Paramedian Forehead Flap Nasal Reconstruction Clinical Presentation

Updated: Dec 30, 2019
  • Author: Christopher S Crowe, MD; Chief Editor: Deepak Narayan, MD, FRCS  more...
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A comprehensive history serves as the basis of a thoughtful reconstructive plan. Several exemplary questions the surgeon must ask are detailed below.

Is this a recurrent cancer, which suggests a larger and more aggressive lesion and, thus, a larger defect? In such instances, consider a preliminary Mohs excision or a staged surgical excision with a delayed primary repair. Usually in the operating room, excise the entire lesion. Remove 1-2 mm of additional tissue along all four lateral margins and the deep margin, orient them for the pathologist, and send them for permanent sections. Ensure complete excision and histologically clear margins. Once permanent sections are returned, 48 hours later, reexcise the margin if positive, with frozen section or permanent control, and proceed with the reconstruction several days later. Such an approach ensures clear margins, prevents intraoperative delay, and allows the surgeon and the patient to establish the extent of the defect, evaluate the options, and create a surgical plan at leisure.

Does the patient have an old traumatic injury or a history of a rhinoplasty or septal operation that may have destroyed septal donor materials or blood supply to the cheek, nasolabial fold, or forehead? Have skin cover flaps previously been harvested? 

Has the nose or forehead been exposed to radiation therapy? This will have profound effects on the skin envelope and vascularity of the tissue.

Is septal, ear, or rib cartilage available?


Physical Examination

Evaluation of defect and deformity

Check the extent of the defect and the deformity. Does it involve old distortion secondary to a past poorly performed rhinoplasty or previous reconstruction? Although unusual, is an open wound contaminated, and should reconstruction be delayed to allow dressing changes to clean the wound? If the wound is healed, wound contraction may distort normal tissues. Thus, restoring normal to normal and recreating the defect prior to reconstruction is vital. Expect an increased tendency for late retraction and brace the reconstruction accordingly. If nasal parts are significantly distorted by scar, releasing them and repositioning them may be appropriate, returning normal to normal, suturing lining to cover, or temporarily skin grafting any residual defects, with reconstruction occurring after the tissues are reliably repositioned.

Examine the wound. What is missing anatomically? Determine the extent of cover, lining, and support loss. Then, examine the wound aesthetically. Keep the normal in mind. Expected quality, outline, and contour must be restored. The nose can be divided into adjacent geographic areas of characteristic quality, outline, and contour—the subunits. Make a list of priorities. Is the goal a healed wound or a normal appearance? Does the patient wish the wound healed quickly and easily, or does the patient want to spend the rest of his or her life looking "normal"? Does the patient's medical history and associated illnesses limit the number of procedures, the type and length of anesthesia, or the likely morbidity?

Examine the patient's photographs. Make a written list of the anatomic and aesthetic problems and consider the options (in writing), listing the pros and cons of each. Think through the operation and each step on paper rather than on the patient's face during an operation. Design a plan and consider possible intraoperative alterations if the unexpected requires a change in plan.