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A 10-Year Experience in Nasal Reconstructionwith the Three-Stage Forehead FlapFrederick J. Menick, M.D.Tucson, Ariz.

Because of its ideal color and texture, forehead skin isacknowledged as the best donor site with which to resurfacethe nose. However, all forehead flaps, regardless of theirvascular pedicles, are thicker than normal nasal skin. Stiffand flat, they do not easily mold from a two-dimensional toa three-dimensional shape. Traditionally, the forehead istransferred in two stages. At the first stage, frontalis muscleand subcutaneous tissue are excised distally and the partiallythinned flap is inset into the recipient site. At a second stage,3 weeks later, the pedicle is divided. However, such soft-tissue“thinning” is limited, incomplete, and piecemeal. Flap ne-crosis and contour irregularities are especially common insmokers and in major nasal reconstructions. To overcomethese problems, the technique of forehead flap transfer wasmodified. An extra operation was added between transferand division.

At the first stage, a full-thickness forehead flap is ele-vated with all its layers and is transposed without thinningexcept for the columellar inset. Primary cartilage graftsare placed if vascularized intranasal lining is present orrestored. Importantly, at the first stage, skin grafts or afolded forehead flap can be used effectively for lining. Afull-thickness skin graft will reliably survive when placedon a highly vascular bed. A full-thickness forehead flap canbe folded to replace missing cover skin, with a distal ex-tension, in continuity, to supply lining. At the secondstage, 3 weeks later during an intermediate operation, thefull-thickness forehead flap, now healed to its recipientbed, is physiologically delayed. Forehead skin with 3 to 4mm of subcutaneous fat (nasal skin thickness) is elevatedin the unscarred subcutaneous plane over the entire nasalinset, except for the columella. Skin grafts or folded flapsintegrate into adjacent normal lining and can be com-pletely separated from the overlying cover from whichthey were initially vascularized. If used, a folded foreheadflap is incised free along the rim, completely separatingthe proximal cover flap from the distal lining extension.The underlying subcutaneous tissue, frontalis muscle, andany previously positioned cartilage grafts are now widelyexposed, and excess soft tissue can be excised to carve anideal subunit, rigid subsurface architecture. Previous pri-mary cartilage grafts can be repositioned, sculpted, oraugmented, if required. Delayed primary cartilage graftscan be placed to support lining created from a skin graftor a folded flap. The forehead cover skin (thin, supple,and conforming) is then replaced on the underlying rigid,

recontoured, three-dimensional recipient bed. The pedi-cle is not transected. At a third stage, 3 weeks later (6 weeksafter the initial transfer), the pedicle is divided.

Over 10 years in 90 nasal reconstructions for partial andfull-thickness defects, the three-stage forehead flap tech-nique with an intermediate operation was used with pri-mary and delayed primary grafts, and with intranasallining flaps (n � 15), skin grafts (n � 11), foldedforehead flaps (n � 3), turnover flaps (n � 5), prefab-ricated flaps (n � 4), and free flaps for lining (n � 2).Necrosis of the forehead flap did not occur. Late revi-sions were not required or were minor in partial defects.In full-thickness defects, a major revision and more thantwo minor revisions were performed in less than 5 per-cent of patients. Overall, the aesthetic results ap-proached normal.

The planned three-stage forehead flap technique of nasalrepair with an intermediate operation (1) transfers subtle,conforming forehead skin of ideal thinness for cover, withlittle risk of necrosis; (2) uses primary and delayed primarygrafts and permits modification of initial cartilage grafts tocorrect failures of design, malposition, or scar contractionbefore flap division; (3) creates an ideal, rigid subsurfaceframework of hard and soft tissue that is reflected throughoverlying skin and blends well into adjacent recipient tissues;(4) expands the application of lining techniques to includethe use of skin grafts for lining at the first stage, or as a“salvage procedure” during the second stage, and also per-mits the aesthetic use of folded forehead flaps for lining; (5)ensures maximal blood supply and vascular safety to all nasallayers; (6) provides the surgeon with options to salvage re-constructive catastrophes; (7) improves the aesthetic resultwhile decreasing the number and difficulty of revision op-erations and overall time for repair; and (8) emphasizes theinterdependence of anatomy (cover, lining, and support)and provides insight into the nature of wound injury andrepair in nasal reconstruction. (Plast. Reconstr. Surg. 109:1839, 2002.)

The tint of the forehead so exactly matches that ofthe face and nose that it must be the first choice. Theforehead makes far and away the best nose.

—Sir Harold Gillies and D. Ralph MillardReceived for publication June 15, 2001; revised August 16, 2001.Presented at the 80th Annual Meeting of the American Association of Plastic Surgeons, in Charleston, South Carolina, on May 14, 2001.

1839

Essentially, all flaps are similar and consist of twoparts—the part chiefly concerned with the traffic ofcirculatory fluids, and the part available for plasticuse.

—Sir Harold GilliesPlastic surgery is a perpetual battle of beauty ver-

sus blood supply.—Sir Harold Gillies and D. Ralph Millard

Because of the ideal quality of its color andtexture, forehead skin has been acknowledgedas the best donor site with which to resurfacethe nose.1,2 However, the forehead is com-posed of skin, subcutaneous fat, frontalis mus-cle, and a thin layer of areolar tissue that over-lies the periosteum and bone. Therefore, allforehead flaps, regardless of their vascularpedicle, are thicker than nasal skin when ele-vated. Stiff and flat, they do not easily moldfrom a two-dimensional to a three-dimensionalshape. Standing above adjacent recipient tis-sue, a bulky flap blends poorly and does notreadily conform to a nasal shape.

Traditionally, the forehead is transferred intwo stages, incorporating later secondary revi-sions at intervals of 6 to 12 months. At the firststage, varying amounts of frontalis muscle andsubcutaneous tissue are excised distally, andthe partially thinned flap is inset into the re-cipient site. Such initial debulking is relativelysafe, at least in nonsmokers, because of theflap’s rich blood supply. However, alar andcolumellar extensions may become necrotic.At a second stage, 3 weeks later, the pedicle isdivided and its proximal aspect is re-elevatedoff the recipient site and debulked. Unfortu-nately, such soft-tissue “thinning” is limited,incomplete, and piecemeal.

Multiple late secondary revisions are oftenrequired once the soft tissues have maturedand softened. At intervals of 6 to 12 months,the flap is partially re-elevated through thescarred, subdermal plane during separate op-erative stages. Additional soft-tissue excisionsare performed and secondary cartilage graftsare placed. However, the skin is now stiff, con-tracted, and noncompliant because of subcuta-neous fibrosis, and it is not readily molded.

Flap necrosis and contour irregularities areespecially common in smokers and in majornasal reconstructions because larger flaps re-quire more extensive soft-tissue thinning, put-ting the blood supply at risk. To overcomethese problems, Millard,3 in 1974, believingthat flap thinning would be safer with the pedi-cle intact, described an intermediate operation

between flap transfer and division to sculpt theala and tip. Burget and Menick,4 in 1992, rec-ommended that a forehead flap be initiallytransferred with no distal thinning in majorreconstructions. All contouring could be per-formed at the second operation, creating athin cover flap and a shaped underlying bed.The pedicle was sectioned at a third stage.Realizing that a skin graft would survive onsuch a highly vascular bed, he also proposedthat a skin graft could be used for lining if latecontraction could be prevented.4 In the past,Kazanjian and Converse5 voiced concern aboutgraft “take” and postoperative shrinkage. Gil-lies,6 however, used grafts for lining with suc-cess in the syphilitic nose by permanentlysplinting the repair with an internal prosthesis.Burget and Menick found that burying a carti-lage graft in the subcutaneous layer betweenskin and frontalis muscle initially or during theintermediate operation, before pedicle divi-sion, was effective.

These concepts have been applied in 90 fore-head flap nasal reconstructions over the past10 years. It has become apparent that the aes-thetic results are improved and the time tocompletion of repair is shortened. Equally im-portant, the implications of a full-thicknessforehead flap transferred in three stages withan intermediate operation expanded the op-tions for lining to include the aesthetic use of afolded forehead flap. It provided insight intothe nature of wound injury and healing, per-mitted the use of both primary and delayedcartilage grafts, and increased the opportuni-ties available for the salvage of complications(Figs. 1 through 15).

TECHNIQUE

Creating Ideal Nasal Cover and a RigidSubsurface Architecture

The forehead is multilamellar, consisting ofskin, subcutaneous tissue, frontalis muscle, anda thin, areolar layer.7 Elevated as a full-thickness flap based on a paramedian pedicle,its supratrochlear vessels pass deeply over theperiosteum at the supraorbital rim and travelvertically upward through the muscle to lie atan almost subdermal position under the skin atthe hairline. It is both a myofascial and axialflap, and highly vascular. Excision of the fron-talis muscle and subcutaneous fat at the time ofinitial transfer removes the myocutaneouscomponent of its blood supply; exposes a

1840 PLASTIC AND RECONSTRUCTIVE SURGERY, May 2002

wounded, raw, bleeding subdermal surfaceprone to fibrosis and contraction; and creates aflap less able to tolerate the tension of closure.However, when it is transposed with all its lay-ers, flap necrosis is unusual. Its soft tissue re-mains soft. The expected severe induration ofwound healing does not occur.

Stage 1. A full-thickness, multilamellar, non-expanded forehead flap (skin, subcutaneousfat, and frontalis muscle) is elevated. Subcuta-neous fat and frontalis are trimmed only at thecolumella and a few millimeters along the nos-tril rim. The cover defect is replaced exactly,using a template derived from the contralateralnormal side or from an ideal. It is inset, withouttension or blanching, with a single layer of finesilk suture. If altering and enlarging the defectwill improve the final aesthetic result, adjacentnormal tissue within nasal subunits is excised,and the entire subunit is resurfaced, rather thanonly the defect.8,9 Primary support cartilagegrafts are a first choice, but they can be posi-tioned in a delayed primary fashion at the sec-ond-stage intermediate operation. Primary car-

tilage grafts are placed if vascularized intranasallining is present or has been restored.4,10,11 Car-tilage grafts are precluded at the first stage ifskin grafts or a folded forehead flap has beenused for lining.

The forehead donor site is closed in layersafter undermining widely in the subgalealplane. Any gap that cannot be approximated isallowed to heal secondarily.

Stage 2. Three weeks later, the full-thicknessforehead flap, now well healed to the recipientbed is, in effect, physiologically delayed. In theintermediate operation, forehead skin with 3 to4 mm of subcutaneous fat (nasal skin thickness)is easily elevated in the unscarred subcutaneoustissue plane over the entire nasal inset, exceptfor the columella. This creates a maximally vas-cularized bipedicle flap that extends from theintact supratrochlear brow pedicle to the colu-mella. The extent of flap elevation can vary,depending on the exposure required for soft-tissue excision and additional delayed primarycartilage grafting. Most often, it is completeexcept for the columellar inset. Perhaps be-cause of the period of delay or the accommo-dation of the flap pedicle to the initial twist attransfer, its blood supply is excellent. In fact,forehead skin (without frontalis muscle) can becompletely re-elevated off the nose, maintain-ing no distal inset, without significant risk, ifsuch exposure is needed to allow more com-plete subcutaneous excision or cartilage graftplacement. Usually, the intermediate operationis performed under general anesthesia, avoid-ing the distortion created by local anesthesia orthe chemical blanching of epinephrine. A com-bination of digital two-hand palpation and tran-sillumination allows the elevation of a smooth,even, thin, supple, conforming skin cover ofideal quality. The skin retains excellent colorand capillary refill. The slightly edematous andpreviously undissected subcutaneous plane sep-arates easily from underlying tissues, with littlebleeding from the deep surface of the skin flap.Axial subcutaneous vessels lying in the subder-mal superficial fat under the skin become visi-ble and are not injured. The underlying sub-cutaneous tissue, frontalis muscle, andpreviously positioned primary cartilage graftsare exposed. This excess soft tissue, a conglom-erate of cartilage, fat, and scar, heals into a rigidliving structure that bleeds readily and is ex-cised to carve an ideal subunit subsurface ar-chitecture. Previously positioned primary carti-lage grafts are visible and can be remodeled by

FIG. 1. A retracted, scarred nose after the failed repair ofa Mohs’ defect of the nasal tip with a bilobed flap and sub-sequent two-stage nasolabial flap to treat alar and tip retrac-tion. The patient had a history of a previous rhinoplasty.

Vol. 109, No. 6 / THREE-STAGE FOREHEAD FLAP 1841

sculpting, further augmentation, or reposition-ing, if required. Delayed primary cartilage graftscan also be placed over vascularized lining skingrafts or the forehead skin that had been foldedfor lining. If the lining is deficient because of aninitial design error or necrosis, additional skingrafts for the lining can be used to expand theavailable lining. After creation of an ideal sub-surface architecture by soft-tissue excision andcartilage grafting, the forehead skin (now ofnasal skin thickness) is replaced on the under-lying rigid, recontoured three-dimensional re-cipient bed with quilting sutures to close thedead space and re-approximate the flap to therecipient site.

Stage 3. Three weeks later (6 weeks aftertransfer), the pedicle is transected. The inferiorforehead scar is reopened, and the proximalpedicle is unfurled, trimmed, and inset as asmall inverted V at the medial brow to simulatea frown crease. The distal flap is elevated with3 to 4 mm of subcutaneous fat, and the prox-imal recipient bed inset is sculpted, as needed,by further excision of excess subcutaneous fat,frontalis muscle, and scar to define the dorsal

lines, alar creases, and sidewall junction. Theflap inset is completed over a stable, sculpturedrigid platform flap whose nasal shape showsthrough the thin, conforming forehead skin.

Expanding Lining Options

In a smaller unilateral lining defect, a full-thickness skin graft can be sutured to fill thedeficiency and fixed to the undersurface of theforehead flap with quilting sutures. No primarycartilage grafts are placed. In the intermediateoperation, the forehead is re-elevated, the softtissue is sculpted, and a delayed primary alarmargin cartilage graft is positioned over theskin-grafted lining (now integrated into adja-cent residual normal lining).

In moderate defects in which residual nor-mal vestibular skin remains intact above thedefect, a bipedicle flap of remnant vestibularskin, based medially on the septum and later-ally on the alar base, can be incised in thevicinity of the intracartilaginous line. This flapis advanced inferiorly to the level of the pro-posed alar margin. The defect, which remainsabove the vestibular flap and is filled with a

FIG. 2. (Left) Scarred skin within the tip, right alar, and sidewall units is excised. The normalalar cartilages are absent and the dorsum is over-reduced. After scar excision, the lining sleeveexpanded to normal. Septal cartilage was used to reconstruct anatomic tip cartilages, a dorsalgraft, and a sidewall brace, and ear cartilage was used for an alar margin batten to restore a skeletalframework. (Right) A nonexpanded right paramedian forehead flap is elevated, without thinningexcept for the columellar inset. The defect that could not be closed in the forehead is temporarilycovered with petrolatum-impregnated gauze, and the raw flap pedicle is temporarily covered witha split-thickness skin graft.


full-thickness skin graft, lines the superior alaand nasal sidewall region. A primary alar rimcartilage graft can be sutured to the raw surface

of the vascularized bipedicle flap at this firststage, but it cannot be placed over the skingraft. The missing covering skin is supplied by

FIG. 3. (Above, left) At 3 weeks, the full-thickness flap appears bulky and the cartilage frame-work does not show through. (Above, right) The forehead flap is incised along its margin. Foreheadskin with 3 mm of subcutaneous flap is elevated over the entire nasal inset, except for thecolumella. The covering skin is supple and highly vascular, and it now has the thinness of nasalskin. The underlying subcutaneous tissue and frontalis muscle are exposed. The proposed alarcrease is marked with ink. (Below, left) Scar, frontalis muscle, and subcutaneous tissue are excisedto create a rigid subsurface architecture that will be visible through the overlying thin conformingforehead cover skin and will have the shape of a nose. (Below, right) The forehead pedicle is nottransected. The flap is re-approximated to the nasal inset with peripheral and quilting sutures.


a full-thickness forehead flap. The skin graft,raw surface outward, will revascularize from theoverlying raw surface of the forehead flap.Contact between the skin graft and foreheadflap is enhanced by the placement of looselytied, absorbable quilting sutures that pass in-tranasally through the skin graft and into thesoft tissues of the overlying cover flap, and by asoft sponge that is placed within the airway for48 hours.

While the alar margin is supported by a pri-mary septal or conchal cartilage alar rim graft,

the superior aspect of the defect overlying theskin graft is unsupported. At 3 weeks, beforewound contraction occurs, the forehead flapand skin graft are separated during the inter-mediate operation. Excessive subcutaneous tis-sue and scar are excised over the skin graft bed.The skin graft lining is well vascularized fromthe periphery, and becomes indistinguishablefrom the residual normal lining to which it wassewn. It is thin, supple, and bleeds readily. Ashaped piece of septal cartilage and bone canthen be inserted in a delayed primary fashion

FIG. 4. Appearance at 2 years after one minor revision.


to support and shape the nasal sidewall andmiddle vault during this second stage. A com-plete nasal framework is restored. An unbro-ken sheet of hard tissue lies throughout thedefect to brace the reconstruction against up-ward retraction or inward collapse.

In larger unilateral defects, when residualvestibular skin is absent, a full-thickness skingraft replaces the entire lining defect. It issutured with the skin surface facing the nasalvestibule and its raw surface outward. Beforeforehead flap inset, a subcutaneous tunnel be-tween the skin and the frontalis muscle can becreated about 3 to 5 mm above the alar margin.A conchal cartilage alar margin batten, approx-imately 5 mm wide and of adequate length, isplaced within the pocket to support and shapethe alar rim. However, the defect superior tothis alar margin cartilage graft remains unsup-

ported. Later, at the intermediate operation,any unsupported skin graft lining above thealar margin batten is exposed and braced witha delayed primary sidewall cartilage graft, afterelevation of the forehead flap and soft-tissueexcision.

The Folded Forehead Flap for Cover and Lining inModerate Nasal Defects

In the past, forehead flaps have been foldedto provide both cover and lining for the alarrim. However, it is difficult to fold a thick flapinto a nasal shape, and the technique pre-cludes the accurate placement of primary col-umellar, tip, and alar support grafts. The noseremains thick and shapeless, and the unsup-ported soft tissues along the alar margin maycollapse, obstructing the airway. Kinking of theflap at the hinge between cover and lining may

FIG. 5. (Left) A full-thickness defect of the right ala and a partial-thickness defect of the leftsidewall after Mohs’ excision of a recurrent basal cell carcinoma. The retracted nose is signif-icantly distorted by prior excisions. Residual normal skin within the lower nose will be excisedto allow the subunit reconstruction of the distal dorsum, tip, and alae. (Right) A bipedicle liningflap based laterally on the branches of the septal artery and medially on the septal branch of thesuperior labial artery is incised and pulled inferiorly to the proposed level of the alar rimbilaterally. In effect, the lining defects are moved from the alar margin to the sidewall of the nose.Superiorly, full-thickness skin grafts are sutured, raw side outward, to line the sidewall defectsabove the bilateral bipedicle flaps. The skin graft is visible above the skin hook. Primary cartilagealar batten grafts, lateral crural grafts, and a tip graft are sutured over the highly vascularizedbipedicle flaps. A sidewall septal cartilage batten, however, cannot be placed over the skin graft,which must be vascularized by the overlying frontalis muscle of a full-thickness forehead flap,which is transposed to resurface the lower one-half of the nose. To improve contact between theskin grafts and forehead flap, absorbable quilting sutures are placed through the skin graft andinto the overlying flap, and the nose is packed lightly with a sponge for 48 hours.


decrease blood supply distally if a thick flap isthinned at the initial time of transfer.

To overcome these problems, a full-thick-ness forehead flap is outlined to replace miss-ing cover skin at the initial operation. At thesame time, the lining deficit is determined, anda second template is designed and positioneddistally on the forehead (in continuity with thecover flap) after adding 2 to 3 mm extra lengthto allow for the rolling in of the lining hinge.Typically, this lining extension of the flap is thesite of the dog-ear excision, performed on clo-sure of the forehead donor site, and would bediscarded. The flap, drawn to provide bothcover and lining, is elevated with all layers. Thedistal extension is turned in to provide thelining and is sutured to the residual mucousmembrane with absorbable suture. The moreproximal flap, which will be used for cover, isfolded back and inset with a single layer of finesuture, opposing the two raw, deep areolar

surfaces of the folded flap. The flap is notthinned; no cartilage support grafts are placed.

Three weeks later, in the intermediate oper-ation, the flap is incised along the proposedalar margin, completely separating the proxi-mal cover flap from the distal lining extensionalong the alar rim. The proximal flap is thenelevated off its inset with a few millimeters ofsubcutaneous fat, or as a full-thickness fore-head flap in the areolar plane between the twofolded frontalis layers. Frontalis and subcuta-neous fat is excised to expose a thin, supplelining of almost normal thickness. Just as in theskin graft-lining technique, the lining becomesvascularized from the adjacent normal mucousmembranes and bleeds freely. It is difficult todistinguish from normal lining. Delayed pri-mary grafts are positioned to provide supportand contour to both the reconstructed liningand the forehead covering skin. They brace therepair against postoperative distortion caused

FIG. 6. (Left) At 3 weeks, the sidewall of the nose remains unsupported; if not buttressed bya delayed primary graft it may retract upward or collapse inward, distorting the external ap-pearance and function of the nose. Fortunately, fibroblastic wound contraction does not beginimmediately, so delayed primary grafts are effective if placed within several weeks after skingrafting. During the intermediate operation, the forehead flap is elevated with 3 mm of sub-cutaneous fat, maintaining its proximal pedicle at the brow and its inset into the columella.Underlying subcutaneous tissue, excessive frontalis muscle, and scar are excised over the primaryalar margin cartilage grafts and expose the skin grafts previously placed for lining. It is difficultto differentiate the full-thickness skin graft from the other nasal lining. The lining grafts are wellvascularized and “integrated into the reconstruction.” (Right) A delayed primary sidewall car-tilage graft is positioned to support and shape the sidewall subunit and prevent upward con-traction (shown on another patient). The forehead flap is then resutured to the recipient site.Three weeks later (6 weeks after initiating the reconstruction) the pedicle is divided.


by the normal fibrosis associated with woundhealing. Once the lining has been thinned andcartilage grafts positioned, the cover flap canbe thinned to a nasal thickness as described orreplaced as a full-thickness flap and thinned ata second intermediate sculpting operation 3weeks later.

Salvage Opportunities: Cover, Lining, and Support

Cover. Rarely, infection, usually associatedwith significant loss of lining, puts an entirereconstruction in jeopardy. The only choice isto discard all cartilage grafts, debride back tohealthy lining, and reattempt repair in 6 to 12months once the wound has settled. However,precious forehead skin must be preserved. For-tunately, a full-thickness forehead flap has max-imal vascularity, and unlike a flap that is signif-icantly thinned during the first stage of a two-stage forehead flap transfer, it suffers minimalphysical injury during its initial transfer. Fur-thermore, it retains its ability to fight infectionand has little tendency to contract. In one in-stance, a full-thickness forehead flap was re-turned to its forehead donor site when a com-plicated repair developed infection because ofnecrosis of hinge-over lining flaps. “Banked” onthe forehead, it suffered no necrosis or con-traction. Six months later when the edema sub-sided, the flap returned to its original supple-ness and became available for re-transposition

during a future nasal repair because it was notthinned initially.

Lining. The skin graft lining technique canbe used in salvage cases. In one instance, a totalnasal defect was reconstructed with a free radialforearm flap for lining, which was initially cov-ered with a thin skin graft. Later, it was resur-faced with a forehead flap and supported witha cantilever dorsal rib graft. However, the di-mensions of the free flap lining were inade-quate. The nostril airway was stenotic and wouldbe too small if not enlarged. The free flap liningwas cut loose at each alar base, and the gapswere filled with 1.5 � 2-cm skin grafts. Theforehead flap, transferred without thinning, re-vascularized the skin grafts. Three weeks later,during the intermediate operation, it was re-elevated, excess soft tissue was excised, and de-layed primary cartilage alar margin batten graftswere placed over the combined free flap/skingraft lining at each alar base, where they pro-vided support and braced the lining.

Although untested to date, if an intranasallining flap developed limited necrosis, thedead lining could be debrided at a secondoperation before invasive infection began, andany primary cartilage grafts in the area couldbe removed. The lining defect could then bereplaced with a full-thickness skin graft posi-tioned against the full-thickness forehead flap.After the skin graft had vascularized, the fore-

FIG. 7. Postoperative results at 1 year. No revisions were performed.


head flap could be re-elevated, and delayedprimary cartilage grafts could be replaced.Such a maneuver could theoretically prevent areconstructive disaster, preserving the fore-head flap, the remaining reconstructed lining,and primary cartilage grafts from progressiveinfection.

Support. As described, support grafts can beplaced primarily or in a delayed primary fashion

and repositioned, sculpted, or added duringany stage to correct imperfections resultingfrom improper design or shift caused by ten-sion, gravity, or edema. The rigid architectureof healed soft tissues and cartilage grafts can becarved into a nasal shape. Nasal reconstructionbecomes an opportunity for repeated artistic,three-dimensional sculpting completed beforepedicle division.

FIG. 8. (Above, left) Mohs’ defect of the tip and medial aspect of the left ala after excision ofrecurrent basal cell carcinoma. The defect is full-thickness with a 1 � 1.5-cm lining defect. (Above,right) Residual normal skin within the tip and part of the dorsal unit is excised. The lining defectis repaired with a full-thickness skin graft, with its raw surface outward, and will be revascularizedby an overlying forehead flap. Primary cartilage grafts cannot be placed. (Below) The nasal surfacedefect is covered with a forehead flap containing all layers of skin, subcutaneous tissue, andfrontalis muscle. The skin graft is fixed to the overlying forehead flap with absorbable quiltingsutures, and the nostril is lightly packed with a foam stent for 48 hours.


FIG. 9. (Above, left) The skin graft take was incomplete, so a second full-thickness skin graftwas placed, which healed without further problems. Six weeks after the initial forehead flapprocedure, the reconstruction was too bulky and the alar rim remained unsupported over thelining skin graft. Excessive bulk was marked for excision. (Above, right) The forehead flap iselevated with 3 mm of fat as a bipedicle, maintaining its proximal blood supply at the brow andits inset into the columella. Underlying subcutaneous tissue, frontalis, and scar tissue are exposed.(Below, left) Excessive bulk is excised, creating a normal nasal shape. The underlying skin graftis well vascularized and incorporated into the residual lining. The pedicle was not transected.A delayed primary cartilage graft is placed to support and shape the right soft triangle and leftalar rim. (Below, right) Three weeks later, at the time of pedicle division, the delayed primarycartilage graft that supports the underlying skin graft is visible.


RESULTS

Over 10 years in 90 nasal reconstructions ofpartial and full-thickness defects, the three-stage forehead flap technique was used withprimary and delayed primary grafts, and withintranasal lining flaps (n � 15), skin grafts(n � 11), folded forehead flaps (n � 3), turn-over flaps (n � 5), prefabricated flaps (n � 4),and free flaps for lining (n � 2). Necrosis ofthe forehead flap did not occur during initialfull-thickness transfer or the intermediatesculpting operation. One infection occurredbecause of lining loss.

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. In full-thickness de-fects, a major revision or more than two minorrevisions were performed in less than 5 percentof patients. At 4 to 6 months, once woundmaturation is complete, the alar crease can bedefined by direct soft-tissue excision; the nos-tril margin trimmed by rim excision; or thenasal aperture enlarged by local excision, locallining redistribution, or a composite skin graft.The forehead donor scar can be revised byexcision and re-advancement, disregarding anyarea of hypertrophy associated with secondaryhealing. Overall, the aesthetic results can ap-proach normal.

DISCUSSION

Rhinoplasty surgeons have long emphasizedthe interrelationship of the skin envelope andits underlying skeleton.12 Ideally, an aestheti-cally structured framework is designed to pos-itively influence the conformation of its overly-ing skin. Although modern augmentationtechniques can modify nasal cartilages that areinadequate in size, shape, or position, little canbe done to improve a skin sleeve that is toolarge or too thick in a cosmetic rhinoplasty.Fortunately, the reconstructive surgeon nowhas the ability to transfer a covering flap of theexact size and of correct nasal thickness whilecreating a supporting framework.

The three-stage forehead flap techniquewith an intermediate operation allows the sur-geon to transfer forehead skin of nasal thick-ness over a rigid, three-dimensional, sculp-tured, subsurface architecture, formed byprimary and delayed primary cartilage graftsand soft-tissue excision before pedicle division.Such staging has many advantages. The inter-mediate operation ensures maximal vascularsafety. Initially transferred with all its vascularlayers, the full-thickness forehead flap is de-bulked at the second stage, taking advantage ofthe delay phenomenon and its new bipediclecharacter. It is highly vascular, and in our ex-perience, necrosis did not occur. A thin, sup-ple flap of even thickness is created during this

FIG. 10. Postoperative results at 1 year. No revisions were performed.


single operative stage, avoiding irregularitiescaused by piecemeal debulkings. With the flapalmost completely elevated off its nasal inset,the exposed subsurface framework of prelimi-nary cartilage grafts and soft tissue—healedinto a solid, three-dimensional, coalesced com-posite—can be modified by additional delayedsuture-fixated cartilage grafts, if needed, andby soft-tissue excision to form a sculpturedmiddle layer that will show through the cover-

ing skin. With an unobstructed view, the sur-geon can visualize the entire construction andthe subtle requirements of contour needed tocreate a proportionate and attractive nasalshape.

The reliable vascularity of a full-thicknessforehead flap ensures the “take” of a skin graftapplied to its raw areolar surface at the time offlap transfer, and it permits folding of the fore-head flap to supply both cover and lining.

FIG. 11. (Above, left) Full-thickness defect of the right tip, ala, and sidewall after Mohs’ excision of a squamous cell carcinoma.(Above, center) Exact templates of both cover and lining defects are used to design a right paramedian forehead flap, with a distalextension that will be folded to provide both lining and cover. (Above, right) The forehead flap is elevated with all layers. (Below)The distal extension is turned in to provide lining, and is sutured to the residual mucous membrane with absorbable sutures.The more proximal flap, which will be used for cover, is folded back and inset with a single layer of fine suture, opposing thetwo raw, deep areolar surfaces of the folded flap. The flap is not thinned; no cartilage support grafts are placed.


Once healed in place, the skin graft or foldedskin, which is now vascularized by its incorpo-ration into the adjacent normal nasal mucosa,can be separated from the overlying cover flapand survive. After excision of excessive subcu-taneous fat and frontalis muscle, delayed pri-mary cartilage grafts, initially precluded, cannow be placed on newly replaced thin supplelining.

Cartilage support is applied in stages and iscoordinated with the replacement of other an-

atomic layers. Primary cartilage grafts are a firstchoice, but they can be positioned in a delayedprimary fashion at the second-stage intermedi-ate operation. An ideal rigid subsurface archi-tecture can be created from soft and hard tis-sues before pedicle division almost regardlessof lining techniques. In fact, it seems that thefibrosis normally associated with wound heal-ing does not occur significantly under a full-thickness forehead flap. One might hypothe-size that the absence of early flap thinning, by

FIG. 12. (Left) Normally, the intermediate operation would proceed after 3 weeks. However, because of unassociated medicalillness in this patient, the second stage was delayed for 2 months. The reconstruction was too bulky, the alar rim collapsed, andthe airway was obstructed by the unsupported soft tissues. However, because the forehead flap was not thinned at the time oftransfer, the tissues were soft. (Right) Using a template, the position of the right alar margin is outlined.

FIG. 13. The flap is incised along the proposed alar margin, completely separating the proximal cover flapfrom the distal lining extension along the alar rim. Frontalis muscle and subcutaneous tissue are excised to exposea thin, supple lining of almost normal thickness. The folded forehead skin used for the lining is vascularizedfrom adjacent normal mucous membranes and bleeds freely.


avoiding injury of the subdermal, subcutane-ous plane at the initial transfer, limits the fi-brotic reaction and the deleterious effects ofcontraction. When the intermediate operationwas delayed even months after forehead flaptransfer, significant subcutaneous scarring didnot occur. The intermediate sculpting opera-tion can be completed with reliably supplecover and lining layers, easily molded by de-layed primary support grafts.

Although intranasal lining flaps are idealand usually are the first choice, this staged,sequential method of nasal reconstruction us-ing full-thickness skin grafts or a folded fore-head flap for lining, and primary and delayedprimary placement of cartilage support grafts,is relatively simple. The reconstructed liningretains most of its original dimensions and re-mains thin and conforming. It is a less complexmethod with a shortened operative time, and itrequires less manipulation of intranasal anat-omy. It is useful in the elderly or debilitatedpatient when the risk of temporary nasal ob-struction caused by crusting, edema, or intra-nasal bleeding should be minimized. It is alsoapplicable when previous injury or rhinoplastyhas interfered with septal blood supply, mak-ing the use of intranasal lining flaps based onthe superior labial artery septal branch or theanterior ethmoid vessels unreliable. Although

contraction can occur, distortion is relativelyminor. The aesthetic endpoint may be less pre-cise, but the results can be quite satisfactory.This compromised technique is applicablewhen less aesthetic precision is acceptable. Aslightly bulkier nose with less definition mayoccur.

The technique ensures a maximal blood sup-ply, a thin covering flap, unimpeded surgicalexposure, controlled shaping, and the maxi-mal use of all lining options. The aestheticresults are improved, and the need for laterrevisions is minimized.

The three-stage forehead flap technique ofnasal reconstruction with an intermediate op-eration should be applied to all nasal recon-structions that require a forehead flap for theresurfacing of partial-thickness or full-thick-ness nasal defects, regardless of defect size ordepth. It is especially useful in smokers who areat risk for forehead flap necrosis and in thereconstruction of large nasal defects that re-quire wide thinning of the covering flap, espe-cially with alar and columellar extensions. Anexception might be an isolated alar or tip de-fect requiring minimal support or lining repairwhen the surgeon thinks that adequate distal,and then proximal, thinning is possible in twostages, without the intermediate operation.

The planned three-stage forehead flap tech-

FIG. 14. A delayed primary cartilage alar margin batten graft, a sidewall graft, and a right lateral crus graftare placed to brace against postoperative distortion and support the soft tissues. The forehead flap is replaced,and the pedicle is subsequently transected at a third stage.


nique of nasal repair with an intermediateoperation:

1. allows the creation of a thin, supple, con-forming cover from a thick forehead flap,with little risk of necrosis;

2. uses primary and delayed primary grafts andpermits modification of initial cartilagegrafts to correct failures of design, malposi-tion, or scar contracture before pedicledivision;

3. creates an ideal rigid subsurface frameworkof hard and soft tissue by cartilage graftingand subcutaneous excision, which is re-flected through overlying skin and blendswell into the adjacent recipient tissues be-fore pedicle division;

4. expands the applications of lining tech-niques to include the use of skin grafts forlining at the first stage, or as a “salvage”procedure during the second stage, andalso permits the aesthetic use of a foldedforehead flap for lining;

5. shows that a skin graft or skin folded as anextension of a forehead flap integrates intoadjacent normal lining and can be sepa-rated from the overlying cover from which itwas initially vascularized, permitting delayedprimary cartilage grafting;

6. ensures maximal blood supply and vascularsafety to all nasal layers;

7. provides the surgeon with options to salvagereconstructive catastrophes;

FIG. 15. Postoperative result at 8 months. No revisions were performed.


8. improves the aesthetic result while decreas-ing the number and difficulty of revisionoperations and overall time to repair; and

9. provides insight into the nature of woundinjury/repair in nasal reconstruction.

Frederick J. Menick, M.D.5285 East Knight DriveTucson, Ariz. [email protected]

REFERENCES

1. Gillies, H. D., and Millard, D. R. The Principles and Art ofPlastic Surgery. Boston: Little, Brown, 1957. Pp. 104–110.

2. Gillies, H. D. Plastic Surgery of the Face. London: Frowde,Hodder, & Stoughton, 1920. Pp. 270–273.

3. Millard, D. R., Jr. Reconstructive rhinoplasty for thelower half of a nose. Plast. Recontr. Surg. 53: 133,1974.

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

5. Kazanjian, V. H., and Converse, J. M. Surgical Treatmentof Facial Injuries. Baltimore: Williams & Wilkins, 1949.P. 352.

6. Gillies, H. D. Deformities of the syphilitic nose. Br.Med. J. 29: 977, 1923.

7. Menick, F. J. Aesthetic refinements in use of the fore-head for nasal reconstruction: The paramedian fore-head flap. Clin. Plast. Surg. 17: 607, 1990.

8. Burget, G. C., and Menick, F. J. The subunit principlein nasal reconstruction. Plast. Reconstr. Surg. 76: 239,1985.

9. Menick, F. J. Artistry in aesthetic surgery: Aesthetic per-ceptions and the subunit principle. Clin. Plast. Surg.14: 723, 1987.

10. Burget, G. C., and Menick, F. J. Nasal reconstruction:Seeking a fourth dimension. Plast. Reconstr. Surg. 78:145, 1986.

11. Burget, G. C., and Menick, F. J. Nasal support and lin-ing: The marriage of beauty and blood supply. Plast.Reconstr. Surg. 84: 189, 1989.

12. Sheen, J. H., and Sheen, A. Aesthetic Rhinoplasty. St. Lou-is: Mosby Yearbook, 1987.


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