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Nasal Reconstruction Forehead
Flap in a Patient
With Recurrent Basal Cell Carcinoma ( Skin Cancer )
This is a commonly used flap with a
good blood supply. The end cosmetic result is usually good. The
biggest disadvantage is that two operations are required and the
patient must live for several weeks with a flap pedicle over his
face. The blood supply to the forehead flap is by the supraorbital
and supratrochlear artery, both are branches of the opthalmic artery
and are of the internal carotid artery system. This flap may have a
very large length to width ratio. The surgeon must be careful not
to create a defect which is too wide and prevents closure of the
forehead donor site. Flaps wider than 2.5 cm will often create
donor sites which cannot be closed primarily.
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The patient had a large nasal defect created by Mohs surgery for resection of a recurrent basal cell carcinoma.
The donor defect is sewn with a combination of a 3-0 chromic stitch for fascia and 5-0 and 4-0 nylon stitch for skin.
Before closure the fascia (frontalis muscle and fascia) is widely undermined and separated from the periosteum. Closure of this fascia plane is important since it takes stress off of the skin and helps prevent skin necrosis.
The patient had a large nasal defect created by Mohs surgery for resection of a recurrent basal cell carcinoma.
A forehead flap with a width of 2.25 cm is outlined on the forehead.
The patient had a large nasal defect created by Mohs surgery for resection of a recurrent basal cell carcinoma.
The flap is sewn into position.
Notice how the flap is flat as it covers the nose. This portion of the flap will swell and become distended with tissue edema.
The patient had a large nasal defect created by Mohs surgery for resection of a recurrent basal cell carcinoma.
The donor defect is sewn with a combination of a 3-0 chromic stitch for fascia and 5-0 and 4-0 nylon stitch for skin.
Before closure the fascia (frontalis muscle and fascia) is widely undermined and separated from the periosteum. Closure of this fascia plane is important since it takes stress off of the skin and helps prevent skin necrosis.
The patient had a large nasal defect created by Mohs surgery for resection of a recurrent basal cell carcinoma.
The triangular defect is filled with Adaptic and the flap is coated with ointment.
If the forehead donor defect is closed too far down it tends to pull up the ipislateral eyebrow.
Antibiotic ointment is applied to the wound.
The patient had a large nasal defect created by Mohs surgery for resection of a recurrent basal cell carcinoma.
Seven days post-op Stage 1 surgery.
The patient had a large nasal defect created by Mohs surgery for resection of a recurrent basal cell carcinoma.
Seven days post-op Stage 1 surgery. Note the slight swelling of the flap. 
The patient had a large nasal defect created by Mohs surgery for resection of a recurrent basal cell carcinoma.
Ten days post-op Stage 1 surgery. Note the slight swelling of the flap. 
The patient had a large nasal defect created by Mohs surgery for resection of a recurrent basal cell carcinoma.
Ten days post-op Stage 1 surgery. Note the swelling of the flap. 
The patient had a large nasal defect created by Mohs surgery for resection of a recurrent basal cell carcinoma.
15 days post-op Stage 1 surgery.
The patient is instructed to train the flap by placing pressure on the pedicel to temporarily cut off its blood supply. This is starting at 5 mins and progresses to 15 mins. It is performed four times a day. If the flap changes color significantly, then the training is immediately discontinued. 
The patient had a large nasal defect created by Mohs surgery for resection of a recurrent basal cell carcinoma.
21 days post-op Stage 1 surgery. The triangular defect is filled with granulation tissue and is almost closed. The flap is starting to form a tube. Note that the left eyebrow is being pulled up with wound contraction. 
The patient had a large nasal defect created by Mohs surgery for resection of a recurrent basal cell carcinoma.
Second Stage Surgery, 22 days after the First Stage of the reconstruction.
The patient had a large nasal defect created by Mohs surgery for resection of a recurrent basal cell carcinoma.
Second Stage Surgery, 22 days after the First Stage of the reconstruction.
The pedicel is cut.
The patient had a large nasal defect created by Mohs surgery for resection of a recurrent basal cell carcinoma.
Second Stage Surgery, 22 days after the First Stage of the reconstruction.
The flap is shaped to fit the donor defect and the proximal portioned is debulked to make it thinner.
Note that the distal portion is swollen in marked comparison to the flatness of the flap when it was first laid into position.
The patient had a large nasal defect created by Mohs surgery for resection of a recurrent basal cell carcinoma.
Second Stage Surgery, 22 days after the First Stage of the reconstruction.
The granulation tissue in the triangular defect is resected and the tissues undermined. Care is taken to return the eyebrow to its proper position. 
The patient had a large nasal defect created by Mohs surgery for resection of a recurrent basal cell carcinoma.
Second Stage Surgery, 22 days after the First Stage of the reconstruction.
Antibiotic ointment is applied to the wound. 
The patient had a large nasal defect created by Mohs surgery for resection of a recurrent basal cell carcinoma.
One days post-op Stage 2 surgery.
The patient had a large nasal defect created by Mohs surgery for resection of a recurrent basal cell carcinoma.
Seven days post-op Stage 2 surgery.
The patient had a large nasal defect created by Mohs surgery for resection of a recurrent basal cell carcinoma.
48 days post-op Stage 2 surgery. Note the increased swelling of the donar site and of the nasal flap.
The patient had a large nasal defect created by Mohs surgery for resection of a recurrent basal cell carcinoma.
Twelve weeks post-op Stage 2 surgery. Note the swelling of the donar site and of the nasal flap is starting to decrease.
The patient had a large nasal defect created by Mohs surgery for resection of a recurrent basal cell carcinoma.
Twenty weeks post-op Stage 2 surgery. Note the swelling of the flap has persisted. The swelling may still decrease over the ensuing months. If it does not, the flap may need debulking.
The patient had a large nasal defect created by Mohs surgery for resection of a recurrent basal cell carcinoma.
Twenty weeks post op Stage 2 surgery. Note the swelling of the flap has persisted. The swelling may still decrease over the ensuing months. If it does not, the flap may need debulking.
