Nasal Reconstruction Art and Practice E-Book_nodrm

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The Two-Stage Forehead Flap
Three weeks later (Figure 6–11), the fl ap is divided and the inset completed.
A
B
Figure 6–11
No revision was performed (Figure 6–12).
A
B
Figure 6–12

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Chapter • 6 • A Modern Approach to Nasal Reconstruction with a Forehead Flap
A Mohs defect of the columella is resurfaced with an exactly sized and shaped forehead
fl ap in two stages. The medial crura remained intact and no cartilage graft was needed
(Figure 6–13).
B
A
C
Figure 6–13

125
The Two-Stage Forehead Flap
After division, the shape and contour of the subunit is restored without revision (Figure
6–14).
A
C
B
Figure 6–14

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Chapter • 6 • A Modern Approach to Nasal Reconstruction with a Forehead Flap
During her pre-Mohs visit, this patient expressed a lifelong deep dissatisfaction with
her nose. Family photographs were an uncomfortable trial. Her dorsal convexity was
a greater concern than her skin cancer!
After excision of a basal cell carcinoma, an ‘adversely located’ defect lay within her
right ala and sidewall, lateral to the dome (Figure 6–15). She wished the defect repaired
and her lifelong dissatisfaction with the appearance of her nose addressed at the
same time.
A
B
Figure 6–15

127
The Two-Stage Forehead Flap
At her repair (Figure 6–16), a columella incision was connected to bilateral rimming inci-
sions, in continuity with the defect. An open rhinoplasty was performed. The dorsum
was lowered. Lateral spreader grafts were fi xed to the dorsal septal border. A small
septal cartilage graft was placed under the supratip to elevate an old depressed scar
which had followed a prior skin cancer excision. A columellar strut was fi xed between
the medial crura. The cephalic margins of the lateral crura were excised and the domes
narrowed with dome spanning sutures. A Peck graft further refi ned the tip.
A
B
C
D
Figure 6–16

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Chapter • 6 • A Modern Approach to Nasal Reconstruction with a Forehead Flap
A conchal cartilage alar rim was then placed to support the nostril margin and soft
triangle. A non-subunit two-stage forehead fl ap, thinned distally, was designed to
exactly replace missing skin to the cancer defect.
The pedicle was divided three weeks later. During a revision, the right alar crease was
further defi ned to outline the expected junction of the ala and sidewall units.
In Figure 6–17, her ‘pretty’ nose provides as much happiness to the patient as her
cancer repair.
A
B
C
Figure 6–17

129
The Two-Stage Forehead Flap
In Figure 6–18, the patient’s Mohs defect encompasses most of the right hemitip and
ala. To correct this, residual skin within the hemitip and alar subunits is excised. Based
on an exact pattern of the contralateral normal, the defect is resurfaced with a parame-
dian fl ap after excision of its distal frontalis and subcutaneous fat. A primary cartilage
graft is positioned for alar support and covered with distal forehead skin equal in
thickness to nasal skin.
A
B
C
Figure 6–18

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Chapter • 6 • A Modern Approach to Nasal Reconstruction with a Forehead Flap
Three weeks later (Figure 6–19), the pedicle is divided. The proximal fl ap is re-elevated
with a few millimeters of fat. The underlying recipient bed is sculpted until the alar
crease is defi ned and the sidewall fl at.
A
B
Figure 6–19
Although the defect covered the hemitip, ala and part of the sidewall, the fi nal contour
was excellent without revision (Figure 6–20). However, such delicacy cannot routinely
be obtained in two stages, especially in larger defects. In this case, the innate thinness
of this patient’s tissue contributed to the result. However, aggressive operative debulk-
ing was required during both stages. This puts the fl ap in some jeopardy and may
create unnecessary surgical anxiety and occasional fl ap necrosis, especially in the
smoker.

131
The Two-Stage Forehead Flap
Forehead skin is traditionally transferred in two stages. Excellent results can be
obtained. However, careful observation of clinical cases over 20 years illustrates that
the two-staged forehead fl ap is ideally used for small defects that:
1. encompass one or two contiguous subunits;
2. require limited and less detailed cartilage support replacement;
3. are partial thickness defects which do not require lining replacement;
4. in patients without risk of ischemic necrosis — the nonsmoker, those without a
history of prior scarring (the unscarred virgin forehead), or whose design does
not require complex distal extensions.
The two-stage forehead fl ap should be avoided in larger, more complex cases.
In larger, deeper and more complex reconstructions, the results of the two-stage
approach are less predictable, will require secondary revisions to further sculpt the
fi nal contour and may put the fl ap at risk for necrosis.
A
B
Figure 6–20

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Chapter • 6 • A Modern Approach to Nasal Reconstruction with a Forehead Flap
A Modern Wish List
The history of nasal reconstruction reveals a shift, over the past 20 years, from the
classic scalping fl ap with turnover hinged fl aps or prefabricated lining and minimal or
no support. Lately, the two-stage paramedian forehead fl ap, with intranasal lining
fl aps and primary cartilage grafts, has been recommended. Results improved. How-
ever, surgeons always seek simpler, easier, more reliable, predictable and less risky
methods.
A modern surgeon might envision a new Wish List:
It would be helpful if a forehead fl ap:
1. Could be thinned safely in one stage to produce a uniform skin paddle with
2–3 mm of subcutaneous fat. This would create thin, supple cover, even if the
fl ap was large. Such a fl ap would more easily conform to the complex three-
dimensional shape of the underlying subsurface framework. But the fl ap must
remain highly vascular with little risk of necrosis.
2. If a complete middle support layer could be precisely shaped and made rigidly
strong during the repair — not a fl imsy fabrication of multiple individual
cartilage pieces lightly sutured together and subject to collapse, shifting, or initial
poor design and which cannot be modifi ed once positioned and resurfaced with
covering skin.
3. If a lining technique was available, that minimized the intranasal dissection
associated with intranasal lining fl aps, avoiding a bloody, time-consuming and
technically demanding dissection of the internal nose. Such a technique would
lessen the risk of epistaxis or prolonged intranasal crusting. The operative time
would be shortened and the patient’s recovery quicker.
4. If the technique was safer, more reliable, produced better results and decreased
the diffi culty and number of late revisions.
5. Allowed for the correction of intraoperative design errors or imperfections and
provided for the effective treatment of disastrous complications, which can occur
during any repair.
Early Advances
The tint of the forehead so exactly matches that of the face and nose that
it must be the fi rst choice. The forehead makes far and away the best nose.
Sir Harold Gillies and D. Ralph Millard
Essentially, all fl aps are similar and consist of two parts — the part
chiefl y concerned with the traffi c of circulatory fl uids, and the part
available for plastic use.
Sir Harold Gillies
Plastic surgery is a perpetual battle of beauty versus blood supply.
Sir Harold Gillies and D. Ralph Millard
Millard, in 1974, believing that fl ap thinning would be safer with the pedicle intact,
described an intermediate operation between fl ap transfer and division. Elevating the
distal aspect of the fl ap, he excised excess soft tissue to improve the shape of the ala
and tip, in a small number of patients.

133
Burget reintroduced the concept in the early 1990s. He thinned the fl ap distally at the
initial transfer, as did Millard. Three weeks later, he re-elevated the fl ap from its bed,
over the mid nose, at a superfi cial subcutaneous level. The pedicle was left intact and
the distal inset was left attached over the tip, alar margins and columella. Hanging
from the proximal pedicle and from the alar margin, underlying fat and muscle were
excised to improve the contour of the dorsum and midvault. Signifi cant wound con-
traction should not occur during the fi rst three weeks after the initial distal thinning
performed during the fi rst stage. It was felt that a better nasal shape might be achieved
before the maturation process began in earnest and before the pedicle was divided.
Although helpful, the Millard and Burget approach still suffers from the disadvantages
of the traditional two-stage fl ap transfer. The blood supply to the fl ap is decreased, at
the initial transfer, due to distal thinning. A raw healing surface, subject to unpredict-
able contraction, is exposed during multiple operative stages. With the pedicle hanging
from the brow and fi xed to the tip and alar rims, visualization for the middorsal sculpt-
ing is poor. The approach remains incomplete, limited and piecemeal. Once the fl ap is
applied to the ala and tip during the fi rst stage, further soft tissue sculpting or cartilage
modifi cation of the distal nose cannot be performed. Manipulation of the midnose is
accomplished, but with diffi culty, and limited exposure.
The Three-Stage Forehead Flap with
an Intermediate Operation
The forehead, when transferred as a full-thickness fl ap, has unique properties.
The forehead is multi-laminar, consisting of skin, subcutaneous tissue, frontalis muscle
and a thin areolar layer. It is a myofascial, axial and a random fl ap and highly vascular.
Initial distal thinning removes the myocutaneous component of its blood supply;
exposes a wounded, raw, bleeding subdermal surface prone to fi brosis and contraction,
and creates a fl ap less able to tolerate the tension of closure. However, when it is
transferred with all its layers, such soft tissue injury does not occur and fl ap necrosis
is unusual. Its tissues remain soft. The expected induration of wound healing
does not occur, even many months after fl ap elevation and transfer — as long as its
subcutaneous plane is not injured or the frontalis excised. These characteristics can be
used to the surgeon’s advantage.
Creating ideal nasal cover and a rigid subsurface architecture
Technique
Stage I
A full-thickness, multi-laminar (skin, subcutaneous fat and frontalis muscle) fl ap is
elevated. The fl ap is not thinned. The defect is replaced exactly, using a template
derived from the contralateral normal or from an ideal. It is inset, without tension or
blanching, with a single layer of fi ne suture. If altering the defect will improve the fi nal
aesthetic result, adjacent normal tissue within subunits is excised, and the entire subunit
is resurfaced, rather than only the defect. Primary cartilage grafts are placed, if vascu-
larized intranasal lining is present or has been restored. Such primary support grafts
are a fi rst choice. The surgeon may place primary support after re-establishing lining
with intranasal fl aps, hingeover fl aps, a second fl ap, or a free fl ap. The advant ages of
a full-thickness fl ap accrue to any lining technique.
The Three-Stage Forehead Flap with an Intermediate Operation

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Chapter • 6 • A Modern Approach to Nasal Reconstruction with a Forehead Flap
However, if a skin graft or a folded forehead fl ap is employed to line a full-thickness
defect, primary cartilage grafts are precluded during the fi rst stage. But cartilage grafts
can be positioned in a delayed primary fashion later during the intermediate stage, if
needed.
The forehead donor site is closed in layers after wide undermining in the subgaleal
plane. Any gap that cannot be approximated is allowed to heal secondarily.
As can be seen in Figure 6–21, after excision of a basal cell carcinoma, the defect
occupies most of the dorsum, tip, left ala and sidewall and part of the medial cheek.
The right rim is retracted from prior excisions.

135
A
B
C
Figure 6–21
The Three-Stage Forehead Flap with an Intermediate Operation

136
Chapter • 6 • A Modern Approach to Nasal Reconstruction with a Forehead Flap
The right alar subunit is outlined and the alar crease is incised (Figure 6–22). The right
retracted ala is released and repositioned inferiorly, in symmetry to the opposite
normal nostril margin. The underlying intact lining re-expands to its normal dimen-
sions once the external scar is released. The nostril rim is braced in position by a side-
wall cartilage graft. The Mohs wound is altered to improve the result. Residual normal
skin is excised within the tip and left alar subunits. The right nasolabial fold is incised
and the skin defi ciency, within the right sidewall, is fi lled by advancement of the cheek
skin, up to the dorsal line. To support and contour the primary defect, the left ala is
supported and shaped by a primary ear cartilage graft. The left cheek is undermined
and advanced to resurface the medial cheek defect. Only the nasal defect remains to
be resurfaced with forehead skin.
This complex composite defect has been modifi ed to allow a regional unit repair of the
nose and cheek (Figure 6–23). Based on an exact pattern, a left paramedian forehead
fl ap is elevated, with all its layers, to resurface the residual nasal defect. No frontalis
or subcutaneous fat is excised. It is sutured in one layer. The forehead defect will heal
secondarily.
A
B
Figure 6–22

137
C
D
E
F
Figure 6–22, Continued
The Three-Stage Forehead Flap with an Intermediate Operation

138
Chapter • 6 • A Modern Approach to Nasal Reconstruction with a Forehead Flap
C
D
B
A
Figure 6–23

139
The Three-Stage Forehead Flap with an Intermediate Operation
E
Figure 6–23, Continued
Stage II
Three or four weeks later, the full-thickness forehead fl ap, now well healed to the
recipient bed, is physiologically delayed. To avoid the distortion created by local anes-
thesia or the chemical blanching of epinephrine, the procedure is performed under
general anesthesia. The forehead skin is easily elevated, with 2 to 3 mm of subcutane-
ous fat (nasal thinness), over the entire nasal inset in the unscarred subcutaneous tissue
plane of the fl ap. A combination of digital two hand palpation and transillumination
allows elevation of a smooth, even, thin, supple, conforming, and viable skin cover of
ideal thickness and quality.
Most often, the fl ap is completely re-elevated and placed to the side of the face.
However, the extent of fl ap elevation may vary, depending on the exposure needed
for soft tissue excisional sculpture or the need to place additional delayed primary
cartilage grafts. In a smoker or in a patient with a previous scar across the fl ap territory,
it may be safer to leave the fl ap partially attached distally, dangling on the columella
or from part of the nostril margin. Hanging as a vascularized bipedicle fl ap, extending
from the intact supratrochlear brow pedicle to the columella, its vascularity may be
protected in high-risk patients. However, in almost all cases, the fl ap is completely
removed from the donor site to permit complete visualization and modifi cation of the
entire recipient site.
Perhaps because of the surgical delay or the accommodation of the fl ap pedicle to the
initial twist at the time of transfer, its blood supply is excellent. Its vascularity is aug-
mented and its blood supply is greater than seen after the fi rst stage transfer.

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Chapter • 6 • A Modern Approach to Nasal Reconstruction with a Forehead Flap
A full-thickness forehead fl ap, when elevated during the intermediate operation, is
unique. Its vascularity is signifi cantly greater than when it was transferred and much
greater than that of a ‘thinned’ two-stage fl ap at its initial transfer. At the intermediate
operation, forehead skin without frontalis muscle can be completely re-elevated off the
nose, maintaining no distal inset, without signifi cant risk. Color and capillary refi ll
remain excellent, refl ecting its abundant blood supply.
The slightly edematous and previously undissected subcutaneous plane, between the
skin and frontalis muscles, separates easily from underlying tissues. The skin seems
softer and more compliant, as well. Often, it has already ‘conformed’ to a nasal shape;
its 2-D fl atness begins to become three-dimensional as it lies over the recipient bed.
Little bleeding occurs from the deep surface of the skin fl ap. Axial subcutaneous
vessels, lying in the subdermal superfi cial fat, become visible and are avoided. Most
are left adherent to the fl ap’s deep surface. However, some injury is inevitable and
without consequence.
The forehead fl ap is temporarily wrapped in a moist sponge and laid on the forehead.
The underlying subcutaneous tissue, frontalis muscle and any previously positioned
primary cartilage grafts are exposed. Lining, residual support or positioned cartilage
grafts, and the deep soft tissue layers of the forehead are healed together into a solid,
living structure. With 360 degrees of exposure, the entire nasal subsurface is now
visible. A three-dimensional shape can be sculpted into the underlying recipient bed.
Excess soft tissue is excised. With unparalled visual access, the surgeon can carve sym-
metrical alar creases, delicate tip contours and dorsal lines. All areas of the recipient
site can be modifi ed by soft tissue excision or cartilage graft repositioning or the addi-
tion of delayed primary grafts. Because the fl ap’s blood supply is so rich, the surgeon
is not limited by fear of necrosis, or by the anxiety associated with overaggressive re-
elevation of the distal fl ap inset when its pedicle is divided during the second stage of
the traditional two-stage approach. Equally important during the intermediate stage
of this full-thickness fl ap technique, the surgeon does not have to work around a
pedicle, bridging from the brow to the columella, while simultaneously prevented from
modifying the tip and ala by the distal inset.
The excess soft tissue, which is adherent to the recipient bed, is a conglomerate of car-
tilage, fat and scar. It heals together and becomes a living rigid structure that bleeds
readily. It can be carved, like a bar of soap, into an ideal subunit subsurface architec-
ture. Previously positioned primary cartilage grafts become visible and can be remod-
eled by sculpting, further augmentation or repositioning, if malpositioned or shifted.
Additional delayed primary cartilage grafts can also be placed over vascularized fore-
head skin that has been folded for lining or over a skin graft that has been used for
lining.
After creation of an ideal subsurface shape by soft tissue excision and cartilage grafting
during the intermediate operation, the forehead skin — now of nasal skin ‘thinness’
— is replaced on the underlying rigid, recontoured three-dimensional recipient bed.
The cover fl ap is fi xed with quilting sutures to close the dead space and better conform
to the underlying contour. The fl ap is sutured to the recipient site with a single layer
of peripheral sutures.
Four weeks later, our patient’s nose is bulky. The regional units are outlined with ink,
as a visual reference. Periosteum over the frontal bone has desiccated. Petrolatum oint-
ment is applied and it is allowed to heal by secondary intention.

141
A
C
B
Figure 6–24
The Three-Stage Forehead Flap with an Intermediate Operation

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Chapter • 6 • A Modern Approach to Nasal Reconstruction with a Forehead Flap
At operation (Figure 6–25) the fl ap’s periphery is incised and the fl ap is elevated with
2–3 mm of subcutaneous fat. The thick forehead fl ap has been converted to supple
conforming skin of nasal ‘thinness’. The fl ap is placed to the side of the face.
Now (Figure 6–26), with the fl ap completely re-elevated, the underlying recipient site
is widely exposed. The subunits are marked with ink over the recipient surface. Excess
subcutaneous fat, frontalis muscle, and scar are excised to sculpt an ideal nasal shape.
The previously positioned alar batten is carved, as needed, to recreate the ideal alar
contour and a defi ned alar crease.
A
B
Figure 6–25

143
A
B
Figure 6–26
C
D
The Three-Stage Forehead Flap with an Intermediate Operation

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Chapter • 6 • A Modern Approach to Nasal Reconstruction with a Forehead Flap
The thin supple fl ap is then re-approximated to the highly sculptured hard tissue
surface of the recipient bed (Figure 6–27). It is affi xed to the contoured recipient bed
with quilting sutures and sutured, in one layer along its periphery, to adjacent skin.
Stage III
Three or four weeks later — 6 to 8 weeks after transfer — the pedicle is transected. The
inferior forehead scar is reopened, and the proximal pedicle is unfurled, trimmed, and
inset as a small inverted ‘V’ at the medial brow, which simulates a frown crease. The
superior aspect of the fl ap is re-elevated with 2 to 3 mm of subcutaneous fat from the
recipient bed, and the proximal recipient bed is sculpted by further excision of sub-
cutaneous fat and scar. This better defi nes the dorsal lines, alar creases, and sidewall
junction. Every opportunity to improve nasal contour should be taken. As the saying
goes: ‘a chance to cut is a chance to cure.’ The undulating contour of multiple units is
not easy to recreate. The fl ap inset is completed.
A stable, sculptured rigid platform of hard and soft tissue with a nasal shape shows
through the thin conforming forehead skin.
Four weeks later (8 weeks after fl ap transfer) (Figure 6–28), the nasal contour is nearly
correct. The nasal subunits, based on a pattern of the contralateral normal ala and
visual observation are outlined. The dorsum, sidewall and alar crease must be further
defi ned.
A
B
Figure 6–27

145
A
C
B
Figure 6–28
The Three-Stage Forehead Flap with an Intermediate Operation

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Chapter • 6 • A Modern Approach to Nasal Reconstruction with a Forehead Flap
To achieve this (Figure 6–29) the fl ap pedicle is divided, the forehead skin re-elevated
with 2–3 mm of fat over the proximal dorsum to the alar crease, the recipient site
sculptured to further refi ne a fl at sidewall and deepen the alar crease. The fl ap is then
sutured to the recipient site and fi xed lightly with quilting and peripheral sutures. The
proximal fl ap is trimmed and inset at the medial brow.

147
A
B
C
D
Figure 6–29
The Three-Stage Forehead Flap with an Intermediate Operation

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Chapter • 6 • A Modern Approach to Nasal Reconstruction with a Forehead Flap
Postoperatively (Figure 6–30), the skin quality, border outline and 3-D contour of the
nose and cheek have been re-established. The forehead has healed secondarily. No
revisions were performed. Thin supple forehead skin covers a complexly shaped rigid
subsurface in three stages.
This repair should be compared to a similar composite defect of the nose, lip and cheek,
illustrated in Chapter 2, which had been repaired using traditional false principles and
techniques.
The three-stage full-thickness forehead fl ap with an intermediate operation is my
workhorse. Most of the larger, deeper and more diffi cult cases, illustrated in this text,
have been repaired with its use. The results of the technique are available for careful
review in almost every chapter.
A
B
Figure 6–30

149
C
D
E
Figure 6–30, Continued
The Three-Stage Forehead Flap with an Intermediate Operation

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Chapter • 6 • A Modern Approach to Nasal Reconstruction with a Forehead Flap
The risk of fl ap ischemia
The risk of forehead fl ap necrosis is insignifi cant during the initial transfer or during
the intermediate sculpting operation, when the full-thickness forehead fl ap technique
is employed. In 200 repairs, fl ap ischemia occurred in two cases — both were complex
revisional reconstructions in patients with a failed prior forehead fl ap. Both occurred
after harvesting a second forehead fl ap from an already injured donor site to resurface
the entire nasal surface. These cases are illustrated in Chapters 8 and 21.
In the fi rst, partial necrosis of one ala followed transfer of a pre-expanded, second
forehead fl ap, used to reconstruct a cocaine nose. A third forehead fl ap was required
to successfully complete the repair.
In the second, a full-thickness transverse scar lay completely across the planned pedicle
of the second fl ap’s base. Superfi cial ischemia of the one ala, within the territory of the
delayed fl ap, occurred during the intermediate operation, even though the fl ap was
well vascularized during the initial Stage 1 transfer. Fortunately, although worrisome,
signifi cant tissue loss did not occur. The injury healed spontaneously. The repair was
successfully completed without further incident.
Improved results and fewer late revisions
The three-stage forehead fl ap can be used to repair both partial and full-thickness
defects. It allows primary and delayed primary cartilage support. It permits a modifi ed
folded forehead fl ap or a skin graft to be used for lining, although it can be combined
with any method of lining replacement.
Because the forehead fl ap is thinned in its entirety and an ideal subsurface architecture
is established during the intermediate operation and before pedicle division, late revi-
sions of partial-thickness nasal defects are not required or are minor. In complicated full-
thickness defects, one (or two) revisions are useful to improve the result. They are
outlined during the initial preoperative plan, prior to beginning the repair. Many
patients will fi nd them to be unnecessary but, seeking the ‘normal,’ such revisions are
often suggested by the surgeon.
At 4 to 6 months, once wound maturation is complete, the alar crease can be defi ned
by direct soft tissue excision; a hanging nostril margin trimmed by rim excision; or the
nasal aperture enlarged by local soft tissue excision, local lining redistribution or a
composite skin graft. The forehead donor scar can be revised by excision and re-
advancement, discarding any area of hypertrophy associated with secondary healing.
Overall, the fi nal aesthetic results can approach normal (see Chapter 22).
Rhinoplasty surgeons have long emphasized the interrelationship of the skin envelope
and its underlying skeleton. Ideally, an aesthetically structured framework is designed
to positively infl uence the conformation of its overlying skin. Modern augmentation
techniques can modify nasal cartilages that are inadequate in size, shape or position.
However, in a cosmetic rhinoplasty, little can be done to improve a skin sleeve that is
too large or too thick. Fortunately, the three-stage forehead fl ap allows the reconstruc-
tive surgeon to supply skin of the exact size and outline, as well as the correct nasal
thickness and suppleness. An ideal supporting framework is simultaneously designed
during all stages.
The three-stage forehead fl ap technique with an intermediate operation allows the
surgeon to transfer forehead skin of nasal thinness over a rigid, three-dimensional,

151
sculptured, subsurface architecture, formed by primary and delayed primary cartilage
grafts and sculpted by soft tissue excision — before pedicle division.
Expanding lining options
The folded forehead fl ap for cover and lining to repair small and
moderate nasal defects
In the past, forehead fl aps have been folded to provide cover and lining for the nostril
rim. However, it is diffi cult to fold a thick fl ap into a delicate shape, and the technique
precludes the placement of primary cartilage columellar, tip and alar support grafts.
The nose remained thick and shapeless, the nostril margins poorly defi ned, and the
unsupported soft tissues collapsed, obstructing the airway.
However, the three-stage fl ap, with an intermediate operation, permits the technique
of the folded fl ap to be reborn.
A full-thickness forehead fl ap is outlined to replace the missing cover skin. At the same
time, the lining defi cit is defi ned and a second template is positioned distally on the
forehead, in continuity with the cover fl ap. Two to three millimeters of extra length
are added between these two templates to permit easy folding. Typically, this lining
extension is the future site of the dog-ear excision normally discarded during the
closure of the forehead donor defect.
The fl ap, outlined to provide both cover and lining, is elevated with all layers. The
distal extension is turned in to provide the lining and sutured to the residual mucous
membrane along the borders of the lining defect. The proximal aspect of the fl ap, which
is used for cover, is folded back and inset with a single layer of fi ne suture, opposing
the two raw, deep areolar surfaces of the folded fl ap to each other. The fl ap is not
thinned; no cartilage support grafts are placed.
Three to four weeks later, during the intermediate operation, the fl ap is incised along
the proposed alar margin, completely separating the proximal cover fl ap from its distal
lining extension. The proximal fl ap is completely elevated off its inset with a few mil-
limeters of subcutaneous fat. A shapeless soft tissue mass of underlying folded frontalis
muscle and subcutaneous fat is exposed. This is excised, exposing a thin, supple lining
of almost normal thickness, fashioned from forehead skin. This new reconstructed
lining is revascularized from the adjacent normal mucous membranes and bleeds
freely. It is diffi cult to distinguish from normal lining. Delayed primary cartilage grafts
can now be positioned to provide support and contour to the reconstructed lining.
These delayed primary grafts brace the repair against postoperative distortion due to
gravity, edema, tension and fi brosis. Once the lining fl ap has been thinned and the
cartilage grafts positioned, the cover fl ap is reapplied with peripheral and quilting
sutures to the recipient site. Its pedicle is divided at a later third stage.
This modifi ed method of folded lining has become a workhorse. It is discussed in
Chapter 20.
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Chapter • 6 • A Modern Approach to Nasal Reconstruction with a Forehead Flap
Skin grafts for nasal lining for small defects
In small lining defects, a full-thickness skin graft, with its raw surface outward, can be
sutured to fi ll the lining defi ciency. It is covered with a full-thickness forehead fl ap and
fi xed to the under surface of the fl ap with quilting sutures. No primary cartilage grafts
are placed. During the intermediate operation, the forehead fl ap is re-elevated with a
few millimeters of subcutaneous fat. This exposes the underlying excess fat and fron-
talis muscle which lay over the skin graft. The lining skin graft is now integrated in
the residual adjacent normal lining. It is no longer dependent on its covering fl ap for
blood supply. The overlying soft tissue excess is excised. A delayed primary graft is
positioned over the newly recreated skin-grafted lining. The newly thinned forehead
fl ap is returned to the recipient site. The pedicle is divided during a third stage.
This modifi ed skin graft lining technique is discussed in Chapter 20.
Advantages of the three-stage forehead fl ap with
an intermediate operation
Such surgical staging has many advantages. The intermediate operation ensures
maximal vascular safety. Initially transferred with all its vascular layers, the full-thick-
ness fl ap is widely thinned and debulked at the second stage, taking advantage of the
delay phenomenon. It is highly vascular and necrosis does not occur. A thin, supple
fl ap of even thinness is created during this intermediate operative stage, avoiding
irregularities caused by piecemeal debulkings. With the fl ap completely elevated off
its nasal inset, the exposed subsurface framework, made from primary cartilage grafts
and soft tissue, is healed into a solid three-dimensional, coalesced composite. With an
unobstructed view, the surgeon can visualize the entire construction and defi ne the
subtle requirements of contour needed to create a proportionate, symmetric and attrac-
tive nasal shape. The midlayer of the nose can be modifi ed by additional delayed
primary cartilage grafts fi xed with suture, and by detailed soft tissue excision, to form
a sculptured middle layer that will show through the covering skin.
The reliable vascularity of the full-thickness forehead fl ap permits folding of the fore-
head fl ap to supply both cover and lining. A skin graft will reliably ‘take’ when applied
to its raw areolar surface. Once healed in place, the folded skin or skin graft, which
are now vascularized by their incorporation into the adjacent normal mucosa, can be
separated from the overlying cover fl ap and survive. After excision of excessive subcu-
taneous fat and frontalis muscle, delayed primary cartilage grafts, initially precluded,
can be positioned on this newly restored thin supple lining.
Cartilage support is applied in stages and coordinated with the replacement of other
anatomic layers. Primary cartilage grafts are the fi rst choice, but support materials can
be positioned in a delayed primary fashion, at the second intermediate operation.
An ideal rigid subsurface architecture is created from the soft and hard tissues before
pedicle division, regardless of lining technique — hinged over fl aps, intranasal
lining fl aps, free fl aps, and folded or skin graft lining. The fi brosis normally associated
with wound healing does not occur within a full-thickness forehead fl ap. One might
hypothesize that the absence of early thinning at initial transfer, by avoiding injury to
the subdermal subcutaneous fat and muscle, limits fi brosis and the deleterious effects
of contraction. Even when the intermediate stage is delayed for months after forehead
fl ap transfer, signifi cant subcutaneous scarring does not occur. Even months after
transfer, the intermediate sculpting operation can be completed with reliably supple

153
cover and lining layers, easily molded by primary and delayed primary support
grafts.
This staged, sequential method of lining replacement, using a folded forehead fl ap or
skin graft for lining and primary and delayed primary placement of cartilage grafts is
relatively simple. The reconstructive lining retains its original dimensions and
remains soft and supple. It is a less complex method with a shortened operative time
and it requires less manipulation of intranasal anatomy. It is applicable to all nasal
defects. It is particularly useful in the elderly or debilitated patient when the risk of
temporary nasal obstruction caused by crusting, edema or intranasal bleeding
should be minimized. It is also applicable when previous injury or rhinoplasty has
interfered with intranasal blood supply, making the use of intranasal lining fl aps, based
on the septal branch of the superior labial artery or the anterior ethmoid vessels,
unreliable.
Little or no late distortion occurs with the folded forehead lining method. The late
results remain excellent. Folded fl ap lining retains its original dimensions.
Although modest contraction can occur, when a skin graft is employed for lining, it is
relatively minor. The aesthetic endpoint may be less precise in the skin graft lining
method but the results can be quite satisfactory. The skin graft method is applicable
when less aesthetic precision is acceptable. A slightly bulkier nose with less defi nition
may follow.
The three-stage forehead fl ap technique ensures a maximal blood supply, a thin cover-
ing fl ap, unimpeded surgical exposure, controlled soft tissue shaping, staged support
placement, and the maximal use of all lining options. The aesthetic results are improved,
and the need for later revision is minimized.
The three-stage forehead fl ap technique of nasal reconstruction with an intermediate
operation should be applied to all nasal reconstructions that require a forehead fl ap to
resurface partial thickness or full-thickness nasal defects, regardless of defect size or
depth. It is helpful in smokers who are at risk for forehead fl ap necrosis, when a scar
lies within the territory of the fl ap, and in the reconstruction of large nasal defects that
require wide thinning of the covering fl ap, especially with alar and columella exten-
sions. An exception to its use might be an isolated, superfi cial alar or tip defect which
requires minimal support or no lining replacement. In such small and superfi cial
defects, initial distal and subsequent proximal thinning may safely restore the correct
contour in two stages, without the intermediate operation and without signifi cant risk
to a two-stage fl ap’s vascularity.
Salvage opportunities and the three-stage forehead fl ap
The intermediate operation provides the surgeon with many opportunities to improve
the result. It allows signifi cant modifi cation of contour during each operative stage.
Support can be placed primarily or in a delayed primary fashion, and can be reposi-
tioned, augmented or sculpted. Soft tissue can also be excised and contoured.
The unique character of a full-thickness forehead fl ap also provides the surgeon with
the opportunity to salvage complications — a major nasal infection after the transfer
of a forehead fl ap, a shortage of lining in the midst of the repair. These are discussed
in Chapter 21.
The Three-Stage Forehead Flap with an Intermediate Operation

154
Chapter • 6 • A Modern Approach to Nasal Reconstruction with a Forehead Flap
The three-stage forehead fl ap technique of nasal repair with
an intermediate operation
1. Allows the creation of thin, supple, conforming covering skin from a thick
forehead fl ap, with little risk of necrosis.
2. Uses primary and delayed primary cartilage grafts. It permits the late modifi ca-
tion of initial cartilage grafts to correct failures of design, malposition or scar
contracture, before pedicle division.
3. Creates an ideal rigid subsurface framework of hard and soft tissue by cartilage
grafting and subcutaneous excision. The 3-D contour of the middle support layer
is refl ected through the overlying skin. The reconstructed nose is fashioned to
blend into the adjacent recipient tissues, before pedicle division.
4. Permits the aesthetic use of a folded forehead fl ap for lining and expands the
application of lining techniques to include the use of skin graft for lining at the
fi rst stage or as a ‘salvage’ procedure during the second stage.
5. Shows that skin, folded as an extension of a forehead fl ap or applied as a skin
graft, integrates into adjacent normal lining and can be separated from the
overlying cover fl ap from which it was initially vascularized, permitting delayed
primary cartilage grafting.
6. Ensures a maximal blood supply and vascular safety to all nasal layers.
7. Provides the surgeon with options to salvage reconstructive catastrophes (as
illustrated in Chapter 21).
8. Improves the aesthetic result while decreasing the number and diffi culty of
revisional operations and the overall time to repair.
9. Provides insight into the nature of wound injury and repair in nasal reconstruc-
tion. Scar contraction and fi brosis do not occur until the subcutaneous layer of a
forehead fl ap is injured or its frontalis muscle is excised. Support can be placed
at any stage prior to pedicle division.

The Forehead Flap: Technique –
Getting the Operation
Underway, Surgical Planning
and the Use of Templates –
Step-by-Step Details of
Transfer, the Intermediate
Operation, and Revision
C H A P T E R
7
Preoperative Preparation
The surgeon must be ready.
As the WW11 English plastic surgeon Archibold McIndoe remarked at East Grinstead
Hospital in 1940 when caring for the Guinea Pig Club of burned pilots during the Battle
of Britain:
When I looked down on the operating table and saw I had to replace
burned eyelids for a boy of 21, I felt God come down my right arm.
The responsibility of the surgeon and the power of reconstruction should not be
underestimated.
Before entering the operating room, identify the aesthetic and the anatomic defi cien-
cies. The patient should understand the plan and accept the goals, stages, materials
and methods required to repair the defect. Medically, the patient is fi t for general
anesthesia. Fortunately, nasal reconstruction is not signifi cantly invasive and is toler-
ated by almost all patients.
The priorities, stages, donors, and techniques are outlined from the fi rst stage, through
pedicle division, and late revision. Prepare for the unexpected and for complications.
Problems, pitfalls, and contingencies must be identifi ed, addressed and satisfi ed before
the fi rst cut. It is useful to put the plan in writing. It is reviewed and modifi ed at each
stage. Intellectually, the repair is completed and success is achieved before beginning
the repair. The operation should be performed in your mind’s eye. If the expected result
seems likely, then you are ready.
If the local tissues are healthy and mature, the defect understood, and the nasal plat-
form is intact or repaired, nasal repair can begin.
When ischemic tissue is identifi ed, the wound is fi rst débrided or allowed to demarcate
and slough. A contaminated, infected or infl amed wound is dressed, débrided, con-
trolled with antibiotics or temporarily grafted with split thickness skin. Signifi cant
edema and wound tension is given time to resolve.

156
Chapter • 7 • The Forehead Flap
Preliminary Operations
The character and dimension of the ‘true’ injury may be unclear. If the wound healed
spontaneously or had been previously repaired, scar and poorly designed tissue
replacements may have distorted the wound. In such circumstances, a preliminary
operation should be considered to recreate the defect. Scar and contracted soft tissue
are excised. Adjacent residual landmarks are returned to their normal position. The
actual tissue loss can then be accurately determined.
A constricted airway may be opened, or bulky obstructing tissue excised, to establish
a patent airway.
For example in the patient depicted in Figure 7–1, the nose, lip and cheek were avulsed
in an automobile accident. The hole had been fi lled, ineffectively, by advancement of
bilateral pre-expanded cheek fl aps. He did not look normal and could not breathe
through his nose.
At a preliminary stage, the midline nasal scar was released. The true nasal defect was
recreated. Old lip scars were excised and excess tissue, within the lip, was shifted to
begin the re-establishment of the lip landmarks.
With a better understanding of the tissue requirements, a future nasal reconstruction
could be more clearly planned. The remaining septum, perfused by bilateral superior
labial arteries, seemed intact. During a future operation, it was swung out of the pyri-
form aperture and positioned anteriorly, fi xed to the nasal bone remnants. It would
provide lining and central support. The residual alar remnants would provide addi-
tional lining for the alar bases and sidewalls. These tissues would be hinged medially
to join the turned-over central septal mucoperichondrium.
An elderly patient, or one with unassociated medical illness, may present unexpect-
edly. The wound, patient, and surgeon are unprepared.
Repair should be delayed. The defi nitive repair is undertaken only after the patient is
cleared medically, time is taken to carefully analyze the defect and plan the repair, the
patient’s goals are understood, and an informed consent is obtained.
Part of the wound may be initially closed with a skin graft or local fl ap.

157
Figure 7–1
Preliminary Operations
A
B
C
D

158
Chapter • 7 • The Forehead Flap
For instance, in the 78 year old patient shown in Figure 7–2, with several signifi cant
comorbidities, a large heminasal defect followed the excision of a recurrent basal cell
skin cancer. This would normally be repaired with ipsilateral and contralateral intra-
nasal lining fl aps and a forehead fl ap. Although effective, the operation would require
multiple stages and relatively lengthy operations. The intranasal manipulation is
signifi cant. Bleeding and temporary nasal obstruction are risks.
As a fi rst step, the wound was simply closed under local anesthesia. The cheek was
advanced and the superfi cial aspects of the nasal defect were skin grafted.
Once the wound was healed, a simple dressing or prosthesis was considered. In fact,
this was recommended to the patient. But the patient was insistent. He wished his nose
to be restored. After serious discussion of the required stages, donor requirements, and
systemic risks, reconstruction of his nose was undertaken, after obtaining medical
clearance.
If the facial platform of the lip and cheek is missing, a stable base must be established,
prior to nasal reconstruction. The maxillary bony and soft tissue must be replaced. Lip
position and length must be re-established. Only after the lip, cheek, and nasal fl oor
are stable, can the nose be built — 6 to 8 weeks later after resolution of tension, gravity,
and edema.
Options include: advancement of cheek fl ap with a nasolabial extension to resurface
the cheek and lip, a fat fl ip fl ap to restore soft tissue bulk, a subunit cross lip Abbe fl ap
(if the full thickness of the upper lip is absent), or a free fl ap to replace missing cover,
lining and soft tissue, after a maxillectomy or major trauma, as appropriate for a spe-
cifi c defect.

159
Figure 7–2
A
C
B
Preliminary Operations

160
Chapter • 7 • The Forehead Flap
A
C
B
Figure 7–3
This patient (Figure 7–3) has a composite defect; the platform is missing and the nasal
fl oor, premaxillary soft tissue and overlying cheek and lip skin are absent. Before
rebuilding the nose, its base must be restored. The ala and sidewall cannot be addressed
until the facial platform is reestablished.

161
First (Figure 7–4), the regional units of the nose and lip were marked with ink. Incising
exactly in the right nasolabial fold, a cheek fl ap was elevated with a few millimeters
of subcutaneous fat. Based medially, a fl ap of subcutaneous fat was hinged over and
transposed to fi ll the premaxillary soft tissue defi ciency.
A
B
C
D
Figure 7–4
Preliminary Operations

162
Chapter • 7 • The Forehead Flap
Then (Figure 7–5) the right cheek was advanced medially. A superiorly-based exten-
sion of cheek skin was incised and transposed to resurface the hairless triangle of the
upper lip.
After this fi rst stage, the maxillary platform was re-established. The nasolabial exten-
sion of cheek, however, obliterated the nasolabial fold. Recreation of the fold would
be included in a subsequent stage or at the time of a revision. (It was not necessary in
this case.)
Consider a surgical delay, if you are in doubt about the blood supply to a potential
fl ap. Although not often needed, it can be useful. Or plan a preliminary placement of
B
A
C
Figure 7–5

163
Getting the Operation Underway
a skin graft and cartilage graft to create a composite prelaminated fl ap, if that is the
best option. Consider using excess tissues that might otherwise be discarded. Shift the
surplus to add subcutaneous bulk or additional surface skin to an area of defi ciency.
Most importantly, take the time to think. Do not be the disheartened surgeon who
mumbles ‘If only I had thought of that before!’
Do not rebuild the nose until you are prepared; the written surgical plan, preoperative
photographs, measurements or models are available in the operating room. The wound,
the patient, and the surgeon are now ready.
Getting the Operation Underway
The patient
This lovely, yet demanding, woman (Figure 7–6) presented with a history of atypical
melanocytic hyperplasia of her left ala. After a superfi cial excision, the initial skin graft
failed. A second composite skin graft failed. With each procedure, the size of the defect
increased.
Now upset and anxious, she has a full-thickness defect within her scarred left ala. The
full-thickness defect was small, but the repair is complicated by the delicacy of her
nose and her desire for perfection.
She was anxious and angry. She wished to look normal. She wished to look beautiful
again. All options were considered.
Figure 7–6

164
Chapter • 7 • The Forehead Flap
Figure 7–8
Anesthesia
Major repairs are performed under general anesthesia. Excessive wound closure
tension, tight sutures or questionable fl ap vascularity must be identifi ed intraopera-
tively, prior to closure. Local anesthesia is avoided to prevent tissue distortion, due to
the volume of injection, and blanching, secondary to epinephrine vasoconstriction.
Local anesthesia with monitored sedation is used only for limited procedures, such as
a full-thickness skin graft or minor cheek fl ap.
The position, proportion and outline of landmarks must be accurately identifi ed.
Templates, defi ning exact dimension and outline, are made at the start of surgery, prior
to tissue distortions, caused by incision or operative edema, or local anesthetic
injections.
Patient safety
Immediately after induction of general anesthesia, the endotracheal tube is secured
with a 2-0 silk suture, sutured to the upper or lower lip frenulum or tied to a tooth
(Figure 7–7).
Figure 7–7
The central face and chin must be visible and available for tissue manipulation. It
should not be obstructed or distorted by tape used to secure the endotracheal tube.
Bland ophthalmic ointment is applied to the globe. The upper and lower eyelids are
sutured together with 6-0 suture to protect the cornea (Figure 7–8). Inadvertent corneal
abrasion must be avoided. Or the eyes are covered with occlusive transparent plastic
wound dressing.

165
Getting the Operation Underway
Exposure and positioning
After induction, the operating room table is rotated to position the anesthesiologist at
the patient’s right hip. Pressure points are padded and a pillow is placed under the
knees. Compressive stockings and alternating pressure devices are applied to the lower
legs.
Operative exposure is vital. The position, proportion, symmetry and overall relation-
ships of the facial landmarks must be visible during surgery. The contralateral normal
must be available for template creation. Donor sites are prepped within the operative
fi eld. Because the operation has been carefully planned preoperatively, these needs are
easily predetermined.
The skin preparation is then carried out (Figure 7–9). In major repairs, the scalp is fi rst
shampooed and hair conditioner applied and lightly rinsed. The head is placed on a
sterile towel and a routine face and neck prep is then completed. Two towels and a
bar drape are placed under the head. The neck is outlined with two more towels. Other
donor sites — the lower chest for rib harvest, the groin for a full-thickness skin graft
— are also prepped and draped. A split paper drape is used to cover the body and
complete the draping. The splint sheet can later be cut with scissors to provide access
to non-facial areas. If even wider exposure of the neck or chest is required, the endo-
tracheal tube is placed in a sterile stockinette, over the sterile fi eld, to permit its manipu-
lation to either side of the face, neck or body.
The entire head and neck is exposed, permitting visualization of the entire operative
fi eld.
Figure 7–9

166
Chapter • 7 • The Forehead Flap
Intraoperative markings
The regional units, old scars, the location of planned vascular pedicles, and areas of
soft tissue excess or defi ciency are determined by careful observation. They are marked
with surgical ink, prior to the fi rst incision (Figure 7–10). Edema, local anesthesia,
tension, and tissue manipulation will make it very diffi cult to identify these landmarks
later during the procedure.
B
A
C
Figure 7–10

167
Getting the Operation Underway
Markings include:
Hairline
Frown lines
Supratrochlear arteries (2–3 mm lateral to each frown crease, verifi ed by Doppler)
Midline of the nasal root, tip, lip and chin
Nasal subunits (the tip, dorsum, ala, sidewalls and soft triangles)
Lip subunits (including the nasal sill, philtrum columns, vermilion and nasolabial
folds)
Peripheral borders of old fl aps or grafts
Old scars
Areas of excess or defi ciency
In most cases, all nasal subunits are marked with ink, as the fi rst step, after draping
the patient. Such markings are performed in all patients, even if they may seem initially
unnecessary in a ‘minor’ case.
Note that the boundaries of the proximal dorsal subunit and the lateral border of the
sidewall and cheek are visibly indistinct. Remember the subunit principle applies
primarily to central convex units. Excess tissue is infrequently excised to comply with
the subunit principle in fl at, planar subunits.
In this case, because the defect only lay within the ala, the dorsal and sidewall subunits
were not marked in their entirety.
Intraoperative templates are designed, prior to any surgical incision.
The use of surgical templates
Although skin quality is important, the size, outline, shape, symmetry, and position of
facial landmarks are pre-eminent. Their border outline and 3-D contour must be
correctly restored or the repair will fail. Visible scars or imperfect color and surface
texture are of secondary importance.
If too much or too little tissue is replaced or its border outline is incorrect, the face will
be distorted and will not appear normal. The dimension, outline, and volume of the
missing tissues must be replaced exactly.
A new cancer may develop or a prior cancer recur, after a previous reconstruction.
Hopefully, the patient’s facial features and the relationships of their landmarks were
re-established correctly, during the original surgery. If they have not, the dimension,
outline, or position of their facial landmarks cannot be used as a guide due to the
earlier, inaccurate replacement of tissue. This adds an additional level of diffi culty. The
face is distorted, even before the second cancer has been re-excised. The wound is even
less likely to refl ect the true tissue loss.
Gaping wounds or contracted scarred tissue replacements do not refl ect what is actu-
ally missing. Measurements of the distorted defect or visual ‘guesstimates’ of needed
fl ap size or shape are unreliable.
Surgeons need precision. Fortunately, the contralateral normal unit and subunit, or the
ideal, can be used as a guide to determine the proper dimension, outline, contour or
position of the missing part. Operative templates are patterns which are used to design
cover or lining fl aps, fabricate support grafts with the correct dimensions and outline,

168
Chapter • 7 • The Forehead Flap
and determine the exact position of a missing facial landmark — the alar base, alar
crease, nasolabial fold, eyebrow or hairline. If the contralateral normal unit remains, it
is used as a model.
Templates, based on the contralateral normal, are especially helpful. For example, if
one side of the nose is missing, the heminose must be rebuilt in symmetry to the oppo-
site side. The ala must be positioned at the correct level with its opposite side — not
too high or low or too medial or lateral.
The nose sits on the cheek and lip in a precise position. If it is missing, where should
the new nose be placed on the face? The surgeon must know where the tissues must
be placed and the nose positioned.
The vermilion of the right lip is marked. Ink is applied to the contralateral normal
upper lip hemilip unit; the midline of the upper lip, philtral columns, nasal sill and
alar base, nasolabial fold. An exact template of the right upper lip is made from Steri-
Strips and collodion. This pattern is fl ipped and repositioned on the left upper lip. The
correct site of the left alar base becomes apparent.
Making an intraoperative template
The nuances of template creation will be explored by examining this and a series of
other patients.
The dimension and outline of the missing left alar skin is diffi cult to determine from
the residual defect after two excisions, skin graft necrosis and late scarring. Fortunately,
the normal right ala remains and can be used as a guide to determine the dimension,
outline and contour required to restore the left subunit.
As illustrated in Figure 7–11, the subunits are outlined on the nose with a surgical
marker; quarter inch Steri-Strips are applied, in a criss-cross fashion, to conform to the
contralateral normal right ala and a thin layer of collodion is applied to consolidate the
paper cast. Ink from the underlying skin surface adheres to the sticky undersurface of
the tape. It is often visible through the tape and additional ink can be reapplied to the
external surface of the paper template to reinforce the outline. The Steri-Strip mold is
then gently pulled from the face, exposing an exact pattern of the ‘normal’. It corre-
sponds to the dimension, outline and contour of the normal, uninjured, ala. Excess tape
is trimmed.

169
Getting the Operation Underway
B
A
Figure 7–11

170
Chapter • 7 • The Forehead Flap
The paper template is then transferred to foil material from a suture pack. Because
it is a pattern of the opposite right normal ala, it must be reversed. The template
must be fl ipped before it can be used to design the repair of the injured left ala. (See
Figure 7–12.)
The foil of a suture pack often has a shiny silver and an opposing colored surface. It
is prudent to develop the habit of using one side to outline the contralateral normal.
Then the template is fl ipped before using it to rebuild the opposite side. I always design
the contralateral normal template with the silver side exposed. Once it is fl ipped and
oriented properly to replace the injured side, the colored surface should be outward.
If not, I recheck my plan. Do not resurface the injured side of the nose with a fl ap
designed to resurface the opposite normal side!

171
Getting the Operation Underway
B
A
C
Figure 7–12