Because of its ideal color and texture, forehead skin is acknowledged as the best donor site with which to resurface the nose. However, all forehead flaps, regardless of their vascular pedicles, are thicker than normal nasal skin. Stiff and flat, they do not easily mold from a two-dimensional to a three-dimensional shape. Traditionally, the forehead is transferred in two stages. At the first stage, frontalis muscle and subcutaneous tissue are excised distally and the partially thinned flap is inset into the recipient site. At a second stage, 3 weeks later, the pedicle is divided. However, such soft-tissue "thinning" is limited, incomplete, and piecemeal. Flap necrosis and contour irregularities are especially common in smokers and in major nasal reconstructions. To overcome these problems, the technique of forehead flap transfer was modified. An extra operation was added between transfer and division.At the first stage, a full-thickness forehead flap is elevated with all its layers and is transposed without thinning except for the columellar inset. Primary cartilage grafts are placed if vascularized intranasal lining is present or restored. Importantly, at the first stage, skin grafts or a folded forehead flap can be used effectively for lining. A full-thickness skin graft will reliably survive when placed on a highly vascular bed. A full-thickness forehead flap can be folded to replace missing cover skin, with a distal extension, in continuity, to supply lining. At the second stage, 3 weeks later during an intermediate operation, the full-thickness forehead flap, now healed to its recipient bed, is physiologically delayed. Forehead skin with 3 to 4 mm of subcutaneous fat (nasal skin thickness) is elevated in the unscarred subcutaneous plane over the entire nasal inset, except for the columella. Skin grafts or folded flaps integrate into adjacent normal lining and can be completely separated from the overlying cover from which they were initially vascularized. If used, a folded forehead flap is incised free along the rim, completely separating the proximal cover flap from the distal lining extension. The underlying subcutaneous tissue, frontalis muscle, and any previously positioned cartilage grafts are now widely exposed, and excess soft tissue can be excised to carve an ideal subunit, rigid subsurface architecture. Previous primary cartilage grafts can be repositioned, sculpted, or augmented, if required. Delayed primary cartilage grafts can be placed to support lining created from a skin graft or a folded flap. The forehead cover skin (thin, supple, and conforming) is then replaced on the underlying rigid, recontoured, three-dimensional recipient bed. The pedicle is not transected. At a third stage, 3 weeks later (6 weeks after the initial transfer), the pedicle is divided. Over 10 years in 90 nasal reconstructions for partial and full-thickness defects, the three-stage forehead flap technique with an intermediate operation was used with primary and delayed primary grafts, and with intranasal lining flaps (n =...
The face tells the world who we are and materially influences what we can become. The nose is a primary feature. Thin, supple cover and lining are shaped by a middle layer of bone and cartilage support to create its characteristic skin quality, border outline, and three-dimensional contour. The delicacy of its tissues, its central projecting location, and the need to reestablish both a normal appearance and functional breathing make its reconstruction difficult. Nasal repair requires careful analysis of the anatomical and aesthetic deficiencies. Because the wound does not accurately reflect the tissue deficiency, the repair is determined by the "normal." A preliminary operation may be required to ensure clear margins, recreate the defect, reestablish a stable nasal platform on which to build the nose, and prepare tissues for transfer. Major nasal defects require resurfacing with forehead tissue; support with septal, ear, or rib grafts; and replacement of missing lining. This requires a staged approach.
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