|Year : 2014 | Volume
| Issue : 2 | Page : 21-23
Experience with a two-stage nasal reconstruction with the paramedian forehead flap
Abdulrasheed Ibrahim1, Ferdinand O Ijekeye2, Malachy E Asuku1
1 Department of Surgery, Division of Plastic Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
2 Department of Surgery, Division of Plastic Surgery, University of Benin Teaching Hospital, Benin, Edo, Nigeria
|Date of Web Publication||15-Apr-2015|
Department of Surgery, Division of Plastic Surgery, PMB 06, Ahmadu Bello University Teaching Hospital (ABUTH), Shika, Zaria, Kaduna
Source of Support: None, Conflict of Interest: None
The unique anatomy of the nose combined with its aesthetic and functional importance makes its reconstruction a challenging but rewarding undertaking. The authors of this study present their experience in a two-stage nasal reconstruction with a paramedian forehead flap. The patient underwent reconstruction with a narrow pedicle to resurface the dorsum, and its distal wings covered the alae. He had a significant amount of residual intranasal lining and this was used for a pedicle flap. The reconstructed dorsum and nasal tip appeared bulky, and the soft triangle needed better definition after the second stage. The patient underwent two revisions with improvement in the projection, outline, and contour of the nose.
Keywords: Nasal reconstruction, paramedian forehead flap, revision, two-stage
|How to cite this article:|
Ibrahim A, Ijekeye FO, Asuku ME. Experience with a two-stage nasal reconstruction with the paramedian forehead flap. Nigerian J Plast Surg 2014;10:21-3
|How to cite this URL:|
Ibrahim A, Ijekeye FO, Asuku ME. Experience with a two-stage nasal reconstruction with the paramedian forehead flap. Nigerian J Plast Surg [serial online] 2014 [cited 2020 May 29];10:21-3. Available from: http://www.njps.org/text.asp?2014/10/2/21/155185
| Introduction|| |
The unique anatomy of the nose combined with its aesthetic and functional importance makes its reconstruction a challenging but rewarding undertaking. , The nose is located in the middle of the face and is perceived as a series of topographic aesthetic subunits that are defined by subtle changes in contour and natural creases. Thus, it naturally attracts the gaze of onlookers. ,,
The nose is covered by a thin, conforming envelope of skin that matches the face in color and texture. It overlies a sculpted soft and hard tissue middle layer framework that supports, shapes, and braces, while suspending the internal lining of the nose and maintaining the airway. , The lining is thin and supple; it neither obstructs the airway by bulging inward nor distorts the external shape of the overlying support or covering skin by bulging outward.  The plastic surgeon must take bits and pieces of expendable tissue to create a facsimile of the lost nose that gives the appearance of a normal nose. ,,
Nasal reconstruction remains the historic centerpiece of plastic surgery.  A thorough understanding of anatomy, reconstructive options, and defect considerations is necessary for optimal reconstruction.  Several local tissue options are available including the nose itself, the cheeks, the periauricular areas, and the forehead.  The forehead flap continues to be the modern workhorse for nasal reconstruction, providing similar skin color, texture, structure, and reliability. , The authors of this study present their experience in a two-stage nasal reconstruction with a paramedian forehead flap.
| Case Report|| |
A 27-year-old civil servant was referred for nasal reconstruction to the plastic surgery unit of our institution. He had sustained a loss of the lower third of the nose following a windshield injury in a road traffic accident 6 months prior to presentation. There was full-thickness loss of the nasal tip, the distal third of dorsal skin, and the lining on both sides. Portions of the columella and the soft triangle were also disrupted [Figure 1]a and 1b. The upper lateral cartilages and the nasal bones were intact. The patient expressed his concern with the cosmetic defect and had recently become socially withdrawn. He required reconstruction of two elements: Cover and a lining. He underwent a two-stage nasal reconstruction with a paramedian forehead flap, and the defect in the alar margin had a pedicle flap of residual lining.
The design of the paramedian forehead flap was based on a template that was created from the defect. The pedicle is designed to be based on the medial brow to include the supratrochlear artery as well as collaterals from the angular artery. The flap is outlined on the forehead with a skin marker [Figure 2]a. The paramedian forehead flap was elevated from distal to proximal. This was initially in the subcutaneous plane, and subsequently deepened in the subgaleal plane along the vertical component of the pedicle, up to the subperiosteal plane. The pedicle was designed with a narrow skin bridge but with a sufficiently wide subcutaneous pedicle to safely include the supratrochlear vessels [Figure 2]b. The narrow skin pedicle was carried below the medial eyebrow toward the medial canthus. A selective thinning to match the nasal skin thickness was done, and the raw undersurface of the exposed pedicle was skin grafted to facilitate the maintenance of a cleaner wound between the first and second stages. A pedicle flap of residual lining above the alar on both sides was elevated to line the defect along the margin of the alar. The paramedian forehead flap was then transposed into the defect [Figure 2]c and sutured to the columella and the nostril margins with one layer of interrupted 5-0 polypropylene suture. The donor site was closed after undermining in a submuscular plane. The muscle and fascia were closed in a single layer with a 2-0 vicryl suture [Figure 2]c, and the skin was closed with a 5-0 polypropylene suture. A residual defect just beneath the hairline was allowed to heal secondarily. The skin sutures on the donor site of the forehead flap were removed on the fifth postoperative day.
|Figure 2: (a) Paramedian forehead flap design (b) Flap elevation in the subcutaneous plane (c) Intraoperative picture with the forehead flap in situ|
Click here to view
The patient had the division of the pedicle completed 3 weeks from the date of initial surgery. The pedicle division was done with the patient under local anesthesia. The inferior forehead scar was reopened, and the proximal pedicle was trimmed and inset at the medial brow. The proximal portion of the inset flap was thinned by excision of excess subcutaneous fat and contoured to reconstruct the nasal dorsum subunit.
The patient was seen at the follow-up clinic after 6 weeks, and although he was satisfied with the outcome of the procedure, he did not seem to like the convexity at the dorsum and tip of the nose where the forehead flap was transposed [Figure 3]a and 3b. The patient underwent two flap-debulking procedures approximately 6 months and 12 months after his flap division, with some improvement in the bulkiness of the nasal tip and dorsum [Figure 3]c. However, at his 36-month follow-up, he did not wish for any further surgical intervention.
|Figure 3: (a and b) Postoperative view at 6 weeks; convexity at the dorsum and tip of the nose (c) Postoperative view after two revisions. The projection, outline, and contour of the nose are good|
Click here to view
| Discussion|| |
The origin of plastic surgery is rooted in the relief of facial deformity, specifically the restoration of the nose. Emphasis has always been on the replacement of tissue loss in anatomic layers (cover, lining, support) and on methods of tissue transfer (grafts or flaps).  The forehead flap, traditionally, has been the workhorse of such reconstructions. Its dependability and consistent anatomy make it an ideal choice. 
The classic Indian forehead flap had a midline design with a wide pedicle based above the eyebrow, which received its blood supply from paired supratrochlear vessels and sometimes included the supraorbital artery. This flap had a limited arc of rotation and created significant torsion on the vessels.  Later, anatomic studies demonstrated that a paramedian forehead flap based on a narrower pedicle receiving rich blood supply from one supratrochlear artery and the angular artery could be used. The narrow pedicle allows for a greater arc of rotation and flap reach without compromising viability.  Repair of the mucosal nasal lining is essential for optimal restoration of nasal function and form. The lining flaps not only help restore nasal airflow but also provide a bed of vascularized tissue to support the integration of cartilage and bone grafts that reconstruct the shape and rigidity of the nose.  The optimal option would be to use local intranasal flaps. Local lining from the vestibule, septum, and middle vault provide thin vascularized tissue that does not distort overlying skin or cartilage grafts or obstruct breathing. ,
A forehead flap may be transferred in two or three stages. In the two-stage transfer, because the forehead skin is thicker than nasal skin, the subcutaneous flap and muscle are sculptured distally to thin the flap during the first stage. Axial vessels in the superficial subcutaneous fat are preserved. Although the frontalis muscle is excised, the supratrochlear vessels remain tightly adherent to the distal skin. The flap remains perfused by its axial supply. Its distal aspect is inset into the recipient defect, after restoring missing support or lining. The pedicle is divided during the second stage 3 weeks or 4 weeks later. 
Our patient underwent nasal reconstruction using a paramedian flap with a narrow pedicle to resurface the dorsum, and its distal wings covered the alae. The vascularity and size of the flap accounted for minimal immediate postoperative complications. The patient's lining defect was limited to the soft triangle subunit. He had a significant amount of residual intranasal lining and this was used for a pedicle flap. The donor site healed satisfactorily. Primary closure is the ideal way to deal with the donor site but sometimes it cannot be achieved because of the width of the flap needed. When primary closure is not possible, the area may be left open for secondary healing. Some authors have noticed wide and depressed scars in some of their patients after leaving the area for secondary healing. Tissue expansion of the forehead has also been extensively reported in the literature for closure of the forehead defects after forehead flap elevation. ,,
Overall, the patient had an adequate result, but there were some imperfections. The reconstructed dorsum and nasal tip appeared bulky, and the soft triangle needed better definition after the second stage. In retrospect, debulking should have been done more aggressively to better redefine the nasal tip and dorsum, sidewall, and alar lobule [Figure 3]a and 3b. Excellent results can be obtained with the two-stage transfer. Unfortunately, because the flap's blood supply is entirely dependent on its distal inset at the time of pedicle division, the distal and most aesthetic aspects of the repair (the tip and ala) cannot be altered after the flap is transferred.  Revisions can be made only months later, in stages, by elevating the flap from the recipient site.  This case study also demonstrates the important principle of revision: The desire to achieve the best aesthetic and functional result through continual revisions and touch-ups until that goal is reached. , The patient had two revisions with improvements in the dimension, volume, and position of the fundamental character of the nose. The two-stage method remains invaluable in the repair of moderate full-thickness losses.
| References|| |
Ribuffo D, Serratore F, Cigna E, Sorvillo V, Guerra M, Bucher S, et al
. Nasal reconstruction with the two stages vs three stages forehead flap. A three centres experience over ten years. Eur Rev Med Pharmacol Sci 2012;16:1866-72.
Rohrich RJ, Griffin JR, Ansari M, Beran SJ, Potter JK. Nasal reconstruction--beyond aesthetic subunits: A 15-year review of 1334 cases. Plast Reconstr Surg 2004;114:1405-19.
Fudem GM, Montilla RD, Vaughn CJ. Single-stage forehead flap in nasal reconstruction. Ann Plast Surg 2010;64:645-8.
Park SS. Reconstruction of nasal defects larger than 1.5 centimeters in diameter. Laryngoscope 2000;110:1241-50.
Ullmann Y, Fodor L, Shoshani O, Rissin Y, Eldor L, Egozi D, et al
. A novel approach to the use of the paramedian forehead flap for nasal reconstruction. Plast Reconstr Surg 2005;115:1372-8.
Boyd CM, Baker SR, Fader DJ, Wang TS, Johnson TM. The forehead flap for nasal reconstruction. Arch Dermatol 2000;136:1365-70.
Menick FJ. Nasal reconstruction: Forehead flap. Plast Reconstr Surg 2004;113:100-11e.
Menick FJ. The use of skin grafts for nasal lining. Clin Plast Surg 2001;28:311-21, viii.
Huang AH, Wong MS. Acute nasal reconstruction with forehead flap after dog bite. Ann Plast Surg 2013. [Epub ahead of print].
Adigun IA, Oladele AO, Olabanji JK. The Naso-labial and lateral forehead flaps as a single stage: A case report and review of literature. Indian J Plast Surg 2008;41:171-4.
Sinha M, Scott JR, Watson SB. Prelaminated free radial forearm flap for a total nasal reconstruction. J Plast Reconstr Aesthet Surg 2008;61:953-7.
Oo KK, Park SS. The midline forehead flap in nasal reconstruction. Facial Plast Surg Clin North Am 2011;19:141-55.
Bhrany AD. Complex nasal reconstruction: A case study: Reconstruction of full-thickness nasal defect. Facial Plast Surg Clin North Am 2011;19:183-95.
Bruschi S, Marchesi SD, Boriani F, Kefalas N, Bocchiotti MA, Fraccalvieri M. Galea-including forehead flap for lower one-third nasal reconstruction. Ann Plast Surg 2009;63:67-70.
Menick FJ. Nasal reconstruction with a forehead flap. Clin Plast Surg 2009;36:443-59.
Angobaldo J, Marks M. Refinements in nasal reconstruction: The cross-paramedian forehead flap. Plast Reconstr Surg 2009;123:87-97.
Menick FJ. An approach to the late revision of a failed nasal reconstruction. Plast Reconstr Surg 2012;129:92-103e.
[Figure 1], [Figure 2], [Figure 3]