Nasal reconstruction using a paramedian forehead flap

Nasal reconstruction using a paramedian forehead flap is a surgical technique to reconstruct different kinds of nasal defects. In this operation a reconstructive surgeon uses skin from the forehead above the eyebrow and pivots it vertically to replace missing nasal tissue. Throughout history the technique has been modified and adjusted by many different surgeons and it has evolved to become a popular way of repairing nasal defects.

The tint of forehead skin so exactly matches that of the face and nose that it must be first choice. Is not the forehead the crowning feature of the face and important in expression? Why then should we jeopardize its beauty to make a nose? First, because in many instances, the forehead makes far and away the best nose. Second, with some plastic juggling, the forehead defect can be camouflaged effectively.

Probably the first nasal reconstructions using a forehead flap were performed by Sushruta in India during 600 to 700 BC. The method was introduced in Europe in the 15th century. The first English description of the Indian midline forehead rhinoplasty was published in the Madras Gazette in 1793 and later Carpue, an English surgeon, published his experience with two successful median forehead flaps in 1816. The classic median forehead flap supplied by paired supratrochlear vessels was popularized in the United States by Kazanjian in 1947, however, this flap was not optimal because it was not long enough. To solve the problem of the short median forehead flap, its design was modified so that central forehead tissue could be transferred on a unilateral paramedian blood supply.

A forehead flap is usually required if the nasal defect is larger than 1.5 cm, requires replacement of support or lining, or if it is located within the infratip or columella. If the defect is small and superficial it can be resurfaced with a skin graf or it can heal by secondary intention. Limited alar defects can be resurfaced using a nasolabial flap, however, the amount of tissue available from the nasolabial area is limited and the flap is thicker, less vascular, and hair bearing in males.

Nasal defects mostly result from excision of (malignant) skin tumours as basal cell carcinoma, squamous cell carcinoma, malignant melanoma, keratoacanthoma, lentigo maligna, lymphoma, and sweat gland carcinoma. Other acquired nasal defects are usually caused by trauma, burns or sepsis.

The forehead flap is known as the best donor site for repairing nasal defects because of its size, superior vascularity, skin color, texture and thickness. Especially the color and texture of the forehead skin matches exactly with the skin of the nose. This is why the forehead flap is used so much for nasal reconstruction.

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Wikipedia