Paramedian forehead flap pedicle division after 7 days using laser-assisted indocyanine green angiography

The paramedian forehead flap is a major workhorse for reconstruction of medium- to large-sized nasal defects. The tissue bridge that results from the vascular pedicle results in significant cosmetic deformity, with associated social and occupational costs to the patient. This prospective cross-sectional study sought to assess efficacy and safety of takedown of the flap pedicle at 1 week using indocyanine green (ICG) angiography to assist in determining neovascularization of the flap. This study was performed at a tertiary care center from April 13, 2018 to March 22, 2019. Patients eligible for enrollment included those with defects appropriate for reconstruction with a paramedian forehead flap, partial-thickness defect, vascularized tissue in more than 50% of the recipient bed, and lack of nicotine use. Ten patients were included, and all underwent reconstructive surgery by a single surgeon. Laser-assisted ICG angiography was used during the first stage as well as at the second stage both immediately before and after flap division. Perfusion was in both time-independent and time-dependent analyses relative to a cheek reference point. Herein, we found successful 7-day flap takedown with no flap-related complications in all patients. There was an average of approximately 44% flap-to-cheek vascularity across all patients, and pre-division flap perfusion correlated well with post-division perfusion. In conclusion, in carefully selected patients with amenable defects, division of the pedicle at 1 week after initial flap transfer is safe and has the potential to limit the morbidity associated with the procedure.