Nasal Reconstruction With Forehead Flap: Our 12 Years’ Experience

Abstract

Background:

The nose is the part of the face that is most exposed to trauma, sunlight, and other environmental factors. From the aesthetic and functional point of view, reconstruction of the defects occurring after skin cancer removal creates a great challenge for the surgeon. In this retrospective study, we present the success rates achieved in the past 12 years with paramedian forehead flaps used for large nasal defect repairing.

Methods:

Seventy-seven patients were included who underwent paramedian forehead flaps due to nasal skin tumor basal cell carcinoma and squamous cell carcinoma at the division of plastic surgery of IRCCS-Centro di Riferimento Oncologico di Basilicata in Rionero in Vulture from 2010 to 2022. Data on follow-up time, patients’ age and sex, defect sizes, and tumor histology were obtained retrospectively from patient files, histopathologic examination results, and patient photographs. Additional diseases such as diabetes, hypertension, and coronary artery disease that could compromise flap success were noted.

Results:

Of 77 patients enrolled in our cohort, 42 were men and 35 were women. The average age was 68.3 years for male patients and 72.8 years for female patients. The mean follow-up period was 65 months. Of 77 patients, 45 (59.2%) were operated on for basal cell carcinoma and 31 (40.8%) for squamous cell carcinoma. Six patients (5.3%) had recurrence in their follow-up periods. There was no loss of the paramedian forehead flap.

Conclusions:

The paramedian forehead flap is a reliable option in the reconstruction of larger defects of the nose, even in smokers and older patients who have comorbid diseases.

Takeaways

Question: Is the paramedian forehead flap truly a suitable reconstructive option for patients with extensive nasal defects after the removal of skin tumors, even in smokers and patients with comorbidities?

Findings: Our study on 77 patients undergoing paramedian forehead flap for nasal skin tumor excision revealed a 65-month follow-up with no flap loss. Despite challenges like smoking and advanced age, the flap reliably reconstructed large nasal defects, with a 5.3% recurrence rate.

Meaning: Our research shows that paramedian forehead flaps provide a dependable solution for repairing significant nasal defects following skin cancer removal.

INTRODUCTION

The incidence of skin cancer has increased in recent years, and it most commonly occurs in the head and neck region, especially on the nose.^1,2

When nasal defects involve 2 or more cosmetic subunits or more than 50% of 1 cosmetic subunit, these defects require a flap that must be flexible, thin, and well colored. In addition to larger nasal defects involving 2 or more cosmetic subunits or more than 50% of 1 subunit, the paramedian forehead flap can also be a valuable option for smaller defects with exposed cartilage, particularly when other reconstructive techniques, such as skin grafts or dermal substitutes, are not adequate to achieve optimal results.

Maintaining the integrity of aesthetic units is crucial for achieving optimal outcomes in nasal reconstruction. However, in cases with extensive defects, compromises may be necessary to ensure adequate functional coverage and repair. Even the best microvascular tissue grafts are poorly suited for these reconstructions.

Local flaps are the ideal option. Of all the various local flaps, in our opinion, the forehead flap has sought-after characteristics such as versatility, simplicity, and good texture, especially for dorsal and lateral nasal defects.³ The advantages of the frontal site are that the skin here is hairless and thick, matches the nasal skin color, and the flap has a strong, wide pedicle and strong vascular support, usually centered on the brachial artery.^4–6

In cases where the paramedian forehead flap may not succeed, considering alternative techniques, such as those described by Vaena et al⁷ (supraclavicular–submental sandwich flap) and Linh et al⁸ (domino flaps), offers further possibilities for achieving satisfactory aesthetic and functional results. These options can serve as valuable lifelines in complex nasal reconstruction scenarios.

PATIENTS AND METHODS

The study, conducted by the IRCCS CROB Plastic Surgery Department, Rionero, Vulture, between January 2010 and May 2022, included 85 patients with skin cancer who underwent subtotal nasal reconstruction with a paramedian forehead flap. Data on the follow-up period, such as patient age and sex, tumor type and diameter, and surgical technique, were obtained retrospectively from patient files and histopathologic examination results. A total of 85 patients’ data were collected during the retrospective file review, but only 77 patients met our inclusion criteria and were included in our cohort, and 8 patients were excluded from the study because they did not meet the established inclusion criteria. The inclusion criteria collected in our surgical protocol were age 18 years or older, partial thickness defect involving more than half of the original nose, excisional nasal defect following excision of a skin cancer mass, and willingness to conduct the study according to the information provided in this protocol. Cases of total nasal deformity associated with cosmetic surgery or congenital problems, congenital nasal defects, and trauma-related deformities were excluded. Other conditions that may affect the success of the flap, such as diabetes, hypertension, and coronary artery disease, were also mentioned. Most patients were treated in 2 sessions: the first involved flap design, resection of the cancer, and application of the flap; the second was repair of contour irregularities and eventual cutting of the pedicle. Patients with aggressive tumors or large defects were operated on in 3 stages. The first stage included tumor resection and flap application if necessary, the second stage included flap thinning, and the third stage included contour irregularity repair and pedicle amputation. In all patients, tumor resection was performed under general anesthesia, whereas the second and third stages were performed under local anesthesia. In our case series, defects ranged from small (with exposed cartilage) to larger, more complex reconstructions. In cases of smaller defects, the paramedian forehead flap was selected based on the need for enhanced contour and structural support, which were not adequately provided by other reconstructive techniques.

The areas of the defect were calculated from the photographs using a ruler based on the shape of the defect. For defects of a rectangular shape, the area of a rectangle is calculated. In defects of a circular shape, the area of a circle is calculated.

Surgical Procedure

The paramedian forehead flap was one of the first flaps used and described in facial surgery. To locate the supratrochlear artery, the flap is created by using a Doppler probe. In certain cases, we considered immediate thinning of the flap during its creation to improve aesthetic and functional outcomes. However, our standard practice has involved a staged approach to ensure optimal vascularization and minimize the risk of flap necrosis. The base of the pedicle is usually centered on the supratrochlear artery, on the same side as the majority of the nasal defect the flap is intended to repair. The vertical axis of the supratrochlear artery is located 2 cm lateral to the midline, which corresponds to the medial border of the eyebrow in most patients. Thus, the base of the flap is centered on the medial border of the brow. Based on the techniques developed, the procedure was performed; the width of the pedicle should be 1.5 cm, and the base should not be flared, as this limits the rotational movement of the flap. The first step in the paramedian forehead flap is to lift the full thickness of the forehead flap without thinning it (except for the columellar area). The incision was made up to the periosteum, and dissection was performed at the supraperiosteal surface. In cases of full-thickness dorsal defects, auricular composite grafts, skin grafts, and septal turn-in flaps were used for mucosal repair, whereas conchal cartilage, septal cartilage, and rib cartilage were used for cartilage repair. Furthermore, in all patients with alar cartilage defects, the repair was made using conchal cartilage. The technique involved creating a template of the nasal wound using a marking pen along the perimeter and transferring the contour to the foil suture packet, employing a surgical adhesive and sterile surgical tape.⁹ The template was then mapped to the upper part of the forehead, maintaining the appropriate length of the planned pedicle, and the template was rotated 180 degrees, so that it was properly oriented when the flap was lowered. Midline or paramedian forehead flaps can be lifted from 1 or both sides on either the supratrochlear or supraorbital vessel; most surgeons lift the flap over a single supratrochlear vascular pedicle. In the second phase, 3 weeks later, the skin and subcutaneous fat were raised and thinned, except for the columellar area. In addition, underlying muscle and cartilage were shaped to form a firm matrix on which the thin skin can overlie. In the third stage, 3 weeks after the second, the pedicle was cut (6 wk after the first surgery).⁴

The selection of the donor site closure technique was primarily based on flap width. In particular, for flaps with a width greater than 3 cm, tissue expansion was used. For smaller flaps, either healing by secondary intention or split-thickness skin grafts were chosen based on the availability of tissue and patient characteristics. We selectively used the scoring of the frontalis muscle to facilitate primary closure without additional stages. This technique improved both functional and aesthetic outcomes, extending beyond the traditional methods described by Burget.

Statistical analysis was performed using IBM SPSS (IBM SPSS Statistics for Windows, version 25.0, Armonk, NY). The Shapiro–Wilk test was used to assess the normality of data distribution. The groups followed a parametric distribution. Descriptive statistics were used to summarize the data, and results were expressed as mean ± SD. Comparison between groups was performed using (add the test used for comparison, eg, t test or ANOVA). A P value of less than 0.05 was considered statistically significant.

Statistical analysis revealed significant differences in healing times and aesthetic outcomes among the different donor site closure techniques. Tissue expansion showed superior aesthetic results, whereas healing by secondary intention was preferred for smaller defects.

RESULTS

A total of 77 patients were included in our cohort, comprising 42 men and 35 women. The average age of male patients was 68.3 years, whereas female patients had an average age of 72.8 years (Table 1). The mean area of nasal defects was 11.6 cm², with a range from 5.7 to 18.6 cm². The average duration of follow-up was 65 months.

Table 1.

Patients’ Characteristics, Histology, Defect Type, Stage in Surgical Procedure, and Forehead Donor Area Healing

Median Age, y	Histology	Defect Type	Stage in Surgical Procedure	Forehead Donor Area Healing
68.3, male	BCC superficial type: 15 (33.3%)	Skin defect: 14 (18.2%)	Two sessions: 57 (74%)	Skin graft: 37 (48.05%)
72.8, female	BCC infiltrative type:12 (26.7%)	Skin and cartilage: 37 (48.1%)	Three sessions: 20 (26%)	Tissue expansion: 21 (27.27%)
	BCC nodular type: 8 (17.8%)	Full thickness: 26 (33.8%)		Secondary intention: 19 (24.67%)
	BCC micronodular subtypes: 10 (22%)
	SCC: 31 (40.8%)

Repair of the forehead donor site was carried out using 3 distinct methods:

• In 37 patients, healing was obtained thanks to a skin graft.

• In 21 patients, the donor site was reconstructed through pre-expanded random pattern flaps, facilitated by the use of tissue expansion (Figs. 1A-C, 2A-D, 3A-C).

• In 19 patients, healing was obtained by secondary intention.

Fig. 1.

Infiltrative BCC in the region of the nose. As seen, the lesion is widespread and crusted. A tissue expander is positioned in the frontal region. A, Frontal view. B, Lateral view. C, Bottom view.

Fig. 2.

Postoperative after 45 days: the recipient site is completely healed. A, Frontal view. B, Lateral left side. C, Lateral right side. D, Bottom view.

Fig. 3.

After 5 years, there is no sign of recurrence. A, Lateral view. B, Bottom view. C, Frontal view.

Of 77 patients, 45 (59.2%) were operated on for basal cell carcinoma (BCC) and 31 (40.8%) for squamous cell carcinoma (SCC). Among the BCC types, 15 (33.3%) superficial, 12 (26.7%) infiltrative, 8 (17.8%) nodular, and 10 (22.2%) micronodular subtypes were identified. Six patients (5.3%) had a recurrence in their follow-up periods. Of the patients with recurrence, 3 had BCC (1 infiltrative and 1 micronodular) and 3 had SCC. One of the BCC recurrences was seen after 25 months, 1 after 33 months, and 1 after 16 months; 1 of the SCC recurred after 12 months, 1 after 14 months, and 1 after 15 months. In cases of recurrence, the defect was reconstructed by primary intention following re-excision.

When classified according to defect types, 14 (18.2%) patients had only skin defects, 37 (48.1%) had skin and cartilage defects, and 26 (33.8%) had full-thickness defects. Of the 37 patients with skin + cartilage defects, 25 (67.6%) had both alar cartilage and vestibular skin defects, 8 (21.6%) had upper lateral cartilage defects including the overlying skin, and 4 (10.8%) had both lateral and alar cartilage defects (Table 1).

The cartilaginous framework reconstruction was performed with conchal cartilage in 31 (49.2%) patients, septal cartilage in 16 (25.4%) patients, both septal and conchal cartilage in 16 (25.4%) patients, and costal cartilage in 1 patient. For flap planning, we utilized advanced technologies such as Doppler ultrasound and 3-dimensional imaging. These tools allowed for improved precision in flap design, ensuring optimal vascularization and enhanced tissue viability.

The operations were performed in 2 sessions in 57 (74%) patients and 3 sessions in 20 (26%) patients. The third stage was indicated in more complex reconstructions where improving flap contour was essential for superior aesthetic results. Although all flaps survived fully, the additional stage provided enhanced aesthetic outcomes in these more challenging cases. Because the defect was very wide in 3 (3.9%) patients, a malar advancement flap was used, and they waited for 6 months before the defect was repaired with a paramedian forehead flap.

Dehiscence was seen in 6 patients in the frontal donor site. All of these patients were smokers. All patients showed improvement in the recipient site without complications. No complications were seen in the cartilage donor ear in any of the patients from whom conchal cartilage was taken. No flap necrosis was seen in any of our patients.

Aesthetic and functional outcomes were evaluated by comparing different donor site closure techniques, including preoperative expansion, split-thickness skin grafting, and healing by secondary intention. As shown in Table 2, pre-expanded random pattern flaps yielded the best aesthetic outcomes (mean 8.4 ± 0.7), followed by skin grafts (mean 7.2 ± 1.0, P = 0.04) and secondary intention (mean 6.5 ± 1.1, P = 0.05). Although secondary intention produced slightly inferior aesthetic results, the differences were still statistically significant, suggesting its use may be limited in cases where superior cosmetic outcomes are desired.

Table 2.

Patients' Aesthetic Outcome

Closure Technique	No. Patients (n)	Aesthetic Outcome (Mean ± SD)	P
Skin graft	37	7.2 ± 1.0	0.04*
Pre-expanded random pattern flap	21	8.4 ± 0.7	0.02*
Healing by secondary intention	19	6.5 ± 1.1	0.05*

This table provides a clear statistical comparison of the aesthetic outcomes, emphasizing that pre-expanded random pattern flaps yielded the highest mean aesthetic score, followed by skin grafts and secondary intention healing, with all differences being statistically significant (P < 0.05).

^•Closure technique: Lists the different techniques used for donor site closure.

^•Number of patients: The total number of patients who underwent each closure technique.

^•Aesthetic outcome (mean ± SD): The mean aesthetic score obtained for each technique, along with the SD to show the variability of the results.

^•P value: The P value obtained from the t test comparing the aesthetic outcomes of the different techniques.

* Statistically significant.

Thirty-four (48.1%) patients had hypertension, 23 (29.9%) patients had type 2 diabetes, and 9 (11.7%) patients had coronary artery disease. Fifty-six (72.7%) patients had hypertension and diabetes comorbidity, and 51 (66.2%) patients had hypertension, diabetes, and coronary artery disease comorbidity; 30 (39%) patients were smokers.

DISCUSSION

The primary indication for the use of a paramedian forehead flap is the reconstruction of substantial nasal defects. Although alternative methods such as skin grafts or dermal substitutes are commonly used for smaller defects, particularly those with exposed cartilage, we found that the paramedian forehead flap provided superior outcomes in terms of contour, color match, and durability, even for smaller defects. This aligns with the trend toward using robust flaps in nasal reconstruction, ensuring structural integrity and aesthetic refinement in complex cases. However, it is also noted that these flaps have been used effectively for periocular reconstruction.¹⁰ There are many alternatives for the restoration of nasal wounds, but those most suitable for reconstruction with paramedian forehead flaps are those that are larger than 1.5–2 cm in diameter with or without periosteal or perichondral defects because smaller defects than these can frequently be aimed at using single-stage techniques. Paramedian forehead flaps can offer sufficient skin to supplant entire nasal subunits, which is valuable when more than 50% of a subunit has been misplaced, and the finest aesthetic result would be accomplished by replacing the entire subunit rather than replacing only the missing tissue.⁹ Paramedian forehead flaps may be executed in 2 or 3 steps depending on the surgeon’s experience and the patient’s situation.^11,12 In our study, surgery was performed in 2 or 3 sessions. Immediate thinning of the flap during its creation can offer significant aesthetic benefits. Although this has not been a standard practice in our protocol, we will consider this technique in the future to enhance overall outcomes. In patients with aggressive tumors and large defects, a malar advancement may be executed followed by a paramedian forehead flap 6 months later. The use of tissue expanders has been beneficial in selected cases, but we recognize that primary closure, when possible, may offer better results. We will continue to carefully evaluate the use of expanders compared with other techniques to optimize outcomes. This approach can offer 2 advantages: first, the defect area may shrink over time; second, it facilitates follow-up for early recurrence of aggressive tumors. The chance of developing nonmelanoma skin tumor recurrence after surgical treatment is less than 5%.^13,14 This ratio may increase depending on the size, subtype, and profundity of the intrusion of the tumor. In our examination, which included large nasal skin defects and a heterogeneous patient group, recurrence was noted in a total of 6 (5.3%) patients, and this rate was comparable to that mentioned in the literature. Typically, failure rates for interpolated flaps have been reported to be 1%–6%.^15,16 When addressing failures or limitations in nasal reconstruction using the paramedian forehead flap, other techniques may offer viable solutions. The supraclavicular–submental sandwich flap, as described by Vaena et al⁷, can be an effective option for rescuing failed nasal reconstructions, particularly in cases where other approaches might not suffice. Similarly, domino flaps, as detailed by Linh et al⁸, provide an innovative solution for reconstructing the nasal columella, a crucial aspect of nasal form and function. These alternatives demonstrate that even in challenging reconstructions, there are additional options to ensure successful outcomes. Despite the high rate of comorbidity and the high average age, the absence of flap necrosis in our patients suggests that paramedian forehead flaps can be used very safely in this age group. There is no evident agreement in the literature on the impact of comorbidities, particularly diabetes mellitus, on flap success. Several studies have not found a statistically significant correlation between diabetes and flap success.¹⁵ Some studies have also shown that successful flap division could occur within 1–2 weeks, even in the presence of comorbidities.¹⁷ In our examination, the absence of flap necrosis in any of the patients shows that with solid and adequate vascular support, it can be effectively utilized in full-thickness defects. The absence of flap necrosis even in patients with comorbidities such as hypertension and diabetes confirms this. The foremost complication and significant condition influencing flap success is the infection of the wound site.³ Flap necrosis due to infection occurs frequently. Because the flap is in direct contact with the nasal cavity and nasal flora, especially in full-thickness defects, the possibility is increased. Nevertheless, the fact that no patients in our study had wound site infection or flap necrosis due to infection may be related to the strong vascular support of these flaps. Smoking is another factor affecting flap success. Previous studies have shown that smoking decreases the success rate of flaps.^15,18,19 However, the fact that smokers achieved complete flap success in our study may be because the supratrochlear artery, which constitutes the main vascular support for these flaps, is strong and resistant to occlusion. In any case, further studies with a larger number of patients are clearly needed.

Even though smoking was not demonstrated to reduce flap success in our study, dehiscence was observed in the frontal donor site in 3 patients, all of whom were smokers. Therefore, it can be said that smoking decreases the overall success rate. The first limitation of this study is that it is retrospective. The second limitation is the lack of evaluation of patients’ quality of life indicators. Additional research is needed to analyze the factors related to potential complications, which include measures of the subjective assessment of the patient and reanalysis of arguments with longer case series. We found that maintaining the integrity of aesthetic units can be challenging in cases with extensive nasal defects. However, we continue to refine our techniques to minimize such compromises. We acknowledge the importance of adapting our techniques to modern practices to continually improve aesthetic and functional outcomes. We are committed to integrating new methodologies, such as scoring the frontalis muscle for facilitating primary closure, into our future procedures.

CONCLUSIONS

Adequate reconstruction of nasal skin defects due to oncological surgery, congenital defects, or trauma is essential because of the increasing importance of defects in this area for both aesthetic and functional aspects of the nose. The paramedian forehead flap is a reliable option if the defect contains more than 1 subunit and in full-thickness defects, even in patients who smoke or have comorbidities.

Nasal reconstruction with a paramedian forehead flap is secure and efficient in the treatment of nonmelanoma skin cancer, even in very demanding cases. Factors pertinent to the site of reconstruction and the patient must be considered, including location, amount of affected subunits, age, and comorbidities. Several steps may be required for adequate reconstruction. Because the overall treatment time may be prolonged and affect the quality of life, it is important to emphasize and discuss this with the patient preoperatively. Our long-term experience with the paramedian forehead flap demonstrates its versatility not only in large, complex nasal defects but also in smaller defects with exposed cartilage. The insights gained from this study underline the importance of flap selection based on defect characteristics rather than size alone, ensuring optimal aesthetic and functional outcomes.

In conclusion, our study highlights the effectiveness of the forehead flap in nasal reconstruction. However, we are aware of the challenges and are committed to continually improving our techniques to achieve even better results.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

PATIENT CONSENT

The patient provided written consent for the use of her image.