CME

Nasal Reconstruction: Forehead FlapFrederick J. Menick, M.D.Tucson, Ariz.

Learning Objectives: After studying this article, the participant should be able to: 1. Understand the history of nasalreconstruction and its implications to modern nasal repair. 2. Understand current developments in the use of intranasallining flaps and primary cartilage grafts. 3. Understand the use of the two-stage and, specifically, the three-stageparamedian forehead flap with an intermediate operation. 4. Understand methods that allow the use of skin grafts anda modified folded forehead flap for lining. 5. Understand the use of regional unit reconstruction as it applies to repairof nasal defects.

Nasal reconstruction remains the historic centerpieceof plastic surgery, and the forehead flap, the workhorse ofrepair. All anatomic layers—cover, lining, and support—must be replaced to reestablish the aesthetic quality of thenose and a patent airway. This article addresses the ob-jectives and principles of aesthetic nasal reconstruction,emphasizing the use of the two- and three-stage foreheadflap, intranasal flaps, skin grafts and the folded flap forlining, and primary and delayed primary cartilage graftsfor support. (Plast. Reconstr. Surg. 113: 100e, 2004.)

“The tint of forehead skin so exactly matchesthat of the face and nose that it must be firstchoice. Is not the forehead the crowningfeature of the face and important in expres-sion? Why then should we jeopardize itsbeauty to make a nose? First, because inmany instances, the forehead makes far andaway the best nose. Second, with some plasticjuggling, the forehead defect can be camou-flaged effectively.”

—Sir Harold Gillies and D. Ralph Millard1

A HISTORY OF NASAL RECONSTRUCTION

The origins of plastic surgery are rooted inthe relief of facial deformity. Even though car-tilage, bone, and mucous membrane are oftenmissing in larger defects, when the nose hasbeen injured the most obvious deficiency isskin. The forehead has been acknowledged asthe best match for nasal skin because of itssuperb color and texture. Well vascularizedand lying adjacent to the nose, it is the idealdonor material. However, many surgeons willnot use a forehead flap because of a fear of

forehead deformity and scarring, or believethat they cannot use the forehead because it isof inadequate size.

The origins of forehead rhinoplasty2 (theIndian method) are obscure, but it has beenperformed in India since 1440 A.D. and proba-bly long before the birth of Christ.3 Sicily wasthe center of Arabian, Greek, and Occidentallearning at the time, which probably madeknowledge of Arabic translations of the Indianoperations accessible to the Branca family inItaly during the fifteenth century. The firstwritten account in English of the Indian mid-line forehead rhinoplasty appeared in the Ma-dras Gazette in 1793. One year later, it was pub-lished in the Gentleman’s Magazine of London.Carpue, an English surgeon, published his ac-count of two successful operations in 1816.4The classic median forehead flap, which took avertical flap from the midline of the forehead,was popularized in the United States by Ka-zanjian5 in 1946. It received its blood supplyfrom paired supratrochlear vessels. The base ofthe flap twisted 180 degrees, with an arc ofrotation at or above the eyebrows. The fore-head donor sites in the early operations wereallowed to heal by secondary intention.

Between 1940 and World War I, it becameapparent that the results of repair using un-lined flaps were poor.6 The external shape ofthe nose and its airways became distorted bycontracting scar on the underlying raw surfaceof the covering flap. Residual intranasal mu-

Received for publication December 10, 2002.

DOI: 10.1097/01.PRS.0000117382.57120.23

100e

cous membranes seemed inadequate. Around1842, Petralli folded the distal end of the flaponto itself, so that it created its own inside andoutside and, in a manner of speaking, formedthe tip, ala, and columella while eliminatingraw surfaces in the lower part of the recon-structed nose.2 However, normal hairline posi-tion limited the length of a vertical medianforehead flap, unless hair was transferred. Mid-line forehead tissues seemed unable to provideenough tissue to create a long columella thatcould, at the same time, maintain projection,allow infolding of the covering flap for lining,and avoid unnecessary tension that might di-minish flap vascularity. To obtain a longer flap,Auvert, in 1850, slanted it across the foreheadat an oblique angle of 45 degrees.5,6 Germansurgeons of the same period positioned fore-head flaps horizontally; the flaps were suppliedby the supraorbital vessels on one side. In 1935,Gillies7 described an up-and-down flap that wascentered over one supraorbital pedicle, passedinto the hear-bearing scalp, and then de-scended into the forehead. In 1942, Conversemodified the up-and-down flap by creating along pedicle that was camouflaged within thehear-bearing skin and that included the majorvascular supply of the scalp.2,5 All these flapswere designed solely to provide additionallength, and each created a forehead defectthat was harder to close. Surgeons were caughtin a difficult predicament. On the one hand,they worried about forehead scarring. On theother hand, they bemoaned insufficient tissueto make a nose. To add insult to injury, theyoften used forehead tissue not only for nasalreconstruction but also for adjacent defects.Neighboring cheeks, lips, and nose losses inthe midface were filled with one even largerflap, creating a single plump lump that re-placed the subtle three-dimensional contoursof these multiple contiguous facial units. Theforehead was scarred beyond repair. Despite itslimitations, the folding of covering skin forlining, and specifically the Converse scalpingflap, came to be the most commonly usedmethod of nasal reconstruction during most ofthe twentieth century. The median foreheadflap was recommended only to replace smallnasal losses, unless the patient was bald or hadan unusually high hairline that might allow alonger vertical flap.

Rather than folding the forehead flap, oth-ers sought to eliminate the raw area on thedeep surface of the covering flap in other

ways.5 In 1873, Volkmann turned down por-tions of residual nasal skin adjacent to the de-fect, hinged down on scar to provide lining.Thiersch transferred flaps from other facialareas in 1879. More recently, Millard8,9 advo-cated rolling over bilateral nasolabial flaps toline both the ala and the columella.

In 1898, Lossen first described skin grafts forlining. Most often, grafts of split- or full-thickness skin were placed under the coveringflap during a preliminary operation. Weekslater, once the viability of the grafts was as-sured, these prelaminated flaps were trans-ferred to the nose. Although described muchearlier by Konig, in 1943 Gillies10 popularizedthe placement of composite chondrocutane-ous grafts to supply both lining and support. In1956, Converse11 suggested a septomucoperi-chondrial graft as an alternative.

During the same period, it became obviousthat without a skeletal framework, the softtissue of cover and lining would collapse inmajor reconstructions, impairing the airwayand limiting projection. A rigid skeleton wasneeded to provide support, projection, andcontour. However, folded flaps were thickand often ischemic, and precluded the accu-rate placement of primary columellar, alar,and tip support. When residual nasal skin oradjacent cheek skin was turned over to linethe nose, the tissues were thicker than nor-mal intranasal lining and distorted the exter-nal nasal shape and clogged the airway. Onlyafter the soft tissue had healed could largebone and cartilage pieces be placed as canti-lever grafts to lift the dorsum and tip. Be-cause of their bulk and risk of extrusion, theywere not used primarily but were addedmuch later in final touch-up operations. Un-fortunately, once gravity and the contractualeffects of the healing process had distortednasal contour, it could rarely be regained.Covering skin became contracted and stiff.Multiple revisions were required to sculptsubcutaneous tissue into the semblance of anasal shape. When lining and cartilage sup-port were supplied as a composite graft un-der a prelaminated forehead flap, one ormore preliminary stages were required be-fore the nose could be put together. Theirshape was fixed both by their natural config-uration and by the scar that surroundedthem as they sat in the forehead awaitingtransfer to the nose.

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MORE RECENT ADVANCES

The classic Indian forehead flap carried mid-line tissue on paired supraorbital and su-pratrochlear vessels. Its base lay at or above theeyebrows. When so designed, its length wasquickly limited by the hairline; it is reached bythe pedicle’s high arc of rotation. A 180-degreetwist could lead to kinking at the nasal root andcould impair blood supply. Early on, changesin flap design were made to overcome theselimitations.5 If the height of the forehead couldnot be changed, the flap could be effectivelylengthened by modifying incisions at the baseof the pedicle and by lowering the point ofrotation. Lisfranc, in 1827, extended one inci-sion lower than the other. Dieffenbach length-ened one incision until it reached the defect.Labat curved his incisions proximally, center-ing the flap over the medial brow and canthuson one side. This reduced the twist of thepedicle base and brought the flap closer to therecipient site. Central forehead tissue could betransferred on a unilateral paramedian bloodsupply. Strangely, except for the use of theparamedian forehead flap by Millard,12–14 thismodification has received little attention. Heclearly demonstrated that bilateral pedicleswere not essential for flap viability. More re-cently, the anatomic studies of McCarthy andcolleagues15 demonstrated that the forehead isperfused by an arcade of vessels supplied by thesupraorbital, supratrochlear, infraorbital, dor-sonasal, and angular branches of the facial ar-tery and the superficial temporal artery. A richanastomotic plexus centered on the medialcanthus can supply a unilaterally based flap,even after division of the supraorbital, su-pratrochlear, and infratrochlear vessels. Theparamedian forehead flap is perfused by a ver-tically oriented axial blood supply. Its arc ofrotation is centered near the medial canthus.

Refinements in design of transferred tissuealso serve to minimize donor deformity.5 Theoutlines of the earliest forehead flaps weremade from wax patterns, shaped to fill a defect,and then flattened on the forehead as a guide.In 1828, Veltech drew his flap as a reversed aceof spades, its stem forming the columella andits tapering tip remaining attached as a pedi-cle. In 1834, Labat diagramed a similar tripod-shaped flap, with limbs extending obliquelyacross the forehead. More recently, Millard12–14

has used a seagull-shaped flap with a centralvertical component and lateral wings. The

wings extend horizontally and lie in the naturaltransverse wrinkle lines of the forehead. Thevertical component resurfaces the dorsum, tip,and columella, and the lateral extensions arewrapped around the ala and carried into thenostril flare as alar bases. The flap takes excessforehead tissue in both horizontal and verticaldimensions. This facilitates primary closure ofthe forehead wound as an inconspicuous mid-line T-shaped scar. It became apparent thatsimple undermining of adjacent wound mar-gins was satisfactory for near-complete primaryclosure. It was not necessary to make additionalparallel incisions along the brow or hairline, torotate large scalp flaps, or to skin graft the fore-head for closure, as some have recommended.

Because midline forehead tissue can betransferred successfully as a paramedian flap, itis not necessary to use distant tissue to recon-struct the nose or to expand available fore-head. Skin expansion delays reconstruction formonths and is associated with some degree ofdiscomfort and social isolation. Such expandedskin may be subject to uncontrollable shrink-age and contracture. Forehead expansion maybe appropriate to lengthen the reach of theflap when the forehead is inordinately short, orif flaps have been harvested previously, but isunnecessary in almost all cases. The results ofnasal reconstruction using expanded foreheadskin or other distant flaps rarely meet criticalanalysis. In most cases, the motivation for theiruse is an ill-conceived wish to take inordinatelylarge amounts of forehead tissue to cover non-nasal units or to line the covering flap by fold-ing its distal end.

More recently, Burget and Menick16,17

showed that a broad expanse of residual andwell-vascularized intranasal mucosa lies avail-able within most nasal defects and can pro-vide lining for lateral, heminasal, and totalnasal defects. These lining flaps are thin andreliably viable. Loss of lining, the chief en-emy of nasal reconstruction, seldom occurs.The septal branch of the superior labial ar-tery allows the elevation of the entire ipsilat-eral septomucoperichondrium on a narrowpedicle. If both right and left septal branchesare included, the entire septum can beshifted as a composite flap containing a sand-wich of cartilage between the two leaves ofmucous membrane. Such flaps of septomu-coperichondrium, cartilage, and bone ex-tend from the nasal floor below to the levelof the medial canthus above and posteriorly

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beyond the ethmoid perpendicular plate.They also noted that a bipedicle flap of re-sidual vestibular skin based medially on theseptal and laterally on the nostril floor couldbe advanced inferiorly to line the ala andnostril margin, creating a dry, thin lining forthe alar rim.

Realizing that the forehead is a multilaminarstructure of skin, subcutaneous tissue, andfrontalis muscle, Burget and Menick17 revisitedthe use of full-thickness skin grafts for liningwith a forehead flap. Because a skin graft willsurvive on such a highly vascular bed, theyproposed that a skin graft could be used forlining if late contraction could be prevented.They buried a cartilage graft in the subcutane-ous layer between the skin and the frontalismuscle at the time of flap transfer. However,such an alar margin remains somewhat thick.More recently, Menick18 noted that skin grafts(and folded forehead flaps) integrate into ad-jacent normal lining and can be completelyseparated from the overlying cover from whichthey were initially vascularized. So, a skin graftcan be placed on the raw surface of a full-thickness flap without any primary support.Three weeks later, once the skin graft is revas-cularized from its peripheral inset, the cover-ing flap can be re-elevated. Alternatively, afolded flap18 can be incised free along the rimand the covering flap can be lifted off the distalaspect used for lining, completely separatingthe proximal cover flap from the distal liningextension. The underlying subcutaneous tissueand frontalis muscle which covers a skin graftor folded flap is now widely exposed and canbe excised to normal lining thickness. Delayedprimary cartilage grafts are placed to supportlining created from a skin graft or a folded flapduring an intermediate operation before divi-sion. These modified uses of skin grafts forlining and the folded forehead flap are espe-cially advantageous in the elderly or medicallyfrail patient who demands a nasal reconstruc-tion, or when the septal blood supply or theseptum itself precludes the use of intranasallining flaps. Because significantly less intrana-sal manipulation is required as compared withintranasal lining flaps, these new methods con-tribute significantly to lesser morbidity inpatients.

Because they are thin and highly vascular,new lining flaps of vestibular skin and nasalmucosa allowed the use of primary cartilagegrafts from the septum, ear, or rib to be cut,

carved, bent, and fastened together to form adelicate hard-tissue construction that nearly re-sembles the normal cartilaginous framework ofthe nose. When covering skin is supplied by avery thin forehead flap, the shape of this carti-lage construction shows through the skin andthe contour of the nose is correct from theonset. Cartilage grafts provide support andprojection, recreate a three-dimensional con-tour, and brace the repair against the contrac-tile effects of wound healing. It has also be-come apparent that when a full-thicknessforehead flap is used to cover intranasal liningflaps, a skin graft, or a folded forehead flap, itbecomes physiologically delayed. Such a flapcan be completely re-elevated, creating asmooth, supple, thin, and even skin envelopeof ideal skin quality at an intermediate opera-tion. The previously undissected subcutaneousplane separates easily. Subcutaneous tissue,frontalis muscle, and previously positioned pri-marily cartilage graft (if placed) are exposed.This underlying excess soft tissue (conglomer-ate of fat, cartilage, and scar) heals into a rigid,living structure that bleeds readily and can beexcised and carved into an ideal subunit sub-surface architecture. Previously positioned pri-mary cartilage grafts are visible and can beremodeled. Just as importantly, delayed pri-mary cartilage grafts can be placed over vascu-larized lining, skin grafts, or forehead skin thathas been folded. An ideal subsurface architec-ture is created by soft-tissue excision and carti-lage grafting. The forehead skin (now of idealnasal skin thickness) is replaced on the under-lying rigid, recontoured, three-dimensional re-cipient bed at the completion of this interme-diate operation. Three weeks later (6 weeksafter the transfer), the pedicle is transected.Nasal shape is imparted to the reconstructionby resupplying thin skin cover and lining, pri-mary and delayed cartilage grafts, and asculpted soft- and hard-tissue framework, rec-reating an ideal three-dimensional subcutane-ous architecture.

A MODERN APPROACH TO NASAL RECONSTRUCTION

WITH A FOREHEAD FLAP

Planning

Nasal reconstruction requires that the sur-geon analyze the defect, both anatomically andaesthetically. Most importantly, the surgeonmust visualize the end result. Anatomically, thenose is covered by a thin, conforming envelope

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of skin that matches the face in color andtexture. It overlies a sculpted soft- and hard-tissue middle layer framework that supports,shapes, and braces the repair against gravityand wound contraction. The underlying liningmust be thin, supple, and vascular, neither dis-torting the external shape outward nor bulginginward and causing obstruction. Aesthetically,the nose can be described in terms of regionalunits17,19,20; adjacent topographic areas are ofcharacteristic skin quality, border outline, andthree-dimensional contour. The “normal” noseis created by the reestablishment of aestheticcontour, highlights, and landmarks. The surgeonmust take bits and pieces of expendable tissue tocreate a facsimile of the lost nose that gives theappearance of a normal nose. The presence orabsence of scars is much less important.

Assume that patients wish to look normal.Rarely do patients really want less. It is unusualfor an associated medical illness to requirehealing by secondary intention, a simple clo-sure of cover to lining, or a nonaesthetic skingraft or flap. Almost always, the goal should bean aesthetic result.

It follows, then, that if restoration of nasalsubunits is the goal, certain principles20 follow.Because flaps often trap-door due to fibroticcontraction in the underlying bed between therecipient and the donor bed, flaps rise abovethe adjacent normal nose (unlike skin grafts,which may become atrophic or unpredictablypigmented but do not become “pincush-ioned”). It is often better to resurface an entireconvex subunit rather than part of a subunit sothat the expected wound contraction will aug-ment, rather than distort, the contour of thefinal result. Frequently, the wound should bealtered in size, site, or depth to improve thefinal result. The subunit principle then follows:If a defect occupies greater than 50 percent ofa subunit, consider discarding adjacent normaltissue within the subunit so that the entiresubunit is resurfaced with the flap, rather thanthe defect being simply patched. This ap-proach (which is not applicable to skin graftsor to flat or concave subunits) also positionsscars in the contoured depressions betweensubunits, where they are better camouflaged.

Missing tissue must be replaced exactly, nei-ther underfilling or overfilling the defect. Flapdimensions are not taken from a fresh, gapingwound or old, contracted defect but from thecontralateral normal or the ideal.

In repairing composite defects that encom-

pass multiple facial units, anticipate late tissuesettling and scar distortion before proceedingwith subsequent stages. If a facial landmarkmust be built upon another (nose on lip andcheek), reconstruct the lip and cheek at thefirst operation and build the nose only after astable platform is assured. Stage the repair. Formassive facial wounds, by necessity, distant freeflaps have become a first choice for large, com-plicated defects. Although the wound can behealed or closed, distant tissue does not matchfacial skin in color, texture, or thickness, orhave a facial shape. Massive facial defectsshould be approached in two stages. Initially,distant tissue is supplied to provide bulk, pro-tect vital structures, revascularize the wound,and reconstruct a stable platform. At laterstages, a subunit approach is emphasized torestore facial skin quality, border outlines, andthree-dimensional contour. Local tissues andtraditional methods of transfer are utilized toestablish aesthetic cover and three-dimen-sional shape, whereas distant tissues are usedfor the “invisible” requirements of lining andsupport.

Reconstruction of the nose is an artistic en-deavor. Technology is not the answer. Derm-abraders or lasers to improve scars, or expand-ers and free flaps to provide more tissue, are, atbest, limited tools in restoring the normalnose, although they may be useful.

Technique

The forehead is multilaminar, consisting ofskin, subcutaneous tissue, frontalis muscle, anda thin areolar layer. Elevated as a full-thicknessflap18 based on a paramedian pedicle, its su-pratrochlear vessels pass deeply over the peri-osteum and the supraorbital rim and travelvertically upward in the muscle to lie in analmost subdermal position under the skin atthe hairline. It is both a myofascial and an axialflap, and it is highly vascular.

Forehead skin can be transferred as an is-land flap in one stage. However, the excessivebulk of the pedicle passing under intact glabel-lar skin jeopardizes the blood supply and dis-torts nasal contour.

Traditionally, the forehead is transferred intwo stages. At the first stage, frontalis muscleand subcutaneous tissue are excised distally,and the partially thinned flap is inset into therecipient site. At a second stage 3 weeks later,the pedicle is divided. However, excision of thefrontalis muscle and subcutaneous fat at the

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time of initial transfer removes the myocutane-ous component of its blood supply, exposes awounded, raw, bleeding subdermal surfaceprone to fibrosis and contraction, and creates aflap less able to tolerate the tension of closure.Such soft-tissue “thinning” is limited, incom-plete, and piecemeal. Fat necrosis and contourirregularities are especially common in smok-ers and patient undergoing major nasal recon-structions. Flap transfer, followed 3 weeks laterby division, is best limited to small defects thatdo not require complicated support or liningreplacement.

To overcome these problems, the techniqueof forehead flap transfer has recently beenmodified. An extra operation has been addedbetween transfer and division. This three-stagetechnique ensures a maximum blood supply, athin covering flap, unimpeded surgical expo-sure, controlled shaping, and the maximumuse of all lining options. The aesthetic resultsare improved, and the need for later revision isminimized (Figs. 1 through 5).

Stage 1

In stage 1, a full-thickness, multilaminar,nonexpanded forehead flap (skin, subcutane-ous tissue, fat, and frontalis muscle) is elevated.Subcutaneous fat and frontalis muscle are

trimmed only at the columella and a few mil-limeters along the nostril rim. An exceptionmight be the isolated alar or tip defect requir-ing minimal support or lining repair, when thesurgeon thinks that adequate distal and thenproximal thinning is possible in two stageswithout the intermediate operation. The coverdefect is replaced exactly using a template de-rived from the contralateral normal side orfrom an ideal. It is inset without tension orblanching with a single layer of fine silk su-tures. If altering and enlarging the defect willimprove the final aesthetic result, adjacent nor-mal tissue within the nasal subunit is excised,and the entire subunit is resurfaced ratherthan only the defect.

Primary support grafts are a first choice, butthey can be positioned in a delayed primaryfashion at the second-stage intermediate oper-ation, if necessary. Primary cartilage grafts areplaced if lining is present, or if it can be re-stored with vascularized intranasal lining flaps.Although not apparent, significant amounts oflining normally remain within the residualnose and the piriform aperture.

Lining flaps from intranasal donor sites (thevestibule, the middle vault, and the septum)are thin. They are vascular enough to nourishprimary cartilage grafts without the risk of ne-

FIG. 1. Preoperative views of a 14-year-old girl with an involuted nasal hemangioma involvingthe tip, columella, dorsum, and both alae. Anterior and inferior septal cartilage at the septal angleand both alar cartilages were destroyed. The columella had previously been reconstructed withlocal flaps of scar tissue.

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crosis and soft enough to conform to the shapeof a cartilage framework. Branches of the an-terior ethmoid artery supply the dorsum dor-sally, while septal branches of the superior la-bial artery supply it inferiorly. Laterally, thenasal base is supplied by branches of the angu-lar artery. So, when lining of the ala or lateralsidewall is missing, frequently vestibular skin

and mucosa remain above the upper border ofthe defect. A bipedicle flap of vestibular skin, 7to 10 mm wide, can be designed just superiorto the defect. It is based medially on the nasalseptum and laterally on the nasal floor. Thisflimsy, ribbon-like strip of tissue can bebrought down to the level of the nostril mar-gin. The secondary lining defect which persists

FIG. 2. (Above, left) Atrophic telangiectatic skin of the dorsum, tip, both alae, and part of the right sidewall is marked forexcision. (Above, right) Skin and residual hemangioma were excised. The distal septum and alar cartilages are absent. (Below, left)Through a dorsal approach, septal cartilage is harvested from the residual septum, as in a submucosal resection, and used toreplace missing septal cartilage to recreate the distal dorsum and caudal septum. This septal graft is fixed with figure-8 suturesand bilateral lateral spreader grafts. (Below, center) After reconstruction of the central dorsal and caudal support of the septumis achieved, septal cartilage anatomic tip grafts are positioned to replace the medial, middle, and lateral crura, and conchalcartilage alar battens are positioned to support the alar rims. (Below, right) A full-thickness forehead flap is transferred to resurfacethe nose. A 3.5-cm gap in the superior forehead is allowed to heal secondarily.

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above the nostril margin can be filled with anipsilateral septomucoperichondrial flap basedon the septal branches of the superior labial

artery, or by a dorsally based contralateral sep-tal flap based on the ethmoid vessels. If thenose has been totally amputated, the entire

FIG. 3. (Left) At 3 weeks, the forehead flap has healed uneventfully. The outlines of the normal ideal nasalsubunits are drawn on the surface of a bulky reconstruction. (Right) Forehead skin with 2 to 3 mm of subcutaneousfat is elevated over the entire inset except for the columella, exposing a conglomerate of subcutaneous fat, frontalis,scar, and primary cartilage grafts.

FIG. 4. (Left) After the forehead skin with a layer of subcutaneous fat has been elevated, the tip, dorsal lines, and alar creasesare marked with ink. (Center) Excess soft tissue is excised until an ideal subcutaneous framework is formed from hard and softtissue, exposing the now rigidly healed primarily cartilage grafts. (Right) Thinned to ideal nasal skin thinness, forehead skin isreturned to the recipient site and held in place by percutaneous quilting sutures and fine silk sutures at the periphery. Threeweeks later, the forehead pedicle will be divided and the residual proximal aspect inset as a small inverted V between the brows.

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lining of the anterior vault is missing. If theseptum is present, even if it has been trimmedoff flush with the piriform aperture, it cansupply a broad, bilateral expansive mucoperi-chondrium sufficient to line both nasal vesti-bules. A large septal composite flap is incisedbased on both septal branches of the superiorlabial artery and pivoted out of the nasal cavityand onto the front of the face. It is fixed withsutures or wire to the residual nasal bones. Inmost instances, such a complex lining replace-ment is performed at an initial operation, al-lowing the composite lining flap to lie perchedin space for about 4 weeks. At a second oper-ation, the cartilaginous framework and coverflaps are restored.

Fortunately, the reliable vascularity of a full-thickness forehead flap also ensures the “take”of a skin graft applied to its raw areolar surfaceat the time of flap surface, and also permits thefolding of a forehead flap to provide bothcover and lining. These lining replacementsare especially useful in the elderly or debili-tated patient, when the risk of temporary nasalobstruction caused by crusting edema or intra-nasal bleeding should be minimized, or whenprevious injury or rhinoplasty has interferedwith the septal blood supply, making the use ofintranasal lining flaps based on the superiorlabial artery branches or the anterior ethmoid

vessels unreliable. In a smaller unilateral liningdefect, the full-thickness skin graft can be su-tured to fill the deficiency and fixed to theundersurface of the forehead flap with quiltingsutures. With moderate defects, in which resid-ual normal vestibular skin remains intact abovethe defect, a bipedicle flap of remnant vestib-ular skin based medially on the septum andlaterally on the alar base is incised in the vicin-ity of the intercartilaginous line. Once ad-vanced inferiorly to the level of the proposedalar margin, the defect (which remains abovethe vestibular flap) is filled with a full-thicknessskin graft, lining the superior ala and nasalsidewall region. A primary alar rim cartilagegraft can be sutured to the raw surface of thevascularized pedicle as a first stage but cannotbe placed over the skin graft. A skin graft, rawsurface outward, will revascularize from theoverlying raw surface of the forehead flap.Contact between the skin graft and the fore-head flap is enhanced by the placement ofloosely tied, absorbable quilting sutures thatpass intranasally through the skin graft andinto the soft tissues of the overlying cover flap,and by a small sponge placed within the airwayfor 48 hours.

In the past, forehead flaps have been foldedto provide both cover and lining for the alarrim. However, it is difficult to fold a thick flap

FIG. 5. Postoperative views at 18 months. The forehead scar in the area of secondary healinghas been revised.

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into a nasal shape, and the technique pre-cluded accurate placement of primary colu-mellar tip, and alar support grafts. The noseremains thick and shapeless, and the unsup-ported soft tissues along the alar margin maycollapse, obstructing the airway. More recently,it has become apparent that just as the skingraft lining is well vascularized from the pe-riphery and becomes indistinguishable fromresidual normal lining to which it was sewn, sotoo a full-thickness forehead flap can be de-signed to replace missing skin cover. At thesame time, the lining deficit is determined andthe second template is positioned distally onthe forehead (in continuity with the cover flap)after adding 2 to 3 mm of extra length to allowfor rolling in the lining hinge. The flap, de-signed to provide both cover and lining, iselevated with all layers. The distal extension isturned in to provide the lining and is suturedto the residual mucous membrane with absorb-able sutures. The more proximal flap, whichwill be used for cover, is folded back and insetwith a single layer of fine suture, opposing thetwo raw, deep areolar surfaces of the foldedflap. The flap is not thinned; no cartilage sup-port grafts are placed.

The forehead donor site is closed in layersafter wide undermining in the subgaleal plane.Any gap that cannot be approximated is al-lowed to heal secondarily.

Stage 2

Three weeks later, the full-thickness fore-head flap, now healed to the recipient bed,is, in effect, physiologically delayed. At anintermediate operation, forehead skin with 3to 4 mm of subcutaneous fat (nasal skinthickness) is easily elevated in the unscarredsubcutaneous tissue plane over the entirenasal inset, except for the columella. Theextent of flap elevation varies depending onthe exposure required for soft-tissue excisionand additional delayed primary cartilagegrafting. In fact, forehead skin (without anyfrontalis muscle) can be completely re-elevated off the nose, maintaining no distalinset without significant risk if such exposureis needed to allow more complete subcuta-neous excision or cartilage graft replace-ment. This intermediate operation is per-formed under general anesthesia, avoidingthe distortion created by local anesthesia orthe chemical blanching of epinephrine. Theunderlying subcutaneous tissue, frontalis

muscle, and previously positioned primarycartilage grafts are exposed. The underlyingexcess soft tissue is a conglomerate of carti-lage, fat, and scar healed into a rigid, livingstricture that bleeds readily. This is excisedand carved into an ideal subunit subsurfacearchitecture. Previously positioned primarycartilage grafts can be remodeled by sculpt-ing, augmentation, or repositioning. Delayedprimary cartilage grafts can also be placedover vascularized lining, skin grafts, or theforehead skin that has been folded for lining.No significant wound contraction occurs be-tween the skin graft or the folded flap andthe overlying covering flap. The skin graftlining becomes indistinguishable from theresidual normal lining to which it is sewn. Itis thin, supple, and bleeds readily. Thefolded forehead flap is incised along the pro-posed alar margin, completely separating theproximal cover flap from the distal liningextension along the alar rim. The proximalflap is then elevated off its inset with a fewmillimeters of subcutaneous fat. Just as in theskin graft lining technique, this folded liningbecomes vascularized from the adjacent nor-mal mucous membrane and remains well vas-cularized. Both the skin graft lining tech-nique and the folded forehead flap restore athin, vascular, and supple lining to replacethat missing from a defect.

Support must be supplied during the con-struction of the soft-tissue lining and cover,because once soft-tissue collapse occurs, itbecomes fixed by constricting scar. Late sec-ondary placement of nasal support cannotfully regain what has been lost. If missing, thenormal cartilaginous framework of the dor-sum, tip, and sidewall should be replaced asit was before. In addition, a strip of cartilageshould be placed along the new nostril mar-gin, even though the alar lobule normallycontains no cartilage. This braces the alarrim and prevents contraction inward, con-tracture upward, and collapse during thehealing phase. Four different hard-tissuegrafts are required for a major nasal restora-tion—a dorsal buttress, a sidewall brace, analar margin batten, and alar cartilage tip re-placements. Primary cartilage grafts are afirst choice, but they can be positioned in adelayed primary fashion at the second-stageintermediate operation. An ideal rigid sub-surface architecture can be created from softand hard tissues before pedicle division, al-

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most regardless of lining technique. Goodsupport can be supplied in stages and is co-ordinated with the replacement of other an-atomic layers. When the intermediate opera-tion is delayed even months after foreheadflap transfer, significant subcutaneous scar-ring does not occur. The intermediate sculpt-ing operation can be completed with reliablysupple cover and lining layers, easily moldedby primary and delayed primary supportgrafts.

After creation of an ideal subsurface archi-tecture by soft-tissue excision and cartilagegrafting, the forehead skin (now of nasal skinthickness) is replaced on the underlying rigid,recontoured, three-dimensional recipient bedwith quilting sutures to close the dead spaceand reapproximate the flap to the recipientsite.

Stage 3

Three weeks later (6 weeks after transfer),the pedicle is transected. The inferior fore-head scar is reopened, and the proximal pedi-cle is unfurled and inset as a small, inverted Vat the medial brow. The distal flap is elevatedwith 3 to 4 mm of subcutaneous fat, and theproximal recipient bed inset is sculpted asneeded by further excision of excess subcuta-neous fat, frontalis muscle, and scar to definethe dorsal lines, alar creases, and sidewall junc-tion. The flap inset is completed over a stable,sculptured, rigid platform whose nasal shapeshows through the thin, conforming nasal skin.

Revisions

Because the forehead flap is thinned in itsentirety and an ideal subsurface architecture iscompleted before pedicle division, late revi-sions may not be required or will be minor inpartial-thickness defects. Once wound matura-tion is complete in 4 to 6 months, the alarcrease can be defined by direct soft-tissue exci-sion, the nostril margin can be trimmed by rimexcision, or the nasal aperture can be enlargedby local excision, local lining redistribution, ora composite skin graft if needed. The foreheadscar can be revised by excision and readvance-ment, and any area of hypertrophy associatedwith secondary healing can be discarded.

DISCUSSION

It is widely believed that plastic surgery offersthe promise that a facial feature cut off, burnedoff, necrosed away, or lost to cancer can be

returned to its condition before it was dam-aged. A healed wound can be achieved by sec-ondary intention, a skin graft, or any numberof flaps, but such a repair does not necessarilyreestablish the subtle form that distinguishes afacial feature from a facial blob. In postopera-tive clinics, the surgeon’s efforts often initiatethe unsettling patient query, “But when do westart the plastic surgery?” Or, the plastic sur-geon’s hollow apologia, “It sure looks betterthan it did before.”

Remember, most patients wish to look asthey did before injury. In reality, however, it isimpossible to recreate a normal nose. The sur-geon’s task can only be to take pieces of otherexpendable tissues and create a facsimile thatappears to be a nose, although it is not.

First, the surgeon must know the “normal.”The nasal subunits (adjacent topographic ar-eas of characteristic skin quality, border out-line, and three-dimensional contour) allow usto visualize the ideal end result. Aristotle said,“Art is the conception of the result to be pro-duced before its realization in the material.”Aesthetic appreciation of the normal and theability to visualize are prerequisites to achiev-ing such results. Certainly, the paramountquality of a plastic surgeon should be a sense ofform. Such an intellectual and visual approachprovides principles that are useful in planningthe reconstruction.

Frequently, the repair should be staged toensure a stable platform, viability of tissues,and the absence of infection. The surgeonmust conceptualize the various tissue optionsavailable to close the wound or fill the hole.The regional unit theory is important because,although we cannot control wound healing orprevent scars, we can select the color, texture,and thickness of donor tissue, control the size,shape, and directions of incisions and exci-sions, and judiciously choose and modify recip-ient and donor tissues to provide for the exactreplacement of defects to recreate and main-tain the expected contours and landmarks of asuccessful result.

As a first priority, a surgeon must use goodmaterials. Each missing layer of tissue must berestored with raw materials that most exactlymatch lost tissue in color, texture, thickness,hair distribution, bulk, and function.

The forehead is acknowledged as the pre-ferred donor site for resurfacing the nose.Small defects less than 1.5 cm can be repaired

110e PLASTIC AND RECONSTRUCTIVE SURGERY, May 2004

with local flaps. Superficial defects consistingof skin and minimal subcutaneous fat can berepaired with skin grafts. Limited alar defectscan be successfully repaired with a nasolabialflap. The forehead flap, however, remains thepremier donor site for a nasal reconstructionbecause of its size, vascularity, and excellentcolor, texture, and skin thinness.

A paramedian forehead flap allows thetransfer of forehead tissue in an efficient andreliable manner with minimal donor defor-mity and creates the most aesthetically pleas-ing reconstruction, both to the recipientnose and the donor forehead. Althoughthere has been a shift away from midlineforehead tissues toward more extensive orless satisfactory methods such as the scalpingflap, skin expansion, or the use of distant orfree flaps in nasal reconstruction, the para-median forehead flap remains the bestchoice. It allows the surgeon to restore thin,supple, and conforming cover from thickforehead tissue in two or, preferably, threestages. Reflecting through the overlying skin,an ideal rigid subcutaneous subsurface archi-tecture of hard and soft tissue is created byprimary and delayed primary cartilage andbone grafts and by subcutaneous excision.Thin, supple, and vascularized lining is mostoften recreated with intranasal lining flaps,the skin graft technique, or the modifiedfolded forehead flap method.

The three-stage forehead flap is useful forpartial- or full-thickness defects, regardless ofsize or depth. It is especially helpful in smok-ers who are at risk of forehead flap necrosis,in patients with large nasal defects that re-quire wide thinning of the covering flap, es-pecially when the flap design requires alarand columellar extension, and when intrana-sal lining flaps are precluded or unnecessaryand lining will be provided with the skin graftor modified folded flap technique.

Frederick J. Menick, M.D.5285 East Knight DriveTucson, Ariz. 85712drmenick@drmenick.com

REFERENCES

1. Gillies, H., and Millard, R. The Principles and Art of PlasticSurgery. Boston: Little, Brown, 1957.

2. Converse, J. M. Introduction to plastic surgery. In J. M.Converse (Ed.), Reconstructive Plastic Surgery, Vol. 1,2nd Ed. Philadelphia: Saunders, 1977. P. 3.

3. Antia, N. H., and Daver, B. M. Reconstructive surgeryfor nasal defects. Clin. Plast. Surg. 8: 535, 1981.

4. McDowell, F. The Source Book of Plastic Surgery. Baltimore:Williams & Wilkins, 1977.

5. Kazanjian, V. H. The repair of nasal defects with a me-dian forehead flap: Primary closure of foreheadwound. Surg. Gynecol. Oncol. 83: 37, 1947.

6. Converse, J. M. Full thickness nasal loss. In J. M. Con-verse (Ed.), Reconstructive Plastic Surgery, Vol. 2, 2nd Ed.Philadelphia: Saunders, 1977.

7. Gillies, H. D. Experiences with the tubed pedicle flaps.Surg. Gynecol. Obstet. 60: 291, 1935.

8. Millard, D. R., Jr. Hemirhinoplasty. Plast. Reconstr. Surg.40: 440, 1967.

9. Millard, D. R. Reconstructive rhinoplasty for lower halfof nose. Plast. Reconstr. Surg. 53: 133, 1974.

10. Gillies, H. A new free graft applied to reconstruction ofthe nostril. Br. J. Surg. 30: 305, 1943.

11. Converse, J. M. Composite graft from septum for nasalreconstruction. Trans. Am. Cong. Plast. Surg. 8: 281, 1956.

12. Millard, D. R., Jr. Various uses of the septum in rhino-plasty. Plast. Reconstr. Surg. 81: 112, 1988.

13. Millard, D. R. Total reconstructive rhinoplasty and amissing link. Plast. Reconstr. Surg. 37: 167, 1966.

14. Millard, D. R., Jr. Reconstructive rhinoplasty for the lowertwo-thirds of the nose. Plast. Reconstr. Surg. 57: 722, 1976.

15. McCarthy, J. G., Lorenc, Z. P., Cutting, C., and Rachesky,M. The median forehead flap: The blood supply.Plast. Reconstr. Surg. 76: 866, 1985.

16. Burget, G., and Menick, F. J. Nasal support and lining:The marriage of beauty and blood supply. Plast. Re-constr. Surg. 84: 189, 1989.

17. Burget, G. C., and Menick, F. J. Aesthetic Reconstruction ofthe Nose. St. Louis, Mo.: Mosby, 1994.

18. Menick, F. J. A ten-year experience in nasal reconstruc-tion with the three-stage forehead flap. Plast. Reconstr.Surg. 109: 1839, 2002.

19. Burget, G. E., and Menick, F. J. The subunit principle innasal reconstruction.” Plast. Reconstr. Surg. 76: 239, 1985.

20. Menick, F. J. Artistry in aesthetic surgery: Aesthetic percep-tion and the subunit principle. Clin. Plast. Surg. 14: 723,1987.

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