IDEAS AND INNOVATIONS

A New Approach to an Old Flap: A Technique

to Augment Venous Drainage from the
Paramedian Forehead Flap
Martin Wiener, M.D.
Summary: The paramedian forehead flap is commonly used in nasal recon-
Narayan Karunanithy,
struction, and survival of the distal part of the flap is usually essential for a
F.R.C.R.
good cosmetic outcome. Venous congestion leading to tissue necrosis is a rec-
Natalie Pease, M.B.B.S. ognized complication with this flap. The standard paramedian forehead flap
Andrew Davies, M.B.Ch.B. is designed with a number of aims. These are to include the supratrochlear
Nolan Walker, F.R.C.R. artery, to maximize mobility of the flap pedicle, to maximize the reach of the
Konstantinos Katsanos, flap, and to minimize cosmetic implications at the donor site. The supratroch-
E.B.I.R.
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Ben Aldridge, Ph.D.
Ciaran Healy, M.D.
Sheffield and London, United Kingdom
lear artery does not possess sizable venae comitantes; thus, the main pathway
for venous drainage of the paramedian forehead flap is through superficial
veins. The pattern and location of the superficial veins varies and therefore a
standard skin pedicle design cannot be expected to always include sufficient
veins to prevent venous congestion and subsequent flap necrosis. This article
demonstrates the superficial venous anatomy of the forehead using computed
tomographic venography, clinical demonstration, and cadaveric dissection,
and describes a technique that can be carried out to augment flap venous
drainage by performing careful dissection to identify additional superficial
veins at the margins of the flap skin pedicle. One or more veins can then be
mobilized and included with the flap pedicle to augment its venous drainage.
Use of this technique should lead to a lower incidence of flap necrosis second-
ary to venous congestion.  (Plast. Reconstr. Surg. 143: 269, 2019.)

D
espite a long and well-documented his-
tory of application in nasal reconstruc-
tion, important anatomy relating to the
paramedian forehead flap is only recently becom-
ing recognized.1 The arterial anatomy has been
relatively well studied.2–6 Less attention has been
given to the venous anatomy, resulting in a com-
mon misconception that the venous drainage of
this flap occurs through venae comitantes of the
From the Department of Plastic Surgery, Sheffield Teaching
Hospitals NHS Foundation Trust; the Departments of Ra-
diology and Plastic Surgery, Guy’s and St Thomas’ NHS
Foundation Trust; and the Department of Anatomy, King’s
College London.
Received for publication April 26, 2017; accepted June 6,
2018.
Presented in part at Doctors Updates, in Val d’Isere, France,
January 27, 2016; the Winter Meeting of the British As-
sociation of Plastic, Reconstructive and Aesthetic Surgeons,
November 25 through 27, 2015; and the Joint Meeting of
British Association of Clinical Anatomists, European As-
sociation of Clinical Anatomists, and Sociedad Anatomica
Espanola, in Rouen, France, June 24 though 27, 2015.
Copyright © 2018 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000005121
supratrochlear artery. Flap design has evolved
around a number of goals, which include maximiz-
ing the reach of the flap, maximizing the mobility
of the pedicle at its base, ensuring that the skin
pedicle overlies the supratrochlear artery (so that
it is included within the flap), and minimizing the
width of the skin pedicle at the brow so that sig-
nificant cosmetic deformity of the brow does not
occur when the donor site is closed.7 To achieve
these goals, a flap that is designed with a pedicle
width of 12 to 15 mm, that curves from the central
forehead into the medial brow, and that overlies
the supratrochlear artery has been recommended,
although some surgeons do not narrow the flap
more than 13 to 14 mm “to minimize flap conges-
tion.”8 Studies of the venous anatomy of the fore-
head have led to alternative suggestions regarding
the skin pedicle position.1,4 Shimizu et al. have
demonstrated that the supratrochlear artery is
accompanied by only very-small-caliber veins and
Disclosure: The authors have no financial interest
to declare in relation to the content of this article.

www.PRSJournal.com 269
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Plastic and Reconstructive Surgery • January 2019

it is therefore the larger caliber superficial sub-

cutaneous veins that provide the majority of the
venous drainage from this region and thus for the
paramedian forehead flap.1 The location of the
superficial veins is variable; thus, it follows that a
standard skin pedicle would not be guaranteed to
always include adequate superficial veins. In such
cases, there would be good inflow but inadequate
outflow, resulting in venous congestion, a well-
recognized complication that can occur with the
paramedian forehead flap and that, if untreated,
can result in loss of at least part of the flap. Mak-
ing alterations to the position or size of the skin
pedicle may allow improved venous drainage but
would introduce compromises in other aspects of
flap design; thus, a different approach is required Fig. 2. Clinical demonstration of the effect of increased venous
and is presented in this article. pressure to identify the locations of superficial veins on the
We have studied the superficial venous system forehead intraoperatively. This clearly demonstrates right-side–
of the forehead on 20 computed tomographic dominant venous drainage.
venograms and found it to be variable (Fig. 1).
However, these veins can be easily identified in possible to carry out careful dissection at the mar-
a given patient by increasing venous pressure gins of the flap to identify the superficial veins
by means of head-down positioning or perform- emanating from the flap (Fig. 3). The initial skin
ing a Valsalva maneuver (Fig. 2). This allows the incision around the margin of the flap should be
locations of superficial veins to be marked intra- performed just to the base of the dermis to avoid
operatively on the forehead; thus, preoperative inadvertent injury to the superficial veins at the
imaging is unnecessary. The decision as to which flap margin. Once identified, these veins can then
side to base the flap on may be influenced by the be followed in the subcutaneous tissue adjacent
pattern of superficial venous drainage observed, to the flap. Their connections to the flap can be
and in the example shown in Figure 2, it is clear preserved and their lateral branches divided. In
that drainage was predominantly to the right side. doing this, the veins can then be mobilized and
Once the side has been chosen, a standard para- included with the flap pedicle to augment its
median forehead flap can then be designed, cen- venous drainage and reduce the risk of venous
tered over the supratrochlear artery, with a narrow congestion. The additional dissection required
skin pedicle (8 to 12 mm) at its base. When rais-
ing this standard paramedian forehead flap, it is

Fig. 3. Intraoperative photograph demonstrating a superficial

Fig. 1. Computed tomographic venogram of the forehead dem- vein identified at the margins of a paramedian forehead flap
onstrating the pattern of superficial veins that drain this region. skin pedicle.

270
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 143, Number 1 • Drainage of the Paramedian Forehead Flap
Fig. 4. Cadaveric dissection with Acid Etch gel injection (SS
White Group, Gloucester, United Kingodm) of a superficial vein
to demonstrate its caliber and its connections to a paramedian
forehead flap based on the contralateral supratrochlear artery.
using this technique can be accomplished using
2.5× loupe magnification and adds a few minutes
to the operative procedure time. In cadaveric dis-
sections carried out on 11 intact foreheads, we
have confirmed the subcutaneous nature of such
veins and their relatively large caliber, suggest-
ing a significant contribution to venous drainage
from the superficial tissues of the central forehead
(Fig. 4). In all 11 cases, it was possible to identify
at least one additional superficial vein within
10 mm of either side of the pedicle that could be
dissected out and included with the flap to con-
tribute additional venous drainage. Our studies
using cadaveric dissections and computed tomo-
graphic venograms of the forehead have led us
to conclude that the venous anatomy of the fore-
head is highly variable in terms of both the loca-
tions of veins and their branching patterns. Veins
descending the forehead can be broadly classified
into nonbranching and multiple branching types,
with multiple branching veins having more than
one connection to the flap.
In the past 20 years, one of the authors (C.H.)
has performed over 320 forehead flap nasal
reconstructions and began dissecting out addi-
tional superficial veins in 2014. A retrospective
case review was performed to compare standard
cases (carried out from 2009 to 2013; n = 95)
and new technique cases (carried out from 2014
to 2018; n = 89). At least one additional super-
ficial vein was included with the flap in the new
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
technique cases; otherwise, the surgical technique
remained the same. There were no cases of com-
plete flap failure in either group. Six of 95 cases
of venous congestion required leech therapy in
the standard surgery group, but all flaps survived
such that the intended reconstruction could be
completed. In the new technique group, with
inclusion of additional superficial veins, there
have been no cases of venous congestion requir-
ing leech therapy. There has been one case of
partial flap loss, which was attributable to external
compression on the pedicle from reading glasses.
Thankfully, as evident from this and other series,
venous congestion resulting in flap necrosis does
not occur frequently when using the traditional
technique for flap elevation.8 However, the tech-
nique of flap elevation described in this article
could reduce this frequency further and avoid
the need for leeches or other methods for treat-
ing venous congestion, without introducing com-
promises relating to aspects such as reliability of
arterial inflow, mobility and reach of the flap, or
donor-site cosmesis.
Ciaran Healy, M.D.
Department of Plastic and Reconstructive Surgery
St Thomas’ Hospital
Westminster Bridge Road
London SE1 7EH, United Kingdom
ciaran.healy@gstt.nhs.uk
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