Paramedian Forehead Flap Nasal Reconstruction

Early reconstruction

The origin of plastic surgery is rooted in the treatment of facial deformities, specifically the restoration of the nose. Although cartilage, bone, and mucosal lining often are missing in major nasal defects, the most obvious deficiency is skin. In ancient India, a common punishment for crimes was nasal tip amputation. The medical treatise Sushruta Samhita described the earliest known reconstruction of these defects circa 700 BC, using cheek flaps. ^[3] The origins of forehead rhinoplasty (ie, the Indian method) are largely unknown, but the procedure was performed in India by the Kanghiara family in 1440 AD, and likely centuries, if not millennia, before that. The operation was also adopted and performed by the Koomas, a caste of potters.

In Europe during the 15th century, the Branca family practiced the Indian method of rhinoplasty. At this time, Sicily was the center of Arabian, Greek, and Occidental learning, which made translations of the Indian method accessible. Tagiacozzi subsequently refined the technique of arm rhinoplasty (ie, the Italian method) in the late 16th century. The 17th and 18th centuries represented a regressive period for surgical practice in general, and particularly for plastic surgery. Tales of slaves donating their buttocks to provide tissue for their owner's noses were ridiculed. It was said that a mystic sympathy existed between the new nose and the person from whom it was taken; when the donor died, so did the new nose. Yet, when the first written account in English of the Indian midline forehead flap rhinoplasty procedure appeared in the Madras Gazette in 1793, public opinion was more receptive toward nasal reconstruction.

One year later, the article was reproduced in Gentleman's Magazine of London, stirring the imagination of European practitioners. One of these surgeons, Joseph Constantine Carpue, is credited with the first British rhinoplasty, and published his account of two successful operations in 1816. By 1897, at least 152 rhinoplasties had been performed in Europe, almost all of them utilizing a median forehead flap.

The classic Indian rhinoplasty was popularized in America by Kazanjian in 1946. This technique employed a vertically oriented flap of skin and subcutaneous tissue from the midline of the forehead, with known perfusion through the paired supratrochlear vessels. ^[4] The incisions extended from the hairline to a point immediately above the nasofrontal angle and penetrated to the periosteum. At the junction of the forehead and the root of the nose, the lower portion of the flap was elevated by blunt dissection to protect its paired feeding vessels. The base of the flap was rotated 180°, with its pivot point at or just above the eyebrows. The forehead donor sites in these early operations were not closed primarily and instead were allowed to heal by secondary intention.

New designs of the forehead flap

From 1840 to World War I, it became apparent that the results of reconstruction using unlined flaps were poor. The external shape of the nose and its airway passages became distorted by the contracting scar tissue on the underlying raw surface of the flap. Surgeons realized that they must provide replacement for all layers of the nose, not simply the skin. Ideally, missing tissue should be replaced in kind and quantity; however, residual intranasal mucous membrane was usually inadequate. Carpue, Von Dreafe, Delbech, Labat, Blandin, and Dieffenbach folded the distal end of the forehead to form a columella but left the alar portions unlined. The nostril openings simply were stented with rubber tubing.

Around 1842, Petrelli emphasized using the forehead to line itself. His solution was to line the covering flap by folding and twisting it onto itself, thus creating internal and external surfaces. This formed structures analogous to the nasal tip, ala, and columella, while eliminating raw surfaces on the lower part of the reconstructed nose. Naturally, this created a sizable forehead defect and, unless the hairline was high, moved hair-bearing scalp onto the nose. To this day, many surgeons incorrectly feel that an area of skin of at least 7.5 X 7.5 cm is required to reconstruct a major nasal defect, seeming to preclude the use of midline forehead tissues.

Normal hairline position limited the flap length available for folding unless hair was to be transferred to the nose. The problem seemed insurmountable. First, the 180° twist of the Indian pedicle and the location of its base at or above the eyebrows created a high arc of rotation. Too often, the flap did not reach the columella. Second, at least one third of the flap was used for lining and cover. Midline forehead tissue seemed unable to provide enough tissue to create a long columella that at the same time could maintain projection, allow infolding of the covering flap for lining, and avoid unnecessary tension that might diminish flap vascularity. Thus, in 1850, Auvert designed a longer flap by slanting it across the forehead at an angle of 45°. These "oblique" flaps came into general use in the latter part of the 19th century and were designed to follow the hairline onto the temple.

German surgeons of the same era positioned forehead flaps horizontally and included blood supply from the supraorbital vessels on one side. Gillies used such flaps during World War I; subsequently, in 1935, he described a radical departure from the oblique forehead flap, specifically, an "up-and-down flap." This ascended over one supraorbital pedicle onto the hair-bearing scalp and then descended back into the forehead, providing greater flap length and proving sufficiently wide to ensure the blood supply.

In 1942, Converse modified the up-and-down flap by creating a long pedicle that was camouflaged within hair-bearing skin and included the major vascular supply to the scalp. Converse felt its advantages were an ability to transfer larger amounts of forehead tissue and the location of a permanent skin-grafted donor site over the lateral aspect of the forehead, where it was thought to be less conspicuous. Unfortunately, the irregular pigmentation and texture of a skin graft stands out as a patch regardless of position. In addition, the scalping flap is an operation of greater magnitude than the median forehead flap and leaves a large donor area that must be left open temporarily or skin grafted. It produces a hairy pedicle that hangs, sutured to the recipient site and stretched across the orbital region, obstructing vision during transfer.

All of these flaps were designed solely to provide additional length to the forehead flap, and each produced a forehead defect that was harder to close. Surgeons faced a difficult predicament, worrying about both facial scarring while bemoaning the insufficient tissue available to make a nose. Obviously, when forehead skin is used for lining as well as cover, the burden imposed on the forehead is increased, and even greater donor deformity is created. Adding insult to injury, surgeons often used forehead skin for nasal reconstruction and for adjacent defects. Neighboring cheek, lip, and nose losses in the midface were filled with one even larger flap. Frequently, a single plump lump replaced the 3-dimensional contours of these multiple contiguous facial units, and the forehead was scarred beyond repair.

Additionally, without a skeletal framework, the soft tissue of cover and lining collapsed in major reconstructions, impairing the airway and limiting projection. A rigid support was needed to provide a buttress, projection, and contour, but these folded flaps were thick and often ischemic. Because of their bulk and the risk of extrusion, cartilage grafts were not used primarily but were placed during subsequent operations. Only after soft tissues had healed could large bone-and-cartilage pieces be placed as cantilever grafts to augment the nasal dorsum and tip. Unfortunately, gravity and the healing process caused contraction of the soft tissue envelope, and the nasal contour rarely could be regained after this occurred. Multiple late revisions were required to sculpt subcutaneous tissue into a semblance of the natural nasal shape.

The folding of forehead flaps for lining wasted forehead skin and precluded the accurate placement of primary columellar, alar, and tip support. A single covering flap simply cannot be folded into the 3-dimensional shape of the normal nose. The alar rims and tip can only be made into thick and shapeless folds of soft tissue. Despite these limitations, however, the folding of covering skin for lining, and specifically the scalping flap, came to be the most commonly used method of nasal reconstruction. The median forehead flap was recommended only to replace small nasal losses, unless the patient was bald or had an unusually high hairline allowing for a longer vertical flap.

In reality, recreating the nose is impossible. What nature has fabricated is not reproducible. Thus, the reconstructive surgeon's task can only be to fashion bits and pieces of expendable tissue into a facsimile of cover, lining, and support, to give the visual impression of a normal nose. However, the quandary remains as to how enough tissue can be provided to reconstruct the nose without excessive donor-site morbidity. The riddle of plastic surgery is to find and fit the piece that best solves this puzzle and produce as an outcome a happy, normal-looking patient.

Further modifications

The classic Indian forehead flap carried midline tissues on paired supraorbital and supratrochlear vessels. Its base lay at or above the eyebrows. When so designed, its length was quickly limited by the hairline; its reach, by the pedicle's high arc of rotation. A 180° twist produced a kink at the nasal root that also could impair blood flow. Early modifications in flap design aimed to overcome these difficulties.

Depending on the height of the forehead and position of the hairline, the flap could be lengthened effectively by modifying the incisions at the base of the pedicle and by lowering the arc of rotation. In 1929, Lisfranc extended one incision lower than the other. Dieffenbach lengthened one incision until it reached the defect. Labat curved his incisions proximally, centering the flap over the medial brow and canthus on one side. This reduced the twist of the pedicle and immediately brought the flap closer to the recipient site. More tissue was available to reconstruct the nose. Central forehead tissue was transferred on a unilateral paramedian blood supply.

Strangely, except for the use of the paramedian forehead flap by Millard, this modification has received little attention. He clearly demonstrated that bilateral pedicles were not essential for flap viability. Subsequent anatomic studies by McCarthy and colleagues demonstrated that the forehead is perfused by an arcade of vessels, including the supraorbital, supratrochlear, infratrochlear, dorsonasal, and angular branches of the facial artery. ^[5]  Thus, a rich anastomotic plexus, centered on the medial canthus, can supply a unilaterally based flap, even after division of the supraorbital, supratrochlear, and infraorbital vessels. The paramedian forehead flap, as it is known today, is richly perfused by a vertically oriented axial blood supply, with an arc of rotation near the medial canthus. It can reach the columella and be thinned aggressively, if desired, prior to inset. This flap is the workhorse of the modern facial plastic surgeon.

Rather than folding the forehead flap for lining, others sought to eliminate the raw area on the deep surface of the forehead flap in different ways. In 1874, Volkman turned down portions of residual nasal skin adjacent to the defect, hinged on scar, to provide lining. Thiersch transferred flaps from other facial areas in 1879 and, more recently, Millard advocated rolling over bilateral nasolabial flaps to line the ala and columella. In 1898, Lossen first applied skin grafts for lining. Most often, grafts of split- or full-thickness skin were placed under the covering forehead flap during a preliminary operation. Weeks later, once the viability of the grafts was assured, these prelaminated flaps were transferred with the forehead flap to the nose. Both cover and lining were supplied. However, the result could be thick and shapeless, and the cleavage plane between the skin graft and forehead flap precluded the later placement of significant skeletal support.

Additional refinements

Considerable work has gone into addressing the need for structural support in the newly reconstructed nose. Although Konig developed the procedure much earlier, in 1943 Gillies popularized the placement of composite chondrocutaneous grafts that simultaneously added both lining and support. In 1956, Converse suggested a septomucoperichondrial cartilage graft as an alternative. ^[6] The advantages, which Converse ascribed to the septal composite graft for lining, were equally applicable to all methods that did not fold the covering flap on itself. The length of the forehead flap could be decreased because skin was used only for cover, and the blood supply was hardier because the forehead flap was not doubled on itself. Bulky, shapeless alar margins formed by flap infolding also were avoided. Unfortunately, even when residual nasal skin or adjacent cheek skin is turned over to line the nose, the tissues are still thicker than normal intranasal lining, distorting the nasal shape and crowding the nasal passage. Rarely are these tissues vascular enough to support primary cartilage grafts.

In the past, the best combination of lining and cartilage support came from a composite graft using the ear or septum. However, the techniques used required one or two preliminary stages to prelaminate the forehead flap. At best, the graft tissue made a satisfactory alar margin. Unfortunately, its shape was fixed both by its natural configuration and by the scar that surrounded it as it sat in the flap on the forehead awaiting transfer to the nose. When the nose finally was assembled, often little could be done to shape the cartilage fragments so that they resembled the subcutaneous architecture of a normal nose. They were glued to the undersurface of the flap and fixed in whatever position they had assumed on the forehead.

At first glance, residual intranasal mucous membrane seems inadequate to line a major nasal reconstruction. However, some surgeons sought ways to use it. In 1902, DeQuervain first used the septum to provide lining and support to the lateral wall of the nose. Later, the technique, adopted by Kazanjian, was employed to reconstruct the ala. ^[4] Ipsilateral septal mucoperichondrium was discarded. A flap of septal cartilage and contralateral mucous perichondrium, based on the dorsum of the septum, was hinged laterally to line the piriform aperture and supply support and lining. Sufficient septal cartilage remained along the dorsum of the nose to maintain the bridge line. In 1918, Sir Harold Gillies described a caudally based septal flap used for tip support.

More recently, Millard pioneered the use of a superiorly based septal flap to provide dorsal support. Although it was lined by its own mucoperichondrium, no excess lining was provided for use elsewhere. Residual septal mucous membrane that lay within the piriform aperture was then unavailable to line other parts of the reconstructed nose. Millard also described an anteriorly and inferiorly based ipsilateral septal mucous membrane flap that could be transferred to line the middle third and the ala.

Burget and Menick have studied the blood supply of the septum. ^[7] The septal branch of the superior labial artery allows elevation of the entire ipsilateral mucoperichondrium on a narrow pedicle. If both right and left septal branches are included, the entire septum can be shifted as a composite flap containing a sandwich of cartilage between the two leaves of the mucous membrane. Such flaps of septomucoperichondrium, cartilage, and bone extend from the nasal floor below to the level of the medial canthus above and posteriorly to the ethmoid and the perpendicular plate.

Burget and Menick also described a bipedicle flap of residual vestibular skin, based medially on the septum and laterally on the nasal floor, that could be advanced inferiorly to line the ala and nostril margin. They have shown that a broad expanse of residual and well-vascularized intranasal mucosa is available to provide lining for lateral heminasal and total nasal defects. These lining flaps were thin and reliably variable. Neither external shape nor airway patency was distorted by excessive bulk. Loss of lining, the bane of nasal reconstruction, seldom occurred. Recently, Burget and Walton suggested the use of a multi-paddled free radial forearm flap to simultaneously supple external skin to the lip and nasal floor and intranasal lining (initially covered externally by a full-thickness skin graft) in one stage. ^[8] At a later date, the skin graft covering the nose is excised and a forehead flap and cartilage grafts are positioned to restore the nose.

More recently, other lining options have found favor. Forehead flaps have been folded distally to line themselves. Unfortunately, this precluded primary support and created a thick, shapeless and unsupported nostril margin with airway collapse. Menick modified the technique. ^{[9, 10]} He folded a distal extension of a full thickness flap. Three weeks later, the lining aspect integrates into the residual normal adjacent lining, and the covering more-proximal flap can be separated along the nostril margin and completely reelevated. The excess underlying soft tissue of frontalis and fat is excised, and the new lining is supported with delayed primary cartilage grafts. This has become the workhorse of lining methods and has replaced the use of the more complex and morbid intranasal lining flaps.

Free flaps, usually the radial forearm flap because of its relatively thin, pliable, mostly glabrous skin, ^[11] have also been applied to especially complex defects. Burget and Walton have chronicled their use of the free flaps, often as individual paddles to restore the nasal floor, vault, and columella as independent extensions. ^[8] However, free flaps can be designed in several ways, and each surgeon must analyze the defect and the tissue requirements to fit each patient. Menick has discussed the spectrum of free flap lining options. ^[12]

Primarily cartilage grafts to replace the missing tip, ala, and dorsum could be placed to create support, projection, and a nasal contour. When covered by a thin and conforming flap, the shape of the subcutaneous architecture showed through. Forehead skin was not needed for lining; it was employed only to resurface the nose. The paramedian forehead flap was well vascularized and sufficient to provide covering skin for alar, heminasal, and total nasal reconstructions. A method was identified that permitted the surgeon to combine cover, lining, and support into a nasal shape.

Further refinements in the design of transferred tissue also served to minimize the donor deformity. The outlines of the earliest forehead flaps were made of wax patterns, shaped to fill the defect, and then flattened on the forehead as a guide. In 1828, Velpech drew his flap as a reversed ace of spades with its stem forming the columella and its tapering tip remaining attached as a pedicle. In 1834, Labat diagrammed a similar tripod-shaped flap, with limbs extending obliquely across the forehead.

Recently, Millard used a seagull-shaped flap with a central vertical component and lateral wings. The wings extended horizontally and lay in the natural transverse wrinkles of the forehead. The vertical component resurfaced the dorsum, tip, and columella, and the lateral extensions could be wrapped around the ala and curled into the nostril floor as alar bases. The flap took excess forehead tissue in both horizontal and vertical dimensions. This facilitated primary closure of the forehead wound as an inconspicuous midline T-shaped scar. The transverse scar was well hidden in the normal wrinkle lines of the forehead, and the vertical component usually was not noticeable.

Simple undermining of adjacent wound margins appeared satisfactory for near-complete primary closure. Making additional parallel incisions along the brow or hairline to rotate large scalp flaps for forehead closure or to skin graft the forehead was not necessary. Kazanjian and Converse have pointed out that a gap exists between the paired frontalis muscles. A flap can be removed from the mid line with little interference in the forehead component of facial expression. Such vertical midline forehead scars are extremely forgiving.

Because midline forehead tissue can be transposed successfully as a paramedian forehead flap, using distant tissue to reconstruct the nose or to expand available forehead skin is unnecessary except in unusual circumstances. Skin expansion delays reconstruction by months and is associated with discomfort and social isolation. Such expanded skin is also subject to shrinkage and contracture.

When closely examined, the results of nasal reconstruction using the nonparamedian skin or other distant flaps rarely meet critical analysis. The motivation for their use is an ill-conceived wish to take inordinately large amounts of forehead skin to cover nonnasal units or to line the forehead flap by folding its distal end. Expansion of forehead skin is rarely necessary in nasal reconstruction but may be considered to increase available flap length, hoping to avoid hair on the distal aspect of the flap in a very short forehead, or when the forehead unit previously has been injured. Under most circumstances, the nasal reconstruction should proceed without expansion, and expansion should be applied later only to reconstruct the forehead donor deformity if needed.

Gonzales-Ulloa and associates have described anatomic units of the face based on cadaver skin thicknesses. ^[13] Millard designed his gull-winged forehead flap to improve the aesthetic result. It was successful because it replaced the entire nose as a single unit. Burget and Menick have provided a detailed analysis of nasal subunits based on intrinsic contour configurations and the psychology of perception. ^[14] The surface of the nose is crossed by shallow ridges and valleys that separate it into slightly convex and slightly concave surfaces, establishing the tip, dorsum, paired sidewalls, alar lobules, and soft triangles subunits. Scars can be placed strategically so that they are camouflaged in the joins between units. Minimizing the visibility of scars is a useful tool. A normal nose looks normal because it has the correct skin quality, landmark outline, and 3-dimensional contour. These, not scars, are the essential components in a successful reconstruction.

Etiology of nasal defects

Nasal defects can arise secondary to malignancy, trauma, infection, congenital anomalies, and degenerative disease. Each of these etiologies presents unique reconstructive needs.

Facial trauma represents a spectrum of soft tissue and bony injury, from simple lacerations with involvement of nasal cartilage to complete loss of the nose. For nasal defects of traumatic etiology, the surgeon must account for those structures that are lost or unsalvageable, those that are present, and those that are displaced. Destruction or loss of nasal support alone may be an isolated sequela of facial fracture. Dog bites will often amputate or devascularize any number of nasal subunits. Following irrigation and decontamination, the amputated nasal tissue should be handled as a composite graft; however, the distance from the amputated tissue to the wound bed should not exceed 5 mm. ^[15] This may sometimes necessitate the removal of cartilage from the amputated part if it will impair appropriate healing of the graft. The cartilage can then be restored at a second stage. Facial avulsion, human bites, and burns also present as skin losses with progressive cartilage support and lining deficits.

Cartilage destruction without cover loss more often follows intranasal lining necrosis due to the infectious complications of syphilis, leprosy, or noma or the illicit intranasal use of cocaine. In these conditions, inflammation and destruction of nasal lining exposes and devascularizes septal cartilage. Progressive nasal collapse due to loss of support and lining contraction follows. Except for full-thickness injuries due to noma or meningococcemia, the nasal skin cover may be relatively uninjured but difficult to reexpand after scar contraction occurs on its raw inner surface. Although not common, the multiply operated cosmetic rhinoplasty patient can present with scarred, contracted, or excised nasal lining; absent or distorted nasal bone and cartilage framework; and avascular scarred and contracted external skin covering, which may require replacement of all three layers to restore a normal nose. ^[16]

Defects that follow the surgical excision of skin cancer require the replacement of external skin and varying amounts of deeper tissues, depending on tumor extension. Basal cell carcinoma is the most common skin cancer, growing slowly and locally. If untreated, it can lead to severe deformity and death due to orbital and central nervous system (CNS) extension. Squamous cell carcinoma is less frequent but is associated with more aggressive local growth and occasional lymph node metastasis if neglected or recurrent due to inadequate initial excision. Melanoma is even less common but is more frequently associated with lymph node and systemic spread.

Electrodesiccation and cryotherapy are destructive techniques frequently employed by dermatologists for small, superficial, primary basal cell carcinomas with well-defined borders. All other skin cancers are treated with surgical excision. Prior to removal, an incisional biopsy is performed to verify the histologic diagnosis of basal cell and squamous cell carcinoma. An excisional biopsy is used for all but large melanomas. Radiation therapy may be a safe, noninvasive treatment for selected basal cell and squamous cell carcinomas, but it usually is limited to elderly patients who are poor surgical candidates due to the risk of postradiation osteitis and chondritis or other late radiation injury, including carcinogenesis. The cosmetic effects of radiation therapy can be good but are variable. Fortunately, because head and neck surgery is associated with minimal morbidity, surgical excision and reconstruction are the time-honored therapies for significant skin cancers.

Skin cancers recur unless adequately excised. Surgical excision with examination of the specimen margin by permanent or frozen sections is adequate for small primary tumors with visible clinical margins but may be inadequate in other circumstances. Certainly, all peripheral and deep margins must be examined for tumor extension and reexcised until clear.

Mohs micrographic surgery uses a technique of microscopically guided cold knife excision. All clinically visible tumor is excised in saucerlike layers, marking the exact size and shape of the tumor. Horizontal frozen sections from the undersurface of the excised specimen are examined microscopically, with reexcision of all tumor extensions as required. Mohs surgical excision is indicated for basal cell and squamous cell carcinomas that are large (>2.0 cm), are recurrent, have poorly defined clinical borders, are morphea or sclerosing basal cell cancers, or are in difficult locations such as the nose, eye, or ear.

The cure rates for a primary basal cell carcinoma by Mohs excision are 99%, and for squamous cell carcinoma, 95%. Recurrent basal cell and squamous cell carcinomas have cure rates of 95% and 90%, respectively. Because the cure rates of Mohs frozen-section excision are so high, a delayed primary reconstruction can yield excellent results. ^[17]

Melanomas are excised with 1.0-cm and 2.0-cm margins, depending on the tumor depth (< 1.0 mm, 1.0-4.0 mm, or >4.0 mm), and verified by permanent section examination.

For excellent patient education resources, visit eMedicineHealth's First Aid and Injuries Center. Also, see eMedicineHealth's patient education articles Broken Nose and Facial Fracture.