A novel approach to the use of the paramedian forehead flap for nasal reconstruction

Reconstruction of the nose, the most prominent feature of the face, is a substantial challenge for the plastic surgeon. Currently, many types of flaps are used for this purpose. The forehead flap is frequently used for larger nose defects because of its similarity in color, mobility, and suitability to substitute extensive defects. The flap thickness and problems that may occur in the donor area closure are the shortcomings of this type of flap. In this article, we introduced a novel approach to overcome these obstacles. Seventeen patients underwent nose reconstruction vising our approach for the paramedian forehead flap, which involves applying a method that is regularly used for the hairline cut subcutaneous forehead lift. The flap dissection was started by an incision along the temporal and frontal hairline and was continued within the subcutaneous plane, leaving the frontalis muscle untouched. During the dissection the supratrochlear vessels were clearly seen traveling within the subcutaneous plane. The flap was trimmed "on-site" according to the nasal defect, enabling a greater precision in estimating the amount of tissue needed. Direct vision of the vessel pathway enabled the development of the whole flap on a very narrow pedicle without endangering its blood supply. After the flap was inset, the remaining two lateral forehead flaps were rotated and advanced toward the midline to close the donor area primarily. The flap pedicle was disconnected 2 to 3 weeks later. All flaps survived and the donor areas were closed primarily. Ten patients needed small revisions. For three patients, this included slight defatting of the proximal part of the flap for better inset; for the other seven, only minor scar revision of the previous flap's stalk was required between the eyebrows. There was one partial necrosis of the distal edge of the flap, one small dehiscence at the flap's pedicle inset, and one instance of cellulitis of the donor area. All patients were satisfied with their results. This approach for nasal reconstruction with the forehead flap has the advantages of safe dissection under vision of the vessels, on-site design of a thinner flap compared with those previously described, and primary closure of relatively large donor areas.