Elegant Solutions for Complex Paramedian Forehead Flap Reconstruction

Nasal reconstruction is one of the most challenging aspects of facial plastic surgery. The authors present reconstructive techniques to maximize the final aesthetic result and minimize scarring. They discuss techniques used in nasal reconstruction with a paramedian forehead flap (PMFF) that help to achieve these goals and minimize the chance of complications, including performing a surgical delay, using generous, supportive cartilage grafts, adding extra length and bulk to the flap at the alar rim and using topical nitroglycerin and triamcinolone injections when indicated. The steps outlined can help to create a more elegant and consistent result in PMFF nasal reconstruction.

Elegant solutions are frequently sought by both artists and engineers. In dance, for example, elegance is defined by the minimum amount of motion that results in the maximum visual effect. Similarly, engineers strive to provide simple and practical solutions to their challenges while efficiently balancing the demands of time, materials, and other constraints. The confluence of art and engineering is never more intertwined than it is in complex multistage nasal reconstruction. The surgeon must draw on both the practical and scientific qualities of an engineer and the creativity of an artist. Experienced surgeons can quickly identify challenges, craft efficient solutions, and optimize reconstructive benefits for their patients with each surgery. In short, experienced surgeons reconstruct complex nasal defects with the most elegant of solutions.

The basic principles and techniques of facial reconstruction have been in use and relatively unchanged for a surprising number of years. As early as the fourth century, a Byzantine physician named Oribasius described advancement flaps, recognized the importance of tension-free closure, and warned of complications in poor wound healers, the elderly, and individuals in generally poor health. Because the human eye can perceive asymmetries of only millimeters, the modern facial plastic surgeon must be creative and precise to recreate facial symmetry as much as is humanly possible.

In evaluating a patient for facial reconstructive surgery, the reconstructive ladder of increasing complexity and surgical involvement must always be discussed and patients must be guided to the surgical option that best suits their needs and goals. A skin defect can be closed primarily, allowed to heal by secondary intention, repaired with a split or full-thickness skin graft, or reconstructed with a local, regional, or free flap. This article describes refinements in the technique of paramedian forehead flap (PMFF) nasal reconstruction by the senior author (SRM) over his years of practice in a university setting.

Preoperative planning

There are several factors to consider before initiating any discussion of reconstructive options for a specific patient. In patients undergoing Mohs surgery, the margins should be pathologically clear before reconstruction. If there is a significant risk of recurrence, methods of reconstruction may be suggested that allow for easy monitoring, such as skin grafting. In such a case, a more cosmetically acceptable definitive reconstruction can be deferred to a later date.

Certain patient populations have poor peripheral circulation, putting them at risk for flap necrosis. Risk factors that cause endothelial dysfunction and impaired neoangiogenesis include tobacco use, poorly controlled diabetes, and irradiation. Tobacco use, in particular, increases the risk of flap necrosis and skin slough, and this has been well documented in patients who have undergone rhytidectomy. A study in patients undergoing breast reconstruction with a transverse rectus abdominis muscle flap suggests the results are best when a patient abstains from smoking for at least 4 weeks both preoperatively and postoperatively. We also advise our patients to abstain from smoking for a minimum of 4 weeks both preoperatively and postoperatively. However, because many Mohs reconstructions present with little forewarning, the smoking status of the patient must be factored into a safe reconstructive plan, with the performance of a delayed PMFF often the method of choice in a patient who smokes.

Only gold members can continue reading. Log In or Register to continue