Median Forehead Flap

This is Richard Allen at the University of lowa. This video demonstrates reconstruction of a relatively large defect with a median forehead flop. In addition, the defect involves the medial portion of the upper and lower lid. A periosteal strip will be used to rebuild the posterior LA mell of the medial upper and lower lid to and to provide support. A 15 blade is used to make an incision through the periosteum and a freer periosteal elevator is used to elevate the flap and reflect it medially. This flap will stretch to the medial edge of the upper and lower eyelid. The flap will be split centrally with wescott scissors and then each limb of the periosteal strip will engage the upper and lower eyelid. The periosteal strip is sutured to the eyelids with five dash zero Vicryl suture. 

This is performed in a cross swords fashion so that the upper limb engages the lower eyelid and the lower limb engages the upper eyelid. The forehead flap is then raised.A 15 blade is used to make an incision through the skin, subcutaneous fat and frontalis muscle to the subgaleal plane, which is superficial to the periosteum. The monopolar cautery is used to dissect in this pre periosteal plane, approximately two centimeters superior to the orbital rims.The periosteum is then incised with a 15 blade and further dissection is carried out inferiorly in the subperiosteal plane.

This plane is used to avoid damage to the neurovascular structures in this area by staying deep to them. Wide undermining is then performed with the monopolar tery at the edges of the donor site. The donor site is then closed. In doing this, the forehead flap should be transposed into appropriate position. Closure of the donor site is performed with deep interrupted for death zero Vicryl sutures. This is can sometimes be challenging dueto the tension at the closure and further undermining may be necessary. The flap is then reflected into position and sutured in positionwith deep interrupted five dash zero Vicryl sutures followed by a combination of five dash zero and six dash zero proline sutures.Superficially, depending on the thickness of the skin, the donor side is closed superficially with interrupted five Gero prolene sutures placed in a vertical mattress fashion in order to evert the skin edges. At the conclusion of the case, the flap should appear healthy.Mineral pressure should be applied to the graft postoperatively to ensure adequate perfusion.