Forehead flap reconstruction

Picture of skin surgeon

Forehead flap reconstruction

The forehead flap has been used for over 2000 years to fix nose wounds, & is still in use today as it is such a versatile operation

What is a forehead flap used for?

A forehead flap is usually used to reconstruct nose wounds, especially after large skin growths such as basal cell carcinomas (BCCs) have been removed, or after an injury that has left large or deep wounds on the nose

How is a forehead flap performed?

As the name suggests, a forehead flap is taken from the forehead. Broadly speaking a cut is made, starting from the inner aspect of the eyebrow near to the nose. The cut is extended up to the hairline, then curves round to come back down to the eyebrow, about 2cm away from the first cut. The skin is then lifted with the underlying fat and some muscle, but kept attached at the eyebrow. This is called the flap, and it is now turned round to reach the wound on the nose.
The flap is stitched in place on the nose, and the forehead wound is closed. Sometimes the upper part of the forehead wound is too tight to close, and this is usually left to heal over the next few weeks.
The forehead flap is kept attached to the eyebrow, as this is how the blood flows in and out of the flap. Over the next 3-4 weeks the flap ‘learns to live’ from the nose, and new blood vessels from the nose grow into the flap skin. At this point, the forehead flap can be divided from the eyebrow as the skin can now survive on the nose.
Sometimes, a cartilage graft is also used under the forehead flap, to help give the nose more strength and shape.

What is a cartilage graft?

A cartilage graft is a piece of cartilage, often taken from the ear or the ribs, that is stitched into the nose to give it more strength and better shape. This can be very important if the nose strength has been lost after skin growth removal or after an injury to an extent that the nostril is closing in and breathing is difficult. The cartilage graft is usually take from the ear through a cut on the front or back, and the shape of the ear only changes very slightly. Sometimes, for larger grafts, rib cartilage can also be used, by taking a piece from where the rib meets the breastbone

What happens while the forehead flap is attached?

The nose, flap and forehead will usually have dressings on them, and over the first few days the wound can ooze a little so the dressings may need changing every few days. This usually stops after 4 or 5 days. Any non-dissolving stitches will usually be taken out after about 5 or 6 days, then it’s a case of just waiting until the 3 or 4 week stage, when the flap is divided.

How is a forehead flap divided?

At the eyebrow, the forehead flap skin is cut free and the wound is stitched closed. At the nose, the flap is thinned and sculpted to try and match the contours of the nose, and stitched in place. Any non-dissolving stitches are removed at 5-6 days. This can often be performed under local anaesthetic (with you awake), but sometimes will be under general anaesthetic (with you asleep)

What is a 3-stage forehead flap?

This is a forehead flap that is performed in 3 stages, and usually for wounds that have gone through to the inside of the nose (full thickness wounds). The first stage is to raise the forehead flap and stitch it in place on the nose, with the end part of the flap being tucked up to close the lining of the nose. After 3-4 weeks the second stage is performed and the nose part of the flap is split, leaving the lining part in place as by now it has ‘learnt to live’ from the nose. A cartilage graft can now be placed to add strength and shape. The flap is stitched back in place for another 3-4 weeks. At the third stage the forehead flap is divided as above

What are the risks of forehead flap reconstruction?

There are risks that are common to many operations, such as bleeding, wound infection and scars from where the flap has been raised.

The main risk of a forehead flap though is that it may not survive being moved from the forehead. The flap relies on blood flow from the eyebrow area to keep it alive for the first 2-3 weeks while it ‘learns to live’ from the nose. This blood flow relies on a tiny artery and vein, which can sometimes get kinked, blocked or injured during surgery. The risks of failure also increase if the flap gets cold, or if you smoke. If the forehead flap dies, then you may well need further surgery

This information is for general information only. If you have any concerns about your health or are considering any treatments, you should seek advice from a healthcare specialist

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