Esthetic Refinements in Forehead Flap Nasal Reconstruction

Vito C. Quatela, MD; David A. Sherris, MD Mark F. Rounds, MD

Objective: To identify refinements in forehead flap nasal reconstruction that consistently provide better esthetic and functional results.

Design: Case series of patients undergoing forehead flap nasal reconstruction from July 1, 1987, to May 31, 1994.

Setting: University hospital ambulatory surgery depart­ment.

Patients: Thirty-two patients with various nasal defects.

Interventions: Modifications of currently accepted techniques of paramedian forehead flap nasal recon­struction, namely, flap harvest and contouring, W-plasty closure of the superior forehead donor site, and creation of soft-tissue triangles. The principles of open-structure rhinoplasty are incorporated into carti­laginous reconstruction of the the nasal tip and columella. The alar rim is reconstructed with cartilage grafts placed at the nasal rim.

Main Outcome Measures: Esthetic and functional results of nasal reconstruction were subjectively graded by three otolaryngologists (V.C.Q., D.A.S., and M.F.R.) and the patients.

Results: Improved esthetic and functional nasal recon­struction. The most common nasal subunits recon­structed were as follows: ala, 27 patients (84%); side-wall, 22 patients (69%); dorsum, 18 patients (56%), and tip, 15 patients (47%). The esthetic results ranged from average to excellent (3 to 5 on a scale of 5), the func­tional results ranged from improved to much improved over preoperative breathing (4 to 5). Two patients re­quired unplanned surgical revisions. Forty-seven per-cent of patients chose to undergo dermabrasion. Five pa­tients required postoperative intradermal injection of triamcinolone acetonide (Kenalog). Three patients re­quired preoperative tissue expansion. Flap or graft loss, infection, or hematoma did not occur.

Conclusions: The predictability of the techniques in providing excellent results in patients undergoing nasal reconstruction decreases the need for revision procedures and helps the patient and the surgeon achieve the de-sired outcome.

Nasal reconstruction may have been performed as long ago as 3000 BC in India. The first written record of the Indian forehead flap was in 1440. In 1837, Warren performed the first forehead flap nasal reconstruction. The work of Millard,' and Burget and Menick has elevated nasal reconstruction to an art form.

Millard, starting in 1966, described the evolution of important concepts that are true today. Millard was one of the first to recommend placing the skeletal support for the nose before or at the time of soft-tissue reconstruction.' Previous authors had recommended reconstructing soft-tissue structures first and replacing skeletal structure later. Unfortunately, soft-tissue contracture prevents optimal skeletal reconstruction at the secondary procedure. More recently, Millard described modifications of forehead flap harvest, creation of internal nasal lining with nasal skin turn-in flaps, and creation of dorsal and tip sup-port with chondromucosal septal composite flaps. In 1967, he wrote that "in general, it is better to cover the entire half nose with a one-piece unit rather than just patch the hole.

ATERIALS AND METHODS
During the study period from July 1, 1987, to May 31, 1994, 32 patients underwent forehead flap nasal reconstruction in the division of Otolaryngology Head and Neck Surgery at the University of Rochester (NY) Medical Center . In-formed consent was obtained before the patients under-went treatment. The medical charts of the patients were ret­rospectively reviewed periodically by us for subjective analysis of results and appropriate modification of techniques. The techniques described are the result of refining this procedure during the study period.

Table 1 gives the subunits involved and recon­structed. The most common subunits that were recon­structed were the ala, sidewall, dorsum, and tip of the nose. The soft-tissue triangles and the columella were rarely de­ficient. Table 2 gives the tissue layers involved. Most de­fects involved skin and cartilage with or without a lining defect, but some involved skin only.

INDICATIONS
Guidelines for the use of the midline forehead flap in nasal reconstruction are not absolute. This flap is typically used to reconstruct defects larger than 2 cm in diameter and down to the depth of nasal cartilage or deeper. Defects of this size usually involve more than 50% of one or more subunits.

FLAP HARVEST
Some authors have described harvest of the precise midline forehead flap based on supratrochlear vascular pedicles. We prefer the paramedian forehead flap based on one supra­trochlear vascular pedicle. The anatomic basis for this flap design has been described.' The supratrochlear vessel con­tralateral to the nasal defect is marked after it is identified by atopical Doppler scope as it exits the superior medial orbit. Precise identification of the vascular pedicle allows maxi­mal narrowing of the pedicle to 1 cm (Figure 1). The nar­row pedicle harvested from the side contralateral to the de­fect provides maximal flap length and ease of rotation.

The shape of the flap to be harvested is planned using a foil template made from the corresponding undisturbed sub-units. The flap is marked as close to the midline as the loca­tions of the vascular pedicle and hairline allow (Figure 1). This ensuress closure of the donor site in the midline. Midline scars of the face, and especially the forehead, are less perceptible when healed. Some authors advocate forehead tissue expansion for reconstruction of large nasal defects. We believe that tissue ex­pansion is indicated only in patients with less than 5 cm be­tween the eyebrow and the hairline. We have harvested flaps measuring up to 5X6 cm without tissue expansion.

LINING REPLACEMENT
In full-thickness defects, the nasal lining needs to be re-placed to provide a deep layer to act as a bed for cartilage grafts. Local mucosal advancement flaps can be used in small defects. Some authors have described mucoperichondrial and mucochondral flaps from the nasal septum.'" These flaps occasionally are useful for unilateral full-thickness de­fects. When used for bilateral nasal lining, they result in iatrogenic nasal septal perforations, which we consider ex­cessive donor-site morbidity. In most unilateral nasal lin­ing defects and all bilateral nasal lining defects, we recom­mend the use of local epidermal turn-in flaps harvested from the local nasal subunit to be reconstructed or from the ad­jacent nasolabial crease (Figure 2). These flaps are de-epithelialized in their subcutaneous portions and are sutured into place with absorbable sutures. Commonly, transna­sal bolster sutures and packing are used to obliterate dead space between the lining and structural reconstruction.

CARTILAGINOUS RECONSTRUCTION
Cartilaginous and bony structural reconstruction is done at the time of primary flap placement. Solt-tissue contracture prevents optimal results if structural reconstruction is un­dertaken secondarily.' The nasal septum is the primary do-nor site for material to reconstruct the cartilaginous defects of the nose. The long, thick cartilage along the premaxillary crest provides excellent material for the alar reconstruction or the columellar strut. The cartilage along the bony carti­laginous junction at the ethmoid plate provides good mate­rial for the structural nasal tip graft and lateral sidewall. If not enough septal cartilage is available, auricular cartilage har­vested from the conchal bowl can be used. If auricular car­tilage is unavailable, rib cartilage can be harvested, although the donor-site morbidity is higher than for the other two sites.

Applying the techniques of open structure rhinoplasty, the cartilaginous nose can be precisely reconstructed with more than preexisting structure. Because the flap acts like the skin and soft-tissue envelope in rhinoplasty, the cartilaginous re-construction must be sounder than the natural nose to oppose the deforming forces of flap contracture. The missing cartilagi­nous structure is sequentially reconstructed. In cases of loss of the nasal tip, a columellar strut is placed in a pocket between the medial crura of the lower lateral cartilages just superficial to the nasal spine and fixed with 4-0 plain gut horizontal mat-tress sutures (Figure 3). A structural-shield nasal tip graft de-scribed by Johnson et al is then sutured to the reconstructed nasal tip with 5-0 or 6-0 nylon sutures. The caudal medial Crura are sculpted to form a receptacle bed as necessary. Multilay­ered tip grafts can be used to change nasal tip rotation and pro­jection (Figure 4).

Alar rim defects are reconstructed by fixing convex bat-tens precisely at the level of the planned alar rim caudally, rather than at the more cephalad, natural position of the lower lateral cartilage (Figure 5). This nonanatomic place­ment of the alar reconstruction prevents retraction at the alar rim. Medially, the alar batten is typically sutured to the medial crural remnant, the columellar strut, or the oppo­site lower lateral cartilage, depending on the original de-exception was that if the alar rim was intact, one could spare this structure and hide the suture line in the natural line of the alar crease. This principle is known as subunit nasal reconstruction.

The principle of subunit nasal reconstruction is based on the broader principle of esthetic units of the face. Gonzalez-Ulloa et al" separated the face into esthetic units based on skin thickness, color, texture, and contour. The nose is considered a separate esthetic unit in this system. Burget and Menick

Laterally, the alar batten is fixed to the periosteum and soft tissue at the pyriform aperture. Permanent suture ma­terial is used to prevent graft migration during flap con­tracture. A horizontal mattress suture of 5-0 chromic gut is placed through the batten and the inner nasal lining to prevent deadspace during initial healing.

SKIN AND SOFT-TISSUE ENVELOPE RECONSTRUCTION
The distal one third of the midline forehead flap is thinned to the suhdermal layer at the time of harvest to give better esthetic results (Figure 6). In this region of the flap, the supratrochlear vessels run superficial to the frontalis muscle and can be directly visualized during flap thinning.' If the pedicle is damaged in the distal one third of the flap, this region will survive as a random flap based on the subder­mal plexus. Hair follicles harvested in the flap are cut to prevent hair growth at the recipient site.

The flap is inset at the alar rim with subcutaneous ab­sorbable sutures and monofilament skin sutures. The natu­ral, thin, webbed appearance of the soft-tissue triangles can-not be reconstructed immediately with the thicker forehead flap tissue. We have found that leaving these small areas open at the time of flap inset allows healing by secondary intention that better approximates the natural appearance (Figure 7). Sutures are placed to within 5 mm of the soft-tissue triangle along the alar rim and columella, thereby eliminating a notched appearance.

Horizontal mattress stay sutures of 5-0 monofila­ment material are placed through the outer and inner lin­ing at the cephalic margin of the newly formed ala and are tied over external cotton bolsters (Figure 8. This ma­neuver fixes the distal flap and cartilage grafts at the de-sired level and creates the supra-alar hollow in the new skin and soft-tissue envelope. The distal flap has never been lost, even with aggressive bolstering. A standard rhinoplasty dressing of taping and Aquaplast (Zinnanti Surgical In­struments, Woodland Hills , Calif ) cast are always used to avoid hematoma formation. Petroleum-impregnated gauze (Xeroform) is placed under the unattached pedicle and proximal flap. Antibiotic ointment is applied to the fresh wound edges.

DONOR-SITE CLOSURE
As previously explained, the donor site lies as close to the midline as anatomic constraints allow. Some authors ad­vocate direct midline closure, while leaving the cephalic most aspect of the harvest site open to close by contrac­ture if it is under undue tension. We prefer to use a W-plasty closure at the hairline combined with bilateral fore-head advancement flaps (Figure 9). The W-plasry is planned so that three to four limbs are placed at the donor site on the cephalic side. The W-plasry is then extended to either side of the donor site at the level of the hairline. The edges of each unit of the W-plasty measures about I cm, and the angles of the peaks are greater than 90°. The hairline incision is beveled opposite of the direction of the lo-cal hair follicles to allow hair growth through the scar.

Subgaleal advancement flaps are elevated along the en-tire length of the forehead and down to the level of the su­perior orbital rim. Care is taken to preserve the superior orbital nerves. The galea is then closed with 3-0 absorb-able sutures. The lateral-most limbs of the W-plasty on the cephalic side are sutured together, creating Burow's tri­angles, and thereby avoiding "dog-ears" laterally (Figure 10). The subcutaneous tissue is closed with 5-0 absorbable suture, and the skin is closed with 5-0 mono-filament suture. This technique obviates the dressing changes and wound care necessary when this area is al-lowed to heal by secondary intention. In addition, our tech­nique provides scar camouflage similar to that seen with trichophytic forehead lift procedures (Figure 11).

SECONDARY FLAP INSET
During the 3 weeks between the primary and secondary procedures, the patient is instructed to change the petro­leum-impregnated gauze under the unattached flap each day. The rhinoplasty dressing, holster sutures, and skin su­tures are removed on postoperative day 5. The patient is brought back to the operating room on day 21 for pedicle division and final flap inset. The subunits to be com­pletely replaced are marked on the nose. The pedicle is di­vided carefully to leave enough tissue attached to the dis­tal defect for closure. The pedicle remnant is replaced in the midline incision site. Minimal tissue is inset at the fore-head site because attempts to return maximal tissue to the forehead at this time have not provided optimal cosmetic results. Better results have been obtained by returning tis­sue no higher than the level of the glabellar frown lines (Figure 12).

The edges of the unattached flap are sharply incised, and underlying granulation tissue, fat, and sub-cutaneous tissue is aggressively debulked to appropriate thickness. Care is taken not to disturb the subdermal plexus or the portion of the flap that is attached to the distal nasal defect, because these structures provide the new blood supply to the flap. The feeding vessel need not he preserved at this time. The skin and soft-tissue envelope to be replaced is then excised down to the level of underlying perichondrium and periosteum. Hemosta­sis is achieved, and the flap is cut to slightly less than the size of the newly created nasal defect. The subcuta­neous tissue is closed with 5-0 polyglactin (Vicryl) simple buried sutures, and the skin is closed with 5-0 and 6-0 nylon sutures (Figure 12).

The wounds are dressed with antibiotic ointment and nonadhering gauze. The nose is dressed with a rhino­plasty dressing of nasal taping and aquaplast cast. The dress­ing and sutures are removed 5 days later. Dermabrasion to the entire nasal unit and the forehead scar is routinely per-formed 4 to 6 weeks after the secondary procedure. The entire nasal subunit is dermabraded for better color blend­ing between the forehead and nasal skin.
divided the nose into topographic subunits of dorsum, tip, columella, alae, sidewalls, and soft triangles. In 1985, they published the first in a series of articles applying the subunit concept to nasal reconstruction.' In patients with 50% or greater subunit losses, these authors performed esthetically superior reconstruction by removing the remaining portion of the subunit and reconstructing the entire subunit with a skin graft or flap. Burget and Menick later supported the prin­ciple of subunit nasal reconstruction and emphasized that like tissue should be replaced by like tissue. They developed various creative nasal septal mucoperichon­drial and mucochondrial flaps for nasal lining and structural reconstruction. The results obtained by adhering to the principles supported by these innova­tors are self-evident.

Table 1. Reconstructed Subunits in 32 Patients

Subunit	No. (°/) of Patients
Ala	27	(84)
Sidewall	22	(69)
Dorsum	18	(56)
Tip	15	(47)
Soft-tissue triangle	6	(19)
Columella	1	(3)

Still, nasal reconstruction has numerous pitfalls. Like cosmetic rhinoplasty, the combination of contracture of the skin and soft-tissue envelope and inadequate struc­tural strength in the nasal skeleton can result in unto-ward, unpredictable results. In addition, inadequate na­sal lining and notable donor-site morbidity are pitfalls that must be overcome in nasal reconstruction. The suc­cess of modern nasal reconstruction is measured in the adequacy of esthetic and functional replacement of

 

Figure 12. Case 1. Appearance at pedicle division and secondary flap inset.
Figure 13. Case 1. Left, Defect with cartilage graft in place. Right, Three-quarters view 8 months postoperatively.

internal and external nasal lining and cartilaginous struc- ments in flap harvest and contouring, closure of the foreture of the nose. Future improvements in nasal recon- head donor site, and re-creation of the soft-tissue tristruction depend on refinements in techniques that have angle. The principles of open-structure rhinoplasty are been available for years. We describe detailed refine- incorporated into cartilaginous nasal reconstruction. We describe a nonanatomic alar rim reconstruction that results in more natural, consistent reconstruction of this diffi­cult area. These refinements have enabled us to achieve more predictable and consistent results that approach the esthetic standards of cosmetic rhinoplasty.

Table 3. Functional and Esthetic Ratings for Nasal Reconstruction
Tissue Layer Involved	Function, Average Score (Range)	Esthetics, Average Score Range)
Skin only Skin and cartilage Skin, cartilage, and lining	4.63 (4-5) 4.35 (4-5) 4.27 (4-5)	4.33 (3-5) 4.0 (3-5) 3.81 (3-5)

*Ratings for function are I (much worse than before operation) to 5 (much better than before operation), judged subjectively by patients. Ratings for esthetics are 1 (poor) to 5 (excellent), judged by three surgeons.

The esthetic and functional results of nasal reconstruction with the paramedian forehead flap are given in Table 3.

Figure 14. Case 2. Top left, Defect after Mohs' surgery. Top right, Planned cheek rotation flap. Bottom left, Planned forehead flap. Bottom right, Three-quarters view 11 months postoperatively.

Figure 15. Case 3. Top left, Defect of tip, soft-tissue triangles, columella, and dorsal subunits. Top right, Base view 18 months after nasal reconstruction. Bottom left, Three-quarters view of patient before first Mohs' surgery. with basal cell carcinoma visible on nasal tip. Bottom right, Patient after multiple recurrences of basal cell carcinoma of nose and Mohs' surgery and 18 months after nasal reconstruction.

The subjective judgment of the patients that function improved postoperatively is partly because septoplasty was done to harvest cartilage grafts in almost all patients who required structural graft place­ment. Some cases of improved function in the skin-only defects may be attributed to better nasal tip rota­tion or support, although some may be related to general satisfaction with the appearance of the nose. Objective testing of nasal function was unavailable to these patients, although we believe it would support our conclusion that function is improved.

Revision surgery and adjunctive procedures were rarely necessary (Table 4). Dermabrasion was rou­tinely offered, but only half of the patients elected to undergo the procedure. Injection of triamcinolone for prolonged edema and tissue defatting was necessary in five patients. Preoperative tissue expansion was neces­sary in three patients. Complications resulting from forehead flap nasal reconstruction were as follows: one combined alar retraction and flap thickening that required revision surgery, one seroma that resolved with drainage, and one hypertrophic scar in the naso­facial groove that required revision surgery. No cases of airway obstruction, flap loss, cartilage graft loss, or infection were seen in the study group. Case reports are included to illustrate important points.

REPORT OF CASES
CASE 1
A 75-year-old man presented after Mohs' surgery for a nodular basal cell carcinoma. The original defect in­cluded the skin and soft-tissue envelope and cartilage loss to the depth of the inner lining of portions of the dorsal and right sidewall subunits (Figure 13, left). The pa­tient had a cartilage graft that was sewn in place for na­sal sidewall structural reconstruction. After the patient underwent forehead flap reconstruction (Figure 13, right), he reported that his function improved (5 on a scale of 1 to 5). His esthetic result was judged good (4).

CASE 2
A 48-year-old man presented after Mohs' surgery for a basal cell carcinoma of the nasofacial groove that had recurred three times. The original defect included portions of the right cheek unit, the right lateral and alar nasal subunits to the depth of the inner nasal lining, and the right soft-tissue triangle (Figure 14, top left). The cheek defect was reconstructed with a cheek rotation advancement flap (Figure 14, top right). The cartilage was reconstructed with an alar batten. The forehead flap measured 4X5 cm. The donor site was closed primarily (Figure 14, bottom left). The nasofa­cial groove developed a hypertrophic scar and had to be revised 3 months later. The esthetic result was judged as excellent (5)(Figure 1, bottom right), and his function was much improved (5).

CASE 3
A 70-year-old woman presented after Mohs' surgery for a recurrent morpheaform basal cell carcinoma. She had undergone glabellar flap reconstruction of the primary lesion 3 years previously. Because of her low hairline, the patient underwent forehead tissue expansion before re-construction. Tissue expansion was done for 5 weeks. The patient then underwent reconstruction of a defect that included the entire nasal tip (including cartilaginous struc­ture), soft-tissue triangles, portions of the anterior alar subunits, and the dorsal subunit (Figure 1 5, top left). The inner lining was reconstructed with two epidermal turn-in flaps. Cartilaginous reconstruction included bi­lateral alar battens, a columellar strut, and a multilay­ered nasal tip graft (Figures 3 and 4). The soft-tissue tri­angles were allowed to heal by secondary intention (Figure 7). Preoperative and 18-month postoperative views are shown (Figure 15). This patient underwent postopera­tive dermabrasion. She was also rated excellent (5) in func­tion and esthetic results.

The combination of the techniques described result in functional and esthetically acceptable nasal reconstruc­tion. The functional results obtained with epidermal turn-in flaps for inner lining reconstruction, and nonana­tomic, structural cartilage grafts for skeletal support have been excellent. Some authors believe that local epider­mal turn-in flaps are too bulky for inner lining recon­struction, but we have not found this to be true. These flaps are readily available because local tissue is usually resected to complete the subunit defect for reconstruc­tion. The flaps themselves are reliable, and they support the structural cartilage grafts well. In addition, aggres­sive forehead flap thinning, bolstering, and casting provide immediate soft-tissue contouring that can be obtained only at the primary procedure. Finally, the donor-site clo­sure we describe minimizes donor-site morbidity.

The combination of a vascular lining, increased struc­tural support, a properly contoured soft-tissue enve­lope, and minimal donor-site morbidity results in excel-lent nasal reconstruction. Revision procedures are rarely necessary after secondary flap inset. In some cases, the final nasal reconstruction is more esthetically pleasing than the appearance of the nose before surgery (Figure 15, lower left and lower right). The reconstructive sur­geon must strive to improve available techniques until the results of reconstruction equal or surpass the func­tion and esthetics of the anatomic structure that has been repaired. The techniques we describe are one small step toward these final goals in nasal reconstruction.

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