Nasal Reconstruction Art and Practice E-Book_nodrm

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Getting the Operation Underway
The importance of templates is illustrated in the case of another patient (Figure 7–14);
skin is missing within parts of the tip and dorsum. Both alar cartilage domes have also
been excised.
The pattern design is complicated by the convexity of the normal tip. A template must
be made of the three-dimensional tip subunit. It must then be fl attened to two
dimensions and used to design a fl ap from the fl at 2-D surface of the forehead.
The nasal subunits were outlined with ink. Foil from a suture pack was folded to simu-
late the volume and shape of a future tip graft, which would replace the ablated domes
of the alar cartilage. Steri-Strips and collodion were applied over the partially ablated
tip cartilages and the artifi cially fabricated tip ‘graft’.
An exact three-dimensional surface template of the tip and dorsal subunits is made. It
accurately refl ects the dimension and outline of the forehead skin that will be needed
to resurface the tip and dorsum. Excess Steri-Strip is trimmed outside the markings.
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Figure 7–14

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Chapter • 7 • The Forehead Flap
This paper mold precisely refl ects the three-dimensional contour of the round tip
subunit. However, it must be converted to two dimensions (Figure 7–15). Small radial
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Figure 7–15

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Getting the Operation Underway
cuts are made along the periphery of the paper template, in the area of convexity, to
allow the pattern to lie fl at. This expanded outline is then transferred to foil. The outline
of the two-dimensional foil template is then crimped along its borders into a 3-D shape
with smooth pickups. This pattern is then reapplied to the defect to ensure correctness
and trimmed, as needed. The pattern is fl attened on the forehead to design the required
fl ap.
Residual normal tissue was excised within the tip and dorsal subunits. An ear cartilage
tip graft was designed to replace the cartilage tip defi ciency, after suture repair of
the cartilage remnants. A forehead fl ap of the exact dimension and outline was trans-
ferred. No revision was performed.
In yet another patient (Figure 7–16), tip and dorsal skin necrosed following the infec-
tion of a Medpor implant used to augment a saddlenose. The dorsal and tip support
framework were also destroyed.
First, the subunits were marked. Then bone wax was applied, intraoperatively, to the
nasal surface. It was sculpted into the shape of an ideal bridge and tip. Over the wax
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Figure 7–16

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Chapter • 7 • The Forehead Flap
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Figure 7–17

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Getting the Operation Underway
model, a tape template was prepared to refl ect the outline and the dimension of the
missing skin needed to resurface these subunits (Figure 7–17). This pattern would
determine the size and outline of forehead skin required to cover the nose after the
underlying support was replaced.
Residual skin and scar within the tip and dorsal units were excised. A dorsal rib graft
and columellar strut were positioned. Then small foil patterns were cut and modeled
until they accurately refl ected the proper length, dimension and shape of planned
anatomic tip grafts. These fabricated ‘alar’ grafts would replace the missing medial and
lateral crura. Based on these templates, anatomic tip grafts of conchal cartilage were
made and fi xed to the columellar strut. After the underlying support framework was
restored, the nose was resurfaced with full-thickness forehead fl ap, based on the initial
template (Figure 7–18). See Chapter 25.
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Figure 7–18

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Chapter • 7 • The Forehead Flap
Another patient (Figure 7–19) was unhappy. Since her prior repair, she had not left her
home without a bandage.
A Mohs excision of a basal cell carcinoma had ablated only skin and subcutaneous fat.
The underlying tip cartilage was exposed.
Unfortunately, the intact lateral crural cartilage and lining were excised, to ‘simplify’
the repair. A full-thickness defect was then closed primarily. Parts of the tip, sidewall,
and ala were resurfaced with a postauricular skin graft.
It is assumed that fear of a forehead fl ap drove the initial repair in the wrong direction.
This was a mistake. It only created more distortions and made things more diffi cult to
repair. A superfi cial defect had been, unnecessarily, converted to a full-thickness loss
— a much more complicated situation.
And throwing away alar cartilage and lining, to facilitate the application of a skin graft,
makes no sense. Although in many cases, it is useful to enlarge a wound and discard
additional normal tissue, excision of support and lining, without replacement, can only
lead to a permanent distortion of the tip, ala, and nostril.
Now the tip is pulled to the right, the nostril margin is notched, and the airway is
collapsed. And the color and texture of the covering skin graft do not match the
remaining nose.
The surgeon must analyze the problem. The wound has contracted and the normal
convexity of the right tip and ala is destroyed. The skin graft surface does not refl ect
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Figure 7–19

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Getting the Operation Underway
the true tissue loss. How much tissue is missing? What are the dimension and outline
of skin needed to resurface the true defect? How much lining must be replaced? Where,
when and how should the cartilage support be restored?
Intraoperatively, the nasal subunits were marked with ink. Exact templates of the left
contralateral normal heminose, the residual right ala, and the nostril circumference
were made. By subtracting the template of the residual right ala from the contralateral
normal left heminasal pattern, the exact dimension and outline of the missing skin and
the true surface defi cit was identifi ed (see Figure 7–20).
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Figure 7–20

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Chapter • 7 • The Forehead Flap
The lining defi cit was determined by a careful measurement of the circumference of
the injured and contralateral normal nostrils. Occasionally, an old operative report may
provide information on the initial size of the lining loss. In this case, the surgeon
described excising ‘5 mm’ width of normal lining and this corresponded well to the
measurements made in the operating room.
The skin graft was excised and the full-thickness defect recreated. The right dome and
alar crus were gone.
Extra skin was excised within the right hemitip subunit. However, because most of the
right ala and dorsum were not involved, subunit excisions were not performed in those
areas. The fl ap was designed to resurface the hemitip but the rest of the defect was
replaced as a non-subunit fl ap.
An exact forehead fl ap, based on templates, was transposed to resurface and to line
the nose as a folded forehead fl ap. Delayed primary cartilage grafts were placed to
recontour and support the tip and nostril margin during an intermediate operation.
Four months after pedicle division, exact templates have guided precise tissue replace-
ments and helped restore symmetry and outline.

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Getting the Operation Underway
Figure 7–20, Continued
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Chapter • 7 • The Forehead Flap
In more complex cases (Figure 7–21), the contralateral normal may not be available. To
defi ne the needs of the defect, a plaster facial moulage of the patient can be obtained.
This model is studied to leisurely determine the site, number, degree of injury, and the
interrelationships of a complex deformity. Art clay is then applied to the moulage and
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Figure 7–21

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Getting the Operation Underway
Figure 7–21, Continued
shaped to the correct dimension, outline, proportion, symmetry, and position of the
missing parts. The sculpture is used as the ideal model. The depth of the missing bulk
can be measured. The ideal dorsal length, tip projection, alar base width, maxillary
projection, etc. are determined. Steri-Strips and collodion are placed onto the model’s
clay surface. Templates are created and sterilized for use in the operating room to
design fl aps for the lip or nose. The model also serves as a visual guide during
surgery.
Calibrated photographs can be useful. Facial photographs are taken with a centimeter
ruler in the fi eld of view and enlarged until the image corresponds to the dimension
of the ruler. Or computer graphics can be applied. Onto the paper image, the desired
normal is drawn. Measurements, based on the calibrated photographs, can be used in
the operating room to determine the length, breadth and position of facial landmarks
and their relationship to other parts. ‘Eyeballing’ the needs of a repair is unreliable.
Exact measurements can be an invaluable guide.
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Chapter • 7 • The Forehead Flap
Normative measurements based on the examination of the normal population can also
be used to guide planning and template design (Figure 7–22). The basic measurements
for adults and children, which determine normal nasal base width, columellar and lip
length, philtral width, etc., can be found in Millard’s Cleft Craft volumes. The recom-
mendations of Sheen, Gunter, and Byrd, described for cosmetic rhinoplasty, can be
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Figure 7–22

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Getting the Operation Underway
helpful to the reconstructive surgeon in defi ning the ideal angles, lengths, projection,
and positioning of facial parts.
Fear and panic are common reactions to a complicated facial wound. The surgeon must
learn to control this apprehension. Careful observation and cautious refl ection are vital.
In every case, the surgeon must visualize the facial units in his or her planning and
design.
Templates are a simple, practical and necessary tool. You must decide what tissue is
missing and then identify the available donor needed to replace each anatomic layer.
You must also determine the correct dimension, border outline, shape and position of
each fl ap and graft. If you know where you are going, it is a lot easier to reach that
destination — with much less anxiety. Use the template pattern to turn your ‘vision’
into the objective and concrete.
Defi ne the visible units by direct observation and mark them with ink.
Create exact three-dimensional templates of the facial landmarks with Steri-Strips and
collodion.
Flatten the three-dimensional pattern to two dimensions and transfer the design to a
foil pack. Convex paper patterns are incised along their edges to allow their expansion
onto a fl at surface.
Determine the dimension, outline and contour of planned fl aps and cartilage grafts
and the position of landmarks and placement of scars.
Save templates for future surgical stages.
For example, the vital importance and multiple applications of templates are illustrated
(Figure 7–23) by the repair of this composite defect of the nose, lip and cheek. The
initial wound is illustrated earlier in the chapter. The patient is seen after repair of the
lip and cheek platform.
Figure 7–23

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Chapter • 7 • The Forehead Flap
Analysis and Planning
Where should the nose be positioned on the face? What is the dimension and outline
of the missing cover and lining surfaces? What is the shape and size of the required
cartilage grafts? How is a delicate nostril margin shape outlined? How is a revision
planned to refi ne the repair?
A detailed preoperative plan, as illustrated in this case, is helpful. The preliminary
operation to restore the nasal base is seen earlier in this chapter.
Surgery should be a ‘thinking man’s’ game. A written plan is made, preoperatively.
The pros and cons of individual materials, techniques, and stages are considered. This
outline is available in the operating room.
History
Forty-four-year-old healthy man.
History of recurrent basal cell carcinoma of the right ala.
s/p Mohs excision.
Patient desires the restoration of normal.
Physical examination and photographic analysis
Defect
Right ala, tip, sidewall, cheek and lip missing.
Deep dermal shave of a precancerous nasal tip lesion.
Aesthetic loss
Absence of the expected quality, outline, and contour of the medial cheek, lip, and
nose.
Scarring within the tip subunit.
Anatomic loss
Cover
Scarring within 10% of the right tip subunit with altered skin quality and modest
contour depression.
Skin of the right ala and adjacent parts of the inferior nasal sidewall, medial cheek,
and the hairless triangle of the right upper lip.
Support
Fibrofatty framework of the ala.
? Inferior edge of the right upper lateral cartilage and distal lateral crus.
Premaxillary subcutaneous fat and muscle under the nasal base which overlie the
piriform aperture and create the cheek platform.
Lining
Stratifi ed squamous vestibular lining of the ala and mucous membrane of sidewall.
Summary
Composite defect of nose, lip and cheek with scarring of the nasal tip.

187
Problems and priorities
1. Create a stable platform. Re-establish the lip and cheek prior to nasal repair to
avoid postoperative shifts and late distortion. Resurface the combined cheek and
lip defect with matching local tissues at a preliminary operation. Note: this may
obliterate the nasolabial fold and require secondary nasolabial crease creation.
2. Nasal reconstruction. Restore three-dimensional nasal cover, support, and lining,
once the platform is stable.
Lining options
Prefabrication, modifi ed folded forehead fl ap, hingeover lining fl aps, second fl ap from
forehead or nasolabial fold, the skin graft lining technique, intranasal lining fl aps, or
free fl ap.
Method chosen: The modifi ed folded forehead lining will avoid the manipulation and the morbid-
ity of intranasal lining fl aps. The routine dog-ear excision of the forehead covering fl ap, (which
would normally be discarded) can be used as an extension of the forehead fl ap and folded for
lining.
Cover
Because of the size and depth of this defect, a forehead fl ap is needed.
Although less than 10% of the tip skin was missing, a subunit excision of the residual
tip was planned. The scarred tip would likely mar the nasal repair. Even though the
injury to the tip was limited, scarred skin within the subunit would be discarded and
the entire tip subunit resurfaced. Balancing gain vs. risk, it was decided that the fi nal
result would be better if the wound was enlarged. This was based on clinical judgment,
experience, and the surgeon’s confi dence in the technique. The defect within the fl at
sidewall would not be enlarged. The sidewall would be resurfaced as a non-subunit.
Method chosen: a three-stage forehead fl ap for nasal cover and
modifi ed folded lining
Support
The nasal midlayer support framework must be replaced, if missing. The ala normally
contains no cartilage but it must be added during repair to support, shape and brace
it against the forces of wound healing.
Support grafts can be placed primarily if vascularized lining remains or is restored
with intranasal lining fl aps. Because primary cartilage grafts are precluded in the three-
stage folded forehead fl ap for lining technique, delayed primary support will be placed
during the second-stage intermediate operation to support the right ala.
(Non-subunit support grafts for parts of the inferior upper lateral and lateral crus will
be applied, if necessary.)
Detailed subcutaneous soft tissue sculpture to recreate a fl at sidewall and upper lip, a
round ala and tip, and a defi ned nasolabial crease is planned during the intermediate
operation and at pedicle division.
Method chosen: delayed primary support grafts to the ala and detailed sculpture for soft tissue
contour.
Analysis and Planning

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Chapter • 7 • The Forehead Flap
Details of the preoperative plan
Stage I
Preliminary operation
The nasal platform is fi rst re-established.
Stage II
First-stage forehead fl ap
Excision of residual skin within the tip subunit (the subunit principle).
First-stage full-thickness forehead fl ap with the distal extension folded for lining.
No primary cartilage support.
Small hingeover lining fl ap along the defect edge to allow inset of the fl ap.
Stage III
Intermediate operation
Incise the ideal alar rim margin, separating the folded lining from the overlying
proximal cover.
Elevate the cover fl ap with 2 to 3 mm of subcutaneous fat.
Excise the folded double excess of frontalis and subcutaneous fat from the
underlying lining, revealing thin vascular lining now vascularized from adjacent
normal lining.
Place a delayed primary alar margin support graft (add non-subunit support to the
distal alar or upper lateral cartilage, as appropriate.)
Reposition the forehead fl ap covering skin to the recipient site.
Stage IV
Pedicle division
Divide the pedicle.
Re-elevate the distal inset.
Sculpt the soft tissues of the dorsum, sidewall, and alar crease to restore subunit
contour.
Return the proximal pedicle to the forehead as a small inverted ‘V’ at the brow.
Stage V
Planned revision
Sculpt alar crease and nasolabial fold contour, disregarding old scars.
Debulk nostril, as needed.
Revise the forehead scar or peripheral fl ap scars, if needed.
Operation 1 – Repair of the Lip and Cheek Platform
The cheek was advanced with a nasolabial extension to resurface the medial cheek and
the upper lip defects. A fat fl ip fl ap was hinged, on a medial subcutaneous base, to fi ll
the underlying bulk loss. This re-established the nasal platform. The nose will be rebuilt
after tension and edema have resolved and the tissues are mature.

189
After stage I, the maxillary platform is re-established. The nasolabial extension of the
cheek may obliterate the nasolabial fold. (In this case, it did not.) Recreation of the fold,
by direct incision, will be included in a subsequent stage or at the time of a revision,
if needed.
Operation 2 – Nasal Reconstruction
First, the hairline, frown crease, the supratrochlear artery and vein, the midline of the
nose and lip, the nasal regional units, the lip units, including the midline, philtral
columns and vermilion and nasolabial fold are marked (Figure 7–24).
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Figure 7–24
Operation 2 – Nasal Reconstruction

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Chapter • 7 • The Forehead Flap
Templates based on the contralateral normal left upper lip, the left ala, the left tip, the
combined ala and tip subunits, the left nostril and the missing right lining defect are
designed.
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?
If one side of the nose is missing, it must be rebuilt in symmetry to the opposite side.
The ala must be positioned at the correct level with its contralateral side — not too
high or low or too medial or lateral. Templates, based on the contralateral normal, are
especially helpful in this instance.
The left hemilip template is used to determine the future position of the right alar
base.
The midline, philtral columns and vermilion, nasal sill, alar base and nasolabial fold
of the left lip are marked with ink. An exact template of the left upper lip is made from
Steri-Strips and collodion. This pattern is fl ipped and repositioned on the right upper
lip. The correct site of the right alar base becomes apparent (Figure 7–25).
Small hingeover fl aps are elevated to prepare the recipient site and the wound edges
of the entire defect are freshened to allow inset of lining and cover.
Adjacent normal skin within the tip subunit is excised.
The template, designed to resurface the defect, is positioned above the right supra-
trochlear vessels.
The lining template is positioned as a distal extension of the forehead fl ap and includes
an extra 2 to 3 mm between the templates to allow for easy folding.
The full-thickness forehead fl ap is elevated, transposed and folded on itself to supply
both lining and cover.
No primary cartilaginous support is positioned.
The forehead is closed inferiorly. A superior gap is allowed to heal secondarily.
Operation 3 – The Intermediate Operation
After the fi rst stage of the forehead fl ap transfer, the forehead donor site is healing
spontaneously. The nasal repair appears bulky, shapeless, unsupported and the airway
is collapsed. The regional units of the nose and lip, the peripheral forehead fl ap border
scars, the ideal nostril rim and nostril aperture and the excess between the cover and
lining fl aps are marked. Templates, which were resterilized from prior operations, are

191
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Figure 7–25
Operation 3 – The Intermediate Operation

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Chapter • 7 • The Forehead Flap
available. They include the tip and ala cover unit, a separate ala template, nostril, and
hemilip templates (see Figure 7–26).
An incision is made along the tentative margin of right alar rim, separating the cover-
ing fl ap from the distal extension for lining.
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Figure 7–26

193
The proximal cover fl ap is elevated with 2 to 3 mm of subcutaneous fat and completely
removed from the recipient site. The underlying bulky excess of frontalis muscle and
subcutaneous fat is excised to expose thin vascular lining, which had been folded from
the distal forehead fl ap. It is now revascularized from adjacent residual normal lining
(see Figure 7–27).
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Figure 7–27
Operation 3 – The Intermediate Operation

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Chapter • 7 • The Forehead Flap
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Figure 7–28

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The ideal outline of the right reconstructed alar lining is determined by remarking the
correct rim position and outline, based on a template of the contralateral normal. Excess
lining is trimmed to recreate the refi ned shape, symmetry and dimension of the nostril
margin (see Figure 7–28).
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Figure 7–28, Continued
Operation 3 – The Intermediate Operation

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Chapter • 7 • The Forehead Flap
The distal margin of the forehead fl ap in the area of folding does not correspond to
the ideal shape of the opposite alar margin. The excess fl ap between the cover and
lining templates in the area of folding must be eliminated. The contralateral normal
left template is reversed and used to mark the correct margin outline. The excess is
trimmed (see Figure 7–29).
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Figure 7–29

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The dimension and shape of the right conchal cartilage alar batten graft is also designed
from the nostril margin outline of the contralateral normal left alar template. The car-
tilage graft is positioned on the reconstructed lining and fi xed with sutures to support,
shape, and brace the soft tissues of both cover and lining.
The forehead fl ap is resutured to recipient site (Figure 7–30).
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Figure 7–30
Operation 3 – The Intermediate Operation

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Chapter • 7 • The Forehead Flap
After the intermediate operation, thin, pliable and healthy lining is restored. Thin,
supple and vascular skin resurfaces the nose. Delayed primary support has re-estab-
lished the shape, position, contour, and provided rigidity. Intraoperative templates
helped determine the position, outline, and dimension of the cover and lining fl aps
and of the cartilage graft.
Operation 4 – Pedicle Division
The right ala and sidewall remain bulky.
The lip and nasal subunits are marked, based on templates of the left ala and left
hemilip. The forehead scar, in the area of secondary healing, is marked for revision.
The pedicle is divided and the distal fl ap is elevated with 2 mm of subcutaneous fat
over the proximal aspect of the inset. Underlining subcutaneous fat, frontalis muscle
and scar are excised to recreate the contour of the dorsum, sidewall and ala, guided
by template outlines. Excess skin is trimmed and the fl ap inset is completed. The
proximal forehead fl ap is untubed and excess subcutaneous fat and soft tissue is dis-
carded. The inferior aspect of the forehead scar is reopened and the proximal fl ap is
trimmed and inset at the medial brow as a small inverted V (see Figure 7–31).
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Figure 7–31

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Figure 7–31, Continued
Operation 4 – Pedicle Division

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Chapter • 7 • The Forehead Flap
Operation 5 – Revision
After the third stage of the forehead fl ap transfer, the overall result is good. However,
the right alar crease is poorly defi ned; the nostril rim is thick and the nostril small. A
depressed transverse border scar lies across the bridge of the nose. Based on templates,
the right nasolabial fold, right alar crease and ideal rim are marked. The forehead donor
scar and the slightly depressed scar on the nasal bridge are revised. Disregarding old
scars, a direct incision is made in the proposed ideal right alar crease and subcutaneous
bulk is excised. A fl at sidewall, a round ala, and a more defi ned and deep alar crease
are sculpted. The right alar margin is incised and the lining is elevated thinly. Excess
soft tissue between the delayed primary cartilage support and the reconstructed lining
is excised, opening the airway (see Figure 7–32). A small inferiorly based rim skin fl ap
is transposed into a lining release to enlarge its circumference.
The nasolabial fold did not require further defi nition.
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Figure 7–32

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Figure 7–32, Continued
Operation 5 – Revision

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Chapter • 7 • The Forehead Flap
The expected skin quality, border outline, and three-dimensional contour of the nose,
cheek and lip have been restored (Figure 7–33).
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Figure 7–33

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Forehead Flap Technique
Step by step
Although the defect encompassed only part of the left alar subunit (Figure 7–34), it is
repaired as a subunit. Residual normal skin is discarded and the wound enlarged. This
harnesses the contractile forces of healing under the fl ap to augment the underlying
shape of a cartilage support graft. A three-stage forehead fl ap will provide external
skin cover, folded lining and permit delayed primary placement of a subunit support
graft. In this demanding patient, a revision, months later, to thin the nostril margin
and defi ne the alar contour was likely.
The goal and specifi cs of the repair were discussed with the patient. The nose is an
important facial feature. Despite past failures, she was eager to look normal and happy
to start her repair. A forehead scar was not a concern. Shown photographs of other
patients, she was put at ease.
Her photographs were carefully evaluated. A written plan was developed to defi ne the
injury and plan the stages of her surgical repair.
Preliminary operative plan
Anatomic defi ciency
Non-subunit full-thickness defect of the left ala.
Figure 7–34
Forehead Flap Technique

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Chapter • 7 • The Forehead Flap
Aesthetic defi ciency
Missing quality, outline, and contour of the left ala subunit.
Available donor tissues
Nasolabial or forehead fl ap for cover.
Prefabricated, hingeover, intranasal lining fl aps, folded fl ap or skin graft for lining.
Ear or septal cartilage for support.
Stages
Two or three operations depending on the cover and lining choices with a possible
revision.
Final operative plan
Subunit reconstruction of the left ala with a three-stage forehead fl ap folded for lining,
and delayed primary ear cartilage grafts for support. A nasolabial fl ap could be used
to resurface the ala but the fi nal nasolabial fold scar would be more visible than a
forehead donor scar. It cannot supply lining, effectively. Prefabricated lining, hinge-
over fl aps, or intranasal lining fl aps could be used to repair this full-thickness defect,
but not to advantage.
Stage 1: forehead fl ap transfer
All surgical stages are performed under general anesthesia.
Photographs and a written plan outlining the problems, priorities, marking, donors
and intraoperative steps are available in the operating room.
Intraoperatively, the entire head and neck is prepped and draped to allow complete
visualization of the operative fi eld and all donor sites. The corneas are protected
and the airway assured.
The facial landmarks and subunits, determined by direct visual observation are
marked with ink — hairline, frown lines, Dopplered positioned of the right and
left supratrochlear arteries, nasal and lip subunits.
This patient expected restoration of the left alar subunit quality, border outline and
contour. She wished to look normal. However, her defect did not refl ect the true tissue
loss. The contracted wound must be re-expanded and missing tissue replaced in exact
quantity. Because the ala is a convex central subunit, subunit excision of residual
normal tissue within the left ala is planned.
The contralateral normal right ala was used as a guide to create a template which
would accurately refl ect the dimension and border outline of covering skin needed to
resurface the distorted left ala.
A subunit excision of residual normal skin and scar within the left alar unit is per-
formed. A separate lining template is designed to refl ect the missing lining require-
ment. The reversed and fl ipped cover template is positioned vertically over the
ipsilateral supratrochlear vessels, just under the hairline (see Figure 7–35).
A forehead fl ap can be carried on either supratrochlear pedicle. Either pedicle can be
used for a midline defect. However, unilateral defects are best repaired with an
ipsilateral pedicle because the distance from the medial brow to the defect will be
shortest, if the pedicle is based on the same side. If the ipsilateral pedicle is unavailable,
however, either pedicle will suffi ce.

205
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Figure 7–35
Forehead Flap Technique

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Chapter • 7 • The Forehead Flap
The supratrochlear vessels pass over the supraorbital rim through the corrugator
muscles, just lateral to the frown crease. They pass vertically upward, through the
frontalis muscle, and travel superiorly into the subcutaneous tissue. So a forehead fl ap
should be designed with a vertical orientation. This maintains maximal blood supply.
An oblique design transects these axial vessels, diminishes the quality of perfusion,
and is more likely to distort the eyebrow on donor closure.
If the defect is full-thickness, the modifi ed folded fl ap method will often be the best
option. The lining template is positioned at the end of the forehead fl ap and marked
as a distal extension, adding 2 to 3 mm between the cover and lining templates to allow
for easy folding of the fl ap. It is important that the surgeon maintain the proper spatial
relationships between the two templates when marking the forehead. The distal margin
of the nostril, drawn for the forehead fl ap, should abut the distal nostril margin of the
lining fl ap. This correctly positions the extension as it is folded inward to line the nose.
It is easy to incorrectly orient the cover and lining templates, if care is not taken as they
are outlined on the donor site.
The proximal pedicle is drawn with a base between 1.2 to 1.5 cm in width, centered
over the supratrochlear vessels. The base of the pedicle should be carried through the
medial brow. A narrow pedicle base allows the fl ap to rotate comfortably without
kinking and allows a tensionless closure of the inferior forehead.
It should be noted that, although the inclusion of the axial vessels within the fl ap is
traditional, the arcade of vessels from the supraorbital, supratrochlear, infratrochlear,
and angular arteries is so profuse that fl ap loss is unlikely, even if one or more of these
named vessels have been ablated or are not identifi able by Doppler.
When designing a forehead fl ap, regardless of the size of the distal template, the pedicle
should be tapered to its base at the medial brow. Do not abruptly transition between
the skin paddle, needed to resurface the defect, and the pedicle, which perfuses the
fl ap. Design it like an ‘ice cream cone’. If the paddle ‘fl ows’ into the stalk and a minor
design error becomes apparent intraoperatively (or a minor distal necrosis is seen
postoperatively), you may be able to ‘save the day’. The fl ap can be re-elevated, the
distal outline redesigned and trimmed or ischemic tissue excised. The fl ap is then
advanced a few millimeters. This may provide enough skin to recover the defect and
make up for the defi ciency, without distorting the repair. If the fl ap had been designed
as a ‘popsicle,’ no extra tissue is available to advance, yet still close the more superior
aspect of the defect from side to side.
In another patient, a basal cell skin carcinoma recurred after multiple excisions and
two therapeutic radiation treatments. A Mohs excision was performed, creating a
defect within part of the tip, dorsum, sidewall, ala, and a few millimeters of medial
cheek.
To repair the defect, the cheek was advanced to the sidewall and additional skin was
excised within the dorsal and alar subunits. Enlarging the wound was approached
cautiously in this heavy smoker. His age, comorbidities, and history of radiation were
already cause for concern. He was at risk of healing complications. A highly vascular
full-thickness forehead fl ap was designed to resurface the dorsal, sidewall and left ala.
The left ala was supported with a primary cartilage graft (see Figure 7–36).

207
A
B
D
C
Figure 7–36
Forehead Flap Technique

208
Chapter • 7 • The Forehead Flap
On transfer, despite careful design, the forehead fl ap was defi cient in horizontal dimen-
sion along the nostril margin. The skin closure was too tight and collapsed the cartilage
graft along the rim, narrowed the nostril, and risked fl ap necrosis.
The fl ap was wider proximally than distally. Because the pedicle had been drawn on
the donor site with a gradual taper toward its base at the brow, the fl ap could be
advanced inferiorly. Using a template designed from the contralateral normal alar rim,
a new distal fl ap margin was inked. The distal aspect of original fl ap was reincised. A
new, more proximal, distal free margin was cut to design a new nostril rim. This effec-
tively increased the horizontal dimension of the fl ap along the rim and permitted a
comfortable closure. If the fl ap’s reach had been too short to advance comfortably, the
inferior aspect of the pedicle would have been lowered across the brow, toward
the medial canthus. This would lower the pivot point and increase its reach (see
Figure 7–37).
Figure 7–37
A
B

209
F
E
D
C
Figure 7–37, Continued
Forehead Flap Technique

210
Chapter • 7 • The Forehead Flap
The arc of rotation of a forehead fl ap was evaluated to insure adequate fl ap length,
prior to its incision (Figure 7–38). The fl ap must not be inset under tension. If its reach
seems inadequate and the fl ap has not yet been incised, it can be lengthened by extend-
ing its distal aspect into the hairline. Better to have a few hairs on a nicely shaped nose,
than a failed repair without hair!
More often the surgeon has designed the fl ap’s base too high. Its base is moved
inferiorly toward the medial canthus. Its base is designed to cross the medial brow
toward the medial canthus. This lowers the pivot point and shortens the distance to
the defect, effectively lengthening the fl ap. When the medial end of the eyebrow is
elevated with the fl ap’s base, it is returned to its normal position at the time of pedicle
division. This restores eyebrow shape, length and position.
Do not elevate the pedicle base underneath the periosteum. This restricts its rotation
and reach. If periosteum has been included, it should be incised to allow adequate
length and rotation.
Very rarely, if all else fails and the fl ap is too short after elevation, a transverse incision
can be made across the deep surface of the fl ap, incising frontalis muscle just into the
subcutaneous fat about 2 cm superior to the rim. The supratrochlear vessels originate
under the frontalis muscle at the orbital rim and then travel superiorly toward the
hairline. About 2 cm above the rim, they pass through the muscle to lie subcutaneously.
The fl ap’s vascularity is not signifi cantly impaired by transection of the muscle at the
fl ap’s base. Although rarely performed, this lengthens the fl ap by a few millimeters
and increases its reach.
B
A
Figure 7–38

211
Hopefully, you have designed the fl ap correctly, prior to elevation and transfer and it
rotates comfortably to the recipient site without additional manipulation.
Let us examine an illustrative case (Figure 7–39). A defect lay within the tip and distal
nose. The dome of the left alar cartilage has been excised and vestibular lining is absent.
B
A
D
C
Figure 7–39
Forehead Flap Technique

212
Chapter • 7 • The Forehead Flap
A full-thickness fl ap, folded for lining, was planned. How low can the pedicle be dis-
sected? How narrow can the pedicle be cut? What is the margin of safety? How can
you regroup and keep the repair on track if the fl ap seems inadequate in length to
reach the defect without tension? Several intraoperative challenges provoked concern
when repairing this patient.
Trying to avoid hair on the distal nose and failing to measure the correct arc of rotation,
the fl ap did not reach the recipient site, after elevation.
The forehead template was positioned too low on the forehead.
As a fi rst step, the pedicle was extended further inferiorly, across the eyebrow, toward
the medial canthus. Its base was now, at least, 1 cm below the medial brow and about
one-half the distance to the medial canthus. Although the fl ap moved closer to the
nasal tip, it was still short. So, the frontalis was incised to subcutaneous fat. The
‘thinness’ of the pedicle is visible. The fl ap was comfortably inset without incident.
Note that as the fl ap was extended inferiorly, due to lack of attention, its width
was inadvertently narrowed to about 4 mm. Still it survived — a testimony to the
vascularity of a forehead fl ap. She is seen one month after pedicle division.
Local anesthesia with epinephrine is injected in the lateral aspects of the forehead
(Figure 7–40). It was not injected into the fl ap itself, or into the recipient site, to avoid
distortion and blanching.
E
Figure 7–39, Continued

213
In this case, a three-stage forehead fl ap was planned. The peripheral borders of the
forehead fl ap, which included both the skin and lining paddles, were incised inferiorly
through the medial brow. The fl ap was elevated full thickness, from superior to
inferior, and over the periosteum, at the supraorbital rim (Figure 7–41). The vessels
were preserved. Individual fi brous and corrugator muscle bands can be snipped to
allow their release. The medial incision of the pedicle base extends more inferiorly than
the lateral incision.
A
B
Figure 7–40
Figure 7–41
Forehead Flap Technique

214
Chapter • 7 • The Forehead Flap
The fl ap is then rotated, medially, toward the nose (Figure 7–42). As the fl ap is elevated,
pressure is applied along the margins of the donor wound to minimize bleeding. The
injection of epinephrine into a forehead fl ap itself may not be detrimental, but the
resultant blanching interferes with the assessment of skin tension, as the fl ap is inset.
So the fl ap itself is not injected.
The fl ap should ‘fl ow’ gently to the recipient site. Rotate a paramedian forehead fl ap
toward the nose on transfer. The medial rotation puts the raw surface of the pedicle
away from the patient’s eye, which is an advantage. It should reach the defect without
tension, in a gentle curved sweep without kinking. If the fl ap is rotated laterally, the
risk of an ischemic twist is signifi cant and the fl ap length is effectively shortened.
In complex repairs — large defects that require the resurfacing of multiple nasal sub-
units, or in defects that require cartilage replacement, or lining repair with hingeover,
intranasal lining fl aps or a free fl ap — a full-thickness forehead fl ap is transferred in three
stages to supply the missing covering skin. Its vascularity and ‘plump’ ability, to fi ll
the nooks and crannies between the suture fi xated primary cartilage grafts and the
recipient site, closes dead space and should help revascularize the site.
During the second stage intermediate operation, the surgeon will improve the under-
lining 3-D contour with soft tissue excision and cartilage graft modifi cation or addition,
as needed. The middle support layer will be sculpted, repositioned or augmented. The
pedicle is divided during a third stage.
A two-stage fl ap is used to repair smaller defects (those that encompass only one or two
nasal subunits, such as the ala or sidewall or tip) and that do not require complex
cartilage or lining replacement.

215
A
B
C
Figure 7–42
Forehead Flap Technique

216
Chapter • 7 • The Forehead Flap
In the previous patient, the fl ap was elevated with all its layers as a full-thickness fl ap.
If a two-stage forehead fl ap is planned, only skin and a thin layer of subcutaneous fat are
raised with the distal 1.5 cm of the fl ap (Figure 7–43). Once the distal 1.5 cm is elevated,
A
B
C
Figure 7–43

217
Forehead Flap Technique
the knife passes deeply to enter the loose areolar plane just above the periosteum. The
frontalis muscle is then included with the fl ap to the level of the eyebrow.
When a two-stage repair is planned, the distal 1 to 2 cm can also be thinned, after fl ap
elevation, by removing frontalis muscle and fat with a curved Joseph scissors. This
approach is more tedious and more traumatic to the fl ap.
Branches of the supratrochlear artery are inherent to the dermis in the distal half of the
fl ap and can be visualized and avoided as the distal end of a two-stage fl ap is thinned.
If hairbulbs are noted within the subcutaneous tissue of the distal fl ap, some surgeons
attempt to clip and coagulate them, hoping to depilate their buried follicles. In my
hands, this is rarely successful and may jeopardize fl ap viability.
The pedicle of the two-stage fl ap is divided in three weeks. Its proximal aspect is re-
elevated with a few millimeters of fat. Excess bulk in the superior aspect of the recipient
site is excised. The underlying soft tissues are shaped prior to completing the fl ap’s
inset.
Occasionally, after the fi rst stage of a two-stage fl ap, the repair may appear too bulky,
even after its initial distal thinning at the time of fl ap transfer. The repair may not seem
to be heading in the right direction.
The surgeon can convert to the three-stage approach. An intermediate operation can
be performed at 3–4 weeks, even if not originally planned. If the fl ap seems too thick
or the primary cartilage grafts are inadequate or have shifted, take the fl ap off the entire
recipient site to allow more complete fl ap thinning or support alteration. Re-elevate
the fl ap evenly, with 2–3 mm of fat, sculpt the underlying recipient bed, alter the
support framework if needed, and resuture the fl ap to the recipient site.
Other than adding an extra stage, there are no disadvantages to this approach. Wound
healing is not signifi cantly underway so early after transfer. The fl ap can be safely and
easily remanipulated without harm. Divide the pedicle at a later third stage. Although
this prolongs the reconstruction, the fi nal result may be improved and the need for late
revisions minimized.
If the underlying nasal lining is intact or vascular lining has been replaced, nasal
support can be placed at the time of fl ap transfer — whether a two- or three-stage fl ap
is planned. Primary cartilage grafts are sutured to each other and to the lining with
5-0 permanent propropylene or slowly absorbable sutures. To minimize the risk of
infection, the suture passes through the cartilage graft and catches the raw external
surface of the lining. It then travels back out the underlying lining or cartilage, quilting
the two surfaces together. It does not pass through the lining into the nasal airway to
avoid contamination and possible infection.

218
Chapter • 7 • The Forehead Flap
In our case, the distal lining aspect of the folded fl ap turned into the lining defect
and was sutured to the residual normal lining along the periphery of the defect with
6-0 absorbable suture (Figure 7–44). No primary cartilage support was added. The fl ap
was then folded back on itself and its skin margins sutured to the residual external
skin with a single layer of fi ne suture.
Individual sutures are placed with care. Blanching tension must be avoided. Any tight
suture is removed and replaced. Often the fl ap is positioned incorrectly initially, and
is shifted slightly to allow a better redistribution of tension. The fl ap is sutured to the
columella and along the alar rim initially, progressing superiorly stitch by stitch along
the sides of the inset.
In fact, it is unnecessary to fi x the fl ap to the recipient site along its entire peripheral
border. If the repair seems tight and there is any question of blanching, the stitch is
removed and the fl ap is inset no further. Although not approximated edge to edge
superiorly, the wound edges heal together without incident, by secondary intention.
Although semi-exposed, cartilage grafts do not become infected or resorb. After several
weeks, the fl ap edges spontaneously approximate to the recipient wound.
A
B
Figure 7–44

219
In another patient (Figure 7–45), after inset along the rim and columella, the full-
thickness fl ap blanched as it was inset superiorly along its periphery. These sutures
A
B
C
Figure 7–45
Forehead Flap Technique

220
Chapter • 7 • The Forehead Flap
were removed. The fl ap was left to hang from the brow to its distal inset along the
columella and rim. The wound edges healed spontaneously without incident. The
repair was completed in three stages.
The forehead is a forgiving donor site. Whatever skin is required should be harvested
to resurface the nose without great concern for the secondary defect. Even if the fore-
head defect can only be partially closed, the residual donor defect will close biologically
by wound contraction and forehead autoexpansion. No further incisions, hospitaliza-
tions, or expanders are necessary. Myofi broblasts close any remaining forehead defect
by contraction.
If the forehead is dragged together under great tension, the skin edges may necrose
and, ultimately, the defect is enlarged. Closure with local fl aps, especially large advance-
ment fl aps, designed with incisions along the lower and upper borders of the forehead
unit, produce unsightly scars. Although a skin graft can provide immediate closure, it
will remain visible as a permanent pigmented or pale atrophic depressed patch.
Mechanical tissue expanders require a preliminary operation and a prolonged uncom-
fortable interval, prior to the nasal repair.
After the fl ap is elevated, a layer of loose areolar tissue and periosteum remains in the
base of the wound. The forehead and scalp adjacent to the forehead defect are elevated
in the loose areolar sub-frontalis plane, laterally into both temples and superiorly into
the scalp. Under moderate tension, the forehead is pulled together and held with
several 4-0 permanent sutures (see Figure 7–46). These key tension sutures remain in
place for 10 days. They are inserted about 1 mm from the wound edge to minimize
stitch marks.
The dog-ear at the upper end of the forehead donor site is excised and the rest of the
wound is closed with clear slowly absorbing 4-0 and 5-0 sutures for the frontalis and
subcuticular closure, respectively. 6-0 fi ne sutures close the skin and are removed 4 to
5 days later. If the upper one third to one half of the forehead defect cannot be closed,
it is left open. Exposed periosteum is protected with a petrolatum dressing, sutured in
place with a running chromic. The gauze is removed at one week. The area is bathed
daily and covered with petrolatum ointment and a light nonadherent dressing, if
desired.
No contraction occurs in the open wound for about three weeks. Then the wound
gradually fi lls with healthy granulation tissue. The base of the raw defect rises to the
level of the adjacent skin surface. The edges of the wound are dragged together by the
force of wound contraction, auto expanding the adjacent forehead. This creates a sur-
prisingly satisfactory donor scar. Defects as large as 3–4 cm in width are easily closed
by the biologic force of the myofi broblast over 4–5 weeks. Even if the periosteum desic-
cates and raw frontal bone is exposed, the forehead wound closes sponteously, although
the period of secondary healing will be extended.
Most often, a full-thickness skin graft, harvested from a groin crease, is sutured to the
raw deep surface of the pedicle, as it dangles, across the nose, from the brow to the
recipient site. Although not vital, this closes its raw undersurface and limits drainage
and crust, which is appreciated by the patient. At times, a Steri-Strip or suture is
suspended from the mid pedicle and fi xed to the bridge of the nose for a few days to
pull the stalk more medially and keep the pedicle out of the patient’s line of sight.
Postoperative care
To ensure patient comfort and permit postoperative observation, most patients are
observed in the hospital overnight after a forehead fl ap transfer. The patient sleeps

221
A
B
C
Figure 7–46
with his head elevated 15 degrees. They may shampoo and wash the following day.
Glasses are suspended from the forehead with a piece of 0.5-inch paper tape wrapped
around the bridge of the spectacles. Skin sutures are removed in 5 days. Petrolatum
gauze covers any gap which remains under the hairline and is removed at one week.
Tensions bearing key sutures along the wound edge are removed in 7 to 10 days with
the petrolatum gauze. The patient may cover the fl ap with a nonadherent bandage, if
desired. A light sponge bolus is gently inserted in the nostril when a folded fl ap or
skin graft is used to approximate the cover and lining. The bolus is removed after
several days.
Forehead Flap Technique