Including Forehead Flaps
SOURCE: Dept. of Otolaryngology, UTMB, Grand Rounds
DATE: March 20, 1996
John Yoo, M.D.
FACULTY: Karen H. Calhoun, M.D.
SERIES EDITOR: Francis B. Quinn, Jr., M.D.
to Grand Rounds Index|
"This material was prepared by resident
physicians in partial fulfillment of educational requirements established for
the Postgraduate Training Program of the UTMB Department of Otolaryngology/Head
and Neck Surgery and was not intended for clinical use in its present form. It
was prepared for the purpose of stimulating group discussion in a conference setting.
No warranties, either express or implied, are made with respect to its accuracy,
completeness, or timeliness. The material does not necessarily reflect the current
or past opinions of members of the UTMB faculty and should not be used for purposes
of diagnosis or treatment without consulting appropriate literature sources and
informed professional opinion."
Various deformities of the nose can
be brought about due to trauma, as well as iatrogenically through the excision
of skin malignancies via Mohs microsurgery. Just as many techniques have evolved
to repair those various deformities, but a set of general principles guides the
reconstruction of the nose with loss of soft tissue and/or underlying framework.
First, since the defect belongs
to the patient, it is incumbent on the surgeon to determine, “What does the
patient want?” Some patients desire as much as can be done in order to obtain
a normal as possible nose even if it means multiple staged procedures with multiple
hospitalizations. Other patients desire the bare minimum, such as leaving the
defect alone and allowing the defect to heal by secondary intention or skin
grafting the wound, even if this bare minimum will produce a suboptimal cosmetic
Next, the defect must be analyzed
in terms of which tissues are missing, since nasal tissue must be replaced by
like tissue in order to effect the best cosmesis. The nose is by and large made
up of three layers: the thin, vascular nasal mucosa, the nasal framework consisting
of cartilage or bone, and the overlying skin and soft tissues of the nose.
Reconstructive techniques must
also take into account the varying thickness of nasal skin depending on the
location. The skin of the upper two thirds of the nose is thin, mobile, and
has fewer sebaceous glands, whereas the skin over the lower one third is thicker,
filled with sebaceous glands, and lacks mobility.
In addition to replacing the missing
tissues, however, the nasal contours, highlights, and shadows must also be restored.
In order to do this, the nose must be analyzed with regards to the topographic
nasal subunits. The nose is divided into 9 subunits: dorsum, 2 nasal side walls,
tip, 2 ala, 2 soft tissue triangles, and the columella. Of these, 5 of them
are convex (dorsum, columella, tip, and 2 nasal ala) and 4 are concave (2 sidewalls
and 2 soft tissue triangles). In order to maintain these concavities and convexities,
it is usually best to repair the nasal defect with a different flap or graft
technique for each subunit. If a defect involves more than 1/2 of a nasal subunit,
the rest of that subunit is excised to achieve better cosmesis. Incisions should
be placed along the midline, at the subunit boundaries, and along the lines
of minimal tension (vertical in glabella and horizontal over the rest of the
nose) to maximize scar camouflage.
The patient should be questioned
regarding any intercurrent illnesses as well as previous surgeries. Especially
important is whether the patient has a smoking history or any peripheral vascular
disease which may compromise the cutaneous vascular supply of the flaps used
The framework and underlying support
of the nose is provided by the nasal bones, upper and lower lateral cartilages,
and indirectly by the septum. The blood supply of the nose is provided by the
alar and septal branches of the facial artery to the ala and lower septum, respectively.
The dorso-lateral areas are nourished by the dorsal nasal branch of the ophthalmic
artery and the infraorbital branch of the maxillary artery. The superior labial
and angular branches of the facial artery supply the lower and upper nose. The
anterior facial and ophthalmic veins provide the venous drainage of the nose.
The lymphatics of the anterior nose drain into the submandibular nodes and the
rest of the nose drains into the parotid and upper deep cervical lymph nodes.
Techniques for Repair (by subunit)
The actual reconstruction for each
patient’s nasal defect must be individualized and tailored to optimize cosmesis,
but at all times following the general guidelines as outlined above. However,
a systematic guide to the the repair of nasal defects has been published by Larrabee
and Sherris and addresses each subunit separately as per the topographic subunit
1. DORSAL SUBUNIT
For superficial defects less than 2.0
cm in size that are vertical or round, the defect can be repaired by primary closure,
single transposition flap, or a bilobed flap. For superficial defects less than
2.0 cm that are horizontal, the defect can be repaired by primary closure or a
glabellar flap. For defects that are greater than 2.0 cm or are deep, a forehead
flap should be used for reconstruction.
2. SIDEWALL SUBUNIT
For defects in the medial canthal area
that are less than 1.0 cm, primary closure, FTSG, secondary intention, or a glabellar
flap can be used. For medial canthal area defects greater than 1.0 cm, secondary
intention or a glabellar flap can be used. In other areas of the sidewall, a modified
bilobed flap is used for defects less than 2.0 cm, a superiorly based melolabial
flap for defects greater than 2.0 cm, and a forehead flap for defects that are
greater than 2.0 cm and/or are deep.
3. TIP SUBUNIT
For superficial defects less than 1.5
cm, primary closure, delayed FTSG, or bilobed flap can be used. For superficial
defects 1.5-2.5 cm in size can be repaired with a two stage melolabial flap. If
the defect is superficial, but greater than 2.0 cm or if the defect is deep involving
underlying cartilage or nasal lining, then a forehead flap should be used
4. SOFT TISSUE TRIANGLES
The defect of the soft tissue triangles
should be allowed to granulate to avoid unsightly notching.
5. COLUMELLA SUBUNIT
Skin only defects of the columella
can be repaired by secondary intention or be FTSG. For defects involving both
skin and cartilage, a composite graft of lobule and cartilage can be used if the
vascular supply is good, and a two stage melolabial flap if the vascular supply
6. ALAR SUBUNIT
For superficial defects less than 1.0
cm in size, FTSG can be used (secondary intention may cause excessive alar retraction).
For superficial 1.0-2.0 cm defects, a bilobed flap, two stage melolabial flap,
or a nasofacial groove flap can be used. For full thickness alar defects less
than 1.5 cm, a composite graft of skin and cartilage can be used to reconstruct.
For full thickness alar defects greater than 1.5 cm, reconstuction can be performed
using the melolabial flap or a forehead flap.
Full thickness skin graft
Skin grafts work well for defects involving
thin nasal skin or those subunits that are concave. These areas include the columella,
sidewalls, dorsum, and soft triangles. FTSG’s blend in well in defects of the
upper 2/3 of the nose. They can be harvested anywhere, but the best donor site
for the reconstruction of the superficial defects is preauricular skin where 2.0
to 2.5 cm grafts can be taken. The underlying recipient area must be well vascularized
and quilting sutures must be placed to avoid sheering.
The Zitelli modification of the bilobed
flap is a useful tool for the reconstruction of nasal defects, particularly if
the defect is between 0.5-1.5 cm in diameter in the thick-skinned part of the
nose. The modification allows for only 45-50 degrees of rotation for each lobe
of the flap (rather than the original 90) for a total arc of rotation of 90-100
degrees (rather than the original 180). The smaller arc of rotation poses a lesser
problem with a standing cone defect. A triangle of skin equal in length to one
radius of the defect is excised to the pivot point. The second lobe of the flap
should be brought from the loose skin of the upper 2/3 of the nose. As per Dr.
Burget, the bilobed flap should be based laterally for defects of the tip, and
medially based for the defects of the ala.
A rotational flap utilizing the lax
skin of the glabella can be used to fill in defects of the upper 1/3 of the nose.
A midline transposition flap (finger flap) can also repair defects of the upper
1/3 of the nose, but can also address defects if the medial canthal area as well.
A standing cone in the inferior rotational area can be trimmed without compromising
the blood supply. In both flaps, the donor site is closed primarily without dificulty.
Melolabial flap The superiorly based melolabial flap can be used to repair defects
greater than 1.5 cm on the ala. This flap is nourished by the branches of the
facial and angular arteries that perforate the levator labii muscle near the ala
and then extend laterally. Because of this hearty blood supply, the proximal pedicle
need not be wide. The flap is elevated in a plane superficial to the facial musculature
and can be thinned prior to insetting. This flap can be rolled onto itself (with
a cartilage graft placed at the most inferior end to prevent alar retraction)
to provide inner nasal lining if none are available. The donor site can be closed
along the melolabial crease. At 3 weeks post-operatively, the pedicle can be divided,
trimmed, and thinned to close the remnant donor site and the lateral flap bed.
An inferiorly based variation of
the this flap can be used to repair small defects of the ala and can be useful
because of its use of the nose/cheek boundaries.
Paramedian Forehead Flap
The forehead is a source for abundant
donor tissue available for large and/or deep nasal defects. The paramedian forehead
flap has a hearty blood supply in a vertical orientation provided primarily by
the supratrochlear vessels and to a lesser extent, the supraorbital and dorsal/angular
branches of the facial artery. The supratrochlear artery exits the orbital septum
and crosses the orbital rim deep to the orbicularis oculi and superficial to the
corrugator muscles. The supratrochlear vessels travel 2 cm lateral to the midline
and superficial to the frontalis muscle.
The precise location of the supratrochlear
artery is identified with a pencil doppler, so that the base of the flap can
be narrowed to approximately 1.0-1.5 cm. A base that is too wide can strangulate
the flap as it twists to reach the recipient bed or limit the length of the
The shape of the distal flap is
planned with the use of a foil template taken of the contralateral uninvolved
side (*remember to flip the template over for the mirror image of the defect*).
A suture or gauze measured from the pivot point to the most distal portion of
the nasal defect is used to determine if the flap is going to be long enough.
The flap is elevated in a subgaleal plane and just above the periosteum inferiorly
to avoid injurying the vascular pedicle.
Prior to insetting the flap, the
nasal lining and the underlying framework are reconstructed, and any remaining
portions of the subunit(s) are excised. To match the thickness of the defect,
the distal end of the flap may be thinned before suturing into place. However,
thinning of the distal flap should be avoided at the primary repair in a smoker
due to compromised blood supply. The length of the flap can be increased by
1.5 cm by extending the flap into the scalp or across the orbital rim. Regrowth
of hair can be prevented by clipping the bulbs of each hair follicle if extended
into the scalp.
If the defect to be reconstructed
also involves the nasal lining, the forehead flap can be harvested with the
underlying pericranium 2 cm beyond the confines of the distal flap attached
to the forehead flap, in a flap designed by Seikaly. Once the flap and its pericranium
is elevated, the pericranium can be separated from the overlying skin and sutured
into place to replace the nasal lining. Next, the cartilaginous framework can
be inserted inset superficial to the pericranial flap, followed by the placement
of the skin of the forehead flap.
The donor site can usually be closed
primarily after undermining the surrounding skin, but healing by secondary intention
or STSG can be used if closure is not possible. The forehead flap pedicle can
be divided 3 weeks post-operatively under local anesthesia. The proximal portion
of the flap is trimmed/thinned and used to fill in the V-shaped donor defect
and trimming/thinning of the distal flap/nasal dorsum is performed to obtain
maximal cosmesis of the distal portion.
Nasal defects involving all three layers
require that the deepest layer (nasal mucosa/vestibular skin) be reconstructed.
Since this tissue is thin, soft, and vascular, the optimal donor tissue should
be similar in character. The nasal lining can be provided by skin grafts, local
turn-in flaps, or nasolabial flaps, but the best donor tissue is uni-pedicled
or bi-pedicled intranasal tissues such as from the vestibule, middle vault, or
the septum. In small full thickness defects of the alar margin, the lining can
be replaced by freeing the vestibular skin from its attachment superiorly and
rolling it inferiorly and outward like the hem of a skirt until it lines the margin.
In addition, if a paramedian forehead flap is used to reconstruct a defect and
nasal lining is required, pericranium associated with the distal flap can be used
to replace the nasal lining.
When the nasal defect involves the
underlying bone and cartilage framework, like tissues must be used to replace
them. Bone may be obtained from the cranial, iliac, or costal bone. Cartilage
from the septum, conchal, or costal areas may be obtained to recreate the cartilaginous
nasal framework. Because of the close proximity to the surgical field, the conchal
and septal cartilages are more widely used. The conchal cartilage has the advantage
of having inherent curves that more closely mimic the shape of the alar cartilages.
The septal cartilage has to be weakened at certain points in order to bend, but
is more easily carved due to its hyaline nature.
Conchal cartilage is harvested
by making an incision medial to the rim of the conchal bowl, elevating the overlying
mucoperichondrium, excising the conchal cartilage, repairing the incision, and
placing a bolster on both sides of the conchal bowl.
Burget recommends even placing
cartilage grafts in those parts of the nose that normally contain no cartilage
(such as the alar lobule) in order to impart stability to the overlying soft
Burget, GC and Menick, FJ. Aesthetic
reconstruction of the nose. Mosby-Year Book: St.Louis, MO. 1994.
Larrabee, WF and Sherris DA. Principles
of facial reconstruction. Lippincott-Raven publishers: Philadelphia, PA. 1995.
Jackson, IT. Local flaps in head
and neck reconstruction. C.V. Mosby Co.: St.Louis, MO. 1985.
Burget, GC. Nasal restoration with
flaps and grafts in: Head and neck surgery-Otolaryngology edited by Byron J.
Bailey. J.B.Lippincott Co.: Philadelphia, PA. 1993.
Stucker, FJ and Shaw GY. Reconstructive
rhinoplasty in: Otolaryngology-Head and neck surgery edited by Charles Cummings.
Mosby-Year Book: St.Louis, MO. 1993.