report

Expanded temporal hair-bearing scalp as a pedicled flap was used to reconstruct the upper lip with a moustache and also the ipsilateral eyebrow, on a patient with an old chemical burn of the face. It is a relatively simple method of providing cover of the upper lip and eyebrow with a good density of hair and a natural hair flow. The results were satisfactory and the donor site morbidity was minimal.     

预扩张额部皮瓣用于鼻再造及修复面部缺损

目的　扩大额部扩张皮瓣应用范围 ,改进鼻再造及面部缺损的修复方法。　方法　对10例鼻缺损伴面部其他部位组织缺损的患者先行额部皮瓣供区预扩张术 ,在二期行扩张皮瓣移位鼻再造术同时修复面部其他部位组织缺损。　结果　治疗 10例鼻缺损及面部组织缺损者 ,疗效满意。行鼻再造的额部扩张皮瓣最大为 8 5cm× 10cm ,最小为 6 5cm× 8cm ;同时行面部缺损修复的额部皮瓣最大为 6cm× 4cm ,最小为 2cm× 6cm。　结论　预扩张额部皮瓣同时用于鼻再造及面部缺损修复是较理想的一种方法 ,可扩大额部扩张皮瓣的应用范围     

Repeated tissue expansion in reconstruction of a huge combined scalp-forehead avulsion injury

A 29-year-old woman sustained a severe combined forehead-scalp avulsion injury (20 X 17 cm) in an automobile accident 4 years ago. The skull was covered with split skin-grafts. The defect was successfully removed by the use of simultaneous and repeated tissue expansion of the normal occipital area and the remains of the forehead. The case illustrates the possibility of using large expander volumes (1,700 cc) in the head area and the fact that even narrow skin bridges (2.0 cm above the left eyebrow) can be expanded. The expander shape can be chosen to create a desired flap size and form. Finally, hair thickness and growth can be quite acceptable even after huge expansions of the scalp.     

Paramedian Forehead Flap Reconstruction for Nasal Defects

Background. The paramedian forehead flap is the ultimate reconstructive method for repair of extensive nasal defects. Changes in technique have resulted in the evolution of the modern-day forehead flap, which is a streamlined, efficient, reliable flap that can be counted on to provide superior function and cosmesis in the reconstruction of large nasal defects.
Objective. Consistent success in the execution of a forehead flap hinges on a careful stepwise approach to the defect, the patient, and the surgical technique. Characterization of these steps was undertaken to assist the surgeon in achieving consistent post- operative results.
Methods. The process of executing a paramedian forehead flap beginning with preoperative assessment through the intraoperative procedure and culminating in the postoperative care is elucidated and discussed.
Results. Through thoughtful planning and correct execution of technique, very large nasal defects are reconstructed, with excellent functional and esthetic results. Specific examples illustrate the range of approaches that can be used to address a variety of nasal tissue loss.
Conclusion. With careful attention to the reconstruction of all components of a nasal defect, a forehead flap can restore virtually any large nasal defect with excellent functional and cosmetic results. The skill sets that help optimize the process of nasal reconstruction are important to acquire. With careful planning and surgical finesse, forehead flaps can often result in nearly imperceptible restoration of the nose.     

Bilateral eyebrow reconstruction using a unilateral extended superficial temporal artery flap

In cases of the bilateral eyebrow reconstruction in men, two superficial temporal artery (STA) flaps are usually designed for both temporal regions according to the flap movable range and the direction of hair growth. Recently, the authors have successfully reconstructed bilateral eyebrows with normal directions of hair growth using a unilateral STA flap, extended by anastomosis of the STA and the occipital artery, with two hair-bearing skin islands. Using this method, the direction of the hair growth can be optimally selected by changing the direction of the skin islands for each eyebrow. The authors were able to reconstruct symmetric eyebrows with the hair growing laterally and a little upward. The invasiveness, bleeding, and operating time required for this method are less than those for the bilateral STA flap method. For cases in which one temporal scalp could not be used, bilateral eyebrow reconstruction remains possible with this method.     

Double Forehead Expanded Flaps for Reconstruction of Total Nasal Defect: A Case Report

ObjectiveTo introduce a method for total nasal defect reconstruction with a double forehead expanded flap.Case presentationA 55-year-old man underwent three-stage total nasal reconstruction for a complete nasal defect due to electrical injury. The skin expander was implanted during the 1st stage. Total nasal reconstruction was performed with double expanded forehead flap transfer during the 2nd stage. The unilateral forehead flap was used for lining and the contralateral forehead flap, together with the autologous cartilage and titanium mesh framework, were used for skin replacement. The forehead donor defect was covered with a skin graft. Pedicle division and inset were performed in the 3rd stage.ResultsThere was no flap loss, infection, hematoma, rhinostenosis, or implant exposure over the 2-year follow-up, and satisfactory aesthetic results were achieved.ConclusionThe double forehead expanded flap method is useful for the reconstruction of large composite nasal defects in patients who are not suitable for nasolabial flaps and those who may not tolerate free tissue transfer. The operation has fewer complications and is uncomplicated.     

Immediate or delayed nasal reconstruction in infant after subtotal amputation? Nasal reconstruction with forehead flap in a 2-year-old child

Nasal reconstruction using the forehead flap is one of the oldest recorded reconstructive procedures. The forehead flap is considered a standard for reconstruction of large defect. Most of reports concerning the forehead flap in nasal reconstructions deal with adults. Nasal reconstruction in infants raises some controversies, and very few articles report nasal reconstruction in the infants. A 15-month-old boy was presented after subtotal nasal amputation, after a dog bite. Microsurgical replantation was performed, but proved unsuccessful. The wound healed with debridement and local care. At age 2, nasal reconstruction was performed with autogenous ear cartilage and forehead flap. The reconstructed nose currently appears to be of good color, texture match, and functional. To our knowledge, few reconstructions of acquired nasal deformities using a forehead flap have been previously reported in infants. This 2-year-old patient may be among the youngest to have undergone this procedure. The forehead flap can be applied in very young children with reasonable expectations of excellent functional and esthetic outcome. Long-term results remain to be seen regarding nasal function and growth.