Residency · Residency · Plastic Surgery
Nasal Reconstruction: The Paramedian Forehead Flap
Introduction
The paramedian forehead flap is the workhorse of nasal reconstruction for moderate to large nasal defects, considered the gold standard since its description by Kazanjian and refinement by Menick and Burget. Based on the supratrochlear artery, it provides reliable, well-vascularized tissue with excellent skin color and texture match to the nose. Indications include defects from Mohs micrographic surgery for skin cancer, traumatic nasal loss, and revision rhinoplasty with soft tissue deficiency. The subunit principle (Burget and Menick) guides reconstruction: if >50% of a nasal subunit is lost, the entire subunit should be resurfaced for optimal aesthetic result.
Reconstruction requires a systematic approach to the three layers of the nose: inner lining, structural framework, and external cover.
Nasal Anatomy
Subunits
The nose is divided into nine aesthetic subunits: dorsum, tip, columella, paired sidewalls, paired ala, and paired soft tissue triangles. Borders between subunits correspond to natural light reflexes and shadows, which camouflage scars placed along these boundaries. The tip and ala are the most complex subunits due to their convex contour and the need for cartilage support.
Nasal Framework
Upper lateral cartilages: fused to the caudal edge of the nasal bones; contribute to the internal nasal valve (10-15 degree angle). Lower lateral cartilages (LLC): medial, intermediate, and lateral crura; define tip shape and alar contour. Septum: provides central structural support; a source of autologous cartilage for grafting. Loss of cartilaginous support leads to alar collapse, nasal valve obstruction, and poor aesthetic contour.
Blood Supply
External nose: supratrochlear artery, dorsal nasal artery (from ophthalmic), angular artery (facial artery), and lateral nasal artery. Internal lining: branches of the superior labial artery, greater palatine artery, and anterior ethmoidal artery. The supratrochlear artery exits the orbit approximately 1.7-2.2 cm lateral to midline, courses deep to the corrugator supercilii, then becomes superficial above the brow.
<image>Anatomical illustration of the nose showing the nine aesthetic subunits (dorsum, tip, columella, paired sidewalls, paired ala, paired soft triangles) with color-coded boundaries, alongside a sagittal cross-section showing the three layers of nasal reconstruction: inner lining, cartilage framework, and external skin cover</image>
Defect Analysis
Three-Layer Assessment
Inner lining: mucosa and vestibular skin; deficiency causes cicatricial contracture and nasal obstruction; must be reconstructed first. Framework: cartilage and bone; provides structural support and defines nasal shape; reconstruct second. External cover: skin and soft tissue; provides contour and color; reconstruct last (paramedian forehead flap).
Defect Classification by Depth
Superficial: skin only; local flaps or skin grafts often sufficient. Partial thickness: skin and cartilage loss; requires cartilage grafting and flap coverage. Full thickness: all three layers absent; complete reconstruction of lining, framework, and cover required.
Decision-Making Framework
Defects <1.5 cm: bilobed flap, nasolabial transposition flap, or dorsal nasal (Rieger) flap. Defects 1.5-2.5 cm: consider local flaps or paramedian forehead flap depending on subunit involvement. Defects >2.5 cm or involving multiple subunits: paramedian forehead flap is the optimal choice.
The Paramedian Forehead Flap
Flap Design
Pedicle: based on the ipsilateral supratrochlear artery; pedicle width of 1.2-1.5 cm. Doppler mapping of the supratrochlear artery preoperatively confirms vessel location. Template of the nasal defect (or entire subunit if applying the subunit principle) is used to design the skin island on the forehead. Flap is oriented vertically on the forehead with the skin island positioned to maximize use of forehead skin between hairline and brow.
Effective flap length: brow to hairline (~5-7 cm skin island plus 2-3 cm pedicle); arc of rotation reaches the nasal tip and ala. For patients with a low hairline, the flap may be designed obliquely or tissue expansion may be considered.
Surgical Technique: Stage 1
Template creation: precise template of the defect (or completed subunit) from foil or suture packaging. Template placed on forehead, oriented vertically, contralateral to the defect side when possible. Incise the flap from distal to proximal; in the upper forehead, dissect in the subcutaneous plane to thin the flap. At the brow level, include frontalis muscle and periosteum in the pedicle to protect the supratrochlear artery as it transitions from deep to superficial.
Rotate the flap 180 degrees; avoid kinking the pedicle. Inset the distal skin island into the nasal defect with precise three-layer closure. Forehead donor site: close primarily as much as possible; remaining defect heals by secondary intention or is skin grafted.
Structural Cartilage Grafting
Septal cartilage: first-line graft source; provides flat, strong cartilage for dorsal, sidewall, and alar batten grafts. Conchal cartilage: curved; ideal for alar contour grafts and lower lateral cartilage replacement. Rib cartilage: for large structural requirements when septal and conchal sources are insufficient; risk of warping. Common grafts: alar batten grafts (prevent alar collapse), columellar strut (tip support), dorsal onlay graft (contour), lateral crural strut graft (alar support). Cartilage framework is placed and secured before or during external cover placement.
Inner Lining Reconstruction
Residual septal mucosa: bipedicled septal mucoperichondrial (septal pivot) flap based on septal branch of superior labial artery. Ipsilateral septal mucoperichondrial flap (door flap): hinged on the septum; rotated laterally to line the nasal sidewall and ala. Folded forehead flap: the distal portion of the flap is folded on itself to provide both lining and cover (increases bulk). Nasolabial flap: for alar lining; based on the angular artery; tunneled into the nasal vestibule. Free mucosal grafts: from turbinate or septum for small lining defects; less reliable than vascularized options.
Stage 2: Pedicle Division (3-4 Weeks)
Allow 3-4 weeks for neovascularization of the flap from the recipient bed before dividing the pedicle. Division and inset of the pedicle: excise excess tissue at the pedicle base, thin the proximal flap, and return the pedicle skin to the glabella and medial brow. Contour refinement: thin the flap to match native nasal skin thickness; sculpt to define subunit contours.
Three-Stage Paramedian Forehead Flap
Menick's three-stage technique: adds an intermediate stage for flap thinning and cartilage grafting. Stage 1: transfer the flap (full thickness). Stage 2 (4-6 weeks): elevate the flap, thin aggressively, place cartilage grafts for structural definition. Stage 3 (4-6 weeks): divide pedicle and final contouring. Produces superior aesthetic results for complex defects, particularly of the nasal tip and ala.
<image>Step-by-step surgical illustration of the paramedian forehead flap: (A) nasal tip and alar defect with template creation, (B) forehead flap design based on the supratrochlear artery with pedicle marked, (C) flap elevation showing the plane of dissection transitioning from subcutaneous distally to subperiosteal at the pedicle, (D) flap rotated 180 degrees and inset into the nasal defect with primary forehead closure</image>
Complications
Partial flap necrosis: usually distal; from excessive thinning at stage 1, pedicle kinking, or vascular injury; minimize by preserving pedicle width and including frontalis at the brow. Pin-cushioning: trap-door deformity of the inset flap; managed with steroid injection or surgical revision. Alar notching: from inadequate cartilage support or cicatricial contraction of the inner lining; prevent with alar batten grafts. Nasal airway obstruction: from lining contracture or inadequate valve support; may require revision with cartilage grafting.
Forehead donor site: visible scar, alopecia (if flap extends into hairline), sensory loss (supratrochlear nerve). Asymmetry: careful preoperative planning with templates and subunit analysis minimizes this risk.
<image>Before and after clinical photographs showing nasal reconstruction with a paramedian forehead flap: preoperative full-thickness nasal tip defect, and 6-month postoperative result showing restored nasal tip contour, alar symmetry, and healed forehead donor site</image>
Key Clinical Pearls
The subunit principle (Burget and Menick) is foundational: resurfacing entire subunits when >50% is involved produces superior aesthetics by placing scars at natural subunit junctions. Three-layer reconstruction (lining, framework, cover) is essential for full-thickness defects; neglecting any layer leads to functional and aesthetic failure. The supratrochlear artery is the key to flap reliability; Doppler localization and including frontalis/periosteum at the brow protects the vessel. Aggressive thinning at stage 1 risks distal flap necrosis; Menick's three-stage technique allows safe thinning at an intermediate stage after neovascularization. Always place structural cartilage grafts (alar battens, columellar struts) to prevent long-term alar collapse and nasal valve compromise.
References
- Menick FJ. Nasal reconstruction with a forehead flap. Clin Plast Surg. 2009;36(3):443-459.
- Burget GC, Menick FJ. The subunit principle in nasal reconstruction. Plast Reconstr Surg. 1985;76(2):239-247.
- Boyd CM, Baker SR, Fader DJ, Wang TS, Johnson TM. The forehead flap for nasal reconstruction. Arch Dermatol. 2000;136(11):1365-1370.
- 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(6):1405-1416.
