Tunneled paramedian forehead flap for a composite nasal sidewall to medial cheek defect

INTRODUCTION

The concept of cosmetic units typically informs the approach to facial reconstruction. First discussed in 1954, Gonzalez-Ulluoa et al., suggested that respecting the natural boundaries of facial subunits helps to camouflage subsequent scarring.¹ Combination defects that abut or cross these boundaries present a reconstructive challenge. Rather than attempting to repair composite defects with a single approach, it is generally recommended to divide the cosmetic units with multiple closures for optimal functional and cosmetic outcomes.

With aesthetic importance and prominence, reconstruction of combination defects involving the nasal sidewall, medial canthus, and medial cheek requires careful planning and precise approximation to avoid cicatricial ectropion and blunting of the nasofacial sulcus. Deep defects in this area, as seen in this case, are often also affected by poor vascularization and benefit from repairs that ensure robust vascular supply.

CASE REPORT

A 92-year-old woman presented to dermatology with a 1.5 cm pink nodule involving the left medial cheek that approached the nasal sidewall and medial canthus, and an 8 mm pink papule involving the left lateral cheek [Figure 1]. Shave biopsy of both lesions revealed nodular basal cell carcinomas (BCC). The patient was referred to Mohs micrographic surgery for treatment; the medial lesion was removed in 2 stages, resulting in a 2.5 cm defect, while the lateral lesion was removed in 1 stage, resulting in a 1.2 cm defect. Both defects extended into the deep subcutaneous tissue.

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Figure 1:

Left medial cheek just inferior to nasojugal fold with 1.5 cm pink nodule (red) and lateral cheek with 8 mm pink papule (blue).

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After tumor resection, a tunneled paramedian forehead flap reconstruction was planned and prepared for the medial defect. The defect was measured and templated onto the ipsilateral forehead to include the supratrochlear artery, which was identified using a Doppler ultrasound. Local anesthesia was achieved using 0.5% lidocaine without epinephrine around the circumference of the templated pedicle, and the site was prepared in routine sterile surgical fashion.

The flap was subsequently raised in the subcutaneous plane and the pedicle rose in the subgaleal plane until 1 cm superior to the eyebrow, at which time the pedicle was transitioned to the subperiosteal plane, taking care to preserve the supratrochlear artery. The portion of the flap to be buried was marked and subsequently de-epithelialized to avoid the formation of inclusion cysts. The flap was then wrapped in moist, sterile gauze until inset. A tunnel was incised through the frontalis muscle from the pedicle base to the nasal sidewall using blunt-tipped surgical instruments to avoid damage to nearby structures. The flap was rotated and brought through the tunnel using non-toothed forceps, and the distal portion of the flap was placed into the primary defect with minimal tension. Running epicuticular suture was used to secure the flap; the secondary defect was repaired in a layered fashion [Figure 2]. Finally, the lateral defect was closed with a complex linear closure.

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Figure 2:

Immediately after suturing of the primary and secondary defects of the tunneled paramedian forehead flap.

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The patient returned for wound checks on postoperative days 1, 2, and 5 with minimal bleeding that was managed using butterfly bandages. At 3-month follow-up, the patient demonstrated well-healed scars with excellent cosmesis and avoidance of ectropion [Figure 3].

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Figure 3:

At 3-month follow up, patient demonstrated excellent functional and cosmetic outcomes.

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DISCUSSION

BCC is the most common skin cancer worldwide, with up to 80% of tumors occurring on the head and neck.² Importantly, tumor recurrence is significantly more common in high-risk locations, namely the mask areas of the face, and the majority of BCCs are found on patients aged 80 years and up.^3,4 Between 1990 and 2021, the incidence of BCC in the United States amongst adults aged 60 years and above rose 345% and is expected to continue increasing.⁵ These trends emphasize the importance of reconstruction methods for skin cancer surgeries that are appropriate for an aging population but still maintain function and aesthetics. As seen in this case, challenging composite defects require special attention to respect multiple facial subunits, in addition to concerns of vascular supply when the defect extends into the deep subcutaneous tissue.

Deep composite defects involving the nasal sidewall, medial cheek, and/or medial canthus can be approached using a variety of techniques. Variations on a medial cheek advancement paired with a full-thickness skin graft for the nasal sidewall have been well described.^6,7 Similarly, a 2-stage 2-flap approach to reconstruct the individual cosmetic units could be considered in a “like for like” fashion; an example of this option could include a glabellar transposition flap for the nasal sidewall and a V-Y advancement flap for the cheek.⁷ Nonetheless, further complicating this repair was the concurrent defect on the lateral portion of the ipsilateral cheek. While the mentioned repairs would have addressed the medial defect, they would have risked stretching and compromising the tension vectors affecting the lateral defect. Similarly, an advancement-rotation flap could have been considered for the medial defect, but such repairs invite the possibility of a flattened nasofacial sulcus, require significant undermining, result in a large scar, and may have risked the integrity of the lateral closure. Although primary closure is typically preferred for small lesions, it would not be ideal here given the risk of tension on the inferior eyelid and subsequent cicatricial ectropion.

The single-stage tunneled paramedian forehead flap has cosmetic and functional advantages compared to the above and is a useful technique for defects in this challenging location because it can achieve excellent skin texture and contour matching and ensure reliable vascular supply while avoiding the morbidity of a skin graft or a 2-stage approach. For patients facing ambulation, home wound care, and/or healthcare accessibility issues, minimizing morbidity is a critical part of creating patient-centered surgical plans. In addition, because this tunneled flap does not rely on medial movement of the cheek, it preserves the cheek for a low-tension closure of the lateral defect.

Surgical defects along the entirety of the nasofacial sulcus - from the medial canthus and eyelid down to the nasal tip - have been successfully repaired using the tunneled paramedian forehead flap, demonstrating its utility, versatility, and robust vascularization.^8,9 Complication rates with this approach are low thanks to its axial design; minimizing tension, avoiding excessive thinning, and ensuring the pedicle’s base width is at minimum 1 cm further decreases the rate of flap failure. A trapdoor effect can be avoided by reducing the flap size by 20–25% compared to the primary defect.¹⁰ Moreover, while burying the vascular pedicle along the dorsum of the nose is technically demanding, the tunnel provides a more direct course towards the defect and an overall more elegant, efficient repair. Care to not fold the pedicle must be employed to protect vascular irrigation from the supratrochlear artery. Buried melolabial and glabellar flaps have also been applied to similar defects along the nose and nasofacial sulcus with excellent results.¹⁰

CONCLUSION

Tunneled paramedian forehead flaps can be used to reconstruct composite defects along the nasofacial sulcus with excellent results. Conveying less morbidity compared to multi-stage repairs, single-stage tunneled island flaps are good options for elderly patients and those with barriers to medical care.