What is a Paramedian Forehead Flap?

What is a 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.

What does a Paramedian Forehead Flap look like?

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. This stays in place for approximately 4 weeks while new blood vessels grow from the nose into the forehead skin. The second step is to divide the flap blood supply and return excess skin back to the forehead while leaving 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?

I work closely with many Mohs surgeons in the DFW area for closure of nasal and facial skin cancer defects. I recommend patients with skin cancer of the face or neck see me prior to removal of skin cancer. This allows us adequate planning for the most streamlined process possible – often performing the closures on the same day as the removal!

Please do not hesitate to contact me with any questions and check our Facial Reconstruction page for more examples!

Total Facial Volume Replacement – Sculptra and Fat vs Gel Fillers

Total Facial Volume Replacement – Sculptra and Autologous Fat vs Gel Fillers

Misconceptions, Questions, and Expections

Is my face going to look too full or round? 

Short answer: No. I am replacing lost volume that has occurred.

Long answer: The face has lost about 25% of bone volume by age 60. That causes increased size of the orbits, decreased projection of the midface, and shortening of the mandible. Fat volume decreases (especially in temples, cheeks, and perioral areas) and the fat pads separate and descend down the cheek. Providing replacement of this loss in the proper locations, allows restoration of youthful shape and contour.

What is total volume loss? 

I use this term to refer to the changes described above. This differs from localized areas of volume loss that we routinely enhance such as the lips and cheeks. Total volume restoration allows more general replacement of the loss of subcutaneous fat.

What is the best filler to use for total volume replacement? 

There are currently two fillers that I feel address the total soft tissue loss that occurs in the face. Autologous fat (harvested from the patient) and Sculptra. Both allow soft improvement in the areas of volume loss without creating heaviness in highly mobile areas such as the lower cheeks.

I use these fillers to complement the typical gel fillers (Juvederm Voluma, Juvederm Ultra, Restylane, Belotero).  I continue to use gel fillers for bone-volume replacement (deep injections to provide structure) and for superficial, small-diameter wrinkles.

How long does Sculptra last?

Sculptra results last up to two years. It works by promoting the patient’s own collagen production. This collagen formation is appealing to many patients with its soft and natural feel. These results do take some time which is different than the immediate gratification of many of the other fillers I use.

Here is an example of a Sculptra injection schedule: 

Day 1: Injection of 2 vials of sculptra

Day 3: Back to normal without evidence of swelling.

Day 3-60: increasing collagen formation and volume replacement

Day 45-60: Injection of 2 vials of sculptra:

Day 60-120: further collagen formation

This can repeated for another cycle if needed.

Every year: Touch up with 1-2 vials of sculptra.


If you are interested in a consultation to see what the best options are for you, please get in touch with us!

Have a great week!


Facelift Post-Operative Instructions

Jordan Rihani, MD provides information to his patients following facelift, necklift, and browlift in this podcast. Jordan Rihani, MD performs facelift, necklift, and browlift surgery in Southlake and Fort Worth, TX.

Rhinoplasty Post-Operative Instructions

Jordan Rihani, MD of the Facial Plastic Surgery Institute provides post operative information for his patients undergoing rhinoplasty. Jordan Rihani, MD performs rhinoplasty in Southlake and Fort Worth, TX.

Improve Healing with Proper Nutrition

If you have a surgery in the near future or have chronic conditions that require healing, diet is an important part of that process. Proper nutrition provides your body with the building blocks it needs to heal itself. Let’s review a few of my recommendations for proper nutrition in the peri-operative period.

  • The power food groups:
    • Protein (Meats, Beans, Nuts, Milk and Yogurt) 
    • Vitamin C (Oranges, Grapefruit, Brussel Sprouts, Kale)
    • Magnesium (Pumpkin, Spinach, Soy)
    • Zinc (Beef, Lamb, Seafood)




  • Not a big eater? Eat more meals throughout the day. Try eating your typical meals, but increase to five or six times
    a day to increase your caloric consumption.
  • Consider supplementation of essential nutrients with a multi-vitamin if you are not meeting the nutritional daily requirements.
  • Control blood sugars if you have a history of diabetes. This is critical, as elevated blood sugars can have detrimental effects on wound healing.
  • Eliminate any nicotine-containing products from your daily routine. Patients who are quitting smoking are advised to avoid patches and gums which cause vascular constriction and impair wound healing.


Thanks and happy eating!




See below for more information:

Radiofrequency Skin Tightening

House of Preservation + FPSI collaboration now up! House of Preservation reviews Radiofrequency Skin Tightening at my office in Southlake, TX with information on how it works and what to expect. Rylie (from House of Preservation) was interested in collagen tightening of the face and jowls. The treatment feels almost like a hot stone massage as it heats the tissues beneath the skin. The endpoint of heating is monitored throughout the treatment to ensure precise temperatures are reached. This allows changes to the collagen under the skin, while preventing any damage to the surface of the skin.

Radiofrequency skin tightening is one of the many modalities available for skin tightening and can be combined with other rejuvenation options (including Botox/Dysport or Fillers) for optimum results. We employee this as well as other options such as laser therapies and radiofrequency microneedling in our Fort Worth and Southlake Plastic Surgery Offices. For more information on the various technologies that are out there and how they work, please see my technology summary page:

Non-surgical options for facial rejuvenation is obviously a huge market internationally. As someone who performs both surgical and non-surgical options, I am able to objectively provide opinions based on what the desired results may be. Feel free to contact me to schedule your complimentary consultation regarding both surgical and non-surgical skin tightening options.

Microcannulas vs. Needle Injection for Injectable Fillers

Isn’t it enough that there are so many different fillers out there? Now we have to keep up with HOW they’re injected? Bear with me, as I think this is an important topic for anyone that is undergoing filler injections – more important that the type of filler.

What is a microcannula?

microcannulaA microcannula is similar in size to a needle, but instead of a sharp point at the end, there is a rounded end with an opening on the side. Also, microcannulas are flexible and bend with pressure, as opposed to needles that are rigid and designed to pierce skin (and blood vessels).

What are the benefits of microcannula injections?

Because microcannulas are flexible and blunt-tipped, they are able to be push blood vessels out of the way. As a result, they cause less trauma to blood vessels which means less bleeding under the skin, and therefore less bruising. Patient also experience less pain and discomfort with microcannula injections. Lastly (and most importantly), microcannulas are SAFER. The most feared complication of fillers is due to intravascular injection of filler which causes occlusion of blood vessels. As a result, there can be loss of skin of the face due to compromised blood supply. Because cannulas are blunt and have a side injection port, the incidence of intravascular injection is substantially decreased.

Why aren’t all injectors using microcannulas?

Good question! I think this will change as the popularity of microcannulas increases. Unfortunately not all injectors have trained with microcannulas so there is a bit of a learning curve.

What areas are you using microcannula injections?

I perform most of my injections with microcannulas, including lips, cheeks, marionette lines, tear trough. I use needles very occasionally for fine tuning and deep injections in conjunction with microcannulas.

See the demonstration below for microcannula injection of sculptra:

Please let me know if you have any other questions! Have a great weekend.




Technology in Plastic Surgery

versusI know how confusing it can be to keep up with all the brand names and technologies in this field. As a result, I have combined many of the name brand technologies (like Coolsculpting, ThermiRF, Clear & Brilliant, etc) into easy-to-understand categories. I will be updating this list based on your feedback or as new technologies emerge, so please keep me posted! You can find the list at – ENJOY!


Thinking about your first Botox consultation?

So you’ve heard about Botox and your friends may be getting it BUT you still have a lot of unanswered questions before you schedule a consultation like “What happens during the consultation?”. So here is my rundown of some common Q&A’s to get everyone caught up.


Some common questions:

Where should I start learning about Botox?  

Schedule the consultation! It’s complimentary and the best way to assess whether you would benefit from Botox in the first place! I see a large number of patients bothered by something and think that they need Botox, but in fact need something else quite different.  I invite you to explore my Concern Based Menu to research more information on the various options available to you. You may also explore the Botox page.

How long does a Botox consultation last? 

Consultations last 15-20 minutes and you meet with me, personally, to discuss the various options available and come up with a customized plan for you.  I see new Botox patients in both my Southlake and Fort Worth offices.


If I want to have Botox performed, can it be done the same day? 

Yes. Botox can be done at my Southlake and Fort Worth offices on the same day and simply adds around 10 minutes to the length of the consultation.

Is getting Botox painful?

I have performed many, many Botox injections, but would say probably 95% of patients report that the injections were much easier than expected. I use a combination of ice as well as vibration nerve distraction (and good music, of course), to ensure patients are comfortable. Pain during or afterwards is rare.

How will I look after a Botox appointment?

Since effects take 3-5 days to start working, you will be moving your forehead normally when you leave. The effects are gradual. You may notice some small injection site swelling (less than a small pea) that resolves in a couple hours. Most people can go right back to work after their lunchtime touchup.

If I start using Botox, will I need to keep using it? 

The short answer is NO. People that ascribe to Botox prevention, typically maintain use of Botox because they like to avoid deepening of wrinkles on the forehead. However, when the effects of Botox wear off, movement returns to normal.

How long does Botox last? 

Typical results are 2-4 months.

How much does Botox cost? 

Typical Botox prices may range from $320 to $550.

What is the difference between Botox and Dysport?

Please see my earlier blog post on this topic. In short, I tend to use both interchangeably depending on the effect I am trying to achieve. They are both derived from the same original botulinum toxin, but simply purified differently. They are equal in price.

Any other questions? Simply send me an email at




Under Eye Rejuvenation with House of Preservation

I’m very excited to be teaming up with some fantastic women with an eye for aesthetics. It is not every day that you can take your fashion/design careers and funnel those energies into blogging about beauty and the art of “age preservation”. But Brittany and Rylie have done just that. Their blog is entitled “House of Preservation” and features many current beauty product reviews as well as some treatment reviews. Our focus will be on education of my patients (and their followers), which has always been a top priority for both of us. I hope you enjoy!

Under Eye Rejuvenation with House of Preservation and Jordan Rihani, MD


tear trough

Our first video discusses my Facial Plastic Surgery Institute under eye rejuvenation package. This combination of procedures improves the “tired eye” appearance or a prominent “tear trough”. For more information, see the Tired Eyes Page on this website.

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