PARAMEDIAN FOREHEAD

FLAP FOR NASAL

RECONSTRUCTION
Oleh : Dewa Ayu Agung Anggita Ningrat
Introduction
Paramedian forehead flap :

• Interpolated flap
An interpolation flap is a at least 2-stage tissue flap in which the base of
the flap is not immediately adjacent to the recipient site.
• Pivot point is at medial orbita (near medial canthus)
• Axial flap: Supratochlear artery as main artery
• Flap of choice for nasal reconstruction
History

• 700 BC by Sushruta  for

nasal amputation
• Kazanjian  supratochlear
artery as main blood
supply of the flap (1930)
• Millard, Gillies, dan
Converse  innovation of
design flap
Millard’s gull-
Indian median flap Gillies’ up- Converse
winged
and-down design
paramedian
flap forehead flap
Anatomy
Blood Supply of forehead:
Midline and paramedian
• Dominant: supratochlear artery
• Collaterals : dorsal nasal branch of the angular
artery, supraorbital artery plexus periorbital
rich with anastomosis

Layers of Forehead - Scalp :

-Skin
-Subcutaneous
-Galea aponeurotica – Fibromuscular
Frontalis muscle and Corrugator
muscle
-Loose areolar connective tissue
-Periosteum
Anatomy
Supratochlear Artery
-Supratochlear and supraorbital artery (lies laterally)
 terminal branches of ophthalmic artery (branch of
internal carotid artery).
-Located 1.-2.2 cm from midline, corresponding to
medial border of eyebrow
-Travel vertically upward under the frontalis muscle

-Divided into :
1) Superficial branch : enter frontalis muscle 
surface of galea  subcutaneous tissue (until 3.5
cm above orbital rim)
2) Deep branch : within subgaleal fascia  until 1.5-4
cm above supraorbital rim  Crosses the orbital
sandwiched between corrugator and frontalis
muscles
-Many penetrating vessels
Nasal Sub Unit
• Subunit topografi
-Dorsum
-Tip
-Columella
-Paired Sidewalls
-Paired alae
-Paired soft triangles

• Zone of skin quality:

- Zona I : smooth, thin and non-sebaceous. glides easily over the underlying
bone and cartilage
- Zona II : Skin is stiff, thick, and filled with sebaceous glands
- Zona III : Skin is smooth, thin, and non-sebaceous. fixed to the deep cartilage
and fibrofatty structures and dose not move easily.

• Nasal layer :
-Skin/Cutaneous
-Subcutaneous : Superficial fatty panniculus, fibromuscular layer, deep fatty
layer, periosteum/perichondrium
-Internal lining : mucose
-Structural support : Bone, cartilage, fibrofatty
Nasal Sub Unit
• Subunit topografi
-Dorsum
-Tip
-Columella
-Paired Sidewalls
-Paired alae
-Paired soft triangles

• Zone of skin quality:

- Zona I : smooth, thin and non-sebaceous. glides easily over the underlying
bone and cartilage
- Zona II : Skin is stiff, thick, and filled with sebaceous glands
- Zona III : Skin is smooth, thin, and non-sebaceous. fixed to the deep cartilage
and fibrofatty structures and dose not move easily.

• Nasal layer :
-Skin/Cutaneous
-Subcutaneous : Superficial fatty panniculus, fibromuscular layer, deep fatty
layer, periosteum/perichondrium
-Internal lining : mucose
-Structural support : Bone, cartilage, fibrofatty
Nasal Reconstruction
Nasal Base 

Nasal Lining

Nasal Support
Nasal Defect Evaluation
Size:
Small defects : <1.5 cm
Medium defects : 1.5–2.5 cm
Large defects : >2.5 cm

Depth:
Superficial
Partial thickness
Full thickness
Superficial Defect: Partial Thickness Defect Full Thickness Defect 
Location: Cutaneous Included cutaneous surface,
Based on nasal sub units internal lining, structural
support
Indication
• Nasal defect is larger than 1.5 cm
• Full thickness defect
• Requires replacement of support or lining
• Located within the infratip or columella.

Etiology :
• Excision of (malignant) skin tumours
• Trauma, burns
• Infection
Advantages
• Large amount of donor
• Size, skin color, texture and thickness  match the nose
• Low turning point  making it easy to reach the defect
• The proximal pedicle is narrow primary closing of donor on proximal
forehead --> medialization of the eyebrow is not significant.
• Abundant blood supply  revascularization of cartilage and bone grafts
covered by the flap, distal donor can heal by secondary intention
• Multilaminar  to fill considerable fill
• Muscle and subcutaneous fat from the distal portion can be removed 
thin, pliable, and easily contoured to fit any defect
Disadvantages
• Multiple stages (2-3 stages)  patients must tolerate
• Conspicuous donor site(Forehead)
• Difficult in short forehead patient
• May include hair bearing scalp
• May remain raw surface area of donor

Contraindications :
-Previous forehead or orbital trauma/surgery  interruption of blood supply
-Previous radiation to donor
-Patients who cannot leave their surgical sites undisturbed
-great care in patients who are receiving anticoagulant therapy or in patients with bleeding
disorders.
Technique

2-Stages Approach

3-Stages Approach
2-Stages Approach
Defect Design
-Start by marking nasal subunits --> design the
template to cover missing subunit

-If defect involves >50% of convex nasal

subunit (tip, ala,) consider discarding
adjacent normal tissue within the subunit
so that the entire subunit is resurfaced,
rather than just part of it.

-Template of defect is made using pliable

material (foil/suture packaging)
Flap Design
-Flap template is based the on the
contralateral normal side if it is available

-Doppler at the brow to capture the

dominant arterial inflow.
 The pedicle is located about 2 cm
lateral to the midline near the medial
eyebrow.

-The base of the flap is designed 1.3-1.5

cm wide to include the pedicle.

-Measure needed flap length

Flap may be extended to 1.5 cm below
orbital rim and above hair bearing scalp

-Rotate to mark distal flap 2

Flap Elevation
-Incise around the marked borders of flap

-Flap is raised from distal to proximal (superior to

inferior)

-Defect portion of flap (distal) is raised in

subcutaneous plane (above galea/frontalis muscle).
Frontalis muscle may be included to fill deep defect

-Remained portion of flap is raised in subgaleal plane

-Forehead flap can be elevated over the periosteum at

the supraorbital rim

-The flap is wrapped in a moist gauze until inset

Flap Inset
• Flap is rotated medially (clockwise
or anti clockwise)
• Pivot point is near medial cantal
(medial orbita)
• Considering deepening the recipient
bed to match the flap depth and/or
thinning distal 1/3-1/2 of flap 
thinning fascia and frontalis muscle
• Undermining adjacent defect skin to
decrease trap door defect
• Suture : 5-0 or 60 nylon/prolene for
skin only , no deep suture

Subdermal incisions along distal borders of flap  removal

of subcutaneous fat.
Donor Closure
• Donor defect is limited to the central-
lateral forehead.
• The defect is closed as much as
possible using a T-shaped scar.
• The adjoining tissues are pulled
together vertically and horizontally.
• Not to attempt to close the donor site
at the level of the rotation to prevent
pinching and venous congestion of
the flap.
• Remianing defect on the forehead
left to heal by secondary intention or
by skin graft
Division of Pedicle
• 3-4 weeks after flap transfer  distal portion of the flap
has developed sufficient collateral blood supply 
pedicle is divided
• The pedicle is separated at superior margin of defect
(cephalic portion of flap)
• The defect is closed along the line of the PMFF closure ,
returning eyebrow to its anatomic position
• Undermining in subgaleal plane
• Incision is closed with 5-0 nylon interrupted stitches
• The remnant pedicle is completely excised in fusiform
shape
• Remained raw surface area  secondary intention In
general, flaps wider than 4.5 cm are too large to allow
complete closure
3-Stages Approach
Defect/Flap Design
Just the same with 2-stage approach
First Stage

First Stage
• Elevating a full-thickness flap, including the skin,
subcutaneous tissue, and the underlying frontalis
muscle.
• Without initial thinning of flap
• Caution : removal of the underlying myocutaneous
tissue  may partially devitalize the distal tip of the
flap and expose raw dermal tissue that is prone to
fibrosis.
Second Stage

• After 3–4 weeks, the skin of the flap is

reelevated from its distal inset (2-3 mm
thickness)
• Healed underlying frontalis and subcutaneous
tissue remaining adherent to the wound bed.
• The supratrochlear pedicle remains intact
during this intermediate stage operation
• The thinned forehead skin is returned to the
contoured recipient
Third Stage
Third Stage
• The final stage is pedicle division
• Proximal portion of pedicle
• Occurring at 6-8 weeks after the first stage or 3-4 weeks
after second stage

Appearance after first, second, and third stage

Post Op Care
-Cleaning the suture lines with normal saline and application of topical
antibiotic for 3 days
-Avoid excessive sunlight exposure for 6 moths  prevent post
inflammatory hyperpigmentation
-Sutures are removed on 7th-10 th postoperative day
Complication
Flap necrosis Infection
flap's rich perfusion, flap necrosis is unlikely to occur
 failure in aseptic
If it happens the result of severe ischemia (excessive
tension on the flap, a misidentification of past injury, techniques or necrosis of
nearby scar formation, fanatic inset to the recipient the
site or exaggerated flap thinning)  Complete daebridement
excise dead tissue at an early stage than to wait
watchfully allowing the injury to heal secondarily 

Recurrence Eyebrow malposition

• New tumor develops
Donor closure was forced to be primary
• First reconstruction was not good enough. closed
• A second flap can be taken from the contra
lateral side in most instances
Journal Reading

(Plast Reconstr Surg Glob Open 2021;9:e3591; doi: 10.1097/GOX.0000000000003591;

Published online 13 May 2021.)
Patients
• Medium and large defect (>1.5 cm)
• Complex nasal defects (need for cartilage framework for inner
lining)
• High risk for vascular compromise;
-Elderly patients (>65 years old)
-Diabetes melitus
-ASA class>3
-Smokers
Outcome

• Aesthetic Outcome
• Flap thickness
• Functional outcome
• Recovery time
• Complication
Outcome

Flap Thickness

• Thinning occurs during the second or intermediate stage, when the

flap has been effectively physiologically delayed and can tolerate
significantly more aggressive thinning.

• 3-stage flaps were significantly thinner

-Nasal tip (1.62 versus 3.26 mm)
-Dorsum (1.84 versus 3.63 mm)
-Sidewall (1.86 versus 3.6 mm)
Outcome
Aesthetic outcome
• Ribuffo et al :
- Visual analog scale (1–10) used to assess aesthetic satisfaction.
-significantly greater in 3-stage group when assessed by both patient and
surgeon at 1 and 6 months.
• Stahl et :
-35-question self-assessment questionnaire developed by a
multidisciplinary team
-No significant difference in overall satisfaction
- subgroup analysis of individual nasal subunits : 2-stage group more
satisfied with the appearance of nasal ala and no difference with the
remaining subunits.
 The authors hypothesized : additional surgical procedure may
lead to increased risk of fibrosis at the nasal ala,
Outcome
Functional outcme
No significant difference
Outcome
Recovery Time

• 3-stages flap cause additional recovery time and absence from

work/school associ- ated with an additional procedure.
Outcome
Complication
• 3-stage increase inherent risks of anesthesia and surgery and surgical site
infection.
• No significant different in others complication (wound dehiscence, flap
necrosis)

• Lo Torto et al17 :
-2-stage : although considered safe, the disruption of the
myocutaneous blood supply may pose a risk in vascularly compromised
patients
-3-stage doesn’t need revision surgery in high vascular risk patient
Conclusion
• The paramedian forehead flap may be approached in either 2 or 3 stages.
• Existing comparative analyses, although limited, suggest that the 3-stage
approach may be beneficial in large, complex nasal defects and in
patients at high risk for vascular compromise.
• Aesthetic results are largely equivocal between the 2 approaches,
• The paramedian forehead flap—in both its 2-stage and 3-stage versions
—is a safe, reliable, and useful flap for the reconstruction of large nasal
defects and will continue to be a staple in the field of reconstructive
plastic surgery for years to come.
• Flap selection should be also based on surgeon comfort,
REFERENCES
• Chung K. Grabb and Smith's plastic surgery. 8th edition. 2014: 1435-1442
• Baker, S. R. (2011). Principles of Nasal Reconstruction. Springer, 2 nd edition
• Lo Torto F, Redi U, Cigna E, et al. Nasal reconstruction with two stages versus three stages forehead
flap: What is better for patients with high vascular risk? J Craniofac Surg. 2020;31:e57–e60.
• Menick FJ. Nasal reconstruction with a forehead flap. Clin Plast Surg. 2009;36:443–459.
• Menick FJ. A 10-year experience in nasal reconstruction with the three-stage forehead flap. Plast
Reconstr Surg. 2002;109:1839–55; discussion 1856.
• Neligan P, ed. Plastic Surgery. 4th edition. London: Elsevier; 2018.
• Stahl AS, Gubisch W, Haack S, et al. Aesthetic and functional out- comes of 2-stage versus 3-stage
paramedian forehead flap tech- niques: A 9-year comparative study with prospectively collected data.
Dermatol Surg. 2015;41:1137–1148.
• Ribuffo D, Serratore F, Cigna E, et al. Nasal reconstruction with the two stages vs three stages forehead
flap. A three cen- tres experience over ten years. Eur Rev Med Pharmacol Sci. 2012;16:1866–1872.