Nasal Reconstruction Art and Practice E-Book_nodrm

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Figure 7–48
Forehead Flap Technique

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Chapter • 7 • The Forehead Flap
Based on a foil template of the contralateral right normal ala, an ear cartilage graft,
with the correct length, margin outline and height, is fashioned. It is fi xed to the lining
with 5-0 permanent sutures on a taper needle (see Figure 7–49). This batten rim graft
supports, shapes, and braces the alar reconstruction against scar contraction.
The forehead fl ap is returned to the recipient site and resutured with quilting and fi ne
skin sutures (Figure 7–50). Quilting sutures are removed in 48 hours. At the end of the
intermediate stage, thin conforming skin is supported and shaped by an ideally shaped
support graft which overlies thin supple vascularized lining.
During the second stage, the forehead fl ap is routinely elevated over its entire inset
with 2 to 3 mm of subcutaneous fat. This permits the fl ap to be placed away from the
nose and completely exposes the underlying recipient bed for modifi cation. However,
if fl ap vascularity is in question, occasionally the fl ap is re-elevated but left adherent
to the columella and nostril margin. In this way, it maintains a bipedicle blood supply,
hanging from the brow pedicle to the distal nose. This bipedicle technique should be
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Figure 7–49

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Figure 7–50
considered in the heavy smoker, when an old scar lies within the fl ap’s territory, when
the fl ap contains unusually complex skin extensions, if the size of the defect necessitates
a fl ap which must extend from high on the radix to the columella and so requires
thinning over an extremely large surface area or if, for any reason, concern for its
vascularity is raised during its initial transfer.
In fact, on rare occasions, it may be helpful to perform two intermediate operations.
The fl ap is debulked to remove excess tissue distally and then, at a later date proxi-
mally. The distal fl ap is re-elevated initially, maintaining the proximal inset into the
nasal bridge to supplement vascularity while the tip and columella are sculpted or
delayed primary cartilage grafts placed. At a second intermediate operation, the fl ap
is re-elevated over the mid bridge and nasal root as a bipedicle, while maintaining the
columella and rim inset. This approach can be useful if signifi cant scarring is present
within the proximal fl ap and the surgeon has a special concern for vascularity during
the intermediate stage when further subcutaneous sculpture is needed to properly
contour the repair or to place additional grafts. The surgeon should be guided by the
needs of the repair and vascular safety. The number of stages is unimportant if the
fi nal result is good and complications are avoided. (See Chapter 8, Figure 8–2–8–4.)
Flap re-elevation to sculpt a nasal shape is required during the intermediate stage and
during the division. Be safe, but do not be overly cautious! Inadequate re-elevation
limits the surgeon’s ability to create a correct nasal contour. At each stage, ask: Where
is the soft tissue in excess? Where does the contour need further sculpting and defi ni-
tion? Should a cartilage graft be modifi ed or added? The fl ap must be elevated in those
areas and soft tissue excised or cartilage support modifi ed. Once the visual needs are
identifi ed, the surgeon need only identify the amount of exposure required, the risk to
fl ap vascularity, and the safest way to stage the necessary changes.
Forehead Flap Technique

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Chapter • 7 • The Forehead Flap
Stage III: pedicle division
Four weeks later (7–8 weeks after the initial fl ap transfer in a three-stage fl ap) the
pedicle is divided. (A two-stage fl ap is divided 3–4 weeks after transfer, in the same
fashion.)
Contraction of the undersurface of the pedicle has temporarily distorted the position
of the left ala. This occurs infrequently. Division of the pedicle will release this con-
tracture and correct the malposition.
Under general anesthesia, the forehead scar, the nasal subunits, and the site of pro-
posed pedicle transection are marked with ink. The site of the proposed left alar crease
is identifi ed, based on template of the contralateral normal ala. The pedicle is divided
above the likely point of fi nal inset to allow for error and later modifi cation.
From the viewpoint of vascular effi ciency, the forehead pedicle might be divided safely
between the 10th and 14th day after inset. However, tensile strength is minimal at this
time. To prevent an avulsion of the nasal fl ap by an eager assistant, it is best to wait
3 to 4 weeks to allow healing. Time also allows the edema to resolve and the contour
to be better appreciated, intraoperatively. As they say, time heals all wounds. Speed
is not the goal. Good results are the desired endpoint.
The pedicle is divided after ensuring that adequate skin remains available for recipient
site closure. Because the pedicle is less than 1.5 cm wide inferiorly, it is unnecessary
to return it to the forehead to preserve eyebrow separation. In fact, if replaced, the
residual stump may disrupt the forehead contour and appear as a nubbin of
trapdoored skin (see Figure 7–51).
The proximal fl ap is untubed and its skin is elevated with a few millimeters of fat. The
underlying soft tissue is debulked by excision of excess skin graft, scar, frontalis muscle
and fat from its proximal end, until the brow contour is correct. The inferior aspect of
the forehead incision is reopened, and the stump of the pedicle marked and trimmed
in the shape of a small inverted ‘V,’ less than 10 mm high. It is fi tted into a similarly
shaped defect at the medial end of the eyebrow. The fl ap is fi xed to the sculpted under-
lying bed with quilting sutures and its peripheral border is approximated with fi ne
subcuticular and skin sutures. Its scars blend into the frown lines at the medial
brow.

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Figure 7–51
Forehead Flap Technique

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Chapter • 7 • The Forehead Flap
Now revascularized from the recipient site, the vascularity of the distal fl ap is excellent
(Figure 7–52). The distal end of the pedicle, attached to the nose, is elevated from its
bed towards the nostril rim. Its skin edge is elevated, with a few millimeters of fat,
from the excess underlying soft tissue adherent to the recipient site. It can be safely
re-elevated to a degree which is much more extensive than might seem appropriate at
fi rst glance.
The surgeon must weigh the risk of ischemia, the extent of re-elevation required to
debulk and shape the desired contour, and his or her ability to make a secondary cor-
rection during planned future procedures. Can you safely correct or improve contour
imperfections by re-elevation at the time of pedicle division or is it wiser to limit the
dissection and make the needed correction during a later revision? Normally, the inset
is re-elevated to within a centimeter of the nostril margin and to the level of the alar
crease in larger defects.
The superior aspect of the nasal defect is pared, excising fat and scar from the recipient
bed, until the underlying surface contour is correct (Figure 7–53). The fl ap is gently
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Figure 7–52

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Figure 7–53
Forehead Flap Technique

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Chapter • 7 • The Forehead Flap
quilted to the recipient bed. It is then fi tted, trimmed and fi xed with fi ne suture into
the periphery of the defect. Quilting sutures must be tied lightly and must not blanch
the fl ap. They close dead space and hold the fl ap to its bed. Quilting sutures are
removed in 24 to 48 hours. Skin sutures are removed at about 5 days.
Any residual defect in the superior aspect of the forehead has been allowed to heal
secondarily. Over time, the forehead expands spontaneously. At the time of transfer,
any gap, which remained high in the forehead, is now almost healed. The forehead
scar can often be excised and the forehead re-advanced and reclosed — often com-
pletely eliminating any area of secondary healing. Or the forehead scar may be revised
at a later date.
Revisions
Although it takes several months for edema to pass and for scars to mature, the fl ap
begins to blend with the normal nose. Scars soften and fade and contour stabilizes,
with time. Secondary contour surgery is not performed during the initial 4 months
after surgery. Once the tissues are soft and the fi nal contour can be fully appreciated,
revisional surgery can proceed.
Although a revision may not be needed when repairing small superfi cial defects, it
should be considered part of the initial surgical plan when repairing large or deep
defects which require complex support or lining restoration.
Patients hate the unexpected. If informed initially of the likely need for a ‘touchup
operation,’ they accept readily. This is especially true if they have been part of the
decision-making process and have understood the logic of the surgical plan. By this
time, you have largely succeeded in accomplishing their goals — things are really
beginning to look normal. You will fi nd patients eager to fi nish the job. Because all has
gone well so far, they have confi dence in your ability to add that little extra.
If a revision is necessary, the forehead scar may be revised, the alar crease defi ned, the
nostril margin thinned, the nostril aperture enlarged or an area of excess tissue sculpted
or a defi ciency augmented.
Some months later, this patient’s alar contour was further defi ned through an alar
crease incision and the nostril margin was thinned by excision of soft tissue between
the folded lining and cartilage rim graft. Her fi nal result is seen (see Figure 7–54).

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Figure 7–54
Forehead Flap Technique

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Chapter • 7 • The Forehead Flap
Useful intraoperative adjustments
1. Start with an exact template of the correct size and outline. Ensure that the fl ap
will reach the defect without tension — extend the fl ap into the hairline or, more
often, carry the pedicle across the eyebrow.
2. Suture the fl ap to the recipient site in one layer, one suture at a time. Remove
and reposition any tight blanching stitches. The patient should not leave the
operating room with a white fl ap. Avoid epinephrine blanching.
3. If the closure seems tight, consider removing an overly projecting tip graft or
other graft material and reapply the fl ap. The cartilage graft can be banked and
replaced during a later stage. Or carefully excise frontalis muscle from the
peripheral margins of the full-thickness forehead fl ap. This decreases the fl ap’s
bulk but may, more importantly, make it more supple. Reapply the fl ap. Care-
fully balance fl ap vascularity versus excess tissue tension and cautiously remove
soft tissue bulk at the fi rst stage. Do not insist on insetting the periphery of the
fl ap along the entire border of the recipient site. Suture the fl ap to the columella
and nostril margins. Then work superiorly, suture by suture. If the closure is too
tight and the fl ap blanches, stop, let the fl ap dangle from the brow to its distal
inset. Its borders will heal spontaneously to the margins of the recipient defect. If
fl ap perfusion is in question postoperatively, release any tight sutures in the
recovery room, or at any time during the early postoperative period.
4. During the intermediate stage, add, reposition or sculpt any initially positioned
cartilage grafts. A poorly designed or malpositioned graft can be corrected
during the second stage.
5. If the alar margins are asymmetric after the fi rst stage, a sliver of cartilage can be
fi xed to a previously positioned cartilage graft, after freeing the distal edge of
the lining in a limited fashion, during the intermediate operation. This pushes
the rim inferiorly. Or if a nostril rim was too low, the initial primary cartilage
graft can be shaved along its inferior edge to allow the rim margin to rise. The
forehead fl ap is then returned to the recipient site. A retracted nostril rim can be
lowered or a hanging rim elevated during the second stage by a few millimeters.
6. After fl ap re-elevation and subcutaneous excision during the intermediate
operation, it may be appropriate to trim a few millimeters off the covering fl ap,
which may appear slightly in excess along its lateral margins, when it is
returned to the recipient site.
7. Intraoperatively, take the time to accomplish each task. Visually and mentally,
analyze the effect of each maneuver and modify or redo that step, if needed.
Haste makes waste and often poor results!
8. Re-evaluate the results after each stage. Examine preoperative, intraoperative
and current photographs. Have priorities been met? Can the next stage be
modifi ed to improve the result? Is the plan on course? If not, how can the
situation be improved?
Thought, Time, and Surgical Principles will get you through.

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Changing Course: Turning a Two-stage Operation into Three Stages
Changing Course: Turning a Two-stage Operation into
Three Stages
After the initial distal thinning and transfer of a two-stage forehead fl ap to resurface a
moderately large defect, the early result, prior to pedicle division, may appear thick
and bulky. Postoperative edema may be responsible. Occasionally, however, inade-
quate fl ap thinning is the likely cause.
A moderately large fl ap requires signifi cant thinning. The surgeon’s fear of fl ap necro-
sis occasionally limits debulking of the fl ap in depth or surface area. The soft tissues
are thin — but not enough.
In this instance, rather than watchful waiting and hoping for the best, an alternative
option is to delay pedicle division and perform the intermediate operation. At 3–4
weeks, the fl ap is re-elevated as a skin fl ap with 2 to 3 mm of subcutaneous fat. Under-
lying excess soft tissue is excised. The thin fl ap is then resutured to the sculpted recipi-
ent site. The pedicle is divided 3 to 4 weeks later.

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Chapter • 7 • The Forehead Flap
This patient presented with dorsal and tip defects (Figure 7–55). The wound was con-
verted to a subunit dorsal tip defect by excision of residual normal skin within the tip
and dorsal subunits. A forehead fl ap was transposed with distal thinning. Although a
Figure 7–55
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two-stage repair was planned, the fl ap seemed bulky prior to pedicle division (Figure
7–56). Initial inadequate thinning seemed likely. Flap division was delayed. Forehead
skin was elevated with 2 to 3 mm of fat and the underlying excess soft tissue was
Changing Course: Turning a Two-stage Operation into Three Stages
Figure 7–56
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Chapter • 7 • The Forehead Flap
removed to sculpt the recipient base (Figure 7–57). Then a fl ap of “nasal thinness” was
resutured to the ideally contoured recipient site with peripheral and quilting sutures.
The pedicle was subsequently divided.
Figure 7–57
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Changing Course: Turning a Two-stage Operation into Three Stages
Figure 7–58
Postoperatively (Figure 7–58), the nasal contour is excellent. I believe the result was
improved and future patient dissatisfaction and the need for revision were avoided by
an intermediate operation. Although this adds an extra stage between transfer and
division, there is little to be lost except time. A few weeks after initial transfer, the
tissues remain soft and are easily manipulated. Fibrotic wound healing has not yet
begun. Additional and more aggressive soft tissue contouring of the fl ap are easily
performed without risk. After the pedicle is transferred, twisted, and, effectively,
delayed after the fi rst stage, further thinning is easily performed and safe during the
intermediate operation.
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Handling the Forehead Donor
— the Basics, Old Scars,
Previous Forehead Flaps,
Delay and Expansion
C H A P T E R
8
Treat the primary defect fi rst. Do not let concern for the secondary defect
endanger the fi nal results.
Sir Harold Gillies
It takes courage to harvest forehead skin from an already anxious and fearful patient.
But the deformed face requires correction. Fortunately, knowledge, experience, and
proper technique build confi dence. The nose can be repaired with little injury to the
donor site. The fi nal result necessitates doing the ‘right thing’. Take whatever you need
from the forehead to make the nose!
The Basics
The size, vascularity and quality of forehead skin make it the fi rst choice for major
nasal repair. Its expansive surface is perfused from multiple arcades of axial vessels
which enter along its periphery. The paramedian forehead fl ap design, based inferiorly
on the supratrochlear vessels, seems best. It harvests skin high under the hairline —
away from the central and most visibly important facial landmarks. Its narrow pedicle
— 1.2 to 1.5 cm in width — allows primary closure of the inferior forehead, leaving
a single-line scar above the brow, which is minimally intrusive. The eyebrow is not
distorted or medialized on return of the proximal pedicle base to the eyebrow.
The fl ap is elevated and transferred in two or three stages. At the time of transfer, the
residual forehead is undermined bluntly in the subfrontalis plane over the periosteum,
superiorly and laterally into each temple. Bleeding is modest and postoperative hema-
toma does not occur. Under moderate tension, several key tacking sutures are placed,
exiting one to two millimeters from the wound edge. Although they remain for 10 days,
because they are so close to the wound edge, a signifi cant suture mark does not follow.
Then a layered closure, using 4-0 and 5-0 permanent or slowly absorbing sutures, is
performed to approximate the frontalis muscle and then the subcuticular skin, followed
by 6-0 silk or plain gut suture for the skin. A superior dog-ear is excised within the
scalp.
If the forehead cannot be closed primarily, the gap remains superiorly positioned. It is
allowed to heal secondarily. A petrolatum impregnated fi ne gauze is applied to cover
the raw periosteum and fi xed temporarily with 5-0 chromic suture. The patient can
shampoo the following day and wash the nose and forehead. The impregnated gauze
dressing is removed in 7 to 10 days. Healthy granulation tissue slowly fi lls the open
gap. It is protected with a light nonadherent dressing, if desired. Daily washing

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Chapter • 8 • The Basics, Old Scars, Previous Forehead Flaps, Delay and Expansion
continues. The wound fi lls with granulation tissue, contracts and spontaneously re-
epithelializes. Intraoperatively and postoperatively, the frontal periosteum should be
protected from trauma and desiccation. But it will heal satisfactorily, even if
large areas of periosteum are denuded and frontal bone exposed. Wait and let nature
heal itself.
Depending on elasticity of the tissue, the presence of old scars, or the harvesting
of a past forehead fl ap, the donor site can often be closed primarily. This applies if
the area that requires resurfacing is limited to the width of a single subunit — the ala,
the ala and sidewall, the tip or the tip and dorsum. Note, however, the expanse of
forehead required to resurface the convex tip or multiple units is frequently
underestimated. In such cases, a gap may remain superiorly and should be allowed
to heal secondarily. The open area may vary from a few millimeters to several
centimeters.
The adjacent normal forehead tissues stretch by autoexpansion. Frequently, a small
gap heals spontaneously within 3 to 6 weeks. If desired, the resultant forehead scar
can be excised, the wound edges undermined for 1 to 2 cm and the incision reclosed,
in layers, at the time of pedicle division. Larger forehead defects heal spontaneously
over 4 to 10 weeks. The gap granulates, re-epithelializes and contracts — an almost
4-cm defect may shrink to 1.5–2 cm. Although the scar will be red and raised for 2 to
6 months, it will not be depressed. The fi nal forehead contour is excellent. Depend-
ing on scar quality, it can be excised and the adjacent forehead re-advanced in one to
two stages, 4 to 6 months after pedicle division. In most cases, it can be completely
excised or nearly completely excised during a late revision. Often, although present,
the scar is unobtrusive and is not revised.
In the typical repair, no revision is performed. The nose looks good and the forehead
does not appear injured. In more diffi cult reconstructions, refi ning the reconstructed
nose by sculpting the alar crease, recreating the nasolabial fold or thinning the nostril
will be helpful. Revision of the forehead scar is easily combined with these procedures.
Forehead scar revisions are primarily performed only in complex repairs which
required a large fl ap.
A forehead allowed to heal secondarily will always have a more aesthetic appearance
than one closed with a skin graft or one distorted and denervated by extensive scalp
or forehead advancements. If a gap remains in the superior forehead which cannot be
closed, let it heal secondarily. Examination of the many cases illustrated in the text
should put the surgeon at ease. When I ask myself the question — ‘Is the scar worth
it?’ — my answer is always ‘yes!’
For example, this 14-year-old girl (Figure 8–1) underwent a three-stage forehead fl ap
and support replacement to reconstruct her nose destroyed by an infantile hemangi-
oma. A large fl ap was harvested to resurface the unit. The gap in the superior forehead
was allowed to heal secondarily. Each week, the residual defect became smaller. At
8 weeks, prior to pedicle division, the wound was nearly healed. Months later, during
a revision, the forehead scar was excised and the adjacent skin advanced and
reapproximated. A small remaining gap was left to heal spontaneously.
Delay and Forehead Expansion
Foreheads vary in height and width (which are determined by hairline position), laxity,
the presence of scars, prior injury or past forehead fl ap harvest.

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Figure 8–1
Delay and Forehead Expansion

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Chapter • 8 • The Basics, Old Scars, Previous Forehead Flaps, Delay and Expansion
Practically speaking, when faced with a nasal defect, the surgeon must ask two ques-
tions: Is skin available to resurface the nose? Can it be transferred with a reliable blood
supply?
Perhaps refl ecting a lack of confi dence, surgeons become misdirected away from the
important problems — recreating outline, symmetry, and contour. Often they look to
unnecessary maneuvers or technology to lessen their anxiety.
Most often, delay of the fl ap or expansion of the donor site is undertaken — not because
it ‘should be’ but because it ‘can be’. Unless specifi cally indicated, neither method
improves the fi nal result of nasal repair. Both delay its completion and both add their
own inherent disadvantages and risks of complications to an already complex situa-
tion. Do not waste time or energy on the forehead unless it will contribute to the fi nal
result.
The forehead is a very forgiving donor site — expansive, highly vascular, self-healing
and lending itself to secondary revision. Employ delay or expansion only when appro-
priate. Such cases are the exception.
Nature blessed the reconstructive surgeon with the forehead to repair a nose. The fear
of late forehead deformity is a misdirected priority. Ask yourself: Is this maneuver
going to help build a better nose or will it divert attention away from the truly diffi cult
aspects of repair? — taking bits and pieces of expendable tissue and recreating a
facsimile that looks and breathes like a nose.
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Figure 8–1, Continued

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Surgical delay
Under most circumstances, delay of a forehead fl ap prior to transfer is neither helpful
nor required. It is almost never needed when harvesting tissue from a previously
uninjured and virgin forehead.
In occasional cases, a surgical delay of the fl ap is employed, prior to transfer, to enlarge
the available fl ap territory or to augment its blood supply and improve vascular
safety.
Consider surgical delay of a forehead fl ap when:
1. A signifi cant old scar, which may interfere with its axial vessels, lies within the
proposed fl ap territory.
2. The pedicle’s named blood supply is suspect due to previous injury (prior
trauma, history of a previous overly aggressive browlift, multiple past forehead
fl aps).
3. Unusually complex extensions of fl ap design are required (very uncommon). The
perfusion of a paramedian forehead fl ap is excellent especially if it has not been
thinned.
4. The fl ap design extends across one vascular territory into the territory of another
fl ap. For example, the axial blood supply of the Sickle fl ap is based on the
superfi cial temporal artery of the scalp. This scalp vessel collateralizes with the
supraorbital and supratrochlear systems which are the primary blood supply to
the lateral forehead. Surgical delay of a Sickle fl ap ensures the safe transfer of
skin within the secondary forehead angiosome. Because the supratrochlear
vessels reliably perfuse the forehead, high into the hairline, a paramedian fl ap of
almost any size can be transferred without delay.
5. The patient is an end stage smoker or has a history of radiation.
6. During a complementary procedure, the surgeon is in doubt and a preliminary
operation is required for other reasons (a prefabrication, a delay of lining
hingeover fl aps, etc.).
To delay a fl ap, the dimension and outline of the defect, which requires resurfacing,
are determined. The template is positioned on the forehead donor site over the
territory of the planned pedicle and marked with ink. This will routinely be the
supratrochlear vessels. The proposed fl ap edges are incised to periosteum. In many
cases, a few millimeters of the peripheral outline are left intact at the fl ap’s
columellar and alar tips, to ensure that the fl ap can initially handle the intervention.
These minor tissue connections may be transected in the offi ce prior to formal fl ap
transfer.
Because all signifi cant contributions to the forehead blood supply arise from peripheral
axial vessels and not from the areolar connections to the underlying periosteum, the
fl ap does not need to be elevated to stimulate the increased vascularization associated
with surgical delay. The diffuse sources of blood supply, which normally contribute
to the forehead survival, are eliminated, ‘training’ the fl ap to survive on a single source
at the pedicle’s base.
One month later, vessels at the base of the fl ap are enlarged. Overall vascularity is
increased, the territory available for transfer is enlarged, and perfusion across an old
scar supplemented, if needed.
Always consider the many disadvantages of delay.
Delay and Forehead Expansion

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Chapter • 8 • The Basics, Old Scars, Previous Forehead Flaps, Delay and Expansion
1. Additional stages, added cost, and prolongation of the overall reconstruction.
2. The inability to alter fl ap dimensions at the time of transfer — length, width and
border outline. Although it may be possible to create a template which will
accurately defi ne the recipient requirements, it is diffi cult to precisely determine
the dimensions and outline of a forehead fl ap before recreating the defect,
returning normal to normal and placing support grafts over reconstructed lining.
3. Possible fl ap induration and loss of pliability. This should not be a signifi cant
problem as long as the fl ap itself is not undermined during the delay. It should
be incised along its borders, but not elevated, during the preliminary operation
to improve its blood supply.
For instance in this patient (Figure 8–2), signifi cant facial scarring followed smallpox
in infancy. During his teenage years, the cheeks were resurfaced with split-thickness
skin grafts, and the nose with a left lateral horizontal forehead fl ap, pedicled on the
superfi cial temporal artery. After pedicle division, the residual fl ap was returned to
the forehead and the remaining right temple defect was skin grafted. When seen many
years later, he desired improvement.
Lengthy horizontal scars lay across the forehead both beneath the hairline and above
the brow within the territory of a planned left paramedian forehead fl ap. Survival of
the skin distal (superior) to two transverse scars was unlikely without surgical delay.
Prior to nasal repair, the left supratrochlear vessels were identifi ed and a full-thickness
paramedian forehead fl ap was outlined. It was incised through the skin to the
periosteum except for a few millimeters at the tip of the columella and both alar
bases.
Four weeks later, nasal lining was restored with hingeover fl aps to lengthen the nose.
Primary cartilage batten grafts were positioned to support the alae. The fl ap was ele-
vated with all its layers and transferred without incident. Note that two transverse
scars cross the fl ap’s territory. But the fl ap was well vascularized and healed without
incident. The large gap in the forehead was allowed to heal primarily.

245
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Figure 8–2
Delay and Forehead Expansion

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Chapter • 8 • The Basics, Old Scars, Previous Forehead Flaps, Delay and Expansion
One month later, the fi rst of two intermediate operations was performed (Figure 8–3).
The defect extended from high on the radix to the nasal base. Total re-elevation and
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Figure 8–3

247
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Figure 8–3, Continued
debulking of frontalis muscle and subcutaneous fat over such a large area, crossed by
full-thickness scars, would put the fl ap at risk. So initially, forehead skin with 2 to 3 mm
of subcutaneous fat was re-elevated over the inferior two thirds of the nose. The trans-
verse scar which crosses the proximal aspect of the fl ap is visible, crosshatched with
ink. For vascular safety, the columella inset was not re-elevated. However, extensive
subcutaneous sculpturing of excess frontalis and subcutaneous fat as well as placement
of a delayed primary tip graft was performed. The fl ap was reapproximated to the
recipient site with peripheral and quilting sutures. Despite profuse vascularity at the
time of initial transfer to the nose 4 weeks before, the tip of the right ala became super-
fi cially ischemic, over several days. Fortunately this healed without signifi cant inci-
dent, although the alar base became slightly malpositioned.
Six weeks later, a second intermediate operation was performed to further sculpt the
proximal dorsum and nasal root. The fl ap was re-elevated from the superior inset to
expose the midnose and radix, the excess soft tissues excised and the fl ap returned to
the sculpted recipient site. The forehead fl ap was divided one month later. Vascularity
remained excellent during the later procedures.
Delay and Forehead Expansion

248
Chapter • 8 • The Basics, Old Scars, Previous Forehead Flaps, Delay and Expansion
Seen, just 6 weeks later, in this early postoperative photograph (Figure 8–4), his nasal
appearance is signifi cantly improved. Despite the harvest of a horizontal fl ap with skin
grafting of the donor site and a later paramedian forehead fl ap, with secondary healing
of the second new donor gap, the appearance of the forehead has not been impaired.
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Figure 8–4

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Signifi cant scarring within the paramedian territory necessitated technique modifi ca-
tion in this patient. To maintain maximal vascularity, the fl ap was delayed. A full-thick-
ness forehead fl ap was employed to include all vascular layers. During the intermediate
operation, the fl ap was re-elevated in stages, maintaining a partial distal inset to
augment the blood supply coming from the brow. Interestingly, the fl ap tolerated
initial transfer without incident. Superfi cial necrosis developed only during the fi rst
intermediate operation, suggesting this may have been a technical error due to too
superfi cial re-elevation or tension on closure. Fortunately, the borderline vascularity
of the right alar tip did not signifi cantly limit the result.
Scars within the Forehead
Determine the recipient requirements and outline the available surface area of the
forehead. If a scar lies within the proposed fl ap territory the surgeon must determine
the site, direction, depth, and length of the scar. A transverse scar puts the fl ap at
greater risk. A review of old operative reports may clarify whether the injury extended
only superfi cially, injuring only the random cutaneous blood supply, deeper through
the galeal frontalis or directly to the vascular pedicle at the fl ap’s base. Doppler exami-
nation of the supratrochlear artery and its ascending vertical branches may confi rm
their presence or absence. If the vessels can be followed up the forehead, the surgeon
can be reassured that they are intact. This would also apply if history suggests that the
pedicle may have been injured by past injury or surgery.
Options when a scar lies within the fl ap territory
1. In many cases, it is possible to quickly determine that a visible scar is of little
consequence. A scar can be disregarded if it is short, vertical, superfi cial, or the
presence of fl ap’s named vessel can be verifi ed by Doppler.
2. The surgeon may avoid the scarred area entirely. The opposite contralateral
pedicle can be used to transfer skin from the opposite side of the forehead, if it is
adequate in size and vascularity. This has the disadvantage of increasing the
distance to the defect and the need for a longer fl ap to reach the defect on the
opposite side of the nose.
3. The fl ap territory can be surgically delayed to augment its blood supply. This is
useful when the surgeon has special concern.
4. The fl ap can be elevated as a full-thickness fl ap to maintain its maximal blood
supply. Under such circumstances, the full-thickness forehead fl ap is thinned
later during the intermediate operation. It is re-elevated as a bipedicle extending
from the brow to the columella and nostril rims. Because the fl ap remains well
vascularized from both the proximal pedicle and distal inset during the second
stage, the scar should be of signifi cantly less concern because it lies within the
middle of the fl ap’s surface.
5. Even if the forehead is scarred, an area of virgin skin may be available
to expand. An area of the forehead is transferred that avoids the area
of concern.
6. In rare instances when both supratrochlear arteries have been ablated and
extensive scarring may exist within the inferior forehead, available forehead skin
can be transferred on other vascular pedicles — e.g. use a scalping fl ap or sickle
fl ap, rather than a paramedian fl ap based on the supratrochlear vessels.
Scars within the Forehead

250
Chapter • 8 • The Basics, Old Scars, Previous Forehead Flaps, Delay and Expansion
For example, this patient presented after a repair of an extensive midfacial nasal,
canthal, and cheek defect (Figure 8–5). Bilateral cheek, eyelid, and scalp advancement
and rotation fl aps dragged the borders of the wound medially to close the holes.
The nasal dorsum was fl at and the tip pulled superiorly. A plan was outlined. A full-
thickness release of her nasal tip would reposition it to its normal position. A septal
composite fl ap would be pulled out of the pyriform aperture to restore a septal parti-
tion and provide lining. Multiple dorsal, sidewall and columellar rib cartilage grafts
would support the repair and forehead skin would resurface the midvault and nasal
sidewalls.
Unfortunately the prior repair complicated future reconstruction. Both supratrochlear
and supraorbital arteries had been transected. An oblique scar extended superiorly
from the left medial brow into the right temple. Incisions lay within both upper lids,
along the lower lids, and lateral to both nasolabial folds.
However, skin was available in the left upper forehead and could be transferred based
on superfi cial temporal vessels. This is the Sickle fl ap, as described by New.

251
Figure 8–5
A
B
C
Scars within the Forehead

252
Chapter • 8 • The Basics, Old Scars, Previous Forehead Flaps, Delay and Expansion
Skin within the forehead receives its primary blood supply from the supratrochlear
and supraorbital vessels and a secondary perfusion from the lateral scalp. During an
initial operation (Figure 8–6), a forehead fl ap, based on the left superfi cial temporal
and postauricular vessels, was delayed by incising its periphery. This skin was too
valuable to risk and the superfi cial temporal vessels may not reliably perfuse this sec-
ondary angiosome without delay.
At the same time, the residual normal tip was repositioned by incising the nose trans-
versely into the nasal cavity. This reopened the signifi cant full-thickness defect of the
midvault.
A composite septal fl ap was swung out of the nasal cavity to fi x the position of the
nasal tip. It also provided lining for the future nasal vault. At a later procedure, muco-
perichondrium of the composite fl ap was hinged laterally bilaterally. Rib grafts were
placed for dorsal, columellar, and sidewall support. And the Sickle fl ap was transferred
to resurface the upper and middle nose.
During an intermediate sculpting operation to improve the nasal contour, an expander
was placed under the intact right forehead (Figure 8–7).
A
B
Figure 8–6

253
A
B
C
D
Figure 8–7
Scars within the Forehead

254
Chapter • 8 • The Basics, Old Scars, Previous Forehead Flaps, Delay and Expansion
After expansion, the forehead fl ap pedicle was divided and the residual fl ap was
returned to the scalp. The expanded right forehead skin was elevated and pulled
laterally to resurface the remaining donor defect within the left forehead.
Postoperatively (Figure 8–8), a normal nasal contour has been re-established. The
paramedian forehead fl ap should be the surgeon’s fi rst choice. However, scars within
its territory or injury to the supratrochlear vessels do not preclude the use of forehead
skin, based on other named vessels. Historically, although more morbid, the Converse
Scalping fl ap has been used most often.
The Technique of Forehead Flap Delay
1. Design a fl ap template with the required dimension, outline and length to
supply the defect. Remember that it cannot be altered or extended at the time of
transfer. Transfer the template to the donor site and mark with ink. Then stop
and check the measurements a second time and reconfi rm your requirements.
2. Reconfi rm adequate fl ap length, the position of the pivot point and fl ap reach.
Mark twice or more and cut once.
A
B
Figure 8–8

255
3. Delay the fl ap, making peripheral incisions through the skin, subcutaneous
tissues and frontalis down to the areolar layer over the frontal bone. Because
little blood supply enters from the frontal bone, no undermining is required to
stimulate vascularization of the fl ap by delay. Undermining causes unnecessary
induration and edema and has no advantage. Frequently the entire border
outline will be incised in one stage, leaving just a few millimeters of intact skin
at the columella or alar tips. If the fl ap seems at greater risk, it may be delayed
in one or two stages, leaving 4 mm bridges of intact skin along its peripheral
border and at the tip and at each alar extension. These are incised at two week
intervals until its border is completely incised.
4. At transfer one month later, elevate the fl ap with all its layers as a full-thickness
forehead fl ap.
5. Thin the fl ap’s excess soft tissue during the intermediate operation to ensure
vascular safety. Consider re-elevating the fl ap incompletely or in multiple stages.
It can be re-elevated while maintaining a distal inset during the inter-
mediate stage or, if the recipient site and its required fl ap is large and its
vascularity in question, it can be debulked in stages during a second
intermediate operation.
6. Occasionally, in the tight and scarred forehead, both tissue expansion and delay
are required to provide an adequate surface area for repair and to ensure
vascularity. First, expansion is completed. Then the expanded skin is delayed, in
stages. The required defect pattern is applied over the surface of the expander
and border incisions are made through the skin, subcutaneous tissue and
frontalis muscle to the underlying capsule. When performed using loupe
magnifi cation, the risk of injury to the underlying implant is real, but injury is
avoidable. After incision of the skin with a scalpel, the underlying soft tissue can
be safely divided with the blunt tip of a cautery. Frequently, the capsule space
will be entered but this can occur without incident. The wound edges are
reapproximated and a layered closure performed. The outline of the fl ap may be
delayed in stages, if needed.
Expansion of the Forehead
In special circumstances, pre-expansion of the forehead will improve the surgeon’s
ability to reconstruct a nose. It can increase the amount of tissue available for transfer.
In unusual circumstances, it is useful. However, it is rarely necessary.
The surgeon must measure the dimension of the needed cover skin and compare it to
the size of forehead available for nasal resurfacing. A ‘virgin’ forehead can supply
enough skin to resurface any nasal defect. Most defects are relatively small. The fore-
head is easily closed primarily. When total nasal resurfacing is required, a gap may
remain which cannot be closed. However, secondary healing heals the wound. Auto-
expansion and contraction decrease the size of the late scar. A scar revision can be
performed later, if desired.
Occasionally, the donor site is limited by old scars or past harvest. In these unusual
circumstances, pre-expansion can enlarge the excess available for nasal repair. It is not
employed, however, to make closure of the forehead easier.
Preliminary forehead expansion has many disadvantages.
Expansion of the Forehead

256
Chapter • 8 • The Basics, Old Scars, Previous Forehead Flaps, Delay and Expansion
1. It delays the nasal repair, increases the number of operative stages and adds
additional expense.
2. It necessitates multiple offi ce visits and additional supplies.
3. It subjects the patient to a lengthy period of social isolation due to its unusual,
but temporary, deformity.
4. It risks infection and extrusion.
5. It causes frontal bone erosion and callus formation.
6. Unexpected fl ap recoil may occur after transfer, if the stretched expanded skin is
not rigidly braced with a hard tissue framework to maintain its proper
dimension.
7. It is diffi cult to outline the fl ap template on the globelike surface of the
expander, especially where the expanded skin joins the normal adjacent unex-
panded skin.
8. An expander makes surgical delay of the fl ap more complicated.
9. Expansion does not reliably improve the blood supply of the fl ap.
Forehead expansion should be considered:
1. In an especially tight forehead with limited available skin — one with extensive
forehead scarring or prior forehead fl ap harvest. Expansion can increase the
length and width of available skin by expanding any remaining useful skin
territory. The surgeon may expand the proposed fl ap, prior to its transfer, or
expand the residual forehead adjacent to a planned fl ap, using the expanded
skin for secondary closure of the primary forehead defect.
2. Very rarely, in an especially short forehead (less than 3–4 cm in height),
pre-expansion can be used to increase fl ap length and minimize the amount of
hair transferred to the nose.
However in most instances, expansion is not employed. The pedicle is simply incised,
more inferiorly, across the brow. This lowers the pivot point and brings the base of the
fl ap closer to the defect. Or the fl ap can be lengthened by extending the design into
the hairline, accepting some hair on the distal aspect of the fl ap.
In the following example, this delightful lady, born with congenital syphilis (Figure
8–9), had been subjected to multiple attempts to repair nasal maldevelopment and
collapse since youth. Bilateral nasolabial fl aps, a widely based forehead fl ap, ear, rib
and cranial bone grafts, and multiple local fl aps had been used over the years. The
nose was short, irregular and shapeless.
A transverse scar, about 1 cm below the hairline, traveled across the superior forehead
from one temple to the other. Two vertical scars also extended, superiorly, from the
left medial brow and the mid right brow. They joined the superior transverse scar.
These scars were the sequelae of the old forehead fl ap.
The unused portion of the old fl ap had been returned to the forehead some years
before. The residual donor defect was then closed by advancing the scalp, inferiorly.
Unfortunately, it also shortened the forehead and created a scar which completely
transversed the forehead several centimeters under the hairline.
Presumably, the past surgeon utilized a wide pedicle to ‘preserve fl ap vascularity’. This
is unnecessary.
To close the donor site, the residual fl ap was returned to the forehead. If you design a
fl ap with such a wide pedicle, its wide base must be replaced to repair the forehead.

257
A
B
Figure 8–9
Unfortunately to ‘minimize donor deformity,’ and close any remaining open gap, the
forehead was incised transversely and the scalp advanced, inferiorly. Both maneuvers
signifi cantly limited the harvest of another fl ap.
A plan was formulated. The nose would be lengthened with hingeover lining fl aps,
supported and shaped with a dorsal rib graft, rib alar battens, a columellar strut and
an ear cartilage tip graft. The forehead would be expanded within the territory of the
previous forehead fl ap, which was less than 5 × 5 centimeters in all dimensions — too
narrow to resurface a nose and too short to reach the defect.
Expansion of the Forehead

258
Chapter • 8 • The Basics, Old Scars, Previous Forehead Flaps, Delay and Expansion
During a preliminary procedure (Figure 8–10), a skin expander was placed under the
old forehead fl ap territory. It was positioned through a midline scalp incision. Two
A
C
B
Figure 8–10

259
months later, after expansion, support grafts were placed over hingeover lining fl aps
and an expanded full-thickness paramedian forehead fl ap was harvested and trans-
ferred for cover. The donor site was approximated. The gap which remained in the
forehead was allowed to heal secondarily. An intermediate operation was performed
to thin the fl ap excess and sculpt the soft tissues. The pedicle was subsequently divided.
No revision has been performed (Figure 8–11).
A
B
Figure 8–11
Expansion of the Forehead

260
Chapter • 8 • The Basics, Old Scars, Previous Forehead Flaps, Delay and Expansion
This nose is collapsed and foreshortened after several rhinoplasties and subsequent
destruction from Wegener granulomatosis (Figure 8–12). Many years before, a classic
Millard Seagull forehead fl ap was performed to reconstruct the nose. The retracted tip
elements were released, allowing the inferior nose to fall back to its normal position.
The resultant midvault defect was later lined with delayed hingeover fl aps and covered
with a two-stage forehead fl ap; its gull wing scar criss-crosses her central forehead. In
the interval, the result deteriorated. However, the Wegener granulomatosis remained
inactive. The patient requested further reconstruction.
A
B
C
Figure 8–12

261
The size of the donor site was increased by preliminary expansion (Figure 8–13). But
the reliability of the skin, distal to the old transverse scar, was still in question. Fortu-
nately, by increasing the ‘width’ of forehead, the fl ap could now be designed to the
side of the vertical component, avoiding it completely. The transverse component of
the old scar remained within the fl ap’s territory. Once the dimensions of the available
tissues were adequate, the fl ap was outlined and delayed by staged incisions about its
periphery. Partial implant extrusion is visible at the time of transfer. Local lining hinge-
over and random nasolabial fl aps were delayed and shifted into position, at the same
time. Then a second delayed expanded and now full-thickness forehead fl ap was
transferred in three stages to resurface primary rib grafts and lining fl aps. Much of the
donor site was closed primarily. A small gap healed secondarily. The repair was oth-
erwise uneventful.
A
B
Figure 8–13
Expansion of the Forehead

262
Chapter • 8 • The Basics, Old Scars, Previous Forehead Flaps, Delay and Expansion
C
B
A
Two months after division, her appearance and function are improved (Figure 8–14).
Scars will mature.
Figure 8–14

263
The Technique of Forehead Expansion
1. Determine the correct site for expander placement, above the desired pedicle.
2. Create a subfrontalis pocket slightly larger than a 4-cm rectangle smooth
expander by blunt dissection. The expander is placed through a radial incision
within the scalp. An old scar can also be employed.
3. Position the expander. Minimize folds by injecting several cubic centimeters of
saline into the expander but avoid excessive tension. Close the scalp incision in
layers. Prophylactic antibiotics are used. A drain may be placed.
4. Some weeks later, the expander is injected weekly over 6 to 10 weeks until the
overlying skin is stretched to the proper dimensions. Wound tension, blanching
and patient discomfort are useful parameters to avoid overfi lling at each injection.
5. Measure over the dome of the implant, until adequate length and width of the
proposed fl ap is achieved and suffi cient tissue is available to resurface the defect.
The goal is to enlarge available forehead skin for transfer to the nose. The goal is
not to assure primary closure of the residual forehead defect — any gap can be
allowed to heal secondarily.
6. Beware of visible or palpable knuckles, thinning or a bluish color visible through
the overlying skin, which may presage extrusion. Often the surgeon can continue
fi lling the expander and work through a temporary knuckle. Fortunately, if a
minor exposure occurs, it is often late in the expansion. Occasionally, the expan-
sion can cautiously continue. Most often even if expansion must stop a limited
wound breakdown will not preclude using the fl ap. Beware infection. Sterile
technique is important. If infection is noted, it can sometimes be controlled with
antibiotics and closed drainage but expander removal may be necessary.
7. If the vascularity of the fl ap’s territory is in doubt due to past scars, the pro-
posed fl ap can be surgically delayed, in stages. Once the expansion is completed,
the fl ap is outlined over the dome. The skin is incised with a scalpel. Then the
dissection is carried to the capsule with the blunt tip of a cautery. If the capsule
is entered, it is repaired. The skin incision is closed in layers.
8. At the time of fl ap transfer, the template is positioned over the expander to
determine the correct dimension, border outline and length of the required fl ap.
When using expanded skin, it may be safer to design the fl ap a few millimeters
larger than the template to make up for recoil.
9. When ready for transfer, the fl ap is incised. The expander is removed with its
port and a full thickness fl ap moved to the donor site. The fi brous rind which
forms over the frontal bone, along the periphery of the capsule, will spontane-
ously resolve. It is often recontoured by excising the excess scar with an electro-
cautery to smooth the bony forehead. To allow easy transposition of the fl ap and
proper length, the fl ap must be elevated across the supraorbital rim, opening
and transecting the capsule at the fl ap’s base. The dissection is continued over
the supraorbital rim towards the medial canthus. The entire expander capsule,
with its contracting myofi broblasts, is routinely excised.
10. Frightening elastic shrinkage of the fl ap occurs on elevation of the expanded
skin from the surface of the expander. Fortunately, the fl ap stretches back
to its initial expanded dimensions when sutured to the nasal inset. However, a
strong support framework is needed to prevent late fl ap recoil and skin
contraction.
11. During the intermediate operation, if a signifi cant scar lies within the expanded
fl ap’s territory, the skin can be elevated as a bipedicle, extending from the brow
The Technique of Forehead Expansion

264
Chapter • 8 • The Basics, Old Scars, Previous Forehead Flaps, Delay and Expansion
to the nasal columellar and rim. This maintains the maximum blood supply
when contouring the underlying soft tissue or modifying the cartilage support.
General Guidelines to Protect and Repair the Forehead
Donor Site
1. Routinely use the vertical paramedian forehead fl ap design.
2. Allow any gap within the superior forehead, which cannot be closed primarily,
to heal secondarily.
3. Revise the forehead scar secondarily, if necessary.
4. In most circumstances after fl ap harvest, the defect which remains after harvest
lies within the superior forehead. The inferior forehead donor, after transposition
of its narrow 1.2–1.5 cm pedicle, can be closed primarily at transfer. Later, at
pedicle division, most of the excess proximal pedicle is discarded. Only its most
inferior aspect is replaced as a small inverted ‘V’ to restore the medial eyebrow.
The remnant will simulate the frown crease.
5. Occasionally, if the defect extends high onto the radix or its width extends
laterally towards each medial canthus, the inferior forehead cannot be closed at
the time of initial fl ap transfer. A gap remains in the inferior forehead (as well as
the superior forehead) which cannot be closed primarily, even after advancement
of the residual adjacent forehead skin. It is left open or temporarily skin grafted.
At pedicle division, the unused proximal pedicle is returned to the donor site. An
A
B
Figure 8–15

265
C
D
E
F
Figure 8–15, Continued
area of secondary healing (or a temporary skin graft) is excised and the unused
proximal skin base, with medial eyebrow hair, is returned to the inferior forehead.
The superior gap higher under the hairline is allowed to heal secondarily.
After multiple failed repairs, a third forehead fl ap was harvested in this patient (Figure
8–15). The size and height of the defect and donor availability precluded primary
General Guidelines to Protect and Repair the Forehead Donor Site

266
Chapter • 8 • The Basics, Old Scars, Previous Forehead Flaps, Delay and Expansion
closure of the inferior forehead at transfer. The donor site was left open, initially. At
pedicle division, the unused proximal portion of the fl ap was returned to the donor
site to facilitate closure and restore the medial brow. The residual superior aspect of
the defect was left to heal secondarily.
6. Consider pre-expansion of the fl ap but only when needed to increase the length or
width of the available forehead. This is performed to construct a nose. It is not
done to ease donor closure.
7. Consider expansion of the forehead skin adjacent to the forehead fl ap. This is
ordinarily performed after fl ap transfer to ease repair of the forehead defect
which remains after fl ap harvest. This is rarely needed but remains an option.
The nose must come fi rst and the forehead second! Build the nose. Later expand
the residual forehead to improve the donor site.
8. Rarely, skin graft the residual gap which remains after forehead fl ap transfer.
9. Rarely, resurface the entire forehead unit with a full-thickness skin graft. A tight
shiny skin graft can simulate the expected tight shiny forehead unit. The skin graft
border scars lay hidden in the junction between units and are not distracting.
In this patient (Figure 8–16), extensive recurrent basal cell carcinoma necessitated a
total nasal amputation after a prior reconstruction which had resurfaced the nose with
an oblique median forehead fl ap. The old donor site had been closed with a thigh skin
graft.
A second nasal repair was planned using a free radial forearm fl ap for lining, rib grafts
for support, and a right paramedian forehead fl ap for total nasal resurfacing. Complica-
A
B
Figure 8–16

267
tions, discussed in chapter 21, required the harvest of a third forehead fl ap. At the time
of pedicle division, the forehead was signifi cantly distorted by the old thigh split thick-
ness skin graft and extensive areas of secondary healing. Supra-clavicular skin was
pre-expanded. Scar and old skin graft were excised within the forehead unit. The
forehead donor site was grafted with full-thickness skin as a complete unit (Figure
8–17).
A
C
B
D
Figure 8–17
General Guidelines to Protect and Repair the Forehead Donor Site

268
Chapter • 8 • The Basics, Old Scars, Previous Forehead Flaps, Delay and Expansion
E
Figure 8–17, Continued
The appearance of the forehead is relatively good after total unit grafting. The expected
tight shiny and relatively uniform character of the skin graft replicates the smooth
shiny tight character of the normal forehead. The graft’s border scars lay relatively
hidden along the periphery of the unit adjacent to the hair line, the eyebrows, and the
junction of the medial and lateral forehead subunits along the temporal creast. The
forehead is a peripheral unit of lesser priority.
Guidelines for the Excessively Short Forehead (Less Than
Three to Four Centimeters)
1. Extend the design into the hairline. Accept hair on the nose. Shave, pluck,
depilate, laser, or destroy the subdermal hair bulbs by excision and coagulation,
secondarily.
2. Lower the fl ap pivot point by extending its base across the eyebrow towards the
medial canthus. This effectively lengthens the fl ap and improves its reach.
3. Rarely, expand the available height of forehead tissues by pre-expansion of the
donor site.
Remember the nose is the primary concern. A good nose with a few hairs is acceptable
to patients — a bad nose without hair is a failure.

269
Guidelines for Harvesting Multiple Forehead Flaps
1. Check the position and length of old scars.
2. Determine the available forehead surface versus the recipient requirement.
3. Consider use of the contralateral pedicle.
4. Use a full-thickness forehead fl ap to increase vascular safety when old scars or
past dissection may have interfered with the normal blood supply.
5. Delay the fl ap across an old scar, if one is present or if the pedicle is suspected
of having been injured during previous surgery.
6. Consider tissue expansion, if the available forehead surface seems inadequate.
7. Consider using a non-paramedian forehead fl ap design based on other intact
axial vessels (Scalping or Sickle fl ap).
8. If the donor site cannot be closed primarily under the hairline, allow any
residual gap to heal secondarily.
9. If the inferior forehead cannot be closed primarily due to the size and location of
the nasal defect, return the unused proximal pedicle to the forehead at its
division to facilitate its closure and the appearance of the eyebrow.
10. In extreme circumstances, when the forehead has been extensively destroyed by
previous injury or multiple forehead fl ap harvests, excise scar and residual skin
within the unit and resurface the entire forehead with a one-piece full-thickness
skin graft, obtained after expansion of supraclavicular skin.
Guidelines for Harvesting Multiple Forehead Flaps

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How to Kill a Forehead Flap
and Other Design Errors
C H A P T E R
9
Forehead skin is ideal for nasal resurfacing. Although the vertical paramedian forehead
fl ap is the fi rst choice, forehead tissue can be transferred on numerous vascular pedi-
cles. At least two to three fl aps can be harvested from the forehead depending on the
size, height, laxity, history of prior injury and the size of the nasal defect. The forehead
donor site almost never limits nasal repair.
Do not minimize the aesthetic and functional importance of restoring a normal nose.
Do not exaggerate your concerns regarding forehead donor deformity.
The forehead is a forgiving donor site. However, it must be used correctly. Technique
does matter.
Errors
1. Flap too short or pivot point too high
Position the template at the hairline. Check the arc of rotation and ensure that the fl ap
will comfortably reach the defect — measure to the columella and to each alar base, as
required for the specifi c defect. Use a tape to verify the distance from the planned pivot
point to the distal inset. Double check prior to incising the fl ap.
If the fl ap will not comfortably reach the defect, its design can be extended into the
hairline or the base of the fl ap can be lowered, moving the pivot point inferiorly.
If, after elevation, the fl ap seems short, further extend the skin incisions of the pedicle,
inferiorly. It crosses through the medial brow towards the medial canthus. Then release
restricting fi brous or muscle fi bers within the soft tissue at the fl ap’s base. Preserve
visible vessels. Do not elevate periosteum under the pedicle base. The supratrochlear
vessels pass over the supraorbital periosteum within the corrugator soft tissue. A sub-
periosteal dissection is not helpful and restricts the fl ap’s movement.
Cut and release, as you go, until the fl ap can be positioned to the defect without tension.
Vascular compromise is very unlikely to occur.
Although rarely performed, one can carefully incise the frontalis muscle transversely,
at the base of the fl ap, to expose the subcutaneous fat. This permits the overlying soft
tissue to stretch, gaining a few extra millimeters of length. The vessels pass under the
frontalis, at the orbital rim, and travel through the muscle into the subcutaneous layer,
within 2 cm of the brow. Muscle transection is positioned to protect the distal axial
vessels, superfi cial to the frontalis.