Local Flaps in Facial Reconstruction

244
SECTION I  FUNDAMENTALS
A
B
C
D
FIGURE 12-9  ■  A, A 2 × 1.4-cm skin defect of medial cheek. Superiorly based melolabial transposition flap designed for repair.
Standing cutaneous deformity marked for excision. B-D, Flap transferred. Standing cutaneous deformity excised.

12  MELOLABIAL FLAPS
245
the large size of the defect, the choice of reconstruction
with a local cutaneous flap was restricted to the use of
either a rotation or transposition flap. A rotation flap
would have required dissection of the entire remaining
skin of the cheek. In addition, the curvilinear incision
necessary for the flap would have extended from the nose
to the ear perpendicular to RSTLs. A superiorly based
melolabial transposition flap was selected for repair of the
wound. The flap was constructed of the lax skin of the
jowl and was elevated in the subcutaneous tissue plane.
The standing cutaneous deformity was excised lateral to
the skin defect. The flap donor site was closed so the
resulting scar for most of its length would parallel the
melolabial crease. The patient’s postoperative photo­
graphs show obliteration of the melolabial fold because
of the large size of the flap necessary for reconstruction
of the defect. One of the disadvantages of melolabial
transposition and interpolated flaps is the reduction of
the fold and the resulting facial asymmetry. The larger
the flap is, the greater is the flattening of the melolabial
fold contour. In this case, facial asymmetry was unavoid­
able because the upper two-thirds of the fold had been
resected with surgical excision of the skin cancer.
Case 4
A 64-year-old woman developed a melanoma in situ of
the right cheek. Surgical margins were established by the
modified by making the line tangent to the defect equal
to the diameter of the defect instead of 1.5 times the
diameter. This was done to prevent an incision crossing
perpendicular to the melolabial crease. In the case shown,
the tip of the flap was preserved and part of the wound
was closed around the tip by advancing wound margins.
This created a small standing cutaneous deformity that
was excised at the junction of the nasal sidewall and the
lower eyelid. As with rectangular and parabola-shaped
transposition flaps, the greatest wound closure tension is
at the donor site. In the case of the note flap, the greatest
wound closure tension is approximately perpendicular to
the tangent line created when the flap is designed. The
surface area of the note flap is designed so that it is 25%
less than the area of the defect; thus, clinical judgment is
required when this flap is used. The flap is recommended
primarily for small (2 cm or less) skin defects, although
it worked well for the larger defect shown in Figure
12-11. Because the pivotal arc of the note flap is approxi­
mately 45°, a small standing cutaneous deformity devel­
ops that requires excision lateral to the defect.
Case 3
A 62-year-old man had micrographic surgical excision of
an extensive basal cell carcinoma of the medial cheek.
The defect measured 8 × 8-cm and was contained within
the aesthetic region of the cheek (Fig. 12-12). Because of
E
F
E, Preoperative and F, Postoperative result at 6 years. No revision surgery performed.
FIGURE 12-9, cont’d  ■

246
SECTION I  FUNDAMENTALS
C
FIGURE 12-10  ■  A, A 1.8 × 1-cm cutaneous defect of medial cheek and lateral upper lip. Melolabial transposition flap designed for
repair. B, C, Flap transferred and wound closed. D, E, Postoperative result at 18 months. Z-plasty scar revision performed 1 year
after wound repair.
A
B
D
E

12  MELOLABIAL FLAPS
247
FIGURE 12-11  ■  A, A 3 × 2-cm skin defect of medial cheek. Inferiorly based melolabial transposition flap designed for repair. Antici­
pated standing cutaneous deformities marked medial and lateral to defect. Medial deformity resulted from partial closure of superior
aspect of defect by advancement of wound borders. B, C, Flap incised, dissected, and transposed. D, Flap in place.
A
B
C
D

248
SECTION I  FUNDAMENTALS
FIGURE 12-12  ■  A, An 8 × 8-cm skin defect of medial cheek and alar base. Superiorly based melolabial transposition flap designed
for repair. B, Flap transposed. Alar component of defect covered by full-thickness skin graft (not visible in photograph) obtained
from excised standing cutaneous deformity of transposition flap. C, D, Postoperative views at 9 months. No revision surgery per­
formed. (From Baker SR: Local cutaneous flap. Otolaryngol Clin North Am 27:139, 1994.)
A
B
C
D

12  MELOLABIAL FLAPS
249
A
B
FIGURE 12-13  ■  A, B, A 4 × 3-cm planned skin excision marked by linear scars.
Continued
square technique (Fig. 12-13). This technique is described
in detail in Chapter 8, Case 3. The skin planned for exci­
sion was outlined by linear scars and measured 4 × 3-cm.
Reconstruction of the skin defect after resection of the
melanoma could have been accomplished with a rotation
flap. There was insufficient cheek skin medial to the
defect to repair the wound with a melolabial transposi­
tion flap. To minimize the size of the rotation flap
required for reconstruction, it was elected to use two
local flaps, one with a rotation and the other with a trans­
position design. The flaps are shown in Figure 12-13C.
A laterally based rotation flap and a superiorly based
melolabial transposition flap were designed. The antici­
pated standing cutaneous deformity of the rotation flap
is marked with vertical lines. The standing cutaneous
deformity of the transposition flap developed superome­
dially and assisted the rotation flap with repair of the
superior aspect of the defect. The use of two cutaneous
flaps in place of one eliminated the need to design a much
wider rotation flap, which by necessity would have
extended above the medial canthus and would have placed
more wound closure tension on the lateral canthus and
lower eyelid. The intervening skin between the antici­
pated defect and the designed melolabial flap was
transposed toward the lip, thus creating a large Z-plasty
repair (Fig. 12-13D). Figure 12-14A shows an 8-month
postoperative photograph of the repair. Trap-door defor­
mity of the transposition flap was persistent and neces­
sitated contouring of the flap and Z-plasties of the scars.
The Z-plasties are shown in Figure 12-14B, C. The tech­
niques of revision surgery of local flaps are discussed in
detail in Chapter 27. The final results of the reconstruc­
tion are shown in Figure 12-14D, E.
Case 5
In general, skin-only defects of the lip are best repaired
with skin flaps designed and transferred within the con­
fines of the aesthetic region of the lip. This maintains
scars along aesthetic boundaries and maximizes the match
of skin color, texture, and hair growth patterns. However,
when skin-only defects of the lip are very large, there is
insufficient remaining skin within the lip aesthetic region
to repair the wound. In these circumstances, the only
alternative for repair is the use of a full-thickness skin
graft or cheek skin in the form of a transposition or
advancement flap. Such was the circumstance in the
patient shown in Figure 12-15. Most of the skin of the

250
SECTION I  FUNDAMENTALS
D
E
C
C, Laterally based rotation flap and superiorly based melolabial transposition flap designed for repair of antici­
pated defect. Standing cutaneous deformity of rotation flap marked with vertical lines. D, Skin adjacent to transposition flap pivoted
inferiorly to create Z-plasty. E, Flaps in place. Transposition flap represents a modified Z-plasty.
FIGURE 12-13, cont’d  ■

12  MELOLABIAL FLAPS
251
FIGURE 12-14  ■  A, Same patient shown in Figure 12-13 at 8 months after surgery. Trap-door deformity of transposition flap observed.
B, C, Z-plasties of scars and contouring of transposition flap performed. D, E, Result 11 months after revision surgery.
A
B
C
D
E

252
SECTION I  FUNDAMENTALS
FIGURE 12-15  ■  A, B, A 5 × 3-cm skin-only defect of upper lip. Superiorly based melolabial transposition flap designed for repair.
Remaining skin of right lateral aesthetic unit of lip marked for excision. C, Postoperative view at 3 months. Standing cutaneous
deformity was not excised and is adjacent to alar base.
A
B
C
upper lip was removed with micrographic surgery for a
basal cell carcinoma while the underlying muscle was
spared. The defect measured 5 × 3-cm. It is the author’s
opinion that full-thickness skin grafts should be used to
repair lip defects only as a last resort because of the poor
texture match with the remaining lip skin and the ten­
dency toward scar contracture and subsequent deforma­
tion of the vermilion. In general, transposition flaps
rather than advancement flaps from the cheek work best
for repair of skin defects of the lip because the donor site
scar remains in or parallel to the melolabial crease. In
contrast, advancement flaps that extend to the lip from
the cheek usually cross the melolabial crease at right
angles.
A superiorly based melolabial transposition flap was
selected for repair of this patient. The remaining skin of
the lateral aesthetic unit of the lip between the cheek and
the lip was removed to position scars along the vermilion
and in the alar-facial sulcus. This also allowed the resur­
facing of the entire lateral lip aesthetic unit. Because of
the large size of the flap, it was elected not to completely
excise the standing cutaneous deformity during the initial
transfer of the flap. The deformity formed adjacent to the
nose and is seen in Figure 12-15C. This figure also shows
the typical trap-door deformity that frequently develops
in transposition flaps in the early stages of healing. A
secondary contouring of the flap and removal of the
standing cutaneous deformity was performed 3 months
later. The patient also required two Z-plasties of the
vertical scar of the central lip (Fig. 12-16).
Another patient with a defect of the upper lip recon­
structed with a large melolabial transposition flap is
shown in Figure 12-17. This defect measured 4 × 3.5-cm
and was more complex than the preceding case. The
defect was deeper with loss of soft tissue and muscle of
the upper lip and loss of the entire nasal sill, floor of the
nasal vestibule, and base of the ala after micrographic
surgery for a basal cell carcinoma. Whenever defects
involve the upper lip and the base of the nose, it is often
prudent to reconstruct the defect in stages. The lip is
always repaired first to provide a platform on which to
rest the nose. The nasal defect is reconstructed second,
once the lip is completely healed and the scars of the lips
are maturing and not likely to suffer further contraction
(4-6 months).
A superiorly based melolabial transposition flap (Fig.
12-18) was selected for repair of the defect. The small
parabola marked at the superomedial border of the flap
represents that portion of the flap designated to line the
floor of the nasal vestibule. The remaining ala was sutured
to the flap simply to facilitate closure of the raw surface
of the ala and with the intent of reconstructing the alar
base by subsequent separation of the flap from the ala. A
piece of auricular cartilage was placed within the depths
of the nasal vestibular defect to prevent medial dislocation
of the ala from scar contracture (Fig. 12-18A). Because of
the large size of the flap necessary for reconstruction, the
lip defect was not enlarged by removing the remaining
skin of the lateral aesthetic unit of the lip. The transposi­
tion flap was dissected in the subcutaneous tissue plane.
The dissection was deepened superomedially to convey
extra cheek fat with the flap so that it could be used to fill
the depths of the deep defect located at the base of the
nose. The flap donor site was closed by advancement
creating a scar parallel to the melolabial crease. In this
case, the standing cutaneous deformity that formed during
transposition of the flap was not excised but used to assist
the closure of the defect. The deformity provided bulk
and skin for restoration of the floor of the nose.
Four months later, the standing cutaneous deformity
at the base of the nose was detached from the ala, trimmed
of excessive skin and fat, and contoured so that it restored
the normal configuration of the nasal sill and floor of the
vestibule. Three months later, a third surgical stage was
performed. In this stage, the base of the ala was recon­
structed with a composite auricular graft that was inserted
between the remaining ala and the reconstructed lip.
Additional contouring of the transposition flap was also
performed in an attempt to restore the melolabial crease
and the natural contour of the lateral upper lip. A small
persistent standing cutaneous deformity at the inferior
aspect of the flap donor site was also trimmed. Figure
12-19 shows the repair 1 day after the third stage of the
reconstruction. Quilting sutures are seen in the area of
previously transferred flap. These were used to eliminate
dead space and to prevent hematoma after undermining
of the flap and removal of redundant subcutaneous fat. A
pale composite graft is also seen at the base of the ala.
Figure 12-20 shows the completion of the reconstruction
of the lip and nose. The asymmetry of the face resulting

12  MELOLABIAL FLAPS
253
FIGURE 12-16  ■  A-D, Same patient shown in Figure 12-15. Preoperative and 5-year postoperative views after revision surgery consist­
ing of excision of standing cutaneous deformity and Z-plasties of vertical scar of central lip.
A
B
C
D

254
SECTION I  FUNDAMENTALS
FIGURE 12-17  ■  A, B, A 4 × 3.5-cm skin and muscle defect of upper lip, alar base, nasal sill, and floor of nasal vestibule.
A
B
FIGURE 12-18  ■  A, Superiorly based melolabial transposition flap designed for repair of defect of patient shown in Figure 12-17.
Auricular cartilage graft is spanning defect between remaining ala and floor of nasal vestibule. Small parabola marked at supero­
medial border of flap represents that portion of flap designated to line floor of nasal vestibule. Horizontal lines mark anticipated
standing cutaneous deformity (SCD) resulting from closure of flap donor site. B, Flap transposed. Bolster dressing used to compress
flap against floor of nasal vestibule. Remaining ala sutured to standing cutaneous deformity left intact after transposition of flap.
C, At 5 months after first stage of reconstruction. Standing cutaneous deformity of flap obliterates alar-facial sulcus and superior
portion of melolabial crease. Deformity was detached from ala and trimmed of excess fat and skin 4 months later in second surgical
stage.
A
B
C

12  MELOLABIAL FLAPS
255
FIGURE 12-19  ■  A, B, One day after third surgical stage of patient shown in Figure 12-17. During this stage, base of ala reconstructed
with composite auricular graft seen as segment of pale tissue inserted between remaining ala and reconstructed lip. Additional
contouring of transposition flap also performed to restore melolabial crease and more natural contour of upper lip. Quilting sutures
are observed in area of flap contouring. Small persistent standing cutaneous deformity removed from extreme inferior aspect of
flap donor site.
A
B
FIGURE 12-20  ■  A, B, Same patient shown in Figure 12-17 at 9 years after three-stage surgical reconstruction.
A
B

256
SECTION I  FUNDAMENTALS
FIGURE 12-21  ■  A 1.5 × 2-cm skin and soft tissue defect of ala.
from use of the melolabial flap is minimal, and the flap
donor site scar is well camouflaged by remaining in
RSTLs.
The two patients discussed in this case study demon­
strate the usefulness of large melolabial transposition
flaps for repair of extensive skin defects of the upper lip.
Such flaps can also be used for similar defects of the lower
lip (see Chapter 8, Case 8). Although large, the flap donor
defects were closed primarily and the resulting scars were
unobtrusive once healing had occurred. These patients
also demonstrate the versatility of the melolabial flap. In
the second patient, the flap was used to line the floor of
the nose, to provide a foundation for the alar base, and
to resurface the lip defect.
Case 6
A 69-year-old woman presented with a 1 × 1-cm super­
ficial skin defect of the right nasal tip and a 1.5 × 2-cm
skin and deep soft tissue loss of nearly the entire left ala
after micrographic surgical excision of two independent
basal cell carcinomas (Fig. 12-21). The defect extended
to the depth of the nasal mucosa but not through it.
Because of the proximity of the ala to the melolabial fold,
skin defects of more than half of the surface area of the
ala are ideally reconstructed with an interpolated melo­
labial flap. The flap provides skin nearly identical in
color, thickness, and texture to native alar skin. A melo­
labial flap with an interpolated design was selected for
repair of the wound rather than a transposition flap for
reasons discussed in an earlier section of this chapter. The
interpolated flap was designed as a subcutaneous tissue
pedicle island flap because the flap tends to be more reli­
able than a cutaneous base interpolated flap. The remain­
ing skin of the alar aesthetic unit was removed, and an
auricular cartilage graft was sculpted and inserted in the
wound so that it extended from the alar base to the nasal
facet (Fig. 12-22B). It was secured to the underlying
vestibular skin with mattress sutures. The melolabial flap
is shown drawn so that the major portion of the flap is
centered just lateral and superior to the level of the lateral
oral commissure (Fig. 12-22A). The anticipated inferior
standing cutaneous deformity resulting from closure of
the flap donor site is marked in Figure 12-22A. This
triangular piece of skin is excised and discarded during
wound closure. The triangle of skin marked at the supe­
rior border of the flap also represents a standing cutane­
ous deformity that forms from closure of the donor site
wound. However, this triangle is left attached to the flap
and is excised and discarded when the flap pedicle is
divided and the flap inset at 3 weeks after initial transfer
to the nose. A third surgical stage consisting of a contour­
ing procedure to thin the flap and to restore the alar
groove was performed. This technique is discussed in
detail in Chapter 18. Figure 12-23 shows the postopera­
tive results after the third surgical stage. The scar on the
cheek lies in the melolabial crease, and there is minimal
deformation of the melolabial fold. The alar-facial sulcus
has a natural appearance because it was left undisturbed
by use of an interpolated rather than a transposition
melolabial flap.
The author selects a subcutaneous tissue pedicle island
flap for the majority of nasal reconstruction cases requir­
ing an interpolated melolabial flap. However, a cutaneous
pedicle peninsular flap is often used for reconstruction of
skin defects of the ala or nostril margin that do not require
resurfacing of the entire aesthetic unit of the ala. The
patient shown in Figure 12-24 is an example of this. The
defect resulting from micrographic excision of a basal cell
carcinoma was more superficial than the defect described
in the preceding patient and was nearly confined to the
nostril margin. For this reason, a cutaneous pedicle inter­
polated melolabial flap was selected for repair (see Fig.
12-24). To create right-angle corners to the defect, 1 mm
of skin was removed from the border of the wound. The
angulated corners of the defect help prevent trap-door
deformity. An auricular cartilage graft was positioned to
span the defect of the nostril margin. A rectangular melo­
labial interpolated flap was designed and dissected by the
same methods discussed earlier except that the cutaneous
pedicle was maintained rather than creating a skin island.
The flap was dissected in a more superficial tissue plane
because it was dependent for its vascular supply not on
subcutaneous fat but rather its cutaneous attachment.
Three weeks after flap transfer, it was inset by dividing
and discarding the cutaneous pedicle. The wound from
excision of the pedicle was closed in the superior melola­
bial crease lateral to the alar-facial sulcus, which was left
undisturbed by the reconstructive process. The 6-month
postoperative results are shown in Figure 12-24. The
donor site scar of the melolabial flap is perfectly posi­
tioned within the aesthetic boundary of the melolabial
crease for maximum scar camouflage. The melolabial
interpolated flap is a valuable method of resurfacing nasal
defects, particularly for repair of skin defects of the ala,
columella, and caudal nasal sidewall. For an in-depth
discussion of nasal reconstruction, the reader is directed
to Chapter 18.
Case 7
Transposition flaps are the most common local flap har­
vested from the melolabial fold. In the author’s practice,
the subcutaneous tissue pedicle island advancement flap
is the second most common melolabial flap used. The

12  MELOLABIAL FLAPS
257
FIGURE 12-22  ■  A, Same patient shown in Figure 12-21. Remaining skin of ala marked for excision. Melolabial interpolated subcuta­
neous tissue pedicled flap designed for repair. Center of flap is lateral and superior to level of oral commissure. Medial border of
flap is designed to lie in melolabial crease. Triangle of skin at superior border of flap represents standing cutaneous deformity (SCD)
resulting from closure of donor defect. This is transferred with flap and removed when flap is inset. Horizontal lines mark anticipated
second standing cutaneous deformity inferior to flap. This deformity is excised and discarded during closure of donor defect.
B, Auricular cartilage graft positioned to span gap between alar-facial sulcus and nasal facet. C, In situ flap incised. D, Flap is pedicled
on ample subcutaneous fat of melolabial fold. E, Flap in position. F, One week after first-stage reconstruction.
A
B
C
D
E
F

258
SECTION I  FUNDAMENTALS
FIGURE 12-23  ■  A-C, Same patient shown in Figure 12-21 at 6 months after reconstruction of ala. Flap contouring procedure performed
3 months after flap inset.
A
B
C
A
B
C
D
FIGURE 12-24  ■  A, A 1.5 × 1-cm skin and soft tissue defect of nostril margin. Melolabial interpolated cutaneous pedicle flap designed
for repair. Auricular cartilage graft has been positioned to span nostril margin defect. B, In situ flap incised. C, Flap transferred to
nose on cutaneous pedicle. D, Flap in place.

12  MELOLABIAL FLAPS
259
E
F
E-J, Preoperative and 6-month postoperative views. No revision surgery performed.
FIGURE 12-24, cont’d  ■
G
H
Continued

260
SECTION I  FUNDAMENTALS
I
J
FIGURE 12-24, cont’d
indications and techniques for dissecting this flap are
discussed in an earlier portion of the chapter. Presented
are two cheek defects repaired by melolabial V-Y subcu­
taneous tissue pedicled island advancement flaps.
A 57-year-old man presented with a rectangular skin
defect having a long diagonal of 6 cm and a short diago­
nal of 5 cm (Fig. 12-25). The defect resulted from surgi­
cal resection of a superficial spreading melanoma. The
three best options for repair of the defect with a local flap
included transposition and rotation pivotal flaps and a
melolabial subcutaneous tissue pedicle island advance­
ment flap. The island flap was selected for repair because
of the redundancy of skin in the jowl that could be used
for construction of the flap. Figure 12-25 shows the
design of the flap and the flap in place. A great advantage
of the subcutaneous tissue pedicle island advancement
flap is that no significant standing cutaneous deformity is
created and so excision of facial skin is not necessary. This
is in marked contrast to transposition and rotation flaps.
If such flaps had been used in this case, large standing
cutaneous deformities would form on pivoting of the
flaps. These deformities would have required excision,
discarding valuable facial skin in a patient who had already
lost a large portion of his cheek skin from resection of
the skin cancer. Figure 12-26 shows the preoperative and
3-month postoperative views of the reconstruction. The
majority of scars rest in RSTLs, and there is minimal
deformation of the melolabial fold.
A 39-year-old patient was also treated for a basal cell
carcinoma of the medial cheek. The tumor was treated
with micrographic surgical excision, resulting in a 2.5 ×
2.6-cm cutaneous defect. The defect is shown in Figure
12-27, in addition to the design of a melolabial subcutane­
ous tissue pedicle island advancement flap. The flap was
designed to use skin of the melolabial fold. The medial
border of the flap was designed so that it was within the
melolabial crease. Island advancement flaps have the
greatest mobility and thus are most useful when designed
in areas having ample subcutaneous fat. Relative to the
remaining face, the melolabial fold contains the greatest
amount of fat, making the fold an ideal donor site for
island flaps. The ample subcutaneous tissue on which to
base the flap and the marked mobility of the melolabial
island flap are demonstrated in Figure 12-27C. As was
noted in the preceding patient, excision of a standing
cutaneous deformity was not necessary, so all facial skin
was preserved except for that required to resect the skin
cancer. Figure 12-28 shows the preoperative and 1-year
postoperative views of the reconstruction. Minimal defor­
mation of the melolabial fold is observed on the frontal
and oblique postoperative views.
Case 8
The melolabial subcutaneous tissue pedicle island
advancement flap is most effective for repairing 3-cm to

12  MELOLABIAL FLAPS
261
FIGURE 12-25  ■  A, A 5 × 4-cm medial cheek defect. Melolabial subcutaneous tissue pedicle island advancement flap designed for
repair. Borders of designed flap parallel melolabial crease. B, Flap in place and donor site closed.
A
B
A
B
FIGURE 12-26  ■  A-D, Same patient shown in Figure 12-25, preoperative and 3-month postoperative views. No revision surgery
performed.
Continued

262
SECTION I  FUNDAMENTALS
C
D
FIGURE 12-27  ■  A, A 2.5 × 2.6-cm skin defect of medial cheek. Melolabial subcutaneous tissue pedicle island advancement flap
designed for repair of wound. Stippled area represents extent of flap undermining in subcutaneous plane. B, In situ flap incised.
C, Ample subcutaneous tissue pedicle provides mobility to skin island. D, Flap in place and donor defect closed.
A
B
C
D
FIGURE 12-26, cont’d

12  MELOLABIAL FLAPS
263
FIGURE 12-28  ■  A-D, Same patient shown in Figure 12-27, preoperative and 1 year postoperative views. No revision surgery
performed.
A
B
C
D

264
SECTION I  FUNDAMENTALS
A
B
C
D
FIGURE 12-29  ■  A, A 2.5 × 3-cm skin defect of upper lip. Melolabial subcutaneous tissue pedicle island advancement flap designed
for repair. B, In situ flap incised. C, Subcutaneous tissue pedicle lateral to orbicularis oris provides mobility to flap. D, Flap in place
and donor defect closed.
6-cm skin defects of the medial cheek adjacent to the alar
base. It is also useful for repair of lateral upper lip skin
defects that extend into the adjacent cheek.16 In such
circumstances, skin from the melolabial fold is recruited
into the island flap along with any remaining lip skin
lateral to the defect. Presented are two cases of large
lateral upper lip defects that were repaired with melola­
bial island advancement flaps.
The first patient, a 73-year-old woman, had an exci­
sion of a 3 × 2.5-cm area of skin of the upper lip and
medial cheek to remove a basal cell carcinoma. A melo­
labial subcutaneous tissue pedicle island advancement
flap was designed for repair of the defect (Fig. 12-29).
The island flap was dissected by surgical techniques
similar to those discussed earlier except that the portion
of the flap consisting of lip skin was undermined to free
the lip skin from its attachment to the orbicularis oris.
For melolabial island flaps including lip skin, the dissec­
tion requires freeing the skin of the island from any
muscle attachments to the orbicularis oris. The flap is

12  MELOLABIAL FLAPS
265
E
F
G
H
E-H, Preoperative and 10-month postoperative views. Scar revision performed 7 months postoperatively.
FIGURE 12-29, cont’d  ■
A
B
FIGURE 12-30  ■  A, A 3.5 × 2.5-cm skin and muscle defect of upper lip and nasal sill. B, Melolabial subcutaneous tissue pedicle island
advancement flap designed for repair. Skin inferior to lip defect marked for excision to enlarge defect so inferior border of flap will
be along vermilion-cutaneous aesthetic boundary.
Continued

266
SECTION I  FUNDAMENTALS
C
D
FIGURE 12-31  ■  A, B, Same patient shown in Figure 12-30. Preoperative and 3-month postoperative views. No revision surgery
performed.
A
B
based on the ample subcutaneous fat lateral to the orbi­
cularis oris. Figure 12-29C demonstrates the flap’s sub­
cutaneous tissue pedicle and the mobility that the pedicle
provides to the flap.
A second patient reconstructed with a melolabial sub­
cutaneous tissue pedicle island advancement flap consist­
ing of skin of the lip and the melolabial fold is shown in
Figure 12-30. The patient, a 41-year-old man, presented
with a 5-year history of a tumor of the upper lip and nasal
sill. Biopsy of the lesion revealed a basal cell carcinoma.
The tumor was resected by micrographic excision, result­
ing in a skin and muscle defect of the upper lip measuring
3.5 × 2.5-cm. As in the preceding example, there was
insufficient upper lip skin remaining for reconstruction
of the defect without recruitment of skin from the melo­
labial fold. Similar to the preceding example, a melolabial
subcutaneous tissue pedicle island advancement flap was
used to repair the wound. The skin inferior to the defect
was removed to the level of the vermilion to position the
border of the flap along the vermilion (Fig. 12-30B). The
ample subcutaneous tissue pedicle is demonstrated in
Figure 12-30C. Enlargement of the defect to facilitate
positioning of the border of the island flap along an aes­
thetic boundary provided maximum scar camouflage as
noted in the early postoperative results seen in Figure
12-31B.
C, Flap based on subcutaneous fat lateral to orbicularis oris. D, Postoperative result at 1 day. Lateral border of
flap parallel to melolabial crease.
FIGURE 12-30, cont’d  ■

12  MELOLABIAL FLAPS
267
REFERENCES
1. Cameron RR, Latham WD, Dowling JA. Reconstruction of the
nose and upper lip with nasolabial flaps. Plast Reconstr Surg
1973;52:145.
2. Pers M. Cheek flaps in partial rhinoplasty. Scand J Plast Reconstr
Surg 1967;1:37.
3. Cameron RR. Nasal reconstruction with nasolabial cheek flaps. In:
Grabb WC, Myers MB, editors. Skin flaps. Boston: Little, Brown;
1975.
4. Clevens RA, Baker SR. Defect analysis and options for reconstruc­
tion. Otolaryngol Clin North Am 1997;30:495.
5. Baker SR. Reconstruction of facial defects. In: Cummings CW,
Fredrickson JM, Harker LA, et al, editors. Otolaryngology—head
and neck surgery. 3rd ed. Philadelphia: Mosby; 1998.
6. Baker SR. Local cutaneous flaps in soft tissue augmentation and
reconstruction in the head and neck. Otolaryngol Clin North Am
1994;27:139.
7. Rustad TJ, Hartshorn DO, Clevens RA, et al. The subcutaneous
pedicle in melolabial reconstruction. Arch Otolaryngol Head Neck
Surg 1998;104:1163.
8. Burget GC, Menick FJ. Aesthetic restoration of one-half the upper
lip. Plast Reconstr Surg 1986;78:583.
9. Baker SR, Johnson TM, Nelson BR. The importance of maintain­
ing the alar facial sulcus in nasal reconstruction. Arch Otolaryngol
Head Neck Surg 1995;101:617.
10. Fader DJ, Baker SR, Johnson TM. The staged cheek-to-nose
interpolated flap for reconstruction of the nasal alar rim/lobule.
J Am Acad Dermatol 1997;37:644.
11. Burget GC, Menick FJ. Nasal support and lining: the marriage of
beauty and blood supply. Plast Reconstr Surg 1989;84:189.
12. Herbert DC. A subcutaneous pedicled cheek flap for reconstruc­
tion of alar defects. Br J Plast Surg 1978;31:79.
13. Sheen JH, Sheen A, editors. Aesthetic rhinoplasty. 2nd ed.
St. Louis: Mosby; 1987. p. 255.
14. Walike JW, Larrabee WF Jr. The note flap. Arch Otolaryngol
1985;111:430.
15. Larrabee WF Jr. Design of local skin flaps. Otolaryngol Clin
North Am 1990;23:899.
16. Griffin G, Weber S, Baker SR. Outcomes following V-Y advance­
ment flap reconstruction of large upper lip defects. Arch Facial
Plast Surg 2012;14:193.

268
C H A P T E R 1 3 
INTERPOLATED PARAMEDIAN
FOREHEAD FLAPS
Shan R. Baker
INTRODUCTION
Median forehead flaps were first described in an Indian
medical treatise, the Sushruta Samita, in approximately
700 BC.1-3 The operation was performed by members of
a caste of potters known as the Koomas. The need for
this operation arose from the common Indian practice of
amputating the tip of the nose as punishment for a variety
of crimes ranging from robbery to adultery.4,5 The first
reported use of the median forehead flap outside of India
was by Antonio Branca of Italy. Based on an Arabic trans­
lation of the Sushruta Samita, Branca performed a nasal
reconstruction using the midforehead flap in the 15th
century.6,7 In the 16th and early 17th centuries, little
advancement was made in the use of the median forehead
flap because plastic and reconstructive surgery fell into
disrepute.4,5,7 The flap had a revival in 1794, when J. C.
Carpue read an editorial in the Gentleman’s Gazette of
London describing the flap’s use for nasal reconstruction.8-10
Initially, Carpue practiced the median forehead flap oper­
ation on cadavers. Twenty years passed before he per­
formed the operation on two patients. He reported his
successful results in a monograph entitled “An Account
of Two Successful Operations for Restoring a Lost Nose
from the Integuments of the Forehead.” His article was
widely circulated throughout Europe and served to popu­
larize the operation.6,9 In the 1830s, Ernst Blausius (Chief
of Ophthalmologic Surgery of Berlin), Johann Friedrich
Dieffenbach (Chief of Surgery at Munich Hospital), and
Natale Petrali of Milan simultaneously reported on uses
and variations of the median forehead flap for reconstruc­
tion of the face and nose. On the basis of their influence
as respected surgeons at large European teaching hospi­
tals, the use and popularity of the forehead flap grew.6 In
the late 1830s, use of the median forehead flap for nasal
and facial reconstruction crossed the Atlantic when J. M.
Warren performed the operation in the United States.4,11
By the early 1900s, the forehead flap was used
to reconstruct losses of the nose secondary to battle,
scrofula, syphilis, and cancer. Many American surgeons,
such as Pancoast, Mutter, Buck, Davis, and Fomon,
wrote about the use of the forehead flap in nasal recon­
struction. Little modification of flap design, use, harvest,
or donor site closure occurred until articles authored by
Kazanjian appeared in the plastic surgery literature of
the 1930s. This pioneer plastic surgeon was the first to
determine that the primary blood supply of the flap is
from the supratrochlear and supraorbital arteries. Kaza­
njian described a forehead flap designed precisely in the
midline, allowing primary closure of the donor site. This
technical modification minimized the forehead donor
scar, which up to that point represented the major mor­
bidity of the operation. Before Kazanjian’s modification,
the donor site of the forehead flap had either been skin
grafted or left open to heal secondarily by granulation
and wound contraction. This practice commonly left the
patient more scarred and disfigured than before the
reconstructive surgery.12
Kazanjian carried incisions from the hairline to a point
immediately above the level of the nasofrontal angle. By
his time, surgeons had recognized that the use of unlined
forehead flaps to repair full-thickness nasal defects pre­
dictably resulted in contraction of the flap and compro­
mise of the nasal passage. The contour of the external
nose also deformed as the airway constricted from pro­
gressive contracture of scar developing on the undersur­
face of the flap. In response to this, surgeons developed
a number of modifications in the design of the forehead
flap to achieve additional length so the flap could be
folded on itself for internal lining. These designs included
oblique and horizontally oriented flaps. Gillies13 described
a U-shaped flap with an ascending and descending com­
ponent that he called the up-and-down flap. The ascend­
ing portion of the flap was positioned over the axis of
the supraorbital artery on one side and the descending
portion over the contralateral supraorbital artery. Con­
verse14 harvested lateral forehead skin based on a long
pedicle of hair-bearing scalp, which became known as the
scalping flap. The designs by Gillies and Converse cir­
cumvented the need to include hair-bearing scalp to
provide additional length so that the flap could be folded
on itself. Unfortunately, these modifications of the origi­
nal design of the median forehead flap left marked defor­
mities of the forehead. It also became apparent that
folding the flap on itself created a great deal of tissue bulk
that caused the nose to collapse. In addition, partial
necrosis of the portion turned internally was common.
In the 1960s, Millard11,15 designed a large modified
median forehead flap called the seagull flap, in which
 Videos available online

13  INTERPOLATED PARAMEDIAN FOREHEAD FLAPS
269
below the bony orbital rim provided additional flap
length. This often avoided the need to extend the flap to
hair-bearing scalp for sufficient length to reach the nasal
tip. They noted that the end arterioles of the supratroch­
lear artery are located immediately under the dermis,
superficial to the frontalis muscle. The authors deter­
mined that the frontalis muscle could be safely removed
from the distal flap without impairing the vascularity of
the skin.1
Studies by Mangold, McCarthy, and Shumrick better
defined the vascular anatomy of the forehead. In 1980,
Mangold et al20 demonstrated that the blood supply to
forehead skin is from the dorsal nasal (a terminal branch
of the angular artery), supratrochlear, supraorbital, and
superficial temporal arteries. Each of these vessels pro­
vides a primary blood supply to a particular region of the
forehead, but all demonstrate numerous interconnecting
anastomoses. Mangold’s injection studies and dissections
of cadavers showed that the forehead could be divided
into regions based on their predominant vascular supply
(Fig. 13-1). On the basis of these vascular regions,
Mangold determined that median and paramedian verti­
cally oriented forehead flaps are nourished primarily by
the supratrochlear artery and secondarily by the dorsal
lateral extensions were used to cover the nasal alae. Inci­
sions for the pedicle of the flap extended below the bony
orbital rim to gain additional flap length. Millard also
described methods of donor site repair and techniques
for constructing nasal support, all of which improved the
outcome of nasal reconstruction.
Labat7,16 was the first surgeon to design a median fore­
head flap with the base centered over a unilateral supra­
trochlear artery. He curved the incisions of the proximal
pedicle so the base of the flap rested immediately above
the medial brow and canthus on one side. This reduced
the standing cutaneous deformity resulting from pivoting
of the flap and increased the effective length, making
more tissue available for reconstruction. Millard shifted
the entire vertical axis of the central forehead flap to a
paramedian position, demonstrating that the flap could
survive without including the central glabellar skin in
the pedicle.7 Menick modified Millard’s design of the
paramedian flap by making the pedicle narrower.7 This
offered a greater freedom of tissue movement, a smaller
standing cutaneous deformity, and a longer effective
length to the flap.
In the 1980s, Burget and Menick17-19 found that
extending incisions for the pedicle of the paramedian flap
FIGURE 13-1  ■  A, Supratrochlear artery
exits orbit approximately 2 cm lateral to
midline, passing under orbicularis oculi
and over corrugator supercilii. At level of
eyebrow, supratrochlear and supraorbital
arteries pass through orbicularis and
frontalis muscles and continue superiorly
in superficial subcutaneous tissue plane.
B, Vascular territories of arteries supply­
ing forehead skin. (From Baker SR: Interpo­
lated paramedian forehead flaps. In Baker
SR, editor: Principles of nasal reconstruction,
ed 2, New York, Springer, 2011.)
Supratrochlear a.
Frontalis m.
Corrugator
supercilii m.
Orbicularis
oculi m.
Supraorbital a.
A
Supraorbital a.
Supratrochlear a.
Dorsal nasal a.
Superficial
temporal a.
B

270
SECTION I  FUNDAMENTALS
corrugator supercilii.10 At approximately the level of the
eyebrow, the artery passes through the orbicularis and
frontalis muscles and continues superiorly in the superfi­
cial subcutaneous tissue. This transition of the artery
from a deeper to a more superficial tissue plane was con­
firmed by histologic examination of cross sections of
forehead skin at various levels. Doppler examinations of
healthy volunteers helped confirm the findings of the
cadaver studies.10
Studies of the vascular anatomy of the forehead
confirm that the supratrochlear artery serves as the axial
blood supply of median and paramedian vertically ori­
ented forehead flaps. The studies also confirm a rich
anastomotic network in the medial canthal region. Surgi­
cal techniques that preserve this regional blood flow have
allowed surgeons to harvest paramedian forehead flaps
based on pedicles narrower than those used for median
forehead flaps. The narrower pedicle provides the flap
with greater freedom of transposition about its pivotal
point and greater effective length. The pedicle may be as
narrow as 1.2 cm, reducing deformity of the inferior
forehead area and always enabling the surgeon to achieve
primary closure of the lower half of the donor defect
(Fig. 13-3).7,23
PARAMEDIAN FOREHEAD FLAP
Midforehead flaps, which include the median and para­
median flaps and their many variations, have proved to
be dependable flaps for midfacial reconstruction.2,3,24
However, the paramedian forehead flap based on a single
supratrochlear artery has replaced the median forehead
flap for nasal reconstruction because it has a more axial
design, narrower base, and greater effective length. The
design also enables the simultaneous or sequential use of
two vertically oriented forehead flaps. The paramedian
flap has an abundant blood supply, providing for revas­
cularization of cartilage and bone grafts covered by the
flap. Removal of muscle and subcutaneous fat from the
distal portion can make the paramedian forehead flap
thin, pliable, and easily contoured to fit any defect of the
nose. Maintaining the attachment of the frontalis muscle
to the flap is occasionally useful when more bulk is
required to fill defects of considerable depth.25 In most
instances, however, freeing the flap from the frontalis
muscle and most of its subcutaneous fat is essential when
the forehead flap is used as covering for the nose. Proper
thinning of the flap will ensure that the shape and
contour of the underlying nasal framework are visually
manifested. Flap thinning may be accomplished without
concern for compromise of the flap’s vasculature because
the supratrochlear artery travels superiorly in the
subcutaneous/subdermal tissue plane from a point 1 cm
superior to the level of the eyebrow.10 The superficial
location of the artery enables thinning of the distal
portion of the flap by removal of the fascia and frontalis
muscle and, if necessary, nearly all of the subcutaneous
tissue. The ability to modulate the thickness of a flap so
that it may exactly match the thickness of the nasal
defect at the recipient site greatly enhances the aesthetic
result.25
nasal and supraorbital arteries. McCarthy and others21,22
confirmed Mangold’s work in clinical experiences with
patients. McCarthy injected the facial artery after ligation
of the supraorbital and supratrochlear arteries and showed
sufficient filling of the forehead vasculature to supply
vertically oriented flaps in the region of the central fore­
head.21 This suggested that a paramedian forehead flap
could survive even when the supratrochlear artery on the
side of the flap is not present.
In 1992, Shumrick and Smith10 performed detailed
anatomic studies of the forehead using techniques of latex
injection, radiography, and microdissection to determine
the precise vascular anatomy of the central forehead.
Examination of the radiographic data confirmed a clini­
cally apparent fact: the forehead region contains an intri­
cate system of anastomosing vessels among the angular,
supratrochlear, supraorbital, and superficial temporal
arteries (Fig. 13-2). The paired supratrochlear arteries
connected with each other by several horizontal unnamed
arteries that cross the midline. Moreover, the supratroch­
lear arteries consistently demonstrated anastomotic
branches with the angular and supraorbital arteries in the
medial canthal region. Microdissection of the forehead
vasculature confirmed these radiographic findings. The
supratrochlear artery was consistently found to exit the
superior medial orbit approximately 1.7 to 2.2 cm lateral
to the midline and continued its course vertically in a
paramedian position approximately 2 cm lateral to the
midline. This position closely corresponds to the location
of the medial border of the eyebrow. The supratrochlear
artery was found to exit the orbit by piercing the orbital
septum, passing under the orbicularis oculi and over the
FIGURE 13-2  ■  Radiograph showing skin vasculature after injec­
tion of contrast medium. Horizontal wire markers delineate
superior bony orbital rims. Vertical wires mark medial end of
eyebrows. Note intricate system of anastomosing vessels. (From
Baker SR: Interpolated paramedian forehead flaps. In Baker SR,
editor: Principles of nasal reconstruction, ed 2, New York, Springer,
2011.)

13  INTERPOLATED PARAMEDIAN FOREHEAD FLAPS
271
C
D
A
B
FIGURE 13-3  ■  A, Heminasal cutaneous defect. Auricular cartilage graft placed along nostril rim for structural support. B, Paramedian
forehead flap designed for reconstruction of nose. Centering of pedicle over vertical axis of supratrochlear artery enables narrow
pedicle 1.2 cm wide. C, D, Narrow pedicle provides greater effective length and smaller standing cutaneous deformity than wider
pedicle.
Continued

272
SECTION I  FUNDAMENTALS
E
F
G
H
E-H, Preoperative and 1.5-year postoperative views. No revision surgery performed.
FIGURE 13-3, cont’d  ■
Paramedian forehead flaps used as interpolated flaps
for nasal reconstruction require a second operation to
separate the pedicle.26 The pedicle may safely be detached
as soon as 10 to 14 days after flap transfer. The author
prefers a 3-week interval between the time of flap transfer
and flap inset for all patients, especially those who use
tobacco products. At 3 weeks, the distal portion of the
flap has developed sufficient collateral blood supply from
the nose to allow thinning and sculpturing of the more
proximal portion of the flap left attached to the recipient
site. If the nasal defect is small, the portion of the fore­
head flap covering the defect may be completely thinned
at the time of initial transfer.
A minor disadvantage of the paramedian forehead flap
is the donor site scar and the necessity for a two-stage
procedure. However, forehead scars are rarely unsightly
because primary wound closure is easily achieved in the
inferior portion of the forehead owing to the narrow
pedicle required (Fig. 13-4). Although the narrow pedicle
enables primary repair of the inferior aspect of the donor
site wound, the width of the superior portion of the flap
may be several centimeters, precluding complete wound
approximation. In general, flaps wider than 4.5 cm are
too large to allow complete primary closure of the donor
site. In such circumstances, the superior portion of the
donor site wound must, in part, be left to heal by second­
ary intention. Fortunately, the resulting midline or para­
median scar in the superior portion of the forehead is
extremely forgiving and only occasionally requires revi­
sion. The acceptable scar is related to the immobile

13  INTERPOLATED PARAMEDIAN FOREHEAD FLAPS
273
division of the pedicle and inset of the flap, another pro­
cedure is performed to eliminate the hair. The portion of
the flap bearing hair is elevated in the subdermal plane
where the follicles of scalp hair are located. Exposed fol­
licles are removed or cauterized with a fine-tip needle
cautery, with use of magnification to assist in visualiza­
tion. A third depilation may sometimes be required. Even
with this persistent approach, a few hair follicles may
survive and are treated individually with electrolysis. The
hair bulb that is responsible for hair regeneration is
located in the subcutaneous fat just beneath the dermis.
In some instances, remnants of the bulb may be left in
the dermis after removal of the follicle during surgical
depilation. These remnants may have sufficient germi­
nating potential to cause breakthrough hair growth in
spite of aggressive removal of exposed hair follicles.
The fine vellus hair that is prominent in some patients
just in front of the forehead hairline is even more difficult
skin and convex contour of the superior central forehead
(Fig. 13-5).
The forehead provides a source of skin with an excel­
lent color and texture match to the nasal skin. The para­
median forehead flap may be designed with sufficient size
and length to provide covering for the entire nose. For
patients who have a low anterior hairline or a widow’s
peak, the surgeon may not be able to design the flap with
adequate length to reach the columella or tip without
transferring hair-bearing skin to the nose. When flap
extension to hair-bearing scalp is necessary, the distal flap
is thinned sufficiently to expose hair follicles. Under
magnification, each hair follicle is meticulously cauter­
ized either at the time of transfer or at the time of pedicle
division. In patients with a high concentration of hair
follicles in the distal portion of the flap, it is usually not
possible to eradicate all hair at the time of initial transfer
or subsequent pedicle detachment. Two to 3 months after
FIGURE 13-4  ■  A, A 1.5 × 1.8-cm cutaneous defect of nasal tip. B, At 8 months after repair of defect with paramedian forehead flap.
C, Donor site forehead scars are rarely unsightly. No revision surgery performed.
A
B
C

274
SECTION I  FUNDAMENTALS
A
B
C
FIGURE 13-5  ■  A, A 5 × 4-cm cutaneous defect of nasal tip, caudal dorsum, and right ala. B, Paramedian forehead flap designed for
repair. C, Flap in place. Flaps wider than 4.5 cm are too large to allow complete wound closure of donor site. Portion of superior
donor site wound left to heal by secondary intention.

13  INTERPOLATED PARAMEDIAN FOREHEAD FLAPS
275
D
E
F
G
D-G, Preoperative and 9-month postoperative views. Contouring procedure to restore alar groove performed 6
months postoperatively. No revision surgery performed on forehead scar.
FIGURE 13-5, cont’d  ■

276
SECTION I  FUNDAMENTALS
to eliminate from a forehead flap because the hair follicles
are not visible by the human eye and are located in the
dermis rather than in the subdermal plane. This hair may
be treated by electrolysis with limited success. The best
treatment is to have the patient periodically use a depila­
tory cream for removal. Laser hair removal may be used
in place of electrolysis for dark-pigmented scalp hair, but
it is not effective for vellus hair.
To avoid multiple procedures directed at depilation,
paramedian forehead flaps should be designed not to
include scalp hair whenever possible. Avoiding scalp hair
may be possible by extending the incision for the pedicle
through the eyebrow to the level of the bony orbital rim.
The pedicle is skeletonized on the soft tissue surround­
ing the supratrochlear artery as it exits the orbit. This
requires complete sectioning of the corrugator supercilii
to achieve free tissue movement. If this step is unlikely
to lend sufficient length to the flap, another helpful
approach is to obliquely angle the flap from the midline
laterally toward the temporal recession just beneath the
hairline (Fig. 13-6).27,28 This modification in design of
the paramedian forehead flap is possible only for smaller
flaps measuring less than 3 cm in maximum width. Har­
vesting of flaps 3 cm or greater in width from the lateral
portion of the forehead may occasionally cause more
apparent scars than centrally located donor sites. It may
also cause excessive upward displacement of the central
portion of the eyebrow on the donor side. Thus, flaps
wider than 3 cm are usually extended to the hair-bearing
scalp rather than designed in an oblique fashion when
the necessary length of the flap requires such extensions
(Fig. 13-7). When the oblique forehead design is used,
the distal portion of the flap does not have the advantage
of an axial vascular pattern. However, the author
has been successful in transferring forehead skin based
on a supratrochlear artery but positioned several centi­
meters lateral to the axis of the artery. This success is
related to the rich vascular anastomotic network of fore­
head skin.
Historically, the paramedian forehead flap has been
used for reconstruction of larger defects of the nose. It is
the preferred method for covering nasal defects too large
to be repaired with full-thickness skin grafts, nasal cuta­
neous flaps, composite auricular grafts, or interpolated
melolabial flaps.4,5,12 In general, nasal defects larger than
2 cm in width in the horizontal axis are best repaired with
a paramedian forehead flap (see Fig. 13-7).12 In addition,
this flap is best for repair of nasal defects with exposed
bone and cartilage deficient of periosteum or perichon­
drium and in instances in which the central face has been
irradiated.5,12
Reconstruction of a nasal defect with a paramedian
forehead flap requires planning and preparation. Preop­
erative assessment includes measurement of the defect
and consideration of the required length and width of the
flap. Attention is given to the height of the anterior
hairline and degree of forehead skin laxity. Patients are
counseled concerning their appearance during the
staged reconstruction. They are shown photographs of
patients who have had similar surgery after the first stage
and after flap inset. Wound care of the pedicle, donor
site, and recipient areas and information about realistic
expectations and goals of the reconstructive procedure
are discussed.
SURGICAL TECHNIQUE
The paramedian forehead flap is usually harvested with
use of a combination of a short-acting local anesthetic
(lidocaine 1% with epinephrine 1:100,000 concentra­
tion), long-acting local anesthetic (bupivacaine 0.25%),
and intravenous sedation. Thirty minutes before skin
incision, a prophylactic antistaphylococcal antibiotic of
the surgeon’s choice is administered intravenously if a
cartilage or bone graft is required. The patient is placed
supine on the operating room table in 20° to 30° of a
reverse Trendelenburg position. This position decreases
venous pooling, causing less intraoperative blood loss
during flap harvest and transfer. The eyes are protected
by covering them securely with moist eye pads. The full
face and scalp, from the mid vertex to the submental area,
are prepared with a sterilization solution of the surgeon’s
choice. A sterile head drape is placed, and full-body
draping is completed in the usual sterile fashion.
The flap may be designed with the assistance of a
Doppler probe to localize the supratrochlear artery, but
the author has not found this to be necessary. The base
of the pedicle is usually centered over the supratrochlear
artery on the same side as the majority of the nasal defect
for which the flap is intended for repair. The vertical axis
of the supratrochlear artery is 2 cm lateral to the midline,
which corresponds to the medial border of the eyebrow
in the majority of patients. Therefore, the base of the flap
is centered over the medial border of the eyebrow. The
width of the pedicle is designed 1.5 cm wide, and the base
is not flared as this restricts the pivotal movement of
the flap.
The cutaneous defect is outlined by squaring off the
corners of the defect with a skin marker. Giving the
defect angular rather than curvilinear borders reduces
the propensity for development of trap-door deformity
(see Fig. 13-5). If the defect occupies more than 50% of
the surface area of a convex-shaped nasal aesthetic unit
(tip and alae), the remaining skin of the unit is marked
for removal (Fig. 13-8). When a unilateral cutaneous
defect encompasses half or less of the surface area of the
nasal tip, the defect is usually enlarged only to the degree
that the enlargement creates a hemi-tip defect (Fig. 13-9).
This will limit the size of the forehead flap necessary for
reconstruction, which in turn minimizes the deformity of
the forehead. The aesthetic result of resurfacing a hemi­
nasal defect with a paramedian forehead flap is as pleasing
as resurfacing the entire nasal tip, provided the remaining
nasal skin is of thin or medium thickness.
An exception to the rule of resurfacing the entire nasal
unit when the defect occupies half or more of the surface
area of the unit is the dorsum. When cutaneous defects
occur on the dorsum, the thin skin of the rhinion is never
removed unless it is required for tumor ablation. In most
patients, the intrinsic thickness of forehead skin is greater
than that of the native skin covering the rhinion. Even
with removal of all the subcutaneous tissue from a
Text continued on p. 284

13  INTERPOLATED PARAMEDIAN FOREHEAD FLAPS
277
FIGURE 13-6  ■  A, A 2 × 1-cm cutaneous defect of nasal tip and ala. B, Paramedian forehead flap designed for repair. Distal flap angled
toward temporal recession beneath anterior hairline to provide additional length to flap while avoiding transfer of scalp hair to nose.
C, Flap in place. D, At 2 months after flap inset. E, Postoperative view at 1.5 years. No revision surgery performed.
A
B
C
D
E

278
SECTION I  FUNDAMENTALS
A
B
C
Auricular cartilage
framework graft
Auricular cartilage
rim graft
FIGURE 13-7  ■  A, A 5 × 2-cm cutaneous defect of nasal tip, caudal dorsum, and right ala. Paramedian forehead flap designed for
repair. Size of defect necessitated extending forehead flap into hair-bearing scalp. B, C, Auricular cartilage grafts in place to provide
structural support to right ala and left nostril margin.

13  INTERPOLATED PARAMEDIAN FOREHEAD FLAPS
279
F
G
Continued
D, E, Flap in place. Portion of superior donor site wound left to heal by secondary intention. Bolster dressings
used to appose flap to cartilage grafts. F-M, Preoperative and 5-year postoperative views. Contouring procedure and nasal base
reduction performed.
FIGURE 13-7, cont’d  ■
D
E

280
SECTION I  FUNDAMENTALS
H
I
J
K
FIGURE 13-7, cont’d

13  INTERPOLATED PARAMEDIAN FOREHEAD FLAPS
281
L
M
FIGURE 13-7, cont’d
C
D
A
B
Skin removed
Auricular cartilage
rim graft
FIGURE 13-8  ■  A, A 3 × 2.5-cm cutaneous defect of nasal tip and small portion of left ala. Defect involves left nostril margin. Remain­
ing skin of tip marked for excision. B, Skin excised. Auricular cartilage rim graft in place to prevent nostril retraction. C, Paramedian
forehead flap designed for repair. D, Flap in place.
Continued

282
SECTION I  FUNDAMENTALS
E
F
G
H
E-J, Preoperative and 9-month postoperative views. Patient had contouring procedure and forehead scar revi­
sion 7 months postoperatively.
FIGURE 13-8, cont’d  ■

13  INTERPOLATED PARAMEDIAN FOREHEAD FLAPS
283
I
J
FIGURE 13-8, cont’d
Continued
FIGURE 13-9  ■  A, A 2.8 × 3.5-cm melanoma of nasal hemi-tip marked for excision. B, When a unilateral skin defect encompasses half
or less of surface area of nasal tip, defect is usually enlarged only to create hemi-tip defect. This will limit size of forehead flap
necessary for reconstruction, which in turn minimizes deformity of forehead. Ear cartilage graft in place for structural support.
C, Paramedian forehead flap designed for repair. D, Flap in place. E, F, Flap inset 3 weeks after flap transfer.
C
A
B
F
D
E
Alar cartilage
Auricular cartilage
graft

284
SECTION I  FUNDAMENTALS
forehead flap, the thickness of the flap will not match the
thinness of the in situ skin and muscle of the rhinion. In
this region, contour outweighs the advantage of placing
the borders of the flap along the junction of aesthetic
units. It is wiser to leave this skin intact and to resurface
only the caudal dorsum than to resurface the entire dorsal
nasal aesthetic unit (Fig. 13-10). The same principle
applies to skin of the superior nasal sidewall, which is very
thin and is not replaced with forehead skin unless the
defect involves this region of the nose.
Similar to the rhinion, the skin of the nasal facets is
delicate and thin. It is supported only by fibroconnective
tissue. Forehead skin cannot replicate the delicate nostril
margin in this area of the nose. Nasal tip defects requir­
ing a forehead flap as a cover should be enlarged only to
a line along the upper border of the facet (Fig. 13-11).
This line corresponds to the caudal border of the inter­
mediate crura of the lower lateral cartilages.
A three-dimensional template exactly duplicating the
surface area and contour of the region to be resurfaced
is fashioned from foil or a thin sheet of foam rubber. The
author prefers foam rubber because it has the flexible
qualities of skin and easily conforms to the convex and
concave contours of the nasal topography (Fig. 13-12).
The final defect to be resurfaced is marked on the nasal
skin, outlining additional skin removal to square off the
defect or to remove the remaining cutaneous portions of
the aesthetic unit. The template is designed before the
defect is enlarged because once the additional skin is
removed, the wound will spread and the defect will appear
larger than it is. For this reason, if the nasal defect
involves an aesthetic unit that has an intact counterpart,
the intact unit is used to design the template because it
will give a more accurate measurement of surface area.
The template is then reversed to design the flap. When
the defect involves an aesthetic unit that is unpaired, the
template is designed as an ideal size for the specific
patient. In dealing with large surface defects, it is helpful
to suture the rubber foam template to the margins of the
defect to fashion the template more precisely (see Fig.
13-12). Cartilage grafts are required to replace missing
framework, and the template is designed after the grafts
are in place. Templates should not be oversized but tai­
lored exactly.
The template is used to design the flap on the forehead
skin (see Fig. 13-12). The center of the template is posi­
tioned approximately 2 cm lateral to the midline. At a
minimum, the upper border of the template is positioned
at the frontal hairline unless the patient has a receding
hairline or frontal balding. The length of the flap is mea­
sured by a length of suture extending from the distal end
of the positioned template to the level of the medial
eyebrow. Holding it at the eyebrow, the suture is rotated
180° in the coronal plane toward the midline to the most
distal recipient site on the nose. If the suture does not
reach this point, the template must be repositioned
higher on the forehead or the pedicle must be lowered
by extending it below the level of the eyebrow. By use of
this method of determining flap length, a decision can be
made concerning the necessity of placing a portion of the
template over hair-bearing scalp. The flap is then pre­
cisely outlined on the forehead with a skin marker, fol­
lowing the exact shape of the template (see Fig. 13-12).
Cutaneous defects that involve the nose and significant
portions of the medial cheek or upper lip are recon­
structed in stages. The first surgical stage is directed
toward repair of the cheek to provide a stable foundation
for subsequent reconstruction of the nose. The surgical
plan of first restoring the foundation on which to place
the constructed nose, before initiating nasal reconstruc­
tion, is used whenever a sizeable full-thickness defect of
the cheek or lip is associated with a full-thickness nasal
defect. For example, when there is a full-thickness loss of
the ala or columella and adjacent upper lip, it is prudent
I
G
H
G-I, Postoperative views at 5 months. No revision surgery performed.
FIGURE 13-9, cont’d  ■

13  INTERPOLATED PARAMEDIAN FOREHEAD FLAPS
285
A
B
C
D
FIGURE 13-10  ■  A, A 2 × 2-cm cutaneous defect of nasal tip and caudal dorsum. B, Remaining skin of tip aesthetic unit removed.
Defects of dorsal aesthetic unit are never enlarged to remove thin skin of rhinion unless it is required for tumor ablation. Intrinsic
thickness of forehead skin is greater than native skin covering rhinion. C, D, Immediately and 1 week after flap transfer.
Continued

286
SECTION I  FUNDAMENTALS
E
F
G
E, Preoperative view. F, G, Postoperative
views at 1 year, 9 months. No revision surgery performed. Note
smooth transition between skin of flap and native skin of rhinion.
FIGURE 13-10, cont’d  ■

13  INTERPOLATED PARAMEDIAN FOREHEAD FLAPS
287
A
B
C
D
FIGURE 13-11  ■  A, Base of paramedian forehead flap is 1.5 cm wide centered over medial end of eyebrow. Axis of pedicle is vertical
and 2 cm from midline. B, Flap is elevated from underlying periosteum. C, Donor site closure is achieved by undermining in sub­
fascial plane from one temporalis muscle to another. Standing cutaneous deformity of scalp from advancement of forehead skin is
removed vertically. D, Galea and frontalis muscle completely removed from distal flap.
Continued

288
SECTION I  FUNDAMENTALS
is typically reconstructed with a cheek advancement flap.
The flap is advanced medially to the nasofacial sulcus. The
leading border of the flap is secured to the periosteum of
the ascending process of the maxilla to prevent the flap
from migrating laterally during the healing process. The
cheek flap is secured in place first before a template is
designed for the paramedian forehead flap that is used to
resurface the nasal sidewall. If periosteal sutures are inad­
equate to hold the advancement flap in place, holes are
drilled in the exposed bone along the piriform aperture.
These holes are used for anchoring sutures placed along
the advancing border of the cheek flap.
Figures 13-13 and 13-14 show two examples of cuta­
neous defects that extend from the nasal sidewall into the
cheek. The patient shown in Figure 13-13 had a limited
extension of the cutaneous defect into the cheek. The
adjacent cheek skin was advanced and secured to the
nasofacial sulcus without the necessity of making inci­
sions in the cheek skin. Small standing cutaneous defor­
mities resulting from advancement of the cheek skin
were removed in the nasofacial sulcus superiorly and
alar-facial sulcus inferiorly. In contrast, the patient shown
in Figure 13-14 suffered a more extensive defect of the
to delay reconstruction of the nose until the lip is repaired
and scars have contracted to their maximum propensity.
In contrast to full-thickness nasal defects, defects of the
nose that are not full thickness and that extend into the lip
or cheek can usually be reconstructed concurrently. This
is because there is less scar contracture surrounding the
nose during the healing stages compared with repair of
full-thickness defects and thus fewer problems with distor­
tion of the constructed segments of the nose. Keeping with
the principles of repairing each portion of a defect involv­
ing multiple facial aesthetic regions with an independent
covering flap, individual flaps are used to reconstruct the
cheek, nose, and lip if all three aesthetic regions are
involved by the defect. The most common circumstance
leading to defects involving the nose, lip, and cheek is a
skin malignant neoplasm arising from the ala and extend­
ing into the alar-facial sulcus with subsequent growth into
the medial cheek and upper lip. Another common circum­
stance is for the malignant neoplasm to arise from the nasal
sidewall and extend across the nasofacial sulcus into the
medial cheek. The cutaneous defect resulting from resec­
tion of this type of neoplasm should be reconstructed with
two independent flaps. In such instances, the cheek defect
E
F
E, Majority of subcutaneous fat is removed from distal flap. F, Flap is sutured at recipient site with vertical
mattress cutaneous sutures. Subcuticular sutures are not used. Forehead donor site is closed in two layers: interrupted
suture approximation of muscle and galea and continuous cutaneous suture. (From Baker SR: Interpolated paramedian forehead flaps.
In Baker SR, editor: Principles of nasal reconstruction, ed 2, New York, Springer, 2011.)
FIGURE 13-11, cont’d  ■

13  INTERPOLATED PARAMEDIAN FOREHEAD FLAPS
289
A
B
Skin removed
Alar cartilage
Auricular cartilage rim graft
Auricular cartilage rim graft
Alar cartilage
Skin removed
Skin removed
C
D
E
F
G
Template
Template
H
I
J
cheek necessitating an incision that was made inferior to
the defect, paralleling the melolabial crease. In both
cases, the remaining skin of the nasal sidewall involved
with the defect was removed to resurface the entire aes­
thetic unit. Likewise, the remaining skin of the nasal
dorsum was removed from the nose of the patient shown
in Figure 13-14 so that the aesthetic unit could be covered
with the paramedian forehead flap used to reconstruct
the nose.
Paramedian forehead flaps are usually dissected with
use of local anesthetic and intravenous sedation. Lido­
caine 0.5% with 1:100,000 concentration of epinephrine
mixed in equal parts with bupivacaine 0.25% without
epinephrine is injected circumferentially and deeply
about the surgical defect. The entire forehead from the
level of the lateral canthus to its counterpart is injected
with 15 mL of similar anesthetic solution. The skin along
the entire length of the supraorbital bony rims is infil­
trated to the level of the periosteum. Particular attention
is given to a broad vertical band of skin in the axes of the
supratrochlear and supraorbital nerves. The anesthetic is
injected into the subcutaneous tissue plane because this
is the location of the nerves and vessels supplying the
forehead skin. The base of the flap and skin over the root
FIGURE 13-12  ■  A-E, A 2.5 × 3-cm cutaneous defect of dorsum after micrographic surgery for basal cell carcinoma. Rhinophyma of
tip and alae removed. Auricular cartilage rim grafts placed caudal to alar cartilages to prevent nostril retraction and to provide
contour to alae. F, G, Foam rubber sheet sutured to nasal defect to create template. H, Template used to design paramedian forehead
flap. I, J, Forehead flap designed and transferred to nose.
Continued

290
SECTION I  FUNDAMENTALS
M
N
K
L
K-N, Postoperative views at 11 months. Two contouring procedures, Z-plasty of nostril and forehead scar revi­
sion, performed at 5 and 8 months postoperatively.
FIGURE 13-12, cont’d  ■

13  INTERPOLATED PARAMEDIAN FOREHEAD FLAPS
291
of the nose are also injected. Dolasetron (Anzemet) is
administered intravenously to control postoperative
nausea commonly associated with the procedure. A tem­
plate used to design the forehead flap is constructed as
previously described. The margins of the nasal defect are
made perpendicular with a scalpel. If indicated, the
remaining skin of the aesthetic unit is removed to
the level of the perichondrium or periosteum. Until the
pedicle of the flap is detached and the flap is inset, it is
not necessary to excise the skin of the more extreme
cephalic portion of the dorsum and sidewall aesthetic
units when defects involve these units. The skin border­
ing the nasal defect is undermined below the muscle layer
for 1 to 2 cm. Undermining of adjacent nasal skin may
help prevent trap-door deformity.
The template is centered over the axis of the supra­
trochlear artery on either side of midline. With use of the
template, the flap is outlined with a skin marker (Fig.
13-15). To avoid oversizing the flap, incisions are made
inside the lines of the designed flap. The flap is incised
through the skin, subcutaneous tissue, muscle, and fascia.
The flap is elevated from superior to inferior in the sub­
fascial plane, just superficial to the periosteum of the
frontal bone. Rapid dissection may be performed in this
plane until the corrugator supercilii muscle is encoun­
tered, at which point the muscle is dissected away from
the underlying periosteum bluntly with scissors or a peri­
osteal elevator. If it is necessary to extend incisions of the
pedicle below eyebrow level, it is accomplished with a
scalpel cutting through skin only. Blunt dissection by
spreading tissue with a hemostat is then performed to
mobilize the pedicle away from the medial bony orbit. The
supratrochlear artery may sometimes be visually identified
in the area on the deep surface of the frontalis muscle just
as it exits over or through the corrugator supercilii muscle
and before passing deep to the orbicularis oculi muscle to
enter the orbit. Adequate flap mobilization usually requires
complete sectioning of the corrugator muscle to achieve
sufficient flap length. Blunt and sharp dissections are used
to continue flap elevation downward into the root of the
nose (see Fig. 13-10) or until sufficient pedicle length and
flap mobility have been attained to allow tension-free
wound closure. Hemostasis along the border of the flap is
achieved with an electrocautery applied judiciously.
The forehead flap is covered with a damp sponge and
reflected downward to allow repair of the donor site.
Donor site closure is accomplished by extensive under­
mining of the forehead skin in the subfascial plane from
the anterior border of one temporalis muscle to the other
(see Figs. 13-11 and 13-15G). A few parallel vertical
galeotomies 2 to 3 cm apart may be made to facilitate
primary repair of the superior portion of the donor site
if the donor defect is large. Galeotomies should be made
just through the galea to the level of the muscle and
removed from the vertical corridor of the supraorbital
and supratrochlear nerves. The deep branch of the supra­
orbital nerve can readily be seen through the galea as it
travels superiorly just medial to the temporal line, and it
should be protected when galeotomies are performed.
Horizontal incisions along the hairline to facilitate
closure of the donor site are not performed. This would
increase anesthesia of the anterior scalp by cutting
through the distal branches of the supraorbital nerves and
create an additional visible scar on the forehead. As the
wound edges are advanced, a standing cutaneous defor­
mity of scalp tissue occurs at the superior apex of the flap
donor site defect. This is excised completely by extending
an incision sufficiently superiorly in the scalp to enable
excision of the tissue cone (see Fig. 13-15).
The muscle and galea of the forehead are approxi­
mated as a single layer with 2-0 polyglactin suture. These
are left untied until all have been placed (see Fig. 13-15).
The skin incision is repaired with a simple running suture
of 5-0 polypropylene. A drain is not employed. Primary
approximation of the inferior forehead wound is rarely a
problem because the pedicle width is 2 cm or less.
However, superior portions of the donor site may not
close completely. Any remaining open wound is filled
with an antibacterial ointment. The patient is instructed
to keep the wound moist with petroleum ointment until
healing is complete. Healing by secondary intention takes
4 to 6 weeks.
The forehead donor site wound is repaired before the
flap is sutured in place. The thickness of the flap is tai­
lored by thinning the distal portion. This usually requires
removal of the muscle and most of the subcutaneous fat
to match the thickness of the nasal defect (Fig. 13-16; see
also Fig. 13-11). When necessary, all but the subcutane­
ous fat immediately attached to the dermis may be
removed. If the vertical height of the nasal defect is less
than 2 cm, the portion of the flap covering the entire
defect may be thinned at the time of initial transfer. For
larger defects, the proximal flap covering the more
cephalic portion of the defect is left with all of its muscle
and subcutaneous fat intact and is thinned at the time of
pedicle division. If necessary, the muscle and galea may
be removed from the entire length of the flap beginning
1 cm superior to the point at which the supratrochlear
artery pierces the frontalis muscle. Any hair follicles
transferred with the flap should be individually cauterized
with a fine-pointed electric cautery or removed manually.
The distal flap, appropriately thinned, will be sufficiently
supple and thin to conform to the nasal framework and
manifest its contour.
The practice of removing the frontalis muscle and the
majority of subcutaneous fat from a paramedian forehead
flap used to cover the nose begs the question of why the
frontalis muscle is transferred with the flap. Including
the muscle in the flap inferiorly near the eyebrow protects
the supratrochlear artery as it ascends from the eyebrow
between the muscle and skin. The superior aspect of a
paramedian forehead flap may be dissected in the deep
subcutaneous tissue plane, leaving the frontalis muscle in
place. However, elevation in the subcutaneous tissue
plane causes more bleeding than elevation beneath the
muscle and places the axial blood supply to the distal flap
at some risk for injury. Unfortunately, leaving the frontalis
muscle in situ when a paramedian forehead flap is trans­
ferred to the nose does not preserve the supratrochlear
nerve, which must be sacrificed when the pedicle of the
flap is divided. Transferring the muscle as part of the flap
does not impair the motor function of the more lateral
aspect of the frontalis muscle. In addition, removal of the
muscle beneath the flap facilitates subgaleal dissection of

292
SECTION I  FUNDAMENTALS
A
B
C
D
E
FIGURE 13-13  ■  A, B, A 3 × 2-cm cutaneous defect of nasal sidewall with minimal extension into cheek. C, D, Cheek skin advanced
to nasofacial sulcus. Paramedian forehead flap designed for repair of nasal sidewall. E, Flap in place. Bolster dressing used to reduce
bleeding beneath flap.