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Long Term Outcomes of Nasal Reconstruction Using the Expanded Forehead Flap: 45 Consecutive Cases
Gaurav Bharti, MD, Louis Argenta, MD, Anthony Defranzo, MD, James Thompson, MD, Joseph Molnar, MD, Lisa David, MD, Malcolm Marks, MD.
Wake Forest University Baptist Medical Center, Winston Salem, NC, USA.
PURPOSE: In its central location, the nose provides important aesthetic and functional value to the human face. Nasal deformities can occur secondary to resection of cutaneous neoplasms, trauma, burns, and congential defects. These deformities can present more than just an aesthetic challenge but a functional one as well. Therefore the goal of reconstruction must be to address both the aesthetic outcome and the functionality of the reconstructed nose, while limiting donor site morbidity. The forehead flap has been a reliable and time tested donor site for such a reconstruction. However, in some circumstances the classic forehead flap may not provide enough tissue for reconstruction without resulting in an open wound or skin graft on the forehead. With the use of an expanded forehead flap, the donor flap size can be maximized, while minimizing the morbidity of the donor site. Utilizing the expanded forehead flap with a rigid underlying framework, one can create a large, thin, and pliable skin envelope that resists contracture after inset. We present our experience of total nasal reconstruction with the expanded forehead flap technique.
METHODS: This IRB approved retrospective study included a consecutive series of forty-five patients over a twenty five year period (1985-2010) that underwent nasal reconstruction with the expanded forehead flap technique. All patients underwent a three-stage procedure. Information obtained from chart review included age, gender, etiology of nasal defect, past medical history, complications, and aesthetic outcomes of the reconstructed nose and donor site. Our follow up time ranged from 1 to 23 years.
RESULTS: We performed forty-five nasal reconstructions with expanded forehead flaps between 1985 and 2010. There were forty adults, and five children. All patients tolerated the staged procedures well, and all expanded forehead flaps survived after rotation. All donor sites were closed primarily after transposition of the forehead flap. There were no reports of significant shrinkage or contracture formation requiring reoperation in any of the cases. With the exception of a single patient, all patients required at least one minor revision after inset. Complications included mild columellar retraction in three patients, nostril stenosis in four patients, exposure of the cantilevered bone graft requiring operative repair in three patients, and one infection which was controlled with debridement and oral antibiotics. All patients reported a high level of functional and aesthetic satisfaction.
CONCLUSION: We conclude that the expanded forehead flap is a reliable option in nasal reconstruction with minimal donor site morbidity. The expanded flap provides a thin pliable skin envelope with a very high success rate and excellent longevity. Utilizing a rigid underlying framework with a cantilever bone or cartilage graft, the expanded forehead flap for nasal reconstruction retains its contour and does not retract.
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