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soft tissues, hard tissues or a combination of both and may be retrospectively studied. Information was sourced from patient’s
[4]
congenital or acquired in origin. Congenital defects include case notes and operating theatre register. Information retrieved
cleft lip/palate, maxillary and mandibular hypoplasia. Acquired included age, gender, indication for surgical reconstruction, type
defects may result from trauma, surgery or infections. Generally, of forehead flap, duration of hospital stay and complications. All
the main etiological factor in acquired orofacial defects varies patients agree with this publication and use of photographs.
from one environment to another.
Preoperative planning
Reconstruction of orofacial tissue defects may be undertaken The superficial temporal artery was assessed preoperatively by
as an immediate or delayed procedure. Traditionally, the palpatory method only. This involved the identification of its
reconstructive ladder approach has been advocated in soft tissue outline and feeling the strength of its pulsation. The position
defect reconstruction and this allows a stepwise option from the of other axial vessels of the forehead was planned based on
simplest to the most complex procedures. These procedures are established anatomical guidelines. Presence of significant scars
healing by secondary intention, primary closure, skin grafting along established axial vessels of the forehead which may
and use of local, regional and free flaps techniques. However, indicate vascular compromise were also excluded. Patients for
recently the concept of reconstructive escalator or elevator has
been advocated since reconstruction should be individualized to complete forehead flap raising were instructed to shave their
each patient and not based on a rigid approach. [5,6] hair but preserve the hairline.

Despite advances in soft tissue reconstruction using free Surgical procedure
flaps, pedicle flaps are still relevant in functional and aesthetic Reconstruction was carried out as a two or three (if debulking
rehabilitation of patients. Free flaps provide enough volume is necessary) stage procedure involving initial flap raising and
[7]
of tissue for reconstruction; they are more resistant to transfer, followed by flap division usually after a period of
radiation injury (which is important cancer patients requiring three weeks, and finally debulking of the reconstructed site.
radiotherapy); allow for unrestricted flap repositioning, and When complete forehead flap was raised, split thickness skin
achieve optimal reconstruction with resultant reduction graft from the thigh was used to cover the flap donor site
in the cost and morbidity often associated with repeat either intraoperatively or 24-48 h postoperatively (to reduce
surgeries due to failure of suboptimal reconstructions using operating time or allow for adequate hemostasis) on the
locoregional flaps. However, use of free flaps is technique dental chair, secured with sutures and a pressure dressing
[8]
sensitive, involves prolong procedure, require extensive applied on the forehead to prevent hematoma collection
postoperative monitoring, may be relatively contraindicated under the skin graft.
in some patients with co-morbid conditions, and there may be
aesthetic problems such as flap bulkiness, colour and texture The critical aspect in successfully raising a complete forehead
mismatch. [9,10] Locoregional flaps have reduced vulnerability flap is the plane of dissection close to its base to avoid damage
to infection and thrombosis; they are much easier to raise to the nutrient vessels. The key is to initially raise the flap
and transfer when compared to free flaps, and usually provide supraperiosteally from one end of the forehead until the
excellent colour match. Limited reach of locoregional flaps, temporalis fascia is encountered on the contralateral side. Once
difficulty in achieving three-dimensional reconstruction the temporalis fascia is encountered on the contralateral side,
or cover extensive tissue defects, and occasional need for dissection with scissors should follow a connective tissue plane
[11]
multistage procedure are some of its limitations. Moreover, above the fascia to preserve the nutrient vessels of the flap.
locoregional flaps frequently have complications in irradiated
fields and may require specific patient positioning to raise. [9] Classification
Forehead flap was classified as either complete (if the whole
In current practice, locoregional flaps are still important for head forehead tissue between hairline and supraorbital rim was
and neck reconstruction in environment where microvascular
free tissue transfer is not feasible. In technologically developed mobilized from a point perpendicular to the lateral canthal
environment, they are used as rescue flaps following free flap region on one side to the corresponding point or beyond
failure and in patients with relative contraindications for free flap on the contralateral side) or partial (if only a part of the
transfer such as the presence of co-morbid medical conditions. [12] forehead tissue was mobilized), while timing of flap division
was classified as early (less than 16 days), conventional
The forehead region over the years has remained the best donor (between 16-28 days) or delayed (greater than 28 days).
site for nasal reconstruction, having the advantage of textural, Reconstruction was classified as immediate (if done within
[13]
thickness and colour match. Different types of forehead flaps 24 h following defect formation) or delayed (if done after
with axial or random pattern blood supply have been described. 24 h following defect formation), and two stage (initial flap
[14]
The aim of this study therefore is to review the use of forehead raising and flap division later) or three stage (initial flap
flap in orofacial reconstruction, highlighting our experience in raising, flap division and secondary debulking of recipient
the management of forty-three cases. site).

METHODS Data retrieved was analyzed using Statistical Package for Social
Sciences (SPSS) version 16 and Microsoft Office Excel 2007.
All patients who had orofacial reconstruction using forehead flap Findings from descriptive statistics were represented in the form
at a regional teaching hospital from April 1991 to June 2014 were of graphs, tables and charts.
116 Plast Aesthet Res || Volume 3 || April 25, 2016