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
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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. Millard" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Plast Reconstr Surg" "fecha" => "1974" "volumen" => "53" "paginaInicial" => "133" "paginaFinal" => "139" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/4590746" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Usefulness of the paramedian forehead flap in nasal reconstructive surgery: A retrospective series of 41 patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "N. Blázquez-Sánchez" 1 => "I. Fernández-Canedo" 2 => "J.B. Repiso-Jiménez" 3 => "F. Rivas-Ruiz" 4 => "M. De Troya Martín" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Actas Dermosifilogr" "fecha" => "2016" "volumen" => "107" "paginaInicial" => "133" "paginaFinal" => "141" "itemHostRev" => array:3 [ "pii" => "S0365669110003096" "estado" => "S300" "issn" => "03656691" ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Nasal reconstruction with a forehead flap" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "F.J. 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. Park" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Arch Facial Plast Surg" "fecha" => "2002" "volumen" => "4" "paginaInicial" => "32" "paginaFinal" => "36" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11843675" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15782190/0000010800000009/v1_201711021004/S1578219017302731/v1_201711021004/en/main.assets" "Apartado" => array:4 [ "identificador" => "6209" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Videos of Surgical Procedures in Dermatology" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15782190/0000010800000009/v1_201711021004/S1578219017302731/v1_201711021004/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219017302731?idApp=UINPBA000044" ]
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| 2022 Noviembre | 39 | 30 | 69 |
| 2022 Octubre | 32 | 15 | 47 |
| 2022 Septiembre | 35 | 27 | 62 |
| 2022 Agosto | 98 | 39 | 137 |
| 2022 Julio | 77 | 51 | 128 |
| 2022 Junio | 23 | 26 | 49 |
| 2022 Mayo | 63 | 41 | 104 |
| 2022 Abril | 93 | 34 | 127 |
| 2022 Marzo | 90 | 52 | 142 |
| 2022 Febrero | 96 | 24 | 120 |
| 2022 Enero | 119 | 40 | 159 |
| 2021 Diciembre | 74 | 36 | 110 |
| 2021 Noviembre | 81 | 49 | 130 |
| 2021 Octubre | 87 | 44 | 131 |
| 2021 Septiembre | 64 | 45 | 109 |
| 2021 Agosto | 68 | 34 | 102 |
| 2021 Julio | 45 | 24 | 69 |
| 2021 Junio | 41 | 25 | 66 |
| 2021 Mayo | 52 | 41 | 93 |
| 2021 Abril | 95 | 101 | 196 |
| 2021 Marzo | 72 | 31 | 103 |
| 2021 Febrero | 71 | 37 | 108 |
| 2021 Enero | 50 | 29 | 79 |
| 2020 Diciembre | 39 | 19 | 58 |
| 2020 Noviembre | 36 | 26 | 62 |
| 2020 Octubre | 39 | 17 | 56 |
| 2020 Septiembre | 31 | 15 | 46 |
| 2020 Agosto | 36 | 33 | 69 |
| 2020 Julio | 56 | 21 | 77 |
| 2020 Junio | 37 | 30 | 67 |
| 2020 Mayo | 19 | 9 | 28 |
| 2020 Abril | 36 | 18 | 54 |
| 2020 Marzo | 26 | 17 | 43 |
| 2020 Febrero | 5 | 0 | 5 |
| 2020 Enero | 4 | 0 | 4 |
| 2019 Diciembre | 8 | 0 | 8 |
| 2019 Noviembre | 4 | 0 | 4 |
| 2019 Septiembre | 13 | 0 | 13 |
| 2019 Agosto | 4 | 0 | 4 |
| 2019 Julio | 3 | 0 | 3 |
| 2019 Junio | 6 | 0 | 6 |
| 2019 Mayo | 4 | 1 | 5 |
| 2019 Marzo | 2 | 0 | 2 |
| 2019 Enero | 2 | 0 | 2 |
| 2018 Diciembre | 1 | 0 | 1 |
| 2018 Noviembre | 1 | 0 | 1 |
| 2018 Octubre | 6 | 0 | 6 |
| 2018 Septiembre | 10 | 0 | 10 |
| 2018 Febrero | 36 | 7 | 43 |
| 2018 Enero | 39 | 6 | 45 |
| 2017 Diciembre | 36 | 13 | 49 |
| 2017 Noviembre | 66 | 36 | 102 |
| 2017 Octubre | 5 | 5 | 10 |
| 2017 Septiembre | 2 | 7 | 9 |
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