Paramedian Forehead Flap Nasal Reconstruction Treatment & Management

Updated: Dec 30, 2019
  • Author: Christopher S Crowe, MD; Chief Editor: Deepak Narayan, MD, FRCS  more...
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Treatment

Approach Considerations

Anatomic Significance

The nose, one of the major aesthetic units of the face seen in primary gaze, is composed of many smaller parts, which are termed regional or topographic subunits. Each regional unit is a topographic area with characteristic skin quality, outline, and contour. Along the surface of the nose are several ridges and valleys that separate it into slightly convex or concave surfaces (eg, the tip, dorsum, paired sidewalls, alar lobules, soft triangles).

Reconstruction must be accurate because the opposite, or contralateral, side of each subunit (eg, the ala, hemi-tip) is available for visual comparison. If part or all of the nose is missing, the basic elements that make a nose must be provided, deficiencies minimized, and substantial abnormality avoided so that the repair in itself does not draw attention. To achieve the appearance of normal, the goal must be to restore the expected regional skin quality, subunit outline, and 3-dimensional contour to their preinjury state.

An intimate knowledge of what must be restored, as well as how it will be reconstructed and for what reason, is required to provide a satisfactory outcome. A thoughtful consideration of the patient, surgeon, wound, and donor material is helpful in identifying the most appropriate option.

Patient

The patient will often be anxious regarding a proposed resection or a present defect created by trauma or Mohs excision. The individual must be provided with information about the anatomic loss and the options for secondary healing, primary healing, the use of a skin graft or flap, and the associated stages, morbidity, and likely end result. A frank and honest discussion will create a cooperative partner for the reconstructive surgeon.

If basic information is provided to explain the surgical problem and reconstructive plan, disruption of the patient's life and the psychological impact of surgery can be lessened significantly. The patient should never be surprised by a dangling forehead flap pedicle, the need for hospitalization, or the requirement for multiple stages. Most patients wish to be restored to their pre-injury/surgery appearance. Although some may wish the wound to simply be healed or the defect refilled with missing tissue, most are grateful to the surgeon who provides information and options and is committed to achieving an end result that fits the patient's goals.

Other important approach considerations include age; sex; site, size, shape, depth, and condition of the wound; morbidity; donor site; support framework; the surgeon's preferences and abilities; and previous treatment, trauma, or surgery.

Age

In elderly patients, associated illness and health risks may require a quick, less complicated reconstruction. However, the paramedian forehead flap has proven to be a safe and effective reconstructive option in patients older than 75 years. [18] In children, the degree of social isolation due to deformity must be balanced against the risk that a complicated nasal reconstruction theoretically may interfere with facial growth. During childhood (and as an adult), later revisions often are required, and the initial surgical plan must preserve valuable donor materials for the future. In these circumstances, a simple approach may prove to be the superior one pending a definitive reconstruction. [19]

Sex

In general, the differences between men and women are overemphasized; both will appreciate a normal-appearing nose. If the correct contour is restored, minor imperfections in color or texture more easily are covered by makeup in women. The thicker skin of the male nose, especially in the tip, may make skin grafts and scars more obvious.

Previous treatment, trauma, or surgery

Previous cancer treatment, including radiation, old trauma, or a rhinoplasty, adds scars to the nose and may interfere with blood supply, impair wound healing, or preclude a specific flap option. Evaluate the availability of each cover and lining option and of rib and cartilage support materials. Patients with skin cancer may have a second primary tumor or more extensive disease due to recurrence.

Morbidity

Consider operative time, anesthetic requirements for monitored or general anesthesia, outpatient or inpatient needs, the number of stages and the time to completion of the reconstruction, pain, risk of intranasal obstruction, bleeding and crusting, the degree of social isolation required during the healing period, and the cost of reconstruction.

Wound Characteristics

The site, size, shape, depth, and wound condition of each defect influence the reconstructive approach.

Site

As mentioned previously, the nose is a central facial feature. Central facial units (in contrast to the forehead or cheek) are areas of visual attention. In frontal view, the contralateral normal tip, ala, or nostril allows comparison. Thus, symmetry is vital. The skin covering the nose imparts a characteristic skin quality, and its 3-dimensional form establishes an outline for landmarks and a natural nasal contour. The face may be divided into regional units, that is, topographic areas of characteristic skin quality, unit outline, and 3-dimensional contour that create the appearance of normal. Smaller regions within each regional unit have been termed subunits. The delicate 3-dimensional contour establishes the normalcy of the nose. The nasal subunits consist of the dorsum, tip, columella, and paired sidewalls, alae, and soft triangles. 

The nasal surface of an adult also can be divided into areas of thin smooth skin and thick pitted skin. These zones of skin thickness do not correspond to the subunits of surface contour. The skin of the dorsum and sidewall units is thin, smooth, pliable, and mobile. The skin of the columella, alar margins, and soft triangles is also thin and pliable, although relatively fixed to the underlying tissues. Zones of thick skin (the tip, alae) are stiff and pitted with sebaceous glands. Small superficial defects in the zone of thick sebaceous skin present special problems for the patient who insists on an aesthetic result. Because skin grafts are sometimes shiny and unpredictably pigmented, they frequently appear as a patch if placed within the thick-skinned zones of the tip or ala. Local flaps are preferred in these instances.

Frequently, a nasal defect extends into the adjacent lip and cheek, creating a large, 3-dimensional wound that consists of several facial units. This significantly increases the difficulty of reconstruction. If the defect is reconstructed as a single wound, residual scars are more obvious because they do not lie within the boundaries of adjacent units. If a large single flap spans the gap between the nose, cheek, and lip, the skin defect is shortchanged. Far more skin is required to restore the complex bas-relief of the alar base, lip, and cheek than a single 2-dimensional flap provides.

The biologic force of wound contracture also pulls the tissue of a large, single flap centrally. This pincushion effect creates a single 3-dimensional bulge rather than the subtle contour of the normal nose. Large 3-dimensional defects spanning multiple facial units normally should not be resurfaced as one large flap if an aesthetic result is desired. They should be broken up into regional areas and each resurfaced individually and sometimes during separate stages. This approach reestablishes the basic segmental nature of the face and supplies enough surface skin to recreate a normal facial form.

It is critical to realize that the ala sits on a platform of lip and cheek at a precise facial location and angle. If the lip, cheek, and ala require reconstruction, only the lip and cheek should be built initially. If the lip-cheek platform is fabricated at the same time as the nose, subsequent wound settling distorts the subsequent position of the nasal reconstruction. Tension from healing shifts the lip and cheek platform, dragging the reconstructed nose inferiorly and laterally. The nose should therefore be rebuilt at a second stage when its platform is stable. Most often, when multiple facial units have been destroyed, each facial unit should be reconstructed with a separate flap, often in stages.

Size and shape

Frequently, the wound is distorted and does not reflect true tissue loss. The distortion may result from edema, local anesthesia, gravity, and resting skin tension. It may be diminished by wound contraction due to secondary healing. Landmarks may be distorted by scarring, previous surgery, or abnormal growth. A preliminary operation may be needed to release scar tissue and reposition structures to their native position.

In all circumstances, missing tissue must be replaced in the exact amount necessary to restore a normal appearance. Preoperative photographs, measurements, or a moulage may be helpful. More importantly, the contralateral unit or subunit, or the ideal, should be used, whenever possible, as a guide to creating a template that exactly replaces the missing surface skin in size and outline. If too much soft tissue is resupplied, adjacent landmarks are pushed outward. In addition, an overly large flap, which contracts postoperatively, obscures the detail created by an underlying support framework. If too little soft tissue is supplied, then it is too tight, pulling and distorting adjacent landmarks inward and causing underlying cartilage grafts to collapse.

Depth

The nose is made of covering skin, a middle supporting framework, and an internal lining. A superficial defect with residual well-vascularized subcutaneous tissue accepts a skin graft. However, cartilage or bone without perichondrium or periosteum does not.

The nasal bones and cartilages support the nose, impart a nasal shape to the soft tissues of lining and cover, and brace any reconstruction against the force of the contracting myofibroblast, which tends to pull the tip and alae superiorly or to constrict the nasal airway. To restore nasal contour, flimsy soft tissue must be positioned, made rigid, and shaped. If missing, support must be reassembled. If absent, the normal bony and cartilaginous framework of the dorsum, tip, columella, and sidewall must be restored. Cartilage also should be placed along the new nostril margin, even though the alar lobule normally contains little cartilage. Such a primary cartilage graft supports the alar rim and prevents contraction upward and constriction inward, while recreating a bulging convex alar contour.

In the past, bony and cartilaginous grafts have been placed secondarily, months after the initial reconstruction. Unfortunately, once the soft tissues have healed in place, the soft tissues are scarred and rarely can be reexpanded and reshaped by cartilage grafts positioned at a later date. If cartilage is missing and must be replaced, a regional flap from the forehead or cheek is required for cover. Local flaps do not add skin to the nose; they simply rearrange residual skin that remains about the defect and redistribute it over the entire nasal surface. Under the tension of local skin rearrangement, a local flap may collapse the delicate reconstructive cartilage framework, even if the defect is small.

In summary, nasal defects may be classified as small and superficial or large and deep. A small superficial lesion is less than 1.5 cm, with an intact underlying cartilage framework. If a vascularized bed of perichondrium or periosteum is present, a skin graft may be placed or the defect resurfaced with a local nasal flap. If the defect is greater than 1.5 cm, not enough residual adjacent skin is present over the nose to spread over the entire nasal surface without distorting the tip or alar rims. A large deep defect is greater than 1. 5 cm or requires the replacement of a cartilage framework or lining. A regional flap from the forehead or cheek is employed for nasal resurfacing.

Most often, a failure in reconstruction results from a shortage of lining, even though it is normally hidden from view. If the defect is full thickness, the lining chosen for replacement must be vascular enough to support any primary cartilage grafts, supple enough to conform to the proper shape, and thin enough to avoid congesting the airways or distorting the external shape of the nose.

Wound condition

Infection or tissue ischemia may preclude immediate reconstruction until the wound is stable and viability is ensured. A cartilage graft placed under or over poorly vascularized cover or lining frequently suppurates or slowly reabsorbs. Previous radiation therapy may be associated with poor vascularity and healing and may be accompanied by other primary skin cancers, soft tissue distortion due to fibrosis, or previous repair. Soft tissue foreign bodies such as injectable or implantable silicone increase the risk of infection, fibrosis, and subsequent extrusion.

Donor site

A nasal defect requires the replacement of variable amounts of cover, support, and lining. Each is chosen by evaluating the quality of material needed, the available excess that can be shared from the donor site to the recipient site, and the ability of the donor materials to be transferred, either to a vascular bed that supports grafting or by a pedicle with an adequate arc of rotation.

Covering skin must be replaced with skin that matches the face in color and texture. Only skin obtained from a donor site above the clavicle matches the face. Equally important is the effect of tissue transfer on wound healing. Skin grafts can be transferred simply and with minimal morbidity. They are thin and avascular but require a vascular bed and immobilization to ensure take. Unfortunately, their final color and texture is unpredictable due to the initial period of ischemia. A shiny, atrophic, irregularly pigmented skin graft placed within adjacent thick nasal tip skin appears as a highly visible patch.

In contrast, skin transferred as a flap retains the skin quality of the donor area due to its intrinsic vascularity. However, skin flaps frequently "trapdoor" due to wound contraction. [20] The fibroblasts that lie under the flap in the recipient bed may elevate the transferred tissue above the level of adjacent skin. This pincushioning effect may be employed to advantage when a flap is used to reconstruct an entire convex nasal subunit such as the dorsum or tip, where the trapdoor effect enhances a convex contour. It is a disadvantage if resurfacing the flat sidewall or only part of a convex subunit.

Skin grafts generally lie flat and are satisfactory when a defect is superficial and involves a planar or concave surface. The color, texture, and thickness of the skin graft, not its shape, are important. Skin grafts best are used to replace areas of normally thin and tight skin such as a nasal sidewall but are a poor choice to replace normally thick, sebaceous tip skin. When skin color, texture, and thickness are important, only a flap can transfer skin reliably. Flaps contract centrifugally into convex geometric forms. Over time, any flap is drawn into a hemisphere. For this reason, discarding adjacent normal skin within a subunit and resurfacing the entire unit, not only part of it, often is advantageous. When used to replace an entire subunit, the contractile nature of a flap can contribute to contour re-creation.

Although scars are believed to have a great impact on the results of nasal reconstruction, most nasal wounds heal with minimal scarring. Contour is the most important quality describing the nose, while scarring tends to be less significant. Scars interfere with the success of a nasal reconstruction only when they distort the expected skin quality, outline, or contour.

All wounds heal with scar, and all scars are depressed or elevated, thus reflect a line of light or cast a shadow. Scars are best positioned in the boundaries between subunits, blending within the hidden valleys and depressions of the nasal surface. A shiny scar, visible across the smooth convex surface of the nasal tip, is much more visible than one hidden along the edge of the soft triangle and dome-alar junction. Scars positioned within subunit joins also can contribute to the restoration of unit outline. Because skin flaps contract due to underlying myofibroblasts in the recipient bed during healing, positioning of the flap so that it resurfaces an entire convex unit, with its borders lying within the joins of adjacent units, harnesses the effect of wound healing and, with primary cartilage grafts, helps contribute to the restoration of a convex nasal subunit.

Previously healed nasal defects are sometimes distorted by constricting scar. Remaining nasal parts must be replaced to their normal positions before an accurate assessment of what is missing can be made. In addition, one must resist the impulse to fit the flap to the defect created or recreated on the operating room table. Such defects are distorted by edema and local anesthetic injection and do not represent the accurate size or shape of what is missing. Instead, the contralateral normal nasal subunit should be used as a guide to create a mirror image of the defect and a template for an ideally shaped flap.

The replacement of lost tissue as regional units allows the surgeon to disguise the scars of injury and repair by hiding them in the expected shadows and reflections of abutting subunits. When reestablishing soft tissue contour, old scars often should be disregarded. A successful result is determined by the reestablishment of the correct nasal shape, not by the presence or number of scars. Frequently, new incisions should be made within the expected joins of newly created units, with underlying subcutaneous scar and soft tissues directly excised to create a subsurface soft tissue contour that restores the 3-dimensional shape of the nose. If the contour is correct, the scar is not apparent.

Support framework

Materials for a support framework must be chosen. Primary cartilage grafts support against gravity and internal forces. They create nasal tip shape, projection, and length. They form a subcutaneous sheet of hard tissue that braces remaining or reconstructed cover and lining against centrifugal trapdoor contraction. A nasal framework must extend from the nasal bones superiorly down to the alar margin inferiorly and from the tip anteriorly to the maxilla posteriorly. Each graft is carved to create in miniature a subsurface unit of the nose. This framework of grafts imparts a normal surface contour when draped with skin. These donor materials, primarily cartilage, may be taken from the septum, floor of the concha, or rib (especially the eighth rib as an osteocartilaginous dorsal graft). The material itself is not of great importance. Its subtle and exact shape creates the ideal normal, whether it is taken from the cranium, ilium, septum, concha, or rib.

An alar cartilage replica that is 4-mm wide is sutured to the stump of the medial crura or to a columellar strut, and its projecting ends are scored and bent laterally where they are sutured to the reconstructed lining of the vestibule. A brace of septal bone and cartilage or slices of rib cartilage, cut into a trapezoidal shape, can be positioned on the sidewall to replace missing upper lateral cartilage and nasal bones. This graft supports the middle vault against collapse and provides a platform for eyeglasses. It also braces the sidewall against upward contraction. A batten graft of conchal or septal cartilage 4-6 mm wide can be fastened along the edge of the lining sleeve from the alar base to the nostril apex. It fixes the new alar rim in position while recreating the normal bulging contour of the ala. This is placed, even though the ala normally does not contain cartilage, to support and brace the repair.

An architectural buttress of layered septal cartilage or rib is installed along the dorsum to prevent upward contraction or postoperative shortening of the nose. It gives shape to the nasal bridge and recreates the normal dorsal subunit shape. Previous trauma or rhinoplasty may limit the availability of these donor sites and must be considered in the operative plan.

Although normally hidden from view, a shortage of lining often contributes to the failure of a nasal reconstruction. Donor materials chosen for lining replacement must be vascular enough to support primary cartilage grafts and supple enough to conform to the proper shape of the overlying primary cartilage grafts. They must also be thin enough to avoid stuffing the airway or bulging outward, distorting the external shape.

Surgeon

The surgeon must evaluate the patient, the wound, and the available donor material. Determining the goal of reconstruction (eg, a healed or filled wound, a restoration, or a normal appearance) is of considerable importance. Priorities may vary from patient to patient, and decisions must be made regarding acceptable risks, time to completion, and the required effort of the patient and surgeon.

Traditionally the emphasis has been on technique—which flap or graft—and how the wound can be healed or the tissues replaced. Because tissues must survive, the vascularity of the recipient bed or the blood supply to the flap is important. Too frequently, too much attention is given to the preliminary operation, with limited conceptualization of an entire staged reconstructive plan.

Several planning errors must be avoided. Often, extra tissue is transferred "just to be safe" or is designed smaller to conserve the donor site. A single defect may be filled with a single flap, even though it covers multiple adjacent facial regions. Support grafts may be placed secondarily, with the clinician hoping to wait until wound healing is completed and the soft tissues have matured. Too often, the final result is not aesthetic.

The modern challenges are to hide scars, create symmetry, match the contralateral facial feature, reestablish contour, transfer ideal donor materials, and limit functional abnormalities. The secret of success is to visualize an ideal result prior to initiating treatment and then to create a thoughtful plan of how to achieve it.

If the normal face is described by regional units of characteristic skin quality, outline, and contour, then these units must be replaced. The surgeon can reestablish skin quality by choosing ideal donor materials and understanding the effects of tissue transfer and wound healing on the final appearance.

A retrospective study by Sanniec et al looked at 420 patients in whom forehead flap nasal reconstruction was performed and determined that pedicle division took place at 32 days on average. About 50% of the patients underwent cartilage grafts, and lining reconstruction was performed in half of the patients. The nasal ala and tip were the most frequent defect locations. Sixteen complications occurred, including one postoperative death. [21]

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Surgical Therapy

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

Site

As discussed, 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 well 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 void 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 graft to maintain alar support and contour. 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. [22] 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 bolster 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. [23] 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 graft 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. [24]

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. [2] 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.

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Intraoperative Details

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 sit is stable. This prevents an otherwise satisfactory nasal reconstruction from being pulled inferolaterally 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 boundaries between subunits and helps to 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. Some authors suggest careful inclusion of superficial veins beneath the dermis, as the venae comitantes of the supratrochlear artery are often small caliber. [25] Use blunt scissors to carry the dissection down to the supraorbital rim, separating 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, deep to the frontalis. Perform wide dissection under the frontalis muscle into both temples. The forehead is drawn together and the frontalis is closed with deep Vicryl sutures; the is skin closed with 6-0 Prolene sutures, which are removed in 7-10 days. 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 Prolene 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. The exposed raw undersurface of the flap pedicle can be dressed with a skin graft or dressing, such as Biobrane or Mepilex.

Patients undergoing the first-stage forehead flap procedure should stay overnight in the hospital. The patient can shower the next day. Remove skin sutures at 4-5 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 Prolene sutures for 4-5 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. Care should be taken to carefully reconstruct the normal brow contour, as a malpositioned pedicle base can leave the patient with a conspicuous aesthetic deformity.

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 Prolene sutures.

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.

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Complications

Several issues have the potential to complicate nasal reconstruction.

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.

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 disfigured, peculiar, or different. A nose functions properly when it permits easy nasal breathing and appears normal. 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. [26]

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.

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. 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 normality in 1-3 stages, creating a result that does not deteriorate over time.

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 the initial stages, or a failure to stage procedures. These are often errors of judgment. Flap necrosis can be avoided by careful design, maintenance of axial vasculature, and staging of 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.

In a retrospective study of 2175 patients in whom paramedian forehead flap reconstruction was performed for skin cancer–related facial defects, Chen et al found postoperative infection to be the most frequent complication, occurring in 2.9% of subjects. The report also found that cases with postoperative bleeding, a neurologic disorder, or alcohol use were marked by increased risk of an immediate return to the emergency department or readmission within 48 hours postsurgery. [27]

Barton has examined the reconstruction of difficult basal cell carcinomas. [28] 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.

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