Understanding the Paramedian Forehead Flap
One of the most common ways to reconstruct the nasal tip is a flap known as the paramedian forehead flap. This uses skin and its blood supply borrowed from the forehead to replace lost skin of the nasal tip. Shown below is a typical nasal tip defect.
Refining the defect and using the forehead
The defect is typically “refined” to ensure the borders are smooth and the defect follows natural subunits of the nose. This will ensure the entire tip is composed of the new, matching skin. A template is then created which allows us to create the same defect from the forehead. This is elevated and moved into place.
What does the inset Paramedian Forehead Flap look like?
After the flap is raised, it is sewn into place on the nose which is shown below.
The above example demonstrates the appearance of a paramedian forehead flap. This was used to recreate a nasal tip defect from skin cancer. There are two stages to this flap reconstruction. First step – rotate the forehead flap into place. This contains a flap of skin and its blood supply from the forehead. This is sewn into place over the nasal defect. The middle image demonstrates a finger-like connection between the patient’s eyebrow and the tip of the nose.
What happens next?
This stays in place for approximately 3-4 weeks while new blood vessels grow from the nose into the forehead skin. Once we know the forehead skin has attached to the nose, we can safely divide the blood supply and remove the pedicle of the flap. This leaves the new skin on the tip of the nose.
What happens to the forehead when using a Paramedian Forehead Flap?
The forehead in most cases has enough elasticity that it can be closed easily. This heals up with a thin vertical scar that is about 4 inches long.
What are other options besides Paramedian Forehead Flaps for nasal tip defects?
There are other options for reconstructing the nasal tip including skin grafts, flaps taken from the cheek, and local flaps from the nose. The options are determined by the size of the defect and if the underlying cartilages are involved or if the inside lining of the nose is involved (which would require closure at the same time). I discuss all possible options with my patients prior to surgery. Closure using a paramedian forehead flap does allow similar thickness and color-match skin for an excellent cosmetic and functional result.
Should I have a facial plastic surgeon close my skin cancer defect?
Dr Rihani is a double board certified Facial Plastic & Reconstructive surgeon. He works closely with many Mohs surgeons in the DFW area for closure of nasal and facial skin cancer defects. We recommend patients with skin cancer of the face or neck see us prior to removal of skin cancer. This allows us adequate planning for the most streamlined process possible.
Please do not hesitate to contact us with any questions and check our Facial Reconstruction page for more examples!
