Surgery Spotlight: Aesthetic Reconstruction of the Nose: The Three-Stage Folded Forehead Flap-Surgery Spotlight: Aesthetic Reconstruction of the Nose: The Three-Stage Folded Forehead Flap

Surgery Spotlight: Aesthetic Reconstruction of the Nose: The Three-Stage Folded Forehead Flap

Video Transcription

This woman presented prior to a Mohs excision of recurrent basal cell carcinoma. Some years earlier, a composite skin graft had been applied to her right ala. Her ala is notched.  The width and flare of the right nostril are diminished. The residual ala is scarred and somewhat contracted. An old skin graft was visible in her left bar head and brow.  After her Mohs re-excision, a composite graft could have been used to reclose the defect. However, she wanted to look normal.  In this case, the true skin defect is greater than that apparent on her photographs. The defect looks smaller within her contracted, scarred nose.  She is missing about 1.2 centimeters by 6 millimeters of lining. The skin defect is larger. After a discussion with her, a three-stage folded forehead flap was planned to resurface  the ala and to supply lining. The blood supply to a forehead flap is random from adjacent skin, axial, based on the supratrochlear vessels, and myocutaneous from the frontalis.  A full thickness forehead flap has maximum vascularity. After its elevation, it is physiologically delayed.  Wound healing and fibrosis do not occur until the frontalis muscle is excised or the fat layer is injured, so it remains soft and supple. Stistilane can be folded for lining.  This lining integrates into the residual adjacent normal lining and, four weeks later, no longer depends on the forehead flap for survival.  So the nostril margin can be incised and the proximal covering flap can be re-elevated without devascularizing the lining. Delayed primary cartilage grafts can then be placed.  Her repair was performed under general anesthesia. The outline of the contralateral normal subunit was marked with ink.  A 1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1  It is applied to a foil suture pack to create an exact replacement for the injured ala. It will be used as a guide to determine the exact dimension, border outline and contour  needed to rebuild the nose. Remember that the visible defect may not reflect the true tissue loss. Her right ala is distorted by past scar and a composite graft.  The fresh wound is now distorted by gravity and tension. The contralateral normal ala will determine how much skin must be replaced. That 3D foil template is bent and cripped.  The right ala subunit is marked. The pattern is placed over the defect. The external surface of the cover template is marked with ink to identify the exact position  and width of the lining defect along that nostril margin. A separate foil template is made for the lining defect.  The surface template is used as a model to ensure that the nostril margin of the lining defect is properly shaped.  Although the surface defect is relatively small, a subunit ala repair was planned. If the subunit principle is applied and adjacent normal tissue is discarded within the subunit,  the final scars will lie along the joins between the subunits and the tendency of the flap to contract will be harnessed to improve the overall nasal shape.  The entire subunit is resurfaced rather than just patching the defect. In this case, although the defect does not encompass quite 50% of the subunit, I felt  the overall result would be improved by subunit excision. The surgeon must visualize the likely end result prior to starting surgery.  I felt it would be advantageous to remove the adjacent scar and cancer prone skin around this recurrent cancer.  The subunit principle is applied only when repairing central facial defects in areas of convex contour.  There is little advantage to use it, for instance, when rebuilding a flat sidewall. Skin and underlying soft tissue were then excised within the right ala and soft triangle  down to the thin lining. This wound does not reflect the true tissue loss. We will use an exact subunit flap with the correct dimension and outline to fill this wound.  It will be supported by a cartilage graft designed on the contralateral normal as well. The lining pattern is rechecked.  The lining is designed as an extension to a full thickness forehead flap, remembering that the lining extension will be folded over.

Video Summary

A woman with a recurrent basal cell carcinoma underwent Mohs excision followed by a three-stage folded forehead flap procedure to repair a distorted ala from previous scarring and grafts. The forehead flap, benefiting from the supratrochlear vessels, provided a soft, supple lining, integrating seamlessly for nostril reconstruction. Using a foil template for precision, the surgeon planned a subunit ala repair, prioritizing the overall nasal shape by excising scarred areas. The repair included a cartilage graft and a full-thickness flap, ensuring that scars aligned with facial contours for optimal aesthetics. The procedure aimed to restore normal appearance and eliminate cancer-prone skin.

Asset Caption

This video, narrated by Frederick J. Menick, MD, demonstrates the "Three-Stage Folded Forehead Flap" for cover and lining in aesthetic reconstruction of the nose. This material is presented thanks to a generous licensing grant from Elsevier, and is taken from Plastic Surgery: 6-Volume Set, 3rd Edition edited by Peter C. Neligan, MD. "Three-Stage Folded Forehead Flap" appears in Volume 3: Craniofacial, Head and Neck Surgery and Pediatric Plastic Surgery.

Surgeon Frederick J. Menick, MD

Source

Neligan, P. C. (Ed.). (2012). Plastic Surgery: 6-Volume, 3^rd Edition. Philadelphia: Saunders.

Disclosure This video was published with permission from Elsevier. This product is not certified for CME.

Keywords

surgery spotlight

Surgical Videos

Reconstructive

Microsurgery

Frederick J. Menick MD; Memben

Mohs excision

forehead flap

nostril reconstruction

cartilage graft

nasal aesthetics