Paramedian Forehead Flap Nasal Reconstruction Treatment & Management

The technique of reconstruction is determined by the site, size, and depth of the defect.

Site

The nose can be divided into nasal subunits of characteristic skin quality, outline, and contour. The surface of the nose also can be divided into zones of skin thickness. The upper two thirds of the nose (ie, dorsum, sidewall) are covered by relatively thin, smooth, nonsebaceous skin, which is mobile over the underlying nasal bones and upper lateral cartilages. Small unipedicle flaps can be transposed without difficulty in this area of slight excess. In contrast, the tip and alar subunits are covered by thicker sebaceous pitted skin that is adherent to underlying cartilage and soft tissue. No available skin is present.

Although a skin graft may settle satisfactorily into a smooth nasal sidewall, it rarely blends into the pitted thicker nasal skin. The nasal tip and alae most often should be resurfaced with adjacent tissue from the upper two thirds of the nose as a bilobed flap or from the nasolabial fold or forehead. However, smaller defects can be resurfaced, often quite satisfactorily, with full-thickness forehead skin grafts that, unlike supraclavicular, postauricular, or preauricular skin, can blend satisfactorily. The nasal rim and soft triangle areas are covered by adherent smooth skin and are good sites for small composite grafts.

Size

Nasal defects can be divided into small and large. Practically speaking, a small defect is equal to or less than 1.5 cm. If the defect is greater than 1.5 cm, not enough residual skin is present on the average nose to allow it to be redistributed by local flap transfer over the entire nose without distorting the tip or rim. For this reason, if the defect is greater than 1.5 cm, either a skin graft or a flap from the nasolabial fold or forehead must be employed.

Depth

A superficial defect is one of skin and a small amount of subcutaneous tissue. Full-thickness skin grafts do not take on exposed cartilage. Thus, skin grafts are limited to superficial defects, allowing them to cover residual subcutaneous fat with little or no cartilage exposure.

If cartilage is missing, it must be replaced. Although no cartilage exists within the normal alae, reconstruct any significant deep defect of the alae with a primary alar margin cartilage batten to maintain alar support and contour. However, local flaps usually are precluded if cartilage must be replaced. If no new skin is added to the nose and only local tissue is redistributed over the entire nasal surface, closure tension usually crushes and distorts underlying cartilage grafts. In such instances, use regional tissue from the cheek or forehead (nasolabial or forehead flap) to resurface the defect and cover required cartilage grafts.

Full-thickness skin grafts

Skin grafts are avascular and must be revascularized. During that period of temporary ischemia, melanocytes may be injured, causing hypopigmentation or hyperpigmentation. Frequently, skin grafts become shiny and atrophic. Supraclavicular skin grafts usually appear too brown, and postauricular skin grafts appear too red.

Preauricular skin grafts provide a better match for the dorsum and sidewall but do not blend well in the thicker skin of the nasal tip. Over the last several years, the forehead has been found to be an excellent skin graft donor site for nasal defects, including the tip and alae. Skin and a few millimeters of subcutaneous fat can be transferred from the forehead to superficial defects of the tip and alae. Small areas of cartilage exposure can be covered by the bridging phenomenon.

A pattern is made of the defect and transferred to the forehead in the right or left temple bay. Do not harvest a skin graft in an area that is a possible site for a potential forehead flap. Thin the forehead composite graft to the appropriate thickness and suture it in place with 5-0 Prolene interrupted quilting sutures and peripheral 6-0 silk sutures. Cover the wound with a light sponge bolus dressing, which is removed with the quilting sutures in 48 hours; remove the silk sutures in 4 days. Close the forehead with 5-0 clear subcuticular sutures and skin sutures.

Bilobed flap

The Zitelli bilobed flap ideally is suited for the deeper defect that requires local flap coverage but no cartilage reconstruction.^[15] The defect should be less than 1.5 cm in width. Design the flap as a bilobed flap with a maximum of 100-110° of rotation required for both flaps. Draw the flap entirely on the nose and not on the cheek. Undermine the flap widely in all directions under the nasalis and over the perichondrium and periosteum. Extensive scars are created, but they usually settle well. When local tissue is redistributed over the nose, the risk of tip and alar rim distortion always is present, especially when the defect lies close to these mobile structures. This may require a revision. The Zitelli bilobed flap normally is performed on an outpatient basis with intravenous sedation and is associated with significant swelling for approximately 1 week to 10 days.

One-stage nasolabial flap

A 1-stage nasolabial flap can resurface defects up to approximately 1.5-2 cm on the ala and adjacent sidewall. However, the alar base cannot be reconstructed with this technique. Use another technique if the alar inset is missing. Draw the flap on the cheek along the nasolabial fold and advance it as an extension of a subcutaneous cheek flap, which closes the donor site and carries the nasolabial skin to the nasal sidewall and ala simultaneously. Reconstruct the nasofacial sulcus with buried permanent sutures from the subcutaneous surface of the flap to the deep tissue of the alar base and piriform aperture. Lay the nasolabial flap into the nasal defect without tension. The flap is vascular, but ischemic problems can occur. Primary cartilage grafts can be placed along the alar margins for support and contour.

Two-stage nasolabial flap

The 2-stage nasolabial flap is useful for isolated alar defects and can include a few millimeters of adjacent sidewall if needed. The quantity of skin available in the nasolabial fold is limited and the arc of rotation is short, thus the flap is not useful for larger defects and does not reach the tip. The soft nasolabial flap has a significant tendency to trapdoor and is best used as a subunit flap to resurface the entire ala. This harnesses wound contraction and hides scars in joins between units.

Position a primary cartilage alar margin batten for contour, support, and airway maintenance. If the defects include a few millimeters of nasal sidewall, an alar crease reconstruction is required 4-5 months later. To create the alar crease, draw the ideal nasolabial fold and alar crease. Disregard old scars. Incise the ideal alar crease, debulking excess soft tissues above the incisions, on the nasal sidewall, and below onto the superior ala. Close underlying dead space by quilting sutures, leaving the final scar in the desired alar crease. The 2-stage nasolabial flap procedure is performed on an outpatient basis under intravenous sedation 3 weeks apart.

Forehead flap

A forehead flap transfers skin of ideal quality to resurface nonsubunit or subunit nasal defects of part or all of the nose in patients of all ages. It is best performed as a 3-stage operation. The forehead heals well, and donor site scars are not an issue. The success of the nasal reconstruction is determined by restoration of quality, outline, and contour and not by the presence or absence of scars. An ideal result is achieved by thinning the forehead flap to nasal thickness during transfer, blending the flap into the adjacent donor recipient tissues, placing primary cartilage grafts, and establishing a hard-and-soft technique that avoids suture marks.

Lining hingeover flaps

Until cover has healed to lining, hingeover flaps cannot be used. This technique delays the reconstruction. It is a useful technique for small defects, especially along the alar rim and soft triangle area. Keep the flap short (< 0.5-1 cm). The flaps are thick and stiff and risk ischemia. They can be used with primary cartilage grafts. When employed for larger defects, scar contracture along the hinge between cover and lining frequently leaves an inadequate internal airway and places these hingeover flaps at risk of necrosis if they are too long.

Prefabricated forehead flap

This technique also delays the reconstruction but minimizes intranasal manipulation. It is useful for elderly patients with medical problems when the surgeon wishes to avoid extensive intranasal manipulation with its risks of bleeding, avoid extensive airway obstruction due to crusting and swelling, and keep the operative time and anesthesia time to a minimum. It is best employed for small full-thickness defects of the tip and alae. Covering skin is designed to replace all or part of the nasal surface subunits.

A template also is made of the required missing lining. Position the forehead flap pattern on the forehead and mark the areas of lining deficiency. Incise the proposed alar margin of the flap, elevate the forehead flap full-thickness to periosteum, and line the deep surface of the frontalis muscle with a postauricular skin graft. Insert an alar margin graft in a subcutaneous pocket between the skin and underlying frontalis muscle. Resuture the forehead flap on the forehead donor site. Three days later, elevate the entire flap and transfer to the nasal recipient site. Three weeks later (6 wk after initiating reconstruction), divide the pedicle. Although some contraction can occur, this is a useful technique that can create good results.

Intranasal lining flap

Significant amounts of intranasal lining remain within the residual nose and can be used. These lining flaps are based on the angular artery, the septal branch of the superior labial artery, and the anterior ethmoid vessels.

A bipedicle flap of residual lining above the defect can be pulled down from the superior margin of the defect based on a pedicle at the alar base laterally and medially from the septal angle. This bipedicle flap lines the alar margin.

The ipsilateral septal mucosa, based on the ipsilateral septal branch of the superior artery, can be transposed to line the alar margin or sidewall.

The contralateral septal mucoperichondrial flap based dorsally on the contralateral anterior ethmoid vessels can be transposed through an incision in the septum to line the sidewall.

A composite sandwich of both septomucoperichondrial surfaces with the enclosed septal cartilage and bone can be hinged out on bilateral septal artery branches of the superior labial arteries, creating a central support platform and providing lining to the dorsum, tip, and ala. These intranasal lining flaps are vascular, thin, and supple and allow the placement of primary cartilage grafts.

Skin grafts for lining

Skin grafts are thin and supple but avascular. However, they take on the raw surface of a forehead flap, thus can be sutured raw side out into a nasal defect. The full-thickness forehead flap is sutured in place over the underlying graft. Once the graft is revascularized 3 weeks later, the forehead flap can be elevated off the graft, which now is incorporated into the adjacent normal lining. Excise overlying excess soft tissue and position delayed primary cartilage grafts to support and contour the repair. Skin grafts also can be employed simultaneously with the intranasal bipedicle flap.

Free flaps

Free flaps are useful for large defects of the nose, lips, and cheeks when intranasal lining flaps are unavailable. Such repairs are quite complex. Free flaps should be used for lining and then should be covered with a forehead flap in stages. Free flaps are especially useful when a composite defect of multiple units exists (eg, a combined nose, lip, and cheek defect).

Support grafts

Cartilage grafts supply support and contour to a nasal reconstruction and brace the reconstruction against gravity and the forces of myofibroblast contraction. They should be positioned before wound healing has occurred and prior to covering flap pedicle division. They can be placed primarily at the time of forehead flap transfer or they can be placed in a delayed primary fashion during an intermediate operation to thin the forehead flap prior to pedicle division.

Forehead flap

First stage

First, ensure a stable platform. If the patient has a significant defect of the lip or cheek, it is useful to reconstruct the lip and cheek initially and delay the nasal reconstruction until the platform upon which the nose will lie is stable. This prevents an otherwise satisfactory nasal reconstruction from being pulled down laterally in the early postoperative period.

Check the surface defect and outline the nasal subunits with ink. Consider altering the wounds in size, size, and depth if that improves the result. Consider using the subunit principle: If the defect occupies more than 50% percent of the subunit, it may be useful to discard adjacent normal tissue and enlarge the defect so that the entire subunit is resurfaced. This positions scars in the joins between subunits and helps harness centripetal contraction, augmenting the desired convex subunit shape of the tip and ala.

A forehead flap normally is performed under general anesthesia with an overnight stay. Local anesthesia is not injected directly into the transferred flap to prevent blanching and intraoperative evaluation of the blood supply.

Once the nasal subunits are drawn with ink and the wound altered as necessary, design a template of the missing skin defect with the foil from a suture pack. Position required lining and primary cartilage grafts. Position the forehead flap template over the ipsilateral supratrochlear vessels if the defect is unilateral or over the right or left supratrochlear vessels if the defect is midline or covers the entire nose. Position the template at the hairline, directly vertically above the supratrochlear pedicle, which need not be more than 1.5 cm in width. The site can be determined with a Doppler and lies a few millimeters lateral to the corrugator crease.

Increase flap length by placing the columella extension of the forehead flap into the hair-bearing scalp. The pivot point can be lowered inferiorly and the arc of rotation increased by carrying the pedicle through the brow and toward the medial canthus, using a sponge as a measuring tape to ensure the flap reaches the defect without tension.

Elevate the forehead flap from distally to proximally. It is elevated with all layers of skin, subcutaneous tissue, and frontalis tissue, exposing periosteum. Use blunt scissor dissection in the area of the supraorbital rim to separate muscle fibers while preserving blood vessels. Release the flap until it swings to the defect without tension.

Close the donor site by elevating the residual forehead over the periosteum. Perform wide dissection under the frontalis muscle into both temples. The forehead is drawn together and fixed with several tacking sutures of 4-0 Prolene, which are removed in approximately 10 days.

Close the rest of the wound with 4-0 clear nylon frontalis sutures, 5-0 clear subcuticular skin sutures, and 6-0 silk sutures for the skin. Cover any gap that remains with petroleum jelly gauze and allow it to heal secondarily, removing the petroleum jelly gauze in approximately 10 days.

Thin the forehead flap only at the columella inset and 1-2 mm along the alar rim. Close the flap with one layer of fine 6-0 silk sutures. If any tension or blanching is present, suture the flap only at the columellar inset and along the rim. Placing other peripheral sutures is not necessary. Avoid blanching. The soft tissues of the flap cover primary cartilage grafts adequately, and the forehead flap heals spontaneously to the nasal recipient site over 2-3 weeks without problems.

Patients undergoing the first-stage forehead flap should stay overnight in the hospital. The patient can shower the next day. Remove skin sutures at 4 days and the Prolene tacking sutures at 10 days.

Second stage

At the second stage (3 wk later) under general anesthesia (no local anesthesia is injected to avoid tissue distortion or blanching), mark the subunits on the surface skin.

Incise the forehead flap along its borders and elevate it with 2-3 mm of fat in all areas except for the columella. This creates a bipedicle flap that extends from the supratrochlear vessels at the brow to the columellar inset. This is a very vascular, supple, and thin flap.

Expose the underlying soft tissues, which are composed of subcutaneous fat, frontalis muscle, and scar. Excise underlying soft tissues and sculpt them to create a soft tissue nasal shape. This usually reexposes the initial primary cartilage graft, which then can be repositioned if shifted, sculpted if thick, or augmented if additional grafts are appropriate.

Replace the forehead flap on the recipient bed with quilting sutures for 48 hours and peripheral silk sutures for 4 days. The pedicle is maintained intact.

Third stage

At the third stage, 3 weeks later (6 wk after the initial reconstruction), divide the pedicle. Unroll the proximal flap and debulk and/or inset it as a small, inverted V in the inferior aspect of the forehead wound at the medial brow.

Unroll and elevate the distal forehead flap with 2-3 mm of subcutaneous fat. Sculpt the underlying soft tissues of fat and frontalis muscle in the proximal aspect of the defect to create a nasal shape.

Trim excessive skin and re-inset the forehead flap with quilting sutures and peripheral silk sutures.

Two-stage nasolabial flap

The 2-stage nasolabial flap is performed on an outpatient basis under intravenous sedation or general anesthesia. Outline the nasal subunits. Using the contralateral normal ala as an ideal, create a template of the contralateral normal alar subunit. Position this template along the nasolabial fold at the commissure level. Check the arc of rotation to make sure that the flap reaches the defect. Mark a distal dog-ear excision along the nasolabial fold.

Proximally, the skin pedicle narrows and does not extend onto the nose. The 2-stage nasolabial flap is designed as a subcutaneous axial flap and not as a cutaneous flap, thus a proximal skin pedicle, if desired, is not necessary. Keeping scars off the nose and placing the final scar exactly within the nasolabial crease is important.

Excise adjacent normal tissue within the residual ala and resurface the entire alar subunit. Position a primary cartilage graft to create an alar margin batten. The contralateral concha, because of its intrinsic shape, makes an ideal alar margin batten. The template also can be used as a pattern to design the rim shape of the cartilage batten.

Fix the primary cartilage graft medially and laterally in subcutaneous pockets at the nasal tip and alar base with percutaneous 5-0 Prolene sutures. Fix it with sutures to the underlining lining.

Incise the nasolabial flap distally and elevate it with 1-2 mm of subcutaneous fat over the planned distal one half of the inset. The dissection then goes deeper toward the facial musculature. As the proximal flap is approached, snip fibrous bands to allow a tension-free rotation of the flap to the nasal-alar defect.

Close the donor site in two layers with fine subcuticular nylon sutures and suture the skin so the final scar lies exactly within the nasolabial fold.

Inset the flap into the nose with one layer of 6-0 silk sutures. It does not need to be and should not be inset completely. Avoid blanching. The raw surface of the pedicle can be left open, or a temporary, thin split-thickness skin graft can be employed as a wound dressing.

Incise the pedicle 3 weeks later. Open the superior aspect of the nasolabial fold scar and unroll, debulk, trim, and inset the proximal pedicle to leave a final scar exactly in the nasolabial fold.

Elevate the distal pedicle with 1-2 mm of subcutaneous fat over approximately one half of its inset. Sculpt the underlying subcutaneous tissue and scar to recreate the alar crease and normal alar contour. Trim the flap and wrap it around the alar base, completing the inset.

Revisions

A thick alar rim can be debulked through an alar margin incision 4-6 months later. The alar rim shape can be sculpted by primary excision. The alar crease can be deepened by direct incision at its ideal position, sculpting subcutaneous tissue above and below to recreate a flat sidewall and appropriate alar contour. If necessary, the forehead scar can be excised and the forehead readvanced once it has healed spontaneously by secondary intention and autoexpanded.

The most common indication for nasal reconstruction is destruction of the nose due to skin cancer. Skin cancer recurs if the tumor is not completely destroyed or excised. Complete tumor excision is ensured best by a complete pathologic examination of all lateral and deep margins and can be accomplished with frozen sections, permanent sections, or by Mohs histographic excision.

Zitelli, a Mohs surgeon, has analyzed comparative costs of treatment by destruction (electrodesiccation and curettage), simple office excision, ambulatory surgical facility excision, radiation therapy, and Mohs micrographic surgery for small skin cancers of 1-2 cm. In each case, the cost of biopsy, standard pathology, anesthesia, facility fees, and laboratory costs were considered. Wounds were allowed to heal by secondary intention or closed by simple suture, depending on the technique employed. The cost for destruction of a 1- to 2-cm skin cancer was $653 with a 7.7% recurrence rate. Similar fees for office excisions were $1239 with a 10% recurrence rate. Ambulatory surgical facility excisions cost $2112 with a 10% recurrence rate. Radiation therapy was $2573 with a 9% recurrence rate, and Mohs surgery cost $1252 with a 1% recurrence rate.

Outcomes of tumor control must be differentiated from those of a successful reconstruction. One of the most important functions of the face is to look normal. The face tells the world who an individual is and influences what an individual can become. Patients wish to look normal, not horrible, peculiar, or different. A nose functions properly when it permits easy nasal breathing and appears normal. Before the birth of Christ, Sushruta exclaimed in the Hindu Book of Revelation, "The love of life is next to the love of our own faces in the mutilated cry for help." In modern times, Freud noted, "A terrible sensation took possession of the patient. No way out. No escape. There remained only one activity—to look constantly in his pocket mirror, attempting to establish the degree of his mutilation."

Interestingly, Harris, a British plastic surgeon, evaluated a series of cosmetic and reconstructive patients and noted that the psychogenesis of symptoms in patients who are treated for gross disfigurements, whether from congenital malformation, disease, or injury, are the same as that in patients treated for aesthetic surgery.^[16]

Few patients are happy with an artificial prosthesis. Patients who undergo facial reconstruction, just like patients who undergo breast reconstruction, have a constant fear of prosthetic displacement and the discovery of their deformity. A prosthesis is never integrated into the person's self-image of his or her body. Although a temporary prosthesis may be employed for a period between tumor excision and the beginning of a complex reconstruction, unless indicated by poor health or a high risk of recurrence requiring continued visual observation, most patients prefer that their nose be rebuilt with their own tissues.

Medicare reimburses $2000 for a full or partial nasal prosthesis in Arizona. They deteriorate with time and require replacement every 1-2 years, although Medicare replaces them only every 4-5 years. Required adhesives cost approximately $100 per year. Osteointegrated implants fixed to the maxilla or glabella also can be employed using 2-3 titanium implants at $1000-1400 an implant. The retention clips and bar required to fix the prosthesis to the implants are approximately $1400 more.

Importantly, prostheticians are recommending removal of the residual normal septum even if not involved with malignancy to simplify prosthetic retention. However, loss of vascularized septal lining significantly complicates and may preclude later surgical reconstruction.

Radiation therapy is used to treat skin cancer in the hopes of avoiding the deformity associated with excision and the need for reconstruction. Radiation therapy has an overall cure rate of 92% in the treatment of skin malignancies, but the technique requires specialized personnel and equipment and normally is reserved for older individuals who are not surgical candidates. It may be recommended for larger lesions to preserve tissue but the resultant scar tends to worsen over time and even may ulcerate. A small risk also exists of radiation osteitis and chondritis or late radiation-induced cancer. Radiation also complicates a future reconstruction. Using an electron beam linear accelerator, 20-30 fractions normally are given to larger skin cancers over 4-6 weeks at approximately $125 per treatment. The total cost is approximately $4000-6000. Although it obtains satisfactory cure rates, radiation therapy generally has not been found to provide as good of a cosmetic result as surgical modalities.

Plastic surgical repair of a defect following surgical excision can create the appearance of normal in 1-3 stages, creating a result that does not deteriorate over time. The total Medicare reimbursement for the surgeon, anesthesiologist, and all hospital charges, including overnight stay if needed, for a 1-stage reconstruction with a nasolabial flap and ear cartilage graft is approximately $2280. For a 2-stage reconstruction with nasolabial flap and ear cartilage graft, this cost is $3260. A 2-stage forehead flap and cartilage graft reimbursement is $6670. A 3-stage forehead flap and cartilage graft reimbursement is $7000, and with multiple septal mucosal lining flaps, the reimbursement is $11,500.

Complications after nasal reconstruction are relatively infrequent. Usually, they are associated with a failure to identify preexisting risk factors such as smoking or a prior history of facial surgery or injury that interferes with tissue blood supply, excessive thinning of flaps or closure tension at initial stages, or a failure to stage procedures.

These are often errors of judgment. Flap necrosis can be avoided by careful design, maintaining axial vasculature, and using staged reconstructions. Cartilage graft loss and infection are unusual and present as acute purulent infection or as slowly progressive chondritis with overlying inflammation and prolonged drainage. Usually, they follow loss of lining or covering skin. Prophylactic antibiotics are appropriate. If a nasolabial or forehead flap is found to be necrotic at its tip, rather than waiting for spontaneous separation of the necrotic wound, aggressive surgical excision prior to development of infection is vital with immediate resurfacing with healthy tissue. Although minor loss of the tip of a forehead flap may seem insignificant, it may lead to exposure of the underlying cartilage framework, lingering infection, and shrinking of the overlying covering flap, which rarely can be expanded secondarily.

Barton has examined the reconstruction of difficult basal cell carcinomas.^[17] Lesions in critical anatomic areas (eg, eye, nose, ear), greater than 2 cm, recurrent, or with indistinguishable clinical margins (morphea) have a greater than 50% recurrence rate after standard electrodesiccation and curettage excision or radiation therapy. He analyzed a patient population of 281 patients with 359 basal cell carcinomas who underwent a delayed primary reconstruction by primary closure, flaps, or grafts after Mohs histographic excision. Within a 64-month follow-up period, only a 1.4% recurrence rate and a 1.9% infection rate occurred, with less than one third causing failure of reconstruction.

Burget also has reviewed his 5-year experience with unipedicle and contralateral septal flaps for full-thickness heminasal losses of the tip, ala, and sidewall. Of patients, 40% also had associated cheek or lip defects. All patients had high aesthetic standards and wished to look normal. Reconstructions were completed in 2-6 procedures, using cheek flaps, forehead flaps, septal and ear cartilage grafts, and contralateral superiorly based septal mucoperichondrial flaps and inferiorly based ipsilateral septal flaps, with an average follow-up period of more than a year. All patients were satisfied with the aesthetic result. No losses of flap, soft tissue, or cartilage grafts occurred. Any nasal fistula that followed the use of septal flaps was asymptomatic.