Nasal Reconstruction Art and Practice E-Book_nodrm

73
be harvested. Larger grafts may be taken in women but fi ne vellus hair may be carried
with the cheek skin and require plucking. In men, once the graft extends more anteri-
orly, the transfer of bearded skin becomes problematic.
Postauricular skin can be harvested from the back of the ear and mastoid across the
postauricular crease. Although a common donor site, its pink color, thinness and skin
quality do not always match the nose. However, the donor site is out of sight, easily
closed and available. In unusual circumstances, the entire posterior surface of the ear
can be utilized.
As seen in Figure 4–5, occasionally, a preauricular skin graft can even provide satisfac-
tory covering skin for the inferior nose. A signifi cant non-subunit defect lay within the
tip of this elderly woman with unusually thin smooth tip skin. In this case, the wound
was enlarged and the entire subunit resurfaced. This positioned the graft’s border scars
in the subunit outline. Hopefully, this would keep the subsequent scar from disrupting
the tip surface.
A pattern was made of the defect. The defect should have clean, sharp, right angle skin
edges and a healthy vascular bed. The margins and base of the wound were freshened.
Old scar, skin graft, or granulation tissue must be removed.
A
B
Figure 4–5
Skin Grafts

74
Chapter • 4 • Secondary Intention Healing, Primary Repair, a Skin Graft or Local Flap
The preauricular crease was marked with ink. The template was positioned anterior
to the crease and the required graft was outlined. Superior and inferior dog-ear exci-
sions were added. Frequently the length of the anterior and posterior incisions is dif-
ferent. After harvest of the skin graft with several millimeters of subcutaneous fat, the
anterior cheek skin was elevated superfi cially and pulled back and up. If skin excess
exists anteriorly, a dog-ear can be excised within the hair bearing skin, above the ear.
The donor site was closed in layers. A drain may or may not be placed.
Fat is removed from the undersurface of the graft with curved scissors. It is not neces-
sarily thinned to the dermis. The thickness of graft skin and subcutaneous fat should
match the depth of the recipient site. Laid on the prepared bed, the graft is trimmed
and inset with a single layer of fi ne 6-0 suture. Quilting sutures are placed through the
skin graft and into the recipient bed to prevent lateral motion. It is often helpful to
close the wound peripherally, suture by suture, while simultaneously placing indi-
vidual quilting sutures under direct vision. A layer of antibiotic ointment and fi ne
gauze is applied, followed by a soft foam bolus. Tie-over sutures are placed. Tradition-
ally, individual sutures are fi xed to the wound edge and tied one to another. It is
quicker and more effi cient to tie a single 4-0 or 5-0 polypropylene suture about 5–
10 mm from the wound edge and then criss-cross back-and-forth across the bolus, in
a running fashion. With each pass, the needle takes a bite of skin several millimeters
away from the wound edge, fi nally tying the suture to itself. Days later, the surgeon
need only clip the suture in one or two areas and the dressing is easily removed.
The full-thickness forehead skin graft
Forehead skin is acknowledged as the best match to replace nasal skin. Although not
traditionally transferred as a skin graft, it has a useful application for resurfacing small
superfi cial defects. Forehead skin and its underlying compact fi brofatty subcutaneous
layer are thicker and stiffer than other donors. Such forehead grafts can be used as a
full-thickness skin graft or as a composite graft. Signifi cant amounts of soft tissue can
be carried with the graft to permit the replacement of deeper soft tissues.
Because skin graft take remains precarious, the graft must be applied to an ideal vas-
cular recipient site. Skin grafts revascularize from their peripheral edges and from their
underlying recipient bed. Healthy perichondrium must be intact. Ideally more vascu-
larized soft tissue remains over the underlying cartilage.
After skin cancer excision, hemostasis is carefully obtained. If the fresh defect is ideal,
the graft is applied immediately. However, the bed of a Mohs defect or other excision
may be ‘blackened’ due to signifi cant coagulation injury. Excessive electrocoagulation
injury signifi cantly impairs revascularization. The deleterious effect of thermal injury
is more extensive than apparent and immediate surgical débridement is not suffi cient
to prepare the bed. If present, the skin graft should be delayed for 7 to 14 days or more
to allow spontaneous separation of debris and revascularization of the wound.
The skin graft should be applied as a delayed primary graft, after spontaneous separa-
tion of the injured and desiccated tissues and the development of a modest amount of
granulation tissue. Avoid exposing the underlying cartilage, during débridement.
Forehead skin grafts revascularize normally, with progressive changes in color from
white to blue to pink. A good take is routinely expected. The result can be excellent.
(See Figures 4–6 and 4–7.)

75
A
B
C
D
Figure 4–6
Skin Grafts

76
Figure 4–6, Continued
G
F
H
Surgical sponge
Petrolatum gauze
Surgical sponge
Petrolatum gauze
Quilting sutures
6
3
2
4
5
Bite
1
E

77
However, when graft failure seems imminent, the clinical evolution of a forehead skin
graft is unique. Unlike grafts harvested from other sites, if the ‘take’ of a forehead skin
graft is poor, early separation does not occur. A hard and tightly adherent eschar
A
B
C
D
Figure 4–7
Skin Grafts

Chapter • 4 • Secondary Intention Healing, Primary Repair, a Skin Graft or Local Flap
develops. This eschar should be left undisturbed and not débrided. It may remain fi xed
to the underlying tissues for 4 to 6 weeks. After spontaneous separation, the surgeon
often fi nds the wound healed, fi lled, and the aesthetic result good. Although the color,
texture and contour may not be perfect, it is often better than that obtained with other
grafts. The healing characteristics of a full–thickness forehead skin graft are distinctive.
Perhaps this is due to its intrinsically stiffer and thicker quality.
Occasionally, if any skin graft survives but does not supply adequate bulk, the area
remains depressed. Months later, once the graft is matured, a cartilage graft can be
placed under the edge of the graft, secondarily.
Skin graft technique
To ensure skin graft ‘take,’ it must lie on a vascular bed. It must be in direct contact — it
will not survive if tented across the defect, suspended in air or fl oating on a hematoma.
It must also be immobile — if it shifts over the recipient bed, its developing vascular
connections will be disrupted.
Avoid excessive coagulation at the time of skin cancer excision. If signifi cant, delay the
repair. Allow spontaneous separation of the burn eschar and the development of
granulation tissue.
Protect the recipient site from desiccation. Do not allow the periosteum or perichon-
drium to dry out, if the repair is delayed. Daily cleansing and multiple applications of
antibiotic or petrolatum ointment are applied to protect it.
Employ quilting sutures to help approximate the skin graft to its bed and diminish
sheer forces.
Employ a stent dressing to immobilize the graft postoperatively. It reinforces the effects
of quilting sutures. However, it is not a ‘pressure’ dressing. If enough pressure is
applied to stop bleeding or prevent hematoma, it will also prevent revascularization.
The dressing is usually removed within 4 or 5 days to minimize maceration to the
superfi cial surface of the skin graft. However, in highly mobile areas, or those subject
to trauma, it may be preferable to leave the stent dressing for one week.
Initially, the skin graft appears white. Over several days, as its perfusion increases, it
changes color from blue to visibly pink.
Skin Flaps
Unlike a skin graft, the quality of skin transferred as a fl ap maintains its original char-
acter. Because they maintain an intrinsic blood supply, the color and texture of fl aps
are predictable. A fl ap is also thicker than a graft. A fl ap can better supply missing
subcutaneous bulk. There is a slight excess of skin within the upper ‘thin’ skin zone
but none within the ‘thick’ skin zone of the tip and ala.
The single lobe transposition fl ap (See Figure 4–8)
Because skin grafts are unpredictable in color and texture, a local fl ap will often give
a better aesthetic result than a graft. A modest amount of excess mobile and lax skin
is available for transposition in the superior nose. A single lobe transposition fl ap,
designed as a banner or Romberg fl ap, can be useful for small defects.

79
A
B
C
Figure 4–8
Skin Flaps

80
Chapter • 4 • Secondary Intention Healing, Primary Repair, a Skin Graft or Local Flap
These fl aps transpose skin through an arc of 90 degrees, taking the excess in one axis
to fi ll a defi ciency in the other axis. The skin in the superior nose is relatively mobile,
available, and lies at a distance from the nostril margins. A well executed fl ap is
unlikely to distort the tip or alar margin. However, if the fl ap donor scar crosses the
bridge transversely, the bridge line may be depressed by the subsequent scar, creating
a permanent irregularity.
They are not useful in the infl exible thick skin of the tip or ala. Single lobe fl aps in the
inferior nose often displace adjacent mobile landmarks. Thick skin shifts with diffi -
culty, creating deforming dog-ears or impairing their blood supply.
The dorsal nasal fl ap (See Figure 4–9)
The dorsal nasal fl ap is an alternative. Skin, subcutaneous tissue, and muscle are ele-
vated just above the perichondrium and periosteum. It slides excess skin from the
glabella toward the nasal tip. The fl ap is well vascularized from numerous vessels
within the sidewall and medial canthus. The fl ap is advanced inferiorly and the fl ap
sutured to the recipient defect in layers. Closure is facilitated by advancing cheek skin
up onto the nasal sidewall. It can resurface the nasal tip and dorsum and parts of the
ala or sidewall with local skin of similar kind.
Unfortunately, it slides thick glabellar skin and soft tissue downward onto the nasal
sidewall near the medial canthus. The mismatch in skin thickness may create an iatro-
genic epicanthal fold. The depth of the radix may be obliterated, effacing the nasal root.
As it slides caudally, a dog-ear must be excised, inferiorly.
Ideally, its border scars are planned to lie along the dorsal sidewall junction but this
is rarely possible. The inferior aspect of the fl ap’s border may be visible as a depressed
scar crossing the smooth surface of the tip unit. Like all local fl aps, the larger the defect
and the closer it lies to the nostril margin, the more likely the tip or rim will be distorted
by tension or displaced by poor design. In practice, the dorsal nasal fl ap is used infre-
quently. As you can see, the result in this patient is good but the right nostril margin
has been pulled up.
The geometric bilobed fl ap
The bilobed fl ap is recommended for defects within the thick skin of the inferior nose.
Unfortunately, although a modest amount of excess skin is present in the upper two
thirds, there is no extra skin in the tip or ala. Its skin is also thick and stiff. It is diffi cult
to shift, buckles upon itself and turns ‘white’ due to ischemia. Because there is no excess
in the tight adherent skin of the tip and ala, a donor site within the tip cannot be
closed.
The bilobe principle is applied. Skin is shifted from an area of excess to an area of
defi ciency. The fi rst lobe is designed adjacent to the tip or alar defect. A second lobe,
which lies at a distance in an area of tissue availability within the upper nose, is out-
lined in continuity. As the primary lobe shifts to repair the defect, the secondary lobe
resurfaces the defect from the primary lobe. The tertiary defect from the second lobe
is closed primarily, within the area of excess.
Traditionally, bilobed fl aps are designed with a 180 degree rotation. This creates large
dog-ears. Their planned excision often narrows the fl ap’s vascular base, jeopardizing
blood supply.

81
A
B
C
D
Figure 4–9
Skin Flaps

82
Chapter • 4 • Secondary Intention Healing, Primary Repair, a Skin Graft or Local Flap
MacGregor and then Zitelli modifi ed the bilobed fl ap (see Figure 4–10). Their geometric
design rotates the fl ap through 90 to 100 degrees and incorporates a dog-ear excision
without diminishing vascularity. It is useful for defects measuring 0.5 to 1.5 cm in the
inferior nose.
A rotation fl ap is designed within the nasal surface. Theoretically, it can be oriented
within 360 degrees around the defect. The surgeon chooses the best location by remem-
bering that its pedicle base must be positioned away from the nostril margin to prevent
its distortion. Its second lobe must also lie within the loose excess skin of the upper
nasal sidewall or dorsum. The position of the lower lid must not be disturbed. A
bilobed fl ap can be based medially or laterally (see Figure 4–11).
Figure 4–10
THE GEOMETRIC BILOBED FLAP
Distance to
pivot point
equals radius
of defect
Excise
triangle
first
First lobe
same size
as defect
90°-100°

83
Skin Flaps
A
B
C
D
Figure 4–11

84
Chapter • 4 • Secondary Intention Healing, Primary Repair, a Skin Graft or Local Flap
1. The pivot point is established at a distance from the defect, equal to one half of
its diameter. The fl ap is based laterally for tip defects and medially for defects of
the alar lobule. Two concentric circles are then drawn. The pivot point is usually
positioned at a distance equal to the radius of the defect. The farther the point is
away from the defect, the larger the fl ap. However, the fl ap must remain on the
nasal surface. It should not extend onto the cheek or towards the eyelids, to
avoid distortion. Sharing the same pivot point, the circumferences of a larger
outer and smaller inner concentric circles are drawn onto the nasal skin. The
circumference of the outer circle is designed based on a radius equal to three
times the radius of the defect. The second smaller inner circle is also marked
using a template which equals the distance from the pivot point to the center of
the initial defect (the diameter of the defect). Because the nasal surface is round,
not fl at, a two-dimensional ruler does not measure the true dimension of the
defect or of the bilobed fl ap. A strip of foil or bent paper ruler must be made to
conform to the convex surface of the nose. This template is rotated around the
pivot point, like individual spokes of a wheel, until the circumferences of both
concentric circles are determined.
2. An exact template is made of the circular nasal defect. It is positioned immedi-
ately adjacent to the defect, along the circumference of the outer circle. The fi rst
lobe should replace the defect exactly, to prevent tip and alar rim distortion on
closure. Because the second lobe lies within the more mobile skin of the upper
nose, it can be designed slightly smaller than the defect, if desired. This second-
ary defect can be partially closed by the recruitment of lax adjacent skin within
the upper nose. A dog-ear excision, which extends lateral to the outer circle, is
added to the second lobe. More importantly, a preplanned dog-ear excision is
marked from the defect to the bilobed pivot point. Its removal permits rotation
advancement of the fl ap. This geometric fl ap rotates less than 100 degrees. Its
base is wide and the fl ap is well vascularized.
3. First, the dog-ear extending from the defect to the pivot point is excised. The
fi rst and second lobes are then incised, including the distal excess which will be
later discarded as a dog-ear. The fl ap includes skin, subcutaneous fat, and
nasalis muscle. It is widely undermined in the areolar plane over the perichon-
drium and periosteum. The skin and soft tissues are also elevated laterally
around the donor and recipient sites.
4. Signifi cant pin cushioning does not occur with the bilobed fl ap, if it is carefully
repaired, in layers. The wide undermining, by developing a uniform plane of
contracting scar in the bed under the fl ap and its adjacent soft tissue, may
contribute. First, the primary lobe is transferred to the defect and then the
secondary lobe is transposed to fi ll the gap created by the fi rst. They are initially
tacked in position. Then the tertiary defect, in the more mobile upper nose, is
closed in layers. This pushes the fl ap inferiorly, preventing the tendency of the
fl ap to return to its donor site. The repair of the primary and then the secondary
fl aps are then completed using 5-0 permanent or slowly absorbing sutures for
muscle closure and 5-0 and 6-0 subcuticular sutures. The skin is sutured with
fi ne permanent or absorbable sutures. Unfortunately, postoperative tip or nostril
distortion is common, regardless of careful intraoperative planning.
If the alar crease is effaced, it can be restored secondarily by direct incision, disregard-
ing old scars. Excess soft tissue is sculpted to recreate the depressed shadow of the alar
crease, months later. Although planned as a one staged repair, it is not uncommon to
revise a bilobed fl ap to correct rim asymmetries or recreate an alar crease. An example
is illustrated in Chapter 22.

85
Skin Flaps
The geometric bilobed fl ap is effective. Because there is only a limited amount of excess
skin in the upper nose, it should be limited to defects of the tip and ala which are less
than or equal to 1.5 cm in diameter. If the defect lies within 1 cm of the nostril margin,
signifi cant rim distortion is common. Skin quality is restored, although the scars are
red for months. If the contour is correct, however, they become barely visible.
Unfortunately, in relationship to the relatively small size of the defect, the technique
is time-consuming, the dissection extensive, scars multiple, the swelling signifi cant, the
risk of alar crease obliteration, and, more signifi cantly, tip and nostril margin distor-
tion, high.
In my practice, the simplicity of a full-thickness forehead skin graft or the perfection
achievable with a forehead fl ap have made the bilobed fl ap a less attractive option for
small defects. It is used infrequently.
The one-stage nasolabial fl ap
The one-stage nasolabial fl ap is useful to resurface defects of the nasal sidewall and
ala up to 2 cm in size. Excess skin of the medial cheek, lateral to the nasolabial fold, is
transferred as a random pattern extension of an advancing cheek fl ap. Unlike local
fl aps which redistribute residual nasal skin, this technique also ‘adds’ regional cheek
skin to the nose. This minimizes the risk of distortion to the mobile structures of the
nose and permits the use of alar support grafts without the risk of their collapse due
to tension. The repair is usually performed under general anesthesia to avoid distortion
and blanching by local anesthesia.

86
Chapter • 4 • Secondary Intention Healing, Primary Repair, a Skin Graft or Local Flap
A
B
C
D
Figure 4–12

87
Figure 4–12 is an example. First, the sidewall and alar subunits are outlined in ink.
Although a subunit excision of the ala is not performed, if skin remains between the
defect and the inferior nostril rim, it can be excised, enlarging the defect inferiorly to
the nostril margin. This positions the scar along the nostril border and improves the
fl aps blending with the recipient site.
To prevent collapse of the nostril margin inward or retraction upward, the underlying
lining is braced with a septal or ear cartilage graft. Its ends are buried, medially and
laterally, in subcutaneous pockets along the rim and alar base. They are fi xed percuta-
neously with 5-0 polypropylene suture. The cartilage graft is quilted to the underlying
lining to fi x the support graft in place.
E
F
Trim excess skin
G
Figure 4–12, Continued
Skin Flaps

88
Chapter • 4 • Secondary Intention Healing, Primary Repair, a Skin Graft or Local Flap
A pattern of the defect is made. The nasolabial crease is marked and the template is
positioned exactly adjacent to the fold. At the completion of the procedure, the fi nal
cheek scar should lie hidden in the nasolabial crease. Be sure that the sliding cheek
advancement will swing medially and correctly position its nasolabial extension to the
nasal recipient site. A dog-ear excision is marked along the nasolabial fold, distal to
the template.
The most important fl ap dimension is width. The width of the fl ap should equal the
width of the defect. The distal margin of the fl ap will be trimmed and inset on closure.
It does not need to be exactly predetermined. The fl ap is elevated in continuity with
the distal dog-ear which is trimmed later in the procedure. Note also that the superior
lateral incision for the alar or sidewall fl ap extension should not extend higher than
the alar remnant that must be ‘jumped’ over to reach the recipient site. A higher inci-
sion is unnecessary and may impair blood supply.
A second dog-ear excision is drawn from the defect towards the medial canthus. This
creates a defect into which the cheek fl ap will advance.
The nasolabial extension is incised and undermined with a few millimeters of subcu-
taneous fat. The cheek fl ap is then elevated laterally for 3–5 cm. The cheek is advanced
and fi xed with 40 deep permanent or slowly resorbing sutures, fi xing its underlying
raw surface to the deep tissues along the nasofacial groove. This solid fi xation advances
the cheek fl ap, closes the donor defect, and recreates the nasofacial sulcus. Very impor-
tantly, it transfers all tension onto the side-to-side cheek closure. It should completely
eliminate lateral and vertical tension on the nasolabial extension, which travels with
the advancing cheek fl ap. The vascularity of the random nasolabial extension is good
but can be impaired by tension. The fl ap should lie comfortably over the recipient bed,
ready for fi nal trimming and inset.
Excess subcutaneous fat is excised until the thickness of the fl ap matches the depth of
the recipient bed. Several 6-0 absorbable sutures can be placed to gently fi x the deep
surface of the fl ap to the underlying soft tissues at the ideal alar crease, if the fl ap’s
vascularity is maintained. If there is any question about fl ap blood supply, these deep
quilting sutures are not employed to deepen the alar crease contour. The crease can be
recreated secondarily, if needed. The distal fl ap is gently laid over the inferior aspect
of the nasal wound and trimmed to fi t. Incisions along the nasolabial fold, cheek
and sidewall are repaired with 50 subcuticular sutures. The skin is closed with 60
sutures.
As in Figure 4–13, the one-stage nasolabial fl ap is useful for superfi cial nasal defects
of the ala and sidewall which do not include the nasal base. The defect must be limited
to the nose and must not extend on to the adjacent lip or cheek. Fortunately, it does
not pin cushion signifi cantly. Although recommended by some authors, it is unlikely
to reliably vascularize an underlying skin graft, or the folding of its distal end, to line
a full-thickness defect. Necrosis, collapse, retraction, or excessive rim thickness would
likely follow. However, it is an extremely useful technique. A secondary procedure to
recreate an obliterated alar crease may be necessary.
The one-stage nasolabial fl ap is also useful as a preliminary operation to resurface the
upper lip and nasal sill, prior to the repair of composite defects which include the nose,
lip and cheek. It is often combined with a Millard fat fl ip-fl ap, which hinges over excess
subcutaneous fat to restore missing premaxillary soft tissue bulk. Depending on the
stability of the restored platform, the one-stage random nasolabial fl ap may be per-
formed to re-establish the nasal base as a preliminary operation or simultaneously with
nasal repair (see Chapter 7).

89
A
B
C
D
Figure 4–13

90
Chapter • 4 • Secondary Intention Healing, Primary Repair, a Skin Graft or Local Flap
E
F
G
Figure 4–13, Continued

Large, Deep and Adversely
Located Defects —
Resurfacing with
Regional Flaps
C H A P T E R
5
When choosing the best option to resurface the nose, the surgeon should consider the
size, depth and site of the defect.
‘Large’ defects are those greater than 1.5 cm in size. When the surface defect is large,
insuffi cient skin remains over the residual nose to redistribute by tissue rearrangement
with a local fl ap. To reconstruct a large defect, skin must be added, not just shared. If
the patient wishes the normal skin surface quality to be restored, a regional fl ap from
the cheek or forehead will be required to resurface the nose. This is especially true if
the defect lies within the thick pitted skin of the lower nose. The color, texture, bulk
and ‘take’ of skin grafts are too unpredictable.
‘Deep’ defects are those in which the underlying support framework is absent or in
which the full thickness of the nose is missing and lining must be replaced.
If the underlying support has been ablated and the nose is resurfaced without cartilage
replacement, the soft tissues collapse and become shapeless and the airways obstruct.
But once cartilage grafts are required, a skin graft or local fl ap will not suffi ce. A skin
graft must lie on a vascular bed and will not ‘take’ over bare cartilage grafts. A local
fl ap is precluded because delicate cartilage grafts will be crushed under the wound
tension associated with tissue sharing alone.
Although cartilage is not present within the normal ala, if a signifi cant area of external
skin is excised, the ability of its compact fi brofatty middle layer to support, shape and
brace the reconstructed ala is diminished. A cartilage framework must be placed. If
not, collapse, retraction and contour distortion are inevitable. Unfortunately, once car-
tilage support is placed, local fl aps and skin grafts are precluded. New skin must be
added to the nasal surface. Only a regional fl ap, harvested from the cheek or forehead,
will do.
Although a small rim defect can be closed with a composite skin graft, more signifi cant
full-thickness defects require a regional fl ap to resurface the nose.
If both cover and lining must be replaced, at least one layer must have an independent
blood supply. It is impractical to apply a skin graft externally over a vascularized lining
fl ap of any type. The likelihood of revascularization is minimal, skin graft quality is
poor, and cartilage grafts are precluded for support. So a full-thickness defect must be
repaired with a regional fl ap for cover, replacing the missing lining by prefabrication,
folding the distal end of the covering fl ap, hingeover fl aps, intranasal lining fl aps, a
skin graft or a free fl ap.

92
Chapter • 5 • Large, Deep and Adversely Located Defects — Resurfacing with Regional Flaps
‘Adversely located defects’ are those whose position necessitates a regional fl ap for cover.
Close examination of the traditional indications for local fl aps limit their use to defects
more than 0.5 to 1 cm above the rim. If employed to fi ll a defect close to the nostril
margin, late nostril and tip retraction or rim asymmetry are frequent. Local fl aps will
also not reach into the infra-tip lobule or columella. So defects near the nostril rim or
within the infra-tip area and columella cannot be resurfaced with local tissue. New
tissue must be added to avoid the distortion created by tissue redistribution. Regional
fl aps, harvested from the nasolabial fold or forehead, are used to repair these adversely
located defects, even though the wound is not necessarily large.
The Superiorly Based Two-stage Nasolabial Flap
As illustrated in Figure 5–1, the two-stage nasolabial fl ap transfers excess skin from
the medial cheek, just lateral to the nasolabial fold. Its primary blood supply comes
from multiple vessels which originate from the facial and angular arteries. The base of
the fl ap is perfused by vessels which pass above and below the levator labii muscle.
These axial vessels travel perpendicularly through the subcutaneous fat to the overly-
ing skin. Although the proximal aspect of the skin fl ap receives a random blood supply
from the adjacent skin, the fl ap is designed as a subcutaneously based island fl ap.
Because of its deep axial blood supply, a wide proximal skin pedicle is not necessary.
This permits use of the fl ap even if the skin, lateral to the ala, is scarred or has been
excised, as long as the underlying subcutaneous vascular base is not signifi cantly
injured. The subcutaneous pedicle also permits easy transposition of the fl ap around
its pivot point. If in doubt, the fl ap can be surgically delayed.
Figure 5–1
Skin
Perforator
Muscle
Facial artery
Arterial perforators
Levator labii superoris
Levator labii alaeque nasi
Arterial perforators
Nasolabial crease

93
In Figure 5–2 the proximal pedicle is tapered to a point at the junction of the lip, cheek
and alar groove, near the upper end of the nasolabial fold. This eliminates a superior
dog-ear and limits the length of the donor scar. The fi nal scar should not extend onto
the nasal sidewall on closure. Distally, a dog-ear is designed with its medial border
exactly along the nasolabial fold. The fi nal donor scar should lie exactly in the nasola-
bial crease.
In young patients or in those with a poorly defi ned fold, the crease may be invisible
under anesthesia. The nasolabial fold should be marked with ink preoperatively, with
the patient grimacing, before sedation or general anesthesia is induced. The fl ap is
designed so the fi nal donor scar lies exactly within the nasolabial fold.
Subunit
excision ala
Pattern
Tapered skin
pedicle
Vascular pedicle
Vascular
pedicle
Pattern marked
Cartilage
graft
A
B
Figure 5–2
The Superiorly Based Two-stage Nasolabial Flap

94
Chapter • 5 • Large, Deep and Adversely Located Defects — Resurfacing with Regional Flaps
In Figure 5–3 the defect encompasses more than 50% of the left ala. The nasal subunits
and nasolabial fold are marked with ink. An exact template is designed, based on the
contralateral right ala. It is positioned adjacent to the nasolabial crease at the level of
the oral commissure. An adequate arc of rotation must be assured.
Figure 5–4 illustrates how residual normal skin is excised within the left alar subunit.
This subunit excision positions the fl ap’s border scars in the joins between subunits
Figure 5–3
Figure 5–4

95
and along the nostril margin. More importantly, when the fl ap’s soft tissues pin cushion
postoperatively, the trapdoored fl ap surface will augment the contour created by the
underlying primary cartilage graft.
In Figure 5–5 the alar template is used to design an ear cartilage graft to support, shape
and brace the soft tissues. Its medial and lateral ends are buried in subcutaneous
pockets in the soft triangle and alar base. The graft is sutured to the underlying alar
lining.
Figure 5–5
The Superiorly Based Two-stage Nasolabial Flap

96
Chapter • 5 • Large, Deep and Adversely Located Defects — Resurfacing with Regional Flaps
A
B
C
D
Figure 5–6
As demonstrated in Figure 5–6, the fl ap is incised and elevated from distal to proximal.
It is raised with 2–3 mm of fat, distally, to allow primary thinning of the most medial

97
aspect of the alar inset. As the dissection proceeds superiorly, it is deepened protecting
its subcutaneous base. The facial muscles are not elevated. Restricting subcutaneous
fi brous bands are released by snipping or spreading with scissors. Undermining con-
tinues until the fl ap can be comfortably transferred to the defect. The cheek is advanced
and the donor site is approximated with subcuticular and skin sutures. The fi nal scar
should lie hidden precisely in the nasolabial crease.
The fl ap is inset with one layer of fi ne skin sutures. Any exposed raw pedicle is covered
with antibiotic ointment. In this case, the patterned fl ap was elevated and the distal
dog-ear excised as the cheek was closed.
Three weeks later (Figure 5–7), the fl ap is well healed. Medially, the alar contour is
satisfactory. Laterally, the inset is bulky and further thinning must be performed.
Figure 5–7
The Superiorly Based Two-stage Nasolabial Flap

98
Chapter • 5 • Large, Deep and Adversely Located Defects — Resurfacing with Regional Flaps
The pedicle is divided (Figure 5–8). Flap skin is re-elevated with 2–3 mm of fat over
the lateral aspect of the alar inset. Underlying subcutaneous fat and scar are then
excised to sculpt a convex alar contour and defi ne the alar crease. The fl ap is reap-
proximated to the recipient site with skin sutures. The superior aspect of the nasolabial
cheek scar is then reopened. The proximal pedicle is unraveled. Excess skin and soft
tissue are excised. The correct cheek contour is re-established. The cheek incision is
then closed in layers, positioning the fi nal scar exactly in the nasolabial fold.
Figure 5–8
Remnant of
alar subunit
excised
Tail of pedicle
thinned
A

99
Figure 5–8, Continued
E
D
B
C
The Superiorly Based Two-stage Nasolabial Flap

100
Chapter • 5 • Large, Deep and Adversely Located Defects — Resurfacing with Regional Flaps
A
C
B
Postoperatively (Figure 5–9), the dimension, contour and symmetry of the ala are
restored. No revision was performed.
However, the nasolabial fl ap has a limited role in nasal reconstruction. There is only a
small amount of excess tissue within the medial cheek — only enough to resurface a
2-cm wide defect, at best. Although a reliable fl ap, its blood supply is adequate, but
not robust. Tension will kill this fl ap. Limited distal necrosis does occur occasionally.
Figure 5–9

101
It will not dependably revascularize a skin graft used for lining or maintain its blood
supply, if folded to supply both cover and lining. Its arc of rotation and reach are
limited. It can be transposed to the ala, columella or upper lip, but cannot be safely
transferred to the tip or dorsum.
Biologic contraction is exerted by myofi broblasts which act, centripetally, within the
scar that underlies a nasolabial fl ap. It tends to pull its soft and gelatinous fat into a
sphere (the trapdoor effect). If a partial defect of the ala is resurfaced with a nasolabial
fl ap, it contracts and stands up above the surface of the residual ala, disrupting its
contour.
So the two-stage nasolabial fl ap is best employed to resurface the entire ala as a subunit,
rather than just patching part of the ala. This may require enlarging the defect and
discarding residual normal skin within the subunit. In this way, the surgeon harnesses
the intrinsic healing characteristics of this donor site to advantage. Although the
contour is re-established primarily by the supporting alar cartilage graft, pin cushion-
ing of the soft tissue fl ap enhances, rather than diminishes, the fi nal result.
A nasolabial fl ap may be used for defects of the ala which extend a few millimeters
above the alar groove onto the nasal sidewall. Although the alar crease will be obliter-
ated, a secondary operation can be performed to recreate the alar crease and sculpt a
fl at sidewall contour, some months after pedicle division (see Chapter 22).
It may also be used to resurface the columella or a non-nasal defect of the lip or the
platform of the nasal base.
Larger defects or defects of the tip or dorsum should not be resurfaced with a nasolabial
fl ap. It is inadequate in size, reach and vascularity. Such defects are resurfaced with a
forehead fl ap. The forehead, with its ideal color, texture, and pliability, is a better
choice.
In summary, the two-stage nasolabial fl ap is a good quality match for the ala. It should
be used to resurface the entire ala, as a subunit. Although no cartilage is present in the
normal ala, a shaped supportive framework must be positioned. The tendency of a
two-stage nasolabial fl ap to pin cushion augments the contour established by primary
cartilage grafts. However, its limited size, reach, vascularity and tendency to trapdoor
preclude most other applications. Its donor scar, lying in the nasolabial fold, is unob-
trusive. However, the harvest of skin and subcutaneous fat within the medial cheek
may distort the nasolabial fold. This creates a distorting asymmetry in contour to the
opposite normal side.
The forehead fl ap with its superior color, texture, size, reach, vascularity, additional
lining applications, and the forgiving nature of its donor site make it the preferred fl ap
for most nasal repairs.
The nasolabial fl ap is reserved for subunit reconstruction of the ala, which may include
2 to 3 mm of the lower sidewall, if a late revision to recreate the alar crease is accept-
able. It is also a useful fl ap to resurface the premaxillary soft tissue platform of the lip,
nasal fl oor, or columella (see Chapter 7).
Traditionally, both a nasolabial and a forehead fl ap require two or three operations,
take about the same time to execute, and leave a single linear scar. Although the upper
aspect of the forehead scar may be wide, even if secondary healing is employed to heal
the superior gap, it does not disrupt the facial contour as much as a nasolabial scar
and can be covered with hair. Although a nasolabial fl ap scar may be hidden in the
The Superiorly Based Two-stage Nasolabial Flap

102
Chapter • 5 • Large, Deep and Adversely Located Defects — Resurfacing with Regional Flaps
nasolabial fold, the cheek often becomes fl attened, necessitating a contralateral excision
of medial cheek tissue to improve symmetry with the opposite normal side. Although
a forehead fl ap occasionally moves hair to the nose, a nasolabial fl ap routinely transfers
beard in the male. Either fl ap can be performed under local anesthesia with sedation.
However, the pallor caused by epinephrine injection makes the vascularity of both
impossible to judge. Excessive closure tension or tight sutures cannot be evaluated if
either fl ap is ‘white’ due to chemical vasoconstriction. This is a special concern when
using a nasolabial fl ap whose blood supply is borderline, at best. I perform both fl aps
under general anesthesia.
In this patient (Figure 5–10), a similar alar defect was repaired with a two-stage fore-
head fl ap. Both nasolabial and forehead donor scars are barely visible. However, the
distortion created by the use of cheek tissue creates an asymmetry of the nasolabial
folds which detracts from the overall result. The forehead repair shows fewer telltale
signs of injury. Compare results in Figures 5–9 and 5–10.
In my practice, considering the time, effort, reliability, morbidity, donor deformity, and
overall range of application, the forehead fl ap remains the most effective, effi cient and
frequently employed method of repair.
Figure 5–10
A
B

103
Figure 5–10, Continued
The Forehead Flap
The Forehead Flap
The normal nose is covered by skin and a soft tissue subcutaneous layer of variable
thickness, which lies over a shaped hard tissue supportive framework and thin supple
lining.
The forehead is acknowledged as the best donor site for nasal reconstruction because
of its ideal skin quality and rich vascularity. It is perfused through multiple pedicles
from the supraorbital, supratrochlear, the superfi cial temporal and postauricular
arteries.
The forehead is multi-laminar — containing skin, subcutaneous fat, frontalis muscle,
and a thin areolar layer that overlies the periosteum and bone. A forehead fl ap is
thicker and stiffer than nasal skin.
So two basic questions arise: How is the forehead best transferred — which pedicle,
how many stages? How should it be thinned (or debulked) of excess frontalis and fat
so that the thickness of the transferred tissue matches the thickness of the residual skin
of the nose?
Many surgeons and patients believe that they ‘can’t, won’t, or don’t’ perform major
nasal reconstructions with forehead tissue. Surgeons often express the belief that
patients will not accept a forehead fl ap — the scar, morbidity or the temporary isola-
tion. Or they believe that the forehead is not available to resurface a major nasal defect
— too short, too narrow, and too tight. They may insist that its blood supply is limited
by an old scar or destroyed by previous surgery or injury. They fear excessive donor
deformity. They fear the ‘scar’.
C

104
Chapter • 5 • Large, Deep and Adversely Located Defects — Resurfacing with Regional Flaps
Concern for donor deformity is misdirected. The nose is a primary facial feature. The
forehead is not. Emphasis on primary closure of the donor site has led to the use of
skin grafts which poorly match the residual forehead, horizontal advancement or rota-
tion advancement fl aps which produce unnecessary forehead scarring , or unnecessary
pre-expansion that then delays the repair. Old forehead scars or a history of
prior forehead fl ap rarely limits the use of a second (or third) fl ap. When properly
designed, experience proves these fears to be erroneous. Patients are interested in
results, not specifi c techniques. If you make a patient look normal, they will thank you.
If a nasal defect is signifi cant, a forehead fl ap is the answer.
An Historical Review of Nasal Reconstruction
Even though cartilage, bone and mucous membrane are often missing in larger defects,
when the nose is injured, skin is the most obvious defi ciency. The origins of forehead
rhinoplasty (the Indian method) are obscure, but the procedure was performed in India
in 1440 AD and probably long before the birth of Christ. The fi rst written English
account of the Indian midline forehead rhinoplasty appeared in the Madras Gazette in
1793. One year later, it was published in the Gentleman’s Magazine of London. Carpue,
an English surgeon, published his account of two successful operations in 1816.
This classic median forehead fl ap (Figure 5–11), which took a vertical fl ap from the
midline of the forehead, was popularized in the United States by Kazanjian in 1946. It
received its blood supply from paired supra-trochlear vessels. The base of the fl ap
twisted 180 degrees, with an arc of rotation at or above the eyebrows. In these early
operations, the forehead donor site was allowed to heal by secondary intention.
Figure 5–11
A
Supraorbital
artery
Superficial
temporal
artery
Posterior
auricular
artery
Supratrachlear
artery
Nasal
artery
Angular
artery

105
Figure 5–11, Continued
MEDIAN FOREHEAD FLAP
B
C
CONVERSE SCALPING FLAP
Frontalis
muscle
Skin graft
Frontalis
muscle
D
WASHIO FLAP
Temporalis
muscle
Superficial
temporal artery

106
Chapter • 5 • Large, Deep and Adversely Located Defects — Resurfacing with Regional Flaps
The importance of nasal lining was not initially appreciated. Between 1840 and World
War I, it became apparent that the results using unlined fl aps were poor.
The external shape of the nose and its airways became distorted by contracting scar on
the underlying raw surface of the unlined external skin fl ap.
Residual intranasal mucous membranes seemed inadequate to line the repair. So,
around 1842, Petralli folded the distal end of the fl ap onto itself, so that it created its
own inside and outside. In a manner of speaking, the folded fl ap could form the tip,
ala and columella, and eliminate the raw surface, on the deep aspect of the fl ap, in the
lower part of the reconstructed nose. However, hairline position limited the length of
the vertical median forehead fl ap, unless hair was transferred. Midline forehead tissues
seemed inadequate to provide enough length to create a long columella, project the
nose, and permit infolding of its distal aspect for lining.
To obtain a longer fl ap, Auvert, in 1850, slanted the fl ap across the forehead at an
oblique angle of 45 degrees. German surgeons positioned their forehead fl aps horizon-
tally, supplied by the supra-orbital vessels on one side.
In 1935, Gillies described an up-and-down fl ap which was centered over one supraor-
bital pedicle, passed into the hair bearing scalp, and then descended back into the
forehead (see Figure 5–11).
In 1942, Converse modifi ed the up-and-down fl ap by creating a long pedicle that was
camoufl aged within the hair bearing skin and included the major lateral vascular
supply of the scalp. According to Converse, the advantages of his scalping fl ap were
its ability to transfer larger amounts of forehead tissue and the positioning of its per-
manent skin grafted donor site to the lateral aspect of the forehead, where it might be
less conspicuous. Unfortunately, the irregular color and texture of the skin graft stood
out as a patch. The scalping fl ap has many limitations. It is an operation of greater
magnitude than a median forehead fl ap. The large donor wound lies low on the fore-
head close to the brow. Its heavy temporary hairy pedicle hangs across the orbital rim,
obstructing vision between stages. Despite its limitations, the Converse scalping fl ap
(lined by folding its distal end for lining and cover or by prelamination), came to be
the most commonly used method of nasal reconstruction during the late 20th
Century.
Based on the superfi cial temporal vessels, New’s Sickle fl ap moved skin from the
temple recess and Washio’s fl ap transferred skin from the retroauricular region. Both
methods are unwieldy, may require a surgical delay, and are relatively poorly vascu-
larized. Neither provides a large amount of tissue.
Almost all these modifi cations created a forehead defect that was harder to close or a
fl ap of inadequate dimensions. Surgeons were caught in a diffi cult predicament. On
one hand, they worried about facial scarring. On the other hand, they bemoaned insuf-
fi cient tissue to make a nose. To add insult to injury, they often used the forehead to
repair adjacent facial defects at the time of nasal repair. Adjacent cheek, lip and nose
defects within the midface were fi lled with a single large fl ap. This approach destroyed
the subtle three-dimensional contours of these multiple contiguous facial units and
further injured the forehead donor.
The classic median forehead fl ap lost popularity. The traditional fl ap transferred
midline tissues on paired supraorbital and supratrochlear vessels. Its base lay at or
above the eyebrows. When so designed, its length was quickly limited by the hairline
and its reach by the high arc of rotation of its pedicle. Its 180 degree twist kinked at

107
the nasal root and impaired blood supply. The median forehead fl ap was recom-
mended only to replace small nasal losses, unless the patient was bald or had an
unusually high hairline, which permitted a longer vertical fl ap. However, changes in
median fl ap design developed to overcome these limitations. If the height of the fore-
head could not be changed, the fl ap could be effectively lengthened by modifying
incisions at the base of the pedicle and by lowering its point of rotation.
Lisfranc, in 1827, extended one incision lower than the other.
Dieffenbach lengthened one incision until it reached the defect.
Labat curved his incisions proximally, centering the fl ap over the medial brow and
canthus on one side.
These innovations reduced the twist of the pedicle base and brought the fl ap closer to
the recipient site.
Equally important, this paramedian forehead fl ap transferred central forehead tissue on
a unilateral pedicle blood supply. It was designed with a vertically oriented axial blood
supply. Its pivot point and arc of rotation was centered inferiorly near the medial
canthus (see Chapter 6).
Strangely, except for the use of the paramedian forehead fl ap by Millard, this modifi ca-
tion received little attention. Millard clearly demonstrated that bilateral pedicles were
not essential for fl ap viability. More recently, the anatomic studies of McCarthy and of
Jackson demonstrated that the forehead is perfused by an arcade of vessels supplied
by the supraorbital, supratrochlear, infraorbital, dorsal nasal, and angular branches of
the facial artery and the superfi cial temporal artery. A rich anastomotic plexus, cen-
tered on the medial canthus, can supply a unilaterally based fl ap, even if the named
vessels have been previously injured.
Refi nements in this paramedian design also served to minimize potential donor defor-
mity. The outlines of the earliest forehead fl aps were made from waxed patterns,
shaped to fi ll the defect, and then fl attened on the forehead. In 1828, Veltech drew his
fl ap as a reversed Ace of Spades — its stem formed the columella and its tapering tip
was attached as the pedicle. In 1834, Labat designed a similar tripod shaped fl ap, with
limbs extending obliquely across the forehead. More recently, Millard used a seagull-
shaped fl ap with a central vertical component and lateral wings. The wings extended
horizontally and were positioned in the natural transverse wrinkle lines of the fore-
head. The vertical component resurfaced the dorsum, tip and columella and the lateral
extensions covered the alae and fl owed into the alar bases and nostril sills. Millard’s
fl ap took excess forehead tissue in both horizontal and vertical directions. Simple
undermining of the adjacent wound margins often allowed near complete primary
closure, leaving an inconspicuous midline T-shaped scar. Forehead donor closure did
not require additional parallel incisions along the brow or hairline, the rotation of large
scalp fl aps, or a skin graft to close the forehead, as some had recommended.
It became clear that midline forehead tissue could be transferred successfully as a
paramedian fl ap. Adequate tissue was available to resurface a nasal defect of any
size.
Pre-expansion of the forehead, to enlarge the donor site or ease its closure, is unneces-
sary, in most cases. Skin expansion delays the reconstruction for months and adds to
the patient’s discomfort and social isolation. Expansion may be used to lengthen a fl ap,
if the forehead is inordinately short, or to enlarge the area of available skin, if the
An Historical Review of Nasal Reconstruction

108
Chapter • 5 • Large, Deep and Adversely Located Defects — Resurfacing with Regional Flaps
forehead is inordinately tight due to previous harvest or limited by past injury and
scars which might impair its blood supply. Expanded forehead skin or distant tissues
are very rarely needed. Pre-expansion is unnecessary and distant skin will never match
the face. Fear, a lack of experience or complacency is not an excuse for their use.
Today, the paramedian forehead fl ap, with its unilateral supratrochlear pedicle, is the
fi rst choice for nasal reconstruction because of its vascularity, size, reach, reliability,
and relatively minimal morbidity. Its design takes skin from high in the forehead under
the hairline, based on a narrow inferior pedicle. The inferior aspect of the donor defect
can be closed primarily. If a gap remains superiorly, it is allowed to heal secondarily.
Wound contraction and re-epithelialization close any residual superior defect. The fi nal
scar is insignifi cant and is relatively hidden under the hairline. Because the gap is away
from the mobile brow, eyebrow distortion does not occur. Because the proximal pedicle
is narrow, medialization of the eyebrow is not signifi cant. A forehead fl ap can resurface
any nasal defect without signifi cant donor deformity.
When in doubt, choose a forehead fl ap to solve the clinical problem. Use the paramedi-
cal design. The surgeon will rarely be disappointed.

A Modern Approach to Nasal
Reconstruction with a
Forehead Flap
C H A P T E R
6
The forehead is acknowledged as the best donor site for nasal reconstruction because
of its ideal skin quality and rich vascularity. It is multi-laminar, composed of skin,
subcutaneous fat, frontalis muscle and a thin areolar layer. Although forehead skin
matches the nose in color, texture and thickness, a forehead fl ap is thicker than nasal
skin. The excess frontalis and subcutaneous fat must be removed to allow the trans-
ferred skin to blend into the adjacent facial skin.
How is the forehead best transferred? How can it be thinned of excess frontalis and fat
so that the thickness of the transferred tissue matches the thickness of the residual
skin?
Planning a Forehead Flap Nasal Reconstruction
Nasal reconstruction requires that the surgeon analyze the defect, both anatomically
and aesthetically.
Anatomically, the nose is covered by thin conforming skin that matches the face
in color and texture. It overlies a sculpted soft and hard middle layer framework
that supports, shapes, and braces the soft tissues against gravity (and postoperative
wound contraction after repair). Its underlying lining must be thin, supple, and vas-
cular — neither distorting the external shape outward nor bulging inward, causing
obstruction.
Aesthetically, the nose is described in terms of regional units — adjacent topographic
areas of characteristic skin quality, and outline, and three-dimensional contour.
The ‘normal’ nose is recreated by the re-establishment of these aesthetic contours,
highlights, and landmarks.
Assume patients wish to look normal. Rarely do they want less. It is unusual for associ-
ated medical illness to interfere with reconstruction. Healing by secondary intention,
a simple closure of cover to lining, or an unsightly skin graft or second choice fl ap is
rarely appropriate. Almost always, the goal should be an aesthetic result.
The surgeon must visualize the desired result before the fi rst incision. He or she must
have a ‘vision’ in their mind’s eye of the goal. Methods, maneuvers, tissues, and timing
must be chosen to reach that end.
If restoration of nasal subunits is the goal, certain principles follow.

110
Chapter • 6 • A Modern Approach to Nasal Reconstruction with a Forehead Flap
Frequently, the wound should be altered in size, site, or depth to improve the result.
Because fl aps often trapdoor due to fi brotic contraction between the donor and the
recipient bed, fl aps rise above the level of the remaining nose. It is often better to
resurface the entire subunit with a fl ap, rather than patching the defect. The Subunit
Principle is applied: If the defect occupies greater than 50% of a convex subunit (tip or
ala), consider discarding adjacent normal tissue within the subunit so that the entire
subunit is resurfaced, rather than just part of it.
Missing tissue must be replaced exactly, neither underfi lling nor overfi lling the
defect.
Flap dimensions are taken from the contralateral normal or the ideal, not from a fresh
gaping wound or an old contracted defect.
When repairing composite defects which encompass multiple facial units, let swelling
resolve, tissues settle, and scar contract before proceeding with subsequent stages. If
the nose, lip and cheek are missing, do not start the nasal repair until a stable
platform is assured. Stage the repair.
By necessity, distant free fl aps have become the fi rst choice for large, complicated
defects. Although they can close the defect and heal the wound, distant tissue does not
match facial skin color, texture or thickness, or have a facial shape.
To restore the patient to normal, the massive facial defect should be approached in two
stages. Initially, distant tissue is supplied to provide bulk, protect vital structures,
revascularize the wound, and reconstruct a stable platform. Distant tissues are used
only for ‘invisible’ requirements — lining and support. During later stages, a unit
approach is used to restore facial skin quality, border outline, and three-dimensional
contour. Local tissue and traditional methods of transfer are used to replace the
mismatched cover skin.
Reconstruction of the nose is an artistic endeavor. Technology is not the answer. Derm-
abraders or lasers to improve scars or expanders and free fl aps to provide ‘more’ tissue
are tools. Although they can be helpful in specifi c instances, they are rarely needed. A
poorly planned or clumsily executed operation will not be improved by technology.
Anatomy
The supratrochlear artery crosses the orbital rim sandwiched between corrugator and
frontalis muscles (Figure 6–1). The artery passes over the brow above the periosteum,
protected by the corrugator muscle. So the base of a unilateral paramedian forehead
fl ap can be elevated over the periosteum at the supraorbital rim without endangering
its blood supply. The supratrochlear vessels then travel vertically upward under the
frontalis. At the mid forehead level, they pass through the muscle and lie in a super-
fi cial, subdermal position as they approach the hairline.

111
Supratrochlear artery
Supraorbital artery
Dorsal nasal artery
Angular artery
Infraorbital artery
Transverse facial artery
Figure 6–1
Anatomy

112
Chapter • 6 • A Modern Approach to Nasal Reconstruction with a Forehead Flap
It can be transferred, as an island fl ap, in one stage, although this is not recommended.
The excessive bulk of the pedicle, passing under tight glabellar skin, jeopardizes the
fl ap’s blood supply. The bulky subcutaneous pedicle also distorts the contour of the
nasal root. Even if the island fl ap survives, a revision will be needed. The island fore-
head fl ap does not solve the diffi cult problems of nasal repair.
The Two-Stage Forehead Flap
Because a forehead fl ap is multilaminar, it is stiff and thick. It must be ‘debulked’ to
nasal ‘thinness’ and suppleness. Traditionally, a forehead fl ap is transferred in two
stages. At the fi rst stage, frontalis muscle and subcutaneous tissue are excised distally
(Figure 6–2). The partially thinned fl ap is transferred to the recipient site, perfused
proximally through its thick vascular pedicle. At the second stage, three weeks later,
the distal end becomes vascularized from the recipient site. It is no longer dependent
on the supratrochlear vessels to survive. The pedicle can be divided. The fl ap’s proxi-
mal aspect is re-elevated, thinned and the proximal fl ap inset is completed.
Unfortunately, excision of frontalis muscle and subcutaneous fat, at the time of the
initial transfer, removes its myocutaneous blood supply, diminishing vascularity to the
distal fl ap. It creates a fl ap less able to tolerate tension. Although relatively safe, fl ap
necrosis may occur in smokers or in patients undergoing major nasal reconstructions
which require large fl aps (and concomitant soft tissue thinning over a large area) or
fl aps with multiple narrow extensions for the ala and columella. A pale or dusky blue
fl ap may survive but the consequences of fl ap loss are too great to risk its necrosis. Do
not stress the fl ap, the patient or yourself.
This two-stage soft tissue debulking is limited, incomplete, and piecemeal. Although
excellent results can be obtained, it is still diffi cult to create a fl ap of uniform thickness.
It also creates a wounded, raw, bleeding subdermal surface which is prone to fi brosis
and contraction. This makes it more diffi cult to create a nose with delicate contour. Tip
and alar cartilage support can be placed at the fi rst stage but, once positioned, cannot
be altered, during subsequent pedicle division.
Re-establishing the contour of a single subunit is achievable, but re-creating the subtle
hills and valleys and highlights and shadows of multiple subunits is more diffi cult.
This is especially evident when the defect is large and covers several units or the defect
is deep, requiring complex support and lining replacement. Later secondary revisions
will be needed, delaying the completion of the repair for months.
The two-stage forehead fl ap is best limited to small defects that do not require delicate
contour recreation, complex support grafts or lining replacement.

113
The Two-Stage Forehead Flap
Axial dermal
vessels preserved
Cut edge of frontalis muscle
Subcutaneous tissue
Frontalis muscle
Supratrochlear artery
Hairline
Cut edge of
frontalis muscle
Periosteum
Subcutaneous
tissue
Flap turned down with subcutaneous fat trimmed
preserving axial dermal vessels
Frontalis muscle
Corrugator muscle
Supratrochlear artery
Figure 6–2

114
Chapter • 6 • A Modern Approach to Nasal Reconstruction with a Forehead Flap
The color and contour of the patient’s nose is signifi cantly distorted after the resurfac-
ing of a large deep defect with a full-thickness skin graft (Figure 6–3). The subunits are
marked with ink and a residual normal skin is excised within the tip subunit and part
of the dorsum. Missing tip cartilage is replaced with a primary ear cartilage lateral crus
replacement and an onlay tip graft.
A
B
C
D
Figure 6–3

115
The Two-Stage Forehead Flap
Based on an exact pattern (Figure 6–4), a left paramedian forehead fl ap is elevated and
transposed to resurface the defect. Within its distal 1.5–2 cm, fat and excess subcutane-
ous fat are excised to produce skin with 2–3 mm of fat to resurface the distal aspect of
the defect.
A
B
C
D
Figure 6–4

116
Chapter • 6 • A Modern Approach to Nasal Reconstruction with a Forehead Flap
Three weeks later (Figure 6–5), the pedicle is divided. The proximal aspect of the fl ap
is re-elevated with 2–3 mm of fat. Underlying excess soft tissue (fat, muscle, and scar),
which remains adherent to the proximal recipient site, is excised to contour the dorsum.
It is safe to re-elevate the fl ap to within 1–2 cm of its distal inset. But the surgeon must
balance the need to excise excess soft tissue to recreate a nasal contour and the risk of
fl ap loss. Although this fl ap was re-elevated quite aggressively to permit soft tissue
contouring of the dorsum, it remained well vascularized through its distal attachment
to the recipient bed. The fl ap inset is then completed. The proximal pedicle is untubed
and returned to the donor site as a small inverted ‘V’. Any excess is discarded.

117
The Two-Stage Forehead Flap
A
B
C
Figure 6–5

118
Chapter • 6 • A Modern Approach to Nasal Reconstruction with a Forehead Flap
When a forehead fl ap is inset at the tip-dorsal junction, it may notch the nose on lateral
view or simulate a ‘bulbous’ tip, if its border scar becomes depressed.
If a dorsal defect is extended into the radix by subunit excision, the superior aspect
may look ‘stuck on’ due to the removal of underlying mobile soft tissue at the nasal
root.
The superior border of the dorsal subunit also blends indistinctly into the forehead
unit, unless an obvious transverse procerus wrinkle is present. So a distinct border
between the dorsum and radix is not available to hide a scar. There is no specifi c rule.
But a mid dorsal inset often works best. So a subunit excision of the entire dorsal unit
is usually unnecessary.
Postoperatively (Figure 6–6), the correct color and contour are restored without
revision.
In Figure 6–7 the Mohs defect occupies most of the right ala. Residual skin is excised
within the subunit. Based on an exact template determined from the contralateral
normal ala, a cartilage graft is buried in subcutaneous pockets under neighboring intact
skin, medially and laterally. The graft is sutured to the underlying lining. This support
will shape and brace the soft tissues from scar contraction. A right paramedian fore-
head is designed based on the same contralateral template. Excess frontalis and
subcutaneous fat are excised distally. A two-stage paramedian fl ap resurfaces the ala
as a subunit.
A
B
Figure 6–6

119
The Two-Stage Forehead Flap
A
B
C
D
Figure 6–7

120
Chapter • 6 • A Modern Approach to Nasal Reconstruction with a Forehead Flap
Three weeks later (Figure 6–8), the pedicle is divided. Distally, the fl ap is partially re-
elevated, superiorly. The underlying soft tissue is contoured to recreate the convexity
of the ala and the defi nition of the alar crease. The excess of subcutaneous fat and any
imperfection of the underlying cartilage graft are excised until the recipient bed
has the contour of the contralateral normal ala. The proximal fl ap is returned to the
forehead after trimming and inset as a small inverted ‘V’.
A
B
C
Figure 6–8

121
The Two-Stage Forehead Flap
Postoperatively (Figure 6–9), alar symmetry, position and contour are correct without
revision.
A
B
Figure 6–9