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lear artery does not possess sizable venae comitantes; thus, the main pathway
Ben Aldridge, Ph.D. for venous drainage of the paramedian forehead flap is through superficial
Ciaran Healy, M.D. veins. The pattern and location of the superficial veins varies and therefore a
Sheffield and London, United Kingdom 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- supratrochlear artery. Flap design has evolved
tory of application in nasal reconstruc- around a number of goals, which include maximiz-
tion, important anatomy relating to the ing the reach of the flap, maximizing the mobility
paramedian forehead flap is only recently becom- of the pedicle at its base, ensuring that the skin
ing recognized.1 The arterial anatomy has been pedicle overlies the supratrochlear artery (so that
relatively well studied.2–6 Less attention has been it is included within the flap), and minimizing the
given to the venous anatomy, resulting in a com- width of the skin pedicle at the brow so that sig-
mon misconception that the venous drainage of nificant cosmetic deformity of the brow does not
this flap occurs through venae comitantes of the occur when the donor site is closed.7 To achieve
these goals, a flap that is designed with a pedicle
From the Department of Plastic Surgery, Sheffield Teaching
width of 12 to 15 mm, that curves from the central
Hospitals NHS Foundation Trust; the Departments of Ra- forehead into the medial brow, and that overlies
diology and Plastic Surgery, Guy’s and St Thomas’ NHS the supratrochlear artery has been recommended,
Foundation Trust; and the Department of Anatomy, King’s although some surgeons do not narrow the flap
College London. more than 13 to 14 mm “to minimize flap conges-
Received for publication April 26, 2017; accepted June 6, tion.”8 Studies of the venous anatomy of the fore-
2018. head have led to alternative suggestions regarding
Presented in part at Doctors Updates, in Val d’Isere, France, the skin pedicle position.1,4 Shimizu et al. have
January 27, 2016; the Winter Meeting of the British As- demonstrated that the supratrochlear artery is
sociation of Plastic, Reconstructive and Aesthetic Surgeons, accompanied by only very-small-caliber veins and
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. Disclosure: The authors have no financial interest
Copyright © 2018 by the American Society of Plastic Surgeons to declare in relation to the content of this article.
DOI: 10.1097/PRS.0000000000005121
www.PRSJournal.com 269
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery • January 2019
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
271
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.