European Journal of Cardiovascular Medicine

The mid-face, the centre third of the human face, is the most noticeable and socially significant feature of the body and is essential to identification, function, and communication. The nose, cheeks and eyelids are some of the essential features that make up the mid-face. These structures all play a part in important functions including breathing, speaking, and expressing oneself. Therefore, every damage in this area needs both functional and cosmetic rehabilitation, regardless of whether it results from oncologic resection, trauma, infection, or congenital abnormalities.

Because of the anatomical details, dynamic muscle activity, three-dimensional shapes, and requirement for skin that matches in colour, thickness, and texture, reconstructing mid-facial lesions presents difficult problems Thorne CH et al. (2012)^[1]. A combination of restorative surgery and aesthetic skill is the focus of contemporary facial reconstructive surgery. For moderate to large mid-facial abnormalities, the forehead flap—especially the paramedian forehead flap—stands out among the several reconstructive choices as a tried-and-true method Menick FJ et al. (2010) and Burget GC et al. (1985)^[2,3].

The forehead flap's history dates back thousands of years. The "Indian Method" Bhishagratna KK et al. (1907)^[4] is a type of forehead flap for nose restoration that was described in the 600 BC Sanskrit surgical treatise Sushruta Samhita. In the 18th century, this method made its way to Europe, where it established the groundwork for contemporary plastic surgery. The supratrochlear artery, a reliable and strong axial circulation feeding the centre forehead, is the main source of support for the paramedian forehead flap, which was first performed and made popular in its current form by Burget et al. (1985) and Menick et al. (2002) ^[3,5]. It is significantly more dependable than random flaps because of its axial blood supply, particularly in high-risk patients like the elderly, smokers, or those who have had radiation therapy in the past Pribaz JJ et al. (2007)^[6].

The key advantages of the forehead flap include:

• Consistent vascularity, reducing flap necrosis risk.
• Excellent tissue match for nasal and cheek defects in terms of color, texture, and thickness.
• Versatility, allowing single, two, or three-stage techniques depending on patient and defect characteristics.
• Minimal donor site morbidity, especially when incisions are planned along forehead wrinkles and creases Park SS et al. (2011) and Burget GC et al. (1990)^[7,8].

The effectiveness and safety of this method have been shown by several research. More than 300 forehead flaps showed a success rate of over 95%, with few problems and great patient satisfaction, according to a review by Gabrysz-Forget et al. (2019) ^[9]. Similar to this, Menick et al. (2016) have highlighted the three-stage forehead flap's advantages in terms of both aesthetics and dependability, especially in nasal reconstructions ^[10]. The most often used technique for moderately sized lesions is still the two-stage paramedian flap. Flap elevation, inset into the defect, and primary closure or grafting of the donor site are all part of the first operation. After vascular ingrowth is guaranteed, the pedicle is usually separated two to three weeks later. This method strikes a compromise between safety and aesthetic results, especially for abnormalities of the cheek, columella, or nasal tip. Lo Tew WP et al. (2001) ^[11].

In terms of appearance, skin that closely resembles natural facial skin must be used to reconstruct the mid-face, particularly the cheek and nose. In general, the forehead skin is well-tolerated, especially after modest improvements during the second stage, due to its somewhat thicker and sebaceous quality Baker SR et al. (2014) ^[12]. Patient-reported outcomes are another crucial component. Patient satisfaction is becoming a key component of evaluating surgical outcomes due to the growing focus on health-related quality of life (HRQoL). Likert scales and FACE-Q surveys are examples of PROMs (Patient-Reported Outcome Measures) that provide useful information on how patients see their reconstructive results Klassen AF et al. (2010)^[13].

Practically speaking, the forehead flap also works well in settings with limited resources. The forehead flap is a regional flap that does not require microvascular anastomosis, which makes it accessible and economical in contrast to free tissue transfer, which necessitates microsurgical infrastructure and experience Bussu F et al. (2013)^[14]. Furthermore, the flap may be customised to fit different defect geometries utilising medially or laterally based designs, and it has been demonstrated to withstand radiated fields better than other local solutions. These traits are especially helpful in tertiary care facilities that treat a variety of facial deformities in diverse populations Ishii LE et al. (2010)^[15].

The forehead flap does have certain disadvantages, though. Despite being carefully concealed, the donor site scar might be problematic, especially in younger patients or those with fewer forehead rhytids. In order to improve harmony, contour, or debulk, secondary revision surgery may be necessary Neligan PC et al. (2018)^[16]. Success also depends on patient participation during the staged operations and subsequent care. Over the course of three years, a tertiary care facility in South India conducted this study to assess the effectiveness of forehead flap surgery for mid-face abnormalities. It aims to provide practical clinical data and results, such as patient satisfaction, complication profiles, and aesthetic outcomes.

Study Design: This prospective observational study was conducted in the Department of Plastic Surgery at Deccan College of Medical Sciences, Princess Esra Hospital, Hyderabad. The study period spanned three years.

Study Location: Department of Plastic Surgery, Deccan College of Medical Sciences, Princess Esra Hospital, Hyderabad.

Study Duration: From May 2022 to May 2025.

Sample Size: A total of 25 patients.

Inclusion Criteria:

• Patients aged 18 years and above.
• Patients with mid-face defects involving the nose, cheek, eyelid.
• Defects resulting from trauma, tumor excision, or infection.

Exclusion Criteria:

• Patients with comorbidities contraindicating major surgery.
• Previous forehead flap surgery or forehead scarring precluding flap harvest.

Surgical Technique: A paramedian forehead flap based on the supratrochlear artery was used in most cases. The flap design was marked preoperatively. After elevation, the flap was transposed to the defect and inset. In two-stage procedures, pedicle division was performed after 3 weeks. Secondary refinements were undertaken as required.

Outcome Measures:

• Aesthetic outcome (evaluated by surgeon and independent panel).
• Functional recovery (speech, nasal patency, eyelid closure).
• Complications (infection, flap necrosis, hematoma, wound dehiscence).
• Patient satisfaction (5-point Likert scale).

Data Collection and Analysis: Descriptive statistics were used to summarize the data. Categorical variables were presented as frequencies and percentages. Qualitative feedback was documented.

Data Collection and Statistical Analysis

Clinical factors, outcome measures, and demographic information were compiled using descriptive statistics. Frequencies and percentages were used to display categorical variables. Additionally, qualitative remarks and patient feedback on their level of functional and cosmetic satisfaction were recorded and descriptively examined. Microsoft Excel was used to assemble the data, and SPSS software (version 26.0; IBM Corp., Armonk, NY) was used for analysis.

Table 1: Demographic Profile of Patients (n = 25)

This table compiles the study population's demographic information. With a mean age of 49, patients undergoing paramedian forehead flap surgery ranged in age from 21 to 75. With 16 men (64%) and 9 women (36%), the group was predominately male.

Figure 1

Table 2: Etiology of Mid-Face Defects

This table displays the underlying reasons of mid-face deformities that require repair. Oncologic excision for either basal cell carcinoma (BCC) or squamous cell carcinoma (SCC) was the most common cause, representing 68% of cases (n = 17). Traumatic injuries, such as assault and traffic accidents, accounted for 24% (n = 6), whereas infectious causes, such as necrotising fasciitis, accounted for 8% (n = 2).

Figure 2

Table 3: Distribution by Defect Site

This table displays the anatomical distribution of facial anomalies among study participants. Nasal deformities were the most frequently seen site, occurring in 12 cases (48%). Four patients (16%) had both nasal and cheek abnormalities, while seven patients (28%) had cheek involvement. Less often, the eyelid were seen instances (8%).

Figure 3

Table 4: Types of Forehead Flap Procedures

The reconstructive techniques used are categorised in this table. A two-stage forehead flap transfer was performed on most patients (n = 20; 80%), allowing for improved contouring and postponed pedicle division. Five patients (20%) underwent a single-stage treatment; they were probably chosen because of their favourable tissue state or reduced defect size.

Table 5: Postoperative Outcomes and Patient Satisfaction

The surgical results, complications, and satisfaction levels following reconstruction are all included in this extensive table. Two patients (8%) and one case (4%), respectively, had minor problems, including flap congestion and wound dehiscence, which were all effectively treated without resulting in flap loss or serious infection. Eighty percent of respondents assessed the practical and aesthetic results as great, sixteen percent as good, and four percent as fair. 72% of participants said they were extremely satisfied, 16% said they were content, 8% said they were indifferent, and only 4% said they were not happy with the outcome, indicating excellent patient satisfaction.

Figure 4: Forehead flap cover for SCC over Nose

Figure 5: Forehead Flap Cover for Post BCC Defect of Nose

Figure 6: Forehead Flap cover for defect over Nose and medial aspect of Cheek.

Figure 7: Forehead Flap cover over Nose. Post BCC Defect.

Figure 8: Forehead flap cover. For Post traumatic defect over nose medial third of Upper eyelid

Figure 9: Forehead flap for Post Basal cell carcinoma defect

The current study supports findings from earlier research by highlighting the forehead flap's effectiveness and dependability in restoring mid-facial abnormalities. Our results confirm that the paramedian forehead flap is still a vital reconstructive alternative for surgeons treating complicated mid-facial abnormalities, with a 100% flap survival rate and a 12% complication rate.
Our study's faulty aetiology, which is mostly oncological resections (68%), is indicative of the rising incidence of skin cancers of the face, especially squamous cell carcinoma (SCC) and basal cell carcinoma (BCC). Given that non-melanoma skin cancers are the most prevalent cancers globally, this pattern is consistent with epidemiological statistics from throughout the world Leiter U, et al. (2020)^[17]. Clear-margin surgical excision frequently results in substantial tissue loss, necessitating careful repair that strikes a compromise between oncologic safety and aesthetic integrity.

In this situation, the paramedian forehead flap provides unmatched adaptability. Even in patients at high risk, its strong perfusion and anatomical predictability provide exceptional dependability. The two venous congestion instances in our sample were treated conservatively, which is consistent with other research suggesting that conservative treatment is adequate for the majority of mild problems Menick FJ et al. (2004) and Cerci FB et al.(2017)^[18,19]. When it comes to mid-face repair, aesthetics are crucial. Facial symmetry is disproportionately influenced by the highly prominent cheek and nasal components. The forehead skin is a close match, particularly in older people, due to its oily nature and pigmentation from sun exposure. Skin mismatch has a substantial impact on patient satisfaction ratings, especially in nose restoration, according a research by Potter et al. (2004) ^[20]. This is corroborated by our own patient satisfaction statistics, which shows that 88% of patients had positive cosmetic results.

Another crucial factor is staging. Our study's two-stage methodology provided the chance for intermediate debulking or reshaping and permitted safe vascularization prior to flap division. Our two-stage approach achieved a compromise between safety, speed, and patient compliance, even though three-stage treatments have occasionally demonstrated better contouring Menick et al. (2002)^[5].

Every option, including free flaps, cervicofacial advancement flaps, and nasolabial flaps, has unique drawbacks. Smaller lesions are the ideal candidates for nasolabial flaps, which frequently have insufficient tissue volume or reach. Despite their versatility, free flaps need more microsurgical skill, longer operating periods, and are linked to increased perioperative risks and expenses Behan FC et al. (2012)^[21]. Therefore, in the majority of clinical settings, the forehead flap continues to be the preferred treatment for medium-to-large abnormalities.

In our group, donor site morbidity—a often mentioned disadvantage—was not a significant problem. The majority of donor sites were mostly closed, and only a small percentage of instances required full-thickness skin grafting. Patients responded favourably to the final scar, especially when it was applied to pre-existing wrinkles on the forehead. This is consistent with research by Manson PN et al. (2018), who highlighted the importance of carefully positioning incisions along the creases in the skin ^[22]. The forehead flap retained the underlying muscle and offered enough structural support in terms of functional recovery, especially for abnormalities involving the nasal alae or cheek junction. In cases of nasal abnormalities, this was especially crucial for preserving airway patency. In our sample, no patients needed revision due to functional failure.

Last but not least, psychosocial rehabilitation must be disregarded. Restoring face integrity has significant effects on social interaction and self-esteem. We might measure this effect by using patient satisfaction measures. Even when face reconstruction is technically effective, it may not be seen favourably by the patient if the cosmetic results are subpar, according to a number of studies, including Reformat et al. (2018) ^[23].

All things considered, our research supports the forehead flap's status as the go-to reconstructive technique for mid-facial abnormalities. It provides consistent results in a variety of therapeutic situations, bridging the gap between form and function.

The forehead flap is still a standard procedure for reconstructing mid-face lesions, especially because of its unmatched vascular dependability, anatomical appropriateness, and aesthetic coherence. The paramedian forehead flap showed good results in terms of flap survival, cosmetic success, and patient satisfaction with few problems in our three-year observational analysis with 25 patients. The most common reason for face deformities necessitating this kind of repair is still oncologic resections, underscoring the growing demand for efficient, repeatable surgical solutions. notably in its two-stage version, the forehead flap effectively treated a range of defect sizes and placements, notably in the cheek and nasal areas.

Its capacity to supply well-vascularized, malleable, and color-matched tissue sets it apart from many other regional alternatives, and its affordability and ease of use give clear benefits over microvascular free tissue transfer, particularly in environments with limited resources.
Positive patient satisfaction results confirmed the flap's psychological effects in addition to its therapeutic feasibility. Scars were effectively hidden along the natural contours of the forehead, therefore donor site concerns were minor.

Although there are certain drawbacks to the method, including as the requirement for staging and the possibility of donor site scarring, these can usually be controlled with meticulous surgical planning. Our results provide credence to the forehead flap technique's ongoing development and application in face reconstructive surgery. It is recommended that larger, multicenter cohorts and longer follow-up times be used in future research to confirm these findings and investigate advancements in minimally invasive flap harvesting and single-stage alterations.

LIMITATIONS OF THE STUDY

1. Sample Size: The results' statistical strength and generalisability are constrained by the very small sample size of 25 patients. More detailed insights could be provided by a larger cohort, particularly when comparing results from various flap procedures.
2. Single-center Design: Institutional procedures, surgical expertise, and patient demographics may not be representative of other healthcare settings due to the study's single tertiary care centre environment, which might introduce bias.
3. Short Follow-up Duration: Long-term effects including scar maturation, late complications, and the durability of cosmetic improvements were not always recorded, despite the encouraging early findings. A more thorough investigation would support the findings.
4. Lack of Control Group: The study limited the potential to contextualise findings within larger reconstructive choices by not comparing the forehead flap with other reconstructive methods as free flaps or nasolabial flaps.
5. Subjective Aesthetic Evaluation: Although aesthetic results and patient satisfaction were assessed, objectivity is limited by an absence of a third-party grading system or standardised photographic assessment.

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