Aesthetic Refinements in Forehead Flap Reconstruction of the Asian Nose

Abstract

Background: Traditional paramedian forehead flap reconstruction exploits the aesthetic subunit principle. Refinements and outcomes of forehead flap nasal reconstruction largely reflect Western experience. Differences in ethnic Asian anatomy and wound healing may foster suboptimal outcomes. We modified methods to address Asian features by extending subunit and flap boundaries, minimizing flap thinning, and overbuilding the nasal framework to combat contraction and suboptimal scarring.

Methods: Between November 2010 and September 2015, 40 Asians were treated for nasal reconstruction with a modified forehead flap technique. Average age of 26 men and 14 women was 50.2 years (range: 10-87 years). Oncologic, traumatic, congenital, and infectious defects involving 1 (37%) or more (63%) subunits were reconstructed. Modifications to the classic forehead flap were extension of involved subunits and flap, conservative flap thinning, and framework overbuilding.

Results: Patients were followed for 20 months (range: 16 months to 4 years 8 months). Nasal lining was reconstructed with hinge-over lining flaps, forehead flaps, free flaps, or regional flaps. Cartilage was reconstructed in 44 (88%) patients with autologous septum or ear in 33 (75%) cases. Costal cartilage was needed in 11 (25%) cases. In 48 (96%) cases, the ipsilateral forehead was used. There were 5 (10%) wound infections, 2 (4%) dehisced wounds, and 2 (4%) occurrences of distal flap necrosis. Nasal aesthetic results were 72.6% good, 23.3% fair, and 4% poor. Donor site aesthetic results were 74% good and 26% fair. Three case reports are included.

Conclusion: We report favourable results of forehead flap nasal reconstruction using refinements tailored to ethnic Asians.

Keywords: cartilage framework; forehead flap; nasal reconstruction.

Figure 1.

Refinements in forehead flap reconstruction include (A) identification of subunits warranting reconstruction, (B) removing the subunit that was extended by 1 mm in all directions (dotted red line), (C) designing and extending (dotted purple line) over the supratrochlear axis and reinforcing cartilage framework (blue arrow), and (D) paramedian forehead flap to cover the extended defect.

Figure 2.

Case 1. A, Front and side views of defect. B, Intraoperative views including left alar reinforcement (yellow arrow) and skin grafting of donor site. C, Reasonable healing and maintenance of results at 15 months with scars along subunit boundaries. A 56-year-old woman was involved in traffic accident resulting in subtotal nasal amputation. The tip, dorsum, both side walls, columella, and left ala were involved. In the first of 4 stages, defects were extended beyond traditional subunit margins except for the ala, since less than half that subunit was affected. Skin thickness at the tip was documented, and there was no lining defect. Septal cartilage was sufficient for columellar and left alar reinforcement as a strut and onlay graft, respectively. A foil template was designed to mirror existing intact structures. The preliminary design was transferred to forehead and extended in all directions. Approximately half the wound was closed primarily, with the remainder left to heal secondarily. The left paramedian forehead flap was conservatively thinned 4 weeks later to match the recipient site. Subsequent division was performed 4 weeks after thinning, with further refinement 2 months after that.

Figure 3.

Case 2. A, Intraoperative view showing cheek and side wall involvement before (left) and after (right) cheek advancement. B, Intraoperative view showing template and extension (dotted line) of flap marking. C, Satisfactory result with minimal alar notching at 20 months. A 68-year-old man had a partial nasectomy for recurrent basal cell carcinoma. A full-thickness defect included 2 cm × 1.5 cm of lining and skin of the right side wall, ala, and cheek. A right-sided facial advancement flap addressed the cheek defect. Affected subunits were marked and extended beyond traditional side wall and alar margins. A folded right-sided paramedian forehead flap was designed to replace lining and skin. The majority of the wound was closed primarily, with the remainder left to heal secondarily. The cartilage framework at the right alar rim was overbuilt in the second stage. Subsequent flap division and additional refinement stages were performed at 2 and 4 months, respectively.

Figure 4.

Case 3. A, Preoperative front and side view of woman with spindle cell tumour of nasal tip. B, Intraoperative view after extirpation that preserved all cartilages (left) still required cartilage reinforcement (right, yellow arrow). C, Post-operative view at 19 months shows reasonable scar position coincident with the aesthetic tip subunit. A 61-year-old woman was treated for a stage I spindle cell tumour of the nasal tip with wide resection. After margin control was confirmed, the skin defect encompassed the tip, part of the nasal dorsum, and side walls. A defect-based template was crafted, transferred to the right forehead, and extended per routine. In the first stage, septal cartilage was used to reinforce the upper and lower cartilages at the midline and a shield graft was used to enhance tip projection. The wound was closed primarily. Flap thinning and division were performed in 2 subsequent stages at 1 and 2 months, respectively. An excellent aesthetic result was obtained by 19 months with no need for additional refinement.