page_title: Nasal reconstruction using a paramedian forehead flap
section_title: Technique
hierarchical_section_title: Nasal reconstruction using a paramedian forehead flap / Technique
caption_attribution_description: English: The defect after adjustement to the aesthetical subunits.
context_page_description: 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.
  — Sir Harold Gillies and D. Ralph Millard
context_section_description: The two most used forehead flap techniques are the two stage and three stage forehead flap. The forehead consists of multiple layers; skin, subcutaneous tissue, frontalis muscle with fascia and a thin areolar layer. Traditionally, the forehead flap is transferred in two stages, where the flap is thinned during the first stage to improve the aesthetic result, possibly jeopardizing its vascularity and increasing chance for flap necrosis. To overcome this problem, Menick described a three-stage forehead flap technique, where initially the flap is transferred containing all tissue layers, making it an extremely safe technique. Only during the second stage, the flap - which now acts as a delayed flap - can safely be thinned aggressively according to aesthetic needs. During the final stage the pedicle is severed, the flap is thinned further and pedicle and flap are trimmed and inset. This three stage flap is especially useful for reconstructing large defects, complex contour deformations, or lining defects, while the two stage flap is used for smaller and superficial defects.
  Before surgery all important landmarks and reference points must be identified and marked. Important landmarks are the hairline, frown lines, location of the supratrochlear vessels, outline of the defect, nasal and lip subunits. Then templates are made using the intact side of the nose to make a precise symmetric reconstruction of the nose. The template resembling the defect is placed just under the hairline and the vascular pedicle is drawn downwards into the medial eyebrow. The pedicle is based on the supratrochlear vessels and can be 1.2 cm wide. This way the flap design has been made.
caption: Figure 2. The nasal defect after adjustment to the aesthetical subunits
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