Plastic surgery





Nature will heal almost any wound by secondary intention eventually. Any skin graft or flap or physician can close a defect. But human beings want to look normal. So nasal reconstruction is both a challenge and an opportunity for the specialty of plastic surgery. Success is determined by choice and compromise. The problem is analyzed, options are identified, limitations are appreciated, and the best solution is chosen to achieve the desired outcome.1,2


In some cases, age (a child less than 5 years of age or the extreme elderly), associated illness, or patient desire dictates a less complicated, quicker repair with minimal surgery or stages. The wound can be allowed to heal secondarily, closed with a skin graft or local flap, or, if full thickness, the skin and lining can be sutured to one another, accepting a permanent deformity. Unless underlying vital structures are exposed, an aesthetic repair can always be performed in the future. The occasional patient chooses a prosthetic reconstruction. However, most patients wish to live without deformity and seek surgical repair.

If a complex repair is planned, the surgeon must be aware that past surgical treatments for skin cancer, radiation, trauma or rhinoplasty may add scars, interfere with blood supply, impair healing, and exclude some of the reconstructive options. The operative time, anesthetic requirements, need for hospitalization, number of stages, and the time to completion must be considered and shared with the patient.


Anatomically, the nose is covered by external skin with a soft tissue layer of subcutaneous fat and facial muscle, supported by a mid-layer of bone and cartilage, and lined by stratified squamous epithelium within the vestibule and mucoperichondrium internally. If missing, each layer must be replaced. Thin, conforming skin cover, shaped mid-layer support, and thin, supple lining are required.

Aesthetically, the nose is a central facial feature of high priority. To appear normal, it must have the proper dimension, volume, position, projection, and symmetry. The surface contour is divided into aesthetic regional subunits—adjacent topographic areas of characteristic skin quality, border outline, and three-dimensional contour: the dorsum, tip, columella, and the paired sidewalls, alae, and soft triangles.3 Restoration of these “expected” visual characteristics must occur to make the nose “appear normal” (Figure 33.1).

The character of nasal skin varies by location. The skin of the dorsum and sidewall (zone 1) is thin, smooth, pliable, and mobile. A small amount of excess skin is present within the upper nose. The skin of the tip and ala (zone 2) is thick, stiff, and adherent, pitted with sebaceous glands. The skin of the columella and alar rim (zone 3) is thin but adherent.

A single-lobe local flap can be efficacious within zone 1, but not within zone 2 or 3. A skin graft can blend satisfactorily within the thin skin of the dorsum and sidewall but may look like a shiny and atrophic patch when used to replace thick tip skin. Traditionally, a local or regional skin flap will blend more accurately within the thick skin of the tip or ala.

Nasal defects can be classified as small and superficial or large and deep. A smallsuperficial defect is less than 1.5 cm in size, with intact underlying cartilage. A superficial defect over residual, well-vascularized subcutaneous tissue can be skin grafted. However, a skin graft will not take on exposed cartilage or bone without perichondrium or periosteum unless the wound is allowed to granulate to improve the vascular bed. The defect may be resurfaced with a local flap, regardless of vascularity, with more predictable skin quality.

A skin graft adds skin to the nasal surface and can be applied to a defect of any size if its bed is well vascularized. In contrast, local flaps do not add skin to the nose. They rearrange residual skin and redistribute it over the nasal surface. Although a modest amount of excess skin is present within the dorsum and sidewall, no extra skin is available within the tip and ala. Most single-lobe local flaps, because of skin laxity and mobility, can be effectively employed for defects of the dorsum and sidewall, but not for wounds within the thick adherent skin of the inferior nose. No local flap will reach into the infratip or columella. When used inappropriately, local flaps may compromise the underlying residual or repaired cartilage support because of the tension of local skin rearrangement.

A largedeep defect is greater than 1.5 cm or one that requires cartilage grafts for support or lining replacement. If the defect is greater than 1.5 cm, there is often not enough residual skin to spread over the entire nasal surface without distorting the mobile tip or alar rims. A local flap is precluded, although a skin graft may still be employed if its bed is well vascularized. A regional flap from the forehead or cheek will be needed to supply missing skin cover or to vascularize a reconstructed support framework or lining.

FIGURE 33.1. The aesthetic subunits of the nose are determined by the three-dimensional contour of the nasal surface.

Bones and cartilage support the nose, impart a nasal shape to the soft tissues of both lining and cover, and brace a repair against the force of myofibroblast contraction. If missing, support must be restored.

The normal ala is shaped by compact fibrofatty soft tissue and contains no cartilage. However, if significant external skin or internal lining is missing from the ala, the internal fibrofatty support becomes inadequate. Cartilage must be placed along the new nostril margin to maintain shape and projection, even though the ala normally contains no cartilage.

In the past, bone and cartilage grafts were placed secondarily, months after the initial reconstruction. Unfortunately, once soft tissues are healed, scarring makes secondary re-expansion and reshaping more difficult. In almost all instances, support should be resupplied prior to the completion of wound healing and prior to the pedicle division of regional flaps used for skin coverage.

Soft tissue foreign bodies, such as injectable or implantable allografts, increase the risk of infection, fibrosis, and later extrusion. As a result, nasal reconstruction is usually best performed with autogenous tissues.


The approach to repair will be influenced by the site, size, depth, and condition of the wound. A fresh wound or healed injury may not reflect the true tissue deficiency. The apparent defect may be enlarged by edema, local anesthesia, gravity, and resting skin tension or diminished by wound contraction due to secondary healing. A prior repair may be distorted by inaccurate tissue replacement—too much or too little. Infection or borderline vascularity may preclude immediate reconstruction.

A preliminary operation may be required to debride necrotic tissue or control infection, or release old scars, replace normal tissue to its normal position, open the airway, or perform preliminary surgical delay, prefabrication, or expansion of the donor site.

Missing tissues must be replaced in exact dimension and outline. If too little tissue is replaced, underlying support grafts collapse under tension and adjacent normal landmarks are dragged inward, distorting the residual landmarks and pushing the lining downward, obstructing the airway. If too much tissue is supplied, adjacent landmarks are pushed outward, distorting the external shape of the nose. The surface area of missing tissue is often underestimated and almost 8 × 8 cm of both lining and cover surface must be supplied in a total nasal defect.


Traditionally, the method of tissue transfer is chosen based on wound vascularity and depth. Skin grafts are used to resurface well-vascularized, superficial defects. Skin flaps are used to supply bulk to a deep defect or to cover a poorly vascularized recipient site, a wound with exposed vital structures, or an exposed or restored support framework or lining.

Unfortunately, the ischemia associated with skin graft “take” leads to unpredictable color and texture match. Even when harvested from traditional facial donor sites (preauricular, postauricular, or submental areas), the quality of a skin graft is unpredictable. Skin grafts often appear shiny and atrophic. Skin grafts are ideally suited to supply thin skin to the dorsum/sidewall or columella/nostril margin, rather than within the thicker skin of the tip and ala where they blend poorly and create a patch-like appearance. A skin graft harvested from the forehead is an exception.

In contrast, a well-healed flap, which maintains its perfusion, retains the skin quality of its donor site. If harvested from a site where the skin quality matches that of the defect, it maintains its characteristics after transfer.

Remember that myofibroblasts lie within a bed of scar between a skin graft or flap and its recipient bed. Although a full-thickness skin graft may shrink minimally within its boundaries, it does not rise above the level of the adjacent recipient skin. In contrast, flaps often “pin cushion,” as the underlying scar contracts. This creates a trapdoor effect that may raise the skin surface of a facial flap into a convex form. For this reason, flaps are best used to resurface convex recipient sites—the tip or ala—as a subunit. Fibroblast contraction under a subunit flap enhances the repair of a convex surface subunit but will distort a repair if the defect lives within the flat sidewall. A skin graft is best for planar or concave recipient sites, such as the dorsum, sidewall, soft triangle, and columella. A subunit flap is best for larger convex tip and alar units.


Each defect requires variable amounts of cover, support, and lining. Donor materials are chosen by determining the dimension and quality of missing tissues, the available excess within the donor site, and its ability to be transferred as a skin graft over a vascularized bed or a flap on a vascular pedicle with an adequate arc of rotation.


1.  Establish a goal. The objective may be a healed wound or the restoration of normal appearance.

2.  Visualize the end result. Normal is described by the skin quality, border outline, and three-dimensional contour.

3.  Create a plan. Specific operative stages, donor materials, and methods of transfer of cover, lining, and support are outlined, prior to the repair. Reconstructive choices will determine the ability to achieve success.

4.  Consider altering the wound in site, size, depth, or position. Most nasal wounds heal with minimal scarring. Scars interfere with a successful reconstruction only when they distort the contour or quality of expected subunits. If a defect of the convex tip or alar subunit is resurfaced with a flap and the wound encompasses greater than 50% of that subunit, consider discarding adjacent normal skin within the subunit. Resurface the entire subunit, rather than just patching the defect. Subunit resurfacing of a convex subunit harnesses the deleterious effects of the trapdoor contraction that occurs under a flap. The pincushioned convexity contributes to the uniform restoration of subunit contour. This is in contrast to the visible “bulge” created by a small flap placed within part of the tip or ala. If residual tissues are distorted by the old scar or a previous repair, normal landmarks must be returned to their normal position at the start of repair.

5.  Use the ideal or the contralateral normal as a guide. A template of the contralateral normal is made to create a mirror image of the true defect or subunit and then used to design flaps and grafts.

6.  Replace missing tissue exactly to avoid overfilling or underfilling of the defect.

7.  Use ideal donor materials. Covering the skin must be thin, conform to the underlying subcutaneous architecture, and match the face in color and texture. Cartilage and bone grafts must be thin, but supportive. The nasal framework must extend from the nasal bone superiorly to the alar margin inferiorly and from the tip anteriorly to the maxilla posteriorly. Cartilage grafts support the repair against gravity, shape the overlying cover and underlying lining, and brace the repair against scar contraction. Each graft is carved to create a subsurface framework, which will be visible through thin, supple covering skin. Lining materials must be vascular enough to support the early cartilage grafts and supple enough to conform to the shape of the overlying support grafts. Lining must be thin, neither stuffing the airway nor bulging outward, distorting the external shape of the nose.

8.  Ensure a stable platform. The defect may be limited to the nose. However, a composite nasal defect that includes two or more facial units may extend onto the adjacent cheek and lip. The lip and cheek provide the maxillary platform on which the nose sits in specific position and projection. A shifting lip/cheek platform pulls the repaired nose inferiorly and laterally, under the influence of edema, gravity, and tension, distorting an otherwise satisfactory result. Unless the underlying platform is stable, composite defects should be reconstructed in stages. The lip and cheek are repaired during a preliminary procedure. The nose is repaired at a later date.


An appreciation of normal determines the principles of aesthetic reconstruction that restore a normal appearance.1,2 The anatomic loss determines the stages, materials, and methods required to replace missing tissues.

Injury to the nasal platform, lining, support, and covering skin is identified and an operative plan developed. Assessment and surgical repair begins with platform, lining, support, and finally covering skin. This basic approach is modified by training and experience.

The Nasal Base Platform

If the nasal defect extends onto the lip and cheek, the nasal platform must be re-established first.4 If the composite defect is limited to the skin and superficial soft tissues of the cheek and lip, nasal repair can be combined with immediate shifting of the cheek and lip skin flaps for cover and a subcutaneous fat island flap (Gillies/Millard fat flip flap) to supply soft tissue bulk.

Deeper and more extensive composite defects should be repaired in stages, after the completion of wound healing. The nose is repaired only when the facial platform of the lip and cheek is stable after a preliminary operation using major cheek flaps, a cross-lip Abbe flap, or microvascular tissue transfer.

Nasal Lining

The Composite Skin Graft. Composite skin grafts, taken from the ear, can be used to repair small defects, which include both cover and lining, along the alar margin or columella. They survive if placed on a well-vascularized recipient bed and immobilized. They are best employed for defects not greater than 1.5 cm, which have been allowed to granulate for 7 to 10 days. The color and texture of a composite skin graft are unpredictable and they may appear thin and atrophic over time.

Local Hingeover Lining Flaps. If a full-thickness defect has been healed, the external skin bordering the defect can be turned over for lining, based on the scar along the border of the full-thickness defect. Such flaps are thick, stiff, and risk necrosis, if greater than 1.5 cm in length. The airway, at the point of the hingeover, is often constricted. Although useful for limited rim defects or in salvage cases, they are unpredictable and are not a first choice in significant defects.

Prelaminated Skin Graft and Cartilage for Lining under a Forehead Flap. A preliminary operation can be performed several weeks prior to formal nasal reconstruction. A composite graft from the ear or septum or separate pieces of skin and cartilage are placed under the distal end of the planned forehead flap 6 weeks prior to its elevation and transfer to the nose. Once healed to the undersurface of the forehead, these preinstalled lining grafts can create a satisfactory alar margin. However, the reconstructed nose is poorly supported and bulky. The technique is limited to small defects in elderly patients to avoid a more complex procedure.

Intranasal Lining Flaps. Residual nasal lining remains within the nose and piriform aperture after injury. It is perfused by the anterior ethmoid artery along the dorsum, the angular artery at the alar base, and from branches of the superior labial artery that perfuse the right and left septal mucoperichondrium (Figure 33.2).5,6

In smaller unilateral defects, residual vestibular skin, lying above the defect, can be elevated as a 6 mm bipedicle flap, based laterally at the alar base and medially on the septum. The flap is advanced inferiorly to line the nostril margin. The defect that remains within the lining donor site is filled with a contralateral intranasal lining flap, based on the dorsum, or a skin graft.

In larger unilateral defects, an ipsilateral septal flap can be hinged laterally to line the lower vestibule and alar margin. A second contralateral mucoperichondrial flap, based dorsally on the nasal bridge, is hinged laterally to line the upper vault. This dorsal flap can be used alone to reconstruct an isolated defect of the sidewall or can be combined with the bipedicle vestibular flap.

An anteriorly based septal composite mucoperichondrial flap, based at the nasal spine and composed of the entire septum, can be advanced out of the piriform aperture, based on the right and left superior labial vessels. This flap can supply dorsal support and bilateral leaves of septal mucoperichondrium to line a central nasal defect. Excess mucoperichondrium can be reflected laterally to provide a modest amount of additional lining for the dorsum and vestibules. These extensions will not reach the alar base.

Overall, intranasal lining flaps are thin, vascular, and supple enabling the placement of primary cartilage grafts. They require moderate to significant intranasal manipulation and the associated morbidity of bleeding and crusting. They are useful for moderate-sized lining defects. Prior traumatic, surgical, or radiation injury to their blood supply precludes their use.

Skin Grafts for Lining. A full-thickness skin graft can survive on the deep surface of a full-thickness forehead flap. One month later, the skin graft is integrated and vascularized into the adjacent normal lining. The forehead flap can be re-elevated, excess soft tissue excised, and delayed primary cartilage grafts placed for support and to prevent significant skin graft contracture. Or, a primary cartilage graft can be placed within a subcutaneous tunnel within a full-thickness forehead flap and a skin graft applied simultaneously for lining. Either technique is useful, although not a first choice, for small lining defects. Because of the risk of poor take and significant contracture, large lining defects should not be repaired with skin grafts.2

Folded Forehead Flap for Lining. An extension of a full-thickness forehead flap can be folded to supply lining. Traditionally, the distal end of a two-stage forehead flap was thinned and folded inward, without cartilage support; the result was poorly contoured and unsupported reconstruction usually followed. In recent years, a full-thickness forehead flap has been folded for lining, but an intermediate operation is performed prior to pedicle division to integrate flap thinning and delayed primary cartilage grafts. Support and a three-dimensional nasal shape are provided.

FIGURE 33.2. Intranasal lining flaps—residual lining which remains within the defect can be shared, based on individual axial vessels, to restore missing lining. Defects of the lateral midvault can be lined with a dorsally based contralateral mucoperichondrial flap, perfused by the anterior ethmoid vessels. Defects of the nostril margin can be lined with a bipedicle vestibular flap or ipsilateral mucoperichondrial flap. The composite flap of the entire septum based on the nasal spine can restore lining and basic support to the dorsum and columella.

Folded skin becomes re-vascularized by adjacent residual lining and is no longer dependent on the covering flap for blood supply. One month after forehead flap transfer, the more proximal covering skin of the forehead flap is incised along the planned alar rim margin, during an intermediate operation. Thin forehead skin is elevated with a few millimeters of subcutaneous fat. Underlying excess soft tissue is excised from the exposed surface of the lining, revealing a thin, supple, and well-vascularized lining surface. Delayed primary support grafts are placed to support the ala and sidewall. A complete support framework is restored prior to pedicle division without the intranasal manipulation associated with intranasal lining flaps and without the unpredictability of skin graft “take.” The modified folded flap should be the “workhorse” for the repair of common lining defects.1,7

Microvascular Lining. The site, size, and depth of tissue loss, prior irradiation, or a massive composite injury to the adjacent cheek and lip may make local tissues inadequate or unavailable. A regional forehead flap can be combined with a free flap, most often a radial forearm flap.

A forearm flap can be folded for the vault and columella with a skin extension for the nasal floor, permitting primary dorsal grafting and providing a long vascular leash for microvascular anastomosis.8

Others have designed separate vascularized skin paddles on the radial artery (like a string of beads), sutured together to provide individual lining flaps for the vault, columella, and nasal floor. The short vascular leash and the need to temporarily skin graft the external raw surface of the forearm flap, which precludes primary dorsal support, may make this approach less desirable.9

During later stages, a subunit support framework and a forehead flap for covering the skin are added (Figure 33.3).

Nasal Support

An architectural framework must be in place to establish support, shape, and resist scar contraction. Ideally, it is established prior to pedicle division with primary or delayed primary cartilage grafts placed at the time of flap transfer or during an intermediate operation. Cartilage grafts can be placed secondarily, months after reconstruction, but their ability to provide projection and contour is less predictable due to the scarring of soft tissues.1,2

If the underlying normal bone and cartilage remain intact, support replacement may be unnecessary, although it may be useful to reinforce tip support with sutures or a columellar strut. Although the ala normally contains no cartilage, a cartilage graft may be needed within the reconstructed ala after soft tissue injury or tumor excision to maintain support and shape. Septal, ear, or rib cartilage are used depending on the size, volume, contour, and strength required.

FIGURE 33.3. Microvascular lining—a single distal paddle of radial forearm skin, with an extension for the nostril floor, can be folded to provide lining for the nasal vaults, columella, and nasal base and allow the placement of primary dorsal support within the folded skin envelope. Alternatively, multiple individual paddles can be incised to create individual islands of skin for the vault, columella, and nasal sill. Primary support is precluded by the temporary skin grafting of the external raw surface of these individual paddles.

When support is missing, each graft is fashioned to mold the overlying skin and the underlying lining into the expected nasal shape: a dorsal buttress, a sidewall brace, tip graft for projection and definition, and an alar batten to support and position the alar margin. Support grafts are designed to replace the missing nasal bones, upper lateral cartilage, tip cartilages, and the missing soft tissue support of the ala (Figure 33.4).

In extensive midline defects, the septum may be absent. A strong central midline support must be re-established to prevent soft tissue collapse of the tip and dorsum. Several methods are useful, often in combination. When the septal composite lining flap is pivoted anteriorly, lining and central support are positioned simultaneously out of the piriform aperture. This creates a basic platform on which to rest other grafts—a dorsal graft, columellar strut, alar battens, and sidewall grafts. The dorsum can also be supported with a cantilever dorsal graft of rib or cranial bone fixed with a wire, screw, or plate to the nasal bones.

Nasal Cover

Small, Superficial Defects. Small, superficial defects within planar or concave surfaces and that do not border adjacent mobile landmarks that might be distorted by wound contracture can be allowed to heal by secondary intention. Defects less than 0.5 cm can be closed primarily within the more mobile skin of the dorsum or sidewall.

Full-thickness grafts from the forehead, postauricular, preauricular, or supraclavicular areas are useful within the thin skin zones of the upper two thirds of the nose. Although unpredictable in color and texture, the smooth and atrophic surface of a skin graft tends to blend within these smooth, thin skin zones. Uniquely, a full-thickness forehead skin graft can blend well within the thick skin of the tip or alar subunit and is a useful option to repair small, superficial defects within the thick skin zones.1 It is often advisable to allow the wound to granulate for 7 to 10 days before skin graft application.

Skin grafts are immobilized with a light bolus dressing for 5 to 7 days and must be placed on a well-vascularized bed. The principle of subunit excision is not applied when resurfacing the nose with a skin graft.

FIGURE 33.4. Support grafts—primary or delayed primary grafts of cartilage or bone are placed to shape and support the soft tissues against gravity and scar contracture and are designed to restore the shape of the individual nasal subunits.

Composite chondrocutaneous grafts from the auricular helix, rim, or earlobe can repair small defects (less than 1.5 cm) of cover and lining along the alar rim and columella. Composite grafts consist of variable amounts of cartilage positioned in a sandwich of outer and inner skin, with or without a skin-only extension. Any part of the graft that lies more than 5 mm from the vascular recipient inset will probably not survive. The “skin-only” extension of a composite graft will behave as any full-thickness skin graft and is not really part of the composite graft. Initially, composite grafts appear white, but over 48 hours, they become blue and congested. Over the next 3 to 7 days, they become pink as the blood supply is re-established. Some believe that cooling for the first 36 hours decreases the metabolic demands of the composite graft and improves “take.”

Except as a temporary wound dressing, split-thickness skin grafts are not employed on the nose because they provide insufficient soft tissue bulk, contract, and hyperpigment.

Single-lobe transposition flaps provide an excellent color match.10 They are useful for defects less than 1.5 cm in the lax mobile skin of the upper one third of the nose, as an alternative to a skin graft. Their 90° arc of rotation makes them unreliable within the thick, stiff skin of the tip or ala due to dog-ear and vascularity concerns.

The geometric bilobed flap (Figure 33.5) is useful for defects up to 1.5 cm within the thick skin zones of the tip and ala.11 A bilobed flap moves the tissue from an area of excess within zone 1 to an area of deficiency within zone 2. Rules for its design are:

1.  Allow no more than 50° of rotation for each lobe.

2.  Excise the triangular dog-ear between the defect and the rotation point, prior to flap rotation.

3.  Undermine widely above the perichondrium on both sides of the incision.

4.  Make the diameter of the first lobe equal to the defect. The second lobe may be reduced in size to ease primary closure of the secondary defect.

FIGURE 33.5. The bilobed flap. A. The skin of the superior two thirds of the nose is mobile. The skin of the tip and ala is thick and tight. The excess in the superior nose is transferred in one stage with a bilobed flap. The pivot point dog-ear is excised. The defect created by the first flap is closed with a second flap, which is closed primarily. B. The flap is elevated in the areolar layer above the perichondrium and includes fat and nasalis muscle with the skin. C. Closure.

FIGURE 33.6. Dorsal nasal flap—residual skin and soft tissue of the superior nose is transferred to the dorsum and tip. A Burow’s triangle excision of the glabella or nasal root may be needed on closure.

dorsal rotation advancement flap can be employed to resurface dorsal and tip defects with residual dorsal skin (Figure 33.6).12

All local flaps can provide good coverage for defects up to 1.5 cm in size that lie at least 0.5 cm above the alar rims and above the tip-defining points. When used for other defects, local flaps may create significant distortion of the tip and nostril margins.

A superiorly based, single-stage, nasolabial flap can be designed as an extension of a sliding cheek advancement flap.1 It is used to resurface defects of the sidewall and ala. A Burow’s triangle is excised at the pivot point toward the inner canthus. Periosteal sutures re-create the nasofacial sulcus and minimize tension on the advanced flap. Rather than just redistributing nasal skin, this flap adds regional skin from the cheek to the nose, minimizing the risk of alar rim or tip distortion (Figure 33.7).

Large, Deep Defects. A two-stage nasolabial flap can provide a moderate amount of excess skin from the nasolabial fold to reconstruct the ala, as a subunit.13 Its size and arc of rotation are short and it will not reach the tip or dorsum or resurface a heminasal defect. It will not tolerate tension (Figure 33.8). When greater than 50% of the alar subunit is missing, residual normal skin is discarded within the subunit. An exact foil template of the contralateral normal ala is positioned along the nasolabial fold. The flap is elevated with a few millimeters of subcutaneous fat distally, maintaining a proximal deep superior subcutaneous base, perfused by perforators from the facial and angular arteries.14 A primary cartilage graft is applied to the underlying residual or reconstructed lining, and the flap is transposed medially to resurface the ala. The donor site within the nasolabial fold is closed primarily. A few weeks later, the pedicle is divided and partially re-elevated, excising excess soft tissue. A two-stage nasolabial flap can achieve an aesthetic alar subunit reconstruction. Although hidden in the nasolabial fold, the scar created by this technique is in the central face and distorts the contour of the medial cheek. It is best applied to the elderly patient with a defined nasolabial crease and medial cheek excess.

Forehead skin is acknowledged as the ideal donor for nasal reconstruction due to its color and texture, vascularity, and the ability to resurface all or part of the nose. Supplied by vessels from the supraorbital, supratrochlear, superficial temporal, postauricular, and occipital vessels, forehead skin has been transposed on numerous pedicles.14

Most commonly, a vertical paramedian flap, based on a single supratrochlear pedicle, is designed extending from the brow to the hairline. The pivot point is lowered by incising across the medial brow toward the medial canthus, lengthening the flap, and minimizing the presence of hair-bearing scalp on the distal flap. If hair follicles are present on the reconstructed nose, they are removed later by depilation. The forehead skin is thicker than nasal skin. The flap must be thinned by excising frontalis and subcutaneous fat at the time of transfer or during an intermediate operation.

A two-stage forehead flap is useful for smaller, more superficial defects. At the time of transfer, the distal flap is thinned by excising frontalis and subcutaneous fat before transposition and inset to the nose. Three to 4 weeks later, the pedicle is divided and the proximal aspect is debulked and inset, completing the repair (Figure 33.9).1,2

A three-stage forehead flap is used in smokers, in patients with scars within the flap’s territory, or to resurface major defects. The 3 stage forehead flap method maximizes the surgeon’s ability to restore complex three-dimensional contour with primary and delayed primary cartilage grafts and soft tissue excision.1,7 Initially, the flap is transferred as a full-thickness flap without thinning, after restoration of missing lining and primary support. One month later, the forehead skin is elevated from the recipient site with 2 to 3 mm of subcutaneous fat, maintaining the proximal pedicle intact. The underlying excess frontalis and subcutaneous fat are excised from the recipient bed. Thin forehead skin is then returned to the recipient site, now contoured by soft tissue excision and delayed primary cartilage grafts, if needed. The pedicle is divided 1 month later (2 months after the initial forehead flap transfer). The three-stage approach maximizes vascularity and the surgeon’s ability to create nasal contour by soft tissue excision and delayed primary cartilage grafting. Most importantly, it permits modification of the distal tip and ala, after flap transfer, but prior to pedicle division. The full-thickness three-stage forehead flap allows two additional modifications: the folded distal extension of a forehead flap and the use of skin grafts for nasal lining.

FIGURE 33.7. The one-stage nasolabial flap—defects of the sidewall and ala can be resurfaced by advancement of a cheek flap with a skin extension of the cheek excess adjacent to the nasal labial fold. A Burow’s triangle is excised toward the medial canthus to allow flap advancement.

FIGURE 33.8. The two-stage nasolabial flap. A. Because of its convex surface contour, a significant defect within the ala is best resurfaced as a complete alar subunit to minimize pin cushioning. Residual normal skin is discarded if the defect is greater than 50% of the subunit. Lining is supported with a primary cartilage graft. B. Based on an exact pattern of the opposite ala, the template is designed and placed precisely along the nasal labial fold. Distally, the flap is tapered to prevent excision of the dog-ear on closure. Proximally, the skin pedicle is tapered to keep the final scar of closure from extending onto the nasal subunit. A wider vascular subcutaneous pedicle base is maintained during flap elevation. The distal flap is thin, maintaining 2 to 3 mm of subcutaneous fat. C. and D. At the first stage, the flap was transposed to resurface the entire subunit. The cheek donor site was closed by advancement. E. and F. Three weeks later, the pedicle is divided. The proximal inset is re-elevated and excess soft tissue sculpted to create a convex alar shape. Final inset is completed. Excess soft tissue in the medial cheek is excised and the donor closure completed.

If the upper aspect of the forehead donor site cannot be closed primarily, it is best left to heal by secondary intention. Multiple flaps can be taken from the forehead without significant deformity.Preliminary forehead skin expansion is not used routinely but can be invaluable in the short (3 to 4 cm), tight, or scarred forehead or after previous forehead flap harvest.

In the rare circumstance where the forehead donor is unavailable and the nasal defect cannot be repaired with a skin graft or a local flap, the nose must be resurfaced with distant skin. Arm flaps, abdominal tube pedicles, deltopectoral flaps, or cervical flaps are of historic interest only. Free flaps, principally the radial forearm flap, have been employed. Unfortunately, distant tissues provide poor color and texture match to the adjacent facial skin. The future of free flap nasal reconstruction lies not as cutaneous coverage but in its use to restore missing lining in massive defects, irradiation, or the cocaine or immunologic injury.


Most repairs heal uneventfully. Small areas of necrosis of lining or cover flaps may be allowed to heal secondarily, but in larger areas of necrosis, early debridement and replacement with vascularized tissue are vital to prevent underlying cartilage infection and progressive chondritis, scarring, and contraction. Once demarcation is obvious and prior to infection, if cartilage grafts are exposed, they are covered by advancement of the covering flap or a second vascularized flap. Exposed cartilage after lining debridement is removed, banked if possible, and a skin graft placed for temporary lining.

FIGURE 33.9. Forehead flap. A. The paramedian forehead flap is based on the supratrochlear vessels just lateral to the frown crease. The blood supply is abundant in the central forehead. B. Vertical paramedian design. The flap is designed vertically directly above the supratrochlear vessels. The forehead, which includes several millimeters of subcutaneous fat and frontalis muscle, is thicker than the nasal skin. The excess soft tissue bulk must be excised prior to the completion of repair. As shown here, in the two-stage technique, frontalis muscle is left at the forehead donor site and only distal forehead skin is transferred to the defect at the first stage. In the three-stage technique, the full thickness of the forehead is transferred to maintain flap viability at transfer, permit the use of a skin graft or folded lining technique, and maximize the use of delayed primary cartilage grafts for contour.

Infection may occur in patients with a history of multiple facial repairs or infection, in contaminated wounds, or in complex defects. Culture-specific antibiotic treatment with early debridement of all infected cartilage must be preformed to limit chondritis. Replacement of support is delayed for 4 to 6 weeks.


Most major reconstructions require a revision to establish near-normal appearance and function.1 In fact, many local flap repairs of smaller, superficial defects create significant scars and contour distortions that require revision.

Since edema and induration require about 4 months to resolve, revisions are usually performed at that time.

When the overall dimension and volume of the nose are correct, soft tissue excision and secondary cartilage graft placement are performed through new incisions, hidden in the junctions between subunits. Disregarding the original scars, soft tissues are excised to define the alar crease or nasolabial fold. Rim excisions are performed to thin or reposition a malpositioned nostril margin. Local tissue excess is used to open the stenotic airway.

When overall dimension and volume are incorrect, gross debulking of excess tissue is performed through peripheral incisions along the border of the previous transferred flap. Underlying soft tissue and cartilage support are modified after extensive re-elevation of the old flap. An additional operation to further refine the nasal landmarks, such as the alar crease, may be required through direct incisions.


1.  Menick FJ. Nasal Reconstruction: Art and Practice. Philadelphia, PA: Saunders–Elsevier; 2008.

2.  Burget GC, Menick FJ. Aesthetic Nasal Reconstruction. St Louis, MO: Mosby; 1994.

3.  Burget GC, Menick FJ. Subunit principle in nasal reconstruction. Plast Reconstr Surg. 1985;76:239.

4.  Menick FJ. Defects of the nose, lip, and cheek: rebuilding the composite defect. Plast Reconstr Surg. 2007;120:887.

5.  Burget GC, Menick FJ. Nasal support and lining: the marriage of beauty and blood supply. Plast Reconstr Surg. 1989;84:189.

6.  Burget GC, Menick FJ. Nasal reconstruction: seeking a fourth dimension. Plast Reconstr Surg. 1986;78:145.

7.  Menick FJ. 10-Year experience in nasal reconstruction with a 3 stage forehead flap. Plast Reconstr Surg. 2002;109:1839.

8.  Menick FJ, Salibian A. Microvascular repair of heminasal, subtotal and total nasal defects with a folded radial forearm flap and a full-thickness forehead flap. Plast Reconstr Surg. February 2011;127:637-651.

9.  Burget GC, Walton R. Optimal use of microvascular free flaps, cartilage grafts and a paramedian forehead flap for aesthetic reconstruction of the nose adjacent facial defects. Plast Reconstr Surg. 2007;120:1171.

10.  Elliot RA. Rotation flaps of the nose. Plast Reconstr Surg. 1969;44:147.

11.  McGregor JC, Soutar DS. A critical assessment of the bilobed flap. Br J Plast Surg. 1981;34:197.

12.  Marchac D, Toth B. The axial frontonasal flap revisited. Plast Reconstr Surg. 1985;76:686.

13.  Menick F. The two-stage nasolabial flap for subunit reconstruction of the ala. In: Cordeiro P, ed. Operative Techniques in Plastic and Reconstructive Surgery. Vol 5. Hoboken, NJ: John Wiley; 2006;59-64.

14.  McCarthy JG, Lorenc PZ, Cutting C, et al. The median forehead flap revisited: blood supply. Plast Reconstr Surg. 1985;76:866.