Videos of Surgical Procedures in Dermatology
The Single-Stage Paramedian Forehead Flap
Colgajo paramedial frontal en un tiempo quirúrgico
A. Martinez-Lopez
, I. Perez-Lopez, E. Garcia-Dura, J. Tercedor-Sanchez
Corresponding author
Unidad de Gestión Clínica de Dermatología, Complejo Hospitalario Universitario de Granada, Granada, Spain
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Martinez-Lopez, I. Perez-Lopez, E. Garcia-Dura, J. Tercedor-Sanchez" "autores" => array:4 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Martinez-Lopez" "email" => array:1 [ 0 => "antoniomartinezlopez@aol.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "I." "apellidos" => "Perez-Lopez" ] 2 => array:2 [ "nombre" => "E." "apellidos" => "Garcia-Dura" ] 3 => array:2 [ "nombre" => "J." "apellidos" => "Tercedor-Sanchez" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Unidad de Gestión Clínica de Dermatología, Complejo Hospitalario Universitario de Granada, Granada, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Colgajo paramedial frontal en un tiempo quirúrgico" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The paramedian forehead flap, described by Millard in 1974,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> was proposed as an alternative to the axial median forehead flap, which had been used for several decades for the reconstruction of large defects of the tip, dorsum, and ala of the nose. The paramedian forehead flap is an excellent alternative for reconstruction of these areas of the nose, as it provides a large volume of cutaneous tissue with good viability.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> Traditionally, this flap has been performed in a 2-stage procedure, sectioning the dissected pedicle 3 weeks after the initial operation,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> although performing this technique in 3 stages has been studied for large defects, finding no differences in the necrosis rates.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> One of the drawbacks of this flap is the need to perform delayed reconstruction, with a significant increase in surgical costs and in patient discomfort. To avoid the disadvantages associated with the traditional technique, and following the modification put forward in 2002 by Park,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> we propose performing a paramedian forehead flap in a single operation, with a buried pedicle passing along the dorsum of the nose.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Description of the Technique</span><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a patient with a sclerodermiform basal cell carcinoma measuring 4.5<span class="elsevierStyleHsp" style=""></span>cm in its longest diameter, localized on the tip of the nose, with partial invasion of both alae nasi. Prior to surgery, the right supratrochlear artery was identified using a portable Doppler device in the operating room, and the flap was designed. Flap length was measured to avoid tension and to facilitate an adequate blood supply, and the foreseen shape of the nasal defect was reproduced at the distal end of the donor region. Tumescent anesthesia was then applied to the perilesional area and to the area of the flap. The anesthetic solution was formed of a mixture of 20<span class="elsevierStyleHsp" style=""></span>ml of 2% mepivacaine, 10<span class="elsevierStyleHsp" style=""></span>ml of 1% bupivacaine with epinephrine, and 2<span class="elsevierStyleHsp" style=""></span>ml of 1 molar bicarbonate in 100<span class="elsevierStyleHsp" style=""></span>ml of normal saline. The use of buffered anesthesia with a vasoconstrictor aids hemostasis, reduces pain on injection of the solution, and does not increase the risk of necrosis. After anesthesia, the tumor was excised with a 3<span class="elsevierStyleHsp" style=""></span>mm surgical margin. The initial incision was performed with a disposable no.<span class="elsevierStyleHsp" style=""></span>15 scalpel, followed by dissection using Stevens scissors, with meticulous hemostasis by electrocautery and ligature of vessels using a fast-absorbing 3/0 suture material. We then dissected the flap, with the pedicle following the path of the previously localized right supratrochlear artery. In order to avoid the formation of inclusion cysts, we removed the epidermis from the part of the pedicle of the flap that was to be buried along the dorsum of the nose. Using Stevens scissors, a tunnel was then fashioned along the dorsum of the nose, starting from the base of the pedicle. The distal end of the flap was passed through the orifice and covered the initial surgical defect without tension. Finally, the flap was sutured in place with 5/0 silk.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Histology confirmed the diagnosis of sclerodermiform basal cell carcinoma and that the borders were free of tumor. The cosmetic result 10 weeks after surgery was good.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Indications</span><p id="par0020" class="elsevierStylePara elsevierViewall">This technique is suitable for tumors that affect a large part of the tip of the nose, with extension onto the dorsum of the nose or alae nasi.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Advantages</span><p id="par0025" class="elsevierStylePara elsevierViewall">The single-stage variant of the paramedian forehead flap with a pedicle buried along the dorsum of the nose, gives us the possibility to close a large surgical defect of the external nose in a single operation without the need for skin grafting, reducing the morbidity associated with the 2-stage technique.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Complications</span><p id="par0030" class="elsevierStylePara elsevierViewall">The single-stage paramedian forehead flap technique is a safe procedure that does not usually give rise to major postoperative complications. The main complications can occur during the de-epidermization process, due to the risk of sectioning the pedicle on removing the epidermis with the scalpel. Likewise, it is important to perform meticulous hemostasis during all phases of the operation in order to avoid the formation of edema in the nasal tunnel, as this could lead to flap necrosis due to supratrochlear artery compression or damage.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="par0035" class="elsevierStylePara elsevierViewall">The aim of oncologic dermatologic surgery is correct excision of tumor lesions in as few operations as possible, with the best cosmetic result. Use of the paramedian forehead flap procedure with a buried pedicle enables us to cover a large surgical defect of the nose in single operation, with a good cosmetic result.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conflicts of Interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Description of the Technique" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Indications" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Advantages" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Complications" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Conclusions" ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of Interest" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Martinez-Lopez A, Perez-Lopez I, Garcia-Dura E, Tercedor-Sanchez J. Colgajo paramedial frontal en un tiempo quirúrgico. Actas Dermosifiliogr. 2017;108:867–868.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0050" class="elsevierStylePara elsevierViewall">Display e-component<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0045" ] ] ] ] "multimedia" => array:1 [ 0 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc1.mp4" "ficheroTamanyo" => 56815359 "Video" => array:2 [ "mp4" => array:5 [ "fichero" => "mmc1.m4v" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "flv" => array:5 [ "fichero" => "mmc1.flv" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Reconstructive rhinoplasty for the lower half of a nose" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "D.R. 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Menick" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.cps.2009.02.015" "Revista" => array:6 [ "tituloSerie" => "Clin Plast Surg" "fecha" => "2009" "volumen" => "36" "paginaInicial" => "443" "paginaFinal" => "459" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19505613" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A cohort study of paramedian forehead flap in 2 stages (87 flaps) and 3 stages (100 flaps)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "A. Santos Stahl" 1 => "W. Gubisch" 2 => "H. Fischer" 3 => "S. Haack" 4 => "C. Meisner" 5 => "S. Stahl" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/SAP.0000000000000209" "Revista" => array:6 [ "tituloSerie" => "Ann Plast Surg" "fecha" => "2015" "volumen" => "75" "paginaInicial" => "615" "paginaFinal" => "619" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25003405" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The single-stage forehead flap in nasal reconstruction: An alternative with advantages" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "S.S. 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| 2022 July | 77 | 51 | 128 |
| 2022 June | 23 | 26 | 49 |
| 2022 May | 63 | 41 | 104 |
| 2022 April | 93 | 34 | 127 |
| 2022 March | 90 | 52 | 142 |
| 2022 February | 96 | 24 | 120 |
| 2022 January | 119 | 40 | 159 |
| 2021 December | 74 | 36 | 110 |
| 2021 November | 81 | 49 | 130 |
| 2021 October | 87 | 44 | 131 |
| 2021 September | 64 | 45 | 109 |
| 2021 August | 68 | 34 | 102 |
| 2021 July | 45 | 24 | 69 |
| 2021 June | 41 | 25 | 66 |
| 2021 May | 52 | 41 | 93 |
| 2021 April | 95 | 101 | 196 |
| 2021 March | 72 | 31 | 103 |
| 2021 February | 71 | 37 | 108 |
| 2021 January | 50 | 29 | 79 |
| 2020 December | 39 | 19 | 58 |
| 2020 November | 36 | 26 | 62 |
| 2020 October | 39 | 17 | 56 |
| 2020 September | 31 | 15 | 46 |
| 2020 August | 36 | 33 | 69 |
| 2020 July | 56 | 21 | 77 |
| 2020 June | 37 | 30 | 67 |
| 2020 May | 19 | 9 | 28 |
| 2020 April | 36 | 18 | 54 |
| 2020 March | 26 | 17 | 43 |
| 2020 February | 5 | 0 | 5 |
| 2020 January | 4 | 0 | 4 |
| 2019 December | 8 | 0 | 8 |
| 2019 November | 4 | 0 | 4 |
| 2019 September | 13 | 0 | 13 |
| 2019 August | 4 | 0 | 4 |
| 2019 July | 3 | 0 | 3 |
| 2019 June | 6 | 0 | 6 |
| 2019 May | 4 | 1 | 5 |
| 2019 March | 2 | 0 | 2 |
| 2019 January | 2 | 0 | 2 |
| 2018 December | 1 | 0 | 1 |
| 2018 November | 1 | 0 | 1 |
| 2018 October | 6 | 0 | 6 |
| 2018 September | 10 | 0 | 10 |
| 2018 February | 36 | 7 | 43 |
| 2018 January | 39 | 6 | 45 |
| 2017 December | 36 | 13 | 49 |
| 2017 November | 66 | 36 | 102 |
| 2017 October | 5 | 5 | 10 |
| 2017 September | 2 | 7 | 9 |
Show all
